Salvatore Cappabianca

Intestinal Ischemia: US-CT findings correlations

BackgroundIntestinal ischemia is an abdominal emergency that accounts for approximately 2% of gastrointestinal illnesses. It represents a complex of diseases caused by impaired blood perfusion to the small and/or large bowel including acute arterial mesenteric ischemia (AAMI), acute venous mesenteric ischemia (AVMI), non occlusive mesenteric ischemia (NOMI), ischemia/reperfusion injury (I/R), ischemic colitis (IC). In this study different study methods (US, CT) will be correlated in the detection of mesenteric ischemia imaging findings due to various etiologies.MethodsBasing on experience of our institutions, over 200 cases of mesenteric ischemia/infarction investigated with both US and CT were evaluated considering, in particular, the following findings: presence/absence of arterial/venous obstruction, bowel wall thickness and enhancement, presence/absence of spastic reflex ileus, hypotonic reflex ileus or paralitic ileus, mural and/or portal/mesenteric pneumatosis, abdominal free fluid, parenchymal ischemia/infarction (liver, kidney, spleen).ResultsTo make an early diagnosis useful to ensure a correct therapeutic approach, it is very important to differentiate between occlusive (arterial,venous) and nonocclusive causes (NOMI). The typical findings of each forms of mesenteric ischemia are explained in the text.ConclusionAt present, the reference diagnostic modality for intestinal ischaemia is contrast-enhanced CT. However, there are some disadvantages associated with these techniques, such as radiation exposure, potential nephrotoxicity and the risk of an allergic reaction to the contrast agents. Thus, not all patients with suspected bowel ischaemia can be subjected to these examinations. Despite its limitations, US could constitutes a good imaging method as first examination in acute settings of suspected mesenteric ischemia.

Multiple jejunal angiodysplasia detected by enema-helical CT.

The small bowel angiodysplasia is a rare entity that causes lower intestinal bleeding; the diagnosis is difficult and based on selective angiogram. In our case, an 85-year-old woman was hospitalized after frequent episodes of melena. We performed an enema-helical CT abdominal examination before and after contrast medium administration per venam, detecting some increased intensity areas that surgery confirmed to be a vascular dysplasia on the jejunal first loop. We found the source of hemorrhage without performing an angiographic examination.

Biomarkers of Periodontal Tissue Remodeling during Orthodontic Tooth Movement in Mice and Men: Overview and Clinical Relevance

Biologically active substances are expressed by cells within the periodontium in response to mechanical stimuli from orthodontic appliances. Several possible biomarkers representing biological modifications during specific phenomena as simile-inflammatory process, bone resorption and formation, periodontal ligament changes, and vascular and neural responses are proposed. Citations to potentially published trials were conducted by searching PubMed, Cochrane databases, and scientific textbooks. Additionally, hand searching and contact with experts in the area were undertaken to identify potentially relevant published and unpublished studies. Selection criteria were as follows: animal models involving only mice and rats undergoing orthodontic treatment; collection of gingival crevicular fluid (GCF) as a noninvasively procedure for humans; no other simultaneous treatment that could affect experimental orthodontic movement. The data suggest that knowledge of the remodeling process occurring in periodontal tissues during orthodontic and orthopedic therapies may be a clinical usefulness procedure leading to proper choice of mechanical stress to improve and to shorten the period of treatment, avoiding adverse consequences. The relevance for clinicians of evaluating the rate of some substances as valid biomarkers of periodontal effects during orthodontic movement, by means of two models of study, mice and men, is underlined.

Orbital Fractures: Role of Imaging

The orbit may be injured directly or indirectly. Blunt and penetrating trauma occurs with equal frequency. Soft tissue swelling often obscures direct clinical evaluation of the globe, limits ocular motion, and may limit clinical assessment of vision. Plain film radiographs of the orbits and sinuses are rarely used for diagnosis in orbital trauma. Computed tomography is considered the imaging modality of choice in this circumstance, as it is deemed to be the most accurate method in detecting fractures. The protocol is based on obtaining thin-section axial scans and multiplanar reformatted images, both are useful tools to guide treatment. Orbital fractures are not considered an ophthalmologic emergency unless there is visual impairment or globe injury. Surgical repair is indicated for patients who have persistent diplopia or cosmetic concerns (enophthalmos) and generaly is not performed until swelling subsides 7-10 days after injury.

Preventing the acute skin side effects in patients treated with radiotherapy for breast cancer: the use of corneometry in order to evaluate the protective effect of moisturizing creams

Background and purposeThe purpose of this study was to add, to the objective evaluation, an instrumental assessment of the skin damage induced by radiation therapy.Materials and methodsA group of 100 patients affected by breast cancer was recruited in the study over one year. Patients were divided into five groups of 20 patients. For each group it was prescribed a different topical treatment. The following products were used: Betaglucan, sodium hyaluronate (Neoviderm®), Vitis vinifera A. s-I-M.t-O.dij (Ixoderm®), Alga Atlantica plus Ethylbisiminomethylguaicolo and Manganese Cloruro (Radioskin1®) and Metal Esculetina plus Ginko Biloba and Aloe vera (Radioskin 2®); Natural triglycerides-fitosterols (Xderit®); Selectiose plus thermal water of Avene (Trixera+®). All hydrating creams were applied twice a day starting 15 days before and one month after treatment with radiations. Before and during treatment patients underwent weekly skin assessments and corneometry to evaluate the symptoms related to skin toxicity and state of hydration. Evaluation of acute cutaneous toxicity was defined according to the RTOG scale.ResultsAll patients completed radiotherapy; 72% of patients presented a G1 cutaneous toxicity, 18% developed a G2 cutaneous toxicity, 10% developed a G3 toxicity, no one presented G4 toxicity. The corneometry study confirmed the protective role of effective creams used in radiation therapy of breast cancer and showed its usefulness to identify radiation-induced dermatitis in a very early stage.ConclusionsThe preventive use of topic products reduces the incidence of skin side effects in patients treated with radiotherapy for breast cancer. An instrumental evaluation of skin hydration can help the radiation oncologist to use strategies that prevent the onset of toxicity of high degree. All moisturizing creams used in this study were equally valid in the treatment of skin damage induced by radiotherapy.

Combined videofluoroscopy and manometry in the diagnosis of oropharyngeal dysphagia: examination technique and preliminary experience

PurposeDysphagia is a symptom of different pathological conditions characterised by alteration of the swallowing mechanism, which may manifest at different levels. We report our experience in the evaluation of the swallowing mechanism with combined videofluoroscopy and manometric recordings.Materials and methodsFor the combined study, we used a Dyno Compact computerised system (Menfis Biomedical s.r.l., Bologna, Italy) equipped with: (1) graphics card for the management of ultrasonographic or radiological images; (2) A.VI.U.S. dedicated software package, which enables digital-quality recording (PAL/NTSC, composite video or S-Video) of the videofluoroscopy study in AVI format with 320×240 resolution and 25 Hz acquisition frequency. The delay introduced by the process of image digitalisation is in the order of 200 ms, so for analysis purposes, the images can be considered synchronised with the manometric recordings. The videomanometry study was performed with the administration of contrast material either in bolus form or diluted. Data were collected on a specifically designed grid for the evaluation of 46 videofluoroscopic items, of which 34 are derived from the laterolateral view (seven in the oral preparatory phase, 15 in the oral transport phase and 12 in the pharyngeal phase) and 12 in the anteroposterior view (six in the oral preparatory phase and six in the oropharyngeal phase). A positive finding for the individual parameters is expressed in a binary fashion. Manometric evaluation was based on 11 items divided into four major and seven minor criteria.ResultsDynamic videofluoroscopy swallow study combined with concurrent manometry enabled the simultaneous recording of anatomical alterations and the functional data of oropharyngeal pressure, thus providing a picture of the anatomical, biomechanical and physiological conditions of swallowing and the manner of bolus propulsion and transit.ConclusionsAn early and effective diagnosis of oropharyngeal dysphagia means being able to effectively implement appropriate rehabilitation techniques, improve the patient’s quality of life, and minimise the complications associated with swallowing disorders (choking, aspiration pneumonia, malnourishment). Distinction of the anatomical level of dysphagia is not a matter of simple classification; rather, it is essential in that different clinical presentations require different diagnostic strategies, and a precise definition of the anatomical-functional substrate is required to implement the correct therapeutic approach. This study presents the authors’ experience with the use of combined videofluoroscopy and manometry with particular emphasis on the examination technique.RiassuntoObiettivoLa disfagia è un sintomo sotteso da differenti quadri patologici, in cui si verifica un’alterazione del meccanismo deglutitorio, che può estrinsecarsi a vari livelli. Gli autori riportano la loro esperienza nella valutazione del meccanismo della deglutizione mediante l’integrazione diagnostica combinata manometrica e videofluoroscopica.Materiali e metodiPer lo studio combinato è stato impiegato il sistema computerizzato “Dyno Compact” (Menfis Biomedical s.r.l., Bologna, Italia) dotato di: 1) scheda grafica per la gestione di immagini ecografiche o radiografiche; 2) A.VI.U.S. software dedicato, attraverso il quale è possibile registrare in qualità digitale (PAL/NTSC, video composito o S-Video) la videofluoroscopia, in filmati AVI con risoluzione 320×240 e con frequenza di acquisizione di 25 Hz; il ritardo introdotto dal processo di digitalizzazione dell’immagine è dell’ordine dei 200 ms, quindi, ai fini dell’analisi, l’immagine si può considerare sincronizzata con i tracciati pressori. Lo studio VFS è stato effettuato mediante somministrazione di boli adeguati di mezzo di contrasto opportunamente diluito. I dati vengono raccolti su una griglia precostituita per la valutazione di 46 items videofluoroscopici, di cui 34 derivano dallo studio in proiezione latero-laterale (7 in fase buccale, 15 in fase orale e 12 in fase faringea) e 12 dallo studio in proiezione antero-posteriore (6 in fase buccale e 6 in fase orofaringea); la positività ai singoli parametri è espressa in maniera binaria. La valutazione pressoria si basa su 11 sialoritems manometrici, a loro volta divisi in 4 criteri maggiori e 7 minoriRisultatiLa valutazione fluoroscopica dinamica della deglutizione con registrazione video abbinata alla manometria simultanea, ha permesso di registrare contemporaneamente le alterazioni anatomiche correlandole al dato funzionale della pressione orofaringea, consentendo durante la medesima registrazione di valutare la situazione anatomica, biomeccanica e fisiologica della deglutizione e le modalità di propulsione e transito del bolo.ConclusioniFare precocemente una buona diagnosi di disfagia orofaringea significa poter intervenire efficacemente con tecniche riabilitative logopediche, migliorare la qualità di vita del paziente, nonché ridurre al minimo le complicanze che questa comporta (soffocamento, polmonite ab ingestis, malnutrizione). La differenziazione del livello anatomico della disfagia non riveste una semplice categorizzazione, ma è indispensabile in quanto alla diversità di presentazione clinica corrisponde un differente approccio metodologico diagnostico, ed a una precisa definizione del substrato anatomo-funzionale responsabile del sintomo, corrisponde un diverso approccio terapeutico. Gli autori con il presente contributo presentano la loro esperienza nell’impiego della videofluoromanometria ed in particolare la metodologia di conduzione dell’esame.

Three-dimensional anal endosonography in depicting anal-canal anatomy.

PurposeThis report describes the advantages of 3D anal endosonography in depicting the normal anatomy of the anal canal in relation to sex and age.Materials and methodsA retrospective study was performed of 85 patients, 33 men and 52 women, previously examined with 3D anal ultrasound (US) for clinically suspected anorectal disease but found to be negative. The examinations were performed with a Bruel and Kjaer US system with a 2050 transducer, scanning from the anorectal junction to the subcutaneous portion of the external anal sphincter (EAS). The 3D reconstructions provided an estimation of sphincter length in the anterior and posterior planes, and axial 2D images enabled calculation of the thickness of the internal anal sphincter (IAS) and EAS in the anterior, posterior and lateral transverse planes.ResultsDistribution of the sphincter complex is asymmetric in both sexes: the EAS and IAS are significantly shorter in females, especially in the anterior longitudinal plane (p=0.005 and p<0.001, respectively). EAS and IAS thickness increases with age, especially the lateral IAS (R2=0.37, p<0.001) and the posterior EAS (R2=0.29, p=0.01).ConclusionsA good knowledge of anal-canal anatomy is essential to detect sphincter abnormalities when assessing pelvic floor dysfunction.RiassuntoObiettivoScopo del presente lavoro è stato documentare la rappresentazione anatomica normale del canale anale attraverso l’ultrasonografia (US) endoanale 3D, in relazione al sesso e all’età.Materiali e metodiIn uno studio retrospettivo sono stati selezionati 85 soggetti, di cui 33 maschi e 52 femmine, sottoposti precedentemente ad US endoanale 3D per sospetto clinico di patologia dell’ano-retto distale ma risultati essere tutti negativi all’esame ultrasonografico. Gli esami sono stati eseguiti con apparecchio dedicato Bruel e Kjaer, con trasduttore tipo 2050 e scansioni dalla giunzione ano-rettale alla porzione più superficiale dello sfintere anale esterno (SAE). Nell’immediato postprocessing sono stati stimati la lunghezza degli sfinteri nei piani anteriore e posteriore e lo spessore anteriore, laterale e posteriore dello sfintere anale interno (SAI) e del SAE.RisultatiLa distribuzione della muscolatura del canale anale risulta asimmetrica in entrambi i sessi: la lunghezza di SAI e SAE è significativamente più breve nelle donne, specie lungo il piano longitudinale mediano anteriore (p=0,005 e p<0,001, rispettivamente). Inoltre, lo spessore di entrambi gli sfinteri presenta una tendenza all’accrescimento proporzionale all’età del paziente, soprattutto nella porzione laterale per il SAI (R2=0,37, p<0,001) e posteriore per il SAE (R2=0,29, p=0,01).ConclusioniLa conoscenza precisa delle componenti anatomiche muscolo-legamentose del canale anale è alla base della identificazione delle alterazioni sfinteriali utili alla comprensione dei disturbi del pavimento pelvico.

Multidetector–row CT enteroclysis: indications and clinical applications

This paper examines the diagnostic potential of multislice computed tomography enteroclysis (MSCT–E) to detect and assess different diseases affecting the small bowel, emphasising the increasingly important role assumed by the technique in the study of this anatomical region. After a short summary of the technical aspects, we discuss the different findings that can be observed during an MSCT–E study and that enable detection of small–bowel disease and, if necessary, assessment of the extent and stage of disease.

Lipomatous lesions of the head and neck region: imaging findings in comparison with histological type

PurposeAim of the study is to demonstrate the main role of magnetic resonance imaging in the identification and characterization of lipomatous lesions of the head and neck.Materials and methodsCT and MRI findings of 78 patients (43 male, 35 female) aged 12–80 (mean 47.5) years surgically treated for lipomatous lesions of the head and neck region between January 1995 and June 2005 were retrospectively analysed and correlated with the histological results.ResultsOn CT images, lipomas and fibrolipomas appeared as smooth (38/50 cases) or lobulated (12/50 cases) well-defined masses associated with moderate displacement of surrounding tissues; tumours had high signal intensity on MR T1-weighted images, with relative decreasing signal on T2-weighted images. Infiltrating lipomas appeared as expansile ill-defined masses with heterogeneous signal. Angiolipomas showed a characteristic contrast enhancement on both CT and MRI. In one case of sialolipoma, the lesion appeared markedly heterogeneous in signal. MR and CT images of Madelung’s disease showed multiple symmetrical lipomatous masses involving the neck region. Intraosseous fatty lesions appeared as well-defined hypodense masses sometimes associated with cortical expansion and disruption.ConclusionsBoth CT and MRI exams are useful for detecting lipomatous lesions. MRI, however, is more accurate in the evaluation of their extent and in the characterisation of uncommon lipomatous lesions of the head and neck, and intravenous administration of gadolinium better depicts the margins of the tumour and its vascularisation.RiassuntoObiettivoLo scopo del lavoro è dimostrare il ruolo primario della risonanza magnetica nell’identificazione e nella caratterizzazione dei lipomi della regione testa-collo.Materiali e metodiGli esami di tomografia computerizzata e risonanza magnetica di 78 pazienti (43 M, 35 F) di età compresa tra i 12 e gli 80 anni (media: 47,5), sottoposti ad intervento chirurgico per l’asportazione di lipomi del distretto testa-collo tra gennaio 1995 e giugno del 2005, sono stati valutati retrospettivamente e correlati successivamente ai risultati dellesame istologico.RisultatiNelle immagini di tomografia computerizzata i lipomi ed i fibrolipomi appaiono come masse ben definite con margini lisci (38/50 casi) o lobulati (12/50 casi) associate, con modesta dislocazione dei tessuti circostanti; le lesioni appaiono iperintense nelle immagini di risonanza magnetica ottenute con sequenze T1-pesate con riduzione proporzionale del segnale nelle immagini T2-pesate. I lipomi infiltranti appaiono come masse espansive scarsamente definite e dotate di segnale eterogeneo. Le immagini di tomografia computerizzata e di risonanza magnetica della malattia di Madelung mostrano lesioni multiple e simmetriche nel distretto testa-collo. Le lesioni intraossee appaiono come aree ipodense ben definite talora associate ad espansione e distruzione della corticale.ConclusioniLa tomografia computerizzata e la risonanza magnetica sono entrambe utili per la diagnosi dei lipomi; la risonanza magnetica, tuttavia, costituisce la tecnica più leaccurata nella valutazione della loro estensione e nella caratterizzazione delle lesioni rare del distretto testa-collo. La somministrazione intravenosa di mezzo di contrasto definisce con maggiore dettaglio i margini del tumore ed il suo pattern di vascolarizzazione.

Early systemic sclerosis: marker autoantibodies and videocapillaroscopy patterns are each associated with distinct clinical, functional and cellular activation markers

IntroductionEarly systemic sclerosis (SSc) is characterized by Raynauds phenomenon together with scleroderma marker autoantibodies and/or a scleroderma pattern at capillaroscopy and no other distinctive feature of SSc. Patients presenting with marker autoantibodies plus a capillaroscopic scleroderma pattern seem to evolve into definite SSc more frequently than patients with either feature. Whether early SSc patients with only marker autoantibodies or capillaroscopic positivity differ in any aspect at presentation is unclear.MethodsSeventy-one consecutive early SSc patients were investigated for preclinical cardiopulmonary alterations. Out of these, 44 patients and 25 controls affected by osteoarthritis or primary fibromyalgia syndrome were also investigated for serum markers of fibroblast (carboxyterminal propeptide of collagen I), endothelial (soluble E-selectin) and T-cell (soluble IL-2 receptor alpha) activation.ResultsThirty-two of the 71 patients (45.1%) had both a marker autoantibody and a capillaroscopic scleroderma pattern (subset 1), 16 patients (22.5%) had only a marker autoantibody (subset 2), and 23 patients (32.4%) had only a capillaroscopic scleroderma pattern (subset 3). Patients with marker autoantibodies (n = 48, 67.6%) had a higher prevalence of impaired diffusing lung capacity for carbon monoxide (P = 0.0217) and increased serum levels of carboxyterminal propeptide of collagen I (P = 0.0037), regardless of capillaroscopic alterations. Patients with a capillaroscopic scleroderma pattern (n = 55, 77.5%) had a higher prevalence of puffy fingers (P = 0.0001) and increased serum levels of soluble E-selectin (P = 0.0003) regardless of marker autoantibodies.ConclusionThese results suggest that the autoantibody and microvascular patterns in early SSc may each be related to different clinical-preclinical features and circulating activation markers at presentation. Longitudinal studies are warranted to investigate whether these subsets undergo a different disease course over time.