[Dynamic contrast-enhanced magnetic resonance imaging of the wrist in early arthritis]

OBJECTIVES

MRI has been proposed as the imaging method of choice to evaluate the long-term outcome in patients with early arthritis. The role of dynamic MRI, performed at presentation, in predicting the outcome of patients with early arthritis has been addressed in the present study.

METHODS

39 patients with early arthritis, involving at least one wrist, were studied with clinical visits and laboratory investigations, every 3 months. Dynamic MRI was performed with a low-field (0.2T), extremity-dedicated machine (Artoscan, Esaote, Genova, Italy) equipped with a permanent magnet and with a dedicated hand and wrist coil. During the intravenous injection of Gd-DTPA, twenty consecutive fast images of 3 slices of the wrist were acquired. The synovial contrast enhancement ratio was calculated both as rate of early enhancement (REE) per second during the first 55" and as relative enhancement (RE) at t seconds.

RESULTS

In our cohort of patients, REE and RE were significantly lower than those observed in a historical cohort of 36 patients with active rheumatoid arthritis. In univariate analysis, low RE predicted complete remission of arthritis. In multivariate analysis, fulfillment of RA criteria during follow-up was predicted by high RE. The need for immunosoppressive treatment at the end of follow-up was predicted by both low RE and high REE.

CONCLUSIONS

Dynamic MRI may be used to predict several outcomes of early arthritis involving the wrist.

[Magnetic resonance imaging of the peripheral joints in psoriatic arthritis]

OBJECTIVE

Magnetic resonance imaging (MRI) has been widely used for the evaluation of rheumatoid arthritis (RA), with only a minority of studies considering other types of arthritis. This review is concerned with an evaluation of the MRI appearance of peripheral joints in psoriatic arthritis (PsA).

METHODS

A Medline search was performed to identify all publications from the years 1985 to 2006 concerning MRI of the peripheral joints and PsA. Additional papers were retrieved by scanning the references to the Medline-listed articles. Articles written in English, French, German, and Italian were included.

RESULTS

Most papers studied the hand and wrist, and only few of them were concerned with the knee, foot, temporomandibular joint, and elbow. Patients with PsA showed often, but not always, a pattern of joint inflammation which extended beyond the capsule into the extraarticular tissue. Bone oedema and erosions were less frequent than in RA. In particular, bone oedema at the entheseal junction was seen, especially in the knee. The degree of synovitis, assessed by dynamic MRI, was similar in PsA and RA.

DISCUSSION

Data on MRI of the peripheral joints in PsA are scanty. Only few studies were specifically designed to evaluate the pattern of arthritis in PsA, with most information deriving from papers where different types of arthritis were considered together. An enthesis-related origin of PsA has been proposed in contrast to the primarily synovial inflammation of RA. This pathogenic interpretation is likely to be true, but does not explain all cases of PsA, and needs to be confirmed by further studies.

Reassessment of holoprosencephaly–diencephalic hamartoblastoma (HDH) association

We report on a 23-week fetus with a hypothalamic hamartoma, lobar holoprosencephaly, right anophthalmia, and facial asymmetry, features which are consistent with the holoprosencephaly-diencephalic hamartoblastoma (HDH) association. In an attempt to better delineate HDH, we reviewed 19 published patients with similar features. The HDH clinical spectrum ranges from classic holoprosencephaly with micro/anophthalmia, multiple additional findings in non-contiguous structures and early lethality, to isolated microforms of holoprosencephaly. Associated cephalic features mainly include cortical/neuronal migration defects (39%), meningeal anomalies (28%), brainstem/posterior fossa malformations (22%), dysmorphic ears (41%), facial asymmetry (35%), and hypoplastic mandible (29%). Fifty-three percent of patients have additional extra-cephalic malformations, for example, vertebral/rib segmentation defects (50%), hypo/aplastic lungs (38%), congenital heart defect (29%), and urinary anomalies (29%). HDH shows etiological heterogeneity, that is, teratogenic exposure, chromosome imbalances, autosomal recessive as well as dominant "de novo" mutations. Several features could directly result from a disruptive sequence caused by an early hamartoma which alters the development of forebrain, hindbrain, meninges, and 1st-2nd branchial arches, although the pleiotropic action of genetic/environmental factors cannot be excluded. HDH does not emerge as a distinct syndrome, but other hypotheses, including separate conditions within a common pathway and the developmental field defect theory, are discussed.

How normal are the hands of normal controls? A study with dedicated magnetic resonance imaging

OBJECTIVE

To investigate bone and soft tissue changes in the hands of normal subjects by MRI.

METHODS

Twenty-three normal volunteers (16 women) agreed to be examined. MRI of the hand was performed with a dedicated-extremity 0.2 Tesla device using gradient echo, spin echo and STIR sequences. Joint space width was measured in 16 different locations of the hand. Bone lesions, including bone oedema, ankylosis, and erosions, as well as the presence of tenosynovitis were investigated.

RESULTS

Reproducibility of measures of joint space width was relatively good with an intraclass correlation coefficient of 0.82 and 0.71 in the intra-observer and inter-observer evaluations, respectively. No age- or sex-related differences of joint space were observed. Reproducibility of the readings of bone oedema and tenosynovitis were optimal. Bone oedema and erosions were observed in 2/23 (8.7%) and in 6/23 (26.1%) subjects, respectively. Tenosynovitis of the extensor tendons was present in 1/23 subjects (4.3%), whereas tenosynovitis of the flexor tendons was seen in 4/23 (17.4%).

CONCLUSION

This study demonstrates that joint changes considered to be peculiar of arthritis can be found by MRI in a relevant percentage of healthy subjects. Our data suggest that a control group of healthy subjects should be included in MRI studies on the appearance of the wrist in disease.

Thyroid hormones as molecular determinants of thermogenesis

Thyroid hormones (TH) are major modulators of energy metabolism and thermogenesis. It is generally believed that 3,5,3'-triiodo-l-thyronine (T3) is the only active form of TH, and that most of its effects are mediated by nuclear T3 receptors, which chiefly affect the transcription of target genes. Some of these genes encode for the proteins involved in energy metabolism. However, a growing volume of evidence now indicates that other iodothyronines may be biologically active. Several mechanisms have been proposed to explain the calorigenic effect of TH, but none has received universal acceptance. Cold acclimation/exposure and altered nutritional status are physiological conditions in which a modulation of energy expenditure is particularly important. TH seem to be deeply involved in this modulation, and this article will review some aspects of their possible influence in these conditions.

Thyroid-hormone effects on putative biochemical pathways involved in UCP3 activation in rat skeletal muscle mitochondria

In vitro, uncoupling protein 3 (UCP3)-mediated uncoupling requires cofactors [e.g., superoxides, coenzyme Q (CoQ) and fatty acids (FA)] or their derivatives, but it is not yet clear whether or how such activators interact with each other under given physiological or pathophysiological conditions. Since triiodothyronine (T3) stimulates lipid metabolism, UCP3 expression and mitochondrial uncoupling, we examined its effects on some biochemical pathways that may underlie UCP3-mediated uncoupling. T3-treated rats (Hyper) showed increased mitochondrial lipid-oxidation rates, increased expression and activity of enzymes involved in lipid handling and increased mitochondrial superoxide production and CoQ levels. Despite the higher mitochondrial superoxide production in Hyper, euthyroid and hyperthyroid mitochondria showed no differences in proton-conductance when FA were chelated by bovine serum albumin. However, mitochondria from Hyper showed a palmitoyl-carnitine-induced and GDP-inhibited increased proton-conductance in the presence of carboxyatractylate. We suggest that T3 stimulates the UCP3 activity in vivo by affecting the complex network of biochemical pathways underlying the UCP3 activation.

Novel and recurrent mutations in the integrin beta 4 subunit gene causing lethal junctional epidermolysis bullosa with pyloric atresia

In this study we examined two unrelated patients affected with the lethal variant of junctional epidermolysis bullosa with pyloric atresia (PA-JEB) who were found to carry mutations in the integrin beta4 subunit gene (ITGB4). Although in both patients Northern blot analysis showed only a 50% reduction in the level of ITGB4 transcript, a complete lack (patient 1) or a strong reduction (patient 2) of beta4 immunoreactivity was observed in the skin. Using immunoprecipitation analysis, integrin beta4 could not be visualized in patient 1 cells while a markedly reduced amount (approximately 20%) of normal sized beta4 chains was detected in patient 2. These data suggested the presence of ITGB4 mutations that interfere with both mRNA and protein stability. Using molecular analysis, patient 1 was shown to be a compound heterozygous for a single amino acid deletion (deltaN318) and a not yet identified mutation that induces a very rapid decay of the encoded mRNA transcript. Patient 2 was, instead, a compound heterozygous for a novel 4-bp tandem duplication (4298-4299ins4) and a previously described missense mutation (R252C). Our data support the notion that PA-JEB lethal phenotypes associated with a markedly decreased/absent alpha6beta4 expression can be due not only to the presence of null alleles, but also to specific mutations leading to protein instability and/or altered function.

Power Doppler analysis of tendon vascularization

Forty-nine patients with tendonitis (patellar in 16, quadriceps in two, Achilles in 12, rotator cuff disease in 19) and 47 patients with tenosynovitis (acute tenosynovitis in 25, stenosing tenosynovitis in 22) underwent ultrasound (US) and Power Doppler (PD)-US examination. Spectral analysis of flow signals was performed in all patients. Ten patients (six with tendonitis, four with tenosynovitis) were rewired after medical therapy. Six healthy volunteers were also examined for control purposes. Three different patterns of flow distribution were found in patients with tendonitis and active tenosynovitis. The vessels of tendons without tendon sheaths began with great peduncles at the level of the peritendinous soft tissues and were then distributed inside the tendon (pattern I). A clear peritendinous hypervascular pattern was found in all active tenosynovitis, but no vessels were found inside the tendons (pattern II). In some cases of intratendinous or partial lesions PD-US revealed some vessels located near or inside the lesion (pattern II). On spectral analysis these vessels corresponded to arteries with a low resistance index or small venules. PD-US revealed a significant reduction of flow signals in patients rewired after medical therapy. No pathological flow signals were found either in patients with stenosing tenosynovitis or in the control group. PD-US gives us an in vivo confirmation of tendon vascularity. Spectral analysis adds further information to gray-scale US.

Skeletal muscle mitochondrial free-fatty-acid content and membrane potential sensitivity in different thyroid states: involvement of uncoupling protein-3 and adenine nucleotide translocase

The effect of triiodothyronine (T3) on mitochondrial efficiency could be related to an increase in the concentrations of some proteins, such as uncoupling proteins (UCPs). Free fatty acids (FFA) seem to be a cofactor essential for the uncoupling activity of UCP3. In this paper, we report that the hypothyroidism-hyperthyroidism transition is accompanied by increases: (i) in the endogenous levels of mitochondrial FFA and (ii) in the sensitivity to FFA shown by the mitochondrial respiration rate and membrane potential, which correlated with the level of UCP3 protein. The level of the mRNA for adenine-nucleotide translocase-1 (ANT) was not affected by the thyroid state, while the ANT contribution to FFA-induced changes in mitochondrial uncoupling was low in the hypothyroid and euthyroid states but became more relevant in the hyperthyroid state at the highest concentration of FFA.

c-FLIP efficiently rescues TRAF-2-/- cells from TNF-induced apoptosis

For the past 20 years, it has been known that preparations of Tumor Necrosis Factor alpha (TNF) fail to induce apoptosis due to cytoprotective responses that render cells resistant to its cytotoxic activity. Here we show that TRAF-2-/- embryonic fibroblasts express reduced levels of the anti-apoptotic molecule c-FLIP due to extensive degradation of the protein. Reconstitution of TRAF-2-/- EF with c-FLIP is sufficient for resistance to TNF toxicity. Our results strengthen the role of c-FLIP in protecting cells from the cytotoxic effect of TNF and have implication for the treatment of inflammatory and proliferative disorders.

Uncoupling protein-3 is a molecular determinant for the regulation of resting metabolic rate by thyroid hormone

Thyroid hormones increase energy expenditure, partly by reducing metabolic efficiency. The control of specific genes at the transcriptional level is thought to be the major molecular mechanism. However, both the number and the identity of the thyroid hormone-controlled genes remain unknown, as do their relative contributions. Uncoupling protein-3, a recently identified member of the mitochondrial transporter superfamily and one that is predominantly expressed in skeletal muscle, has the potential to be a molecular determinant for thyroid thermogenesis. However, changes in mitochondrial proton conductance and resting metabolic rate after physiologically mediated changes in uncoupling protein-3 levels have not been described. Here, in a study on hypothyroid rats given a single injection of T(3), we describe a strict correlation in terms of time course between the induced increase in uncoupling protein-3 expression (at mRNA and protein levels) and decrease in mitochondrial respiratory efficiency, on the one hand, and the increase in resting metabolic rate, on the other. First, we describe our finding that uncoupling protein-3 is present and regulated by T(3) only in metabolically relevant tissues (such as skeletal muscle and heart). Second, we follow the time course (at 0, 6, 12, 24, 48, 65, 96, and 144 h) of both uncoupling protein-3 mRNA levels and mitochondrial uncoupling protein-3 density in gastrocnemius muscle and heart. In both tissues, the maximal (12-fold) increase in uncoupling protein-3 density was reached at 65 h. The resting metabolic rate [lO(2)(kg(0.75))(-1)h(-1)] showed the same time course, and at 65 h the increase vs. time zero was 45% (1.316 +/- 0.026 vs. 0.940 +/- 0.007; P < 0.001). At the same time point, gastrocnemius muscle mitochondria showed a significantly higher nonphosphorylating respiration rate (nanoatoms of oxygen per min/mg protein; increase vs. time zero, 40%; 118 +/- 4 vs. 85 +/- 9; P < 0.05), whereas the membrane potential decreased by 8% (168 +/- 2 vs. 182 +/- 4; P < 0.05). These data are diagnostic of mitochondrial uncoupling. The results reported here provide the first direct in vivo evidence that uncoupling protein-3 has the potential to act as a molecular determinant in the regulation of resting metabolic rate by T(3).

An appraisal of magnetic resonance imaging of the wrist in rheumatoid arthritis

OBJECTIVES

To evaluate the role of magnetic resonance imaging (MRI) in the diagnosis, staging, and follow-up of the rheumatoid wrist.

METHODS

A Medline search was performed to identify all publications from the years 1985 to 1999 concerning MRI of the wrist in patients with rheumatoid arthritis (RA). Additional papers were retrieved by scanning the references to the Medline-listed articles. Details of the MRI technique, as well as clinical data, were analyzed and compared.

RESULTS

A total of 55 papers were identified. There were considerable variations in imaging sequence, section type, and slice thickness. Erosions and synovitis were the conditions that mostly profited from the adoption of MRI. Although the visualization of erosions was better detailed with MRI than with conventional radiography, erosions were only rarely related to clinical and laboratory parameters. Another advantage was that synovitis imaging, which can be enhanced by contrast agents, was amenable to quantitation. The extent of the synovial surface and the rate of contrast enhancement in a series of consecutive, rapidly acquired images were the most common measures.

CONCLUSIONS

MRI of the rheumatoid wrist is a useful technique to ascertain the criteria for diagnosis and progression of RA, and to monitor the effects of treatment. Implementation of a standardized protocol could further increase its value.

Changes in bioimpedance analysis after stable refeeding of undernourished anorexic patients

OBJECTIVE

To evaluate bioimpedance analysis (BIA) parameters in patients with anorexia nervosa when undernourished and then after stable refeeding.

DESIGN

Follow-up study.

SUBJECTS

Thirteen patients with anorexia nervosa who were studied when undernourished (body weight (Wt): 36.9+/-5.6kg, body mass index (BMI): 14.8+/-1.8kg/m2) and after stable refeeding (Wt: 52.9+/-7.1kg, BMI: 21.2+/-2.3 kg/m2) compared to 25 well-nourished control women (Wt: 53.7+/-4.9 kg, BMI: 21.1+/-1.3 kg/m2).

MEASUREMENTS

Impedance and phase angle were determined for the whole body (13 patients) and separately for arms and legs (10 patients).

RESULTS

Bioimpedance index (height2/impedance) and phase angle were lower in the undernourished group. Whole-body impedance declined (median, min-max) by 45, 1-151 Ohm after refeeding; the variations of bioimpedance index (BI-Index) were weakly correlated (P < 0.10) with BMI changes. Limb phase angles increased with refeeding, but only changes in whole-body phase angle were correlated (P < 0.025) with the corresponding variations of Wt or BMI.

CONCLUSION

Whole-body phase angle increased after weight recovery of anorexic patients, suggesting the occurence of modifications in the extracellular-to-intracellular water ratio. These changes were proportional to the increase in BMI and Wt.

The anterior tilt of the acromion: radiographic evaluation and correlation with shoulder diseases

The aim of this study was to test whether the anterior tilt of the acromion can be objectively evaluated on lateral radiographs, and whether there is a relation between this anatomical feature and the most common shoulder diseases. Lateral radiographs of 15 dried scapulas were performed in neutral position and with 5 degrees of caudal, cranial, anterior and posterior angulations. Two hundred and forty-three shoulders, both asymptomatic and affected by chronic and post-traumatic impingement, calcific tendinitis and instability, were examined by conventional radiography. The presence of rotator-cuff tears was investigated by sonography. A method was elaborated to obtain reproducible lateral radiographs and to determine the acromial tilt angle. Inter- and intraobserver and inter- and intraoperator variations in measurements were evaluated. Variations in tube angulation produced changes in tilt-angle values on dried scapulas. The average tilt angle for the chronic impingement and the instability groups were significantly different from the post-traumatic, calcific tendinitis and control groups. Rotator-cuff tears were significantly more frequent in the chronic impingement group and related to a more acute tilt angle. The inter- and intraobserver variability coefficients were 0.95 and 0.98, whereas the inter- and intraoperator variability coefficients were 0.94 and 0.96, respectively. Conventional radiography using fluoroscopy for positioning is a well-reproducible method for the evaluation of acromial tilt. There is a significant difference in tilt-angle values between some groups of subjects examined, but the lack of specificity limits the clinical importance of such measurement.

Case report: isolated neurofibrosarcoma of the liver: US, CT and MR findings

Neurofibrosarcomas are rare neoplasms usually associated with von Recklinghausen's disease. In this paper we describe ultrasound (US), computed tomography (CT) and magnetic resonance (MR) appearances of an unusual isolated neurofibrosarcoma of the liver.

US imaging and color Doppler in patients undergoing inhibitory therapy with calcitriol for secondary hyperparathyroidism

The aim of this study was to evaluate the changes in volume, structure, and flow pattern of parathyroid glands in uremic patients with secondary hyperparathyroidism treated with long-term intravenous calcitriol (CTL) therapy. Ultrasonography was used to follow-up volume changes occurring in 18 enlarged glands in 11 patients during an 18-month period; in 6 of these cases, 11 glands were followed-up also with color-Doppler to monitor variations in flow pattern. Vascularization was classified using three grades: grade 0 = no color signal; grade I = vessels covering less than 50 % of glandular cross-sectional area; grade II = vascular signals covering more than 50 % of glandular cross-sectional area. No significant changes in volume were demonstrated during the 18 months of follow-up. On the contrary, significant decrease in flow was observed with almost complete disappearance of color-Doppler signals. This finding related well with the observed decrease in parathormone blood levels. Lack of volume changes during medical therapy demonstrates the inability of US alone to monitor the effect of this treatment on the parathyroid glands. Conversely, the observed intraglandular flow reduction indicates the possibility to use color Doppler to monitor the effects of CLT in uremic hemodialyzed patients with secondary hyperparathyroidism. This imaging procedure can be proposed for follow-up of the response of the parathyroid glands to therapy.

Echotexture of peripheral nerves: correlation between US and histologic findings and criteria to differentiate tendons

PURPOSE

To correlate the histologic structure and echotexture of peripheral nerves and verify if ultrasound (US) findings can be used to differentiate nerve from tendon.

MATERIALS AND METHODS

In an in vitro study, the echotexture of normal peripheral nerves was correlated with the histologic findings. In an in vivo study, US was used to differentiate median nerve from flexor pollicis longus tendon in healthy volunteers (12 male and eight female subjects 7-68 years of age; mean age, 35 years).

RESULTS

US examination of the peripheral nerve specimens showed hypoechoic areas separated by hyperechoic bands. The hypoechoic areas corresponded to neuronal fascicles at histologic examination. This fascicular pattern was clear in all median and ulnar nerves, 15 of 20 vagus nerves, and 19 of 20 sciatic nerves in the volunteers but not in recurrent laryngeal nerves.

CONCLUSION

Peripheral nerves have a typical US pattern that correlates with histologic structure and facilitates differentiation between nerves and tendons.

Normal prostate gland: examination with color Doppler US

PURPOSE

To evaluate the vascular anatomy of the prostate gland with transrectal color Doppler ultrasound (US).

MATERIALS AND METHODS

Thirty-five normal prostate glands were studied. Imaging findings were interpreted on the basis of findings from previous anatomic studies.

RESULTS

Distribution of flow signals within the gland was differentiated into two parenchymal groups of arteries, urethral and capsular. The urethral group entered the prostate at the bladder neck and sent forth branches to supply the periurethral zone and the inner portion of the gland. The capsular group coursed along the anterolateral surface of the prostate and sent forth perforating branches to the outer portion of the gland. Intraprostatic venous signals were seen mainly within the periurethral zone.

CONCLUSION

Transrectal color Doppler US can depict the vascular anatomy of the prostate gland. Knowledge of the normal vascular appearance of the gland should aid in the differentiation of normal from abnormal findings.

Staging of hilar cholangiocarcinoma with ultrasound

The preoperative assessment of the extent of biliary and vascular involvement by hilar cholangiocarcinoma is clinically important because resectability may be limited by tumor extension along the bile ducts into the hepatic parenchyma or to the adjacent hilar vessels. Thirty-five patients with hilar cholangiocarcinoma were studied with ultrasound, and the results were compared with operative findings and other diagnostic modalities. The level of intrahepatic biliary obstruction was determined in 100% of patients with ductal ectasia, and a tumor mass was shown in 37.1%. Imaging and Doppler ultrasound proved accurate in detecting the neoplastic involvement of the portal vein. Both correctly diagnosed portal occlusion and wall infiltration in 4 of 4 and 15 of 18 (83%) patients, respectively, without any false-positives. On the contrary, imaging ultrasound had poor sensitivity in detecting infiltration of the hepatic artery (43%) and metastases in regional lymph nodes (37%), liver (66%), and peritoneum (33%). In conclusion, ultrasound may be valuable in the preoperative staging of hilar cholangiocarcinoma, specially in predicting ductal and portal involvement.

[Evaluation of rheumatoid arthritis of the knee with Doppler color]

Color-Doppler US was used to study the vascularization of the synovial membrane and of the periarticular tissues of the knee in 14 normal subjects and 15 patients with active rheumatoid arthritis. The normal subjects exhibited few spot signals within the connectival spaces surrounding the knee and adjacent to the femoral condyles and to the tibial plates. The signals were mostly arterial and impedance was high because of the absence of inversion of diastole. A hypervascular pattern was detected in 13/15 patients with rheumatoid arthritis as a result of hyperemia associated with inflammation and synovial neoangiogenesis. In these patients, the signals came mostly from the synovial pannus and the soft tissues surrounding the joint. Spectral analysis detected both venous and arterial waveforms with lower resistance than normal (resistive index ranging 0.65 to 0.76). After local treatment, both venous and low-impedance arterial signals were no longer detectable in 4/9 patients with clinical remission. In conclusion, color-Doppler US can support gray-scale US in the assessment of joint inflammation in rheumatoid arthritis patients. Vascular findings seem to correlate well with local symptoms. Color-Doppler US could make a useful tool for monitoring the clinical activity of the disease in selected joints.

Color Doppler sonography of salivary glands

OBJECTIVE

We used color Doppler sonography to evaluate the vascular anatomy of the salivary glands and to analyze physiologic changes that occur during salivary stimulation in normal subjects and the flow alterations that occur in diseased glands.

SUBJECTS AND METHODS

The vascular appearance of the three major salivary glands was examined in healthy volunteers (n = 24); in patients with chronic autoimmune diseases, including Sjögren's syndrome (n = 23) and salivary sarcoidosis (n = 2); and in a variety of benign (n = 49) and malignant (n = 13) nodules. Physiologic changes were assessed in healthy volunteers by means of a stimulation test with lemon and were quantified with color images and spectral analysis. Tumor vascularity was graded on a four-step analog scale of 0 to (+3) and classified as either peripheral or hilar, depending on the distribution of vessels.

RESULTS

In the control subjects, color Doppler imaging accurately reflected the complex vascular anatomy of the salivary glands and showed dramatic changes occurring in parenchymal vessels during lemon stimulation as a result of the intense hyperemia associated with the secretion of saliva. Sjögren's syndrome and sarcoidosis showed a diffuse hypervascular pattern when morphologic changes of salivary parenchyma were seen on gray-scale sonograms. Benign tumors showed a lower grade of vascularity than did malignant tumors. All but one of the hypovascular nodules graded as 0 (n = 8) and + (n = 23) were benign. Conversely, eight of 11 nodules labeled with the highest grade of tumor vascularity (+3) were malignant. When the pattern of tumor flow signals was peripheral, it could be considered specific enough to aid in diagnosing pleomorphic adenoma. Peak systolic velocities greater than 60 cm/sec were never detected in benign tumors and were seen in only 44% of malignant tumors.

CONCLUSION

Color Doppler sonography is a promising technique for analyzing the vascularity of the salivary glands and for characterizing some pathologic conditions. Our experience suggests that color Doppler sonography can provide additional diagnostic information in patients with chronic inflammatory diseases or suspected malignant tumors and can help in differentiating pleomorphic adenomas from other salivary gland tumors.

Split hand/split foot, syndactyly, urinary tract obstruction, radial, diaphragmatic, and neural tube defects: Czeizel-Losonci syndrome?

We report on a baby girl with absence of the left hemidiaphragm, lumbosacral myelomeningocele, syndactyly with limb deficiencies, and bilateral hydronephrosis. A similar array of malformations was described previously by Czeizel and Losonci [Hum Genet 77:203-204, 1987] in a single family which showed a transmission pattern suggesting autosomal dominant inheritance with variable expressivity. The presence of limb abnormalities and the location of the neural tube defects in these cases suggest that the underlying pathogenesis probably does not involve the same disturbances of midline field development which have been postulated to occur in the schisis association.

Case report: US detection of tendinous metastasis from malignant melanoma

The introduction of high frequency transducers has considerably improved the application of US in the study of musculo-tendinous diseases. We report a rare case of tendinous metastasis from malignant melanoma. The tumour (high karyokinetic index, Clark level IV) arose 4 years earlier in the dorsal region. The patient was admitted for pain in the left knee. A nodular hypoechoic lesion, 0.8 cm in diameter, poorly marginated, located in the subcutaneous tissue and involving the patellar tendon was identified with ultrasound. Histological examination confirmed the diagnosis.

[Abdominal Doppler echography. Pathologic arterial signals]

In this paper, the features are reported of the major pathological flow signals obtained during Doppler examinations of abdominal vessels. The patterns are correlated with the pathological lesions which may cause them, as well as with the underlying changes in arterial hemodynamics. Pathological flow signals are divided into three groups, according to the sites where the lesions producing them are located. a) Lesions of the vessel walls. In this group, both widening of spectrum due to disturbed flow and increased blood velocity from vessel stenosis are presented. Also flow alterations occurring in aneurysms (reduction of flow velocity and presence of vorticous flow) are discussed. b) Changes in peripheral resistances. Peripheral resistances may either increase or decrease due to a variety of diseases. Parenchymal edema, compression, infiltration, as well as small vessel disease, may increase vascular impedance. Fall of vascular resistances may be observed in inflammation or in arteriovenous fistulas either large (congenital or hemodialysis fistulas) or microscopic, as in many hypervascular tumors. A typical "to and fro" flow pattern was seen in vessels where flow resistance is overcome only during systole, such as in arterial pseudoaneurysms. c) Changes in rhythm or strength of the heartbeat, cardiac valvular diseases, postocclusive flow. A variety of pathological findings may be observed in these conditions. Peculiar changes in the waveforms are seen with variations in heart frequency. Changes may be detected also in aortic valvular diseases, with retrograde flow observed in patients with aortic insufficiency. Low and slow flow are seen in post-stenotic and/or postocclusive vessels.

Analysis of echotexture of tendons with US

To evaluate changes in echotexture of normal tendons at different frequencies and establish an anatomic correlation for fibrillar echoes, normal calcaneal tendons were examined in vitro at 7.5, 10, 13, and 15 MHz in calves (n = 8) and sheep (n = 6) and in vivo in humans (n = 8). Histologic correlation was obtained in vitro with 22-gauge needles that marked the position of echogenic fibrils under ultrasound (US) guidance. The human study group consisted of 25 patients with a clinical diagnosis of calcaneal tendon disease and 15 patients who underwent surgery for rupture of the Achilles tendon. At all four frequencies, normal tendons showed an internal network of fine parallel and linear fibrillar echoes that became more numerous and thinner as US frequency increased. These echoes were caused by specular reflections at the interface between collagen bundles and endotendineum septa. In patients, tendons showed a variety of basic changes in fibrillar pattern: increased fibrillar thickness (33 patients), interruption (17 patients), fragmentation (12 patients), and disappearance of echotexture (15 patients). It is concluded that US holds promise in detection of minimal changes in tendinous structure.

Accurate specimen preparation and examination is mandatory to detect lymph nodes and avoid understaging in colorectal cancer

Lymph node involvement in colorectal cancer, one of the most important prognostic factors, can be sometimes underestimated. In this study the authors report the results of two different techniques of specimen preparation and examination. In 240 patients (Group I), histologic examination was performed using a conventional procedure. In Group II (60 cases) the resected bowel and its mesentery were separately stretched, pinned on to a cork board, and fixed. The mesentery was divided according to node location (intermediate and principal) and evaluated by sight and palpation to identify lymph nodes. The bowel segment was divided from 5 cm proximally to 5 cm distally to the tumor every 10 mm in serial 3 mm slices. Three and 10 mm slices were then carefully examined by sight and palpation. Isolated lymph nodes embedded in groups (10-12 per paraffin block) were stained and investigated for neoplastic involvement. The specimen examination procedure used in Group II resulted in identification of a higher number of lymph nodes (mean = 41.1) and nodal metastases (mean = 10) compared to the standard technique used in Group I (mean = 11.3 and 2.4, respectively--P < .05). The percentage of N+ cases also was increased in Group II (48.3%) when compared to that in Group I (30.4%; P < .05). The new technique is simple, inexpensive, and efficacious for the detection of lymphatic metastases in colorectal cancer.

Fetal behavioural states and hypertensive pregnancy

Delay in fetal maturation in diabetic and accelerated fetal maturation in hypertensive pregnancies have been reported in the past. The spontaneous activity of fetal nervous system during pregnancy was followed longitudinally in a group of 29 normal pregnancies from 28 x th to 40 x th week of gestation by means of fetal behavioural states determination. 1 F state (quiet sleep) progressively increases from median values of 5.0% to values of 22.5-25% at term of pregnancy. This state represents the positive activity of inhibitory centers has been related to a positive evolutionary process of brain maturation according to preceding experiences conducted on experimental models and preterm babies followed with EEG and direct observation in the early neonatal period. The method of behavioural states determination has been applied to a group of 33 gestational diabetes (GDM) pregnant women followed longitudinally, and a clear reduction of development of 1 F state has been evidentiated, with significant differences (p less than 0.001) at 35-36 weeks of gestation versus the control group. The normal values are reached in concomitance with L/S value of maturity. In 30 pregnant women affected by gestational hypertension (GH) different result are obtained: 1 F state seems to develop earlier, and is increased (p less than 0.001) around 30-32 weeks versus the control group if a fetal growth reduction is present. The value of 1 F behavioural state in the evaluation of fetal condition of pathological pregnancies is discussed.

Thyroid carcinoma mimicking a toxic adenoma

A young woman with a thyroid papillary carcinoma behaving as an autonomously hyperfunctioning nodule is described. Only 17 similar patients have been seen in the past 25 years. It is emphasized that hyperthyroidism does not exclude malignant disease in hot nodules. This possibility suggests that all thyroid nodules, either cold or hot, require careful management. Therefore, in "at risk" cases, surgery could be the most useful treatment.

[Immediate and long-term results of endoscopic or surgical Oddi sphincterotomy in the treatment of lithiasis of the common bile duct]

Ninety-one patients with choledocholithiasis were admitted for endoscopic (51 cases) or surgical (40 cases) sphincterotomy of Oddi's muscle, and were followed up on a yearly basis thereafter for a period spanning 1 to 5 years. The study protocol included clinical examinations, ultrasonographic investigations and biochemical tests. The post-surgery mortality rate was 3.9% following endoscopic sphincterotomy versus 0% after surgery. Postoperative complications occurred in 3.9% of patients treated endoscopically (bleeding, angiocholitis) and in 5% of surgical patients (bronchopneumonia, suppuration of abdominal wall). Attempts to remove calculi via endoscopic Oddian sphincterotomy failed in 37% of cases. Long-range results were classified as excellent or good in 92% of patients treated endoscopically, and in 100% of cases treated surgically. Endoscopic division of Oddi's sphincter was unsuccessful in 4 patients (8%), who either had recurrent bile-duct stones (2 cases) or developed sphincteric stenosis. Among biochemical indices of biliary stasis, only alkaline phosphatase contents showed a greater increase following endoscopic sphincterotomy than after surgical treatment. Ultrasonographic studies of the bile duct evidenced a greater incidence of air entrapment in the bile ducts of patients subjected to surgical sphincterotomy.

Malignant fibrous histiocytoma of sternum: an unusual cause of pyrexia of undetermined origin

Malignant fibrous histiocytoma of the bone is a very rare tumour mainly affecting long bones, and the most common presenting symptom is local pain. A case of malignant fibrous histiocytoma presenting with pyrexia of undetermined origin and arising in the sternum, a localization not previously described, is reported. The patient died with septic shock after multi-drug chemotherapy including high dose methotrexate treatment with citrovorum factor rescue.