Longitudinal prospective comparison of pancreatic iron by magnetic resonance in thalassemia patients transfusion-dependent since early childhood treated with combination deferiprone-desferrioxamine vs deferiprone or deferasirox monotherapy

BACKGROUND

In transfusion-dependent thalassemia patients who started regular transfusions in early childhood, we prospectively and longitudinally evaluated the efficacy on pancreatic iron of a combined deferiprone (DFP) + desferrioxamine (DFO) regimen versus either oral iron chelator as monotherapy over a follow-up of 18 months.

MATERIALS AND METHODS

We selected patients consecutively enrolled in the Extension-Myocardial Iron Overload in Thalassemia network who received a combined regimen of DFO+DFP (No.=28) or DFP (No.=61) or deferasirox (DFX) (No.=159) monotherapy between the two magnetic resonance imaging scans. Pancreatic iron overload was quantified by the T2* technique.

RESULTS

At baseline no patient in the combined treatment group had a normal global pancreas T2* (≥26 ms). At follow-up the percentage of patients who maintained a normal pancreas T2* was comparable between the DFP and DFX groups (57.1 vs 70%; p=0.517).Among the patients with pancreatic iron overload at baseline, global pancreatic T2* values were significantly lower in the combined DFO+DFP group than in the DFP or DFX groups. Since changes in global pancreas T2* values were negatively correlated with baseline pancreas T2* values, the percent changes in global pancreas T2* values, normalized for the baseline values, were considered. The percent changes in global pancreas T2* values were significantly higher in the combined DFO+DFP group than in either the DFP (p=0.036) or DFX (p=0.030) groups.

DISCUSSION

In transfusion-dependent patients who started regular transfusions in early childhood, combined DFP+DFO was significantly more effective in reducing pancreatic iron than was either DFP or DFX.

Pancreatic T2* Magnetic Resonance Imaging for Prediction of Cardiac Arrhythmias in Transfusion-Dependent Thalassemia

We assessed the value of pancreatic T2* magnetic resonance imaging (MRI) for predicting cardiac events from a large prospective database of transfusion-dependent thalassemia (TDT) patients. We considered 813 TDT patients (36.47 ± 10.71 years, 54.6% females) enrolled in the Extension-Myocardial Iron Overload in Thalassemia Network. MRI was used to measure hepatic, pancreatic, and cardiac iron overload (IO), to assess biventricular function and atrial dimensions, and to detect replacement myocardial fibrosis. The mean follow-up was 50.51 ± 19.75 months. Cardiac complications were recorded in 21 (2.6%) patients: one with heart failure (HF) and 20 with arrhythmias. The single patient who developed HF had, at the baseline MRI, a reduced pancreas T2*. Out of the 20 recorded arrhythmias, 17 were supraventricular. Pancreatic T2* values were a significant predictor of future arrhythmia-related events (hazard ratio = 0.89; p = 0.015). Pancreas T2* remained significantly associated with future arrhythmias after adjusting for any other univariate predictor (age and male sex, diabetes, history of previous arrhythmias, or left atrial area index). According to the receiver-operating characteristic curve analysis for arrhythmias, a pancreas T2* < 6.73 ms was the optimal cut-off value. In TDT, pancreatic iron levels had significant prognostic power for arrhythmias. Regular monitoring and the development of targeted interventions to manage pancreatic IO may help improve patient outcomes.

Impact of the COVID-19 Pandemic on Iron Overload Assessment by MRI in Patients with Hemoglobinopathies: The E-MIOT Network Experience

BACKGROUND

The E-MIOT (Extension-Myocardial Iron Overload in Thalassemia) project is an Italian Network assuring high-quality quantification of tissue iron overload by magnetic resonance imaging (MRI). We evaluated the impact of the COVID-19 pandemic on E-MIOT services.

METHODS

The activity of the E-MIOT Network MRI centers in the year 2020 was compared with that of 2019. A survey evaluated whether the availability of MRI slots for patients with hemoglobinopathies was reduced and why.

RESULTS

The total number of MRI scans was 656 in 2019 and 350 in 2020, with an overall decline of 46.4% (first MRI: 71.7%, follow-up MRI: 36.9%), a marked decline (86.9%) in the period March-June 2020, and a reduction in the gap between the two years in the period July-September. A new drop (41.4%) was recorded in the period October-December for two centers, due to the general reduction in the total amount of MRIs/day for sanitization procedures. In some centers, patients refused MRI scans for fear of getting COVID. Drops in the MRI services >80% were found for patients coming from a region without an active MRI site.

CONCLUSIONS

The COVID-19 pandemic had a strong negative impact on MRI multi-organ iron quantification, with a worsening in the management of patients with hemoglobinopathies.

Prognostic value of multiparametric cardiac magnetic resonance in sickle cell patients

The aim of this multicenter study was to prospectively assess the predictive value of multiparametric cardiac magnetic resonance (CMR) for cardiovascular complications in sickle cell disease (SCD) patients. Among all patients with hemoglobinopathies consecutively enrolled in the Myocardial Iron Overload in Thalassemia (MIOT) Network, we selected 102 SCD patients (34.38 ± 12.67 years, 49 females). Myocardial iron overload (MIO) was measured by the multislice multiecho T2* technique. Atrial dimensions and biventricular function parameters were quantified by cine images. Late gadolinium enhancement (LGE) images were acquired to detect focal myocardial fibrosis. At baseline CMR, only two patients had significant MIO (global heart T2* < 20 ms). During a mean follow-up of 63.01 ± 24.95 months, 11 cardiovascular events (10.8%) were registered: 3 pulmonary hypertension, 2 supraventricular arrhythmias, 1 heart failure, 1 death for heart failure, 1 pulmonary embolism, 1 peripheral vascular disease, 1 transient ischemic attack, and 1 death after acute chest syndrome. In the multivariate analysis, the independent CMR predictors of cardiovascular events were left ventricular (LV) ejection fraction (hazard ratio-HR = 0.88; p = 0.025) and right ventricular (RV) mass index (HR = 1.09; p = 0.047). According to the receiver-operating characteristic curve analysis for adverse events, an LV ejection fraction < 58.9% and an RV mass index > 31 g/m² were optimal cut-off values. Reduced left ventricular ejection fraction and increased right ventricular mass index showed a significant prognostic value in patients with SCD. Our data seem to suggest that CMR may be added as a screening tool for identifying SCD patients at high risk for cardiopulmonary and vascular diseases.

National networking in rare diseases and reduction of cardiac burden in thalassemia major

AIMS

A tailored chelation therapy guided by magnetic resonance imaging (MRI) is a strategy to improve the prognosis in iron-loaded patients, in many cases still hampered by limited MRI availability. In order to address this issue, the Myocardial Iron Overload in Thalassemia (MIOT) network was established in Italy and we aimed to describe the impact of 10-year activity of this network on cardiac burden in thalassemia major (TM).

METHODS AND RESULTS

Within the MIOT network, 1746 TM patients (911 females; mean age 31.2 ± 9.1 years) were consecutively enrolled and prospectively followed by 70 thalassemia and 10 MRI centres. Patients were scanned using a multiparametric approach for assessing myocardial iron overload (MIO), biventricular function, and myocardial fibrosis. At the last MRI scan, a significant increase in global heart T2* values and a significantly higher frequency of patients with no MIO (all segmental T2* ≥20 ms) were detected, with a concordant improvement in biventricular function, particularly in patients with baseline global heart T2* <20 ms. Forty-seven percentage of patients changed the chelation regimen based on MRI. The frequency of heart failure (HF) significantly decreased after baseline MRI from 3.5 to 0.8% (P < 0.0001). Forty-six patients died during the study, and HF accounted for 34.8% of deaths.

CONCLUSION

Over 10 years, continuous monitoring of cardiac iron and a tailored chelation therapy allowed MIO reduction, with consequent improvement of cardiac function and reduction of cardiac complications and mortality from MIO-related HF. A national networking for rare diseases therefore proved effective in improving the care and reducing cardiac outcomes of TM patients.

KEY QUESTION

Which was the impact on cardiac outcomes in thalassemia major by a national network among thalassemia and magnetic resonance imaging centres ensuring the continuous and standardized monitoring of the cardiac iron levels?

KEY FINDING

There was a reduction of myocardial iron overload (MIO) in almost 70% of patients, with consequent improvement of cardiac function and reduction of cardiac complications and mortality from MIO-related heart failure.

TAKE HOME MESSAGE

A national clinical and imaging networking in rare diseases was effective in improving the care and in reducing the cardiac burden in thalassemia major patients.

Impact of the COVID-19 pandemic in the MR availability for iron overloaded patients

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): The E-MIOT project receives “no-profit support” from industrial sponsorships (Chiesi Farmaceutici S.p.A. and Bayer).

Background

The T2* magnetic resonance imaging (MRI) technique for the noninvasive quantification of iron overload has significantly improved the survival of patients with hemoglobinopathies by tailoring the chelation therapy. In Italy, the E-MIOT (Extension-Myocardial Iron Overload in Thalassemia) Network, a collaborative project among MRI and hematological centers, has assured high-quality quantification of iron in vital organs such as heart, liver, and pancreas. The COVID-19 pandemic has disrupted healthcare services around the world, also leading to postpone  or delete deferable diagnostic evaluations.

Aim

  We evaluated the impact of the COVID-19 pandemic on MRI services for iron overload quantification in Italy.

Methods

The activity of the MRI centers of the E-MIOT Network in the year 2020 was compared to the activity in the same months of 2019. A specific survey was filled out by the MRI operators to evaluate if the availability of MRI slots for patients with hemoglobinothies was reduced and the reasons.

Results

In comparison with the year 2019, in 2020 there was a significant reduction in the number of T2* MRIs performed (350 vs 656; P < 0.0001). The comparison month by month between the two years highlighted a marked decline (86.9%) in the four-month period March-June 2020, a reduction in the gap between the two years in the three-month period July-September, and a new decline (41.4%) in the three-month period October-December (Figure 1). No patient with hemoglobinopathy could undergo an MRI scan during the Italian lockdown (9 March-10 May 2020).

Figure 2 shows the percentage of  decline (year 2020 vs 2019) in the number of T2*MRI scans for each MRI center. If no decline or an increase were present, the vertical axis was set at 0. All centers experienced a significant drop in the number of the T2* MRIs in the four-month period March-June (from 75 to 100%). In the three-month period July-September only the centers of Pisa and Taranto dropped the number of T2* MRIs due to the rescheduling of the other MRI appointments deleted during the lockdown. In the three-month period October-December a reduction of the T2* MRI scans was experienced by all centers, except for Campobasso. In the centers of Ferrara and Lamezia Terme the reduction was the consequence of the general reduction in the number of the total MRIs scheduled per day for the  sanitation procedures. In the other centers, the availability for T2* MRI scans was unchanged in comparison to 2019, but the patients refused the MRI follow up for fear of getting sick of COVID.

Conclusion

The COVID-19 pandemic is having a strong negative impact on the quantification of iron overload by MRI, which may seriously worsen the prognosis of patients with hemoglobinopathies. Strategies to ensure proved lifesaving MRI exam and to reassure patients about the health safety of the hospitals are recommended.

Tailored Vessel-Catheter Diameter Ratio in a Direct Aspiration First-Pass Technique: Is It a Matter of Caliber?

BACKGROUND AND PURPOSE

The aspiration technique has gained a prominent role in mechanical thrombectomy. The thrombectomy goal is successful revascularization (modified TICI ≥ 2b) and first-pass effect. The purpose of this study was to evaluate the impact of the vessel-catheter ratio on the modified TICI ≥ 2b and first-pass effect.

MATERIALS AND METHODS

This was a retrospective, single-center, cohort study. From January 2018 to April 2020, 111/206 (53.9%) were eligible after applying the exclusion criteria. Culprit vessel diameters were measured by 2 neuroradiologists, and the intraclass correlation coefficient was calculated. The receiver operating characteristic curve was used for assessing the vessel-catheter ratio cutoff for modified TICI ≥ 2b and the first-pass effect. Time to groin puncture and fibrinolysis were weighted using logistic regression. All possible intervals (interval size, 0.1; sliding interval, 0.01) of the vessel-catheter ratio were plotted, and the best and worst intervals were compared using the χ² test.

RESULTS

Modified TICI ≥ 2b outcome was achieved in 75/111 (67.5%), and first-pass effect was achieved in 53/75 (70.6%). The MCA diameter was 2.1 mm with an intraclass correlation coefficient of 0.92. The optimal vessel-catheter ratio cutoffs for modified TICI ≥ 2b were ≤1.51 (accuracy = 0.67; 95% CI, 0.58-0.76; P = 0.001), and for first-pass effect, they were significant (≤1.33; P = .31). The modified TICI ≥ 2b odds ratio and relative risk were 9.2 (95% CI, 2.4-36.2; P = 0.002) and 3.2 (95% CI, 1.2-8.7; P = .024). The odds ratio remained significant after logistic regression (7.4; 95% CI, 1.7-32.5; P = .008). First-pass effect odds ratio and relative risk were not significant (2.1 and 1.5; P > .05, respectively). The modified TICI ≥ 2b best and worst vessel-catheter ratio intervals were not significantly different (55.6% versus 85.7%, P = .12). The first-pass effect best vessel-catheter ratio interval was significantly higher compared with the worst one (78.6% versus 40.0%, P = .03).

CONCLUSIONS

The aspiration catheter should be selected according to culprit vessel diameter. The optimal vessel-catheter ratio cutoffs were ≤1.51 for modified TICI ≥ 2b with an odds ratio of 9.2 and a relative risk of 3.2.

The novel loss of function Ile354Val mutation in PPARG causes familial partial lipodystrophy

AIMS

Familial partial lipodystrophy (FPLD) is a rare autosomal dominant disorder, mostly due to mutations in lamin A (LMNA) or in peroxisome proliferator-activated receptor gamma (PPARG) genes. In the present study, we aimed to identify and functionally characterize the genetic defect underlying FPLD in an Italian family presenting with several affected individuals in three consecutive generations.

METHODS

Mutational screening by direct Sanger sequencing has been carried out on both LMNA and PPARG genes. In silico analyses and functional in vitro studies on transfected cell lines have been also performed to evaluate the biological impact of the identified mutation.

RESULTS

We identified a novel PPARG missense mutation (i.e., PPARγ2 Ile354Val) segregating with FPLD in the study family. In silico analyses and in vitro experiments showed that probably altering the PPARγ2 ligand binding domain conformation, the Ile354Val aminoacid change leads to a significant reduction (i.e., ~ 30-35%) of transcriptional activity in the mutant receptor, with no evidences of a dominant negative effect on the wild-type receptor.

CONCLUSIONS

Our present data extend the spectrum of PPARG mutations responsible for FPLD3 and reinforce the notion that even loss of function mutations affecting transcriptional activity to an extent lower than that observed in the case of haploinsufficiency are able to cause a severe FPLD3 phenotype.

Cardiac involvement by CMR in different genotypic groups of thalassemia major patients

Beta thalassemia major (β-TM) displays a great deal of phenotypic heterogeneity, not fully investigated in terms of cause-effect. We aimed to detect if different genotypic groups could be related to different levels of cardiac impairment, evaluated by cardiovascular magnetic resonance (CMR). We considered 671 β-TM patients (age 30.1 years, 52.9% females) consecutively enrolled in the Myocardial Iron Overload (MIO) in Thalassemia network. MIO was assessed by T2* technique. Biventricular function was quantified by cine images. Myocardial fibrosis was evaluated by late gadolinium enhancement (LGE) technique. Three groups of patients were identified: heterozygotes β⁺/β° (N = 279), homozygotes β ⁺ (N = 154), homozygotes β° (N = 238). Transfusional needs resulted significantly lower in homozygous β ⁺ TM patients when compared to the other groups. The homozygous β ⁺ group versus the heterozygous and homozygous β° groups showed higher global heart T2* values (P < 0.0001) and a lower number of patients with a global heart T2* value<20 ms (P < 0.001). The homozygotes β ⁺ showed a lower number of patients with a pathological left ventricular ejection fraction (LVEF) than the other two groups (P < 0.05). The β⁺/β ⁺ TM patients showed less MIO and a concordant better systolic heart function. These data support the knowledge of different genotypic groups in the management of β-TM patients.

Preliminary experience with abdominal dual-energy CT (DECT): true versus virtual nonenhanced images of the liver

PURPOSE

The aim of this work was to compare the quality and noise of true non-enhanced (TNE) and virtual non-enhanced (VNE) images in patients undergoing dual-energy computed tomography (DECT) of the liver.

MATERIALS AND METHODS

Twenty consecutive patients (mean age 54.7±19.9 years) prospectively underwent abdominal DECT to assess the liver using a triphasic protocol consisting of precontrast, arterial-phase and portal-phase acquisitions. Exclusion criteria were allergy to iodinated contrast material, impaired renal function and a body mass index (BMI) >35 kg/m(2). The DE portal-phase acquisition was performed with automatic dose modulation (CARE Dose 4D). Nonionic iodinated contrast material (Iomeron 400) was administered at 0.625 gI/kg with a flow rate of 3.5 ml/s. Axial VNE images were reconstructed based on the portal data set using a collimation and an increment of 5 mm and were compared with TNE images reconstructed with the same parameters. The average image quality and noise were analysed by two radiologists in separate reading sessions.

RESULTS

No statistically significant difference (p>0.05) in image quality was observed between VNE (4.00±0.85) and TNE images (4.35±0.58). A sufficient diagnostic quality was found in 95.0% (19/20) of VNE images and in 100% of TNE images. No statistically significant difference (p<0.05) was observed in the average image noise of VNE (9.5±0.7) and TNE (12.3±1.1) images.

CONCLUSIONS

Abdominal DECT allows acquisition of liver VNE images with similar image quality and lower noise than TNE. Nevertheless, a few technical limitations related to the small field of view of the second detector in patients with a high BMI and heterogeneous iodine subtraction restrict the application of this technique to selected patients only.

[Angiomyofibroblastoma of the spermatic funiculus. A case report of this lesion of the spermatic funiculus]

The authors are hereby presenting a rare case of angiomyofibroblastoma of the funiculus in a 20-year-old patient, having a non-aching tumefaction at the left region of the scrotum. This tumefaction was solid and non homogeneous, both on ultrasonography and MRI, of about 5cm in diameter, fully separated from the testicle. The markers were all negative. We proceeded with surgical treatment of the neoformation. It is mandatory to include this lesion within the differential diagnosis of testicle masses. The case is presented for its absolute histopathologic rarity and for the difficulty in diagnosis.

Presence and indigenous nature of Lyme disease in southern Italy

Lyme disease is very common in the countries of the northern hemisphere. In Italy it is endemic in some regions of the northern part of the country and it is more frequent during summer. In Calabria (south Italy) no cases have been reported. To document the presence and indigenous nature of Lyme disease in this territory we conducted a study from 1999 to 2002. We defined as indigenous cases those with erythema migrans with the following characteristics: dimensions equal to or greater than 5 cm; localization on an area of the skin where there was a tick bite; appearance between 4 and 30 days after the tick bite; appearance in patients who had not resided out of Calabria in the previous 3 months. We found 23 patients with the necessary characteristics to be defined indigenous cases. Since 15 of these cases (65.2%) were observed in the October - December trimester and no case was found in the July - September trimester, we suspect that in Calabria the disease follows a seasonal distribution which differs with respect to countries where it is historically endemic.

Male/female ratio in centenarians: a possible role played by population genetic structure

All the demographic surveys on the centenarians have highlighted that females outnumber males. The centenarians' male/female (M/F) ratio reported by most studies ranges between 1:4 and 1:7. A puzzling 1:2 ratio was observed in Calabria, a Southern Italian region. To our knowledge only in Sardinia a similar phenomenon had been previously observed. We have therefore used the data of the Italian Institute of Statistics to figure out the centenarians' M/F ratio in the Italian regions. We found that this ratio gradually decreases from South to North. Such a result is certainly due to many factors. Thus, we have explored the possibility, it is also influenced by the genetic structure of the Italian population. In fact, the distribution of the centenarians' M/F ratio turned out to be significantly correlated with the genetic structure of the Italian population as outlined by the principal component analysis.

Experimental phase synchronization of a chaotic convective flow

We report experimental evidence of phase synchronization of high dimensional chaotic oscillators in a laboratory experiment. The experiment consists of a thermocapillary driven convective cell in a time dependent chaotic regime. The synchronized states emerge as a consequence of a localized temperature perturbation to the heater. The transition to phase synchronization is studied as a function of the external perturbations. The existence and stability conditions for this phenomenon are discussed.

MRI T-staging of laryngeal tumours: role of contrast medium

Our aim was to evaluate the relative diagnostic accuracy of MRI without contrast medium and MRI before and after contrast medium in the assessment of T-staging of laryngeal tumours. We studied 25 men (mean age 51.8, range 41-61) with laryngeal squamous cell carcinomas, using Spin-echo (SE) T1-weighted and fast SE T2-weighted sequences. The T1-weighted sequences were then repeated after gadolinium-diethylene-triaminepenta-acetic acid (Gd DTPA) 0.1 ml/kg. All patients then underwent biopsy and surgery. Two radiologists independently assessed the anonymised images by filling-out two multiple-choice forms, one for each technique, at a 2 week interval. The forms included a judgement concerning tumour identification and infiltration of the anterior commissure, supraglottic region, arytenoid cartilage, Morgagni's ventricle, paraglottic space, thyroid and cricoid cartilages, thyro-hyo-epiglottic space, vocal cords, subglottic region, and epiglottis. Similar forms were filled out by the surgeon and the pathologist after surgery. The sensitivity, specificity and diagnostic accuracy of MRI were unaffected by the use of contrast medium. Since it did not provide additional staging information, its continued routine use in these cases is not justified.

Spontaneous hemoperitoneum from a giant multicystic hemangioma of the liver: a case report

We describe a rare case of hemoperitoneum due to spontaneous rupture of a giant cavernous hemangioma of the liver. CT demonstrated both the intraperitoneal hemorrhage and the hepatic lesion, which showed an atypical multicystic appearance. Furthermore, CT showed the site of rupture of the hemangioma.

Air-space pattern in lung metastasis from adenocarcinoma of the GI tract

PURPOSE

We retrospectively reviewed a series of proven lung metastasis to evaluate the frequency and CT features of metastases showing an air-space (lepidic) pattern of growth.

METHOD

CT examinations of 65 patients with proven lung metastasis from GI carcinomas were reviewed by three observers. Four CT features were used to classify lesions as air-space metastases: (a) air-space nodules; (b) parenchymal consolidation containing air bronchogram and/or showing angiogram sign; (c) focal or extensive ground-glass opacities; and (d) nodules(s) with a "halo" sign.

RESULTS

Six of 65 patients showed air-space metastases: three from pancreatic carcinoma, two from colonic carcinoma, and one from jejunal carcinoma. In one case, metastasis appeared as extensive parenchymal consolidation associated with ground-glass opacities; in one as an area of ground-glass opacity; in one as an extensive parenchymal consolidation with air bronchogram; in one as parenchymal consolidations with angiogram sign and multiple nodules, some of these with halo sign; in one as air-space nodules and patchy air-space consolidations; and in one as a solitary nodule with halo sign.

CONCLUSION

Our study shows that air-space lung metastasis from GI carcinomas is uncommon but not rare. On CT as well as microscopically, differential diagnosis between air-space metastasis and bronchioloalveolar carcinoma may be impossible.

[Computerized tomography in the assessment of obstructive jaundice caused by hepatic hydatid cysts]

This paper reports on the CT findings of obstructive jaundice caused by hydatid cysts of the liver, which are an unusual event occurring in 5-10% of cases. Thus, only a few reports can be found in the literature dealing with the CT features of this syndrome. Eight patients with obstructive jaundice were selected from 87 patients with hydatid disease of the liver and examined with CT. The CT diagnosis of rupture into the largest bile ducts is based upon the demonstration of hepatic hydatid cysts together with intrabiliary hydatid sand, membranes and scolices and/or the identification of parietal discontinuity with communication between the cyst and the biliary tree. Rupture into the largest bile ducts was demonstrated in 7 patients. The following CT patterns were observed: 1) intrahepatic biliary tract dilatation (all cases); 2) extrahepatic biliary tract dilatation (6 cases); 3) cyst wall interruption (5 cases--in 3 of them the communication between the cyst and the dilated bile duct was demonstrated); 4) daughter cysts, fragmented membranes or hydatid sand in the biliary tree (5 cases); 5) hydatid material in the gallbladder (1 case) and, finally, disappearance of the daughter cyst visible on a previous CT examination (1 case). In another patient, the diagnosis of compressive jaundice without biliary communication was suggested because a bulky hydatid cyst was found near the hilum of liver. CT findings were confirmed with ERCP or at surgery. CT failed to reveal small tears with minute biliary radicles, which are usually asymptomatic, whose diagnosis could be made only with preoperative cholangiography. Hydatid cysts of the liver can cause obstructive jaundice because of main bile duct compression or of large bile duct perforation with consequent passage of hydatid material into the biliary tree. This complication should be promptly managed surgically to avoid potentially fatal complications, which makes a preoperative diagnosis essential.

[The computed tomographic semeiotics of rhino-sinusal inflammatory pathology]

Recent advances in "functional" endoscopic surgical techniques require the radiologist to understand the anatomy and pathophysiology of the nose and paranasal sinuses as well as their normal and abnormal CT patterns. Endoscopy and CT are complementary procedures, but in the evaluation of the extent of chronic inflammation and in the demonstration of possible associated local and regional complications, the latter method has become the imaging technique of choice, providing a detailed map for the functional sinus surgeon and replacing plain radiography. The authors reviewed a personal series of 322 coronal thin-slice CT examinations of the paranasal sinuses relative to 169 patients with chronic or acute sinusitis and polyposis. The main CT findings of sinusitis (mucosal thickening, fluid retention, mucous cysts, bone alterations, mucoceles and polyposis) and their complications are reported. Finally, ostiomeatal conditions are considered, particularly the obstruction of ducts and ostia which provide aeration and mucous clearance from the paranasal sinuses.

DiGeorge anomaly with renal agenesis in infants of mothers with diabetes

We report on 2 infants with the DiGeorge anomaly born to diabetic mothers treated with insulin. Both infants had unilateral renal agenesis. One of the mothers has manifestations suggestive of velo-cardio-facial syndrome (VCFS). Cytogenetic studies on both patients and the mother with apparent VCFS were normal. Molecular studies utilizing probes from the DiGeorge critical region did not demonstrate a 22q11 microdeletion in either patient or the mother with apparent VCFS. We conclude that maternal diabetes is a pathogenetic factor in the DiGeorge anomaly, and infants of diabetic mothers who have this anomaly should also be screened for renal agenesis.

[Ketanserin and metoprolol in the treatment of essential hypertension]

In a controlled clinical study, 30 adult patients (16 females, 14 males, mean age 46.0 +/- 7.6, mean body weight 69.4 +/- 10.2 kg) with mild-moderate essential hypertension were treated with ketanserin (20 mg twice daily) or metoprolol (100 mg daily) for the first month and 40 mg twice daily or 100 mg twice daily during the second month. Results showed antihypertensive efficacy and systemic tolerability of ketanserin to be equal to that of metoprolol and better cardiac tolerance for ketanserin.