Percutaneous thrombin injection under contrast-enhanced ultrasound guidance to control active extravasation not associated with pseudoaneurysm.

The technique of percutaneous thrombin injection (PTI) under contrast-enhanced ultrasound (CEUS) guidance for control of acute hemorrhage-active extravasation not associated with pseudoaneurysm is demonstrated in three cases: 1) Massive spontaneous retroperitoneal hematoma in a patient with multiple comorbidities. Contrast-enhanced computed tomography (CT) showed extensive active extravasation, which was only partially controlled by transarterial embolization. CEUS was performed in the angiography suite. Contrary to unenhanced US and colour Doppler US (CDUS), CEUS confirmed persistent extravasation; CEUS-guided PTI was performed immediately thereafter. 2) Large rectus sheath hematoma in a patient on anticoagulant therapy. Contrast-enhanced CT and unenhanced US/CD could not definitely diagnose extravasation. CEUS clearly showed extravasation and was used for guidance of PTI. 3) Chest wall hematoma complicating central venous catheter placement in a patient with coronavirus on anticoagulant therapy. CDUS was inconclusive. CEUS was performed at the bedside, clearly showed active extravasation, and was used for guidance of PTI. In all three cases, post-PTI CEUS confirmed the absence of residual enhancement of the hematomas, and the hemodynamic status of the patients improved. PTI appears to be effective in selected cases of hematomas associated with active extravasation. In this context, CEUS may be the most suitable modality for guidance and for an immediate evaluation of the treatment effect.

On the digitalisation of higher education in times of the pandemic crisis: techno-philic and techno-sceptic attitudes of social science students in Crete (Greece).

Drawing upon empirical evidence from a research carried out at the University of Crete, this paper investigates the social sciences students' perception towards their experiences regarding the emergency online learning amidst the COVID-19 pandemic. The study reveals aspects of digital divides, as well as divergent perceptions of students, ranging from techno-philic attitudes that enthusiastically welcome the pivot to online learning, to ambivalent opinions expressing moderate satisfaction and techno-sceptic views, criticising pandemic pedagogies through digitalised forms of learning. The analysis sheds light on the contextual factors associated with the dystopic condition of the protracted economic crisis and the pandemic, that lie behind the claims of many students, revealing a main tension between contrasting perceptions of digital education. Students with positive attitudes towards online learning tend to highlight the advantages in regard to time and space flexible modalities of digital education, embracing it as an inclusive practice that responds to the social and educational needs of students, especially at times of crisis. Techno-sceptic attitudes criticise online learning models fοr lowering the academic standards, separating students from the real-life world on campus and repositioning them in digital settings where common physical experience, affective body language and classroom socialisation are missing. The article offers insight in the ongoing discussion of the emergency remote learning and underlines the political and pedagogical significance of the accelerating digitalisation of the universities in the post-COVID era.

Prostatic artery embolization performed in anteroposterior projections versus steep oblique projections: single centre retrospective comparative analysis.

BACKGROUND: To present and evaluate an approach for reduction of utilization of steep oblique angiographic projections during prostatic artery embolization (PAE). METHODS: Single-center, retrospective study of patients who underwent bilateral PAE (from October 2018 to November 2019) and in whom it was possible to embolize PA of at least one pelvic side utilizing anteroposterior projections only (AP-PAE group), with the following techniques: Identification of the origin of PA on anteroposterior angiographic views. Utilization of anatomic landmarks from the planning computed tomographic angiography. Distal advancement of the angiographic catheter or microcatheter in the anterior division of internal iliac artery. Gentle probing with microguidewire at the expected site of origin of the PA. The AP-PAE approach was initially applied to all PAE patients during the study period and when this approach failed, additional steep oblique projections were acquired; patients who underwent bilateral PAE, with both anteroposterior and oblique projections for both pelvic sides, formed the standard PAE (S-PAE) group. The AP-PAE group was compared with S-PAE group in terms of baseline clinical and anatomic features, technical/procedural aspects and outcomes. RESULTS: Forty-six patients (92 pelvic sides) were studied. AP-PAE was feasible in 12/46 patients (26.0%): unilateral AP-PAE in 9/46 patients (19.5%); bilateral AP-PAE in 3/46 patients (6.5%). AP-PAE group had larger prostates (p = 0.047) and larger PAs (p < 0.001). Body mass index (BMI) and other baseline features were comparable between the two groups (mean BMI, AP-PAE group: 27.9 ± 3.6, S-PAE group: 27.0 ± 3.5, p = 0.451). Mean fluoroscopy time and dose area product were lower in AP-PAE group (46.3 vs 57.9 min, p = 0.084 and 22,924.9 vs 35,800.4 µGy.m2, p = 0.018, respectively). Three months post PAE, comparable clinical success rates (11/12 vs 31/34, p = 0.959) and mean International Prostate Symptom Score reduction (60.2% vs 58.1%, p = 0.740) were observed for AP-PAE and for S-PAE group, respectively. No major complications were encountered. CONCLUSION: AP-PAE is associated with significant reduction in radiation exposure and appears to be feasible, safe and effective, but it can be applied in a relatively small percentage of patients.

mRECIST criteria and contrast-enhanced US for the assessment of the response of hepatocellular carcinoma to transarterial chemoembolization.

PURPOSE: We aimed to evaluate the combination of the modified Response Evaluation Criteria In Solid Tumors (mRECIST) and contrast-enhanced ultrasonography (CEUS) as a tool for the assessment of hepatocellular carcinoma treated with transarterial chemoembolization. MATERIALS AND METHODS: Forty-seven hepatocellular carcinoma patients (80 target tumors suitable for mRECIST measurements) were studied. They were treated with scheduled transarterial chemoembolization with doxorubicin-eluting microspheres every 5-7 weeks. Imaging follow-up (performed one month after each transarterial chemoembolization) included a standard, contrast-enhanced modality (computed tomography [CT] in 12 patients or magnetic resonance imaging [MRI] in 35 patients) and CEUS. The study focused on response evaluation after the third transarterial chemoembolization. CEUS required a bolus injection of an echo-enhancer and imaging with a dedicated, low mechanical index technique. The longest diameters of the enhancing target tumors were measured on the CEUS or CT/MRI, and mRECIST criteria were applied. Radiologic responses were correlated with overall survival and time to progression. RESULTS: The measurements of longest diameters of the enhancing target tumors were easily performed in all patients. According to mRECIST-CEUS and mRECIST-CT/MRI, complete response was recorded in five and six patients, partial response in 22 and 21 patients, stable disease in 16 and 14 patients, and progressive disease in four and six patients, respectively. There was a high degree of concordance between CEUS and CT/MRI (kappa coefficient=0.84, P < 0.001). Responders (complete+partial response) according to mRECIST-CEUS had a significantly longer mean overall survival and time to progression compared to nonresponders (37.1 vs. 11.0 months, P < 0.001 and 24.6 vs. 10.9 months, P = 0.007, respectively). CONCLUSION: The mRECIST-CEUS combination is feasible and has prognostic value in the assessment of hepatocellular carcinoma following transarterial chemoembolization.

Nonepiphyseal giant cell tumor of the rib: a case report.

A case of a 32-year-old female patient with a giant cell tumor originating in the middle part of the left 10th rib is presented. On X-rays and CT, the tumor caused a well-defined osteolysis with nonsclerotic borders. On MRI, it exhibited intermediate signal intensity on T1 sequences and central high signal and peripheral intermediate signal on T2 sequences. On contrast-enhanced MR images both central and peripheral-periosteal enhancement was noted. Thanks to its small size (2 × 1.3 cm), the lesion was easily resected en bloc with a part of the affected rib. The patient is free of recurrence for 3 years after the operation.

Hepatocellular carcinoma treated with transarterial chemoembolization: Evaluation with parametric contrast-enhanced ultrasonography.

AIM: To evaluate the response of hepatocellular carcinoma (HCC) to transarterial chemoembolization (TACE) using a simplified protocol of parametric contrast-enhanced ultrasound (pCEUS). METHODS: Eighteen patients with HCC (18 target tumors, diameter: 2.8-12 cm) were evaluated before, and 20 d after TACE. The distribution and morphology of TACE-induced necrosis in these tumors precluded accurate evaluation by visual assessment or by simple measurements. For pCEUS, a 4.8 mL bolus of SonoVue (Bracco, Milan, Italy) was intravenously administered and analysis of tumor perfusion during the initial phase of enhancement (0-30 s post injection) was performed with dedicated software (Qontrast, Bracco, Milan, Italy). Time-intensity curves were plotted and three parameters were calculated: peak intensity (PI, in percentage %), time to peak (TTP in seconds, s) and area under the curve during wash-in (AUC-WI, in arbitrary units, a.u). Magnetic resonance imaging was the standard imaging modality for post-treatment evaluation. Changes in tumor size were recorded and response was assessed according to response evaluation criteria in solid tumors criteria. RESULTS: A statistically significant decrease in PI and AUC-WI was observed in the treated tumors post TACE; PIpre: 21.5% ± 8.7% (mean ± SD), PIpost: 12.7% ± 6.7%, P < 0.001, AUC-WI pre: 17493 ± 9563 a.u, AUC-WI post: 9585 ± 5494 a.u, P < 0.001. A slight increase in TTP was noted post TACE, but this was not statistically significant; TTP pre: 13.1 ± 4.3 s, TTP post: 13.6 ± 4.2 s , P = 0.058). The changes in the aforementioned parameters were not accompanied by significant tumor shrinkage. CONCLUSION: pCEUS, even when limited to the study of the arterial phase of tumoral enhancement, can detect and quantify early perfusional changes in HCC post TACE.

Intermediate and advanced hepatocellular carcinoma treated with the antiangiogenic agent sorafenib. Evaluation with unenhanced and contrast-enhanced ultrasonography.

AIMS: To evaluate the sonographic changes observed in hepatocellular carcinoma (HCC) post antiangiogenic treatment with sorafenib. PATIENTS AND METHODS: Twenty one intermediate or advanced HCC patients (19 men, 2 women; mean age: 66.8 years; 32 target tumors-TTs) received sorafenib as monotherapy and were studied with unenhanced ultrasonography (US) and contrast-enhanced ultrasonography (CEUS) with a second generation echo-enhancer (SonoVue) at bimonthly intervals. Changes in lesional size, echotexture and enhancement were evaluated. Response was classified according to RECIST (Response Evaluation Criteria In Solid Tumors) and modified (m) RECIST. RESULTS: Cystic changes were detected on US in 4 patients (7 lesions); CEUS showed a significant (51-100%) decrease of viable, enhancing TTs in the aforementioned patients. Four additional patients (5 lesions) showed a 73-87% decrease of their viable TTs on CEUS, but no changes on US. 13/21 patients showed less than 30% decrease, no change, or increase of their viable TTs. Based on the last sonographic evaluation, response was as follows: RECIST- Complete Response, CR (n=0), Partial Response, PR (n=1), Stable Disease, SD (n=16), Progressive Disease, PD (n=4); mRECIST- CR (n=2), PR (n=6), SD (n=11), PD (n=2). The 8 responders (CR+PR) according to mRECIST had significantly longer mean overall survival (OS) compared to the 13 non-responders (21.5 vs 12.2 months, p=0.018, Kaplan-Meier method). However, statistical significance was reduced (p=0.065) after adjustment for BCLC and Child's class. CONCLUSION: US may occasionally detect changes indicative of the effect of sorafenib on HCC, but CEUS is required to evaluate and grade post-therapeutic reduction of tumoral enhancement. The latter is likely to correlate with OS.

Contrast-enhanced ultrasonography with intraarterial administration of SonoVue for guidance of transarterial chemoembolization: an initial experience.

AIMS: To describe the technique and to evaluate the feasibility of contrast-enhanced ultrasound with intraarterial administration of echo-enhancer (i.a CEUS) as a method for guidance of transarterial chemoembolization (TACE). PATIENTS AND METHODS: Twelve patients with 17 target liver tumors underwent superselective TACE, guided with i.a CEUS. After microcatheter placement in a (sub)segmental artery suspected as a tumor feeder, a diluted suspension of SonoVue was injected through the microcatheter, and imaging of the target tumor was performed with a low mechanical index technique and with contrast-specific software. If intraarterial injection of SonoVue was associated with immediate, strong tumoral enhancement, the injected artery was considered as tumor-feeding and TACE was performed, otherwise another artery was evaluated. RESULTS: From 25 segmental or subsegmental arteries evaluated i.a CEUS confirmed that 16 arteries were actually tumor feeders and unequivocal excluding 4 arteries as a tumor arterial supply. The remainder 5 arterial branches could not be safely characterized due to artifacts or technical limitations. In 8 patients in which tumoral vascular supply could not be elucidated by angiography alone, i.a CEUS increased the accuracy of supereselective embolization, and provided other clinically relevant information in 2 of these patients. No adverse effects were observed. CONCLUSIONS: For guidance of superselective TACE i.a CEUS is a safe and feasible method..

Accuracy of modern ultrasonographic techniques in the follow up of patients with superficial bladder carcinoma.

PURPOSE: The present study was carried out to establish the accuracy of modern ultrasonographic techniques in the follow up of patients with superficial bladder carcinoma and to evaluate the patients tolerability of cystoscopy. METHODS: Thirty-three patients with a history of superficial bladder carcinoma under active surveillance were initially examined using transabdominal ultrasound followed in the same day by cystoscopy. RESULTS: Fourteen out of the 33 subjects were found to have bladder carcinoma recurrence on cystoscopy. In 11 cases (78.57%) US accurately diagnosed the bladder carcinoma. Two out of the 3 patients in which, the US examination failed to clearly diagnose bladder carcinoma, were found with a tumor smaller than 3 mm while, in the remaining patient the tumor was located in the inner part of a diverticula. The sensitivity of modern ultrasonographic techniques in the diagnosis of bladder cancer recurrence was 78.5%, the specificity 100%, the positive predictive value 100% and the negative predictive value 86.3%. Regarding the patient tolerability for cystoscopy, 17 patients (51.5%) reported excessive discomfort-low tolerability, 9 (27.2%) moderate discomfort-intermediate tolerability and 7 (21.2%) reported no discomfort-high tolerability. CONCLUSION: The technological evolution has rendered ultrasonography more accurate in the diagnosis of bladder carcinoma and thus it can be incorporated in the follow up schedule of patients with superficial bladder carcinoma.

Short-term evaluation of liver tumors after transarterial chemoembolization: limitations and feasibility of contrast-enhanced ultrasonography.

PURPOSE: To evaluate the limitations and the feasibility of contrast-enhanced ultrasonography (CEUS) for the assessment of tumor response shortly after transarterial chemoembolization (TACE). MATERIALS AND METHODS: Fifty seven patients (41 patients with hepatomas, 16 patients with metastases) were studied with CEUS before, 1 day after, and 30 days after TACE. A CEUS-efficiency score (CEUS-ES) was calculated, which evaluated: (a) the completeness of visualization of the target tumor(s) (2: good, 1: adequate, 0: poor) and (b) the quality of delineation of post-TACE necroses (2: good, 1: adequate, 0: poor). A CEUS study was considered as "diagnostic," if each of the aforementioned parameters was associated with grade 1 or 2. RESULTS: CEUS studies were "diagnostic" in 36/57 patients (63.1%). Patients with hepatomas were more likely to undergo "diagnostic" CEUS than patients with metastases (70.7% vs. 43.7%, P = 0.0728). Lesions' multiplicity, deep location, hypoenhancement on pretreatment CEUS, and diffuse growth had a statistically significant (P < 0.05) negative impact on CEUS-ES. Hyperechogenicity on pre-treatment, unenhanced US had a non-statistically significant (P = 0.176) negative impact. Differences between "diagnostic" CEUS studies and CT/MR regarding detection of residual tumor were insignificant (P = 0.8178). CONCLUSION: The percentage of lesions which are unsuitable for post-TACE evaluation with CEUS is not negligible. For the rest, the respective role of CEUS is promising.

Unenhanced and contrast-enhanced ultrasonography during hepatic transarterial embolization and chemoembolization with drug-eluting beads.

The purpose of this study was to describe and evaluate the findings of unenhanced ultrasonography (US) and contrast-enhanced ultrasonography (CEUS) when these modalities are applied during transarterial embolization (TAE) or transarterial chemoembolization (TACE) of liver tumors. Sixteen tumors (9 hepatocellular carcinomas, 5 metastases from colorectal cancer, and 2 hemangiomas) were treated with TAE with microspheres and/or TACE with drug-eluting beads. All of these lesions were studied with intraprocedural unenhanced US and 12 were studied with intraprocedural CEUS. For the latter, a second-generation echo-enhancer (SonoVue; Bracco, Milan, Italy) and a low mechanical index technique were used. Intraprocedural findings were classified according to an arbitrary scale and were compared with pretreatment imaging (CEUS and computed tomography or CEUS and magnetic resonance imaging), with postembolization angiography, and with follow-up results. On unenhanced intraprocedural US, 13 of 16 tumors demonstrated intralesional high-level echoes of varying extent. These feature correlated poorly (r = 0.33, p = 0.097) with and generally underestimated the actual extent of necrosis. Exceptionally, high-level echoes that occupied the largest part of the treated lesions were associated with >50% tumor necrosis. Intraprocedural CEUS clearly depicted immediate partial or complete disappearance of tumor enhancement as a result of TAE/TACE. Three of 6 tumors with complete devascularization on postembolization angiogram showed residual enhancement on intraprocedural CEUS. Intraprocedural CEUS findings correlated closely (r = 0.91, p = 0.002) with follow-up findings. Intraprocedural sonography, particularly with echo-enhancers, could be used for intraprocedural monitoring in selected cases of liver tumors that undergo TAE or TACE.

Contrast-enhanced ultrasonography of hepatocellular carcinoma after chemoembolisation using drug-eluting beads: a pilot study focused on sustained tumor necrosis.

The purpose of this study was to assess the use of contrast-enhanced ultrasonography (CEUS) and the sustained antitumor effect of drug-eluting beads used for transarterial chemoembolisation (TACE) of unresectable hepatocellular carcinoma (HCC). Ten patients with solitary, unresectable HCC underwent CEUS before, 2 days after, and 35 to 40 days after TACE using a standard dose (4 ml) of drug-eluting beads (DC Beads; Biocompatibles, Surrey, UK) preloaded with doxorubicin (25 mg doxorubicin/ml hydrated beads). For CEUS, a second-generation contrast agent (SonoVue, Bracco, Milan, Italy) and a low mechanical-index technique were used. A part of the tumor was characterized as necrotic if it showed complete lack of enhancement. The percentage of necrosis was calculated at the sonographic section that depicted the largest diameter of the tumor. Differences in the extent of early (2 days after TACE) and delayed (35 to 40 days after TACE) necrosis were quantitatively and subjectively assessed. Early post-TACE tumor necrosis ranged from 21% to 70% (mean 43.5% +/- 19%). There was a statistically significant (p = 0.0012, paired Student t test) higher percentage of delayed tumor necrosis, which ranged from 24% to 88% (mean 52.3% +/- 20.3%). Subjective evaluation showed a delayed obvious increase of the necrotic areas in 5 patients. In 2 patients, tumor vessels that initially remained patent disappeared on the delayed follow-up. A part of tumor necrosis after chemoembolisation of HCC with DEB seems to take place later than 2 days after TACE. CEUS may provide evidence for the sustained antitumor effect of DEB-TACE. Nevertheless, the ideal time for the imaging evaluation of tumor response remains to be defined.

The efficacy and safety of gonadotropin-releasing hormone analog treatment in childhood and adolescence: a single center, long-term follow-up study.

OBJECTIVE: The objective of the study was to evaluate the long-term effect of GnRH analog (GnRHa) treatment on final height (FH), body mass index (BMI), body composition, bone mineral density (BMD), and ovarian function. SUBJECTS/METHODS: Ninety-two females, evaluated in adulthood, were categorized as follows: group A, 47 girls with idiopathic central precocious puberty (33 GnRHa treated and 14 nontreated); group B, 24 girls with isolated GH deficiency (15 GnRHa and GH treated and nine GH treated); group C, 21 girls with idiopathic short stature (seven GnRHa and GH treated, seven GnRHa treated, and seven nontreated). RESULTS: FH, BMD, and percent fat mass of GnRHa-treated patients in all three groups were comparable with those of the respective nontreated subjects. BMI values of GnRHa-treated and nontreated subjects in groups A and C were comparable, whereas in group B, a higher BMI was found in subjects treated only with GH. Nontreated patients with ICPP had greater maximal ovarian volumes, higher LH and LH to FSH ratio, and more severe hirsutism than GnRHa-treated ones. Menstrual cycle characteristics were not different between treated and nontreated subjects. The prevalence of polycystic ovary syndrome in treated and untreated girls with ICPP was comparable, whereas in the entire cohort, it was 11.1% in GnRHa treated and 32.1% in the untreated (P = 0.02). CONCLUSIONS: Girls treated in childhood with GnRHa have normal BMI, BMD, body composition, and ovarian function in early adulthood. FH is not increased in girls with ICPP in whom GnRHa was initiated at about 8 yr. There is no evidence that GnRHa treatment predisposes to polycystic ovary syndrome or menstrual irregularities.

Abdominal ultrasonographic findings in patients with sickle-cell anaemia and thalassaemia intermedia.

BACKGROUND: The high prevalence and heterogeneity of clinical and haematological phenotypes of sickle-cell anaemia and thalassaemia intermedia (TI) syndromes in the Greek population constitute a major challenge in routine medical practice. PURPOSE: To investigate the spectrum and prevalence of abdominal US findings in these patients. MATERIALS AND METHODS: The study included 105 patients, 13 homozygous for sickle-cell anaemia (S/S) and 92 with TI syndromes (Th/S, beta(thal)/beta(thal )or beta(thal)/deltabeta(thal)). The patients' ages ranged from 1 to 54 years, with 49 males and 56 females. RESULTS: At the time of the examination, 41% of the patients had undergone splenectomy and 23.8% had undergone cholecystectomy. The most frequent US findings (percentages refer to all patients) were: hepatomegaly (70.5%), splenomegaly (48.6%) and cholelithiasis (20%). A bright liver was identified in 3.8% and focal hepatic lesions were present in two patients of the TI group. Functional disorders of the gallbladder concerned mainly patients with sickle-cell syndromes. Of those with S/S, 30.8% had a shrunken spleen. An echogenic pancreas was identified in one patient in each group. Increased renal echogenicity was observed in 17.6% of patients with sickle-cell syndromes. One case of polycystic kidney disease was diagnosed and coexisted with S/S. CONCLUSIONS: The value of US imaging in detecting complications of sickle-cell and TI syndromes is still debated. To our knowledge, there are no previous reports concerning the frequency and spectrum of abdominal US findings in patients with these syndromes.