Effects of intubation timing in patients with COVID-19 throughout the four waves of the pandemic: a matched analysis

BACKGROUND

The primary aim of our study was to investigate the association between intubation timing and hospital mortality in critically ill patients with coronavirus disease 2019 (COVID-19)-associated respiratory failure. We also analysed both the impact of such timing throughout the first four pandemic waves and the influence of prior noninvasive respiratory support on outcomes.

METHODS

This is a secondary analysis of a multicentre, observational and prospective cohort study that included all consecutive patients undergoing invasive mechanical ventilation due to COVID-19 from across 58 Spanish intensive care units (ICUs) participating in the CIBERESUCICOVID project. The study period was between 29 February 2020 and 31 August 2021. Early intubation was defined as that occurring within the first 24 h of ICU admission. Propensity score matching was used to achieve a balance across baseline variables between the early intubation cohort and those patients who were intubated after the first 24 h of ICU admission. Differences in outcomes between early and delayed intubation were also assessed. We performed sensitivity analyses to consider a different time-point (48 h from ICU admission) for early and delayed intubation.

RESULTS

Of the 2725 patients who received invasive mechanical ventilation, a total of 614 matched patients were included in the analysis (307 for each group). In the unmatched population, there were no differences in mortality between the early and delayed groups. After propensity score matching, patients with delayed intubation presented higher hospital mortality (27.3% versus 37.1%; p=0.01), ICU mortality (25.7% versus 36.1%; p=0.007) and 90-day mortality (30.9% versus 40.2%; p=0.02) compared with the early intubation group. Very similar findings were observed when we used a 48-h time-point for early or delayed intubation. The use of early intubation decreased after the first wave of the pandemic (72%, 49%, 46% and 45% in the first, second, third and fourth waves, respectively; first versus second, third and fourth waves p<0.001). In both the main and sensitivity analyses, hospital mortality was lower in patients receiving high-flow nasal cannula (HFNC) (n=294) who were intubated earlier. The subgroup of patients undergoing noninvasive ventilation (n=214) before intubation showed higher mortality when delayed intubation was set as that occurring after 48 h from ICU admission, but not when after 24 h.

CONCLUSIONS

In patients with COVID-19 requiring invasive mechanical ventilation, delayed intubation was associated with a higher risk of hospital mortality. The use of early intubation significantly decreased throughout the course of the pandemic. Benefits of such an approach occurred more notably in patients who had received HFNC.

Predictors of success for Brugada syndrome epicardial ablation

 

Epicardial right ventricular outflow tract (RVOT) ablation has been described for the treatement of Brugada syndrome (BrS) high risk patients.

Purpose

Success evaluation of epicardial ablation for BrS.

Methods

Type 1 ECG was defined as spontaneous if recorded in absence of drugs and/or specific conditions. BrS patients were scheduled for ablation if presented at least one of: spontaneous type 1 ECG, syncope, ventricular arrhythmias (VA).

Programmed electrical stimulation (PES) was performed (2 extrastimuli, 2 sites) in basal conditions and after ajmaline infusion. Epicardial subxifoid access and electroanatomical endo-epicardial maps were obtained during sinus rhythm. Delayed fragmented/low-frequency, low-voltage electrograms (EGM) were targeted: substrate area measured in basal conditions and after ajmaline.

Epicardial ablation

Radiofrequency (RF) was delivered (50 W power control mode) till complete elimination of targeted EGM and BrS-ECG pattern after ajmaline. Eventually PES repeated: if positive a repeated PES scheduled at follow-up (fu).

Success was defined as absence of type 1 ECG either spontaneous or with ajmaline challenge at 3 month. Recurrences were scheduled to redo ablation.

Results

55 patients were submitted to 58 ablation procedures. 38 spontaneous type 1 ECG: 18 symptomatic for syncope/polimorphic VT/VF or appropriate ICD shock; 13 had VA induction at PES. 4 patients with ajmaline-type 1 ECG had VA induction. 36% of the symptomatic patients and 26% of asymptomatic had PES-VA induction. In all patients abnormal EGM area (cm2) was detected in epicardial RVOT (table 1).

Acute success: No patient had ECG type 1 with ajmaline. 5 patients had PES induction of VA. Complications: 1 cardiac tamponade, 16 mild pericarditis.

At FU of 1,1±0,6 yrs no patient had spontaneous ECG type 1 nor arrhythmic events. 50 had negative ajmaline challenge (90% success rate after single procedure), 3 underwent redo: 2 had negative ajmaline challenge at FU, 1 had persistence type 1-ajmaline induction; 2 are scheduled for redo. No patient had VT induction at PES.

Multivariate analysis: Single procedure success was not related either to history (symptoms, VA, type 1 ECG) or to procedural findings (PES results, substrate area).

Conclusion

Epicardial substrate ablation was safe end effective in BrS. No clinical or procedural findings were related to success

Funding Acknowledgement

Type of funding source: None

Valorization of agro-industrial wastes to produce hydrolytic enzymes by fungal solid-state fermentation

Nowadays, significant amounts of agro-industrial wastes are discarded by industries; however, they represent interesting raw materials for the production of high-added value products. In this regard, orange peels (ORA) and exhausted sugar beet cossettes (ESBC) have turned out to be promising raw materials for hydrolytic enzymes production by solid state fermentation (SSF) and also a source of sugars which could be fermented to different high-added value products. The maximum activities of xylanase and exo-polygalacturonase (exo-PG) measured in the enzymatic extracts obtained after the SSF of ORA were 31,000 U·kg^-1 and 17,600 U·kg^-1, respectively; while for ESBC the maximum values reached were 35,000 U·kg^-1 and 28,000 U·kg^-1, respectively. The enzymatic extracts obtained in the SSF experiments were also employed for the hydrolysis of ORA and ESBC. Furthermore, it was found that extracts obtained from SSF of ORA, supplemented with commercial cellulase, were more efficient for the hydrolysis of ORA and ESBC than a commercial enzyme cocktail typically used for this purpose. In this case, maximum reducing sugars concentrations of 57 and 47 g·L^-1 were measured after the enzymatic hydrolysis of ESBC and ORA, respectively.

Alleged malpractice in orthopaedics. Analysis of a series of medmal insurance claims

Background

Medical malpractice is an important topic worldwide, and orthopedics is a clinical branch that is considered to be at a high risk for claims. The analysis of a series of medmal insurance claims allows forensic pathologists, clinicians, and insurance companies to probe the risk of a specific clinical branch for medical malpractice claims and highlights areas where care may be improved. We investigated the main features of a major Italian insurance broker’s archive in order to identify recurrent pitfalls in this field.

Materials and methods

A retrospective study was carried out on orthopedics claims. The archive covered claims from 2002 to 2013 that targeted 1980 orthopedists.

Results

635 claims were found and analyzed with a focus on the clinical activity invocked in the claim, the presence of alleged team malpractice, the clinical outcome of the case, and the final forensic decision regarding the claim. 299 orthopedists had at least one malpractice claim made against them during the available period; 146 orthopedists were subject to more than one malpractice claim. Most of the claims regarded perioperative and operative cases, usually originating from civil litigation. The anatomical sites most commonly involved were the hip or knees, and sciatic nerve lesions were the main contributor.

Conclusions

Orthopedics is a medical specialty with a high risk for malpractice claims. In our study, medical malpractice was observed in nearly 50% of the cases—typically in surgery-linked cases resulting in permanent impairment of the patient. Death from orthopedics malpractice seemed to be rare.

Level of Evidence

IV.

Valorization of exhausted sugar beet cossettes by successive hydrolysis and two fermentations for the production of bio-products

Exhausted sugar beet cossettes (ESBC) show an enormous potential as a source of sugars for the production of bio-products. Enzyme hydrolysis with the combined effect of mainly cellulases, xylanases and pectinases, turned out to be very efficient, obtaining almost double the concentration of sugars measured with the sole action of Celluclast® and β-glucosidase, and increasing 5 times the hydrolysis rate. As the sole pretreatment, ESBC soaked in the hydrolysis buffer were autoclaved, avoiding the application of severe conventional biomass pretreatments. Moreover, a promising alternative for the complete utilization of glucose, xylose, arabinose, mannose and maltose contained in ESBC is proposed in this paper. It consists of sequential fermentation of sugars released in the hydrolysis step to produce bioethanol and lactic acid as main bio-products. Compared to separate fermentations, with this strategy glucose and hemicellulose derived sugars were completely consumed and the 44% of pectin derived sugars.

MR pyelography in 115 patients with a dilated renal collecting system

Purpose: To evaluate the accuracy of MR pyelography in the assessment of hydroureteronephrosis.

Material and Methods: One hundred and fifteen patients, with variable degree of hydroureteronephrosis demonstrated by US and urography were subjected to MR pyelography obtained by means of two ultra-fast sequences.

Results: Of the 228 kidneys examined, the collecting systems of 130 kidneys were dilated and correctly identified on MR pyelography, with only 2 false-positive results. The specificity of MR pyelography in detecting hydronephrosis was 98%. Accuracy in revealing level of obstruction was 100%. Sensitivity in detecting stones, strictures and congenital ureteropelvic junction obstructions was respectively 68.9%, 98.5% and 100%.

Conclusion: MR pyelography can rapidly and accurately depict the morphological features of dilated urinary tracts with information regarding the degree and level of obstruction, without using contrast medium or ionizing radiation.

The Fatty Disc: An Unusual Cause of Bright Intervertebral Disc on T1-Weighted Conventional Spin-Echo MR: A Case Report

A hyperintense intervertebral disc on T1-weighted spin-echo MR image, the “bright disc”, is described in a patient with a long-standing ankylosing spondylitis.

The high signal intensity was due to the fatty infiltration of the discal tissue, as was clearly demonstrated by the comparison of MR and CT scan of the lumbar spine, probably due to progressive endochondral ossification with subsequent bone marrow metaplasia in the ossified disc.

Single-phase dual-energy CT urography in the evaluation of haematuria

AIM

To assess the value of a single-phase dual-energy computed tomography (DECT) urography protocol with synchronous nephrographic-excretory phase enhancement and to calculate the potential dose reduction by omitting the unenhanced scan.

MATERIALS AND METHODS

Eighty-four patients referred for haematuria underwent CT urography using a protocol that included single-energy unenhanced and dual-energy contrast-enhanced with synchronous nephrographic-excretory phase scans. DECT-based images [virtual unenhanced (VUE), weighted average, and colour-coded iodine overlay] were reconstructed. Opacification degree by contrast media of the upper urinary tract, and image quality of virtual unenhanced images were independently evaluated using a four-point scale. The diagnostic accuracy in detecting urothelial tumours on DECT-based images was determined. The dose of a theoretical dual-phase single-energy protocol was obtained by multiplying the effective dose of the unenhanced single-energy acquisition by two. Radiation dose saving by omitting the unenhanced scan was calculated.

RESULTS

The degree of opacification was scored as optimal or good in 86.9% of cases (k = 0.72); VUE image quality was excellent or good in 83.3% of cases (k = 0.82). Sensitivity, specificity, positive predictive value, and negative predictive value for urothelial tumours detection were 85.7, 98.6, 92.3, and 97.1%. Omission of the unenhanced scan led to a mean dose reduction of 42.7 ± 5%.

CONCLUSION

Single-phase DECT urography with synchronous nephrographic-excretory phase enhancement represents an accurate "all-in-one'' approach with a radiation dose saving up to 45% compared with a standard dual-phase protocol.

Computed tomography coronary angiography in asymptomatic patients

PURPOSE

This study assessed the accuracy of computed tomography coronary angiography (CT-CA) for detecting significant coronary artery disease (CAD; ≥50% lumen reduction) in intermediate/high-risk asymptomatic patients.

MATERIALS AND METHODS

A total of 183 consecutive asymptomatic individuals (92 men; mean age 54±11 years) with more than one major risk factor (obesity, hypertension, diabetes, hypercholesterolaemia, family history, smoking) and an inconclusive or nonfeasible noninvasive stress test result (stress electrocardiography, stress echocardiography, nuclear stress scintigraphy) underwent CT-CA in an outpatient setting. All patients underwent conventional coronary angiography (CAG) within 4 weeks. Data from CT-CA were compared with CAG regarding the presence of significant CAD (≥50% lumen reduction).

RESULTS

Mean calcium score was 177±432, mean heart rate during the CT-CA scan was 58±8 bpm and the prevalence (per-patient) of obstructive CAD was 19%. CT-CA showed single-vessel CAD in 9% of patients, two-vessel CAD in 9% and three-vessel CAD in 0%. Per-patient sensitivity, specificity, positive predictive value and negative predictive value of CT-CA were 100% (90-100), 98% (96-99), 97% (85-99), 100% (97-100), respectively. Positive and negative likelihood ratios were 151 and 0, respectively.

CONCLUSIONS

CT-CA is an excellent noninvasive imaging modality for excluding significant CAD in intermediate/ high-risk asymptomatic patients with inconclusive or nonfeasible noninvasive stress test.

Magnetic resonance cholangio-pancreatography versus endoscopic retrograde cholangio-pancreatography in the diagnosis of common bile duct stones: a prospective comparative study

AIM

As it is a non-invasive method, magnetic resonance cholangiography (MRCP) has almost completely replaced endoscopic retrograde cholangiography (ERCP) in the diagnosis of pancreato-biliary diseases. The aim of this study was to evaluate sensitivity, specificity, diagnostic accuracy, positive predictive value (PPV) and negative predictive value (NPV) of MRCP in diagnosis of choledocholithiasis using ERCP/endoscopic sphincterotomy (ES) as gold standard.

METHODS

For this study 140 individuals, suspected for lithiasis of the common bile duct (CBD), were enrolled. After a clinical and biochemical evaluation, patients underwent upper abdominal ultrasonography, then MRCP and diagnostic and/or operative ERCP.

RESULTS

Only 120 out of 140 patients completed the study. MRCP diagnosed lithiasis of CBD in 84. ERCP confirmed the lithiasis in 73/84 patients who were submitted to ES. Eleven were negative after ES. ERCP documented stones in 10 patients among the 36 negative at MRCP; stones were detected only in four patients after ES. In 26 out of 36 patients negative at MRCP, ERCP confirmed this response: only 12 out of 26 patients underwent ES. The sensitivity, specificity, diagnostic accuracy, PPV and NPV of MRCP were: 88%, 72%, 83%, 87%, 72%.

CONCLUSIONS

As the MRCP diagnostic yield is still limited with small stones, the question of which patient is the best candidate to ERCP/ES is still unsolved.

Neuropathic pain in temporomandibular joint disorders: case-control analysis by MR imaging

BACKGROUND AND PURPOSE

Temporomandibular joint disorders (TMJ-D) may be associated with the onset of neuropathic pain. The purpose of this study was to prospectively assess if, at the open-mouth position, the distance between the temporomandibular joint (TMJ) disk and the mandibular nerve is shorter in patients with TMJ-D and neuropathic pain vs patients with TMJ-D without neuropathic pain or in healthy people.

MATERIALS AND METHODS

After ethical committee approval, we evaluated by MR imaging 16 TMJs with TMJ-D and neuropathic pain, 16 TMJs with TMJ-D without neuropathic pain, and 16 TMJs of healthy volunteers. All of the subjects were informed about the study procedure. We evaluated the distance between the TMJ disk and the mandibular nerve at the oval foramen level. Furthermore, the presence within the TMJs of internal derangement, osteoarthrosis, joint effusion, and bone marrow edema was evaluated.

RESULTS

At the maximal open-mouth position, the distance between the TMJ disk and the mandibular nerve is shorter in patients with TMJ-D and neuropathic pain than in patients with TMJ-D without neuropathic pain or in healthy volunteers (P < .05). The imaging findings of TMJ internal derangement, effusion, osteoarthrosis, and bone marrow edema were present both in patients with TMJ-D without neuropathic pain and in patients with TMJ-D and neuropathic pain.

CONCLUSIONS

We suggest that a closer proximity between the TMJ disk and the mandibular nerve could be one of the causes of the onset of neuropathic pain in patients with TMJ-D and neuropathic pain.

Arteriovenous fistula of the mandible simulating an odontogenic cyst. A case report

SUMMARY

We describe a rare case of mandibular highflow arteriovenous malformation (AVM) mimicking an odontogenic cyst in a young man. The diagnosis of mandibular AVM was made by CT angiography and confirmed by digital subtraction angiography. CT scan showed the extent of mandibular bone alteration and a double enlarged mandibular canal on the same side. An AVM containing a large aneurysm was demonstrated by CT angiography.The mandibular AVM was successfully treated by endovascular therapy with Guglielmi detachable coils. On panoramic radiogram, mandibular AVMs can appear as cystic lesions without pathognomonic features. Several benign and malignant tumours of this anatomical region must be considered in the differential diagnosis.We emphasize the radiological sign of double enlarged mandibular canal and the diagnostic role of CT, particularly CT angiography, to discriminate a mandibular AVM from neoplastic entities of this region, sparing the risks of a needle biopsy.

Seminal vesicle cysts with unilateral renal agenesis and contralateral ureteral stenosis in a beta-thalassemic patient: an unknown association by incomplete development of the mesonephric duct

We report the case of a 13-year-old male patient with beta-thalassemic trait who presented for a colic pain. An ultrasound of the abdomen revealed absence of the right kidney with a complex hypoechogenic pelvic mass causing mild pressure on the posterior bladder wall. Urography showed hypertrophy of the left kidney with moderate ureteral enlargement of the distal third due to an insertion defect in the bladder suggestive of a primary segmental nonobstructing megaureter. MR studies showed right multilocular seminal vesicle cysts. One year later an MR examination of the pelvis showed an increase in size of seminal vesicle cysts and open surgery was performed to remove the cystic retrovesical mass. Our case represents a very rare association of seminal vesicle cysts, unilateral renal agenesis and alteration in contralateral ureteral insertion in a patient with beta-thalassemic trait.

Use of sulesomab in the diagnosis of brucellar spondylitis

Twenty-two patients with suspected brucellar spondylitis were investigated to evaluate the possible diagnostic role of Sulesomab, a (99m)Tc-antigranulocyte antibody Fab' fragment. Sensitivity and specificity were compared with those of magnetic resonance imaging (MRI). Skeletal involvement was detected by MRI in 11 cases, while leukoscintigraphy indicated normal vertebral uptake in seven of these patients, increased uptake in two patients, and decreased uptake in two patients. Leukoscintigraphy of the 11 patients negative by MRI demonstrated increased uptake in two cases. The sensitivity and specificity of leukoscintigraphy were 27.2% and 81.1%, respectively. Based on these results, leukoscintigraphy is not indicated for the management of patients with suspected brucellar spondylitis.

Lithiasic Obstructive Uropathy

OBJECTIVES

The purpose of this study was to evaluate the role of magnetic resonance (MR) pyelography in patients affected by hydronephrosis due to ureteric stones, in order to identify a pyonephrotic condition.

MATERIALS AND METHODS

In the last 3 years, 315 patients, who had originally been investigated by ultrasonography, were evaluated with MR pyelography in order to define the etiology of obstruction. In 67 patients hydronephrosis was referred as caused by lithiasis.

RESULTS

MR pyelography not only confirmed urinary tract dilatation in all patients, but also identified grade and site of obstruction, both in acute dilatation (25 patients) and in chronic obstructions (42 patients). In 7 patients, MR pyelography documented pyonephrosis that was obviously confirmed by nephrostomic drainage.

CONCLUSION

MR pyelography, made with ultrafast breath-hold sequences, has a great value in identifying hydronephrosis in patients with ureteric stones. Furthermore, it provides the chance to identify pyonephrosis requiring an immediate drainage of the kidney before major complications develop.

Hepatic artery aneurysm, an unusual cause of obstructive jaundice: MR cholangiography findings

Hepatic artery aneurysms are rare vascular lesions, often with a nonspecific clinical presentation, and difficult to diagnose before rupture. We report the case of a patient with obstructive jaundice caused by a compression on the right biliary duct by a right hepatic artery aneurysm in which the diagnosis was suggested by magnetic resonance cholangiography and confirmed by Doppler sonography and preoperative digital subtraction angiography.

Calcium alginate gel as encapsulation matrix for coimmobilized enzyme systems

Encapsulation within calcium alginate gel capsules was used to produce a coimmobilized enzyme system. Glucose oxidase (GOD) and catalase (CAT) were chosen as model enzymes. The same values of Vmax and Km app for the GOD encapsulated system and for the GOD-CAT coencapsulated system were calculated. When gel beads and capsules were compared, the same catalyst deactivation sequence for the two enzymes was observed. However, when capsules were employed as immobilization support, GOD efficiencies were higher than for the gel beads. These results were explained in terms of the structure of the capsules.

MR pyelography in the assessment of hydroureteronephrosis: single-shot thick-slab RARE versus multislice HASTE sequences

BACKGROUND

We used magnetic resonance (MR) pyelography to compare the value of thick-slab single-shot rapid acquisition with relaxation enhancement (RARE) sequence with that of multislice half-Fourier acquisition single-shot turbo-spin-echo (HASTE) sequence in evaluating the full spectrum of morphologic features in a group of patients with hydronephrosis.

METHODS

MR pyelographic images, with the use of thick-slab RARE and multislice HASTE sequences in 90 patients, were evaluated for image quality, presence of hydronephrosis, and level and cause of obstruction.

RESULTS

HASTE sequences provided images of better quality than did RARE sequences (p < 0.001). There was no statistically significant difference in demonstrating the presence of hydronephrosis (p = 0.5) and level of obstruction (p = 0.125). Sensitivity, specificity, and accuracy in diagnosing cause of obstruction were 61.7%, 62.5%, and 62%, respectively, for RARE sequences and 80%, 82.5%, and 81%, respectively, for HASTE sequences, with a statistically significant difference (all p < 0.05).

CONCLUSION

Multislice HASTE sequence provides better diagnostic information than does thick-slab RARE sequence, particularly in evaluating the cause of obstruction.

Contrast-enhanced MR imaging with fat suppression in adult-onset septic spondylodiscitis

Spinal infections typically involve vertebrae as well as discs, and for this reason they are called septic spondylodiscitis. Magnetic resonance imaging is the most sensitive imaging method for the evaluation of this group of spinal diseases. The use of contrast-enhanced T1-weighted sequences with fat suppression, if correctly applied, may increase information provided by MRI. Firstly, this technique allows the primary vertebral focus, which often precedes disc involvement, to be identified at a very early stage. When the disease spreads, T1-weighted fat-suppressed gadolinium dimeglumine (Gd-DTPA) enhanced images provide macroscopic details of the primary vertebral focus, disc involvement patterns, and pathways of infection diffusion. All this information, when correlated with laboratory tests, may be useful in identifying the infectious agents (tuberculous vs piogenic forms), thus enabling a suitable therapy to be started. This technique is also useful in the assessment of the real extension of the disease, providing a clear depiction of paravertebral space involvement and of psoas muscle abscesses. Dangerous complications, such as meningitis, myelitis, and epidural abscesses, may be more promptly diagnosed and fully evaluated with fat-suppressed post-contrast T1-weighted images. Finally, this imaging technique may help to differentiate infectious processes from degenerative disorders, extradural neoplastic processes, and rheumatic diseases.

Cerebral angiography in the rat with mammographic equipment: a simple, cost-effective method for assessing vasospasm in experimental subarachnoid haemorrhage

We report quantification of vasospasm following subarachnoid haemorrhage (SAH) and the effect of a new antivasospastic free radical scavenger (AVS) in rats, using an angiographic technique developed in our laboratory. We acquired single-exposure angiograms with mammographic equipment, using a 0.1 mm diameter focal spot and single-emulsion mammographic films. Contrast medium was injected through a PE50 catheter in the common carotid artery, after the external carotid artery had been ligated to divert flow towards the internal carotid artery territory. Measurements of the M1 and A1 segments and of the middle third of the basilar artery were made by projecting the angiograms directly as slides and using the endovascular catheter as an internal reference. We tested the technique on 40 male albino Sprague-Dawley rats divided into four groups: sham-operated+saline, SAH+saline, sham-operated+AVS and SAH+AVS. We were able to measure the diameter of the principal intracranial arteries in all the animals. With our technique, which is cost-effective when compared to many of those reported recently, we could detect intracranial vasospasm in all untreated rats with SAH, and confirm antivasospastic effects of AVS.

Polygalacturonase production by Aspergillus awamori on wheat in solid-state fermentation

The production of exo-polygalacturonase (exo-PG) and endo-PG by Aspergillus awamori grown on wheat in solid-state fermentation was studied. Endo- and exo-PG activities were detected after 24 h of inoculation. Glucose released from starch hydrolysis acted as a catabolite repressor for the exo-PG enzyme. In contrast, endo-PG production was not affected by glucose repression. When milled grains were used, the particle-size distribution and the chemical composition of the medium influenced the rate of micro-organism growth and therefore the trend followed by endo- and exo-PG production. However, these two parameters did not affect the maximum production of exo-PG and endo-PG. For one of the milled samples, three different moisture contents were used (50, 55, 60%). Moisture contents of 60% provide a higher yield of pectinases by A. awamori.

Twisted ovarian fibroma with high signal intensity on T1-weighted MR image: a new sign of torsion of ovarian tumors?

Torsion of ovarian tumors is often difficult to diagnose, because of non-specific clinical, laboratory, and imaging findings. We report a case of twisted ovarian fibroma whose main characteristic was the presence of large areas of high signal intensity on both T1- and T2-weighted MR images due to the passive congestion of the mass. This previously unreported finding should be considered a sign of ovarian torsion and may facilitate prompt surgical intervention.

Ossifying lipoma of the parapharyngeal space: CT and MRI findings

Ossifying lipomas independent of bone tissue are very rare. A literature review revealed that only few cases of ossifying lipoma independent of bone tissue have been reported. None of the cases have been reported in the international radiology literature. In addition, there are no reports concerning the MRI features of this entity. We describe CT and MRI findings in a case of ossifying lipoma of the parapharyngeal space.

MR white lung sign: incidence and significance in pulmonary consolidations

PURPOSE

The presence of a pulmonary consolidation with a signal intensity comparable with that of the static fluid on heavily T2-weighted MR images has been named the "MR white lung sign." This sign has been described in mucinous bronchioloalveolar carcinoma (BAC). Our purpose was to establish the frequency and significance of this sign in pulmonary consolidations of varied causes.

METHOD

In this prospective study, 83 patients with pulmonary consolidation underwent MR examination between January and December 1999. Segmental or lobar consolidations were due to pneumonia without central obstruction (n = 22), pneumonitis with central obstruction (n = 21), cicatricial atelectasis (n = 8), passive atelectasis (n = 10), radiation pneumonitis (n = 8), mucinous BAC (n = 5), infarction (n = 3), bronchiolitis obliterans organizing pneumonia (n = 3), nonmucinous BAC (n = 2), and lymphoma (n = 1). The MR white lung sign was considered present when the signal intensity of a pulmonary consolidation was comparable with that of the static fluid on heavily T2-weighted images obtained with MR hydrography sequences. Interobserver agreement, sensitivity, and specificity of the white lung sign in diagnosing mucinous BAC were calculated.

RESULTS

The MR white lung sign was present in 7 (8%) of 83 consolidations, including 5 (100%) of 5 cases of mucinous BAC and 2 (10%) of 21 cases of obstructive pneumonitis. The frequency of the white lung sign was 100% in mucinous BAC and 2.6% in consolidations due to other causes. The difference was statistically significant (p < 0.05).

CONCLUSION

The white lung sign is an uncommon finding in pulmonary consolidations evaluated with heavily T2-weighted sequences. However, the sign is characteristic of mucinous BAC and adds specificity to the radiologic diagnosis.

Perineural spread in a case of sinonasal sarcoidosis: case report

We report a case of sinonasal sarcoidosis with perineural spread along the trigeminal and vidian nerves in which primarily MR imaging but also CT allowed excellent visualization of this infiltration.

Gallbladder duplication: MR cholangiography demonstration

Gallbladder duplication is a rare anatomic malformation. We present a case of gallbladder duplication in a patient who underwent laparoscopic cholecystectomy in which breath-hold magnetic resonance cholangiography showed the biliary anomaly, allowing a correct preoperative differentiation of the specific type of duplication.

Successful treatment of pustulotic arthro-osteitis (Sonozaki syndrome) with systemic cyclosporin

Pustulotic arthro-osteitis, first described by Sonozaki, is a relatively rare disorder, the prevalence of which is probably underestimated in dermatological literature; its early recognition can prevent misdiagnosis, unnecessary surgery, and the use of prolonged and ineffective antibiotic treatment.

Hepatobronchial fistula due to transphrenic migration of hepatic echinococcosis: MR demonstration

We present an uncommon case of hepatic hydatidosis, complicated by transphrenic migration of the cyst, in which the use of magnetic resonance performed with ultrafast, breath-hold, heavily T2-weighted sequences (HASTE) demonstrated a bronchial fistula.

CT and MR findings in neoplastic perineural spread along the vidian nerve

The aims of this article are to describe the findings of perividian tumor spread and to compare the accuracy of MRI and CT in diagnosing perineural metastasis along the vidian nerve. Moreover, the frequency of perividian metastasis in patients with head and neck cancer was evaluated. The CT and MR examinations of 98 consecutive untreated patients with histologically proven head and neck cancer were retrospectively reviewed. We considered as criteria for perineural tumor spread along the vidian nerve the following CT and MR findings: For CT (a) enlargement of the pterygoid canal, (b) erosion of its bony wall, and (c) obliteration of its normal fatty content; and for MR (a) enlargement of the vidian nerve, (b) enhancement of the nerve, and (c) obliteration of fat, particularly in the anterior part of the pterygoid canal. Ten patients met the selected criteria for perineural metastasis, which was bilateral in 3 patients, with a total of 13 vidian metastases. The CT scans demonstrated unilateral involvement of the vidian nerve in 9 patients. The MRI scans showed 13 perineural metastases. In 3 patients MR scans demonstrated involvement of four vidian nerves that appeared normal on CT examinations. The diagnostic difference between CT and MRI was statistically significant (Fisher's exact test; p = 0.04). Perineural spread along the vidian nerve is an event more frequent than previously reported and must be investigated with a careful imaging technique. Although a major limitation of our study is the lack of histological proof, the MR finding of a significant enhancement of the nerve, whether enlarged or normal in size, could be considered very suggestive of this kind of metastatic spreading, particularly if associated with simultaneous involvement of the neighboring structures (pterygopalatine fossa, foramen lacerum, trigeminal branches, etc.).

Chronic infiltrative lung diseases: value of gadolinium-enhanced MRI in the evaluation of disease activity--early report

STUDY OBJECTIVE

To determine the value of gadolinium-enhanced MRI in the assessment of disease activity in chronic infiltrative lung diseases (CILDs).

DESIGN

Retrospective study.

SETTING

University hospital.

MATERIALS AND METHODS

Twenty-five consecutive patients with CILD were studied. The following diseases were diagnosed: sarcoidosis (n = 10), bronchiolitis obliterans organizing pneumonia (n = 3), usual interstitial pneumonia (n = 4), radiation pneumonia (n = 2), desquamative interstitial pneumonia (n = 1), rheumatoid lung (n = 1), vasculitis (n = 1), alveolar proteinosis (n = 1), bronchioloalveolar carcinoma (n = 1), and chronic eosinophilic pneumonia (n = 1). In each patient, the disease activity was assessed by one or more of the following studies: BAL (n = 18), gallium-radioisotope lung scanning (n = 6), serum angiotensin-converting enzyme assay (n = 10), and open lung biopsy (n = 4). T1-weighted breath-hold MRI studies were obtained before and after IV injection of gadolinium. The MRI examinations were analyzed to assess the presence or absence of lesional enhancement.

RESULTS

The presence of enhanced pulmonary lesions was seen in 14 patients. All of these patients had active disease. Of the 17 patients with active disease, 14 had enhanced lesions, and 3 had unenhanced lesions. Pulmonary lesions were not enhanced in any patients with inactive disease. The difference was statistically significant (Fisher Exact Test, p < 0.05).

CONCLUSION

Gadolinium-enhanced MRI may prove to be a useful tool in assessing disease activity in CILDs.

US power Doppler of hepatic angiomyolipoma with low fat content

Hepatic angiomyolipoma (AML) is a rare tumor containing a variable amount of fat. Angiomyolipoma prevalently constituted by vessels can be difficult to differentiate from other hypervascular hepatic tumors containing a small amount of fat. We describe US power Doppler findings in a case of hepatic AML with minimal fat content.

Magnetic resonance imaging of bronchioloalveolar carcinoma

The purpose of this study is to describe the magnetic resonance (MR) features of bronchioloalveolar carcinoma. MR examinations of 18 patients with proven bronchioloalveolar carcinoma were reviewed. Detection at computed tomography (CT) and pathologic confirmation were the entry criteria. Nine patients had a solitary nodule, three patients a lobar consolidation, and six patients had diffuse disease. For each patient, both breath-hold T2-weighted fast spin-echo, and breath-hold T1-weighted gradient-echo images, before and after injection of gadolinium, were available. Nine patients with pulmonary consolidation or diffuse disease had also heavily T2-weighted MR imaging (Haste or TSE 240; Siemens, Erlangen, Germany). MR imaging showed pulmonary abnormalities in 17 of 18 patients. Unenhanced T1-weighted and T2-weighted images depicted tumor in 16 of 18 patients. Contrast-enhanced T1-weighted images showed tumor in 17 of 18 patients. In no case did MR imaging depict abnormalities corresponding to the ground-glass opacities seen on CT scans. In three patients with mucinous bronchioloalveolar carcinoma, heavily T2-weighted images showed lesions isointense with respect to static fluid of the human body. In conclusion, the ability of MR imaging in detecting small nodules and ground-glass opacities is limited. However, heavily T2-weighted sequences are able to show the presence of mucin. This is useful information because mucinous bronchioloalveolar carcinoma carries a poor prognosis.

Diagnostic pitfalls of breath-hold MR urography in obstructive uropathy

Breath-hold MR urography (MRU) is being used with increasing frequency to evaluate urinary tract pathology. Although multiple studies have documented the accuracy of breath-hold MRU in the evaluation of obstructive uropathy, pitfalls associated with this technique may result in diagnostic errors. This essay illustrates both technical and interpretive pitfalls of MRU and suggests strategies for their recognition and avoidance.

Sudden unilateral deafness with endolymphatic sac adenocarcinoma: MRI

A 30-year-old man presented with sudden left deafness and vertigo. CT showed an osteolytic retrolabyrinthine tumour of the left temporal bone. High signal from the tumour and labyrinth was seen on fat-suppressed T 1-weighted images. At surgery, a haemorrhagic papillary-cystic adenocarcinoma of the endolymphatic sac was found.

Mucinous cystadenocarcinoma of the lung: CT-pathologic correlation in three cases

Mucinous cystadenocarcinoma (MCA) is a rare tumor that is considered to be a cystic variant of mucin-producing lung adenocarcinoma. MCA expands grossly by storing mucus and contains few neoplastic cells. We present the CT images of three patients with MCA and correlate them with pathologic specimens. The CT findings of MCA include a uniform low-attenuation, focal thickening of the cystic wall and enhancing septa.

Computed tomography halo sign in pulmonary nodules: frequency and diagnostic value

On computed tomography (CT) scanning, a ground-glass opacity zone surrounding a pulmonary nodule has been named the computed tomography (CT) halo sign. To investigate the frequency and diagnostic value of the CT halo sign, the authors reviewed the CT examinations of 305 patients with proven diseases producing solitary or multiple nodules. The CT halo sign was seen in 22 patients (7%). Eleven patients had a solitary nodule; five patients had multiple nodules; and six patients had nodules associated with areas of pulmonary consolidation, or ground-glass opacity, or both. Solitary nodules were the result of bronchioloalveolar carcinoma (n = 5), tuberculoma (n = 2), squamous cell carcinoma, non-Hodgkin lymphoma, myxovirus infection, and metastasis (n = 1 each). Multiple nodules were the result of metastasis (n = 2), Kaposi sarcoma (n = 2), and Wegener granulomatosis (n = 1). Nodules associated with areas of consolidation or ground-glass opacity were the result of metastasis (n = 2), bronchioloalveolar carcinoma, bronchiolitis obliterans organizing pneumonia, eosinophilic pneumonia, and invasive pulmonary aspergillosis (n = 1 each). The data showed that the CT halo sign is a nonspecific finding. It is known that in immunocompromised patients the CT halo sign should suggest invasive pulmonary aspergillosis, Kaposi sarcoma, and lymphoproliferative pulmonary disorders. However, in immunocompetent patients, the authors found that a solitary nodule with the CT halo sign and pseudocavitations has a high likelihood of being a bronchioloalveolar carcinoma.

Shrinkage of a PRL-secreting pituitary macroadenoma resistant to cabergoline

Cabergoline decreases both serum PRL levels and size of prolactinomas, including some tumors resistant to other dopamine-agonists. It is common observation that the shrinkage of the adenoma is preceded by suppression of PRL levels. A minority of patients, who do not show a significant decrease of PRL after a short trial with dopamine-agonists, undergoes neurosurgery or radiotherapy. We report on the case of a 14-year-old girl with a huge prolactinoma who showed, during cabergoline treatment (0.5 mg twice a week), a significant shrinkage of the pituitary mass but no decrease of the very high PRL values. She was referred to us after partial removal of the suprasellar extension of the pituitary tumor. The post-surgical evaluation showed very high PRL levels (9352 microg/l; 20941 microg/l before surgery), which did not decrease during the 2-year treatment with cabergoline (nadir value: 8735 microg/l). However, one month after the beginning of therapy, MRI showed a significant shrinkage of the tumor (tumor volume 5.7 ml, compared with 45.1 ml prior to surgery and 24.4 ml after surgery). Subsequently MRIs demonstrated a progressive reduction of the size with a complete disappearance of the suprasellar and parasellar tissue (tumor volume 1.8, 0.9 and 0.2 ml, at 3, 6 and 12 months, respectively). The MRI performed at the 24th month showed a secondary empty sella, with residual tumor tissue in the right sphenoidal sinus. Increasing cabergoline, up to 3 mg a week, failed to induce any decrease of PRL levels. In conclusion, in such macroprolactinomas the shrinkage of tumor is not strictly correlated with (or it is partially dissociated from) the inhibition of PRL hypersecretion. The choice of other therapeutic options in cabergoline-resistant macroprolactinomas needs careful neuroradiological evaluation after a short trial of pharmacological treatment.

Radiolucencies and cavitation in bronchioloalveolar carcinoma: CT-pathologic correlation

Bronchioloalveolar carcinoma (BAC) is a polymorphic lung cancer the incidence of which is rising. The presence of intratumoral radiolucencies is an important feature of bronchioloalveolar carcinoma. The aim of this study was to present pictorially the spectrum of intratumoral radiolucencies visible in BAC. In 57 BACs studied with thin-slice CT, we identified six types of radiolucencies: (a) patent intratumoral bronchioles (air bronchiologram); (b) pseudocavitations; (c) cavitation; (d) serpentine radiolucencies; (e) internal alveologram; and (f) multiple cystic lesions.