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Fibrinolysis can be abnormally activated in several critical care settings but it's often misdiagnosed by standard laboratory tests. Although rotational thromboelastometry can assess the whole coagulative process, its ability to detect fibrinolysis has been questioned. Aim of this study was to investigate the ability of thromboelastometry in detecting induced fibrinolysis in an in-vitro model. Whole blood samples were taken from 18 healthy volunteers. Each sample was split and added with increasing urokinase concentrations till to reach 0, 50, 75 and 100 IU/ml. Thromboelastometry tests, extem and aptem, were performed on the obtained samples. If significant lysis at 50 IU/ml was recorded, also 10, 25 and 35 IU/ml drug concentrations were tested. No lytic effects were detected in 10 IU/ml samples. Lysis variables were the most sensitive in detecting fibrinolysis even at 25 IU/ml (P

The mechanisms by which closed chest cardiac massage produces and maintains blood flow during cardiopulmonary resuscitation are still debated. To date, two main theories exist: the “cardiac pump”, which assumes that blood flow is driven by direct cardiac compression and the “chest pump”, which hypothesizes that blood flow is caused by changes in intrathoracic pressure. Newer hypotheses including the “atrial pump”, the “lung pump”, and the “respiratory pump” were also proposed. We reviewed studies supporting these different theories as well as the clinical evidences on the utility of mechanical devices proposed to optimize cardiopulmonary resuscitation, in view of their pathophysiological assumptions with regard to the underlying theory. On the basis of current evidence, a single theory is probably not sufficient to explain how cardiac massage produces blood flow. This suggests that different simultaneous mechanism might be involved. The relative importance of these mechanisms depends on several factors, including delay from collapse to starting of resuscitation, compression force and rate, body habitus, airway pressure, and presenting electrocardiogram. The complexity of the physiologic events occurring during cardiopulmonary resuscitation, together with the need of adequate training for a correct and prompt utilization of mechanical devices, might also partially explain the disappointing results of these devices in most clinical studies.

Background Patients undergoing cardiac surgery are subject to severe alterations of the coagulation system. The four cardiac surgery centers in Tuscany (Italy) structured and shared an algorithm (Granducato Patient Blood Management algorithm, G-PBMa) with predefined interventions for patient blood management. The aim of the study is to analyze the impact of that algorithm on the transfusion needs and bleeding-related outcomes in a large patient population. Methods Multicenter retrospective observational study on 3839 patients undergoing cardiac surgery at the four cardiac centers in Tuscany. The G-PBMa was released at the end of 2015 and it was structured in three parts: pre-, intra-, and post-operative. The year 2014, before the G-PBMa (1955 patients) and the year 2016 (1884 patients) after the G-PBMa in place were compared. Logistic regression analyses were used. Results The main changes introduced were the routine application of viscoelastic tests in bleeding patients (+72%) and the use of fibrinogen and prothrombin complex concentrate (+67%). The G-PBMa resulted in a significant reduction in the overall transfusion rate and in the transfusion rate of the separate blood products (relative risk for transfusions: 0.75, 95% confidence interval 0.65–0.85, P = 0.001). For preoperative hemoglobin values of between 8 and 10 g/dL, the absolute difference in RBC transfusion rate before and after the G-PBMa introduction ranged around 15%–17%. The G-PBMa introduction determined lower ( P = 0.02) chest drain blood loss, lower ( P = 0.001) postoperative acute kidney injury and shorter ( P = 0.001) hospital stay. Conclusions The G-PBMa was effective in reducing blood loss, transfusion requirements, and resulted in a better outcome.

Purpose Use rationally the Red Marrow (RM) and Whole Body (WB) dosimetry pre and during therapy in Differentiated Thyroid Cancer (DTC) focalinzing the relationship between clinical parameters. Methods We enrolled 120 patients (278 dosimetries-196 with complete clinical data) with DTC (March 2012–December 2017). We made double dosimetric study the week before the therapy (19 MBq 131I) and during therapy (range 1019–9342 MBq, mean 6253 MBq, median 6208 MBq), collecting serial blood samples and WB counts according to the AIFM Italian dosimetric protocol and EANM SOP. With a simple regression analysis, we studied the capability of residence times (tau) and mGy/MBq (RM and WB) to predict the respective post therapy values (Fig. 1). We moreover considered a multivariate multiple regression model to control for clinical values (sex, age, histology, variant, multifocality, bilaterality, Tsh Ipo, Tg Ipo, FT4, staging and another tumour). Results All the variables pre-treatment have a significant role in explaining the levels of the corresponding variables post-treatment (Fig. 1). For all the variables, a PRE unitary increase determines a much smaller increase in post values (from 0.3 to 0.5). When considering all the variables as possible predictors (Table 1), none of them seems to have an effect on WBposttau, apart from WBpretau. For RMposttau, instead, we found correlation with RMpretau, WBpretau, age and the presence of another tumour. Concerning WBpostmGyMBq and RMpostmGyMBq, both appear to be reduced for N1b staging; WBpostmGyMBq reduced for advanced tumours and increased for large values of WBpretau. RMpostmGyMBq increases with age and RMpretau. A large parte of the total variability of WBpostmGyMBq and RMpostmGyMBq remains unexplained. Conclusions Dosimetry connected with clinical values could be a useful tool to help in patient management to predict behaviour and efficacy. Mandatory next step is to study follow up. Download : Download high-res image (220KB) Download : Download full-size image

In the framework of the 3-year project of the Italian Legatumori (2003-2006), we evaluated the diagnostic accuracy of computed tomography (CT) colonography in detecting colorectal lesions in a screening population with positive faecal occult blood test (FOBT).Two hundred and thirty asymptomatic subjects (age range 45-80 years) were enrolled in the study. CT colonography was performed with standard patient preparation (no faecal tagging) and a 4-detector-row CT scanner. Image analysis was carried out with primary 2D analysis and the use of 3D endoluminal views to solve difficult cases. Patients were referred for conventional colonoscopy in the following situations: detection of three or more suspected lesions with maximum diameteror=6 mm; evidence of one or more lesions with maximum diameter6 mm; presence of colonic masses (maximum diameter3 cm).CT colonography detected colonic masses in 12 out of 135 subjects (8%). It generated 93 false positives and 19 false negatives in the identification of diminutive lesions (or=6 mm), and 70 false positives and six false negatives in lesions6 mm. Sensitivity was 83% in smaller lesions and 93% in lesions6 mm; specificity was 45% and 59%, respectively.In a screening population with positive FOBT, CT colonography without faecal tagging and no definite size threshold for the reporting of polyps showed very low specificity but high sensitivity in the detection of all colorectal lesions.

Objectives: To develop a consensus and provide updated recommendations on liver MR imaging and the clinical use of liver-specific contrast agents. Methods: The European Society of Gastrointestinal and Abdominal Radiology (ESGAR) formed a multinational European panel of experts, selected on the basis of a literature review and their leadership in the field of liver MR imaging. A modified Delphi process was adopted to draft a list of statements. Descriptive and Cronbach’s statistics were used to rate levels of agreement and internal reliability of the consensus. Results: Three Delphi rounds were conducted and 76 statements composed on MR technique (n = 17), clinical application of liver-specific contrast agents in benign, focal liver lesions (n = 7), malignant liver lesions in non-cirrhotic (n = 9) and in cirrhotic patients (n = 18), diffuse and vascular liver diseases (n = 12), and bile ducts (n = 13). The overall mean score of agreement was 4.84 (SD ±0.17). Full consensus was reached in 22 % of all statements in all working groups, with no full consensus reached on diffuse and vascular diseases. Conclusions: The consensus provided updated recommendations on the methodology, and clinical indications, of MRI with liver specific contrast agents in the study of liver diseases. Key points: • Liver-specific contrast agents are recommended in MRI of the liver. • The hepatobiliary phase improves the detection and characterization of hepatocellular lesions. • Liver-specific contrast agents can improve the detection of HCC., SCOPUS: ar.j, info:eu-repo/semantics/published

The role of diffusion-weighted magnetic resonance imaging (DWI) to differentiate breast lesions in vivo was evaluated. Sixty women (mean age, 53 years) with 81 breast lesions were enrolled. A coronal echo planar imaging (EPI) sequence sensitised to diffusion (b value=1,000 s/mm(2)) was added to standard MR. The mean diffusivity (MD) was calculated. Differences in MD among cysts, benign lesions and malignant lesions were evaluated, and the sensitivity and specificity of DWI to diagnose malignant and benign lesions were calculated. The diagnosis was 18 cysts, 21 benign and 42 malignant nodules. MD values (mean +/- SD x 10(-3) mm(2)/s) were (1.48 +/- 0.37) for benign lesions, (0.95 +/- 0.18) for malignant lesions and (2.25 +/- 0.26) for cysts. Different MD values characterized different malignant breast lesion types. A MD threshold value of 1.1 x 10(-3) mm(2)/s discriminated malignant breast lesions from benign lesions with a specificity of 81% and sensitivity of 80%. Choosing a cut-off of 1.31 x 10(-3) mm(2)/s (MD of malignant lesions -2 SD), the specificity would be 67% with a sensitivity of 100%. Thus, MD values, related to tumor cellularity, provide reliable information to differentiate malignant breast lesions from benign ones. Quantitative DWI is not time-consuming and can be easily inserted into standard clinical breast MR imaging protocols.

To evaluate the effectiveness of the iPad (Apple Inc., Cupertino, CA) for two-dimensional (2D) reading of CT angiography (CTA) studies performed for suspected acute non-variceal gastrointestinal bleeding.24 CTA examinations of patients with suspected acute gastrointestinal bleeding confirmed (19/24, 79.2%) or ruled out (5/24, 20.8%) by digital subtraction angiography (DSA) were retrospectively reviewed by three independent readers on a commercial picture archiving communication system (PACS) workstation and on an iPad with Retina Display® 64 GB (Apple Inc.). The time needed to complete reading of every CTA examination was recorded, as well as the rate of detection of arterial bleeding and identification of suspected bleeding arteries on both devices.Overall, the area under the receiver operating characteristic curve, sensitivity, specificity, positive- and negative-predictive values for bleeding detection were not significantly different while using the iPad and workstation (0.774 vs 0.847, 0.947 vs 0.895, 0.6 vs 0.8, 0.9 vs 0.944 and 0.750 vs 0.667, respectively; p 0.05). In DSA-positive cases, the iPad and workstation allowed correct identification of the bleeding source in 17/19 cases (89.5%) and 15/19 cases (78.9%), respectively (p 0.05). Finally, the time needed to complete reading of every CTA study was significantly shorter using the iPad (169 ± 74 vs 222 ± 70 s, respectively; p 0.01).Compared with a conventional PACS workstation, iPad-based preliminary 2D reading of CTA studies has comparable diagnostic accuracy for detection of acute gastrointestinal bleeding and can be significantly faster.The iPad could be used by on-call interventional radiologists for immediate decision on percutaneous embolization in patients with suspected acute gastrointestinal bleeding.

A 45-year-old man presented with a 1-week history of gastrooesophageal reflux, epigastric discomfort and abdominal pain especially in the right hypochondrium. Abdominal ultrasonography, contrast-enhanced spiral computed tomography and magnetic resonance imaging of the abdomen were performed. Eventually, imaging findings were correlated with histopathological analysis, which confirmed the diagnosis of a 18 cm x 16 cm hepatocellular adenoma.

In the context of Predictive, Preventive and Personalized Medicine (PPPM), radiologists play an essential role in patient management throughout the different phases of hepatocellular carcinoma (HCC). This includes diagnosis, staging, treatment planning, and evaluation of response to treatment. This chapter provides an in-depth examination of the fundamental pathophysiologic mechanisms underlying the radiologic diagnosis and assessment of HCC. Observations made in contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI), in conjunction with alpha-fetoprotein (AFP) can allow the diagnosis of HCC to be made with confidence without the need for biopsy, in many cases. Treatment decisions and prognosis are strongly influenced by the tumor extension, the number and size of lesions, tumor location, biliary dilatation, ascites, and the presence of macrovascular invasion and extrahepatic tumor spread. In addition, radiologic assessment of co-morbidities and response to previous treatments must be included in the overall assessment. The patient-specific findings from diagnostic imaging and interventional radiology identified in this chapter will be designated as Information Entities (IEs) in later chapters. These IEs will ultimately be used in the generation of Digital Patient Models (DPMs) to facilitate diagnosis, prognosis, and treatment selection, i.e. Model Guided Therapy (MGT) and PPPM.

The aim of our study was to evaluate feasibility and accuracy of colour-coded duplex US in the detection of renal artery stenosis before and after stenting. Eighty-four patients (23 women, 61 men; mean age 64 years) with significant renal artery stenosis were studied with Doppler US, before and after stenting. A combined anterior and translumbar approach was used to visualise the renal arteries. Renal artery stenosis and in-stent restenosis were proved by the increase of renal peak systolic velocity (PSV) and reno-aortic ratio (RAR). Laboratory-specific threshold values of PSV and RAR were used to assess sensitivity and specificity of Doppler US. The renal arteries were visualised in all patients (feasibility 100%). A statistically significant difference of PSV and RAR was demonstrated between patent and stenotic renal arteries, before stenting, and between stenotic and stented renal arteries. No difference was demonstrated in cases of in-stent restenosis ( n=21). Before stenting, sensitivity of PSV and RAR was 93%, whereas specificity rates were 92 and 96%, respectively. After stenting sensitivity and specificity rates were, respectively, 90 and 93% for PSV, and 95 and 95% for RAR. Doppler US represents a feasible and reliable technique in the detection of renal artery stenosis and in-stent restenosis, although laboratory-specific threshold values are required to improve its accuracy.

The objectives of this study were twofold: (a) to assess safety and tolerability of the hepatobiliary MR contrast agent MnDPDP; and (b) to investigate the sensitivity of MnDPDP-enhanced MRI, in comparison with dual-phase spiral CT, in the detection of hepatocellular carcinoma (HCC) in cirrhosis. Fifty patients with liver cirrhosis and histologically proven HCC were enrolled in a prospective phase-IIIB clinical trial. All patients underwent evaluation with dual-phase spiral CT and pre-contrast and post-contrast MRI at 1.5 T. The MR examination protocol included spin-echo (SE) and gradient-recalled-echo (GRE) T1-weighted images acquired before and 60-120 min after administration of 0.5 micromol/kg (0.5 ml/kg) MnDPDP (Teslascan, Nycomed Amersham, Oslo, Norway); and fast T2-weighted SE images obtained solely before contrast injection. Gold standard was provided by findings at Lipiodol CT in combination with follow-up spiral CT studies, which were repeated at 4-month intervals over a 10- to 27-month (mean +/- SD 20.1 +/- 5.1 months) follow-up period. No serious adverse event occurred. Eighty tumors ranging 0.8-9.1 cm in diameter (mean +/- SD 3.2 +/- 2.4 cm) were detected by Lipiodol CT or confirmed as cancerous foci by follow-up CT studies. Pre-contrast MRI detected 38 of 80 lesions (48%); MnDPDP-enhanced MRI, 65 of 80 lesions (81%); pre-contrast plus post-contrast MRI, 69 of 80 lesions (86%); and dual-phase spiral CT, 64 of 80 lesions (80%). The difference between unenhanced and MnDPDP-enhanced MRI was statistically significant (p0.001). The difference between MRI (pre-contrast plus post-contrast) and dual-phase spiral CT was not statistically significant (p = 0.33). The confidence in the final diagnosis, however, was significantly higher for MRI as compared with spiral CT (p0.001). MnDPDP is a safe and well-tolerated hepatobiliary MR contrast agent. Magnetic resonance imaging with use of MnDPDP is significantly more sensitive than unenhanced MRI and as good as dual-phase spiral CT for detection of HCC in cirrhosis.

Since the introduction of helical scanners, CT angiography (CTA) has achieved an essential role in many vascular applications that were previously managed with conventional angiography. The performance of CTA is based on the accurate selection of collimation width, pitch, reconstruction spacing and scan delay, which must be modulated on the basis of the clinical issue. However, the major improvement of CT has been provided by the recent implementation of many post-processing techniques, such as multiplanar reformatting, shaded surface display, maximum intensity projections, 3D perspectives of surface and volume rendering, which simulate virtual intravascular endoscopy. The integration of the potentialities of the scanner and of the image processing techniques permitted improvement of: (a) the evaluation of aneurysms, dissection and vascular anomalies involving the thoracic aorta; (b) carotid artery stenosis; (c) aneurysms of abdominal aorta; (d) renal artery stenosis; (e) follow-up of renal artery stenting; and (f) acute or chronic pulmonary embolism. Our experience has shown that the assessment of arterial pathologies with CTA requires the integration of 3D post-processing techniques in most applications.

Background Recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) is still associated with a dismal outcome. Combination therapy with everolimus (EVL) and vascular endothelial growth factor inhibitor sorafenib (SORA) is based on the role of both b-Raf and mammalian target of rapamycin/protein kinase B pathways in the pathogenesis of HCC and is being investigated in clinical practice. Methods This was a single-center retrospective analysis on LT recipients with unresectable HCC recurrence and undergoing combination therapy with EVL and SORA. Patients were included if they were switched to EVL+SORA at any time after surgery. Primary endpoint was overall survival (OS) after both LT and recurrence, and response to treatment based on the modified Response Evaluation Criteria in Solid Tumors (mRECIST) in the intention-to-treat (ITT) population. Secondary analysis was safety of combination therapy with EVL and SORA in the population of patients who received ≥1 dose of the study drug. Results Seven patients (100% male; median age 53 years [interquartile range (IQR) 9 years]) were considered for analysis. HCC recurrence was diagnosed at a median (IQR) interval since LT of 9 (126) months, and patients were administered EVL+SORA at a median interval since LT of 11 (126) months. Baseline immunosuppression was with tacrolimus (TAC) in 2 patients (28.6%), cyclosporine (CsA) in 2 (28.6%), and EVL monotherapy in 3 (42.8%). At a median (IQR) follow-up of 6.5 (14) months, 5 patients (71.4%) were alive, 4 of them (57.1%) with tumor progression according to the mRECIST criteria. Median (IQR) time to progression was 3.5 (12) months. Two patients died at a median (IQR) follow-up of 5 (1) months owing to tumor progression in 1 patient (14.3%) and sepsis in the other (14.3%). EVL monotherapy was achieved in 6 patients (85.7%), whereas 1patient (14.3%) could not withdraw from calcineurin inhibitor owing to acute rejection. Treatment complications were: hand-foot syndrome in 5 patients (71.4%), hypertension in 1 (14.3%), alopecia in 1 (14.3%), hypothyroidism in 1 (14.3%), diarrhea in 2 (28.6%), pruritus in 1 (14.3%), abdominal pain in 1 (14.3%), rash in 1 (14.3%), asthenia in 3 (42.8%), anorexia in 3 (42.8%), and hoarseness in 2 (28.6%). Adverse events led to temporary SORA discontinuation in 2 patients (28.6%) and to SORA dose reduction in 3 (42.8%). Conclusions Treatment of HCC recurrence after LT with a combination regimen of EVL+ SORA is challenging because of SORA-related complications. Longer follow-up periods and larger series are needed to better capture the impact of such combination treatment on tumor progression and patient survival.

To compare the diagnostic performance of high-frequency ultrasound (HFU) as a first- or second-line diagnostic tool in non-palpable lesions (NPL) of the breast and to define the place of HFU in the diagnostic process, 89 women with this kind of lesion, previously detected by mammography, underwent HFU with 7.5-13 MHz transducers. The examinations were performed by two equally experienced operators of which only one (operator I) was aware of the mammographic findings. The mammographic examinations revealed the following non-palpable lesions: asymmetry-hyperdensity (17 cases), nodule (44 cases), stellate lesion (5 cases), microcalcifications (23 cases). Total sensitivity of HFU in the examinations performed by operator I was 83 %, while in the examinations performed by operator II (unaware of the mammographic findings) it was only 35 %. In all cases HFU allowed the operators to determine the basic features of the lesions. Our experience confirms that ultrasonography, even if performed with high frequency, cannot be proposed as a screening examination but may profitably be employed as a second-step technique to characterize NPL previously identified by mammography. This 'second-step' role can do the following: rule out true pathology (cases of false-positive mammography findings); furnish some basic features in the case of focal lesions; show other findings in the case of microcalcifications, such as microcysts, 'filled duct' appearance, parenchymal inhomogeneities and nodules; guide interventional procedures; and localize lesions preoperatively.

The role of high frequency ultrasound (10–13 MHz) in inflammatory disease of the breast is described. Forty-six patients with inflammatory breast problems were examined using both 10–13 and 7.5 MHz ultrasound; 39 patients also had mammography, 15 ultrasound-guided biopsy and 1 ductography. The diagnosis of inflammatory disease was confirmed by clinical and imaging follow-up only in 31, by cytology in 13 and at open surgical biopsy in 2. Diffuse mastitis imaged with 10–13 MHz ultrasound showed the following features: lymphatic involvement with (4 patients) or without (13 patients) a complex mass, ductal involvement with (1 patient) or without (4 patients) a complex mass, and ductal involvement associated with a complex mass and lymphangiectasia (1 patient). Focal mastitis imaged at 10–13 MHz demonstrated the following features: a complex predominantly solid mass (11 patients), a focal lesion with a predominantly fluid content (9 patients) and circumscribed ductal involvement with (1 patient) or without (2 patients) lymphangiectasia. Ultrasound imaging at 7.5 MHz failed to demonstrate lymphatic involvement in 15 of 19 patients and ductal involvement in all the patients. No difference was observed in the detection of axillary nodes at 7.5 MHz and 13 MHz. Ultrasound imaging at 7.5 MHz failed to identify focal solid lesions with a diameter of more than 10 mm in 2 of 6 patients. Ultrasound imaging at 7.5 MHz identified the nature of a solid mass in only 4 of 14 patients. We conclude that high frequency ultrasound (10–13 MHz) is effective, and more useful than conventional ultrasound at 7.5 MHz, in differentiating infection from lymphatic obstruction in patients with breast inflammation.

Objectives: Early assessment of hepatocellular carcinoma (HCC) response during sorafenib (SO) treatment is challenging, since tumor necrosis, extension and radiological appearance can be inhomogeneous. We evaluated the predictive value of different imaging criteria - such as Response Evaluation Criteria in Solid Tumors (RECIST) 1.1, European Association for the Study of the Liver (EASL), modified RECIST (mRECIST), tumor density and volume variations - in the early follow-up of SO treatment. Methods: The study included 22 patients. CT images from baseline and 2 months were reviewed to assess response according to RECIST 1.1, mRECIST, EASL, Choi's criteria (decreased tumor density by ≥15%) and arterial-enhancing tumor volume ratio; α-fetoprotein (AFP) variations were expressed as AFP ratio. Results: The response criteria and volume measurements were reproducible (k > 0.80). The overall disease control rate was 40.9% by EASL and mRECIST, and 27.3% by RECIST 1.1; a ≥15% decrease in tumor density was observed in 9 patients (40.9%). The mean volume ratio was 1.73 ± 2.12, the mean AFP ratio 14 ± 37. The 1-year survival rate was 65.9%. Volume ratio was the only predictive factor for survival, with 1-year cumulative survival rates of 90% for volume ratios ≤1.1 and of 45.4% for volume ratios >1.1 (p = 0.04). Conclusions: Tumor volume measurements are reproducible and might provide an early predictive marker of response in HCC patients treated with SO.

OBJECTIVES--To compare the usefulness of high resolution computed tomography (HRCT) with chest radiography (CR) in the diagnosis and assessment of severity of silicosis. METHODS--27 workers exposed to silica underwent CR, HRCT, and pulmonary function tests. Two experienced readers independently evaluated CR by International Labour Office classification, and grouped the results into four categories. HRCT categories of nodule profusion and the extent of emphysema were graded on a four point scale; in 20 subjects the percentage distribution of lung densities were measured by HRCT. RESULTS--Concordance between readers was higher for HRCT than for CR (K statistic = 0.49 and 0.29 respectively). There was poor concordance between CR and HRCT in the early stage of silicosis. No significant difference in pulmonary function tests was found among different CR categories, but forced expiratory volume in one second (FEV1), maximal expiratory flow at 50% and 75% of FVC (MEF50, MEF75), and diffusion capacity significantly decreased with increasing HRCT categories. Subjects with simple silicosis detected by HRCT had a lower FEV1 than subjects without silicosis, whereas subjects with conglomerated silicosis showed higher residual volume and functional residual capacity than subjects with simple silicosis. These relations were not affected by smoking or symptoms of chronic bronchitis. Different grades of emphysema detected by HRCT were significantly different in diffusion capacity. Only the HRCTs of the lowest and the highest categories of profusion of parenchymal opacities were significantly different in their distribution of density classes. CONCLUSION--HRCT is more reproducible and accurate than CR, as suggested by the higher agreement between readers and the better correlation with pulmonary function tests, irrespective of smoking and chronic bronchitis; however, these data do not support the hypothesis that HRCT is more sensitive than CR in the early detection of silicosis.

To evaluate usefulness of pirenzepine, a selective M1 antimuscarinic drug, for diagnostic double-contrast study of the upper gastrointestinal tract, pirenzepine and scopolamine methylbromide (SMB) were compared in a single blind randomized trial. Seventy consecutive patients were enrolled in the study. Artifacts, bowel distention, painting of stomach and duodenal bulb, and global quality of the images were blindly evaluated by four independent observers by means of a numerical score (1-4). Under SMB slightly but significantly better results for stomach were scored (3.1 +/- .7 vs. 2.7 +/- 7, p0.01). No differences were found in the study of the duodenal bulb. Heart rate and rhythm during the study were recorded by electrocardiogram (ECG). SMB induced tachycardia in all patients (from 77 +/- 20 to 117 +/- 28 beats/min, p0.01) while pirenzepine did not (from 77 +/- 16 to 81 +/- 23, p = NS). After SMB, two patients exhibited faintness, and some patients complained of visual accommodation defects, dryness of the mouth, and dizziness. Thus, pirenzepine provides good results in double-contrast studies (equal to SMB), while presenting no adverse effects. It could be proposed as a first choice hypotonic agent in upper gastrointestinal examination.

The aim of this study was to investigate the usefulness of unenhanced and enhanced MR imaging in evaluating the response of hepatocellular carcinoma to percutaneous injection of ethanol.Thirty-one patients with 40 hepatocellular carcinomas less than 5 cm in diameter were examined with MR imaging before and after percutaneous injection of ethanol. Unenhanced T1- and T2-weighted and contrast-enhanced T1-weighted spin-echo images were obtained. CT and percutaneous biopsy were performed 1 month after the final injection of ethanol and repeated at 6-month intervals to establish the outcome of treatment: complete tumor necrosis was shown in 36 lesions and incomplete tumor necrosis was seen in four lesions.Of the 36 proved necrotic lesions, 31 showed homogeneously low signal intensity on T2-weighted MR images obtained after treatment, owing to coagulative necrosis of the tumor. In the remaining five necrotic lesions, hypointense and hyperintense areas coexisted; the hyperintense areas were caused by liquefactive necrotic material in two cases and by chronic inflammatory tissue along the boundary of the necrotic area in three cases. None of the 36 necrotic lesions showed contrast enhancement on T1-weighted images obtained after IV injection of gadopentetate dimeglumine. In the four lesions with incomplete necrosis, the viable portion of the tumor was identified as a hyperintense area on T2-weighted images and as an enhancing area on contrast-enhanced T1-weighted images. No correlation was found between lesion features on unenhanced T1-weighted images and outcome of therapy.Contrast-enhanced T1-weighted MR images allow a reliable evaluation of the effectiveness of treatment and are more accurate than unenhanced MR studies. Contrast-enhanced MR imaging may be considered a valuable alternative to contrast-enhanced CT in the follow-up of hepatocellular carcinomas treated with percutaneous injection of ethanol.

Reproducibility of the aqueductal CSF signal intensity on a gradient echo cine-MR sequence exploiting through plane inflow enhancement was tested in 11 patients with normal or dilated ventricles. Seven patients with normal pressure hydrocephalus (NPH) syndrome were investigated with the sequence before and after CSF shunting. Two patients exhibiting central flow void within a hyperintense aqueductal CSF improved after surgery and the flow void disappeared after shunting. One patient with increased maximum and minimum aqueductal CSF signal as compared to 18 healthy controls also improved and the aqueductal CSF signal was considerably decreased after shunting. Three patients with aqueductal CSF values similar to those in the controls did not improve, notwithstanding their maximum aqueductal CSF signals decreasing slightly after shunting. No appreciable aqueductal CSF flow related enhancement consistent with non-communicating hydrocephalus was found in the last NPH patient who improved after surgery. Cine-MR with inflow technique yields a reproducible evaluation of flow-related aqueductal CSF signal changes which might help in identifying shunt responsive NPH patients. These are likely to be those with hyperdynamic aqueductal CSF or aqueductal obstruction.

During a 5-year period 229 aneurysms of the abdominal aorta were identified by ultrasonography (US) and subsequently submitted to CT. Of these, 41 were seen to be of the inflammatory type on the grounds of the CT scans, confirmed in 29 cases by surgical findings. The patients were 38 men and 3 women, mean age 64.9 years. US, performed using both 3.5 and 5 MHz probes, revealed the inflammatory nature of the aneurysm in 33 of 41 cases (80.5%). In the remaining cases a correct diagnosis could not be determined because of obesity and/or the distal location of the lesion. Regarding the complications associated with the inflammatory nature of the aneurysm (considered only in those cases submitted to surgery) US revealed a good diagnostic accuracy for ureteral involvement (7/7 cases detected, no false positives). Caval involvement was also correctly identified in 6 of 8 cases, although overestimated in 3 of 21. Both of these complications were correctly detected by CT in all cases. Neither US nor CT furnished reliable signs regarding duodenal and colonic involvement (surgically proven in 4 of 29 cases). US proved effective in detecting the inflammatory nature of the aneurysm. If surgery is considered, CT seems mandatory for a correct assessment of the complications.

A Short TI Inversion Recovery (STIR) sequence with spin-echo data collection was compared to a conventional cardiac gated long TR spin-echo (SE) sequence for detecting intramedullary signal abnormalities. The cervical ( n = 48), cervico-thoracic ( n = 1), and thoraco-lumbar ( n = 18) spinal cord was imaged in a sagittal plane with a 0.5 T ( n = 61) or 1.5 T ( n = 6) MRI unit in 67 patients with clinical evidence of myelopathy of different etiologies (e.g., multiple sclerosis, trauma, herniated intervertebral disk, spondylosis, etc.). In all patients, ungated double or quadruple echo STIR images (TR 1000–1400 msec, TI 100 msec, TE 30–60 or 30–60–90–120 msec) were compared with cardiac gated long TR (1400–2100 msec), double echo (30–100, 50–100, or 50–150 msec) SE images with first order flow compensation for the second echo. Although STIR images appeared “noisier” than long TR SE images, they showed fewer ghost artifacts. In 55 patients, single or multiple, focal or diffuse, hyperintense areas within the spinal cord were observed on both long TR SE and (magnitude reconstructed) STIR images. Lesion conspicuity was better on the STIR images in 25 patients, better on the SE images in 14 patients, and equal in 16. STIR sequence provides a valuable alternative to gated long TR SE sequence for the MRI investigation of intramedullary spinal lesions.

The diagnosis of hepatocellular carcinoma is based on imaging examinations in combination with clinical and laboratory findings. Despite technological advances, imaging cirrhotic patients remains a challenging issue, since preneoplastic hepatocellular lesions, such as dysplastic nodules, mimic a small hepatocellular carcinoma. One of the key pathologic factors for differential diagnosis that is reflected in imaging appearances is the vascular supply to the lesion. It is accepted that imaging techniques may establish the diagnosis of hepatocellular carcinoma in nodules larger than 1 cm showing arterial hypervascularization and venous wash-out. In lesions that do not show a typical pattern, biopsy is still recommended. Contrast-enhanced ultrasound, spiral computed tomography or dynamic magnetic resonance imaging are required for characterization of lesions in cirrhotic liver. However, during the development of hepatocellular carcinoma, significant histological changes are present with or without an evident arterial supply of the nodule. Due to the ability of magnetic resonance to investigate differences in soft tissues and to exploit the properties of tissue-specific contrast agents, this imaging modality is particularly useful in the demonstration of the pathologic changes that take place at the histological level and at the level of the biliary and reticuloendothelial systems during carcinogenetic process in liver cirrhosis.

Progressive multifocal leukoencephalopathy (PML) is a severe demyelinating disease of the central nervous system due to JC polyoma virus infection of oligodendrocytes. PML develops in patients with impaired T-cell function as occurs in HIV, malignancy or immunosuppressive drugs users. Until now no imaging methods have been reported to correlate with clinical status. Diffusion-weighted imaging (DWI) is a robust MRI tool in investigating white matter architecture and diseases. The aim of our work was to assess diffusion abnormalities in focal white matter lesions in patients with PML and to correlate the lesion load measured with conventional MRI and DWI to clinical variables. We evaluated eight patients with a biopsy or laboratory-supported diagnosis of PML. All patients underwent MRI including conventional sequences (fluid attenuated inversion recovery-FLAIR) and DWI. Mean diffusivity (MD) maps were used to quantify diffusion on white matter lesions. Global lesion load was calculated by manually tracing lesions on FLAIR images, while total, central core and peripheral lesion loads were calculated by manually tracing lesions on DWI images. Lesion load obtained with the conventional or DWI-based methods were correlated with clinical variables such as disease duration, disease severity and survival. White matter focal lesions are characterized by a central core with low signal on DWI images and high MD (1.853 x 10(-3) mm2/s), surrounded by a rim of high signal intensity on DWI and lower MD (1.1 x 10(-3) mm2/s). The MD value of normal-appearing white matter is higher although not statistically significant (0.783 x 10(-3) mm2/s) with respect to control subjects (0.750 x 10(-3) mm2/s). Inter-rater correlations of global lesion load between FLAIR (3.96%) and DWI (3.43%) was excellent (ICC=0.87). Global lesion load on FLAIR and DWI correlates with disease duration and severity (respectively, p=0.037, p=0.0272 with Karnofsky scale and p=0.0338 with EDSS on FLAIR images; p=0.043, p=0.0296 with Karnofsky scale and p=0.0365 with EDSS on DW images). Central core lesion load on DWI correlates with disease duration and severity (respectively p=0.043, p=0.0103 with Karnofsky scale and p=0.0112 with EDSS), while peripheral lesion load does not correlate with any clinical variable. The global lesion load in PML correlates with disease duration and severity. DWI images, which can distinguish within lesions a central core from a peripheral rim, reveal that a larger central core component correlates to a worsened clinical status and longer disease duration. On the other hand the peripheral rim lesion load visualized on DWI images does not correlate with clinical variables and does not achieve obtaining further prognostic information with respect to conventional imaging.

Transgenic Centre for Research in Neurodegenerative Diseases 8 (TgCRND8) mice expressing a double mutant form of human amyloid precursor protein represent a good model of Alzheimer's disease, and can be useful to clarify the involvement of mitogen-activated protein kinases (MAPK) dysregulation in the pathophysiology of this neurodegenerative disorder. Activation of extracellular regulated kinase (ERK) 1/2, jun kinase (JNK) and p38MAPK was studied in the hippocampus of 7-month-old TgCRND8 mice by immunohistochemistry and Western blot analysis using antibodies selective for the phosphorylated, and thus active, forms of the enzymes. We demonstrated that the three main MAPK pathways were differentially activated in cells of the hippocampus of TgCRND8 mice in comparison to wild type (Wt) littermates, p38MAPK and JNK being more activated, while ERK less activated. p38MAPK was significantly activated in microglia, astrocytes and neurons, around and distant from the plaques. JNK was highly activated in cells closely surrounding the plaques. No difference was observed in the activation of the two major bands of JNK, at a molecular weight of 46 kDa and 54 kDa. These data indicate the possible involvement of p38MAPK and JNK pathways dysregulation in the pathogenesis of Alzheimer's disease. The ERK2 isoform of the ERK pathway was less activated in the hippocampal dentate gyrus of Tg mice in basal conditions. Furthermore activation of the ERK pathway by ex vivo cholinergic stimulation with carbachol caused significantly higher activation of ERK in the hippocampus of Wt mice than in Tg mice. These findings may pose a molecular basis for the memory disruption of Alzheimer's disease, since proper functioning of the basal forebrain cholinergic neurons and of ERK2 is critical for memory formation.

I mezzi di contrasto per la risonanza magnetica sono sostanze dotate di suscettibilità magnetica positiva e cioè capaci di indurre una magnetizzazione aggiuntiva, un flusso che si somma a quello del campo magnetico principale entro it quale tali sostanze vengono introdotte. Esse sono caratterizzate da un certo numero di elettroni non appaiati negli orbitali e hanno quindi momento magnetico di-verso da 0. Interagendo con i protoni di idrogeno risonanti esse ne modificano i tempi di rilassamento facilitando la transizione da livello energetico maggiore a minore (rilassamento nucleare). L'entità di tale effetto viene denominata «efficacia rilassante» e risulta proporzionale, oltre che al momento magnetico, anche alla distanza ed al tempo di interazione tra molecola di mezzo di contrasto e idrogenioni in rilassamento. I mezzi di contrasto per la risonanza magnetica possono essere suddivisi in 3 classi: paramagnetici, superparamagnetici, ferromagnetici. I mezzi di contrasto paramagnetici, alle concentrazioni normalmente in uso, facilitano gli scambi spin-reticolo agendo come accettori di energia e vengono quindi denominati agenti T1: essi determinano accorciamento del tempo di rilassamento T1 e quindi aumento dell'intensità di segnale del tessuto in cui diffondono. Essi possiedono momento magnetico singolo, sono privi di memoria magnetica, vengono veicolati in acqua e risultano tossici allo stato ionico. La detossificazione è effettuata mediante chelazione con gruppi organici e comporta una riduzione dell'efficacia rilassante per l'aumentata distanza fra Tone e nuclei risonanti, conseguente all'interposizione del chelante stesso. Il Gd-DTPA è il primo agente T1 introdotto nella pratica clinica: esso è un chelato anionico che, in base alle dimensioni molecolari e all'idrofilia, si distribuisce al comparto extracellulare, alla cui entità risulta proporzionale la sua influenza sul segnale. Da notare che, come già i mezzi di contrasto iodati, il Gd-DTPA nel Sistema Nervoso Centrale non supera in condizioni fisiologiche la barriera ematoencefalica; questo avviene in situazioni patologiche (flogistiche, tumorali, ecc.) con relativa impregnazione dell'area di interesse. Alle concentrazioni attualmente in uso (SNC 0,1 millimoli Kilo; Body 0,2 millimoli Kilo) gli effetti collaterali sono risultati rani e di modesta entità. I mezzi di contrasto superparamagnetici e ferromagnetici sono sostanze che facilitano gli scambi spin-spin agendo come disaggregatori di omogeneità e vengono pertanto denominati agenti T2: essi determinano prevalentemente accorciamento del tempo di rilassamento T2 e quindi diminuizione dell'intensità del segnale del tessuto in cui si localizzano. Essi possiedono momento magnetico plurimo (dominio) con memoria magnetica per i ferromagnetici, senza memoria per i superparamagnetici. Sono particelle in fase solida (magnetite, disprosio) ancora in sperimentazione su animali, che introdotte per via endovenosa vengono fagocitate a livello del sistema reticolo-endoteliale in rapporto alle loro dimensioni, espletando la loro azione a livello epatico, splenico e midollare osseo e quindi prive di interesse neuroradiologico.

This study was performed to evaluate the accuracy of multidetector computed tomography (MDCT) in detecting parathyroid lesions in patients with primary hyperparathyroidism.We included 60 patients with primary hyperparathyroidism. Preoperative first-line examinations revealed negative and doubtful ultrasound (US) findings in 34 and 26 cases, respectively, and negative, doubtful and positive scintigraphic findings in 19, 20 and 21 cases, respectively. CT findings were compared with the surgical results.CT examination was positive in 35 cases, negative in 15 cases and doubtful in ten cases. Forty out of 60 patients underwent surgery, and 39 lesions (37 adenomas, two primary hyperplasias) were identified. Surgery was negative in two cases. In eight cases, lesions had ectopic location. Surgery confirmed the CT findings in 23 positive cases. In 8/10 doubtful cases, surgery confirmed the location of the lesion in five cases, identified the ectopic location of lesions in two cases, and was negative in one case. In 9/15 cases with negative CT findings, surgery identified the lesion in eight cases. Sensitivity, specificity and diagnostic accuracy values were 78%, 25% and 73%, respectively.MDCT is an accurate second-line diagnostic technique in the detection of parathyroid lesions, allowing exploration of the entire cervical and mediastinal regions.

Purpose: To evaluate the ability of multi-detector row computed tomography angiography (CTA) in detecting hepatic artery complications in the follow-up of liver transplant patients, performing volume-rendering as reconstruction technique.Material and Methods: The anatomy of hepatic artery was studied in 27 liver transplant recipients with a four-row CT scanner using the following parameters: collimation, 1 mm; slice width, 1 mm; table feed, 6–8 mm/s; spiral reconstruction time, 0.5 s; reconstruction interval, 0.5 mm; mAs, 160; kVp, 120. Before the study, the patients received 1000 ml of water as oral contrast agent to produce negative contrast in the stomach and the small bowel. A non-ionic contrast medium was infused intravenously at a rate of 5 ml/s with a bolus tracking system. Volume-rendering of hepatic artery was performed with the 3D Virtuoso software.Results: The celiac trunk, the hepatic artery, and the right and left hepatic arteries were successfully displayed in high detail in all patients. Side branches, including small collaterals, and hepatic artery anastomosis could also be readily visualized. Volume-rendered CTA detected six hepatic artery stenoses, two hepatic artery thromboses, and two intrahepatic pseudoaneurysms. In two cases, CT detected hepatic artery stenosis with a diameter reduction of less than 50%, while digital subtraction angiography showed a normal artery.Conclusion: Volume-rendered multi-detector CTA is a promising non-invasive technique, since it allows images of high quality to be generated with excellent anatomical visualization of the hepatic artery and its complications in liver transplant recipients.

The aim of our study was to describe the visualization, normal anatomy, and variations of the ileocecal valve with computed tomographic (CT) colonography to provide information about its optimal imaging. We analyzed data in two- and three-dimensional rendering mode in 71 consecutive patients who underwent routine CT colonoscopy followed by conventional colonoscopy for confirmation of the radiologic findings. Complete visualization of the ileocecal valve was better achieved in the supine than in the prone position (82% vs. 62%, respectively); the ileocecal valve appeared in 64% of cases in the supine position when it was invisible in prone position (p < 0.0001). Partial visualization of the ileocecal valve was possible in 94% of cases. The ileocecal valve was of labial type in 76%, papillary type in 21%, and lipomatous in 3% of cases. The orifice was identified in 53% of ileocecal valves; in two cases of cecal carcinoma, the normal ileocecal valve morphology was grossly disrupted. The ileocecal valve was at least partly visualized by CT colonoscopy in 94% of cases, more frequently in the supine position. Its most common normal morphology is the labial type. The absence of orifice visualization alone is not a specific sign for neoplasia, but its presence helps distinguish physiologic bulging from neoplasia.

P167 Proposal of a modified phenotype-based radiological classification: the magnetic resonance Crohn’s disease severity index (MRCSI) R. Sacco1 *, E. Neri2, R. Scandiffio2, L. Faggioni2, M. Bertini1, A. Romano1, F. Costa3, G. Federici1, G. Parisi1, S. Marchi3, G. Bresci1, C. Bartolozzi2. 1Gastroenterology and Metabolic Diseases, Gastroenterology, Pisa, Italy, 2Pisa University Hospital, Radiology, Pisa, Italy, 3Pisa University Hospital, Gastroenterology, Pisa, Italy

Poster: "ECR 2013 / C-0700 / Liver Perfusion CT for Noninvasive Assessment of Response to Sorafenib Therapy in Patients with Advanced HCC: Preliminary Findings" by: "F. Pancrazi1, B. Ginanni1, P. Vagli1, L. Faggioni1, R. Sacco1, I. Bargellini1, G. Bresci1, E. Neri2, C. Bartolozzi1; 1Pisa/IT, 2Pisa, -/IT"

Virtual endoscopy is a technique developed for providing a simulation of fiberoptic endoscopy, and is obtained by processing CT, MR, or US data sets (RUBIN 1996; YUH 1999). Using dedicated computer programs it is possible to fly through or around 3D objects; the anatomical structure to display from the inside is selected by means of a data-set segmentation obtained with 3D processing techniques based on surface or volume rendering.

The purpose of this study is to review the role of the percutaneous interventional procedures in the treatment of vascular complications after orthotopic liver transplantations (OLT). Vascular complications, such as arterial stenosis and venous thrombosis, which occur in approximately 1% to 10% of liver transplant patients, are associated with a higher risk of graft dysfunction. Percutaneous interventional procedures, including angioplasty, local thrombolysis, and embolization, are useful to manage these complications. A reduced blood loss and a low incidence of procedural complications allow for rapid recovery. Hepatic arterial and portal vein anastomotic stenosis can be treated effectively by means of balloon dilation; stenting has also been proposed, particularly for venous complications. Infusional local thrombolysis may be useful in venous thrombosis. Arteriovenous fistulas, occurring at the level of the anastomosis or after liver biopsy, require intraarterial embolization using microcoils or gelfoam. Timing of the intervention for the treatment of ischemic complications is of outmost importance to guarantee liver functional recovery and avoid irreversible parenchymal injuries. Other interventional procedures may be extremely useful to manage portal hypertension after OLT; for example, by creation of transjugular portosystemic shunts, or, in the case of associated hypersplenism, transarterial embolization of the splenic artery. Finally, in patients with recurrent hepatitis, the transjugular approach has been shown to be safe and effective for liver biopsy, whereas transarterial chemoembolization may be extremely useful to treat recurrent hepatocarcinoma.