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Pulmonary embolism is associated with significant morbidity and mortality. Patient outcome depends on early and accurate diagnosis of the disease. Computed tomographic pulmonary angiography is the current reference standard for the diagnosis of acute pulmonary embolism. However, missed diag

Resumen Objetivos Evaluar la reproducibilidad interobservador para cuantificar la funcion y masa ventricular izquierda (VI) y valorar la exactitud para cuantificar estos parametros utilizando un software comercial con respecto a la segmentacion manual convencional. Material y metodos Se incluyeron 20 sujetos consecutivos con estudio cardiaco por tomografia computarizada de doble fuente (TCDF) y sincronizacion electrocardiografica retrospectiva. Se realizaron 2 reconstrucciones multifasicas en intervalos del 5% del ciclo R-R. La funcion y masa del VI la cuantificaron 2 observadores independientes que dibujaron manualmente los contornos endo y epicardicos y utilizaron un software comercial que emplea un metodo de segmentacion semiautomatico. Se analizaron la correlacion entre ambos observadores, la exactitud de los distintos metodos de segmentacion y el tiempo necesario para cuantificar estos parametros. Resultados La correlacion interobservador para cuantificar los parametros de funcion y masa VI fue excelente (r>0,94; p 0,05). Con el metodo semiautomatico la estimacion de la masa VI fue significativamente superior que al utilizar la segmentacion manual (diferencia media 29,45±1,64 g; p software comercial (248,85±99,8 s) que con el trazado manual (452,7±73,92 s) (p Conclusiones La reproducibilidad interobservador para cuantificar la funcion y la masa VI mediante TCDF es excelente. Aunque tiende a sobrestimar la masa miocardica, el software comercial permite cuantificar los parametros cardiacos con la misma exactitud que la segmentacion manual en la mitad de tiempo.

Resumen Objetivo Comparar la exactitud de 2 secuencias cine eco de gradiente para cuantificar funcion, volumenes y masa ventricular izquierda en un modelo animal. Material y metodos Se estudiaron 10 cerdos miniatura tipo Goettingen (7 machos, 3 hembras; peso medio: 49,8±10,65 kg; rango: 35–65 kg) en un equipo 1,5 Tesla con secuencias precesion libre en estado estacionario (SSFP) y eco de gradiente convencionales (FLASH) en respiracion libre. Se utilizaron imagenes de 8 mm de grosor obtenidas en el eje corto para cuantificar los parametros del ventriculo izquierdo. Se calcularon la fraccion de eyeccion (FE), volumenes (volumen telediastolico [VTD], volumen telesistolico [VTS], volumen latido [VL]), masa ventricular y la relacion senal ruido (RSR) con cada secuencia. Se estudiaron la correlacion y concordancia entre las distintas secuencias para cada variable. Resultados Utilizando la secuencia SSFP, la FE media estimada fue 77,35±3,13%; VTD medio 61,55±8,64 ml; VTS medio 13,83±1,92 ml; VL medio 47,72±7,78 ml y la masa miocardica media calculada fue de 75,87±11,44 g. Mediante la secuencia FLASH se calculo una FE media de 81,87±2,22%; VTD medio 55,4±8,08 ml; VTS medio 10,03±1,87 ml; VL medio 45,38±6,83 ml, y masa miocardica media 87,74±15,21 g. Se demostro una correlacion excelente entre SSFP y FLASH para cuantificar VTD, VL y masa miocardica (r>0,8) y moderada para VTS y FE (r>0,4). La RSR que se obtuvo con la secuencia SSFP fue significativamente superior a la estimada con la secuencia FLASH (diferencia media 120,94±42,94). Conclusiones Con la secuencia SSFP se obtienen volumenes ventriculares ligeramente superiores y masa ventricular izquierda ligeramente inferior a los calculados con la secuencia FLASH probablemente por su mayor RSR.

Conventional coronary angiography (CCA) is the gold standard in the diagnosis of cardiac allograft vasculopathy (CAV) in heart transplant recipients. Dobutamine stress echocardiography (DSE) is a useful technique for screening. Dual-source computed tomography (DSCT) is the last generation of computed tomography scanners, which could be useful to noninvasively assess CAV. Thirty cardiac transplant recipients underwent DSE and DSCT coronary angiogram. Exclusion criteria were as follows: renal insufficiency, iodinated contrast media allergy, less than 12 months since transplant, and unstable clinical conditions. DSE showed ischemia in two patients. At DSCT scan 13 patients had a normal angiogram, 13 ones wall thickening and four significant diseases. DSCT showed a sensitivity of 100% with a specificity of 92%. DSCT allowed detection of more patients with CAV than DSE. Four patients showed significant CAV at DSCT compared with two at DSE. Thirteen patients showed initial signs of disease at DSCT despite a normal DSE.

The introduction of coronary CT angiography (cCTA) has reinvigorated the debate whether management of patients with suspected coronary artery disease (CAD) should be primarily based on physiological versus anatomical testing. Anatomical testing (i.e., cCTA or invasive catheterization) enables direct visualization and grading of coronary artery stenoses but has shortcomings for gauging the hemodynamic significance of lesions for myocardial perfusion. Conversely, rest/stress myocardial perfusion imaging (MPI) has been extensively validated for assessing the clinical significance of CAD by demonstrating fixed or reversible perfusion defects but has only limited anatomical information. There is early evidence that contrast medium enhanced dual-energy cCTA (DECT) has potential for the comprehensive analysis of coronary artery morphology as well as changes in myocardial perfusion. DECT exploits the fact that tissues in the human body and iodine-based contrast media have unique absorption characteristics when penetrated with different X-ray energy levels, which enables mapping the iodine (and thus blood) distribution within the myocardium. The purpose of this communication is to describe the practical application of this emerging technology for the comprehensive diagnosis of coronary artery disease in the context of the currently used tomographic imaging modalities (cCTA, nuclear MPI, MR MPI).

The purpose of this study was to compare LV function and mass quantification derived from cardiac dual-source CT (DSCT) exams with those obtained by MRI in heart transplant recipients. Twelve heart transplant recipients who underwent cardiac DSCT and MRI examination were included. Double-oblique short-axis 8-mm slice thickness images were evaluated. Left ventricular ejection fraction, end-diastolic volume, end-systolic volume, stroke volume, cardiac output and myocardial mass were manually assessed for each patient by two blinded readers. A systematic overestimation of all left ventricular volumes by DSCT when compared with MRI was observed. Mean difference was 16.58 +/- 18.61 ml for EDV, 4.9 4 +/- 6.84 ml for ESV, 11.64 +/- 13.58 ml for SV and 5.73 +/- 1.14 l/min for CO. Slightly lower values for left ventricular ejection fraction with DSCT compared with MRI were observed (mean difference 0.34 +/- 3.18%, p = 0.754). Correlation between DSCT and MRI for left ventricular mass was excellent (rho = 0.972). Bland and Altman plots and CCC indicated good agreement between DSCT and MRI left ventricular function and mass measurements. The interobserver correlation was good. In conclusion, DSCT accurately estimates left ventricular ejection fraction, volumes and mass in heart transplant recipients.

The image quality and optimal reconstruction interval for coronary arteries in heart transplant recipients undergoing non-invasive dual-source computed tomography (DSCT) coronary angiography was evaluated. Twenty consecutive heart transplant recipients who underwent DSCT coronary angiography were included (19 male, one female; mean age 63.1 +/- 10.7 years). Data sets were reconstructed in 5% steps from 30% to 80% of the R-R interval. Two blinded independent observers assessed the image quality of each coronary segments using a five-point scale (from 0 = not evaluative to 4 = excellent quality). A total of 289 coronary segments in 20 heart transplant recipients were evaluated. Mean heart rate during the scan was 89.1 +/- 10.4 bpm. At the best reconstruction interval, diagnostic image quality (scoreor = 2) was obtained in 93.4% of the coronary segments (270/289) with a mean image quality score of 3.04 +/- 0.63. Systolic reconstruction intervals provided better image quality scores than diastolic reconstruction intervals (overall mean quality scores obtained with the systolic and diastolic reconstructions 3.03 +/- 1.06 and 2.73 +/- 1.11, respectively; P0.001). Different systolic reconstruction intervals (35%, 40%, 45% of RR interval) did not yield to significant differences in image quality scores for the coronary segments (P = 0.74). Reconstructions obtained at the systolic phase of the cardiac cycle allowed excellent diagnostic image quality coronary angiograms in heart transplant recipients undergoing DSCT coronary angiography.

The purpose of our study was to evaluate reliability of left ventricular (LV) function and mass quantification in cardiac DSCT exams comparing manual contour tracing and a region-growing-based semiautomatic segmentation analysis software. Thirty-three consecutive patients who underwent cardiac DSCT exams were included. Axial 1-mm slices were used for the semiautomated technique, and short-axis 8-mm slice thickness multiphase image reconstructions were the basis for manual contour tracing. Left ventricular volumes, ejection fraction and myocardial mass were assessed by both segmentation methods. Length of time needed for both techniques was also recorded. Left ventricular functional parameters derived from semiautomatic contour detection algorithm were not statistically different from manual tracing and showed an excellent correlation (p0.001). The semiautomatic contour detection algorithm overestimated LV mass (180.30+/-44.74 g) compared with manual contour tracing (156.07+/-46.29 g) (p0.001). This software allowed a significant reduction of the time needed for global LV assessment (mean 174.16+/-71.53 s, p0.001). Objective quantification of LV function using the evaluated region-growing-based semiautomatic segmentation analysis software is feasible, accurate, reliable and time-effective. However, further improvements are needed to equal results achieved by manual contour tracing, especially with regard to LV mass quantification.

Individuals concerned about their risk of lung cancer are recommended to talk with their physicians about computed tomographic screening for lung cancer. To provide the necessary information, the survival benefit of the screening, specific to a particular person for a particular round of screening, is needed. The probability of survival gain from the first, baseline, round of screening was addressed as the product of: 1) the screening resulting in a diagnosis of lung cancer; 2) not dying from some other cause for a sufficiently long period of time; and 3) cure resulting from pre-symptomatic treatment of lung cancer. These probabilities were estimated using the International Early Lung Cancer Action Program data on individuals aged 40-85 yrs with a cigarette smoking history of 0-150 pack-yrs. The estimated probability of survival gain ranged from 0.4% for a 60-yr-old with a 10-pack-yr smoking history who quit smoking 20 yrs ago, to 3.1% for a 70-yr-old current smoker with a 100 pack-yr history and 2.0% for an 85-yr-old current smoker with a 150-pack-yr history. When seeking counsel about initiation of screening for lung cancer, an estimate of the probability of survival gain from the first round of computed tomographic screening, specific to the person's age and history of smoking, can be provided.

Lung cancer screening using computed tomography (CT) is effective in detecting early stage disease. However, concerns regarding adherence have been raised. The current authors conducted a retrospective observational study of 641 asymptomatic smokers enrolled in a lung cancer screening programme between 2000 and 2003. Adherent subjects were compared with nonadherent subjects with regard to lung function, sex, age, motivation for enrollment, smoking status, distance to the referral centre, family history of lung cancer, asbestos exposure, education, the presence and type of nodule(s) seen on initial CT, and exposure to a nursing intervention designed to improve adherence. Overall, early adherence to the study protocol was 65%. Multivariate analysis confirmed the importance of sex, proximity to the referral centre, the presence of noncalcified nodules, and the nursing intervention as factors conditioning adherence to the study protocol. Patients encouraged to participate in the study were more adherent, as were former smokers. Sex interactions were observed in multivariate analysis. The nursing intervention was significant for females, while abnormal lung function improved male adherence. Adherence to lung cancer screening is particularly good among females and subjects living near the referral centre. The present study suggests the need to develop new strategies, especially those targeting males and subjects with low risk perception, in order to improve adherence.

La navegaci?n electromagn?tica es una t?cnica novedosa capaz de facilitar la obtenci?n mediante broncoscopio de muestras de lesiones nodulares perif?ricas de peque?o tama?o y adenopat?as mediast?nicas. Permite realizar tanto biospias transbronquiales como punciones con aguja citol?gica, y por ello es muy vers?til. Publicamos el resultado de 2 casos en los que la combinaci?n de navegaci?n con el sistema superDimension/Bronchus y de t?cnicas diagn?sticas convencionales facilit? el diagn?stico definitivo mediante broncoscopia. La navegaci?n electromagn?tica ofrece la posibilidad de evitar m?todos diagn?sticos invasivos como la cirug?a, con el consiguiente ahorro econ?mico, de tiempo y de complicaciones.

El nodulo pulmonar es un hallazgo frecuente en los estudios toracicos realizados durante la practica clinica diaria. Aunque no existen datos clinicos o radiologicos patognomonicos que indiquen su naturaleza exacta, el contexto clinico y la caracterizacion adecuada del nodulo pulmonar permiten realizar el diagnostico correcto en la mayoria de los casos. En este articulo se exponen los aspectos mas relevantes de la utilidad de la tomografia computarizada multicorte (TCMC) para detectar y caracterizar los nodulos pulmonares de forma no invasiva.

Electromagnetic navigation is a new technique that can be used with bronchoscopy to obtain samples of small peripheral nodular lesions and enlarged mediastinal lymph nodes. It is very versatile in that it enables both transbronchial biopsies and fine-needle aspiration to be performed. We describe 2 cases in which navigation with the superDimension/ Bronchus system combined with traditional diagnostic techniques facilitated a definitive diagnosis by bronchoscopy. Electromagnetic navigation can obviate the need for more invasive diagnostic procedures such as surgery, thus saving time and money and avoiding complications.

Owing to recent advances in computing power, iterative reconstruction (IR) algorithms have become a clinically viable option in computed tomographic (CT) imaging. Substantial evidence is accumulating about the advantages of IR algorithms over established analytical methods, such as filtered back projection. IR improves image quality through cyclic image processing. Although all available solutions share the common mechanism of artifact reduction and/or potential for radiation dose savings, chiefly due to image noise suppression, the magnitude of these effects depends on the specific IR algorithm. In the first section of this contribution, the technical bases of IR are briefly reviewed and the currently available algorithms released by the major CT manufacturers are described. In the second part, the current status of their clinical implementation is surveyed. Regardless of the applied IR algorithm, the available evidence attests to the substantial potential of IR algorithms for overcoming traditional limitations in CT imaging.

Results 239 patients were studied (180 male) with a mean age of 66±10 years old. One hundred and sixteen (48.5%) had previous coronary artery disease, with myocardial infarction in 68 patients. The reason for test referral were: several cardiovascular risk factors 52%, atypical chest pain 33%, typical chest pain 12%, and not conclusive previous test 3%. The CMR-A was positive for myocardial ischaemia in 83 patients (35%) and negative in 156 (65%). The follow-up median was 26 [0-59] months. 53 patients (22%) had events: 16 patients died (4 because of cardiovascular reasons), 26 had an ACS, 5 were admitted for HF and 21 needed invasive coronariography (18 PCI). There were statistical differences in the Kaplan-Meier survival curves (figure 1) between those with a positive result in the CMR-A test and those with a negative one (Long Rank test; p=0.021).

Severe complications associated with a central venous catheter implantation could be repaired successfully. We reported the case of an iatrogenic aortic arch puncture due to a central venous catheter from the left internal jugular vein. Because the patient had a poor prognosis a percutaneous procedure was performed. Aortography was done with a pigtail catheter for guidance. A wire was introduced through the venous catheter to the aorta and the catheter was removed. The hole in the aorta was closed with a Perclose closure system. The patient remained stable and the procedure was performed without complications.

Rationale and Purpose: Low-dose spiral computerized axial tomography (spiral CT) is effective for the detection of small early lung cancers. Although published data seem promising, there has been a significant degree of discussion concerning the potential of overdiagnosis in the context of spiral CT–based screening. The objective of the current study was to analyze the phenotypic and genetic alterations in the small pulmonary malignancies resected after detection in the University of Navarra/International Early Lung Cancer Action Project spiral CT screening trial and to determine whether their malignant molecular features are similar to those of resected lung tumors diagnosed conventionally. Experimental Design: We analyzed 17 biomarkers of lung epithelial malignancy in a series of 11 tumors resected at our institution during the last 4 years (1,004 high-risk individuals screened), using immunohistochemistry and fluorescence in situ hybridization (FISH). A parallel series of 11 gender-, stage-, and histology-matched lung cancers diagnosed by other means except screening was used as control. Results: The molecular alterations and the frequency of phenotypic or genetic aberrations were very similar when screen-detected and nonscreen-detected lung cancers were compared. Furthermore, most of the alterations found in the screen-detected cancers from this study were concordant with what has been described previously for stage I-II lung cancer. Conclusions: Small early-stage lung cancers resected after detection in a spiral CT-based screening trial reveal malignant molecular features similar to those found in conventionally diagnosed lung cancers, suggesting that the screen-detected cancers are not overdiagnosed. (Cancer Epidemiol Biomarkers Prev 2006;15(2):373–80)

Carcinoid tumors are associated with the production of a number of bioactive substances that might deposit on the endocardium (endocardial fibroelastosis) and produce cardiac failure. Carcinoid heart disease usually presents as right-sided valvular heart disease. Even if the diagnosis is frequently made by transthoracic echocardiography, cardiac magnetic resonance imaging adds valuable information when evaluating cardiac structures that might be difficult to analyze on echocardiography.

En pacientes con tumores hepaticos, el tratamiento mas eficaz es la cirugia. Sin embargo, no todos pueden ser tratados de esta manera. Uno de los motivos que contraindican el tratamiento quirurgico es que el parenquima hepatico que queda tras la reseccion de la zona tumoral sea insuficiente para asegurar la funcion hepatica del paciente. Es conocido que el hepatocito, tras determinados estimulos, tiene la posibilidad de desdiferenciarse y clonarse. La embolizacion portal prequirurgica (EPP) del volumen hepatico que se va a resecar puede generar, tras este estimulo y respuesta (que sera diferente en higados fibroticos y no fibroticos), un crecimiento hepatico que alcanzara niveles adecuados en 3-4 semanas. Por tanto, la EPP puede incrementar el numero de candidatos a recibir tratamiento quirurgico y, del mismo modo, puede disminuir la aparicion de posibles complicaciones postoperatorias. En este articulo se presentan lo criterios de inclusion y exclusion que, de forma comunmente aceptada, se utilizan para realizar una EPP. No hay acuerdo, sin embargo, sobre la tecnica mas adecuada para acceder al sistema portal, por ejemplo, la via contralateral (con puncion de los segmentos portales que no van a ser resecados) tiene considerables ventajas tecnicas, pero pone en riesgo de trombosis a las ramas portales del tejido hepatico sano. Son muchos los materiales embolizantes que se han usado en EPP, algunos autores recomiendan el empleo de «pegamentos», pues son relativamente sencillos de utilizar, de bajo coste y altamente eficaces pero, por otra parte, generan una importante inflamacion periportal que puede dificultar la reseccion quirurgica. Si se emplean particulas, estas deben ser de un tamano que oscile entre las 100 y las 300 micras. En conclusion, aunque todavia hay muchos aspectos de la EPP que requieren ser investigados, la tecnica deberia de estar disponible en todos los centros en los que se realice cirugia hepatica, pues los beneficios clinicos derivados de esta son muy satisfactorios.

Ureteroarterial fistulae (UAFs) are a rare entity, often difficult to identify, and associated with a high mortality rate. This fact has been attributed to a delay in diagnosis and treatment. Five conditions that can predispose to the development of this uncommon entity have been described: prior pelvic surgery, prolonged ureteral stenting, radiation therapy, previous vascular surgery and vascular pathology. We present 4 patients with UAFs and at least three of the above-mentioned conditions. Ureteral ischemia and subsequent necrosis promote the formation of these fistulae. The constant pulsation of the iliac artery is transmitted to an already compromised ureter containing a stiff intraluminal foreign body, resulting in pressure necrosis, most likely where the ureter crosses the iliac artery. Cases were managed percutaneously with a combination of the deployment of a covered prosthesis and, when needed, with mechanical occlusion of the ureter. Hematuria stopped in all the patients with no evidence of immediate rebleeding. One patient presented a new episode of vaginal bleeding 13 months after endograft placement and ureteral embolization. Arteriography showed the presence of a hypogastric artery pseudoaneurysm that was occluded using coils. No new bleeding has occurred in this patient 12 months after the second embolization. At present all 4 patients are alive with follow-up periods of 5, 9, 11 and 25 months since the first procedure.

Die neueste Generation der 16-Zeilen-Computertomographen ermoglicht die Darstellung der Koronaranatomie und die Beurteilung einer koronaren Herzkrankheit (KHK) bei Patienten mit einem regelmasigen bradykarden Sinusrhythmus. Fur eine zuverlassige Beurteilung der Koronarmorphologie ist ein dediziertes Untersuchungs- und Kontrastmittelprotokoll obligat. Die Indikation fur eine koronare CT-Angiographie (CTA) ist Gegenstand zahlreicher Studien. Aufgrund der limitierten raumlichen und zeitlichen Auflosung und der Artefakte bei Verkalkungen ist die Beurteilung der Koronargefase bei Patienten mit etablierter koronarer Herzkrankheit (KHK) problematisch. Die Anatomie der Koronargefase kann aber schon jetzt zuverlassig dargestellt werden. Der hohe negative pradiktive Wert konnte die Durchfuhrung einer koronaren CTA bei symptomatischen Patienten rechtfertigen, die eine intermediare Wahrscheinlichkeit fur das Vorliegen einer KHK aufweisen. Wichtige Informationen uber den Abgang und den Verlauf der Arterie liefert die CTA bei Patienten mit Koronaranomalien.

Fur die operative Koronarrevaskularisation kommen zunehmend arterielle Bypassgefase zum Einsatz. Ziel der Studie war die Implementierung eines geeigneten Protokolls zur CTA arterieller Koronarbypasse an einem 16-Zeilen-MSCT und die Untersuchung von Patienten nach uberwiegend arterieller Koronarrevaskularisation. Es wurden 14 Patienten nach Koronarrevaskularisation in die Studie eingeschlossen. Die Untersuchung erfolgte im postoperativen Verlauf mit einem 16-Zeilen-MSCT. Zur Verminderung von Pulsationsartefakten kam EKG-Gating zum Einsatz. Insgesamt wurden 43 Bypassgefase/Bypassschenkel (37 arterielle, 6 venose) untersucht. Bei 13 Patienten war eine Revaskularisation mit T- oder TY-Konfiguration erfolgt. Die mittlere Herzfrequenz betrug 74,1 Schlage/min, und die Bildqualitat zeigte eine negative Korrelation zur Herzfrequenz (r=−0,65; p=0,01). Samtliche Untersuchungen waren diagnostisch verwertbar. Das gewahlte Kontrastmittelinjektionsprotokoll fuhrte zu einer weitgehend homogenen Kontrastierung der Zielgefase. Samtliche nicht nachweisbare Bypassgefase (5) lagen herznah (T- oder Y- Schenkel). In der modernen Herzchirurgie steht heute die arterielle Koronarrevaskularisation im Vordergrund. Hierdurch ergeben sich neue Anforderungen an die nichtinvasive Darstellung der Bypassgefase. Die 16-Zeilen-CT ermoglicht die Darstellung einfacher und komplexer arterieller Bypasse. Fur die zuverlassige Abgrenzbarkeit herznaher Bypassgefase ist jedoch weiterhin eine Reduktion der Herzfrequenz (

Objetivo Aportar nuestra experiencia en la utilizacion de la via percutanea retrograda o transyeyunal como acceso a la via biliar en pa-cientes con hepato o coledocoyeyunostomia. Material y metodo Presentamos a seis pacientes en los que se uti-lizo la via percutanea retrograda con distintas finalidades: en seis casos para la dilatacion de estenosis biliares (cuatro pacientes con estenosis de la anastomosis bilioenterica, un paciente presentaba multiples este-nosis del arbol biliar y uno una estenosis del coledoco distal y de la pa-pila), en tres casos para extraer colelitiasis intrahepaticas y extrahepati-cas, en otro para extraer un tubo tutor migrado fuera de la hepatoyeyu-nostomia al asa yeyunal y, por ultimo, en un caso se utilizo para tratar una fuga biliar en la anastomosis bilioenterica. Ademas, describimos los detalles tecnicos del procedimiento. Resultados El tratamiento dilatador se realizo con exito en todos los pacientes, requiriendo una media de dos sesiones. No hubo compli-caciones inmediatas excepto un caso de hemofilia. Los pacientes lleva-ron colocados los tubos de drenaje transhepaticos durante un periodo de entre 12-30 dias, mientras que el tiempo de los tubos transyeyunales fue de 22 dias y cuatro meses. Conclusiones El acceso percutaneo retrogrado es una via de abor-daje al arbol biliar alternativa y complementaria a la transhepatica. Las principales ventajas de este procedimiento respecto al anterogrado son el acceso sencillo a los conductos biliares, tanto derechos como iz-quierdos, el menor riesgo de complicaciones y la menor severidad de estas, y la posibilidad de realizar el seguimiento de los drenajes de for-ma ambulatoria.

La propia historia natural de la arteriosclerosis posibilita el desarrollo de estudios y proyectos dirigidos a identificar y clasificar los sujetos con alto riesgo de presentar enfermedad coronaria. Han sido diversas las tecnicas radiologicas que han tratado de determinar la severidad de la afectacion de las arterias coronarias, con un exito relativo. En esta ultima decada, los continuos avances en tomografia computarizada (TC) han posibilitado la deteccion y cuantificacion de los depositos de calcio en las arterias coronarias, con una sensibilidad y especificidad practicamente superponibles a los datos obtenidos tras coronariografia. La cuantificacion total del calcio coronario, indicador inequivoco de arteriosclerosis, permite estratificar el riesgo cardiovascular de los pacientes de manera no invasiva y con mayor fiabilidad que con los metodos habituales. Hoy dia, las principales aplicaciones clinicas de la deteccion y cuantificacion de la ateromatosis coronaria incluyen: dolor toracico de caracteristicas atipicas; cribado del riesgo coronario en pacientes asintomaticos, y seguimiento de la progresion de la arteriosclerosis coronaria en los pacientes tratados.

Las fistulas ureteroarteriales se asocian con una alta mortalidad, lo que se ha relacionado a un retraso en el diagnostico y tratamiento. A pesar de que se conocen diversos factores predisponentes y de que existe una manifestacion inicial muy concreta (hematuria), la fistula ureteroarterial es de dificil diagnostico. Clasicamente, el tratamiento de dicha fistula ha consistido en la cirugia abierta y en la embolizacion vascular percutanea. Hoy en dia, las endoprotesis vasculares se perfilan como alternativa terapeutica en el tratamiento de las fistulas ureteroarteriales. Se presenta el caso de una paciente con una probable fistula ureteroarterial tratada mediante embolizacion ureteral y colocacion de endoprotesis vascular cubierta.

Fundamento y objetivo: Presentar los datos iniciales de un programa de deteccion precoz del cancer de pulmon por tomografia computarizada de baja dosis de radiacion, asi como exponer los criterios de inclusion y el algoritmo de actuacion inicial de este proyecto. Sujetos y metodo: Desde septiembre de 2000 a mayo de 2001 se realizo una TC toracica con baja dosis de radiacion a 150 fumadores asintomaticos (intervalo de edad, 40-78 anos). El protocolo de estudio incluia: TC basal de baja dosis de radiacion, control evolutivo por TC convencional de los nodulos pulmonares no calcificados de diametro inferior a 10 mm y exploraciones complementarias (tomografia por emision de positrones [PET]) de los nodulos mayores de 10 mm de diametro, potencialmente malignos. Resultados: Se detectaron 54 nodulos pulmonares no calcificados en 34 sujetos asintomaticos (24,15%). El diametro mayor fue de 5 mm o menos en 24 individuos (70,6%), entre 6 y 10 mm en 7 (20,6%) y mayor de 10 mm en tres (8,8%). Se realizo una PET en un unico caso, con resultado positivo y diagnostico histologico de carcinoma escamoso. Los otros dos nodulos no calcificados mayores de 10 mm se consideraron probablemente benignos al presentar un aspecto radiologico de lesion cicatrizal residual. Conclusion: Siguiendo el protocolo descrito, es posible detectar el cancer de pulmon en estadios tempranos en sujetos asintomaticos con factores de riesgo para desarrollar esta enfermedad. Aunque los resultados preliminares son esperanzadores, es preciso incrementar el tamano de la muestra antes de obtener conclusiones definitivas.

Lung cancer is the neoplasia with the highest worldwide mortality rate. During recent decades, several programs for early detection of lung cancer have been initiated with none having demonstrated a significant reduction in mortality. Recent technological advances (spiral CT) have rekindled an interest in screening programs and results have been encouraging. Nevertheless, the initial question remains: would programs for the early detection of lung cancer be able to significantly decrease mortality rates?

Lung cancer is the leading cause of cancer death. A number of screening trials have been carried out over the past two decades and have failed to demonstrate a reduction of lung cancer-related mortality. Recent advances in new forms of technology – spiral low-dose CT – have resuscitated interest in screening programs. Preliminary results are promising but the outstanding question is whether the magnitude of improvement is sufficient to affect a measurable reduction in lung cancer mortality?

Among the broad spectrum of tumoral bone lesions that affect the sacrum are chondrosarcoma, chondroma, aneurysmal bone cyst, Ewing sarcoma, giant cell tumor, lymphoma, Paget disease, osteosarcoma, plasmacytoma, and neurogenic tumors. The clinical onset may be insidious, and sacral bone tumors may be

European experience regarding lung cancer screening using low-dose chest CT (LDCT) is available. However, there is limited data on the Spanish experience in this matter. Our aim is to present the results from the longest ongoing screening program in Spain.The Pamplona International Early Lung Cancer Detection Program (P-IELCAP) is actively screening participants for lung cancer using LDCT since year 2000 following the IELCAP protocol, including spirometric assessments. Men and women, ≥40 years of age, current or former smokers with a tobacco history of ≥10 pack-years are included. Results are compared to those from other European trials.A total of 2989 participants were screened until March 2014 (73% male). A median of 2 (IQR 1-3) annual screening rounds were performed. Sixty lung cancers were detected in 53 participants (73% in StageI). Adenocarcinoma was the most frequent. The lung cancer prevalence and incidence proportion was 1.0% and 1.4%, respectively, with an annual detection rate of 0.41. The estimated 10-year survival rate among individuals with lung cancer was 70%. Chronic obstructive pulmonary disease and emphysema are important lung cancer predictors.The experience in Spain's longest lung cancer screening program is comparable to what has been described in the rest of Europe, and confirms the feasibility and efficacy of lung cancer screening using LDCT.

The aim of this study was to evaluate whether the use of personal response systems (PRS) or clickers improved learning and retention of radiology concepts within a group of medical students. A total of 175 medical students attended 17 thoracic radiology lectures. Half of the information was taught with traditional teaching methods. The other half was performed using multiple-choice Power Point slides with PRS. Three months later, the students were tested using questions about the topics explained with and without PRS. We compared the average numbers of correct answers, wrong answers and unanswered questions between the topics explained with PRS and those without. The average number of correct answers was significantly higher in the interactive teaching (PRS) questions than in the passive education questions (63.6 vs. 53.2 %, p

Objective to compare the different adipose tissue (AT) compartments, muscle mass, muscle fat infiltration, coronary calcium, as well as associations among changes in different AT compartments between frail and robust nonagenarians. Materials and Methods Forty-two elderly subjects took part in this study: 29 institutionalized frail elderly (92.0±8 years) and13robustelderly(88.2±4.1years).Allpatientsunderwent helical thoracic, abdominal and thigh computed tomography (CT). In addition, a non-enhanced prospectively ECGtriggered cardiac CT was performed to quantify the amount of coronary artery calcification and measure pericardial AT. Results The robust group presented significantly greater pericardial and abdominal AT volume, as well as greater axial and appendicular muscle size and high-density muscle tissue (greater muscle quality) than the frail group (P

CT imaging of myocardial perfusion and viability : , CT imaging of myocardial perfusion and viability : , کتابخانه دیجیتال جندی شاپور اهواز

Anomalies of the course of the right coronary artery are relatively rare but are diagnosed with increasing frequency by noninvasive coronary computed tomography angiography. Although most findings of right coronary artery anomalies are inconsequential, there are certain variants that can result in catastrophic complications during surgical or interventional procedures if not recognized. We present a case of intra-atrial course of the right coronary artery noninvasively diagnosed by dual-source computed tomography coronary angiography.

Patients with respiratory and/or cardiac failure occasionally require the use of extracorporeal membrane oxygenation (ECMO), which presents an obstacle for standard imaging modalities. Computed tomographic angiography (CTA) can be used in patients with congenital heart disease, usually to define extra-cardiac anatomy in the chest. We describe the use of CTA to evaluate two infants with congenital heart disease while on ECMO. The first infant had totally anomalous pulmonary venous connection, and the second had a pulmonary sling that resulted in tracheal stenosis. The studies achieved high diagnostic quality with minimal radiation exposure. Subsequently, both infants had successful surgical repairs.

Unless carcinoid are in general slow-growing tumors, some cases could be frankly malignant. The commonest cause of death in patients suffering a carcinoid tumor is liver failure due to tumor progression. When tumors have a fast evolution a multidisciplinary approach must be perform. This case report is an example of this specific situation.

Background The prognosis of non-cutaneous malignancies after liver transplantation is dismal, mainly because most cases are diagnosed at advanced stages. In the last decade, studies have shown the potential role of screening for lung cancer with low-radiation dose computed tomography. Material and Methods Fifty-nine liver transplant recipients with a cumulative dose of smoking greater than 10 pack-years were enrolled in a lung cancer screening program using yearly low-radiation dose computed tomography. Results Lung cancer was diagnosed in 7 patients (11.8%), 5 of which were in stage Ia at diagnosis. Patients with lung cancer were significantly older (median age 66 vs. 58 years), had a higher cumulative history of smoking, and had emphysema more frequently than patients without cancer. Conclusions Screening for lung cancer with low-radiation dose computed tomography in liver transplant recipients results in the diagnosis of lung cancer in early stages.

The aim of the proposed recommendations is be a tool to facilitate decision-making in patients with a solitary pulmonary nodule (SPN). For an optimal decision, accessibility to the different diagnostics techniques and patient preferences need to be incorporated. The first assessment, which includes a chest computed tomography scan, separates a group of patients with extrapulmonary neoplasm or a high surgical risk who require individualized management. Another two groups of patients are patients with SPN up to 8mm and those who have a subsolid SPN, for which specific recommendations are established. SPN larger than 8mm are classified according to their probability of malignancy into low (less than 5%), where observation is recommended, high (higher than 65%), which are managed with a presumptive diagnosis of localized stage carcinoma, and intermediate, where positron emission tomography-computed tomography has high yield for reclassifying them into high or low probability. In cases of intermediate or high probability of malignancy, transbronchial needle aspiration or biopsy of the nodule may be an option. Radiologic observation with low radiation computed tomography without contrast is recommended in SPN with low probability of malignancy, and resection with videothoracoscopy in undiagnosed cases with intermediate or high probability of malignancy.

RationaleEpicardial Adipose Tissue (EAT) volume as determined by chest computed tomography (CT) is an independent marker of cardiovascular events in the general population. COPD patients have an increased risk of cardiovascular disease, however nothing is known about the EAT volume in this population.ObjectivesTo assess EAT volume in COPD and explore its association with clinical and physiological variables of disease severity.MethodsWe measured EAT using low-dose CT in 171 stable COPD patients and 70 controls matched by age, smoking history and BMI. We determined blood pressure, cholesterol, glucose and HbA1c levels, microalbuminuria, lung function, BODE index, co-morbidity index and coronary artery calcium score (CAC). EAT volume were compared between groups. Uni and multivariate analyses explored the relationship between EAT volume and the COPD related variables.ResultsCOPD patients had a higher EAT volume [143.7 (P25-75, 108.3-196.6) vs 129.1 (P25-75, 91.3-170.8) cm(3), p = 0.02)] and the EAT volume was significantly associated with CAC (r = 0.38, pConclusionsEAT volume is increased in COPD patients and is independently associated with smoking history, BMI and exercise capacity, all modifiable risk factors of future cardiovascular events. EAT volume could be a non-invasive marker of COPD patients at high risk for future cardiovascular events.

We present and evaluate an automatic and quantitative method for the complex task of characterizing individual nodule volumetric progression in a longitudinal mouse model of lung cancer. Fourteen A/J mice received an intraperitoneal injection of urethane. Respiratory-gated micro-CT images of the lungs were acquired at 8, 22, and 37 weeks after injection. A radiologist identified a total of 196, 585 and 636 nodules, respectively. The three micro-CT image volumes from every animal were then registered and the nodules automatically matched with an average accuracy of 99.5%. All nodules detected at week 8 were tracked all the way to week 37, and volumetrically segmented to measure their growth and doubling rates. 92.5% of all nodules were correctly segmented, ranging from the earliest stage to advanced stage, where nodule segmentation becomes more challenging due to complex anatomy and nodule overlap. Volume segmentation was validated using a foam lung phantom with embedded polyethylene microspheres. We also correlated growth rates with nodule phenotypes based on histology, to conclude that the growth rate of malignant tumors is significantly higher than that of benign lesions. In conclusion, we present a turnkey solution that combines longitudinal imaging with nodule matching and volumetric nodule segmentation resulting in a powerful tool for preclinical research.

RationaleLow-grade inflammation and emphysema have been shown to be associated with an increased risk of lung cancer. However, the systemic inflammatory response in patients with emphysema is still unknown.ObjectiveTO COMPARE THE PLASMA CYTOKINE PROFILES IN TWO GROUPS OF CURRENT OR FORMER SMOKERS WITHOUT AIRWAY OBSTRUCTION: a control group of individuals without computed tomography (CT) detected emphysema vs. a study group of individuals with CT detected emphysema.MethodsSubjects underwent a chest CT, spirometry, and determination of EGF, IL-15, IL-1ra, IL-8, MCP-1, MIP-1β, TGFα, TNFα, and VEGF levels in plasma. Cytokine levels in each group were compared adjusting for confounding factors.Results160 current smokers and former smokers without airway obstruction participated in the study: 80 without emphysema and 80 subjects with emphysema. Adjusted group comparisons revealed significant reductions in EGF (-0.317, p = 0.01), IL-15 (-0.21, p = 0.01), IL-8 (-0.180, p = 0.02) and IL-1ra (-0.220, p = 0.03) in subjects with emphysema and normal spirometry.ConclusionsCurrent or former smokers expressing a well-defined disease characteristic such as emphysema, has a specific plasma cytokine profile. This includes a decrease of cytokines mainly implicated in activation of apoptosis or decrease of immunosurveillance. This information should be taken into account when evaluated patients with tobacco respiratory diseases.

Coronary heart disease is a challenging socio-epidemiological problem in developed countries. In the United States, for example, the total prevalence of coronary heart disease in adults is 7.0%, with an annual incidence of myocardial infarction of 610,000 new attacks and 325,000 recurrent attacks. In 2007, mortality due to coronary heart disease was 406,351, with an estimated direct and indirect cost of $177.5 billion to the American healthcare system [1].

Coronary revascularization, comprising coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI), is among the most common major medical procedures provided by the US health care system, with more than 1 million procedures performed annually [1, 2]. Several innovations in coronary revascularization, such as drug-eluting stents, minimally invasive CABG surgery, and “off-pump” CABG surgery, have been adopted widely in the past decade, with the promise of improved clinical outcomes compared with older revascularization technologies and techniques [3, 4]. However, with the advent of PCI and the increased efficacy of medical therapy, a constant decrease in the number of CABG procedures has been steadily observed in the USA. Nonetheless, the results of the recent SYNTAX trial indicated that CABG surgery remains the better choice for coronary revascularization among patients with previously untreated three-vessel or left main coronary artery disease [5, 6, 7].

Background Epicardial adipose tissue (EAT) is an important indicator of cardiovascular risk. This parameter is generally assessed on ECG-gated computed tomography (CT) images. Purpose To evaluate feasibility and reliability of EAT quantification on non-gated thoracic low-radiation-dose CT examinations with respect to prospectively ECG-gated cardiac CT acquisition. Material and Methods Sixty consecutive asymptomatic smokers (47 men; mean age 64 ± 9.8 years) underwent low-dose CT of the chest and prospectively ECG-gated cardiac CT acquisitions (64-slice dual-source CT). The two examinations were reconstructed with the same range, field of view, slice thickness, and convolution algorithm. Two independent observers blindly quantified EAT volume using commercially available software. Data were compared with paired sample Student t-test, concordance correlation coefficients (CCC), and Bland-Altman plots. Results No statistically significant difference was observed for EAT volume quantification with low-dose-CT (141.7 ± 58.3 mL) with respect to ECG-gated CT (142.7 ± 57.9 mL). Estimation of CCC showed almost perfect concordance between the two techniques for EAT-volume assessment (CCC, 0.99; mean difference, 0.98 ± 5.1 mL). Inter-observer agreement for EAT volume estimation was CCC: 0.96 for low-dose-CT examinations and 0.95 for ECG-gated CT. Conclusion Non-gated low-dose CT allows quantifying EAT with almost the same concordance and reliability as using dedicated prospectively ECG-gated cardiac CT acquisition protocols.

Despite a more physiological morphology of atrial anastomosis in the bicaval technique with respect to standard biatrial anastomosis in orthotopic heart transplantation (OHT), the impact on the long-term outcome is still not clear. In this retrospective study, we sought to investigate the morphology and function of the atria through magnetic resonance imaging (MRI) and transthoracic echocardiography (TTE). Moreover, we aimed to analyse the accuracy of TTE with respect to MRI. Cox regression analysis of 216 consecutive patients receiving OHT between August 1987 and January 2010 identified only recipient age at the time of transplant to be an independent predictor of mortality (P = 0.048, odds ratio = 1.04). After a mean follow-up of 96.6 ± 77.7 months, 108 patients were alive, of which 35 were found to be eligible for MRI assessment. In this analysis, left and right atrial volumes were found to be significantly larger in the standard group in comparison with the bicaval group (P = 0.001), and no significant difference between the two techniques was observed in left and right atrio-ventricular output. Moreover, a significantly reduced accuracy was observed (CCC