Lung visualisation on PET/MRI: implementing a protocol with a short echo-time and low flip-angle volumetric interpolated breath-hold examination sequence.

AIM: To assess the diagnostic performance in detecting lung lesions of a short echo-time (TE) and low flip-angle (FA) volumetric interpolated breath-hold examination (VIBE) sequence included in the integrated positron-emission tomography (PET)/magnetic resonance imaging (MRI) protocol. METHOD AND MATERIALS: Thirty-seven oncological patients who underwent computed tomography (CT) and PET/MRI, including both a dedicated short TE, low FA VIBE (modified VIBE) and a standard VIBE of the lung, were enrolled. Modified VIBE images were reviewed retrospectively and independently by three raters, to detect pulmonary nodules, parenchymal consolidation, and bands. Three other groups examined standard VIBE, PET, and CT images. MRI and PET findings were compared to CT using Krippendorff's alpha using patient-based and a lesion-based analysis. Krippendorff's alpha was calculated to assess the interobserver agreement among the three raters of the modified VIBE. RESULTS: In the patient-based analysis (positivity ≥1 lesion), the comparison of modified VIBE with CT showed an alpha of 0.54 for nodules <6 mm (versus 0.41 for standard VIBE and 0.09 for PET) and an alpha of 0.88 for nodules ≥6 mm (versus 0.74 for standard VIBE and 0.42 for PET). On a lesion-based analysis (presence/absence of each lesion), modified VIBE compared to CT showed an alpha of0.58 for nodules <6 mm (versus 0.44 for standard VIBE and 0.09 for PET) and an alpha of 0.90 for nodules ≥6 mm (versus 0.79 for standard VIBE and 0.50 for PET). The alpha value for the interobserver agreement was 0.90 for nodules <6 mm, 0.91 for nodules ≥6 mm, 1.00 for consolidations, and 0.95 for bands in the patient-based analysis and 0.89, 0.93, 1.00, and 0.95 in the lesion-based analysis. CONCLUSIONS: Modified VIBE proved to be reproducible, showed better accuracy than standard VIBE and PET, and very good concordance with CT in assessing lung nodules ≥6 mm, whereas the agreement was less satisfactory for smaller nodules.

Spontaneous involution of diffuse fibrous dysplasia of paranasal sinuses.

We report the case of a 25-year-old patient, diagnosed at age 10, with diffuse fibrous dysplasia of the paranasal sinuses, an extremely rare idiopathic condition. This diagnosis is possible only by cerebral computed tomography (CT), cerebral and anterior skull base magnetic resonance imaging (MRI), and histopathology. Surgical treatment is common. This boy had mild symptoms: moderate headache in the morning that did not affect his daily activity, and rhinitis, partially responsive to medication. The neurologic examination was abnormal. Radiographs, CT, and MRI showed a diffuse mass in the paranasal sinuses which had a histopathological diagnosis of fibrous dysplasias. The family refused to refer the patient to surgery. The boy has been monitored annually for 15 years. He has remained asymptomatic without headache since age 11, with normal, general and neurologic examinations. Serial MRIs showed a spontaneous partial involution of the mass.

Comparison of 18F-FDG positron emission tomography/computed tomography and computed tomography in patients with already-treated breast cancer: diagnostic and prognostic implications.

AIM: The purpose of the study was to assess the comparison of 18F-FDG PET/CT and CT in patients with breast cancer (BC) already treated with primary therapy, in evaluating the diagnostic and prognostic values. METHODS: We retrospectively studied 190 patients (187 women and 3 men, mean age 61±11 years) with previous BC (all stages) after surgery and other primary treatments. They underwent within three months CT and 18F-FDG PET/CT examinations for the evaluation of disease status. Disease relapse was confirmed by clinical evaluation and/or radiological findings. Survival curves of disease-free survival (DFS) and overall survival (OS) were computed using Kaplan-Meier method. Cox analysis regression was used to determine predictive factors of DFS and OS. RESULTS: Of the overall 190 patients, 82 (43%) had evidence of clinical and/or imaging disease relapse, while 108 (57%) did not. Sensitivity, specificity, negative predictive and positive predictive values for disease relapse or progression were of 89% vs. 77%, 73% vs. 53%, 90% vs. 75% and 72% vs. 55%, respectively for PET/CT and CT. DFS curves were significantly different in patients with both negative and positive PET/CT and CT (log-rank test 33.6; P<0.0001 and 12.7; P=0.003, respectively). OS curves were similar in patients with positive/negative PET/CT and CT (P=NS). By both univariate and multivariate Cox regression analysis positive PET/CT was found to be related to the disease recurrence (HR 0.18 and 0.20, both P<0.0001, respectively). CONCLUSION: PET/CT is more accurate than CT in identification of disease relapse in a large population of BC patients. In women at high-risk of recurrence, PET/CT imaging can provide the early detection of BC metastases, tailoring a proper treatment.

Anal endosonography and fistulography for fistula-in-ano.

PURPOSE: In this study, a comparison was made of the accuracy and clinical usefulness of anal endosonography and fistulography in the preoperative classification of fistulas-in-ano. MATERIALS AND METHODS: A total of 113 patients with a clinical diagnosis of cryptoglandular fistula-in-ano who were awaiting surgery were included in this retrospective review. Patients were preoperatively investigated by anal endosonography and/or modified fistulography by inserting a Foley catheter into the rectum and a metal ring close to the anus. The catheter and ring served as radiopaque anal markers. Fistula classification obtained by the two diagnostic modalities was compared with surgical classification as the criterion standard. RESULTS: Endoanal ultrasound and fistulography identified 82.8% and 100% of primary tracks, 79% and 74.2% of internal openings, 98% and 91.8% of secondary tracks and 92.9% and 87.8% of abscesses, respectively. CONCLUSIONS: Anal endosonography and fistulography with radiopaque markers are important complements to surgical exploration for investigating anal sepsis and may be of value to the surgeon in planning a therapeutic strategy.

Are Hodgkin and non-Hodgkin patients at a greater risk of atherosclerosis? A follow-up of 3 years.

Aims and background are to ascertain whether Hodgkin and non-Hodgkin patients are more affected by atherosclerotic process. We studied 96 patients during a period of 3 years (2003-2007). Patients were assessed in the first year soon after receiving radiotherapy and chemotherapy and then reassessed in the third year. All the cases underwent echo-colour Doppler of the carotid axis, and the intima-media thickness (IMT) was measured. When the two time points were compared, the IMT was greater in the arterial district examined at the first assessment; while at the second there was a reduction in the IMT, so patients seemed to improve with time. Flow-mediated dilatation did not improve. Hodgkin and non-Hodgkin patients experience an increase in IMT during treatment, but afterwards they return in their precedent condition. They seem to have a persistently reduced flow-mediated dilatation. Lymphoma therapy probably predisposes patients to early atherosclerosis, and it would be worth trying to reverse this tendency by administering antioxidant therapy.

Colonic total and segmental transit times in healthy Italian adults.

PURPOSE: This study was done to determine colonic transit times in healthy Italian adults. MATERIALS AND METHODS: Institutional review board approval and informed patient consent were obtained. Colonic segmental radiopaque markers were counted and transit times calculated in 36 healthy subjects studied using a technique involving daily radiopaque marker ingestion and single radiological visit, with oral administration of 8-10 ml of a thick barium paste as a colonic trace for the marker count. Two independent radiologists counted the marker twice. Observer agreement was assessed using comparison analysis. RESULTS: There was very good observer agreement for the segmental marker counts. The upper limit for colonic transit times was: 45.6 h in the colon as a whole, 31.2 h in the right colon, 19.2 h in the left colon and 16.8 h in the rectosigmoid. Colonic transit times were not gender-related. CONCLUSIONS: In healthy subjects, a barium trace affords optimal visibility of the different colonic segments, enabling accurate location of all markers and thus providing an anatomy-related, repeatable and reproducible fluoroscopic segmental marker count. We suggest that the reference values for normal colonic transit times could be adopted for Italian people irrespective of gender.

Prediction of rectal lymph node metastasis by pelvic computed tomography measurement.

AIM: Rectal cancer staging represents a crucial step to select the best treatment for this tumour. Particularly after neo-adjuvant chemoradiotherapy (CRT), it may influence the surgical procedure (e.g. radical resection vs. local excision). The aim of this study was to determine the best lymph node size cut-off at computed tomography (CT) to predict nodal metastasis in rectal cancer patients with and without preoperative CRT. METHODS: A consecutive series of patients operated on for primary mid-low rectal adenocarcinoma, all staged with pelvic CT scan, were subdivided as follows: those who underwent surgery alone treatment without CRT (Group A) and those who underwent preoperative CRT (Group B). All CT scans were re-viewed by a single radiologist and, based on the lymph node size, findings were compared with pathologic lymph node status (pN). At each lymph node size cut-off value, the following were calculated: accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). The best cut-off value was defined as having an accuracy >or=70% with the highest NPV. RESULTS: The study population consisted of 162 patients: Group A (n=52) and Group B (n=110). Patients classified as pN-positive (n=45) had a higher number of and larger sized lymph nodes by CT scan than patients classified as pN-negative (n=117). The cut-off values with an accuracy >or=70% ranged between 7 and 11 mm in Group A and between 9 and 14 mm in Group B. The cut-off with the best NPV was 7 mm for Group A and 10mm for Group B. CONCLUSIONS: Acknowledging the limitations of the dimensional criterion, lymph node size cut-off values found in our study may be useful for planning rectal cancer treatment using CT scan.

Interaction between rifaximin and dietary fibre in patients with diverticular disease.

BACKGROUND: Cyclic administration of rifaximin in association with dietary fibre achieves symptomatic relief in uncomplicated diverticular disease (DD) by means of a still undefined mechanism. AIM: To investigate the effects of a combination of rifaximin and fibre on both hydrogen production by intestinal microflora and oro-anal transit time. METHODS: In a controlled, double-blind crossover trial, 64 patients with uncomplicated DD were given bran (20 g/day) and randomly treated with rifaximin (1200 mg/day) or a placebo for 14 days. Evaluation was based on clinical status, breath test, oro-anal transit time and faecal weight. RESULTS: The global symptomatic score was significantly reduced after rifaximin (7.1 +/- 4.1 to 4.1 +/- 3.3; P < 0.005) but not after placebo (6.8 +/- 3.8 to 6.1 +/- 3.5). Hydrogen production significantly increased after placebo from 198 +/- 134 to 267 +/- 161 ppm/min, while Rifaximin reduced it from 222 +/- 187 to 166 +/- 131 ppm/min (P = 0.05). The total oro-anal transit time decreased from 56.1 +/- 28.2 to 51.3 +/- 28.0 h in placebo and from 54.4 +/- 31.9 to 45.1 +/- 32.4 h (P < 0.05) in rifaximin-treated patients. CONCLUSIONS: The administration of rifamixin improves the benefits of dietary fibre in uncomplicated DD by preventing its bacterial degradation.

Treatment of heart failure and ascites with ultrafiltration in patients with intractable alcoholic cardiomyopathy.

BACKGROUND: In Western countries the excess of alcohol intake causes, secondary, non ischaemic cardiomyopathy and cirrhosis. Frequently, therapy is not effective so ultrafiltration was tried on patients affected, with positive effects on life quality. We tried to verify utility and tolerance to peritoneal ultrafiltration in a group of subjects affected by heart failure secondary to alcoholic cardiomyopathy, refractory to conventional therapy. METHODS: Sixteen patients (14 males, 2 females) with heart failure and ascites affected by alcoholic cardiomyopathy were studied. All subjects were in IV class NYHA (New York Heart Association); ejection fraction (EF) was evaluated by echocardiogram and ascites by abdominal ultrasound. Patients were submitted to clinical exam, body weight, abdominal circumference, diuresis and routine biohumoral exams, electrocardiogram and chest X-ray. Subsequently they underwent intermittent nocturnal peritoneal dialysis with a changing cycle of 6-12 hours per session. After 5 days, subjects were checked through echocardiogram and abdominal ultrasound. RESULTS: The patients mean age was 56.7 +/- 3.2 years. After ultrafiltration, all subjects showed decreased body weight, abdominal circumference and urea; there was an increase of diuresis and Natriuria. Fifteen subjects entered III NYHA class without variation of EF; all of them showed clinical and echographic reduction of ascites. Mean ultrafiltration quantity was 6.084 ml with mean dialysis hours 20; 7.36% of patients had fever that disappeared within 24 hours with antibiotic therapy. All subjects referred to feel well and the mean hospitalization period was of 7 day in spite of the usual 22 days.

Chronobiology of non fatal pulmonary thromboembolism.

BACKGROUND: It as been demonstrated that acute myocardial infarction, sudden cardiac death, stroke, and fatal pulmonary embolism show an increased onset rate during certain periods of the day, week, or year. According to some authors, the highest risk appears to occur in the morning, on weekends and during winter. This paper, therefore, intends to examine whether a circadian, weekly, or annual rhythm in the incidence rate of deep vein thrombosis (DVT) and non-fatal pulmonary embolism (PE) in ageing patients does exists. METHODS: A survey was conducted into 212 patients affected by DVT and PE, admitted to the Second Medicine Institute of Padua, Italy, over a period of two solar years. Thromboses were diagnosed via echo-Doppler examination of the legs and pulmonary embolism via perfusive and ventilatory scintiphotographs. RESULTS: In the overall sample, a circadian variation was found, both for deep vein thrombosis (peak at 12:26 hrs, p=0.001), and pulmonary embolism (peak at 10:26 hrs, p=0.001). A weekly, rhythmic recurrence was also found for the two complaints, with a peak on Saturdays, while no significant annual rhythmic recurrence was found. There was, however, a tendency towards an increase during the winter and summer months. CONCLUSIONS: The results may have important clinical applications, both in prevention and in the timing of drug dosage.

Defecographic measurements of rectal intussusception and prolapse in patients and in asymptomatic subjects.

OBJECTIVE: The aim of this study was to provide measurements for the defecographic diagnosis of rectal intussusception and rectal prolapse. MATERIALS AND METHODS: Four hundred thirty-seven consecutive patients with defecation and micturition disorders and gynecologic complaints were studied by means of defecography (120 patients), colpodefecography (17 patients), or cystocolpodefecography (300 patients). As a control group, 43 asymptomatic subjects underwent defecographic examination. RESULTS: Thirty-five patients were found to have rectal intussusception and 18, to have rectal prolapse. Anterior and posterior rectal wall folding thickness, intussuscipiens diameter, intussusceptum lumen diameter, and the ratio between the intussuscipiens diameter and the intussusceptum lumen diameter were measured in all patients. The findings were compared with those obtained in 13 of 43 asymptomatic subjects with rectal outline changes mimicking intussusception. Rectal folding thickness and the ratio between the intussuscipiens diameter and the intussusceptum lumen diameter were significantly greater in subjects with rectal intussusception and rectal prolapse than in asymptomatic subjects with rectal mucosa folding. CONCLUSION: Our findings suggest that dynamic evacuation radiology contributes to making a differential diagnosis between rectal intussusception and mucosal folds in the rectum.

Moderate-dose intravenous immunoglobulin treatment of Job's syndrome. Case report.

Job's syndrome (or hyperimmunoglobulinemia E syndrome) is a rare genetic disease characterized by skin eczema, pyogenic "cold" abscesses, sinopulmonary recidivous infections and high IgE plasma concentrations. Job's syndrome treatment is not satisfactory and cases studied are still limited. To describe the effects of IVIG therapy in a 37-year-old woman with hyper IgE syndrome and pneumonia. We measured IgE serum by immuno-fluorometric test and neutrophil chemotaxis by migration in a Boyden chamber before and after IVIG therapy. A moderate dose of IVIG resolved the clinical-radiological signs of the S. aureus bronchopneumonia and improved cytologic and biohumoral parameters. Intravenous immunoglobulins represent a useful treatment for acute pneumonia in Job's syndrome.

The effect of heparin on trinitrobenzene sulphonic acid-induced colitis in the rat.

BACKGROUND: Reduced blood coagulability seems to protect against inflammatory bowel disease; pilot studies using heparin in patients with inflammatory bowel disease have reported positive results. AIM: To evaluate the effects of heparin treatment on microangiographic and on inflammatory parameters in experimental colitis, induced by trinitrobenzene sulphonic acid (TNBS)-ethanol. METHODS: Four groups of rats: (i) controls (saline enema), TNBS-induced colitis with (ii) sham treatment (saline, s.c.), (iii) dexamethasone (0.25 mg/kg/day s.c.) and (iv) heparin (500 U/kg t.d.s., s.c.). Microangiography was performed 2 and 4 days after colitis induction. Partial thromboplastin time, colonic wet weight, macroscopic damage score and mucosal myeloperoxidase (MPO) activity were determined at day 4. RESULTS: TNBS-induced colitis caused a reduction in visible bowel wall vessels, which was prevented by heparin (P < 0.05) but not by steroids. The macroscopic damage scores and colon wet weights were similar in all colitis groups. Compared to untreated colitis the MPO activity in heparin-treated animals was of borderline significance. CONCLUSIONS: Heparin treatment improved microangiographic features and reduced inflammation to a certain degree. Steroids delayed development of colon hypoperfusion, but were ineffective on MPO activity. It remains to be determined if the observed effects are due to the antithrombotic activity of heparin or to an anti-inflammatory action.

[The 3rd national workshop on defecography: the functional radiology of (neo) rectal ampullae (ileal reservoir, colo-anal anastomosis, continent perineal colostomy)]. / III workshop nazionale sulla defecografia: la fisioradiologia delle (neo)ampolle rettali (reservoir ileale, colo-ano-anastomosi, colostomia perineale continente).

A survey was made in 13 Italian centers with a questionnaire concerning the (a) indications, (b) postoperative complications, (c) functional results and (d) diagnostic imaging modalities related to the making of an ileal or colonic (neo) rectum. Ulcerative colitis (100%), familial polyposis (61.5%) and Crohn's disease (15.3%) were the most common indications for an ileal pouch; rectal cancer (7.96%), chronic inflammatory diseases (15.3%), diverticulosis, rectal prolapse, redundant colon and imperforate anus (7.6% each) were the most common indications for a colonic pouch. Postoperative complications included pelvic abscess (14%), sinus tract/dehiscence (10%) and bowel obstruction (9%). When compared with the S and W variants, the J-shaped ileoanal pouch proved superior because urgency and fecal retention rates were lower (18.4% vs. 44.4% and 23% vs. 28.6%, p < 0.01 and p < 0.05, respectively), despite slightly more frequent staining episodes (15.8% vs. 11.1%; p < 0.05). As for colonic ampullae, fecal retention and provoked evacuation were more frequent in the J pouch and after gracileplasty; urgency and incontinence in the straight colo-anal anastomosis (33.3% vs. 22.2% and 41.6% vs. 33.3%, respectively). The functional outcome was assessed by anal endosonography (available in 4/13 centers), defecography and anorectal manometry. Abnormal findings included: (a) reduced capacity, barium leakage, anal gaping, sphincter damage (urgency and incontinence); (b) barium retention, pouch dilatation, split evacuation, knobs and strictures (fecal retention).

[Defecography study of outpouchings of the external wall of the rectum: posterior rectocele and ischio-rectal hernia]. / Studio defecografico delle estroflessioni della parete posteriore del retto: rettocele posteriore ed ernia ischio-rettale.

PURPOSE: To report the clinical and defecographic features of posterior rectal wall outpouchings, i.e., posterior rectocele and ischiorectal hernia. MATERIALS AND METHODS: Sixty-six patients with posterior rectal wall outpouching (61 with posterior rectocele and 5 with ischiorectal hernia) were selected among the patients examined in the last two years for defecation disturbance. All patients underwent physical examination, rectoscopy and videodefecography. RESULTS: Posterior rectal wall outpouchings were detected at physical examination in 28 patients and at rectoscopy in 9 patients. Posterior rectocele, more frequent and bigger in men, was usually demonstrated at videodefecography as an outpouching of the lower portion of posterior rectal wall: this finding was visible only in the dynamic phases in 51 patients while it was seen also at rest in 10 patients. In 52 patients, posterior rectocele was associated with other abnormalities--i.e., anterior rectocele (64%), puborectal muscle syndrome (38%), descending perineum (33%), mucosal prolapse (33%) and intussusception (20%). An ischiorectal hernia, defined as a posterolateral ampullar outpouching deeper than 4 cm and already visible at rest, was identified in 5 patients. Descending perineum and anterior rectocele were the most common associated disorders. CONCLUSIONS: We report the clinical and defecographic features of these rectal abnormalities and stress the importance of videodefecography in the real-time study of these morphofunctional disorders.

Microradiographic anatomy of the explanted rat colon.

The colon of 32 healthy Sprague-Dawley rats was studied microradiographically. The colonic arterial distribution of 18 rats was examined after injecting barium sulfate into the isolated aorta. The mucosal surface in 9 rats was studied using double-contrast technique after colon explantation. In 5 animals arterial and mucosal studies were carried out simultaneously. The radiographic thickness of the colonic wall was measured using a comparative microscope. The specimens were observed, photographed and examined histologically. Unlike the cecum and distal colon which, when insufflated, do not have mucosal folds, the proximal colon exhibits folds in an oblique direction corresponding to that of the arteries, and the colonic wall in this region is thicker. Comparison between arterial and mucosal microradiographic anatomy and wall thickness enables the proposition of a simple nontopographic division of the rat colon into cecum, proximal colon and distal colon.

[The National Workshop on Defecography: anorectal deformities with a functional origin (prolapse, intussusception, rectocele)]. / II Workshop Nazionale sulla defecografia: le deformità ano-rettali con origine funzionale (prolasso, intussuscezione, rettocele).

The nonoperative treatment--i.e., rubber band ligation and sclerotherapy--of mucous rectal prolapse, rectocele and intussusception is much less expensive than conventional surgery (Lit. 325,000 vs. 6,500,000, p < 0.0001 on the average). Symptom relief, however, has been reported in 0 to 57% of cases only, according to current literature. A possible cause is represented by improper management from misdiagnosis, relying on clinical findings only, overestimating mucous prolapse in 36.37% of cases and underestimating intussusception in 14.22% of cases (with respect to defecography). Defecography is a cost-effective method (average cost: Lit. 37,000) potentially reducing failure rate after the surgical repair of rectal prolapse.

[The kidney xenograft. An echographic assessment of the tissue parameters of the normal pig kidney]. / Trapianto xenogenico renale. Valutazione ecografica di alcuni parametri tissutali del rene normale del maiale.

The prospect of xenogeneic transplantation emphasizes the usefulness of codifying the US patterns of normal pig kidney. Nineteen pigs underwent 35 US studies. Pig kidney is similar to the human one in size and US patterns. However, the average human and pig medullary pyramid indexes (MPI) differ, since the latter is half the former (2.10 vs 4.17). This is a valuable finding, since MPI is a tissular index used in the US evaluation of acute renal allograft rejection. Our results demonstrate that US is a reliable method for the morphological assessment of pig kidney and, therefore in our opinion, it should be used as a major diagnostic tool in the study of xenogeneic renal transplantation.