Diagnostic value of contrast-enhanced ultrasonography in the characterization of ovarian tumors().

INTRODUCTION: Vascularity influences the characteristics of gynecologic tumors observed with direct imaging techniques that reveal the macrovascular component of these lesions (color and power Doppler) and with indirect imaging involving the administration of contrast agents to examine the microcirculation and interstitial perfusion (contrast-enhanced computed tomography [CT] and magnetic resonance [MR] imaging). The purpose of this study was to determine whether contrast-enhanced ultrasonography (CEUS) of ovarian lesions provides useful information that cannot be obtained with conventional US. MATERIALS AND METHODS: We used CEUS to assess 72 nonspecific adnexal lesions in 61 patients. CEUS was performed with a 4.8-ml bolus of a second-generation ultrasonographic contrast agent and dedicated imaging algorithms. For each lesion, B-mode morphology, CEUS morphology, and time/intensity curves were evaluated. RESULTS: In 8/61 cases (13.1%) CEUS offered no additional morphovascular information. In 38/61 cases (62.3%), it provided additional information that did not modify the management of the lesion, and in 15/61 cases (24.6%) it gave additional information that modified the management of the lesion. Malignant lesions were characterized by significantly shorter times to peak enhancement (11.9 ± 3.1 s vs 19.8 ± 4.0 s p < 0.01) and significantly higher peak intensity (24.7 ± 4.2 dB vs 17.8 ± 3.3 dB p < 0.01) compared with benign lesions. CONCLUSIONS: CEUS improves diagnostic confidence in the characterization of liquid-corpuscular lesions where conventional US is inconclusive. CEUS can be proposed as a valid alternative to CT and MR. However, information obtained by CEUS influences the therapy in a limited percentage of cases (24.6%).

High-resolution, three-dimensional, and contrast-enhanced ultrasonographic findings in diseases of the eye().

OBJECTIVES: To review the contrast-enhanced ultrasound (CEUS) and 3D ultrasound findings (3D-US) in various pathologies involving the eye and orbit and to compare them with high-resolution US (HRUS) findings. BACKGROUND: CEUS is a valid diagnostic tool for study several districts. There are numerous pathological conditions of the eye in which CEUS can be very helpful or detrimental. IMAGE FINDINGS: We review a wide range of ocular lesions, traumatic (retinal and choroidal detachments) and malignant (choroidal melanoma, tumors inside and outside the muscle cone) evaluated alternatively with CEUS and 3D and compare these findings with those obtained with HRUS. Dysthyroid orbitopathy is not included in this review. CONCLUSION: CEUS plays a central role in the differentiation of detached retina (vascular) and vitreous membranes (avascular). It is also helpful in the assessment of tumor of the eye, in planning treatment for choroidal melanoma, and in assessing orbital masses for neovascularization. HRUS is highly effective in the detection of traumatic and non-traumatic lesions of the eye, but it is less effective for the assessment of orbital lesions. The 3D module has increased the diagnostic value of CEUS. CEUS is cost-effective and can be used when CT and MR cannot be performed.

Three-dimensional sonohysterography for examination of the uterine cavity in women with abnormal uterine bleeding: Preliminary findings.

INTRODUCTION: To compare the diagnostic values of three-dimensional sonohysterography (3DSH), transvaginal ultrasound (TVUS), and 2-dimensional sonohysterography (2DSH) in the work-up of abnormal uterine bleeding (AUB), in particular the ability of each method to identify intracavitary lesions arising from the endometrium or uterine wall. MATERIALS AND METHODS: 24 patients referred for AUB underwent TVUS followed by 2-D and 3-D HS in the same session. Three-dimensional data were acquired with a free-hand technique during maximal distention of the uterus. Within 10 days of the sonographic session, each patient underwent hysteroscopy, which was considered the reference standard. For each of the 3 imaging methods, we calculated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy. RESULTS: Hysteroscopy demonstrated the presence of an intrauterine lesion in 21/24 patients (87.5%). In 3/24 patients hysteroscopy was negative. For TVUS, 2DSH, and 3DSH, sensitivity was 76% (16/21), 90% (19/21), 100% (21/21), respectively; specificity was 100% (3/3), 100% (19/19), 100% (21/21); PPV was 100%, 100%, 100%; NPV was 37%, 60%, 100%; accuracy was 76%, 90%, 100%. CONCLUSIONS: 3DSH is more sensitive that 2DSH or TVUS in the detection of intrauterine lesions. If these preliminary results are confirmed in larger studies, 3DSH could be proposed as a valuable alternative to diagnostic hysteroscopy.

Diffusion-weighted MRI sequences (DW-MRI) of the kidney: normal findings, influence of hydration state and repeatability of results.

PURPOSE: This study was performed to determine the apparent diffusion coefficient (ADC) of the normal kidney using diffusion-weighted magnetic resonance imaging (DW-MRI) sequences and to analyse both the changes due to hydration state and results repeatability. MATERIALS AND METHODS: Ten volunteers underwent DW-MRI imaging of the kidneys with a breath-hold single-shot spin-echo planar imaging (SE-EPI) sequence in the axial and coronal planes with b values of 300, 500, 800 s/mm(2), in different states of hydration. Urine osmolarity (OsmU) and sodium excretion (NaU) were measured at the time of each examination. ADC maps were created for all b values, and ADC values were calculated and compared between different states of hydration. In five subjects, the protocol was conducted twice to test data repeatability. RESULTS: ADC values were lower with higher b values (3.00 vs. 2.47 vs. 1.99 x 10(-3) mm(2)/s with b values of 300, 500, 800 s/mm(2), respectively). ADC values in different hydration states were not statistically different. Measurements were reproducible. OsmU and NaU were statistically different in the different states of hydration (p<0.01). CONCLUSIONS: ADC values significantly decrease with higher b values. Average ADC values in the normal kidney are reproducible. Hydration state does not significantly influence mean ADC values.

Ultrasound-guided injection of botulinum toxin A in the treatment of iliopsoas spasticity.

PURPOSE: Intramuscular injection of botulinum toxin A (BTX-A) is a common treatment for iliopsoas muscle spasticity, but it is not easy to position the needle in this muscle without guidance. In this paper we describe an ultrasound-guided technique for the intramuscular injection of BTX-A to treat spasticity of the iliopsoas muscle. Its effectiveness was assessed in 10 patients. METHOD AND MATERIALS: The ultrasound-guided technique for BTX-A injection was used on 10 patients. The needle was inserted into the muscle belly at an angle of 45° along the longitudinal axis of the muscle when allowed by patient's condition. RESULTS: In all cases, the iliopsoas muscle was easily identified and both the iliac and psoas components were assessed. Introduction of the needle and drug injection were entirely carried out under ultrasonographic guidance. The procedure was successful in all patients, even in those with a high-grade spasticity, and general anesthesia was not required. CONCLUSIONS: This ultrasound-guided technique allows accurate guidance for the injection of BTX-A, and it can be considered as an alternate supportive therapy in patients with spasticity and dystonia.

Contrast-enhanced ultrasound (CEUS) assessment of superselective uterine fibroid embolization (SUFE): Preliminary experience().

PURPOSE: The use of superselective uterine fibroid embolization (SUFE) requires imaging techniques that can be used to verify the success of the procedure. The purpose of our study was to analyze the potential value of pre- and post-treatment contrast-enhanced ultrasonography (CEUS) for assessing the outcome of SUFE and for posttreatment follow-up. MATERIALS AND METHODS: We studied twelve women undergoing SUFE for uterine fibroids. In those with multiple fibroids, only the three largest were considered in this study. A total of 21 lesions (size range 3.5-9.0 cm, mean 5.2 cm) were examined. Each myoma was examined immediately before and after SUFE (while the patient was still in the angiography room) with transabdominal CEUS performed after intravenous administration of a single bolus of contrast agent. The follow-up protocol included CEUS evaluation one month after treatment and CEUS plus dynamic magnetic resonance (MR) studies six months after treatment. RESULTS: In 20/21 cases, postembolization CEUS revealed total fibroid devascularization. The remaining lesion (in a woman with multiple lesions) showed persistent vascularization after SUFE. These findings were all consistent with angiographic data. No recurrences were observed during the six-month follow-up. One patient reported the reappearance of symptoms 18 months after SUFE, and CEUS showed the persistence of intralesional vascularization. CONCLUSIONS: CEUS is effective for assessing the completeness of vascular occlusion following SUFE for uterine fibroids. CEUS findings correlate with clinical results observed one and six months after treatment. Compared with dynamic MR, CEUS is reliable and cost-effective.

Treatment of inoperable non-small cell lung carcinoma stage IIIb and IV with cisplatin, epidoxorubicin, vindesine and lonidamine: a phase II study.

AIMS AND BACKGROUND: The polychemotherapeutic regimen PEV (cisplatin, epidoxorubicin and vindesine) + lonidamine proved to be valid in terms of activity and efficacy in the treatment of patients with advanced, previously untreated non-small cell lung carcinoma. The goal of the study was to verify whether a different dose of lonidamine, together with an increase in cisplatin and epidoxorubicin compared to the standard regimen, is able to improve the activity and efficacy of PEV without increasing toxicity. PATIENTS AND METHODS: Thirty-one patients were treated with cisplatin (80 mg/m2/i.v.), epidoxorubicin (70 mg/m2/i.v.) and vindesine (3 mg/m2/i.v.) every 28 days for 6 courses in combination with lonidamine (600 mg/day on days 1 and 2 of each course followed by 450 mg/day until progression of disease or intolerance). All the patients were monitored for clinical response, median duration of response and survival and for toxicity. RESULTS: The clinical response in the 29 assessable patients was: 41.4% partial remission, 48.3% stable disease, and 10.3% progression of disease. The median duration of response was 8.5 months (range, 4-26+) and median survival was 12 months (range, 4-26+). Survival was above the median in 15 stage IIIb patients, and 2 patients were long survivors at 26+ months. The toxicity of PEV + lonidamine was mild; there were no toxic deaths nor acute toxicity of grade 4 according to the WHO scoring system. CONCLUSIONS: Our polychemotherapeutic regimen proved to be valid in terms of activity and efficacy, and a further dose increase in single chemotherapeutic agents as well as lonidamine could therefore be justified.

Lonidamine plus cyclophosphamide in the treatment of adanced non-small cell lung cancer in the elderly: a phase II study.

AIM AND BACKGROUND: The aim of this Phase II trial was to verify the therapeutic activity and tolerability of chemotherapy with lonidamine (LND) plus cyclophosphamide (CTX) in advanced non-small cell lung cancer (NSCLC) in the elderly. The rationale of the combination is reported. CTX showed mild toxicity, with a 12% objective response (OR) in monochemotherapy; LND potentiated the in vitro antiproliferative activity of alkylating agents, mainly CTX, without increasing myelotoxicity, particularly important in the elderly. METHODS: The schedule consisted of CTX, 600 mg/m2/i.v. on day 1 every 21 days for 6 cycles; LND, 450 mg/die/p.o. from day 1 to progression. RESULTS: Between November 1990 and April 1991, 41 patients with stage III-IV NSCLC were enrolled; 35 were assessable for response. Median age was 73 years (range, 71-79 years); 13 patients (32%) presented stage III A, 20 (49%) stage III b, and 8 (19%) stage IV disease. Cardiovascular conditions and/or chronic respiratory failure contraindicated surgical treatment in stage III A patients. Of enrolled patients, 14.6% experienced PR, 48.8% SD and 14.6% dropped out of the study. Median time to progression was 4 months (range, 2-9 months) and median survival 9 months (range 3-45 months). No patient showed WHO grade IV LND-related toxicity. In 1 patient (2.5%), LND was discontinued after 5 therapy cycles due to WHO grade III myalgia; in 80% of patients, LND oral dosage was reduced to 300 mg/day due to WHO grade II myalgia, and 20% of patients completed treatment with the full dose. CONCLUSIONS: CTX plus LND can be considered a well tolerated therapeutic approach in the elderly with NSCLC with good PS and good liver, renal and cardiac conditions, but 14.6% PR is a slightly better result as compared with 12% PR obtainable with CTX alone as reported in the literature, even though most patients presented with advanced disease and no specific toxic effect was observed. Therefore, a confirmatory randomized trial (CTX vs CTS plus LND) would hardly be useful.

Slowing of mitral valve annular calcium in systemic hypertension by nifedipine and comparisons with enalapril and atenolol.

Mitral annular calcium (MAC) is a condition that often occurs in patients with systemic hypertension. To evaluate the effectiveness of nifedipine in preventing MAC, 223 patients with systemic hypertension of recent onset and without MAC were selected and randomly enrolled in 3 groups: group 1 (76 patients) received nifedipine; group 2 (72 patients) received enalapril; and group 3 (75 patients) received atenolol. After 5 years, these treatments significantly reduced systolic (p < 0.001) and diastolic (p < 0.05) blood pressure (BP) in 3 treated groups. M-mode echocardiography revealed MAC only in 2 patients in the nifedipine group (2.6%), in 13 in the enalapril group (18%) and in 15 in the atenolol group (20%). The degree of MAC was mild (< 5 mm) in the 2 patients in group 1, in 5 of the 13 in group 2, and in 6 of the 15 in the group 3, whereas it was severe (> 5 mm) in the remaining 8 in the enalapril group and in the other 9 in the atenolol group. There was also a significant correlation in the degree of MAC, left atrial enlargement and mitral regurgitation. In addition, atrial fibrillation and atrioventricular conduction defects were associated with severe MAC. These results indicate that nifedipine is an effective drug both in the long-term management of systemic hypertension and in preventing or delaying MAC.

Progressive impairment of left ventricular diastolic filling with advancing age: a Doppler echocardiographic study.

OBJECTIVE: To identify the sequence and significance of left ventricular filling abnormalities associated with progressive aging in humans. DESIGN: Cross-sectional study comparing three age groups. SETTING: Department of Geriatrics at University of Naples. PARTICIPANTS: Seventy-five healthy subjects in three age groups: 25 subjects from 25 to 45 years (Group I), 25 subjects from 46 to 65 years (Group II), and 25 subjects from 66 to 85 years (Group III). INTERVENTION: None. MAIN OUTCOME MEASURES: All underwent pulsed-doppler echocardiography under color guide to measure the following parameters: peak velocity flow for early (E wave) and late (A wave) mitral flow; A/E wave ratio; deceleration time of mitral flow (MDt); isovolumic relaxation time (IRT); ratio of velocity time integrals of the A wave to the velocity time integrals of the entire mitral spectrum (VTIA/VTIM). RESULTS: Peak velocity of the E wave was slightly lower in Group II and III compared to Group I; in contrast, peak velocity of the A wave was greater (P less than 0.005) in aged individuals. Also A/E wave ratio, MDt, and IRT were significantly greater with advancing age (P less than 0.01; P less than 0.05 and P less than 0.001, respectively). Finally, VTIA/VTIM tended to be greater in the oldest group, but not significantly so. CONCLUSIONS: Left ventricular relaxation is progressively impaired in late middle age and old age, presumably an early marker of cardiac aging. Increased left atrial pressure is compromised only in the oldest group, presumably representing a compensation for impaired left ventricular relaxation.

[Participatory organization and management in local health systems]. / Organización y gestión participativas en los sistemas locales de salud.

Up to now, community participation in local health systems has been rather limited. To increase this participation, the authors propose organizational and management approaches based on the administrative principle that the primary aims served by health institutions need to be established. These aims should be defined in a way that meets the basic needs of individuals, and main actions should focus on improving the relationship between people and services. The proposed approaches include decentralization and microregionalization of health services. Both these processes, which are complex and subject to conflict, should be implemented in tandem. Their use will allow attainment of greater efficiency, transparency, and debureaucratization of health systems and services and, at the same time, facilitate the direct participation of users in the management of these services.

Consideraciones quirurgicas en el feocromocitoma. / Surgical considerations in pheochromacytoma

Se presentan 9 pacientes operados de feocromocitoma durante un periodo de 26 anos.Se analizan aspectos clinicos y los metodos actuales de diagnostico, atribuyendose la mayor importancia a la tomografia computada y a la introduccion del agente radiofarmacologico: la 131 metaiodobencilguanicina (131-IMBG). Se expone el adecuado manejo de los pacientes y las maniobras intraoperatorias que aseguran una extirpacion completa del tumor

Consideraciones quirurgicas en el feocromocitoma. / Surgical considerations in pheochromacytoma

Se presentan 9 pacientes operados de feocromocitoma durante un periodo de 26 anos.Se analizan aspectos clinicos y los metodos actuales de diagnostico, atribuyendose la mayor importancia a la tomografia computada y a la introduccion del agente radiofarmacologico: la 131 metaiodobencilguanicina (131-IMBG). Se expone el adecuado manejo de los pacientes y las maniobras intraoperatorias que aseguran una extirpacion completa del tumor