Massimo Cristofaro

Non-hodgkin's lymphoma of the liver in patients with AIDS: sonographic, CT, and MRI findings.

We analyzed the sonographic, CT, and MRI findings in acquired immune deficiency syndrome (AIDS)–related non‐Hodgkins lymphoma (NHL) of the liver to evaluate the role of sonography in the diagnosis of this disease.

Detection of Pulmonary tuberculosis: comparing MR imaging with HRCT

BackgroundComputer Tomography (CT) is considered the gold standard for assessing the morphological changes of lung parenchyma. Although novel CT techniques have substantially decreased the radiation dose, radiation exposure is still high. Magnetic Resonance Imaging (MRI) has been established as a radiation- free alternative to CT for several lung diseases, but its role in infectious diseases still needs to be explored further. Therefore, the purpose of our study was to compare MRI with high resolution CT (HRCT) for assessing pulmonary tuberculosis.Methods50 patients with culture-proven pulmonary tuberculosis underwent chest HRCT as the standard of reference and were evaluated by MRI within 24 h after HRCT. Altogether we performed 60 CT and MRI examinations, because 10 patients were also examined by CT and MRI at follow- up. Pulmonary abnormalities, their characteristics, location and distribution were analyzed by two readers who were blinded to the HRCT results.ResultsArtifacts did not interfere with the diagnostic value of MRI. Both HRCT and MRI correctly diagnosed pulmonary tuberculosis and identified pulmonary abnormalities in all patients. There were no significant differences between the two techniques in terms of identifying the location and distribution of the lung lesions, though the higher resolution of MRI did allow for better identification of parenchymal dishomogeneity, caseosis, and pleural or nodal involvement.ConclusionTechnical developments and the refinement of pulse sequences have improved the quality and speed of MRI. Our data indicate that in terms of identifying lung lesions in non-AIDS patients with non- miliary pulmonary tuberculosis, MRI achieves diagnostic performances comparable to those obtained by HRCT but with better and more rapid identification of pulmonary tissue abnormalities due to the excellent contrast resolution.

Appropriateness: analysis of outpatient radiology requests

PurposeThis study assessed radiology requests and the influence of previous radiological procedures on their specificity and appropriateness, evaluated diagnostic outcomes and recorded the economic impact of inappropriate examinations.Materials and methodsWe prospectively analysed 4,018 outpatient requests, the appropriateness of which was assessed using an evaluation form. Economic analysis was based on costs listed in the Italian National Health Services (NHS) national tariff as established by the Ministerial Decree of 22 July 1996. Statistical analysis was carried out using Pearson’s test and univariate and multivariate logistic regression models.ResultsOf 4,018 outpatient requests, 57% were not included in a follow-up protocol and 56% were found to be appropriate. The diagnostic question was confirmed in 66% of cases considered appropriate (p<0.001). The existence of previous investigations had a significant impact on appropriateness and diagnostic outcome (p<0.001). The total cost of the requests was 257,317 euros, with inappropriate requests accounting for 94,012 euro (36.5%).ConclusionsWe found a 56% rate of appropriate requests and demonstrated that appropriate prescriptions provided with a specific clinical question led to significantly higher confirmation rates of the diagnostic hypothesis. In addition, inappropriate requests had a major negative economic impact.RiassuntoObiettivoScopo del nostro lavoro è stato verificare l’appropriatezza delle richieste di esami di diagnostica per immagini non inserite in programmi di follow-up e quanto i precedenti radiologici influiscano sulla specificità delle richieste e sull’appropriatezza, valutare il loro riscontro diagnostico, registrare l’impatto economico degli esami inappropriati.Materiali e metodiAbbiamo analizzato 4018 richieste ambulatoriali, l’appropriatezza è stata verificata mediante una scheda di valutazione dedicata. Nell’analisi economica sono stati valutate le tariffe previste dal nomenclatore per il Sistema Sanitario Nazionale (SSN) determinato dal Decreto Ministeriale (DM) del 22/07/1996. L’analisi statistica ha utilizzato il test di Pearson e modelli di regressione logistica univariata e multivariata.RisultatiLe richieste non in follow-up hanno rappresentato il 57% delle prescrizioni esaminate e sono risultate appropriate nel 55,5% dei casi. La conferma del quesito diagnostico si è verificata nel 66% dei casi appropriati (p<0,001). La presenza di precedenti indagini ha influenzato l’appropriatezza delle richieste (p<0,001) e la conferma della diagnosi (p<0,001). Il fatturato totale degli esami è stato di 257317 euro, gli esami non appropriati hanno pesato per 94012 euro (36,5%).ConclusioniAbbiamo documentato una appropriatezza prescrittiva del 56% e come una richiesta appropriata associata alla presenza di un quesito specifico comporti una percentuale significativamente elevata di conferme dell’ipotesi diagnostica, calcolando inoltre il rilevante impatto sul piano finanziario delle richieste inappropriate.

Sonographic Assessment of Facial HIV-Related Lypoatrophy

OBJECTIVE To investigate the utility of ultrasonography (US) for assessing and grading facial lypoatrophy (FLA) in patients with HIV. DESIGN The social effect of FLA is huge and may reduce antiretroviral therapy adherence. Strategies for the early detection of FLA are crucial, because complete correction of FLA in late stages is unlikely. METHODS Fifty‐two HIV‐positive patients undergoing highly active antiretroviral therapy underwent US with nasogenian transversal scan using a high‐frequency broadband transducer (5–17 MHz) to detect FLA. Intra‐ and interobserver variability were calculated to assess US reproducibility. Concerning FLA grading, patients were categorized in five clinical classes and four US classes. RESULTS Our results regarding inter‐ and intraobserver coefficients of variation permit the validation of US as a reproducible technique (p<.001), and a high correlation between US and clinical classification was obtained, with complete concordance for more advanced FLA classes. CONCLUSIONS The lack of a reference objective method to quantify subcutaneous fat is a major difficulty in measuring HIV‐related FLA. Our results, in accordance with data from the literature, suggest that US is an ideal tool for assessing and grading FLA. Furthermore, US may be suitable for routine evaluation in HIV‐infected patients for early detection of FLA and to select its optimal management. The authors have indicated no significant interest with commercial supporters.

Ultrasonography in lesions of the carotid vessels in HIV positive patients.

PurposeThis study evaluated with ultrasonography (US) the presence of epiaortic vessel lesions in HIV-positive individuals receiving highly active antiretroviral therapy (HAART) and compared them with naïve patients and healthy individuals to highlight the differences among the different vascular damage patterns.Materials and methodsA total of 222 HIV-infected patients receiving HAART, 64 HIV-infected patients naïve to antiretroviral therapy and 135 HIV-negative control patients underwent US of the carotid vessels. The morphological examination included grey-scale and colour and power Doppler imaging to better characterise lesions and intima media thickness. An automated computerised software package (Q LAB) was used to determine intima media thickness values. Independent risk factors for the development of carotid lesions and, in particular, cholesterolaemia and triglyceridaemia were considered. Atherosclerotic plaques and inflammatory-type lesions were reported. Statistical analysis included the chi-square test, the Fisher exact test for qualitative variables and the Kruskal-Wallis test to compare continuous variables.ResultsWe observed a higher prevalence of carotid lesions in HIV-positive patients receiving HAART compared with HIV-positive naïve patients (p<0.0000001) and HIV-negative patients (p<0.0001). Findings consistent with inflammatory-type lesions rather than classic atheroma were depicted only in five patients receiving HAART (0.02%).ConclusionsOur study confirms a higher prevalence of carotid lesions in HAART-treated HIV patients. In agreement with other authors, we identified carotid lesions that were consistent with arteritis rather than with classic atheroma, but the percentage was too small to suggest any robust hypothesis. Further studies are warranted to define the mechanism of onset of carotid lesions in HIV-positive individuals.RiassuntoObiettivoScopo dello studio è stato quello di valutare, mediante ecografia (US), la presenza di lesioni intimali nei vasi epiaortici di pazienti positivi al virus della immunodeficienza umana (HIV) trattati mediante terapia antiretrovirale altamente attiva (HAART), confrontando i risultati ottenuti con quelli provenienti dallo studio delle carotidi di pazienti HIV+ che non ricevevano HAART e di individui sani utilizzati come controllo. Abbiamo inoltre differenziato le lesioni intimali sulla base del quadro di presentazione, in placche aterosclerotiche classiche e lesioni di tipo infiammatorio, simili a quelle identificabili in corso di arterite.Materiali e metodiAbbiamo studiato con US le carotidi di 222 pazienti HIV-positivi trattati con HAART, di 64 HIV-positivi naïve per la terapia antiretrovirale e di 135 soggetti HIV-negativi, utilizzati come popolazione di controllo. Lo studio è stato effettuato in B-mode e mediante color e power Doppler, per meglio caratterizzare le lesioni e lo spessore intimale (IMT). Lo spessore intimale è stato valutato utilizzando un software dedicato (Q LAB). In ogni paziente sono stati considerati i fattori di rischio per l’insorgenza di lesioni delle carotidi e in particolare sono state considerate la colesterolemia e la trigliceridemia. L’analisi statistica è stata effettuata mediante test del chi-quadro, di Fischer, di Kruskall-Wallis.RisultatiAbbiamo rilevato lesioni intimali carotidee in misura significativamente maggiore nei pazienti HIV-positivi trattati con HAART rispetto a quelli che non ricevano HAART (p<0,0000001), e ai controlli (p<0,0001). In cinque soggetti in terapia HAART abbiamo documentato la presenza di lesioni carotidee di tipo infiammatorio.ConclusioniIl nostro studio conferma un’elevata incidenza di lesioni carotidee nei soggetti HIV-positivi trattati con HAART. Come già segnalato da altri autori, abbiamo osservato lesioni carotidee compatibili con arterite piuttosto che con il classico ateroma, ma in una percentuale attualmente troppo esigua (0,02%) per supportare valide ipotesi diagnostiche. Ulteriori studi sono necessari per confermare quest’ultimo dato.

Pulmonary measles disease: old and new imaging tools

AbstractBackgroundMeasles virus can cause lower respiratory tract infection, so that chest radiography is necessary to investigate lung involvement in patients with respiratory distress.PurposeTo assess measles pneumonia imaging during the measles outbreak occurred in 2016–2017 in Italy.Material and methodsWe retrospectively observed adult patients with a serological diagnosis of measles, who underwent chest-X rays for suspected pneumonia. If a normal radiography resulted, the patient underwent unenhanced CT. A CT post processing software package was used for an additional quantitative lung and airway involvement analysis .ResultsAmong 290 patients affected by measles, 150 underwent chest-X ray. Traditional imaging allowed the pneumonia diagnosis in 114 patients (76%). The most frequent abnormality at chest X-rays was bronchial wall thickening, observed in 88.5% of the cases; radiological findings are faint in the 25% of the cases (29/114 patients). In nine subjects with a normal chest X-ray, unenhanced CT with a quantitative analysis was performed, and depicted features consistent with constrictive bronchiolitis. ConclusionMeasles may produce bronchiolitis and pneumonia. In the cases in which involvement of pulmonary parenchyma is not sufficient to result in radiological abnormalities, CT used with a dedicated postprocessing software package, provides an accurate lungs and airways analysis, also determining the percentage of lung involvement.

Diagnostic imaging of hepatic tuberculosis: case series

BACKGROUND Hepatic tuberculosis (TB) shows non-specific symptoms, and liver imaging may provide diagnostic clues. Here we describe a series of patients with hepatic TB showing characteristic radiological findings. METHODS Single-centre retrospective evaluation of patients with hepatic TB diagnosed over a period of 16 years who underwent ultrasound, computed tomography (CT) and/or magnetic resonance imaging (MRI). Hepatic lesions were classified as miliary, nodular, serohepatic or cholangitis. RESULTS Of 14 patients with hepatic TB, five were co-infected with the human immunodeficiency virus. All patients had additional extrahepatic TB localisations. An interferon-gamma release assay was performed in 11/14 patients, ultrasound and CT were available for all patients and MRI for four. Observed patterns were miliary (n = 6) with multiple nodules < 2 cm; nodular (n = 5), characterised by a variable number of nodules (2-7 cm); and serohepatic (n = 3), with multiple nodular subcapsular lesions with a thin, smooth wall. Shared findings were hypoechoic lesions on ultrasound, hypodense lesions with ring enhancement on CT, while MRI lesions were hypointense on T1- and hyperintense on T2-weighted images. CONCLUSIONS Ultrasound, CT and MRI can independently contribute to detection of hepatic TB. While a miliary pattern or calcifications are characteristic, no pattern is completely pathognomonic and the diagnosis depends on microbiological evidence. Particularly in risk groups, characteristic radiological findings may prompt targeted diagnostic work-up.

Ultrasonography in lesions of the carotid vessels in HIV positive patients Valutazione ecografica delle lesioni vascolari carotidee nei pazienti HIV positivi

PurposeThis study evaluated with ultrasonography (US) the presence of epiaortic vessel lesions in HIV-positive individuals receiving highly active antiretroviral therapy (HAART) and compared them with naïve patients and healthy individuals to highlight the differences among the different vascular damage patterns.Materials and methodsA total of 222 HIV-infected patients receiving HAART, 64 HIV-infected patients naïve to antiretroviral therapy and 135 HIV-negative control patients underwent US of the carotid vessels. The morphological examination included grey-scale and colour and power Doppler imaging to better characterise lesions and intima media thickness. An automated computerised software package (Q LAB) was used to determine intima media thickness values. Independent risk factors for the development of carotid lesions and, in particular, cholesterolaemia and triglyceridaemia were considered. Atherosclerotic plaques and inflammatory-type lesions were reported. Statistical analysis included the chi-square test, the Fisher exact test for qualitative variables and the Kruskal-Wallis test to compare continuous variables.ResultsWe observed a higher prevalence of carotid lesions in HIV-positive patients receiving HAART compared with HIV-positive naïve patients (p<0.0000001) and HIV-negative patients (p<0.0001). Findings consistent with inflammatory-type lesions rather than classic atheroma were depicted only in five patients receiving HAART (0.02%).ConclusionsOur study confirms a higher prevalence of carotid lesions in HAART-treated HIV patients. In agreement with other authors, we identified carotid lesions that were consistent with arteritis rather than with classic atheroma, but the percentage was too small to suggest any robust hypothesis. Further studies are warranted to define the mechanism of onset of carotid lesions in HIV-positive individuals.RiassuntoObiettivoScopo dello studio è stato quello di valutare, mediante ecografia (US), la presenza di lesioni intimali nei vasi epiaortici di pazienti positivi al virus della immunodeficienza umana (HIV) trattati mediante terapia antiretrovirale altamente attiva (HAART), confrontando i risultati ottenuti con quelli provenienti dallo studio delle carotidi di pazienti HIV+ che non ricevevano HAART e di individui sani utilizzati come controllo. Abbiamo inoltre differenziato le lesioni intimali sulla base del quadro di presentazione, in placche aterosclerotiche classiche e lesioni di tipo infiammatorio, simili a quelle identificabili in corso di arterite.Materiali e metodiAbbiamo studiato con US le carotidi di 222 pazienti HIV-positivi trattati con HAART, di 64 HIV-positivi naïve per la terapia antiretrovirale e di 135 soggetti HIV-negativi, utilizzati come popolazione di controllo. Lo studio è stato effettuato in B-mode e mediante color e power Doppler, per meglio caratterizzare le lesioni e lo spessore intimale (IMT). Lo spessore intimale è stato valutato utilizzando un software dedicato (Q LAB). In ogni paziente sono stati considerati i fattori di rischio per l’insorgenza di lesioni delle carotidi e in particolare sono state considerate la colesterolemia e la trigliceridemia. L’analisi statistica è stata effettuata mediante test del chi-quadro, di Fischer, di Kruskall-Wallis.RisultatiAbbiamo rilevato lesioni intimali carotidee in misura significativamente maggiore nei pazienti HIV-positivi trattati con HAART rispetto a quelli che non ricevano HAART (p<0,0000001), e ai controlli (p<0,0001). In cinque soggetti in terapia HAART abbiamo documentato la presenza di lesioni carotidee di tipo infiammatorio.ConclusioniIl nostro studio conferma un’elevata incidenza di lesioni carotidee nei soggetti HIV-positivi trattati con HAART. Come già segnalato da altri autori, abbiamo osservato lesioni carotidee compatibili con arterite piuttosto che con il classico ateroma, ma in una percentuale attualmente troppo esigua (0,02%) per supportare valide ipotesi diagnostiche. Ulteriori studi sono necessari per confermare quest’ultimo dato.

Valutazione ecografica delle lesioni vascolari carotidee nei pazienti HIV positivi

PurposeThis study evaluated with ultrasonography (US) the presence of epiaortic vessel lesions in HIV-positive individuals receiving highly active antiretroviral therapy (HAART) and compared them with naïve patients and healthy individuals to highlight the differences among the different vascular damage patterns.Materials and methodsA total of 222 HIV-infected patients receiving HAART, 64 HIV-infected patients naïve to antiretroviral therapy and 135 HIV-negative control patients underwent US of the carotid vessels. The morphological examination included grey-scale and colour and power Doppler imaging to better characterise lesions and intima media thickness. An automated computerised software package (Q LAB) was used to determine intima media thickness values. Independent risk factors for the development of carotid lesions and, in particular, cholesterolaemia and triglyceridaemia were considered. Atherosclerotic plaques and inflammatory-type lesions were reported. Statistical analysis included the chi-square test, the Fisher exact test for qualitative variables and the Kruskal-Wallis test to compare continuous variables.ResultsWe observed a higher prevalence of carotid lesions in HIV-positive patients receiving HAART compared with HIV-positive naïve patients (p<0.0000001) and HIV-negative patients (p<0.0001). Findings consistent with inflammatory-type lesions rather than classic atheroma were depicted only in five patients receiving HAART (0.02%).ConclusionsOur study confirms a higher prevalence of carotid lesions in HAART-treated HIV patients. In agreement with other authors, we identified carotid lesions that were consistent with arteritis rather than with classic atheroma, but the percentage was too small to suggest any robust hypothesis. Further studies are warranted to define the mechanism of onset of carotid lesions in HIV-positive individuals.RiassuntoObiettivoScopo dello studio è stato quello di valutare, mediante ecografia (US), la presenza di lesioni intimali nei vasi epiaortici di pazienti positivi al virus della immunodeficienza umana (HIV) trattati mediante terapia antiretrovirale altamente attiva (HAART), confrontando i risultati ottenuti con quelli provenienti dallo studio delle carotidi di pazienti HIV+ che non ricevevano HAART e di individui sani utilizzati come controllo. Abbiamo inoltre differenziato le lesioni intimali sulla base del quadro di presentazione, in placche aterosclerotiche classiche e lesioni di tipo infiammatorio, simili a quelle identificabili in corso di arterite.Materiali e metodiAbbiamo studiato con US le carotidi di 222 pazienti HIV-positivi trattati con HAART, di 64 HIV-positivi naïve per la terapia antiretrovirale e di 135 soggetti HIV-negativi, utilizzati come popolazione di controllo. Lo studio è stato effettuato in B-mode e mediante color e power Doppler, per meglio caratterizzare le lesioni e lo spessore intimale (IMT). Lo spessore intimale è stato valutato utilizzando un software dedicato (Q LAB). In ogni paziente sono stati considerati i fattori di rischio per l’insorgenza di lesioni delle carotidi e in particolare sono state considerate la colesterolemia e la trigliceridemia. L’analisi statistica è stata effettuata mediante test del chi-quadro, di Fischer, di Kruskall-Wallis.RisultatiAbbiamo rilevato lesioni intimali carotidee in misura significativamente maggiore nei pazienti HIV-positivi trattati con HAART rispetto a quelli che non ricevano HAART (p<0,0000001), e ai controlli (p<0,0001). In cinque soggetti in terapia HAART abbiamo documentato la presenza di lesioni carotidee di tipo infiammatorio.ConclusioniIl nostro studio conferma un’elevata incidenza di lesioni carotidee nei soggetti HIV-positivi trattati con HAART. Come già segnalato da altri autori, abbiamo osservato lesioni carotidee compatibili con arterite piuttosto che con il classico ateroma, ma in una percentuale attualmente troppo esigua (0,02%) per supportare valide ipotesi diagnostiche. Ulteriori studi sono necessari per confermare quest’ultimo dato.