Rate of atrial fibrillation by Holter-Stroke Risk Analysis in undetermined TIA/rapidly improving stroke symptoms patients

Introduction

Holter-SRA (Stroke Risk Analysis) is an automated analysis of ECG monitoring for Atrial Fibrillation (AF) detection. The aim of this study was to evaluate the rate of AF in undetermined TIA/Rapidly improving stroke symptoms (RISS) patients.

Methods

Prospective study of undetermined TIA/RISS patients who presented to the emergency department. Early vascular studies (angio CT, transthoracic echocardiography and ECG) were performed in emergency department. The Holter-SRA device was placed for 2 h and the patients were classified into: confirmed AF, high risk of AF or low risk of AF. Prolonged ambulatory monitoring (7 days) was carried out every month for patients with a high-risk pattern. The results were evaluated until definitive detection of AF or low-risk pattern. The endpoints were rate of AF and vascular recurrence at 90 days.

Results

Over a period of 24 months, 83 undetermined TIA/RISS patients were enrolled. The mean age was 70 ± 10 years and 61% were men. The median ABCD2 score was 4 points (1-7). After 2 h of monitoring in the emergency department, AF was detected in one patient (1.2%), 51 patients with a low-risk pattern and 31 patients (37.3%) showed a high-risk pattern of AF. During the ambulatory monitoring, of the 31 patients high risk pattern patients, AF was diagnosed to 17 cases and of the 51 patients with a low-risk pattern, one case experienced a recurrent vascular due to undetected AF (1.9% false negative). Three patients (3.6%) suffered a vascular recurrence within the first 90 days, before AF diagnosis.

Conclusions

In our study, AF was detected in 22.9% of the 83 patients with indeterminate TIA/RISS. Holter-SRA has allowed us to increase the detection of AF, especially those patients with a high-risk pattern in the first 3 months.

Renal endometriosis mimicking complicated cysts of kidney: report of two cases

Endometriosis is a common gynecologic disorder characterized by ectopic endometrial tissue growth outside the uterine cavity. Although usually occurring in pelvic organs, endometrial lesions may involve urinary tract. Renal endometriosis is extremely rare and it has only occasionally been reported in the past. We report two cases of patients with renal cystic lesions, incidentally found at imaging techniques during oncologic follow-up for gastric sarcoma and melanoma, initially misinterpreted as complicated haemorrhagic cysts and then histologically characterized as renal localizations of extragenital endometriosis.

Early lung function abnormalities in acromegaly

BACKGROUND

Acromegaly is an insidious disorder caused by a pituitary growth hormone (GH)-secreting adenoma resulting in high circulating levels of GH and insulin-like growth factor I (IGF-I). Respiratory disorders are common complications in acromegaly, and can severely impact on quality of life, eventually affecting mortality.

OBJECTIVES

The present study aimed to explore structural and functional lung alterations of acromegalic subjects.

METHODS

We enrolled 10 consecutive patients (M/F: 5/5) affected by acromegaly. In all patients, magnetic resonance imaging (MRI) revealed the presence of pituitary tumor. All patients underwent clinical, lung functional, biological, and radiological assessments. Ten healthy age-matched subjects also served as controls.

RESULTS

No statistically significant differences in lung function were detected between acromegalic and healthy subjects (p ≥ 0.05 for all analyses). However, the diffusing capacity for CO (TLCO) was significantly lower in the acromegalic group than in healthy subjects (TLCO% predicted: 78.1 ± 16 vs. 90 ± 6 %, respectively, p = 0.04; KCO% predicted: 77 ± 16 vs. 93 ± 5 %, p = 0.02, respectively). None of the lung function parameters correlated with duration of the disease, or with inflammatory marker of the airways. In acromegalics, biological (exhaled NO concentrations) and imaging (total lung volume, TLV, and mean lung density, MLD) evaluations were within normal values. The TLV measured by HRCT was 3540 ± 1555 ml in acromegalics, and the MLD was -711 ± 73 HU. None of the lung functional, radiological, and biological findings correlated with GH or IGF-I levels, and no correlation was found with duration of disease.

CONCLUSIONS

In the current study, lung function evaluation allowed to detect early involvement of lung parenchyma, as assessed by TLCO and KCO, even in the absence of parenchymal density alterations of the lung by HRCT. These findings suggest to routinely include the carbon monoxide diffusing capacity in the lung function assessment for an early intervention in acromegaly.

Validation of lung densitometry threshold at CT for the distinction between senile lung and emphysema in elderly subjects

BACKGROUND AND AIMS

An ageing lung is characterised by distal airspace enlargement without alveolar wall destruction: therefore the anatomical distinction between senile lung and emphysema is clear-cut. In clinical settings the definition of precise boundaries between normalcy and pathology is more difficult with the risk of overdiagnosis. CT is an important diagnostic advancement in the field of COPD. Most methods for the evaluation of emphysema are based on the detection and measurement of areas characterised by a density level below a threshold assumed to characterize parenchymal destruction.

METHODS

Our retrospective study included 47 healthy subjects (65-91 years), 36 never smokers and 11 former smokers. As a reference sample we recruited 9 patients with emphysema (69-81 years). Thoracic scan was performed by single slice spiral CT and acquired without contrast enhancement. For each scan and on both lungs we sampled eighteen regions of interest in the upper, middle and lower field. Mean lung density (MLD) and lower limit of normal (LLN) of density distribution were calculated.

RESULTS

MLD for the whole study sample was -846 +/- 41 HU. -901 HU was the LLN of density distribution in the study sample. No significant correlation was noted between age and MLD. In the emphysematous sample the average lung density was -946 +/- 18 HU. The mean coefficient of variation was 3% in the healthy sample and 2% in the emphysematous one. The difference between groups was significant (p < 0.0001). In one healthy subject only we measured a value slightly below the threshold reported in literature for conventional CT; no emphysematous value fell above the LLN.

CONCLUSIONS

This study highlights the fact that in the elderly the threshold level of lung density commonly adopted in diagnostic algorithms of emphysema is fully applicable. When applying this method to older subjects the risk of misinterpreting areas of physiologic non-destructive reduction of density as emphysema is low.

[Inspiratory muscles strength training in recreational athletes]

INTRODUCTION

Respiratory muscles strength and endurance influence athletic performance. Besides conventional spirometry, sniff test, inspiratory and expiratory maximal pressures can directly assess respiratory muscle strength. Respiratory muscles can be train through a device offering inspiratory and expiratory resistance.

METHODS

Nineteen subjects aged 18 to 30 years and practicing leisure sport trained inspiratory muscles on Powerbreathe(®) for eight weeks. Resistance was set at 85% of maximal inspiratory pressure determined during a preliminary session. Evaluation was made trough voluntary and non-invasive methods on Macro 5000(®) (PI max, PE max and sniff test).

RESULTS

An increase of 21.77% of the maximum inspiratory pressure, 17% of the maximum expiratory pressure and 18% of the sniff test are recorded after eight weeks of training.

CONCLUSIONS

A specific training of inspiratory muscles (Powerbreathe(®) Sports performance) increases the power of these muscles (voluntary and non-invasive tests).

Sialographic findings in Wharton duct evagination

Ductal evagination is a rare condition affecting the Wharton duct. The aim of this study was to establish the incidence, imaging features and clinical significance of ductal evagination in patients undergoing submandibular gland sialography. The sialographic findings and reports of 322 patients undergoing submandibular gland sialography during the period 1998-2007 were retrospectively reviewed. Ductal evagination was identified on sialograms as a unique diverticulum, filled with contrast medium, of the Wharton duct, with a narrow neck and a blind end. A ductal evagination was found in 5/322 patients with swelling and pain in the submandibular gland. It was always located in the middle tract of the Wharton duct. Other findings were: in 5/5 patients, an enlargement of the primary and secondary ducts due to sialodochitis; in 3/5 patients, salivary stones; in 1/5 patients, a sinuous distal tract of the Wharton duct; in 2/5 patients, a stenosis of the proximal tract of the Wharton duct. In our series, the incidence of wharton duct evagination was 1.6% incidence. It may represent a form of duct wall weakness although its cause is uncertain. It is, however, a condition that needs to be highlighted on sialograms for eventual inflammatory consequences or in guiding sialoendoscopy to avoid eventual ductal perforation.

Non-invasive diagnosis in a case of bronchopulmonary sequestration and proposal of diagnostic algorithm

The case of a 43-year-old woman with intralobar pulmonary sequestration, Pryce type one, is presented. The medical history was characterised by recurrent bronchopneumonia, productive cough with purulent sputum and hemoptysis in the last three years. Diagnosis was made by CT angiography: multiplanar, maximum intensity projection and volume rendering reconstructions were visualised. A volume reduction of middle and lower lobe with multiple cyst-like bronchiectasis was detected and no evident relationship with tracheobronchial tree was pointed out. Reconstructions aimed at evaluating bronchial structures demonstrated no patency of middle and lower lobar bronchi. The study carried out after contrast medium infusion in arterial phase showed a vascular disorder characterised by an accessory arterial branch arising from the upper portion of thoracic aorta which, after moving caudally to pulmonary hilus with a tortuous course, supplied the atelectatic parenchyma. No anomalous venous drainage was detected. The patient underwent surgery with resection of two pulmonary lobes. CT compares favourably with other alternative imaging technique for pulmonary sequestration as multiplanar reconstructions allow not only the detection of supplying vessel, but also the accurate description of heterogeneous characteristics of the mass and adjacent structures. Finally an imaging-based diagnostic algorhithm is proposed.

Morbidity of salivary gland digital sialography using a non-ionic dimeric contrast medium

AIM

Sialography is considered a low invasive procedure, due to cannulation of salivary duct orifice. The aim of this study was to evaluate the morbidity of sialography using a nonionic dimeric contrast medium.

METHODS

A questionnaire was proposed to 90 patients who underwent parotid and submandibular sialography to reveal related symptoms as: pain, swelling, impairment to daily activities and taste alteration. Pain and swelling intensity was assessed using a visual analogue scale (VAS).

RESULTS

Fifty-two out of ninety questionnaires were returned. Sialography was performed in 30/52 patients in the submandibular gland, 22/52 in the parotid gland. Pain during sialography was complained by 28/52 patients with a 2.4 mean VAS score. Pain after sialography, was reported by 17/52 patients with a 1.3 mean VAS score. Swelling was reported by 25/52 patients with a 2.4 mean VAS score; 48/52 patients returned immediately to daily activities; 8/52 complained different taste alterations.

CONCLUSION

Main related symptoms for submandibular and parotid sialography are pain and swelling, spontaneously resolving after 24-48 hours in most of cases. The statistical analysis also demonstrated in patients who underwent submandibular sialography the onset of pain during the procedure is significantly related to an increase of pain after the examination. Thus in patients, who referred severe pain during sialography, antiinflammatory drugs are recommended to control the onset of pain after sialography.

Sialodochoplasty in the treatment of salivary-duct stricture in chronic sialoadenitis: technique and results

PURPOSE

This study was undertaken to investigate peroral balloon angioplasty of salivary-duct strictures (sialodochoplasty) in chronic sialadenitis, analysing the technique, results and limitations.

MATERIALS AND METHODS

Nine patients underwent sialodochoplasty: seven for Stensen's-duct strictures and two for Wharton's-duct strictures. One patient had a double stricture of Stensen's duct and another a salivary stone associated with a Wharton's-duct stricture. All patients were subjected to preliminary sialography to evaluate stricture site, length and grade. Sialodochoplasty was performed after local anaesthesia and progressive dilation of the salivary-duct orifice.

RESULTS

The stricture was successfully dilated in 7/9 patients. The stricture was unchanged after dilatation in one patient, and in another, it recurred after 13 months. In the patient with a double stricture of Stensen's duct, one was resolved and the other was only partially dilated, with significant symptom improvement. One patient developed a new episode of sialadenitis after 3 months, which resolved with medical therapy. Five out of seven patients were asymptomatic at follow-up.

CONCLUSIONS

Sialodochoplasty is an effective procedure in the treatment of salivary-duct strictures, improving symptoms in the majority of patients. The procedure is repeatable and can be proposed as a first-line treatment for symptomatic salivary-duct stricture.

Concentration measurements of 7Be at ground level air at Palermo, Italy-comparison with solar activity over a period of 21 years

Air activity concentrations of (7)Be in Palermo determined for the period January 1995-December 2002 by gamma-ray spectrometric analysis of particulate samples collected on paper filter by a high-volume sampler (approximately 900 m(3) h(-1)) are reported. The temporal behaviour of (7)Be concentration presents the same characteristics already observed in the measurements carried out over the previous 13-year (1982-1994) investigated period. The mean value of 5.06 mBq m(-3) obtained from the analysis of the 4636 particulate samples collected from 1982 to 2002 can be considered a representative value of (7)Be air concentration at ground level in our geographical zone. The comparison of long-term variation in the (7)Be concentrations with the cyclic solar activity-extended to the whole period of 21 years-confirms the inverse correlation between the two quantities.

MRI findings in lingual venous malformations

OBJECTIVES

To describe the plain and enhanced MRI findings of lingual venous malformations and to discuss the importance of contrast medium in the differential diagnosis of high intensity lesions of the tongue on T(2) weighted images.

METHODS

The clinical records and MR images of eight patients affected by a lingual venous malformation were retrospectively reviewed. Patients presented with a palpable submucosal bluish-red soft mass in the tongue. MRI examinations were performed on a 0.5 T superconducting unit. Plain and enhanced SE (spin echo) T(1) weighted and FSE (fast spin echo) T(2) weighted images were acquired in axial, sagittal and coronal planes. Axial SPGR (spoiled gradient recalled echo) T(1) weighted images were also obtained before and after intravenous (i.v.) injection of paramagnetic contrast medium.

RESULTS

Five of eight venous malformations were located at the tip of the tongue. The other three involved the whole tongue and had an extralingual extent; two extended into the submandibular space and one into the glossoepiglottic valleculae. The largest diameter ranged from 2.5 cm to 8 cm. All lingual venous malformations presented as lobulated masses that were slightly hyperintense or isointense on T(1) weighted images and highly hyperintense on T(2) weighted images with respect to normal tongue and/or surrounding muscles. They showed a slow and homogeneous filling following iv injection of contrast medium. Millimetre-sized hypointense foci and linear hypointense strands were sometimes noticed, which were owing to phleboliths, flow void or septation.

CONCLUSION

Knowledge of MRI findings of lingual venous malformations is useful for differential diagnosis with other high intensity lingual lesions on T(2) weighted images. This discrimination is achievable using iv paramagnetic contrast medium.

Interventional treatment of sialoliths in main salivary glands

PURPOSE

The aim of our study was to demonstrate the effectiveness of interventional radiology in the treatment of sialolithiasis, as the first-choice treatment for the removal of stones located in the middle and proximal tracts of the main salivary ducts, and to assess its limitations and contraindications.

MATERIAL AND METHODS

Between February 1998 and May 2001 eleven interventional removals of sialoliths were performed for recurrent obstruction of the main salivary duct associated with chronic sialadenitis. Patients were selected on the basis of a preliminary sialogram, designed to determine the location and size of the stone. Exclusion criteria were location of the stone in the gland hilum or intraglandular stone, maximum stone diameter >20% of the duct calibre, signs of adherence of the stone to the duct wall. Stone removal, performed after obtaining informed consent, involved administering antibiotic therapy and local anaesthesia, and dilatating the duct ostium to enable introduction of the basket catheter. The basket was then advanced along the duct under fluoroscopic guidance and suitably manoeuvred so as to capture and extract the stone. On completing the procedure a sialogram was taken to ensure the complete patency of the duct. Patients were prescribed a short course of antibiotics and were followed up at 1, 3 and 6 months.

RESULTS

In 10/11 patients the stone was located in Wharton's duct and in 1/11 in Stensen's duct. Removal of the calculus was successful in 10/11 patients; in 2 of these it was necessary to reintroduce the basket after extraction of the stone, in order to eliminate small stone fragments and salivary sand; in 1 patient a preliminary balloon-catheter sialoplasty was performed prior to the procedure to dilatate a distal stenosis caused by chronic sialadenitis; in 3 patients it was necessary to make a small incision in the orifice to introduce the dilator. Removal of the sialolith was unsuccessful in 1/11 of the patients treated, as it proved impossible to capture the calculus, even after repeated attempts. 8/11 patients reported pain during the procedure and swelling in the gland region immediately after the procedure, which resolved spontaneously within 24-48 hours. 9/11 patients remained asymptomatic in the follow-up; only 1/11 patients experienced a recurrence of sialadenitis after a short time, with pus secretion, which resolved with antibiotic treatment.

CONCLUSIONS

The interventional removal of sialoliths in the salivary glands is an effective alternative to the conventional treatment of obstructive diseases of the glandular ducts.

A low-level spectrometer with a planar low-energy HPGe: shielding arrangement tests and system performance for 210Pb determination in air filter samples

A system for low-energy photon spectrometry using a planar germanium detector with appropriate specifications is presented. A spectrometric background investigation has been carried out with various detector shielding arrangements. The characteristics of the system for measurements of 210Pb in air-particulate matter on filters have been determined.

[Anastomosis between the left internal spermatic and splanchnic veins. Retrospective analysis of 305 patients]

PURPOSE

To investigate the presence and the rate of anastomoses between the internal spermatic vein (ISP) and visceral veins in patients with idiopathic varicocele.

MATERIAL AND METHODS

We retrospectively reviewed the venographic findings of 305 patients (age range 14-40 years; mean age 28 years) with a US diagnosis of varicocele who were submitted to sclerotherapy from 1991 to 1997. All the venographic examinations had been carried out with selective injection of the ISP for complete mapping of gonadal vessels.

RESULTS

The most frequent venographic patterns (type I) was identified in 139/305 patients (45.5%), type III was found in 86/305 (28.2%), type V in 37/305 (12.1%). Type IVb was found in 32 cases (10.4%) and type IVa in 9 (2.9%). Type II was seen in 2/305 patients only (0.6%). Single or double anastomoses between the ISP and portal or systemic veins were found in 34 patients (11.1%); a single or double communication with the left colic vein was observed in 24 cases (7.8%) and a communication with the paravertebral venous system in 10 patients (3.2%). Other anastomoses with the inferior mesenteric veins and splenic veins were seen in 7 and 4 patients (2.2% and 1.3%, respectively).

DISCUSSION AND CONCLUSION

The presence of vascular variants and of communications of the ISP with the visceral veins needs accurate venographic studies preliminary to sclerotherapy and a skilled interventional radiologist in order to reduce the number of recurrences.

The value of magnetic resonance imaging in a fistula of Wharton's duct

A 30-year-old woman developed a fistula of the Wharton's duct following excision of the submandibular gland. The contribution of conventional fistulography, MRI and MRI fistulography in detecting the exact extent of the fistula is discussed.

Determination of 210Pb concentration in the air at ground-level by gamma-ray spectrometry

210Pb activity concentrations in the air of Palermo were determined by gamma-ray spectrometric analysis of 323 particulate samples collected in the period September 1995-December 1996. For each sample, the air filtered through a cellulose filter paper was 8600 m3 on average. The values of the daily activity concentration of 210Pb were ranging from 136 to 3390 microBq/m3.