The lung ultrasound: facts or artifacts? In the era of COVID-19 outbreak.

Ultrasound is the most disruptive innovation in intensive care life, above all in this time, with a high diagnostic value when applied appropriately. In recent years, point-of-care lung ultrasound has gained significant popularity as a diagnostic tool in the acutely dyspnoeic patients. In the era of Sars-CoV-2 outbreak, lung ultrasound seems to be strongly adapting to the follow-up for lung involvement of patients with ascertaining infections, till to be used, in our opinion emblematically, as a screening test in suspected patients at the emergency triage or at home medical visit. In this brief review, we discuss the lung ultrasound dichotomy, certainties and uncertainties, describing its potential role in validated clinical contexts, as a clinical-dependent exam, its limits and pitfalls in a generic and off-label clinical context, as a virtual anatomical-dependent exam, and its effects on the clinical management of patients with COVID-19.

Insight into Dunbar syndrome: color-Doppler ultrasound findings and literature review.

Dunbar syndrome, also known as median arcuate ligament syndrome, is a rare clinical condition due to the external compression of the celiac trunk by the median arcuate ligament causing abdominal angina. We report a case of Dunbar syndrome and its borderline imaging findings focused on the crucial diagnostic role of color-Doppler ultrasound. We also reviewed the current literature, delineating the clinical manifestations and the diagnostic workup of the Dunbar syndrome with the objective to increase the knowledge of this clinical entity as a cause of postprandial abdominal pain and to underline the pivotal role of color-Doppler ultrasound to avoid incorrect or delayed diagnosis.

High-flow post-traumatic priapism: diagnostic and therapeutic workup.

Priapism is a prolonged penile tumescence or erection unrelated to sexual stimulation that lasts more than 6 h. High-flow priapism is a rare condition usually due to a perineal trauma with the formation of an arterio-cavernosal fistula between a cavernosal artery and the lacunar spaces of the penis. High-flow priapism is usually diagnosed by clinical examination and color Doppler ultrasound, and the gold standard therapeutic management is represented by digital subtraction angiography. We report a case of a young patient with high-flow priapism after a motorcycle blunt perineal trauma, examining in detail the specific color Doppler ultrasound findings, the diagnostic workup and the therapeutic management.

Ultrasound of scrotal and penile emergency: how, why and when.

High-resolution ultrasound is the most common imaging technique used to supplement the physical examination of scrotum and penis with great accuracy in assisting the diagnosis of the various pathologies of male genital system, with the highest diagnostic potential in emergency conditions. Technical advancements in real-time high-resolution, color flow Doppler sonography and contrast enhanced ultrasonography (CEUS) have led to an increase in the clinical applications of scrotal and penile sonography. In this pictorial review we focus on common and uncommon male genitalia emergency with special emphasis on the role of ultrasound assessment and its specific findings to improve diagnostic accuracy.

Pediatric encephalic ultrasonography: the essentials.

Nowadays, cranial ultrasonography (US) of the newborn represents the first imaging method in brain damage study and its possible outcomes. This exam is performed using the natural fontanelles, especially the anterior one. It is fast, non-invasive and does not produce any side effect. Ultrasonographic examination is usually performed in cases of prematurity, especially in children with birth weight less than 1500 g, because important informations about the possible presence of pathologies such as cerebral hemorrhage and hypoxic-ischemic encephalopathy are given. This approach can be useful also in the study of pre- and post-natal infections, for example, type II Herpes Simplex virus or Cytomegalovirus infections, or pointing out vascular malformations such as vein of Galen aneurysm. Although less important than methods such as computed tomography (CT) and magnetic resonance imaging (MRI) in the evaluation of trauma and tumors, ultrasound can provide useful informations or be used in first instance in the suspicion of a brain mass.

Paediatric liver ultrasound: a pictorial essay.

Ultrasound scan is a painless and radiation-free imaging modality and, therefore, it is widely considered the first-choice diagnostic tool in the setting of hepatopathies in paediatric patients. This article focuses on the normal ultrasound anatomy of the liver in neonatal and paediatric age and reviews the ultrasound appearance of the most common diffuse and focal liver affections.

Effect of Annurca Apple Polyphenols on Intermittent Claudication in Patients With Peripheral Artery Disease.

Peripheral arterial disease (PAD) is an atherosclerotic process involving both modifiable and nonmodifiable risk factors. Prospective cohort studies show that patients with PAD have a 6-fold greater risk of death from cardiovascular disease than those without PAD. Currently, there is no effective treatment for PAD. The study was a randomized, placebo-controlled trial, involving 180 patients, aged 35 to 75. The subjects were divided into 2 groups. One group underwent 24 weeks of nutraceutical treatment consisting in the administration of 4 capsules of Annurca apple polyphenolic extract (AMS)/day. The placebo group was administered with identically appearing capsules containing only maltodextrin. Primary outcome measures were: walking autonomy, ankle-brachial index, acceleration time. In the AMS group, at the end of the treatment period, walking autonomy was increased on average by 69% (p <0.05), while slighter effects were registered as regards ankle-brachial index (+25%; p <0.05) and acceleration time (-3.6%; p <0.05), when compared with baseline. Placebo group revealed no significant differences as regards variations of all outcomes measures (p >0.05). Our preliminary results may indicate AMS product as a promising natural and safe tool for treatment of symptoms related to PAD.

Ultrasonography of the pediatric spleen: a pictorial essay.

In infants and children, the spleen is involved in many pathological processes, whether those processes are isolated or related to systemic diseases. Pathology of the pediatric spleen includes congenital anomalies, splenomegaly, trauma, focal lesions, infarction, and tumors. Ultrasonography (US) is a widely available, fast, noninvasive imaging technique to assess the size, shape, and position of the spleen, as well as to define splenic echotexture. US is capable of screening for splenic disorders without the risk of ionizing radiation; it is the initial imaging examination performed to evaluate suspected splenic pathology, providing clinicians with helpful decisional support. US plays an important role in the detection of even very small amounts of hemoperitoneum, a herald of significant abdominal organ injury, in pediatric blunt abdominal trauma. Moreover, contrast-enhanced US may allow early detection of splenic injuries, ideally minimizing children's risk from radiation exposure. This pictorial essay illustrates the normal ultrasound appearance of the pediatric spleen and the sonographic findings which may guide clinicians to a correct diagnosis of pathologic conditions.

Non-Operative Management of Blunt Liver Trauma: Safety, Efficacy and Complications of a Standardized Treatment Protocol.

OBJECTIVE: To evaluate the safety and effectiveness of NOM (non-operative management) in the treatment of blunt liver trauma, following a standardized treatment protocol. METHODS: All the hemodynamically stable patients with computed tomography (CT) diagnosis of blunt liver trauma underwent NOM. It included strict clinical and laboratory observation, 48-72h contrast enhanced ultrasonography (CEUS) or CT follow-up, a primary angioembolization in case of admission CT evidence of vascular injuries and a secondary angioembolization in presence of vascular injuries signs at follow-up CEUS. RESULTS: 181 patients (85.4%) [55 (30.4%) women and 126 (69.6%) men, median age 39 (range 14-71)] were included. Of these, 63 patients (34.8%) had grade I, 48 patients (26.5%) grade II, 39 patients (21.5%) grade III, 21 patients (11.6%) grade IV and 10 patients (5.5%) grade V liver injuries. The overall success rate of NOM was 96.7% (175/181). There was not significant difference in the success rate between the patients with different liver injuries grade. Morbidity rate was 7.4% (13/175). Major complications (2 bilomas, 1 liver hematoma and 2 liver abscesses) were successfully treated by CEUS or CT guided drainage. Eighteen (18/181) patients (9.9%) underwent angioembolization with successful results. CONCLUSION: Non-operative management of blunt liver trauma represents a safe and effective treatment for both minor and severe injuries, achieving an high success rate and an acceptable morbidity rate. The angiographic study with embolization, although required only in selected cases of vascular injuries, represents a fundamental therapeutic option in a significant percentage of patients.

Carotid artery stiffness in obese children with the metabolic syndrome.

Obesity and overweight have been associated with increased carotid intima-media thickness and stiffness in adults and children. Overweight and obesity have also been associated with an increased prevalence of the metabolic syndrome (MS). The aim of the study was to test the hypothesis that obese children with the MS have increased rigidity of their arteries compared with obese children without the MS. We studied 100 obese children (age range 6 to 14 years; 61 males, 39 females) consecutively seen in the outpatient clinic of a hospital department of pediatrics. Anthropometric measures and biochemical tests were performed in all children. Quantitative B-mode ultrasound scans were used to measure intima-media thickness and diameters of the common carotid artery. Common carotid arterial stiffness was significantly higher in the group of obese children with the MS (n = 38) at 1.29 +/- 0.06 mm (values log transformed) versus 1.12 +/- 0.04 mm (p <0.03) compared with those without the MS (n = 62). These differences persisted even after adjustment for age, gender, and C-reactive protein. Obese children with the MS had significantly higher plasma concentrations of C-reactive protein (1.57 +/- 0.06 microg/L, values log transformed) compared with obese children without the MS (1.38 +/- 0.05 microg/L, p <0.03). In conclusion, obese children who met the diagnostic criteria for the MS had higher common carotid artery stiffness and higher C-reactive protein plasma concentrations than obese children without the MS.

Role of multidetector row computed tomography in the assessment of adrenal gland injuries.

OBJECTIVE: To determine the prevalence of adrenal injuries in a group of patients submitted to multidetector row CT evaluation after blunt trauma and to assess the impact of CT findings on clinical management decisions. MATERIALS AND METHOD: During a 4-year period, 2026 emergency CT examinations were performed in the setting of major blunt trauma. A total of 82 patients were retrospectively identified as having adrenal gland traumatic lesions. At multidetector row CT the following findings were considered specific of adrenal injury: round or oval hematoma expanding the adrenal gland, irregular hemorrhage obliterating the gland, uniform adrenal gland swelling, active extravasation of contrast material from the adrenal vessels and adrenal gland rupture. Associated CT findings were: stranding of the periadrenal fat, diffuse hemorrhage in the adjacent retroperitoneum and compression of the adrenal gland by adjacent traumatic lesions. RESULTS: We identified 82 patients (46 males and 36 females, age ranging from 15 to 86 years) with adrenal injuries. The right adrenal gland was injured in 60/82 patients, while the left adrenal gland was injured in 21 cases; in 1 patient bilateral adrenal gland traumatic lesions occurred. In 76 patients with non-isolated adrenal injuries concomitant injuries to the liver (49 cases), ipsilateral kidney (18 cases) and spleen (9 cases) were observed. Round or oval hematoma expanding the adrenal gland (61 cases), irregular hemorrhage obliterating the gland (14 cases), stranding of the periadrenal fat (9 cases) and diffuse hemorrhage in the adjacent retroperitoneum (8 cases) were the more frequent findings detected at CT. Six patients underwent surgical intervention for the presence of major injuries to the spleen (three cases), to the liver (one), to the right kidney (one), to the left kidney (one). Seventy-six patients were conservatively treated. CONCLUSION: Blunt adrenal injuries typically present as part of a multiorgan trauma. Familiarity with characteristic CT findings of adrenal trauma is essential for the radiologist to avoid misdiagnosis.

Preclinical changes in the mechanical properties of abdominal aorta in obese children.

Obesity in childhood has been associated with the development of early cardiovascular abnormalities. The aim of the present study was to investigate whether preclinical functional changes are detectable in the abdominal aorta of obese children. One hundred consecutively seen obese children and 50 healthy controls were studied. The groups were matched in terms of age and gender. The pulsatile wall-motion of the abdominal aorta was determined using a B-mode ultrasound technique. The following mechanical property parameters were measured or computed: lumen diastolic and systolic diameters, relative aortic strain, elastic modulus, and stiffness. Compared to controls, obese children had higher blood pressure values and higher concentrations of total cholesterol, triglycerides, insulin, and C-reactive protein. Homeostasis model assessment (HOMA) score, a parameter of insulin resistance, was significantly higher in obese children than in controls (3.2 +/- 1.9 v 1.4 +/- 0.5, P <.001). Aortic mechanical parameters were significantly different in obese children as compared to controls: stiffness was higher (3.00 +/- 1.45 v 2.22 +/- 0.87, P <.001) as was elastic modulus (0.38 +/- 0.18 v 0.24 +/- 0.10 N/m(2), P <.001). Obese girls with insulin resistance (ie, in the highest tertile of HOMA, >3.7) had increased aortic stiffness (3.79 +/- 2.25) compared to obese girls in the lowest tertiles of HOMA (2.67 +/- 1.09, P =.045), even after adjustment for traditional cardiovascular risk factors (P =.031). The present findings suggest that preclinical changes in the aortic elastic properties are detectable in obese children. Insulin resistance seems to play an important role in the increased rigidity of the aortic wall in obese girls.

Helical CT diagnosis of small bowel obstruction in the acute clinical setting.

Definite confirmation or exclusion closed loop obstruction (CLO) is one of the most difficult tasks the radiologist has to face in the clinical practice. Aim of this retrospective work was to study the value of spiral computed tomography (CT) in the diagnosis of closed loop obstruction complicated by intestinal ischemia. The state of the art CT signs of closed loop obstruction were taken into consideration. Serrated beaks with poor or no contrast enhancement of the bowel walls, ascites or engorgement of the mesenteric vasculature allowed the CT diagnosis of CLO complicated by ischaemia. U or C-sharped of dilated loops, radial distribution of the mesenteric vessels, beaks and whirls suggested CLO, but did not help differentiate CLO from strangulation. CLO is a dynamic entity which may regress or need laparotomy depending on the time and degree of rotation of the incarcerated loops. CT is a reliable imaging modality able to differentiate CLO from strangulation, which is rarely simple and obvious. Detection of ischemic changes in the bowel walls and/or attached mesentery on CT scans imply strangulation highlighting the need for laparotomy; if only signs of CLO are detected, the existence and/or development of strangulation cannot be predicted.

Learning from diagnostic errors: a good way to improve education in radiology.

PURPOSE: To evaluate the causes and the main categories of diagnostic errors in radiology as a method for improving education in radiology. MATERIAL AND METHODS: A Medline search was performed using PubMed (National Library of Medicine, Bethesda, MD) for original research publications discussing errors in diagnosis with specific reference to radiology. The search strategy employed different combinations of the following terms: (1) diagnostic radiology, (2) radiological error and (3) medical negligence. This review was limited to human studies and to English-language literature. Two authors reviewed all the titles and subsequently the abstracts of 491 articles that appeared pertinent. Additional articles were identified by reviewing the reference lists of relevant papers. Finally, the full text of 75 selected articles was reviewed. RESULTS: Several studies show that the etiology of radiological error is multi-factorial. The main category of claims against radiologists includes the misdiagnoses. Radiologic "misses" typically are one of two types: either missed fractures or missed diagnosis of cancer. The most commonly missed fractures include those in the femur, the navicular bone, and the cervical spine. The second type of "miss" is failure to diagnose cancer. Lack of appreciation of lung nodules on chest radiographs and breast lesions on mammograms are the predominant problems. CONCLUSION: Diagnostic errors should be considered not as signs of failure, but as learning opportunities.

E-learning and education in radiology.

PURPOSE: To evaluate current applications of e-learning in radiology. MATERIAL AND METHODS: A Medline search was performed using PubMed (National Library of Medicine, Bethesda, MD) for publications discussing the applications of e-learning in radiology. The search strategy employed a single combination of the following terms: (1) e-learning, and (2) education and (3) radiology. This review was limited to human studies and to English-language literature. We reviewed all the titles and subsequent the abstract of 29 articles that appeared pertinent. Additional articles were identified by reviewing the reference lists of relevant papers. Finally, the full text of 38 selected articles was reviewed. RESULTS: Literature data shows that with the constant development of technology and global spread of computer networks, in particular of the Internet, the integration of multimedia and interactivity introduced into electronic publishing has allowed the creation of multimedia applications that provide valuable support for medical teaching and continuing medical education, specifically for radiology. Such technologies are valuable tools for collaboration, interactivity, simulation, and self-testing. However, not everything on the World Wide Web is useful, accurate, or beneficial: the quality and veracity of medical information on the World Wide Web is variable and much time can be wasted as many websites do not meet basic publication standards. CONCLUSION: E-learning will become an important source of education in radiology.

Using color power Doppler ultrasound imaging to diagnose the acute scrotum. A pictorial essay.

Acute nontraumatic scrotum represents one of the most important emergencies in the male population. Etiology of the acute scrotum greatly varies, but the most common causes include testicular torsion and inflammatory disease. Currently, the most successful diagnostic imaging is ultrasound integrated by the application of color power Doppler. A very important finding is the detection of presence/absence of intratesticular blood flow for the early identification of testicular torsion. This pictorial essay aims to illustrate the various causes of acute nontraumatic scrotum by using color power Doppler ultrasound imaging, based on a retrospective analysis of 768 cases performed at our Level I trauma center between January 2005 and June 2006.

Color power Doppler US and contrast-enhanced US features of abdominal solid organ injuries.

Utilization of color power Doppler and sonographic contrast agents to basic ultrasound (US) further improve the detection and characterization of abdominal injuries, increasing the diagnostic accuracy and value of US as an important technique in the evaluation of the abdominal trauma. This paper provides an illustrated summary of our clinical experience with color power Doppler US (CD-US) and contrast-enhanced US (CE-US) in the evaluation of abdominal solid organ injuries, involving 32 documented cases over a 2-year period. The findings of the CD-US and CE-US were compared with those provided by state-of-the-art contrast-enhanced multidetector 16-row CT.