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To assess the value of combined transvaginal/transabdominal ultrasonographic evaluation performed by experienced examiners for deep infiltrating endometriosis (DIE) lesions of the retrocervical (torus uterinus and uterosacral ligaments) and parametrial areas and summarize the features and anatomic criteria for identification of these lesions and their extent in the above-mentioned pelvic compartments.Retrospective study.A specialized endometriosis center in Avellino, Italy.A retrospective cohort of patients who underwent laparoscopic surgery for clinically suspected DIE between January 1, 2014, and December 31, 2018, with a dedicated ultrasound (US) evaluation performed no more than 1 month before the intervention.Preoperative US findings and surgical reports were reviewed. Using the findings of laparoscopic surgery as the gold standard, the sensitivity and specificity of preoperative US evaluation for retrocervical and parametrial endometriotic lesions were calculated with the corresponding 95% confidence intervals.A total of 4983 patients were included. US evaluation showed high diagnostic accuracy for DIE detection in the examined pelvic compartments, with sensitivity and specificity of 97% to 98% and 98% to 100%, respectively, for both retrocervical (torus uterinus and uterosacral ligaments insertion) and parametrial lesions.Parametrial extension of DIE indicates major surgical technical difficulties and risk of complications, and urologic and nerve-sparing procedures may be required in such cases. Preoperative evaluation of such scenarios will allow proper counseling of patients and facilitate adequate surgical planning in referral centers; moreover, when necessary, it can guide the constitution of a dedicated multidisciplinary surgical team as an alternative to treatment by a pelvic surgeon alone. Detailed imaging evaluation of DIE lesions and their extension is crucial for clinical management of affected patients. It can facilitate optimization of surgical timing and strategies, thereby potentially preventing ineffective, or even harmful, repeated procedures.

To identify bowel nodule features of deep infiltrating endometriosis (DIE) measured through preoperative ultrasound scanning that influence laparoscopic surgical strategy.A retrospective study.Malzoni Clinic-Endoscopica Malzoni Department, Center for Advanced Endoscopic Gynecological Surgery, Avellino, Italy.Patients undergoing laparoscopic surgery between January 1, 2014, and December 31, 2018, for clinically suspected DIE with previous ultrasound evaluation ≤1 month before intervention.Use of sonographic measurements to determine laparoscopic excision technique (segmental bowel resection, discoid resection, shaving) for DIE with bowel involvement.``` MEASUREMENTS AND MAIN RESULTS: Of 5051 DIE surgeries, 4983 were included; 1494 (29.9%) bowel resections (512 bowel segmental resections and 982 nodulectomies [967 shaving and 15 discoid resections]) were performed, accounting for 34.3% and 65.7% of all bowel procedures, respectively. Preoperative sonographic findings and surgical reports were collected. Sensitivity and specificity of preoperative ultrasound evaluation for all types of DIE lesions were calculated, and sonographic measurements of bowel nodules and different surgical techniques were compared. According to preoperative sonographic measurements, most nodules excised by segmental resection had a longitudinal diameter of 3 to 7 cm, none were3 cm; all nodules excised by nodulectomy (shaving or discoid resection) had a longitudinal diameter3 cm. Mean thickness (maximum depth of muscular layer infiltration) of identified bowel nodules estimated through ultrasound scanning was 13.4 mm ± 4.8 mm (mean ± standard deviation) and 5.8 mm ± 2.7 mm for lesions removed by segmental resection and nodulectomy, respectively, and there was a statistically significant difference between them (p.05). Of the 512 segmental resected bowel nodules, 143 (28%) had a maximum depth ≥9 mm, 354 (69%) had 7 to 9 mm, and 15 (3%) had7 mm (6 mm, with length4 cm). All shaved nodules had thickness ≤7 mm. The 15 nodules excised by discoid resection (1.5% of nodulectomies) were25 mm, but thickness ranged from 7 to 9 mm.The need for segmental resection in DIE with bowel-infiltrating nodules depends on the degree of muscular layer infiltration and corresponding thickness (muscularis rule) in addition to nodule length and can be accurately identified by preoperative ultrasound evaluation.

Objective To show the surgical steps used to perform a totally laparoscopic segmental rectal resection, with intracorporeal anastomosis and transanal natural orifice specimen extraction (NOSE), in a context of deep endometriosis. Design Step-by-step video demonstration of the technique. Setting Even though the combined use of intracorporeal anastomosis and NOSE has increasingly been investigated during the last decade, there is still lack of defined consensus, both in terms of patient eligibility and operative technique. In particular, experience with intracorporeal anastomosis and NOSE for treatment of deep rectal endometriosis is very limited. Preliminary reports have documented that a totally laparoscopic rectal resection is equally effective and safe compared with the conventional approach using an abdominal minilaparotomy for extracorporeal anastomosis and specimen retrieval. In comparison to the latter, intracorporeal anastomosis with NOSE seems to offer advantages in terms of less postoperative pain, fewer wound-related complications, better cosmetic results, quicker return of bowel function and shorter hospital stay. Patient A 31-year-old woman with a history of constipation, dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain unresponsive to hormonal therapies. Preoperative ultrasonography showed partial obliteration of the Douglas’ pouch due to a rectal endometriotic nodule of 42 × 12 × 18 mm in contiguity with a deeply infiltrating retrocervical lesion of 13 × 3 × 17 mm. The rectal nodule resulted in the infiltration of the tunica muscularis with a distance of 12 cm from the anal verge and a circumferential extent of 45%. Interventions A 3-dimensional laparoscopic system was used. Rectal mobilization was performed according to our standardized technique [1] . After determining the proximal and distal resection margins, the rectum was transected using a tissue sealing-device. The resected specimen was placed in a retrieval bag and pulled out through the anus. Proximal and distal resection lines were closed using a 60 mm linear endo-stapler, and a totally intracorporeal, side-to-end anastomosis was performed using a 29 mm circular stapler. Main Results The overall operative time was 85 minutes. The estimated blood loss was 10 mL. Neither intra- nor postoperative complications occurred. The patient was discharged 5 days after surgery. The bowel endometriotic nodule measured 41 × 12 × 18 mm on the fresh unfixed specimen. Conclusions Advanced surgical skills are needed to perform an effective and safe, totally laparoscopic rectal resection. The operative technique displayed in this video may contribute to the standardization of such surgical procedure. Accurate patient selection, including adequate preoperative evaluation, is of utmost importance for the best chance of surgical success.

Study Objective To assess the sensitivity and accuracy of combined transvaginal/ transabdominal ultrasonography (TV/TA US) for evaluation of deep infiltrating bowel endometriosis nodules measured after surgery. Design Prospective study (Canadian Task Force classification II.1). Setting A center for advanced endoscopic gynecologic surgery. Patients All women undergoing laparoscopic surgery and scheduled for segmental resection for clinically suspected bowel endometriosis between January 2014 and December 2016. Interventions In all women with clinically suspected bowel endometriosis, a US scan was performed before surgery to detect and measure the 3 diameters of bowel endometriotic lesions: longitudinal, anteroposterior, and transverse. These diameters were compared with those obtained by direct measurement on a fresh specimen. The sensitivity and specificity values of US evaluation were calculated, with 95% confidence intervals. Measurements and Main Results The sensitivity and specificity of TV/TA US in the 328 patients of this study were 100% when rectal endometriotic lesions were investigated. The specificity was 100%, whereas the sensitivity decreased to 91.4% when sigmoid lesions were investigated. Bowel muscularis infiltration was histologically confirmed in all cases in which endometriotic lesions were detected by US (284 of 284; 100%). All missed sigmoid lesions (12 of 296) were located >25 cm from the anal verge. The mean diameters of endometriotic nodules calculated by US evaluation and by direct measurement on the fresh specimen were 43.19 × 19.87 × 10.79 mm and 42.76 × 19.64 × 10.62 mm, respectively, with no statistically significant differences between the 2 methods. Conclusion We believe that US can be considered an accurate diagnostic technique for the evaluation of deep infiltrating bowel endometriosis when performed by a dedicated experienced sonographer in a specialized center.

Generic drugs are increasingly used to treat many diseases including epilepsy. The growing importance of generic antiseizure medications (ASMs) has led the ASMs commission of the Italian League Against Epilepsy (LICE) to review current evidence in the literature about efficacy and safety of these products. Recommendations from other scientific organizations have also been considered to provide an update of the LICE position about their utilization (List of Recommendations). Compared with the previous literature review, randomized controlled trials assessing bioequivalence among branded drugs and generics are currently available. Although some contrasting results have been reported, brand-to-generic switching was effective and tolerable in real-life settings, with similar adverse event ratios. Based on these findings, LICE concluded that, conforming to the rigorous regulation of USA and EU markets, generic ASMs are not inferior to the respective branded, providing a cost advantage for patients starting or replacing monotherapy or add-on, and for those with incomplete seizure control. Branded-to-generic (and vice versa) switching is not recommended (although applicable) during seizure remission, as well as the generic-to-other generic switching. Other recommendations focus on the appropriateness of therapeutic drug monitoring (TDM) when switching is required, paying attention to avoiding the erroneous switch between modified and immediate-release formulations during dispensation. Finally, to support patients' compliance, they should be assured of generics' safety and efficacy and carefully informed with practical advice, particularly when the switching is associated with aspect modifications (e.g. color and shape changes) of the pill or the packaging.

Diabetes Mellitus (DM) is a chronic and severe metabolic disease, characterized by chronic hyperglycemia due to insulin resistance and/or reduced insulin secretion. Concerning the non-insulin glucose-lowering therapy for diabetes, Dipeptidyl-peptidase-4 (DPP-4) inhibitors, members of the incretin family, represent new agents, capable of a glycemic control improvement with an advantageous safety profile, given the absence of weight gain, the low incidence of hypoglycemia and the good renal tolerance in patients suffering from chronic renal failure. In addition to demonstrating efficacy in glycemic control through inhibition of GLP-1 degradation, DPP-4 inhibitors (DPP-4is) seem to demonstrate pleiotropic effects, which also make them interesting in both diabetic and non-diabetic nephropathies, especially for their capacity of reducing proteinuria. Several studies about diabetic nephropathy on patients' cohorts and murine models have demonstrated a solid direct relationship between DPP-4 activity and urinary albumin excretion (UAE), thus confirming the capacity of DPP-4is to reduce proteinuria; the mechanism responsible for that effect was studied to assess if it was the result of a direct action on renal impairment or a secondary consequence of the better glycemic control related to these agents. As a result of these more in-depth studies, DPP-4is have demonstrated an improvement of renal inflammation markers and consequent proteinuria reduction, regardless of glucose concentrations. Considering the nephroprotective effects of DPP-4is might be glycemic independent, several studies were conducted to prove the validity of the same effects in non-diabetic nephropathies. Among these studies, DPP-4is demonstrated an improvement of various renal inflammatory markers on several models of non-diabetes dependent renal impairment, confirming their capacity to reduce proteinuria, independently from the action on glucose metabolism. The objective of this review is to present and discuss the so far demonstrated antiproteinuric effect of DPP-4is and their effects on diabetic and non-diabetic nephropathies.

The γ - summing technique was successfully implemented for the first time in inverse kinematics using the NSCL Summing NaI(Tl) detector at the Nuclear Science Laboratory of the University of Notre Dame. This new method offers a way to measure (p,γ) and (α,γ) reactions on unstable nuclei, which are critical for an improved understanding of nucleosynthesis. As a proof of principle, the well-known resonances at E c . m . = 956 keV in the p(27Al,γ)28Si reaction and at E c . m . = 1400 keV in the p(58Ni,γ)59Cu reaction were measured and their resonance strengths were deduced. The values of the present work agree well with the reported literature values, demonstrating the viability of the technique.

In 1969 the Intersociety Commission for Heart Disease Resources was established through a contract with the American Heart Association under Public Law 89-239. Its responsibility was to produce guidelines defining optimal medical resources and care for the prevention and treatment of cardiovascular disease, including guidelines for radiologic facilities (1). This resource guideline was revised in 1976 (2) and again in 1983 (3). The Intersociety Commission was disbanded shortly thereafter, but a joint ad hoc task force of the American Heart Association and the American College of Cardiology continued this work with “Guidelines for Cardiac Catheterization and Cardiac Catheterization Laboratories” (4), published in 1991. The task force concluded that “. . . while noncardiac diagnostic and therapeutic procedures are growing in number . . . guidelines for these services are beyond the scope of this document.” These documents have charted the evolution of cardiac catheterization from a procedure performed in a few highly specialized laboratories for cardiovascular research to one performed in a number of interventional cardiac laboratories. The documents also have provided useful optimal resource guidelines. In the 1983 report similar standards for angiographic facilities were implied but never specifically stated, with the emphasis always on the heart. Nevertheless, the report mentioned angiographic facilities and considerable involvement by radiologists. Just as cardiac catheterization has evolved, so too have peripheral and visceral angiography. Diagnostic angiography proliferated in the 1960s and the 1970s, and interventional radiology emerged in the 1980s. Nevertheless, optimal resource standards have never been promulgated except in an abbreviated form (5). In 1989 the Council Affairs Committee of the AHA approved the formation of a committee on peripheral vascular disease under the auspices of the Council on Cardiovascular Radiology. In 1992 an ad hoc task force was created, with members from the Councils on Cardiovascular Radiology, Cardio-Thoracic and Vascular Surgery, Clinical Cardiology, and Kidney in Cardiovascular Disease, to develop guidelines for peripheral and visceral angiographic and interventional laboratories. Task force members are Eric C. Martin, MD, chair; William J. Casarella, MD (Council on Cardiovascular Radiology); Barry T. Katzen, MD (Council on Cardiovascular Radiology); Gerald M. Dorros, MD (Council on Clinical Cardiology); Gary S. Roubin, MD (Council on Clinical Cardiology); James A. DeWeese, MD (Council on Cardio-Thoracic and Vascular Surgery); and John H. Laragh, MD (Council on Kidney in Cardiovascular Disease). The task force is grateful for the contributions of the following consultants: John F. Cardella, MD; Joel E. Gray, PhD; Victoria M. Marx, MD; Edward L. Nickoloff, ScD; Michael J. Pentecost, MD; and David C. Levin, MD.

Dr Richard Gunderman deserves credit for his thoughtful analysis and critique regarding the American Board of Radiology (ABR) examination process (1). As a past president of the ABR, I would like to make a few comments regarding Dr Gunderman’s key questions. First, the oral examinations of 2001 are markedly different from those of 1934. Each of the 10 sections has more than 1,000 cases in its electronic database, from which are selected 10–15 cases for each of the eight sessions during the 4 days of the examination. The databases are continually updated, as well. Each examination is standardized for a given session, and the use of computercompatible answer sheets allows for specific analysis of each case and calculation of its merit as a discriminating item. In other words, each case is now validated by experience. All clinical material is presented in digital format on high-resolution monitors, and the images are stored on the hard drives of those individual computers. This format allows more cases to be shown in the allotted time and increases the validity of each section. Second, are the residents studying the right things? Dr Gunderman is correct in his assumption that a scale does not define a desirable weight. It does, however, measure the weight, and someone then determines if that weight is appropriate for a specific purpose. How do we know what the “right things” to study are? Surely, the ability to interpret images and to communicate an impression of the findings to referring physicians is the heart of our specialty, and the ABR oral examinations test that ability well. Third, the written and oral examinations do not cover every area of radiologic practice. All candidates for certification have completed 5 years of training in programs certified by the Accreditation Council of Graduate Medical Education. Each of these programs has a curriculum made up of “essentials.” The program directors must certify that the residents have successfully completed the program and passed a series of monthly evaluations before residents are eligible to sit for the ABR examinations. The entire content of the 5-year program cannot be covered in the written and oral examinations. It is the successful completion of the residency itself that is the sine qua non of ABR certification. Fourth, the ABR examination is not intended to be a quantitative measure of how good a radiologist an individual candidate will become. As Dr Gunderman states, “One of the great virtues of the board examinations is that they are ultimately scored on a pass/fail basis.” The ABR is not charged with ranking radiologists in a manner such as the Associated Press poll ranks college football teams. Rather, “the Mission of the American Board of Radiology is to serve the public and the medical profession by certifying that its diplomates have acquired, demonstrated, and maintained a requisite standard of knowledge, skill and understanding essential to the practice of radiology, radiation oncology and medical physics” (2). The three examinations and the new Maintenance of Certification program fulfill that mission well. The key words in the statement are “requisite” and “essential.” Fifth, the ABR examinations are high-stakes testing. After 25 years of experience in examining in the oral examination, it is clear to me that a wide spectrum of knowledge and ability exists among our candidates. All our psychometric data show that the testing does validly discriminate the “fail group” from the “pass group.” The collective wisdom of experienced oral examiners is a reliAcad Radiol 2001; 8:1260–1261

Once a hepatic abscess has been defined radiologically, percutaneous drainage is the treatment method of first choice. Surgery is reserved for failure of percutaneous therapy. Percutaneous drainage for hepatic abscess has been safe, uncomplicated, and successful in seven patients treated by the authors between 1978 and 1980.

A method has been devised to measure regional myocardial blood flow in man. The approach consists of selective injection of xenon-133 into a coronary artery and the external monitoring of radioisotope washout curves from multiple areas of the myocardium with a multiple crystal scintillation camera. Rate constants of isotope washout are calculated using a monoexponential model, and the capillary blood flow rates in multiple regions of the heart are calculated by the Kety formula. The pattern of perfusion rates is related to the coronary arteriogram obtained in the same study. Myocardial perfusion patterns obtained in patients with and without coronary artery disease and during atrial pacing are given, as well as examples of results obtained in myocardial aneurysms, in regions of ischemic myocardium supplied by collateral vessels and after tracer injection into an aortocoronary bypass graft. Advantages of the method are discussed along with limitations related to the tracer, the scintillation camera, the form of mathematical analysis and the three dimensional nature of the heart.

Digital subtraction angiography enhances the contrast to background signal, enabling the performance of angiography with reduced doses of contrast medium. The objectives of the present study were (1) to validate the accuracy of digital left ventriculography for measurement of left ventricular volumes and segmental contraction; and (2) to compare the hemodynamic effects resulting from low-and high-dose intraventricular contrast injections. Twenty-eight patients underwent digital left ventriculography, performed by intraventricular injection of 7 ml of contrast medium diluted in saline solution, followed by conventional cineangiography of the left ventricle performed with 45 ml of undiluted contrast medium. Left ventricular volumes calculated from digital ventriculograms correlated well with volumes calculated from conventional ventriculograms: end-diastolic volume (r = 0.97, standard error of estimate [SEE] 23.4 ml; end-systolic volume (r = 0.97, SEE 15.4 ml); stroke volume (r = 0.95, SEE 14.7 ml); and ejection fraction (r = 0.97, SEE 3.8%). Segmental left ventricular contraction, measured as percent chordal shortening of hemiaxes, correlated moderately well (r = 0.81, SEE 11.5%). After injection of undiluted contrast medium, left ventricular systolic pressure decreased (133 +/- 31 to 123.5 +/- 27 mm Hg; p less than 0.01) and left ventricular end-diastolic pressure increased (12.0 +/- 7 to 16.9 +/- 10 mm Hg; p less than 0.001). Left ventricular systolic and end-diastolic pressures did not change significantly after injection of diluted contrast medium, and patients had no discomfort. Thus, digital subtraction angiography permits the performance of left ventriculography with markedly reduced doses of contrast medium, obviating the hemodynamic effects resulting from injection of conventional doses of contrast medium. This new approach to left ventriculography provides high resolution ventriculograms for accurate measurement of left ventricular volumes, stroke volume, and ejection fraction.

Measurements of regional myocardialblood flow have been performed rapidly and safely in man at the time of coronary arteriography. Xenon-133 was injected into the coronary artery and estimates of myocardial capillary perfusion were made by computer analysis of the multiple precordial tracer washout curves recorded with a scintillation camera. Blood flow rates/ 1000 g/ min in different areas of the heart were calculated by the Schmidt-kety formula, using an assumed partition coefficient, and were related to the coronary vascular lesions by landmarks provided by the arteriograms. The flow significance of lesions was assessed by making measurements at rest and during interventions that increase coronary blood flow. Perfusion was also estimated in areas supplied by collateral vessels, and regions of scar were detected from the initial distribution of peak tracer activity. In patients with less than 50% obstructions apparent on coronary arteriograms and in those with greater than 50% isolated left anterior descending lesions average mean left ventricular (LV) myocardial perfusion values were not reduced below values found in patients with normal coronary arteries and normal cardiac function. However, in patients with significant two-vessel disease (LAD + right, LAD + circ) mean LV perfusion was significantly reduced. Average regional myocardial perfusion distal to significant lesions was not selectively reduced below the remainder of the ventricle unless the lesions were 100% obstructions. However, both total and distal regional myocardial perfusion increased less in 12 patients with greater than 50% lesions than in 12 others with normal arteriograms or less than 50% lesions. Subnormal flow responses in all of the former group were associated with angina pectoris compared with no angina in the latter. The studies indicate the potential utility of the measurements of regional myocardial blood flow in the evaluation of patients with ischemic heart disease who are potential candidates for myocardial revascularization procedures.

Magnification renal arteriography results in a moderate degree of improvement in its diagnostic accuracy. The differential diagnosis of cyst versus tumor can be made with great accuracy. Various parenchymal renal diseases can be identified and staged so that accurate prognoses can be made. Technical advances in x-ray tubes and electronic imaging systems will result in angiograms of higher resolution and further improve the accuracy of magnification arteriography.

The analytical solution for flow and heat transfer through conduits with heat sources in the fluid stream is studied. The flow is assumed to have a steady uniform velocity profile defined as slug flow. A variety of conduits of different cross-sectional shapes is analyzed in a unified manner by mapping the cross section of the duct onto a unit circle and then transforming the governing equations. The transformed equations are solved using a weighted residuals approach. Solutions for the dimensionless mixing temperatures and Nusselt numbers are obtained for conduits of different cross-sectional shapes (square, hexagon, circle, corrugated, cardioid). In the case of a square duct the results are in excellent agreement with the exact values. The method is applicable to conduits of arbitrary shape and it may prove useful to design engineers since conduits of complicated boundary shape are commonly used in aerospace vehicles, nuclear reactors, etc.