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Aim: The aim of the study is to explore the nature and causes of aggressions and to identify possible solutions to support HCWs., Method: An open and closed questions questionnaire was distributed to the 5337 HCWs (nurses, doctors, nurses aids, technicians) of a large Italian hospital., Results: Only 467 useful questionnaires were returned (8.6%); 37.2% of respondents experienced one or more aggressions, mostly verbal (59.2%) and physical and verbal (16.7%). Nurses and doctors were more exposed to aggressions and the main aggressors were patients and their relatives. Younger people are at higher risk. Half of the victims report consequences on private and working life., Conclusions: As recommended by the Health Ministry, preventive measures should be adopted and the HCWs' ability to deal with conflicts should be reinforced.

Purpose: The authors present a retrospective analysis of a large series of patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) placement., Materials and Methods: Between March 1992 and December 2006, 658 patients were referred to our centre for TIPS placement. Indications for the procedure were digestive tract bleeding (52.8%), refractory ascites (35.3%), preservation of portal vein patency prior to liver transplantation (3.0%) and thrombosis of the suprahepatic veins (2.3%). Other indications (6.6%) included pleural ascites, portal thrombosis and hepatorenal and hepatopulmonary syndromes. All patients were evaluated with colour Doppler ultrasonography and in a few cases with computed tomography. The portal system was punctured under sonographic guidance. Wallstent, Palmaz and Nitinol thermosensitive stents were used. Embolisation of persistent varices was performed in 6.8% of cases., Results: Technical success was 98.9%. During a 1,500-day follow-up, the cumulative incidence of stent revision was 25.7% (Nitinol), 32.9% (Wallstent) and 1.8% (Palmaz). Mortality rates were 31.1%, 38.5% and 56.4%, respectively. The technical complications included six cases of heart failure, six of haematobilia, three of stent migration, two of intrahepatic haematoma and one of haemoperitoneum. Eight patients with severe portosystemic encephalopathy (PSE) were treated with a reduction stent., Conclusions: TIPS placement is safe and effective and may act as a bridge to liver transplantation. Ultrasonography plays a fundamental role in the preliminary assessment, in portal vein puncture and during the follow-up. Stent patency is satisfactory.

The authors report on a case of voluminous perforated gastrointestinal stromal tumor (GIST) of small intestine and make a review to the light of most recent clinicopathologic advancements. The first clinical manifestation as acute abdomen due to their perforation extremely rare. Gastrointestinal stromal tumor (GIST) represent a rare group of multiform tumors with various biological behaviour. Were identified in the past as leiomyomas, leiomyosarcomas or leiomyoblastomas, has been reclassified on immunochemical features, with a positive expression of Kit (CD117 antigen). Traditionally the prognostic factors of these tumour are: mitotic rate, tumor size and anatomic site. The complete surgical resection and use of imatinib mesylate (Gleevec) are the best available approach.

Purpose: The aim of our study was to illustrate the benefits of percutaneous treatment by embolisation of high-flow pulmonary arteriovenous malformations (PAVM) in patients suffering from hereditary haemorrhagic telangiectasia (HHT; Rendu-Osler-Weber disease)., Materials and Methods: From December 2001 to February 2007, we embolised 60 PAVMS in 35 procedures performed on 30 patients, all referred by the HHT centre in Crema, and enrolled in a screening programme of HHT families. All patients underwent clinical evaluation, contrast-enhanced ultrasound (CEUS) and spiral computed tomography (CT). Embolisation was made with nonmagnetic metallic coils via femoral venous access; an endovascular Amplatzer device was used in one patient only., Results: All embolisations were performed without difficulty. One patient only developed partial temporary aphasia, which resolved in 72 H. At spiral-CT follow-up, we generally demonstrated exclusion from circulation of treated PAVMS and regression of clinical symptoms. In the case of new lesions or recanalisation, further embolisation was possible:, Conclusions: Percutaneous embolisation has recently become the initial treatment option in PAVM owing to its good results and minimal invasiveness compared with thoracotomy. Our experience is in agreement with the literature: the procedure has a low complication rate, provides very good technical and clinical results and avoids resection of healthy pulmonary parenchyma.

The Authors describe a case of multiple lipomatosis of the mesocolon and, after a careful review of the literature, they examine particular findings and discuss diagnostic difficulties, anatomopathological features and treatment. Intraabdominal lipoma is very rare and presents difficulties in diagnosis, both for aspecific symptoms and for the unusual site which does not allow early identification. As it is a tumor which arises from primitive and totipotent mesenchymal cells, radical surgery is the only therapeutic option. The correct diagnosis depends on histological testing which can differentiate the lesion from other mesenchymal tumors.

Cystic tumours of the pancreas include a pathologically heterogeneous and rare group of tumours, which however have many common clinical features. They represent about 10% of pancreatic cystic lesions and 1% of all forms of neoplasms, thus having a certain relevance in organ surgery. So far two distinct categories of cystic tumours have been identified, the basically benign serous form and the potentially malign mucinous form, which may sometimes show malignant features as early as the diagnostic stage. As neoplasms are very difficult to interpret before operation, it is essential that diagnosis is as accurate as possible in order to streamline surgery, which will have to be carried out after histological tests have been performed on an adequate number of tumour sections. Basing on these two cases of cystic tumours of the pancreas and on current literature, the Authors discuss the effectiveness of imaging techniques, such as contrast echography, dosage of specific tumour markers and histological tests backed up by immunohistochemistry in identifying these neoplasms, in order to study this rare but interesting pathology more accurately.

Purpose: To assess the diagnostic accuracy and predictive value of Lipiodol CT for hepatocellular carcinoma (HCC) before liver transplantation (OLT)., Material and Methods: Seventy-eight cirrhotic patients awaiting OLT underwent Lipiodol CT to demonstrate the presence and extent of possible HCC. Radiologically, focal uptake areas with dense, homogeneous or "mosaic" iodized oil uptake were considered to be neoplastic nodules. All patients underwent OLT within 4 months of Lipiodol CT. Pathologic examination of the explanted livers was performed using the standard technique and, if necessary, with additional slices. Pathologic findings were compared with radiologic results to calculate the diagnostic accuracy and predictive value of Lipiodol CT in relation to both patients and lesions., Results: Lipiodol CT depicted 61 focal areas of iodized oil uptake in 48 patients; pathologic examinations detected 57 HCC lesions in 42 patients (diameter .8 cm, mean 2.2 cm); agreement with radiologic diagnosis was found in 35 patients only. Patient by patient, Lipiodol CT had 83.3% sensitivity, 63.8% specificity, 74.3% diagnostic accuracy, 72.9% positive predictive value (PPV), and 76.6% negative predictive value. Lesion by lesion, Lipiodol CT showed overall sensitivity and PPV of 75.4-70.5%, 74-69.8% for "small" HCCs (diameter < or = 3 cm), and 72.9-71.1% for nodules < or = 2 cm in size. Eighteen uptake areas in 13 patients were diagnosed as HCC by Lipiodol CT but the finding was not confirmed at histology: 4 were hemangiomas and 14 corresponded to cirrhotic tissue without neoplastic foci., Conclusions: Our study, as the few others comparing radiologic results and pathologic findings of whole explanted liver, demonstrates that Lipiodol CT has relatively low diagnostic accuracy; particularly, specificity and PPV were limited by possible false positives, with HCC overstaging and mistakes in the indications/contraindications for OLT.

Background: The purpose of this work is to show the effectiveness of percutaneous embolization therapy in the treatment of visceral arterial pseudoaneurysms and to propose the method as a valid alternative to surgery., Methods: Twenty-eight patients with visceral artery pseudoaneurysms were treated: 10 of them were hepatic; 9 renal; 7 duodenal-pancreatic; 1 splenic and 1 of the celiac trunk. Materials employed were: Gianturco metallic coils, Spongostan and Poli-Vinyl-Alcohol., Results: Immediate success was obtained in all cases; recurrences occurred in 5 patients (18%) and they have all been successfully retreated with percutaneous method; complications occurred in 3 patients (10%) and they were all directly related to the pre-existing pathology and not to the percutaneous treatment., Conclusions: To obtain the best results from embolization, it is necessary to respect some conditions regarding the correct choice of embolic materials, the superselective catheterization of the injured artery and the low injection pressure of the contrast medium in order to avoid rupturing the thin pseudoaneurysmatic wall. The advantages of the percutaneous treatment are: less trauma, local anesthesia, reduction of the time between diagnosis and therapy, reduction of hospitalization stay and limitation of parenchymal destruction, Complications are relatively not frequent and in no cases the percutaneous therapy compromised the surgical intervention when it became necessary.

Introduction: We report our personal technique and the preliminary results of percutaneous implantation of intraarterial catheters connected to a subcutaneous infusion reservoir (Port-a-cath) for the regional chemotherapy of hepatic and extrahepatic tumors. January, 1996, to February, 1997 fifty patients underwent the procedure: 44 had liver cancers (42 had metastases and 2 hepatocellular carcinomas), 4 pelvic tumors (2 bladder carcinomas, one uterine cancer and one vaginal cancer), one had inoperable pancreatic tumor and one breast cancer., Materials and Methods: The access was the left axillary artery in 45 cases, the femoral artery in 4 and both the femoral and the axillary artery in one case. The infusion catheter was placed in the hepatic artery in 44 cases, in the splenic artery in one case of pancreatic cancer, in the hypogastric artery in 4 cases and in the internal mammary artery in one case. When the catheter was positioned in the hepatic artery, embolization of the gastroduodenal or accessory hepatic arteries was performed using metallic coils; when the catheter was positioned in the hypogastric artery, the contralateral hypogastric artery and the ipsilateral gluteal branches were embolized. The catheter was then tunnelled and connected to a subcutaneous reservoir, sutured to the pectoral fascia or to the inguinal ligament. After the injection of heparinated solution, infusion chemotherapy was started the day after the procedure., Results: We obtained immediate technical success in all cases. Four major complications occurred: a pseudoaneurysm of the left axillary artery (percutaneously treated by placement of a covered stent), 2 thromboses of the hepatic artery and one case of gastritis. Among minor complications, the catheter was displaced in 9 cases and 7 catheters were percutaneously replaced. Side-effects, not related to the procedure, were pain, nausea, vomiting and mucositis. During the follow-up, 7 patients died (6 for tumor progression); median catheter patency was 5.14 months. Though the aim of this work is to present the technical aspects of the procedure, we report the preliminary clinical data: radiological examinations showed partial tumor regression in 15 of 33 patients with 3-month follow-up; no change was shown in 2 patients and disease progression was found in 4; the response could not be assessed in the other cases., Conclusions: In conclusion, the percutaneous placement of intraarterial catheters for continuous regional chemotherapy is a feasible, safe and tolerable procedure and can represent an alternative to the surgical implantation of catheters in the hepatic artery for the treatment of liver metastases from colorectal cancer. The technique opens new therapeutic possibilities for the local treatment of extrahepatic tumors (such as gynecologic, vesical, pancreatic and breast cancers), even though its clinical efficacy must be assessed in selected trials.

In recent years, technical progress has created new complex acoustic implants which send an electrical stimulus to the eighth cranial nerve through one or more electrodes inserted through the round window into the scala tympani of the cochlea. The abnormal--mostly osteosclerotic--processes which cause deep hearing loss may prevent electrode insertion. Therefore, internal ear anatomy must be detailed, which is essential to assess the feasibility of surgery and, if surgery is indicated, to plan it properly. High resolution CT (HRCT) was performed on 79 patients to study cochlear patency, round window shape and patency, degree of temporal bone pneumatization and the proximity of vascular structures (carotid artery and jugular vein). On the basis of HRCT results, 14 of 79 patients were excluded from surgery. Comparing HRCT with surgical findings, the authors conclude that HRCT is the method of choice to examine the candidates to cochlear implant thanks to its high spatial resolution and excellent depiction of even the smallest structures. Its only limitation is that it fails to assess the lack of patency of the cochlear canal due to fibrosis, which is not associated with demonstrable density changes (3 of 19 surgical patients). This problem may be solved by submitting the potential surgical candidates to MRI.

Mutations of the iduronate-2-sulfatase gene have been identified as responsible of Hunter syndrome or mucopolysaccharidosis type II. About 20% of the patients have deletions of the whole gene or other major structural alterations. The mutations found so far include: 34 missense, 8 nonsense, 11 small deletions from 1 to 3 bp, 2 deletions of 8 pb, 2 insertions of 1 bp and 2 insertions of 14 bp, with most leading to a frameshift and premature chain termination. Also 8 different splice-site mutations leading to insertions or deletions in the mRNA have been tabulated. Knowledge of the primary genetic defect allows insight into genotype-phenotype correlation and allows a better understanding of the structure and function of iduronate-2-sulfatase.

Purpose: To investigate the feasibility and the results of percutaneous hot saline injection therapy (PSIT) of liver tumors., Material and Methods: Eight patients with hepatocellular carcinoma (11 nodules), 1 with cholangiocarcinoma and 1 with a metastasis from colon cancer underwent PSIT. The patients were selected according to variable criteria; thus, each patient was considered apart. A boiling saline solution was injected into the hepatic lesions through a needle like those commonly used for percutaneous ethanol injection (PEI). The results were assessed with US, CT, angiography, the measurement of tumor marker levels, the histopathologic examination of needle biopsy material, resected specimens, explanted liver material and follow-up., Results: PSIT was more easily performed and altogether better accepted than PEI; in particular, pain immediately regressed upon infusion interruption. For this reason and for the atoxicity of the injected liquid, relatively large lesions could be treated with a greater volume per session and fewer sessions than with PEI. Treatment outcome was positive in all patients, except for the cholangiocarcinoma patient who required surgery. The only major complication was moderate peritoneal bleeding in a patient with severe coagulopathy., Conclusion: PSIT can be considered a useful tool for the local treatment of hepatic tumors. Its systematic use to treat hepatocellular carcinoma must be proceeded by further comparative studies with PEI.

The transjugular intrahepatic portosystemic shunt (TIPS) is a new interventional radiology procedure which may be assisted by modern ultrasound techniques (US). Color-Doppler US can be used for patients selection, during TIPS and in the follow-up. In a 20-month period, 71 patients were examined: 3 of them were excluded because of the absolute contraindications shown by US; in 14 of the remaining 68 patients, US demonstrated relative contraindications, such as hepatocellular carcinoma, partial portal vein thrombosis and right internal jugular vein occlusion. During the maneuver, US helped to select the most adequate veins for shunt creation and was especially useful in guiding portal vein puncture, thus allowing technical success to be achieved in 65/68 patients. The mean number of passes per patient was 2.7 and no procedure-related complications were observed. US was also used to investigate TIPS patency the day after the maneuver and to monitor shunt function during the follow-up. Color-Doppler US correctly diagnosed both 3/65 early occlusions and 9/65 late stenoses; in particular, in 18/65 patients US showed gradual flow reduction through TIPS, but clinical and endoscopic findings of malfunction appeared only in 9/65 patients whose mean reduction rates exceeded 50% at Doppler US.

We want to present our experience performed at the Institute of Radiology of Turin: 98 TIPS in 97 patients (in 1 patient, twice). METHODS. From March 1992, 97 cirrhotic patients (18 Child A, 48 Child B, 31 Child C) underwent the TIPS procedure for portal hypertension. The indications were digestive hemorrhage in 81 patients (20 of which performed in emergency for acute bleeding), intractable ascites in 13 patients and bleeding prevention in 3 patients. RESULTS. Immediate technical success was obtained in 95/98 cases (96.9%). Patients were monitored by US-Doppler at 24 hours, 2 months and every 6 months and by esophagogastroscopy at 2 and 6 months. Major clinical complications included CID (2 cases), hepatic failure (3 cases), renal insufficiency (2 cases), heart failure (1 case), recurrent bleeding (6 cases) and encephalopathy (15 cases). We had 5 early occlusion and 17 late stenosis of the shunt; 21 patients in this group were successfully treated either by PTA or restenting; one patient underwent a surgical shunt. Mortality rate follow-up was 0/17 among Child A patients, 7/48 (14.5%) among Child B patients and 12/29 (41.3%) among Child C patients. CONCLUSIONS. TIPS is a safe and valuable method for the treatment of portal hypertension. Though shunt stenosis may occur with a certain frequency (22/95, 23.1% in our study), a second intervention is usually effective in reducing gastro-oesophageal varices and ascites.

The data relative to 13 years' experience with percutaneous transluminal renal angioplasty (PTRA) in the 13 major interventional radiology centers in Italy were collected and analyzed to evaluate technical and clinical results. Our aim was to collect homogeneous results in a large series of patients, evaluating both the technical and the clinical success with a long-term follow-up (1 month-13 years). One thousand three hundred forty seven PTRA procedures (including 42 restenoses) in 1,073 patients were retrospectively reviewed. In 807 cases the cause of stenosis was atherosclerosis, in 442 cases fibromuscular dysplasia and in 24 cases arteritis in 12 cases, stenoses were present in patients that had undergone a surgical by-pass. Sixty-two stenoses in patients with solitary kidney and 102 in patients with renal failure were studied separately. The technical success (based on the morphology of the dilated tract) obtained in 91% of cases was considered, together with the clinical success (in 81% of cases), based on the decrease in blood pressure evaluated according to Martin's classification. The blood pressure values collected after the maneuver were also evaluated separately for the different types of stenosis etiology: atherosclerosis, fibromuscular dysplasia or arteritis; moreover, blood pressure was studied in solitary kidney patients and in those with renal failure. Complications were classified as major (4.2%) and minor (4.9%). The high success rate and the low incidence of complications we observed in our series suggest PTRA as the procedure of choice for high blood pressure patients with renal artery stenosis > 50% of the normal caliber.

A new interventional procedure employing metallic stents has been recently suggested to perform percutaneous portosystemic shunts in the treatment of variceal bleeding in portal hypertension; the technique is called TIPSS (transjugular intrahepatic portosystemic stent shunt). This percutaneous treatment presents several advantages over surgery: the shunt diameter can be calibrated according to the degree of portal hypertension; moreover, TIPSS can be performed in patients waiting for liver transplantation because it does not alter the vascular anatomy of liver. The original technique employed transhepatic portography. In this paper the authors report on their personal experience and present their series of 4 patients with portal hypertension and variceal bleeding, in whom TIPSS was performed utilizing noninvasive US guidance. Variceal bleeding was successfully treated in all patients and variceal distension was also obtained.

The correct selection of patients for liver transplantation, which is essential for surgical success, requires thorough radiological evaluation. The authors present their experience on 94 pretransplant adult patients that underwent a total of 251 diagnostic exams (Doppler US, CT, angiography and cholangiography) and interventional radiology maneuvers (biopsy, chemoembolization, biliary drainage). Three sclerosing cholangitis, 3 Budd-Chiari syndromes and 20 hepatocellular carcinomas in cirrhotic patients were identified; venous collaterals were present in 62.7% of the cases, 12.8%, of which had important spontaneous porto-systemic shunts; 6 patients had portal thrombosis; 20 arterial variations were found. Interventional maneuvers were useful and free of complications. US, CT and angiographic findings of each patient were compared. Integrating informations from different exams allowed a significant increase in the accuracy of diagnostic conclusions. Thanks to interventional maneuvers 5 patients could be selected for transplantation (hepatic arterial lipiodolization stopped the growth of 4 hepatic neoplasms; 2 infected fluid collections were sterilized by percutaneous US-guided drainage and topic therapy.

Unlabelled: The authors present their personal experience in percutaneous treatment of portosystemic shunt occlusion and stenosis by percutaneous transluminal angioplasty (PTA) and fibrinolytic local infusion. Twelve patients with portosystemic shunt stenosis or occlusion were percutaneously treated. In 8 patients only PTA was performed, 4 were treated with local fibrinolytic infusion, in 3 of the latter cases this treatment was followed by PTA. In all 12 patients recanalization was successful and non complications arose. Six patients died in the following 15 months, none due to rebleeding. In 5 of these patients the shunt was patent at post-mortem examination. In the 6 patients still alive in the follow-up period (2 to 25 months, mean 14.5 months) the shunt was patent in 4 and occluded in 2., In Conclusion: percutaneous treatment with PTA or fibrinolytic local infusion is preferable in non-functioning portosystemic shunt; further surgery is always extremely risky in such patients.

Some complications of liver transplantation appear as aspecific clinical and blood test abnormalities; others--e.g., hepatic artery thrombosis in the immediate postoperative period and stenosis of the biliary anastomosis before T-tube removal--require early diagnosis. These considerations justify the need of frequent radiologic examination in both the complicated course and the follow-up. The authors report their experience in 59 adult patients submitted to liver transplantation for irreversible liver disease in advanced stage (49 with cirrhosis, 10 with HCC; 5 with cholestatic hepatopathy; 3 with fulminant hepatitis; 1 with Budd-Chiari syndrome; 1 with metastatic APUDoma). Two hundred and sixty-three radiological examinations were performed (Doppler US, CT, angiography and cholangiography) which showed numerous early and delayed complications: 13 of them were treated with interventional radiology maneuvers (US-or CT-guided percutaneous drainage of fluid collections, biliary drainage, bilioplasty, arterial transcatheter embolization). Our results demonstrate that diagnostic and operative radiology are essential for the success of liver transplantation; integrated imaging is particularly important in the diagnosis of complications, while interventional radiology techniques can be usefully employed in their treatment.

The authors present their experience with the percutaneous embolization of 13 splanchnic aneurysms and pseudoaneurysms (2 pseudoaneurysms of gastroduodenal artery, 3 of the hepatic artery, 7 renal pseudoaneurysms, 1 aneurysm of the splenic artery). In 9 of 13 cases the lesions were iatrogenic. Embolizing devices and techniques are described. Percutaneous embolization was successful in 12 of 13 cases, and useless in 1 case of renal pseudoaneurysm. In the 12 successfully treated cases the lesions were still occluded in the follow-up period. Transcatheter percutaneous embolization is the elective treatment in splanchnic aneurysms and pseudoaneurysms; surgery must be performed only when embolization fails.

The Authors report a case of haemobilia following the performance of biliary drainage. Angiography of the celiac tripod and superior mesenteric artery was carried out in order to evidence the lesion and to perform, during the same session, embolization of the leaking vessel by means of fibrin sponge particles (Spongostan). Subsequent cholangiographic controls demonstrated the presence of bile ducts clots then treated by loco-regional infusion of urokinase. On the basis of the Authors' personal experience, the combination of loco-regional biliary fibrinolytic treatment and embolisation leads to the resolution of the cause of hematobilia and of retention jaundice.

The prevalence of the small intestine bacterial overgrowth syndrome has been assessed in 109 in-patients affected by various gastrointestinal disorders using the 1 g [14C]-xylose breath test; 18 healthy subjects acted as a control group: none of them showed abnormal results (100% specificity). None of 14 patients with colonic disease had abnormal results, whereas in 44 patients with ileal diseases the test was positive in 12% to 39% of the cases. Abnormal results were found in 46% of patients who underwent partial gastric resection greater than 20 years before, 29% of patients with irritable bowel syndrome without diarrhoea (faecal wet weight less than or equal to 600 g/72 h), 56% of those with diarrhoea of obscure origin, and 25% of celiac patients. Eight out of 8 patients with altered results showed normalization of the test after antibiotic therapy. Despite its high diagnostic value in the setting of clinical research, the 1 g [14C]-xylose breath test cannot as yet be proposed as a routine investigation.

The authors report their personal experience in percutaneous treatment of portosystemic shunt occlusion and stenosis. Eleven patients with portosystemic shunt stenosis or occlusion were percutaneously treated. Seven patients were treated with PTA alone; in 2 cases, with recurrent variceal bleeding, percutaneous variceal embolization was associated with PTA. Four patients were treated with local fibrinolytic infusion through the catheter inserted into the thrombus; in 3 cases this treatment was followed by PTA. In all 11 patients recanalization was possible, no complications arose. Six patients died in the following 15 months, none due to rebleeding; in 5 patients of this group the shunt was patent at autopsy. In one patient autopsy was not performed but the shunt was functioning at the last duplex US control. Of 5 patients still alive in the follow-up period (2-25 months) the shunt was patent in 3 and occluded in 2.