Digital tomosynthesis and ground glass nodules: Optimization of acquisition protocol. A phantom study.

INTRODUCTION: Ground-glass nodules may be the expression of benign conditions, pre-invasive lesions or malignancies. The aim of our study was to evaluate the capability of chest digital tomosynthesis (DTS) in detecting pulmonary ground-glass opacities (GGOs). METHODS: An anthropomorphic chest phantom and synthetic nodules were used to simulate pulmonary ground-glass nodules. The nodules were positioned in 3 different regions (apex, hilum and basal); then the phantom was scanned by multi-detector CT (MDCT) and DTS. For each set (nodule-free phantom, nodule in apical zone, nodule in hilar zone, nodule in basal zone) seven different scans (n = 28) were performed varying the following technical parameters: Cu-filter (0.1-0.3 mm), dose rateo (10-25) and X-ray tube voltage (105-125 kVp). Two radiologists in consensus evaluated the DTS images and provided in agreement a visual score: 1 for unidentifiable nodules, 2 for poorly identifiable nodules, 3 for nodules identifiable with fair certainty, 4 for nodules identifiable with absolute certainty. RESULTS: Increasing the dose rateo from 10 to 15, GGOs located in the apex and in the basal zone were better identified (from a score = 2 to a score = 3). GGOs located in the hilar zone were not visible even with a higher dose rate. Intermediate density GGOs had a good visibility score (score = 3) and it did not improve by varying technical parameters. A progressive increase of voltage (from 105 kVp to 125 kVp) did not provide a better nodule visibility. CONCLUSION: DTS with optimized technical parameters can identify GGOs, in particular those with a diameter greater than 10 mm. IMPLICATIONS FOR PRACTICE: DTS could have a role in the follow-up of patients with known GGOs identified in lung apex or base region.

Strain analysis reveals subtle systolic dysfunction in confirmed and suspected myocarditis with normal LVEF. A cardiac magnetic resonance study.

AIMS: Lake Louise Criteria (LLC) are time-dependent and some acute myocarditis (AM) with preserved left ventricular ejection fraction (LVEF) could be missed, due to the limited accessibility of Cardiac Magnetic Resonance (CMR). We aimed to assess the potential value of cardiac strain measured by feature tracking (FT) imaging in this population. METHODS AND RESULTS: Eighty-three patients with clinically suspected AM and normal LVEF were divided into 39 "confirmed AM" (positive LLC) and 44 "suspected AM" (negative LLC). An age and gender-matched sample of 42 normal subjects underwent CMR. In all groups, FT-derived biventricular strains and STE- global longitudinal strain (GLS) were assessed, being regularly measurable. Strain values < 5th percentile of the control group were considered abnormal. "Suspected" and "confirmed" AM were similar, except for medium time of CMR evaluation (5.2 vs 1 months from presentation, respectively; p = 0.004). Compared to healthy controls, both "suspected" and "confirmed" AM showed significantly impaired strain values. LV-global circumferential strain (GCS), right ventricular GCS and LV-GLS were abnormal in 15.4% and 15.9%, 20.5% and 15.9%, 7.7% and 9.1% in "confirmed" and "suspected" AM, respectively. STE analysis confirmed the results on LV-GLS, however a weak correlation emerged between STE and CMR-FT LV-GLS (p = 0.08). CONCLUSIONS: Compared to STE, CMR-FT analysis provided a more comprehensive and complementary biventricular strain evaluation that resulted similar in "confirmed" and "suspected" AM with normal LVEF. Conversely, mostly biventricular GCS was significantly reduced in up to 20% of patients, compared to healthy controls.

Charcoal suspension tattoo: new tool for the localization of malignant laterocervical lymph nodes.

We present a retrospective study to evaluate safety and effectiveness of ultrasound (US)-guided tattooing with charcoal of suspicious laterocervical lymph nodes. When an open biopsy of a laterocervical lymph node is needed, the choice of the lymph node to excise and examine is fundamental to avoid rebiopsy. Surgeons tend to choose the most surgical approachable enlarged lymph node that does not always correspond to the one with worst echographic aspect. We present 16 cases of patients with laterocervical adenopathy with inconclusive or non-adequate results at fine needle aspiration cytology addressed to open biopsy. Those patients underwent US-guided preoperative injection of a charcoal suspension inside the lymph node to excise to mark it, and then excisional biopsy was performed. Sixteen marked lesions (100 %) were detected intraoperatively and dissected. The injected charcoal was detected intraoperatively in all cases. In 14 patients (87, 5 %) it was inside the lesion; in two cases (12, 5 %), the charcoal suspension was found in the tissues above the lesion. The procedure was well tolerated in all cases. No major procedure-related complications were encountered. US-guided charcoal tattooing is a new, safe, well-tolerated, and easy-to-perform technique for the marking of US suspicious laterocervical lymph nodes. This preliminary study shows a high technical success rate (76 %) and high percentage of intraoperative detection of marked lesions (100 %) with a low rate of complications.

The use of CEUS in the diagnosis of retinal/choroidal detachment and associated intraocular masses - preliminary investigation in patients with equivocal findings at conventional ultrasound.

PURPOSE: To investigate whether contrast-enhanced ultrasound (CEUS) may help to diagnose retinal/choroidal detachment and may help to differentiate intraocular lumps in cases with equivocal features on conventional grayscale and Doppler modes. MATERIALS AND METHODS: The institutional review board approved this retrospective study. The need for informed consent was waived. A computerized data search was performed in the database of our institution for patients with vitreous hemorrhage who underwent CEUS of the eye to assess retinal/choroidal detachment and/or associated masses. This process yielded a total of 31 patients (18 men, 13 women, age range: 39 - 88 years) in whom CEUS was performed because the findings on conventional grayscale and Doppler modes were equivocal. CEUS was performed using low acoustic power contrast-specific modes. A 2.4 - 4.8  mL bolus of SonoVue was injected, followed by a saline flush. All examinations were digitally recorded for retrospective analysis. Confirmation of CEUS findings was obtained at surgery (n = 20) or with binocular indirect fundoscopy performed after clearance of the ocular media (n = 11). Two readers with different levels of ultrasound experience independently reviewed the imaging features. A five-degree scale ranging from definitely absent (score 1) to definitely present (score 5) was used to assess the presence or absence of retinal/choroidal detachment on conventional ultrasound modes alone and with the addition of CEUS. ROC curve analysis was performed to assess the diagnostic accuracy of both methods. The inter-reader agreement was also evaluated. In patients with associated intraocular lumps, conventional Doppler modes and CEUS were used to differentiate non-tumor masses from tumor masses. RESULTS: According to the reference standard, 13 patients had retinal detachment, 4 had choroidal detachment, and 3 had both retinal and choroidal detachment. There were 8 associated intraocular lumps (4 subretinal hemorrhages, 3 malignant melanomas, 1 metastasis). The inter-reader agreement was good (K = 0.644) and very good (K = 0.833) for conventional modes and CEUS, respectively. The diagnostic performance of CEUS was high for both readers (area ± standard error under the ROC curve: 0.966 ±â€Š0.031 and 0.900 ±â€Š0.055 for readers 1 and 2, respectively). There were 2 false-positive results and 1 false-negative result in patients with proliferative diabetic retinopathy. CEUS was effective in differentiating subretinal hemorrhage from hypovascular tumors. CONCLUSION: CEUS can be used as a problem-solving technique when conventional ultrasound modes are not diagnostic for retinal/choroidal detachment and when intraocular lumps cannot be characterized as tumor or non-tumor masses on conventional modes. The evaluation of patients with proliferative diabetic retinopathy, however, may be problematic.

First application of computed radiology to mammography with synchrotron radiation.

OBJECTIVE: The aim of this study was to evaluate the feasibility of phase-contrast mammography with synchrotron radiation using a high-resolution computed radiology (CR) system devoted to mammography. MATERIALS AND METHODS: The study was performed at the Synchrotron Radiation for Medical Physics (SYRMEP) beamline of the Elettra synchrotron radiation (SR) facility in Trieste (Italy); X-ray beams were in the range 16-22 keV with a high degree of monochromaticity and spatial coherence. The CR system evaluated is the FCR Profect CS by Fujifilm Global. The first images were obtained from test objects and surgical breast specimens. Images obtained using SR and both screen-film and the CR system were compared with images of the same samples acquired with digital mammography equipment. In view of the good quality of the results obtained, the CR system was used in two mammographic examinations with SR. RESULTS: Images acquired using SR and both screen-film and CR were obtained with the same level of delivered dose. Image quality obtained with CR was similar or superior to that of screen-film images. Moreover, the digital images obtained with SR were always better than those acquired using the digital mammography system. CONCLUSIONS: Phase-contrast mammography with SR using the studied CR system is a feasible option.

Preoperative vascular mapping with multislice CT of deep inferior epigastric artery perforators in planning breast reconstruction after mastectomy.

PURPOSE: Our aim was to evaluate the usefulness of computed tomography angiography (CTA) in vascular mapping for planning breast reconstruction after mastectomy using a free flap made with the deep inferior epigastric perforators (DIEP). MATERIALS AND METHODS: We retrospectively evaluated 41 patients, mean age 57 years, scheduled for mastectomy. CTA was performed with a 64-row scanner (Aquilion 64, Toshiba Medical Systems, Japan), with injection of 100 ml of contrast medium (iomeprol 350 mgI/ml, Bracco, Italy) at 4.5 ml/s. Maximum intensity projection (MIP) and three-dimensional volume-rendering (VR) reconstructions were made to mark perforator positions. Presentation frequency, anatomy and artery opacification quality were evaluated. RESULTS: DIEP were always depicted (n=81) and subdivided according to Taylor's classification into type I (65%), type II (28%), and type III (7%). We observed a mean of three (range, 1-5) DIEP arteries on the right and two (range, 1-5) on the left side. The superficial inferior epigastric artery (SIEA) was depicted in 6/41 patients, bilaterally in three cases. Opacification was optimal in 30/41 cases, venous contamination due to late arterial phase in eight and low opacification due to early scan in three. CONCLUSIONS: Studying DIEP with CTA is useful in the surgical planning of breast reconstruction, even though it requires careful optimisation owing to the critical timing of opacification typical of that vascular district.

E-learning in radiology: an Italian multicentre experience.

OBJECTIVE: The aim of this study was to design, deliver and evaluate an e-learning teaching programme for post-graduate radiodiagnostics training that would involve various post-graduate schools throughout Italy. MATERIALS AND METHODS: All of the Directors of Italian post-graduate schools of radiodiagnostics were sent an e-mail on 27 September 2010 informing them of our willingness to set up an e-learning project for the academic year 2010-2011 in the form of single-subject teaching seminars. The proposed subjects were the semeiotics of the various organs and apparatuses in the context of "Urgent/Emergency Pathology". After having received registrations, a calendar of lessons was planned to be held between 10 November 2010 and 12 October 2011. The validity of the project was tested by means of a multiple-choice questionnaire covering the technical and didactic quality of the entire project, to be completed by the students. RESULTS: Fifty-one percent of the universities in Italy participated in the project: Trieste, Udine, Verona, Milan-Bicocca, Novara, Varese, Genoa, Sassari, Rome Campus, the Catholic University of Rome, Chieti, Foggia, Catania, Modena, Florence, Palermo, Bologna, Pavia, Parma and Ferrara. The lessons were attended by a total of 10,261 post-graduate medical students, for an average of 513.1 students per lesson. Seventy percent of the students judged the didactic content "excellent", 25% "good", and 5% "satisfactory"; none said it was unsatisfactory. In terms of visual quality (particularly the details of the radiological images proposed in the form of slides and/or video clips), 73% judged it "excellent", 20% "good", 6% "satisfactory", and 1% "poor". The audio quality was judged "excellent" by 71%, "good" by 22%, "satisfactory" by 6% and "poor" by 1%. In relation to judgement of audio and video quality, it has to be underlined that this was greatly affected by the hardware/software configuration and the band speed and technology of the Internet connection. CONCLUSIONS: Technological evolution is overcoming all barriers, and technology is also having a positive impact on the approach to teaching. Our multicentre teaching experience merits the following considerations: the quality of the teaching product was certified by the students' judgements of its didactic content and the quality of reception; the economic cost of the teaching had a minimal impact on the post-graduate schools (€ 18 per lesson). In terms of breaking down national barriers, it is to be hoped that the coordination and integration of diagnostic imaging e-learning projects, with the participation of post-graduate schools in different European countries, can be developed not only in a spirit of "cultural sharing" and the exchange of teaching experiences.

Fiber density index in the evaluation of the spinal cord in patients with multiple sclerosis.

PURPOSE: The aims of this study were to determine fractional anisotropy (FA) and the fibre density index (FDi) in the cervical spinal cord of patients with multiple sclerosis (MS) by using diffusion-tensor magnetic resonance imaging (DT-MRI) to identify possible differences between MS patients and controls. MATERIALS AND METHODS: We studied 27 patients with MS - nine with primary progressive (PPMS), nine with secondary progressive (SPMS) and nine with relapsing-remitting (RRMS) disease - and 18 healthy individuals as controls. Conventional and DTI sequences with diffusion gradients applied in 32 directions were obtained. The results were compared between healthy controls and patients, between healthy controls and individual forms of MS and between the three forms of MS. Statistical analysis was performed by analysis of variance (ANOVA) and Student's t test. RESULTS: The FDi in the three subgroups of patients and in controls showed a statistically significant difference. Using the t test, we found results from both PPMS and SPMS groups were different from controls. The correlation between FA and FDi was significant both in healthy controls and in MS patients evaluated as a single group. CONSLUCIONS: Despite the small group of patients, these findings suggest that FDi associated with FA is a sensitive parameter for assessing spinal cord damage in patients with MS.

The role of CEUS in the characterization of hepatocellular nodules detected during the US surveillance program--current practices in Europe.

The basic pathological feature for the differential diagnosis between hepatocellular carcinoma (HCC) and non-malignant hepatocellular nodules in cirrhotic patients detected during ultrasound (US) is the vascular supply to the nodule. Computed tomography (CT) and magnetic resonance imaging (MRI) are considered reference imaging techniques for depicting hepatocellular nodule vascularity in the noninvasive diagnosis of HCC. Contrast-enhanced US (CEUS) improves the diagnostic performance of unenhanced US in the diagnosis of HCC, giving an overall diagnostic accuracy that is similar to that of CT, even for nodules smaller than 2 cm. An additional diagnostic feature of CEUS relative to CT is the possibility to visualize contrast wash-in to hepatic nodules during the arterial phase and contrast washout during the portal venous and late phases. Sensitivity for the diagnosis of HCC with combined assessment of CEUS and CT is higher than for separate assessments of CEUS and CT due to the reduction of false-negative findings. CEUS represents a competitive imaging method from an economic point of view, and is an effective imaging tool for assessing the therapeutic outcome after surgery, ablation therapy, and transarterial chemoembolization (TACE).

Functional MRI during the execution of a motor task in patients with multiple sclerosis and fatigue.

PURPOSE: This study was undertaken to assess cortical activation during execution of a motor task in patients with multiple sclerosis (MS) and fatigue. MATERIALS AND METHODS: We enrolled 24 right-handed patients affected by relapsing-remitting MS and mild disability (12 with and 12 without fatigue) and 15 healthy volunteers. Magnetic resonance imaging (MRI) examination (1.5 T) was performed with conventional sequences and an echoplanar imaging (EPI) sequence for functional MRI (fMRI). The motor task consisted of sequential finger tapping performed with the right hand. Statistical maps of motor activation were obtained. Comparison between the two subgroups of patients and between patients and controls was performed with analysis of variance (ANOVA) statistical analysis (p<0.05). RESULTS: Compared with controls, patients without fatigue showed greater activation of the primary sensorimotor cortex bilaterally, of the right supplementary motor cortex, of the left premotor cortex, of the left cerebellum and of the superior parietal lobule bilaterally. Compared with patients without fatigue, patients with fatigue demonstrated greater activation of the right premotor area, of the putamen and the dorsolateral prefrontal cortex. CONCLUSIONS: Patients with fatigue have greater activation of the motor-attentional network when performing a simple motor task.

Prevention of fecal-orally transmitted diseases in travelers through an oral anticholeric vaccine (WC/rBS).

INTRODUCTION: Estimate the efficacy of oral anticholeric vaccine Dukoral in subjects travelling to high-risk areas for traveler's diarrhoea and cholera. METHODS: The study involved subjects of both genders who planned to travel to high-risk areas for traveler's diarrhoea and cholera. Immunization with oral anticholeric vaccine Dukoral was offered to each one of them. Upon returning, all the participants in the study were asked to complete a self-administered questionnaire consisting of 40 close-ended questions mainly concerning: personal and health data, characteristics (length, destination, reason) of the travel, onset of gastrointestinal symptoms, data relating to the assumption of anticholeric vaccine and possible adverse reactions. RESULTS: 296 questionnaires have been collected. Mean age was 38.2 years (55.4% males and 44.6% females). Mean travel length was 22.2 days. Reasons for the travel: 66.8% tourism and 33.2% work-cooperation. Most frequent destination was Africa (48.1%), followed by Asia (32.1%) and central South-America (17.8%). 199 subjects (67.2%) properly executed vaccination with Dukoral. The diarrhoea affected 14.1% of vaccinated subjects and 20.6% of non vaccinated ones. The following cohorts showed statistically significant differences in incidence of diarrhoea: <35 years old age (13.7% vs. 27.1%), travel for work-cooperation (14.1% vs. 35%) and travel length >28 days (12.1% vs. 40%). No serious adverse events were reported following vaccination. DISCUSSION: Oral Anticholeric vaccine proved to be effective and safe in preventing fecal-oral diseases in travelers exposed to high risk conditions.

Multimodal approach to the endovascular treatment of embolisation or exclusion of the renal arteries and their distal and/or polar branches: personal experience.

PURPOSE: This study reviews our experience over the last 10 years with procedures of embolisation and/or exclusion of the renal arteries, their parenchymal branches and the polar arteries [renal artery embolisation (RAE)]. MATERIALS AND METHODS: Twenty-seven patients (19 men and eight women; age range 37-93 years; mean 74 years) underwent RAE. The indications were: symptomatic gross haematuria in nine patients (33.3%) (tumour-related in seven and iatrogenic in two), symptomatic inoperable renal tumour in five (18.5%), large subcapsular or perirenal haematoma in three (11.1%) and aneurysm of the main renal artery in two (7.4%). Eight patients (29.6%) scheduled for endovascular aneurysm repair (EVAR) of the abdominal aorta underwent prophylactic embolisation of the renal polar branch arising from the aneurysmal sac or the subrenal aortic neck to prevent the possible revascularisation of the sac. Different embolisation agents were used: coils (17 cases), embolisation particles (14 cases), glue (one case), coated stent (two cases) and mechanical occlusion devices (two cases). In 11 cases, two to three different embolisation agents were used together. RESULTS: Technical success was achieved in 26/27 patients (96.3%); in one case, embolisation of a polar artery arising from the aneurysmal sac was not possible. One case of gross haematuria recurred 13 months after the procedure and was re-treated with success. There were no cases of major or minor complications. CONCLUSIONS: RAE is an effective and minimally invasive procedure in the treatment of neoplastic/iatrogenic symptomatic gross haematuria and in the palliative treatment of inoperable renal tumours. One possible new indication is the prophylactic exclusion of the polar artery arising from the neck or the sac of an abdominal aortic aneurysm in patients who are candidates for EVAR. In our experience, we observed very low morbidity and a short hospital stay. This procedure requires the availability of various materials for performing embolisation and experience in their use.

E-learning in radiology: Italian multicentre experience.

PURPOSE: The aim of our work was to design, implement and evaluate an e-learning programme in favour of trainee radiologists enrolled at the many specialty schools located throughout Italy, in the spirit of "sharing culture". MATERIALS AND METHODS: Once a common educational programme and time slot had been identified and planned, the programme was delivered via Internet-based video conferencing once a week for 2-h lectures. Each lecture was followed by interaction between the teaching staff and trainees at the individual sites. The universities involved were Trieste, Udine, Verona, Milano Bicocca, Novara, Varese, Genova, Sassari, Rome "Campus", Rome "Cattolica", Chieti, Foggia, Catania, Modena and Firenze. The University of Rome "Cattolica" participated in the project with two locations: Rome "Policlinico Gemelli" and Rome "Cattolica Campus of Campobasso". RESULTS: Eighteen lectures were conducted, for a total of 36 h. "Transient" connection interruption occurred 13 times for a total of 33 min over 2,160 min of lessons. Video quality and, in particular, details of radiological images shown in slides or moving pictures, were rated as very good by 71% of trainees, good by 24% and satisfactory by 4.5%; no one gave a rating of unsatisfactory. CONCLUSIONS: Based on our experience, whereas e-learning in radiology has become established and compulsory, there is the need for legislation that on the one hand protects online teaching activity and on the other allows study and continuing medical education (CME) credits to be recognised.

64-Slice CT urography: optimisation of radiation dose.

PURPOSE: This study assessed means by which to optimise 64-slice computed tomography urography (CTU) in evaluating the urinary tract, with a view to obtaining the best trade-off between image quality and radiation dose. MATERIALS AND METHODS: Image quality was analysed in terms of spatial and contrast resolution on several scans of a phantom performed with automatic dose modulation and different reconstruction kernels and accepted noise level. Data were compared with the radiation dose values recorded for 52 patients who underwent CTU examination. RESULTS: Radiation dose and image quality differed considerably depending on the reconstruction parameters, even though a higher dose did not always imply better image definition. Data obtained in the phantom were consistent with those obtained in patients. Depending on the clinical problem, the radiation dose varied from 6.2 to 17.6 mSv. CONCLUSIONS: CTU cannot be considered a standard examination: the scan parameters need to be adapted to the image quality required for the specific clinical problem.

64-Slice CT urography: 30 months of clinical experience.

PURPOSE: This study sought to assess the diagnostic accuracy of 64-slice computed tomography urography (CTU) in evaluation of the urinary tract. MATERIALS AND METHODS: A total of 322 CTU procedures were carried out in 317 consecutive patients (mean age 64.4 years). The findings were compared with previous and subsequent patient workup considering both laboratory and imaging studies, such as urine cytology, abdominal ultrasound and CT, cystoscopy, retrograde pyelography, surgery and pathology. RESULTS: Out of 322 CTU examinations, 169 showed significant urinary tract changes, whereas 153 revealed no urinary disease, in good agreement with the follow-up. In particular, in bladder evaluation, for which we have a direct comparison with cystoscopy in 125 patients, we calculated a CTU sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of 85%, 94%, 92%, 89% and 90%, respectively. CONCLUSIONS: CTU was accurate for urinary tract evaluation, but it cannot replace cystoscopy in patients in whom a malignant bladder disease is suspected.

Prevalence of extravascular collateral findings during 64-slice CT angiography of the abdominal aorta and lower limbs.

PURPOSE: The aim of this study was to assess the prevalence of extravascular collateral findings during 64-slice CT angiography of the abdominal aorta (AA-CTA) and lower limbs (LL-CTA). MATERIALS AND METHODS: The images of 536 AA-CTA and LL-CTA examinations performed for suspected aortic and peripheral vascular disease in 500 patients were retrospectively reviewed. Two radiologists evaluated the 5-mm axial images independently using appropriate window settings for the area under investigation. Collateral findings were divided according to their clinical significance into significant, nonsignificant and meriting further investigation. RESULTS: No collateral findings were identified in 97/500 patients (19.4%). In the remaining patients, 821 collateral findings were detected, of which 43 (5.24%) were classified as significant, 135 (16.44%) as meriting further investigation and 643 (78.32%) as nonsignificant. The findings indicative of the presence of a malignant lesion totalled 36 (4.5%). CONCLUSIONS: AA-CTA and LL-CTA demonstrate a nonnegligible prevalence of collateral findings, many of them major. It therefore appears that the evaluation should focus not only on the image reconstructions to identify vascular disease, but also on the native axial images to detect incidental findings.