Role of cardiac CT in the diagnostic evaluation and risk stratification of patients with myocardial infarction and non-obstructive coronary arteries (MINOCA): rationale and design of the MINOCA-GR study

INTRODUCTION

Myocardial infarction with non-obstructive coronary arteries (MINOCA) occurs in 5%-15% of all patients with acute myocardial infarction. Cardiac MR (CMR) and optical coherence tomography have been used to identify the underlying pathophysiological mechanism in MINOCA. The role of cardiac CT angiography (CCTA) in patients with MINOCA, however, has not been well studied so far. CCTA can be used to assess atherosclerotic plaque volume, vulnerable plaque characteristics as well as pericoronary fat tissue attenuation, which has not been yet studied in MINOCA.

METHODS AND ANALYSIS

MINOCA-GR is a prospective, multicentre, observational cohort study based on a national registry that will use CCTA in combination with CMR and invasive coronary angiography (ICA) to evaluate the extent and characteristics of coronary atherosclerosis and its correlation with pericoronary fat attenuation in patients with MINOCA. A total of 60 consecutive adult patients across 4 participating study sites are expected to be enrolled. Following ICA and CMR, patients will undergo CCTA during index hospitalisation. The primary endpoints are quantification of extent and severity of coronary atherosclerosis, description of high-risk plaque features and attenuation profiling of pericoronary fat tissue around all three major epicardial coronary arteries in relation to CMR. Follow-up CCTA for the evaluation of changes in pericoronary fat attenuation will also be performed. MINOCA-GR aims to be the first study to explore the role of CCTA in combination with CMR and ICA in the underlying pathophysiological mechanisms and assisting in diagnostic evaluation and prognosis of patients with MINOCA.

ETHICS AND DISSEMINATION

The study protocol has been approved by the institutional review board/independent ethics committee at each site prior to study commencement. All patients will provide written informed consent. Results will be disseminated at national meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT4186676.

Correlation of coronary artery geometry with the complexity and severity of coronary atherosclerosis: rationale and design of the GEOMETRY-CTA study

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This research is co-financed by Greece and the European Union (European Social Fund-ESF) through the Operational Programme «Human Resources Development, Education and Lifelong Learning 2014-2020» in the context of the project “Correlation of coronary artery tree geometry and clinical parameters with the distribution, complexity and severity of coronary artery disease: a pilot study using multislice CT coronary angiography” (MIS 5047882)

Background

Development and progression of coronary atherosclerosis is complex and not yet fully understood. Accumulative evidence supports the notion that coronary artery disease (CAD) results from an interaction of systemic factors, such as dyslipidemia, with local hemodynamic factors that regulate the site-specific predilection of atherosclerosis, particularly low endothelial shear stress (ESS). Since low ESS develops in geometrically irregular regions of the coronary tree for a given arterial blood flow, geometrical factors affect atherosclerotic plaque distribution and vulnerability. However, the correlation of coronary geometric features with the complexity and severity of CAD has not been fully elucidated.

Purpose

GEOMETRY-CTA is a prospective, non-randomized, observational study that aims to investigate the correlation of coronary artery geometrical features with the complexity and severity of CAD using Coronary Computed Tomography Angiography (CCTA). The prognostic value of a CCTA-derived geometric risk score will also be assessed.

Methods

The study aims to recruit 100 consecutive patients with suspected CAD and low/intermediate pre-test probability. Coronary geometrical characteristics such as angulation of coronary bifurcations, tortuosity, coronary artery volume index (CAVi) and vessel-length will be assessed with multi-planar reformation and volume rendering techniques, and integrated into a single geometric risk score. The extent and vulnerability of plaque burden will be calculated using several anatomical scoring systems such as the Leiden CTA risk score, CT-SYNTAX score, and CT-adapted Gensini score. Patients will be prospectively followed for 12 months after enrollment.

Results

The primary objective of the study is to evaluate the correlation of the geometric risk score with CAD severity and plaque vulnerability. We also hypothesize that wider bifurcation angles and lower CAVi augmenting the atherosclerosis-prone environment and predict higher CAD extent and complexity.

Conclusion

The present study aims to introduce a quantitative, non-invasive imaging biomarker expressing CAD severity and investigate its prognostic value in regards to adverse cardiovascular events. The derived index will be available for incorporation in larger national prospective studies for further cardiovascular risk stratification.

A rare cause of acute pancreatitis: ischemia caused by free-floating intraluminal aortic thrombus

BACKGROUND/AIM

Acute pancreatitis is a common gastrointestinal condition worldwide with variable severity and complications. Alcohol and gallstones are the leading causes of acute pancreatitis, while pancreatic ischemia is uncommon. Although venous thrombosis, especially adjacent to the inflamed pancreas, is a common complication of acute pancreatitis, arterial thrombosis secondary to pancreatitis has rarely been described. On the other hand, arterial thromboembolic events, secondary to cardiovascular diseases, are a rare cause of pancreatic ischemia. Herein, we present an interesting case of acute ischemic pancreatitis secondary to aortic atheromatosis complicated with multi-organ infarcts.

DESCRIPTION OF THE CASE

An 80-year-old male patient presented with nausea, abdominal pain, and vomiting accompanied by peripheral edema and ascites. Clinical, laboratory, and imaging investigation showed acute moderate to severe pancreatitis with multiple splenic and renal infarcts. An intraluminal free-floating aortic thrombus, secondary to atheromatosis of the descending aorta, was the cause of the complications. A conservative approach was successfully implemented, including supportive measures, antiplatelets, and vasodilators.

CONCLUSION

Identification of acute pancreatitis' cause, especially in the setting of a systemic disease like atheromatosis, is a challenging task and of great importance, given the implications on treatment decision-making and prevention of recurrent episodes. HIPPOKRATIA 2021, 25 (3):138-140.

Upper extremity pleomorphic dermal sarcoma in a patient with chronic myelomonocytic leukemia

BACKGROUND

Pleomorphic dermal sarcoma is a potentially high-grade cutaneous spindle cell tumor that closely resembles atypical fibroxanthoma in the superficial, dermal aspects but with adverse pathological features. Chronic inflammation, as several autoimmune disorders are co-associated with chronic myelomonocytic leukemia.

CASE DESCRIPTION

We report here an 84-year-old male patient with swelling lump on the upper third of the left arm. Previously he suffered from a type I chronic myelomonocytic leukemia. Based on the initial ultrasound-guided biopsy of the lesion, the histopathological examination revealed an atypical fibroxanthoma. A wide local excision was performed and the diagnosis was revised to pleomorphic dermal sarcoma by the pathologist, based on the currently accepted criteria. Adjuvant radiotherapy was performed.

CONCLUSION

Differentiating between atypical fibroxanthoma and pleomorphic dermal sarcoma is pivotal. A partial sampling of the skin lesion poses a significant pitfall, as important diagnostic features cannot be assessed. Immunosuppression seems to be involved in the pathogenesis of chronic myelomonocytic leukemia and pleomorphic dermal sarcomas, because of the advanced patient age. HIPPOKRATIA 2019, 23(4): 181-185.

CT Evaluation of Compensatory Renal Growth in Relation to Postnephrectomy Time

In 27 patients nephrectoraized for renal carcinoma, the compensatory hypertrophy of the remaining kidney was assessed by 72 CT examinations performed one month before and during 32 months after nephrectomy. Kidney size was estimated on CT by multiple measurements of the renal parenchymal thickness. Kidney growth was evaluated by comparing the amount of renal parenchyma before and after contralateral nephrectomy. Renal compensatory hypertrophy varied with postnephrectomy time. Kidney enlargement was 15% in the first 3 months, reached maximum 30% about a year later, and was reduced to 5%, 2 1/2 years postoperatively.

CT Assessment of Normal Splenic Size in Children

The size of the normal spleen was estimated by CT in 153 children, examined with indication unrelated to splenic disease. In each patient the width, thickness, length and volume of the spleen were calculated. Measurements were also normalized to the transverse diameter of the body of the first lumbar vertebra. The spleen underwent significant growth during the first 4 years of life and reached maximum size at the age of 13. There were no differences in splenic volume between boys and girls. Splenic thickness correlated best with normal splenic volume. The strongest correlation was also found between splenic thickness and volume in a group of 45 children with clinically evident splenomegaly. Splenic thickness, an easy-to-use measurement, may be employed in everyday practice to represent splenic volume on CT.

Splenic involvement in lymphomas: Evaluation on serial CT examinations

Purpose: To prospectively evaluate changes in splenic volume (SV) on serial CT of patients with lymphoma and correlate them with other indicators of the disease process.

Material and Methods: SV was calculated in 290 abdominal CT examinations of 58 consecutive adults with lymphoma (42 non-Hodgkin's lymphoma, 16 Hodgkin's disease). Each patient had one CT investigation before, 2 during chemotherapy and 2 post-chemotherapy. The changes in SV were correlated with clinical, laboratory and other imaging indicators of the disease process.

Results: Three groups of patients were identified. Group A (n=20) presented no changes in SV, showed no splenic parenchymal abnormalities and had normal SV and serum lactic dehydrogenase (S-LDH). Group B (n=25) presented a decrease in SV during treatment suggesting response to therapy. Splenic parenchymal abnormalities (n=5) and other subdiaphragmatic sites of involvement (n=20) underwent remission during treatment. Eighteen patients with high S-LDH at presentation showed normal values during therapy. Group C (n=12) showed an increase in SV post-therapy associated with manifestations of disease recurrence. The S-LDH levels were elevated in 10 patients at the same time.

Conclusion: Quantitatively assessed splenic size on CT may serve as an indicator of splenic involvement in the course of lymphomas.

Pulmonary sarcoidosis: Correlation of expiratory high-resolution CT findings with inspiratory patterns and pulmonary function tests

Purpose: To assess the presence and extent of air trapping (AT) on chest high-resolution CT (HRCT) in sarcoidosis and to correlate such findings with patterns, lesion extent on inspiratory CT and pulmonary function tests (PFT).

Material and Methods: Thirty patients with sarcoidosis underwent inspiratory and expiratory HRCT and PFT. HRCT images were evaluated for presence, distribution and AT extent as well as the predominant HRCT pattern and the extent of lesions at inspiration. Attenuation difference in the AT regions at expiration and at inspiration were calculated. The presence and extent of AT were correlated with PFT, extent of involvement and predominant inspiratory patterns.

Results: AT was present in 25/30 patients with no lung zone predilection. AT was the only CT indication of pulmonary sarcoidosis in 3/30 patients who also had normal PFT. Attenuation difference between inspiration and expiration ranged from -40 HU to 106 HU. In 2 patients, a paradoxical decrease of lung attenuation was observed at expiration. A significant correlation was found between AT extent at expiration, with residual volume-total lung capacity ratio and residual volume.

Conclusion: AT is an additional HRCT finding in sarcoidosis. AT may involve any lung zone, including costophrenic angles and may be the only CT feature of pulmonary sarcoidosis. Strong correlation is only found with PFT values that are specific for incomplete lung emptying at expiration.

Malignant biliary obstruction: the current role of interventional radiology

Cholangiocarcinoma and pancreatic head cancer are still linked with extremely high 5-year mortality in the western world. The management of such patients is complex and typically requires a multidisciplinary approach in a tertiary care center. Interventional radiology offers minimally invasive, image-guided treatment for a variety of diseases and conditions. Regarding patients with malignant biliary obstruction, IR options are considered for more than two decades as a valid management tool for both operable and non-operable cases. The options include placement of percutaneous transhepatic biliary drains, preoperative embolization of the portal vein and deployment of covered and uncovered biliary stents. The purpose of this review is to describe the current evidence in this continuously evolving field.

Subcutaneous and total fat at L4-L5 and subcutaneous, visceral and total fat at L3-L4 are important contributors of fasting and postprandial adiponectin levels

OBJECTIVES

Insulin resistance and central obesity have been implicated in the pathogenesis of hypoadiponectinemia in obesity. The aim of this study is to evaluate circulating post-prandial adiponectin in relation to glucose and insulin metabolism, indexes of insulin resistance and sensitivity and, indexes of body fat accumulation and distribution in obese men.

METHODS

Twenty-eight non-diabetic men underwent an OGTT followed by an oral fat load and were studied at baseline and for 5 h post-prandially for serum adiponectin, glucose and insulin. Insulin resistance was estimated by Homeostasis model assessment (HOMA) and insulin sensitivity by Matsuda index. Body fat accumulation and distribution were evaluated by anthropometric indexes and multiple slices MRI of the abdomen and hip.

RESULTS

Adiponectin was negatively correlated to insulin levels. Fasting and area under the curve (AUC) adiponectin levels were negatively correlated to HOMA (both p < 0.01) and positively to Matsuda index (both p < 0.05). Negative correlations between fasting adiponectin and total fat (r = -0.408, p < 0.05), AUC adiponectin and subcutaneous, visceral and total fat (r = -0.375, -0.413 and -0.475 respectively, all p < 0.05) at L3-L4 were found, and negative correlations between fasting adiponectin and subcutaneous (r = -0.402, p < 0.05) and total fat (r = -0.491, p < 0.05) and between AUC adiponectin and subcutaneous and total fat (r = -0.506 and -0.547, respectively, both p < 0.01) were present at L4-L5.

CONCLUSIONS

Circulating adiponectin is inversely correlated to both visceral and subcutaneous fat in non-diabetic men, implying that both compartments are important for adiponectin levels. The best correlation is found at measurement site L4-L5.

Body fat distribution by anthropometric and MRI-based techniques in relation to insulin secretion and action in men with diabetes

AIM

Differences in fat accumulation and distribution might be responsible for the greater insulin resistance (IR) in type 2 diabetes. The study aims at examining the relationship between fat accumulation and distribution, and insulin secretion and action, by multilevel methodological approach.

METHODS

Thirty-three diabetic men (D), and 28 sex, age and BMI-matched controls (C) were studied for glucose and insulin during OGTT, insulin resistance and sensitivity, employing HOMA and Matsuda index respectively, and, fat accumulation and distribution by anthropometrics, Bioimpendance Analysis (BIA), and multiple slices MRI of abdomen and hip.

RESULTS

D exhibited higher HOMA compared to C (P<0.001), and lower Matsuda index (P=0.062). No differences in fat distribution by anthropometric or MRI measurements were observed; however, fat accumulation by BIA was higher in D (P=0.035). HOMA correlated to basal, AUC, and peak insulin in both groups (all P<0.001); with weight (r=0.415, P=0.031), hip circumference (HC) (r=0.482, P=0.011), %fat (r=0.400, P<0.05) in C; and with weight, BMI, total and %fat, and waist and HC when all subjects were considered as a group. Matsuda inversely correlated with basal, AUC, and peak insulin (all P<0.001), and HC (r=-0.406, P=0.032) in C. HOMA strongest correlated with L3-L4 subcutaneous (r=0.551, P=0.003) in C, and with L3-L4 visceral (r=0.456, P=0.022) in D.

CONCLUSION

The greater IR in diabetic patients may not be interpreted by differences in fat distribution. IR correlates with different fat compartments in healthy and diabetic subjects of comparable fat distribution, suggesting differences in fat function.

The importance of sequence in rescheduling bevacizumab and chemotherapy administration in the first-line treatment of metastatic colorectal carcinoma (mCRC)

617

Background: One of the proposed mechanisms of action for bevacizumab is by reducing the interstitial fluid pressure (IFP) allowing an increased penetration and uptake of chemotherapy agents in tumors. Clinical and laboratory data suggest that the decrease of IFP occurs after a few days of bevacizumab administration and intratumoral delivery of chemotherapy increase when bevacizumab precedes chemotherapy. We hypothesized that altering the schedule of BEV/FOLFOX regimen would improve the efficacy of the regimen and increase objective response rate. Methods: Patients (pts) with mCRC or locally advanced colorectal cancer, with ECOG PS 0-2 were eligible. The treatment schedule was Bevacizumab 5mg/Kg on day 1, standard FOLFOX-4 regimen on days 8-9 at cycles repeated every 14 days. Prior 5-FU/oxaliplatin adjuvant treatment was allowed. The pts were treated for 6 months or until reaching a plateau of response. Standard RECIST v1.1 response evaluation criteria were used. Primary endpoint of the study was the percentage of objective response rate, PR+CR (ORR), secondary end points were PFS, OS and toxicity. A Simon two step, minimax, statistical design was used: the minimum accepted ORR was 45% (p0) and the estimated ORR was 65% (p1). Results: Thirty (n=30) pts were enrolled. The median age was 69.5 years, the performance status was 0 (40%), 1 (40%), 2 (20%), the median follow up was 20.75 months and the K-RAS status was wild type for 63.5% and mutant for 36.5%. Seven pts (23.3%) had received prior adjuvant chemotherapy. Five pts had convertible metastatic disease. Four CR (13.33%), 18 PR (60%), 7 SD (23.33%), and one PD (3.3%) were observed for a total ORR of 73.3% and disease control rate (CR+PR+SD) of 96.7%. Four out of five (80%) pts with convertible disease achieved a R0 resection. The PFS was 12.8 months and OS has not been reached yet. One patient experienced a grade 4 event (febrile neutropenia). The study met its primary endpoint and therefore is considered positive. Conclusions: Delivering bevacizumab before chemotherapy in the first-line treatment of mCRC represents a very effective and promising schedule which warrants further investigation in randomized clinical trials.

Reversible posterior leukoencephalopathy syndrome induced by pazopanib

Background

The reversible posterior leukoencephalopathy syndrome is a clinical/radiological syndrome characterized by headache, seizures, impaired vision, acute hypertension, and typical magnetic resonance imaging findings. There are several reports in the literature that depict its occurrence in cancer patients. The list of common anticancer and supportive care drugs that predispose to reversible posterior leukoencephalopathy syndrome is expanding and includes not only a large number of chemotherapeutic agents but also an increased number of new targeted drugs, particularly angiogenesis inhibitors such as bevacizumab,sorefenib and sunitinib. Pazopanib is an oral tyrosine kinase inhibitor targeting vascular endothelial growth factor receptor, platelet-derived growth factor receptor, and c-Kit which after a positive phase III randomized clinical trial in patients with advanced renal cell cancer received FDA approval for the treatment of advanced renal cell carcinoma. Until now no cases of reversible posterior leukoencephalopathy syndrome induced by pazopanib have been reported.

Case report

We present the case of a 40 years old female patient with heavily pre-treated metastatic renal cell carcinoma who received pazopanib as salvage treatment. After 21 days of pazopanib therapy the patient referred to the emergency department with epileptic seizure, impaired vision at both eyes and headache. MRI of the brain revealed subcortical oedema at the occipital and parietal lobes bilaterally. She was treated with anticonvulsants, i.v. administration of mannitol and antihypertensives and she recovered completely from her symptoms and was discharged on the tenth hospital day. A brain MRI performed 3 weeks after showed that the subcortical oedema had been subsided.

Conclusion

In conclusion this is the first case of pazopanib induced reversible posterior leukoencephalopathy syndrome. Although usually reversible, this syndrome is a serious and potentially life threatening adverse effect, if untreated, that should be considered by physicians treating metastatic renal cell carcinoma patients with pazopanib.

MEG evaluation of taste by gender difference

Magnetoencephalographic recordings were evaluated in five different states: normal condition, sweet, bitter, sour, and salt taste. Twenty-eight healthy volunteers, 14 male and 14 female, ranging from 12 to 50 years of age, were included in the study. The results showed that, in the normal condition, as well as in the sweet and the bitter taste, the male volunteers exhibited a higher count of low-frequency than high-frequency channels compared to the femal ones; in the case of the sour taste, there was no clear differentiation between the genders; with the salt taste, the female volunteers exhibited a higher count of low-frequency channels whereas there was no clear differentiation in the number of high frequencies between the gender. A discrimination in the spatial distribution of the frequencies provides novel insights into the identification of gender-related taste sensation.

Docetaxel plus gemcitabine in combination with capecitabine as treatment for inoperable pancreatic cancer: a phase II study

PURPOSE

To evaluate the activity and tolerance of gemcitabine in combination with docetaxel and capecitabine in previously untreated patients with advanced pancreatic cancer.

PATIENTS AND METHODS

Chemotherapy-naïve patients with locally advanced or metastatic pancreatic cancer were treated with gemcitabine (1,500 mg/m(2) on days 1 and 15), docetaxel (50 mg/m(2) on days 1 and 15) and capecitabine (2,250 mg/m(2), orally in two daily divided doses, on days 1-7 and 15-21). All three drugs were administered in 4-week cycles, in an initial prospective plan of six cycles. The primary end-point was response rate.

RESULTS

Forty patients were enrolled in the study. At the time of enrollment, 40% of patients had locally advanced and 60% metastatic disease. All patients were evaluable for response and toxicity. On an intent-to-treat analysis, the overall response and disease control rates were 40 and 80%, respectively. The median progression-free survival was 6.0 months, and the median overall survival was 9.0 months. Major grade 3/4 toxicities were neutropenia (17.5%), diarrhea (10%) and hand-foot syndrome (7.5%). There was no treatment-related death.

CONCLUSION

The combination of gemcitabine with docetaxel and capecitabine is feasible and exhibits satisfactory degree of activity in patients with advanced pancreatic cancer, deserving further exploration.

Increased prevalence of abdominal aortic aneurysm in patients undergoing inguinal hernia repair compared with patients without hernia receiving aneurysm screening

BACKGROUND

The introduction of screening programs for abdominal aortic aneurysm (AAA) is being contemplated by health services in several countries. The correlation between aortic aneurysm and abdominal wall hernias is well reported, and inguinal hernia has been identified as a risk factor for aortic aneurysm. However, the prevalence of AAA in patients with inguinal hernia has not been adequately documented. This study evaluated whether patients with inguinal hernia are at increased risk of having an AAA compared with patients without hernia receiving aneurysm screening.

METHODS

Men aged >55 undergoing primary inguinal hernia repair underwent ultrasound imaging of the abdominal aorta to screen for aneurysm. A reference group was selected from men without clinical evidence of inguinal hernia participating in an AAA screening program. Prevalence and odds ratios of AAA in the two groups were calculated.

RESULTS

The study cohort comprised 235 patients with inguinal hernia and 203 controls. The mean ± SD aortic diameter was 22 ± 9 mm in patients with inguinal hernia vs 20 ± 6 mm for controls (P = .045). The prevalence of AAA was 8.1% in the hernia group and 3.9% in the control group (adjusted odds ratio, 3.9; 95% confidence interval, 1.6-9.5; P = .039). For aneurysms >4 cm, the prevalence was 5.1% in those with an inguinal hernia and 1.5% in those without an inguinal hernia (adjusted odds ratio, 4.7; 95% confidence interval, 1.2-18.5, P = .025).

CONCLUSIONS

Inguinal hernia was a significant risk factor for AAA. Entry into a screening program of men aged >55 admitted for inguinal hernia repair should be considered.

Diagnosis and laparoscopic management of a rudimentary uterine horn in a teenage girl, presenting with haematometra and severe endometriosis: our experience and review of literature

A unicornuate uterus is a rare congenital malformation of the female genital tract, which appears in about 1/1000 women and is characterized by significant anatomic variability. In the most common type, a noncommunicating rudimentary horn coexists with the unicornuate uterus. The diagnosis of this anomaly is usually delayed, as it remains asymptomatic until adolescence and its initial symptoms are atypical. As a result, it is often diagnosed after the appearance of severe complications, such as haematometra, endometriosis, infertility and ectopic pregnancy. We report a case of a teenage girl presenting with dysmenorrhoea, endometriosis and haematometra secondary to a noncommunicating rudimentary horn. The diagnosis of the anomaly was based on magnetic resonance imaging (MRI) and laparoscopy. The excision of the symptomatic rudimentary horn and the ipsilateral fallopian tube was also performed laparoscopically. A review of the literature follows, focusing mainly on the diagnosis and laparoscopic management of a unicornuate uterus and its complications in adolescence. Laparoscopy is an accurate diagnostic tool, which also carries significant advantages in effective surgical management of congenital uterine anomalies, especially in young women.

Achilles tendon volume in type 2 diabetic patients with or without peripheral neuropathy: MRI study

The aim of this study was to evaluate Achilles tendon (AT) in type 2 diabetic patients with vs. without peripheral neuropathy using Magnetic Resonance Imaging (MRI). The study included 19 patients (group A, mean age 63.9+/-7.4 years) with peripheral neuropathy and 19 patients (group B, mean age 63.6+/-6.1 years) without peripheral neuropathy, as well as 16 healthy controls (group C, mean age 61.6+/-8.4 years). Neuropathy was diagnosed by the Diabetic Neuropathy Index (DNI). The maximum AT thickness and AT volume were measured on sagittal T (1) weighted MRI images. AT volume was calculated by the sum of the tendon surface area of all contiguous sections multiplied by the slice thickness. Diabetic patients had significantly (p<0.001) greater AT volume than controls (9742.0+/-2034.9 mm(3) vs. 7323.8+/-1918.2 mm(3)). This difference was observed both in men (p=0.030) and in women (p<0.001). AT volume was significantly greater in group A vs. C (p=0.003) and in group B vs. C (p<0.001), but there was no difference between groups A and B (p=0.469). Finally, in group A increased AT volume was significantly (p=0.041) associated with clinical severity of neuropathy. CONCLUSIONS Type 2 diabetic patients have increased AT volume as compared to controls. There is no difference in AT volume between patients with and without neuropathy. However, in neuropathic patients increased AT volume is associated with severity of neuropathy.

Ultrasonographic diagnosis of pregnancy in rats

The purpose of the present study was to describe the technique for and findings of ultrasonographic examination of the rat uterus for diagnosis of early and midterm pregnancy. The uterus of anesthetized Wistar rats was examined between days 9 and 16 post coitum by transabdominal real-time ultrasonography by using a 12-MHz linear transducer. Pulsed-waved color Doppler sonography was used to measure the embryonic heart rate. The embryonic vesicles were detected with 25% false-negative diagnosis on day 9, 8% on day 10, and 0% thereafter. By day 12, the embryos were detected with measurable crown-rump length and heart rate. Ultrasonographic evidence of pregnancy in the rat was present by day 9 post coitum. Diagnosis of pregnancy was confirmed by detection of the embryo heart beat by day 12. Embryo characteristics were ultrasonographically measurable between days 9 and 16.

Groove pancreatitis: a diagnostic challenge

Groove pancreatitis is a distinct form of chronic pancreatitis characterized by inflammation and fibrous tissue formation, affecting the groove area between the head of the pancreas, the duodenum and the common bile duct. It is manifested on imaging by a sheet-like mass in the groove area near the minor papilla. Thickening of the duodenal wall and cystic transformation in the duodenal wall also represent common imaging features. Pathogenesis is still unclear, and clinical presentation is not specific. Endoscopic ultrasonography (EUS), computed tomography (CT) and magnetic resonance imaging (MRI) demonstrate imaging findings consistent with the disease in typical cases, but specific diagnosis is challenging in a number of patients where biopsy is required. The disease may mimic pancreatic, common bile duct or duodenal wall cancer that requires prompt and excessive surgical intervention, as opposed to groove pancreatitis where initial conservative treatment is suggested. The clinical, histopathological and radiological features on cross-sectional imaging of this entity are discussed in this review, and differential diagnostic clues are given.

Apneic oxygenation for elimination of respiratory motion artefact in an intubated patient undergoing helical computed tomography pulmonary angiography

Respiratory motion artifact in intubated and mechanically ventilated patients often reduces the quality of helical computed tomography pulmonary angiography (CTPA). Apneic oxygenation is a well established intra-operative technique that allows adequate oxygenation for short periods (up to 10 min) in sedated and paralyzed patients. We describe the use of the apneic oxygenation for elimination of respiratory motion artefact in an intubated patient undergoing CTPA.

Double gall-bladder--two pathologies: a case report

True gall-bladder duplication is a rare biliary anomaly, which is usually discovered as an incidental finding. There are reports of double gall-bladders missed during the first operation. We present the case of a double gall-bladder which, albeit suspected during the operation, was confirmed post-operatively. The patient underwent successful laparoscopic cholecystectomy and the examination of the resected gall-bladder revealed two chambers, only one containing stones. Predisposing factors for the development of gall-stones in one gall-bladder only, as well as surgical options, are briefly discussed.

Differentiation of MEG activity in multiple sclerosis patients with the use of nonlinear analysis

The aim of this study is to investigate if there is any nonlinearity in the magnetoencephalographic recordings of patients with multiple sclerosis in comparison with controls in order to find out the differences in the mechanisms underlying their brain waves. Five multiple sclerosis patients and five controls were included in this study. Chaotic activity of multiple sclerosis patients is lower than in the normal brain. Nonlinear analysis may offer fertile perspectives for understanding the features of patients with multiple sclerosis.

EVALUATION OF AN INTRACRANIAL ARACHNOID CYST WITH MEG AFTER MAGNETIC STIMULATION

A 34-year-old male diagnosed of an intracranial arachnoid cyst arising in the left-sided temporal-parietal area, by computed tomography (CT), underwent evaluation by means of MEG. Biomagnetic waveform recordings were obtained from the target area and the Fourier analysis of these measurements was carried out. External magnetic stimulation in the order of pico Tesla was applied with proper field characteristics (intensity: 1-7.5 pT, frequency: 8-13 Hz), which were obtained prior to the application and the emitted MEG activity was recorded again. The cortical area adjacent to the borders of the arachnoid cyst emitted biomagnetic waveforms with high values. The application of magnetic stimulation resulted in a rapid attenuation of the high MEG activity in the target area. MEG may provide useful information in the diagnostic evaluation of arachnoid cyst patients and could be a supplement to other imaging modalities.

MEG evaluation of Parkinson's diseased patients after external magnetic stimulation

Magnetoencephalographic (MEG) recordings of Parkinson's diseased (PD) patients were obtained using a whole-head 122-channel magnetometer and analyzed with Fourier statistical analysis. External transcranial magnetic stimulation (TMS) in the order of pico Tesla was applied on the above patients with proper field characteristics (magnetic amplitude : 1-7.5 pT, frequency : the alpha-rhythm of the patient: 8-13 Hz) which were obtained prior to TMS. The MEG recordings after the application of TMS showed a rapid attenuation of the high abnormal activity followed by an increase of the low frequency components toward the patients' alpha-rhythm. The patients responded to the TMS with a feeling of relaxation and partial or complete disappearance of tremor, muscular ache and levodopa induced dyskinesias as well as rapid reversed visuospatial impairment, which were followed by a corresponding improvement and normalization of the MEG.

Inferior epigastric artery false aneurysms: review of the literature and case report

A case report is presented of a IEA false aneurysm successfully embolized in a 50-year old man following a blunt abdominal injury. A literature review revealed another 15 cases. Most cases were iatrogenic (13/16) complicating abdominal wall procedures. Treatment options included open surgery (8 cases), percutaneous coil embolization (6), ultrasound guided thrombin injection or ultrasound guided compression (2). The selected treatment (surgical or non-surgical) was not affected by the size of the aneurysm (p=0.6) and was successful in all patients. However two of the non-surgically removed lesions (25%) remained unchanged in size for a long time causing discomfort. IEA false aneurysms represent an uncommon entity. Open surgery for IEA false aneurysms is easy and cheap. Endovascular approaches can lead to a long delay in resolution of the problem.

Low-Frequency MEG Activity and MRI Evaluation in Parkinson's Disease

BACKGROUND

Low - frequency activity has been reported in Parkinson disease (PD). We investigated the magnetoencephalographic (MEG) recordings from PD patients and healthy volunteers in the frequency domain.

METHODS

The MEG recordings were carried out in a magnetically shielded room with a whole-head 122-channel gradiometer. Nine patients suffering from PD and 9 age and gender matched healthy subjects were included in the study. MRI with T1-w and T2-w images, was available in patients' records.

RESULTS

Frequency analysis may be usefully combined in the analysis of data sets, which contain oscillatory components. Prominent low frequencies can be seen in the spectrum obtained from the PD patients whereas in the control group the frequency range was 6Hz in the majority of channels. MRI did not disclose specific findings in any case.

CONCLUSIONS

It is suggested that the MEG could be a complementary method in the diagnostic evaluation of PD using spatial distribution of the raw data in the frequency domain.

Bile leakage presenting as acute abdomen due to a stone created around a migrated surgical clip

BACKGROUND

Surgical clips may migrate into the common bile duct after surgery for cholecystolithiasis leading to usually early or middle-term complications.

CASE REPORT

A 31-year-old woman, 6 years after laparoscopic cholecystectomy, developed acute abdomen and choloperitoneum after rupture of a secondary bile duct and bile leakage. This complication was due to a solitary common bile duct stone. The stone was formed around a surgical clip that had migrated from the cystic duct remnant to the common bile duct. The patient underwent investigative laparotomy and, subsequently, an ERCP with stone extraction and clearance of the common bile duct. She was perfectly well at the follow-up after 14 months.

CONCLUSIONS

Rupture of a bile duct and biliary peritonitis may be a delayed complication of laparoscopic cholecystectomy due to surgical clip migration and formation of a stone. Definitive treatment of the condition may be achieved through ERCP. Surgeons, gastroenterologists and radiologists should be aware of this late complication of laparoscopic cholecystectomy in cases of acute abdomen.

Bilateral metastatic rhabdomyosarcoma to the breast in an adolescent female: touch imprint cytology and implication of MyoD1 nuclear antigen

BACKGROUND

Rhabdomyosarcoma accounts for approximately 4% of all childhood malignancies. Breast metastases from rhabdomyosarcoma are uncommon with an incidence of 6%.

CASE REPORT

We present a patient who developed bilateral mammary metastases from rhabdomyosarcoma arising in the right lower extremity. An 11-year-old female with a 20-month history of rhabdomyosarcoma was referred to our department because of bilateral breast enlargement. A needle core biopsy was performed and touch imprint slides were obtained. Cytology determined the masses to be metastases of rhabdomyosarcoma. MyoD1 immunostain and RT-PCR analysis confirmed the diagnosis.

CONCLUSIONS

Cytomorphology with ancillary methods is essential in the diagnosis of metastatic breast deposits in order to avoid unnecessary mastectomy and to employ systemic treatment.

Intrahepatic extramedullary hematopoietic tumor mimicking metastatic carcinoma from a colonic primary

BACKGROUND

Extramedullary hematopoiesis (EMH) is associated with a number of diseases in which the normal function of the bone marrow is disturbed. While organs with hemopoietic capacity like the liver and spleen are most commonly involved, EMH has also occasionally been found in other organs like the adrenal gland, lymph nodes, breast, thymus, small bowel and central nervous system. However, presentation of a myeloproliferative disorder, such as EMH in these organs is a rare event.

CASE REPORT

We report clinical and fine-needle aspiration (FNA) findings in a patient who presented with intrahepatic EMH which mimicked metastatic carcinoma from a colonic primary.

RESULTS

Ultrasound-guided FNA of the intrahepatic mass revealed megakaryocytes and myelocytes thus establishing the diagnosis of EMH.

CONCLUSIONS

EMH is an unusual condition that can mimic other solid masses of the liver. Because radiologic findings are not specific, EMH should be considered in the differential diagnosis, especially in patients with a myeloproliferative disorder. FNA and subsequent cytopathological interpretation of the aspirates enables avoidance of unnecessary potentially hazardous surgery.

Fine-needle aspiration cytology of a para-aortical solitary plasma-cell tumor

Extramedullary plasma-cell tumor (EMP) is a very rare disease and mainly arises in the head and neck area. An EMP arising in the paraaortical space was diagnosed by fine needle aspiration cytology and immunocytochemistry, in a 48-year-old male. Smears were cellular and showed dissociated monomorphic plasma cells. Immunocytochemistry demonstrated monoclonal expression of kappa-light immunoglobulin chain and CD38 positivity. Cytomorphology and immunocytochemical profile allowed a definitive diagnosis of plasmacytoma.

Optimization of a contrast medium suitable for conventional enteroclysis, MR enteroclysis, and virtual MR enteroscopy

BACKGROUND

The purpose of the current study was to optimize a gadolinium-barium sulfate solution suitable for performing conventional and MR enteroclysis examinations in the same session.

METHODS

Eighteen vials of 20% barium sulfate and various gadolinium concentrations (lower 0 ml/lt, higher 45 ml/lt) were prepared and placed in the magnet. The imaging protocol was consisted of the following sequences: true FISP, HASTE with fat saturation and 3d FLASH with fat saturation in various flip angles. Ten patients underwent conventional enteroclysis with 1.2 lt of 20% barium sulfate enema and 18 ml of gadolinium. MR enteroclysis was performed afterwards using true FISP, fat suppressed 3d FLASH and fat suppressed HASTE sequences.

RESULTS

The lowest gadolinium concentration in the barium sulfate solution generating low intraluminal signal on HASTE and high intraluminal signal on true FISP and 3d FLASH sequences was 15 ml/lt. The presence of gadolinium did not influence the lumen opacification in conventional enteroclysis examination. In all patients the proposed contrast medium acted as positive in 3d FLASH (T1w), true FISP (T2/T1 w) and as a negative in HASTE (T2w). Bowel wall conspicuity, lumen opacification and distention were ranked as very good to excellent on MR enteroclysis images while artifacts level did not downgraded the overall image quality. High quality virtual MR endoluminal views of the small bowel, based on 3d FLASH images, were obtained in all cases.

CONCLUSION

A 20% barium sulfate enema with 15 ml/lt gadolinium is appropriate for conventional and MR enteroclysis examinations.