How do we diagnose acute diverticulitis? Results of a national survey about the role of imaging techniques.

INTRODUCTION: The choice of imaging techniques in the diagnosis of acute diverticulitis is controversial. This study aimed to determine radiologists' preferences for different imaging techniques in the management of acute diverticulitis and the extent to which they use the different radiologic techniques for this purpose. METHODS: An online survey was disseminated through the Spanish Society of Abdominal Imaging (Sociedad Española de Diagnóstico por Imagen del Abdomen (SEDIA)) and Twitter. The survey included questions about respondents' working environments, protocolization, personal preferences, and actual practice in the radiological management of acute diverticulitis. RESULTS: A total of 186 responses were obtained, 72% from radiologists working in departments organized by organ/systems. Protocols for managing acute diverticulitis were in force in 48% of departments. Ultrasonography was the initial imaging technique in 47.5%, and 73% of the respondents considered that ultrasonography should be the first-choice technique; however, in practice, ultrasonography was the initial imaging technique in only 24% of departments. Computed tomography was the first imaging technique in 32.8% of departments, and its use was significantly more common outside normal working hours. The most frequently employed classification was the Hinchey classification (75%). Nearly all (96%) respondents expressed a desire for a consensus within the specialty about using the same classification. Hospitals with >500 beds and those organized by organ/systems had higher rates of protocolization, use of classifications, and belief that ultrasonography is the best first-line imaging technique. CONCLUSIONS: The radiologic management of acute diverticulitis varies widely, with differences in the protocols used, radiologists' opinions, and actual clinical practice.

Critical review of HCC imaging in the multidisciplinary setting: treatment allocation and evaluation of response.

Imaging has not only an established role in screening and diagnosis of hepatocellular carcinoma (HCC) in patients with chronic liver inflammatory diseases, but also a crucial importance for patient stratification and treatment allocation, as well as for assessing treatment response. In the setting of increasing therapeutic options for HCC, the Barcelona Clinic Liver Cancer (BCLC) system still remains the most appropriate way to select candidate cohorts for best treatments. This classification takes into account the imaging information on tumor burden and extension, liver function, and cancer-related symptoms, stratifying patients in five risk categories (Stages 0, A, B, C and D) associated with different treatment options. Still now, there are no clear roles for biomarkers use in treatment allocation. The increasing use of locoregional non-surgical therapies in the different stages is highly dependent on reliable evaluation of treatment response, in particular when they are used with curative intention or for downstaging at liver transplantation re-assessment. Moreover, objective response (OR) has emerged as an important imaging biomarker, providing information on tumor biology, which can contribute for further prognostic assessment. Current guidelines for OR assessment recommend only the measurement of viable tumor according to mRECIST criteria, with further classification into complete response, partial response, stable disease or progressive disease. Either computed tomography (CT) or magnetic resonance (MR) imaging can be used for this purpose, and the Liver Imaging Reporting and Data System (LI-RADS) committee has recently provided some guidance for reporting after locoregional therapies. Nevertheless, imaging pitfalls resulting from treatment-related changes can impact with the correct evaluation of treatment response, especially after transarterial radioembolization (TARE). Volume criteria and emerging imaging techniques might also contribute for a better refinement in the assessment of treatment response and monitoring. As the role of imaging deeply expands in the multidisciplinary assessment of HCC, our main objective in this review is to discuss state-of-the-art decision-making aspects for treatment allocation and provide guidance for treatment response evaluation.

Compact self-illuminated image upconversion system based on intracavity second-harmonic generation.

We present an image upconversion system based on intracavity Type II second-harmonic generation to create an image in the visible spectrum of a target illuminated by an infrared laser. The system has the novelty of being self-illuminated. It uses some fractional leaking power of the infrared laser to illuminate a target located in the object focal plane of the system, and to couple back a created infrared target image to an intracavity nonlinear crystal, where it mixes with the cavity laser beam to obtain a second-harmonic image, visible with a silicon CCD camera. For a proof of concept, we have built a system based on a diode-pumped Nd3+:YVO4 continuous-wave (cw) laser and an intracavity KTP crystal to upconvert 1342 nm target images to 671 nm. The upconverted cw power allowed us to capture real-time video in a standard nonintensified CCD camera, with 2.5 W of a diode pump.

IR-to-visible image upconverter under nonlinear crystal thermal gradient operation.

In this work we study the enhancement of the field-of-view of an infrared image up-converter by means of a thermal gradient in a PPLN crystal. Our work focuses on compact upconverters, in which both a short PPLN crystal length and high numerical aperture lenses are employed. We found a qualitative increase in both wavelength and angular tolerances, compared to a constant temperature upconverter, which makes it necessary a correct IR wavelength allocation in order to effectively increase the up-converted area.

Preoperative progressive pneumoperitoneum and botulinum toxin type A in patients with large incisional hernia.

PURPOSE: Combination of preoperative progressive pneumoperitoneum (PPP) and botulinum toxin type A (BT) has not been previously reported in the management of large incisional hernia (LIH). METHODS: Observational study of 45 consecutive patients with LIH between June 2010 and July 2014. The diameters of the hernia sac, the volumes of the incisional hernia (VIH) and the abdominal cavity (VAC), and the VIH/VAC ratio were measured before and after PPP and BT using abdominal CT scan data. We indicated the combination of both techniques when the volume of the incisional hernia (VIH)/volume of the abdominal cavity (VAC) ratio was >20%. RESULTS: The median insufflated volume of air for PPP was 8.600 ± 3.200 cc (4.500-13.250), over a period of 14.3 ± 1.3 days (13-16). BT administration time was 40.2 ± 3.3 days (37-44). We obtained an average value of reduction of 14% of the VIH/VAC ratio after PPP and BT (p < 0.05). Complications associated with PPP were 15.5%, and with surgical technique, 26.6%. No complications occurred during the BT administration. Reconstructive technique was anterior CST and primary fascial closure was achieved in all patients. Median follow-up was 40.5 ± 19 months (12-60) and we reported 2 cases of hernia recurrence (4.4%). CONCLUSIONS: Preoperative combination of PPP and BT is feasible and a useful tool in the surgical management of LIH, although at the cost of some specific complications.

IR Image upconversion using band-limited ASE illumination fiber sources.

We study the field-of-view (FOV) of an upconversion imaging system that employs an Amplified Spontaneous Emission (ASE) fiber source to illuminate a transmission target. As an intermediate case between narrowband laser and thermal illumination, an ASE fiber source allows for higher spectral intensity than thermal illumination and still keeps a broad wavelength spectrum to take advantage of an increased non-collinear phase-matching angle acceptance that enlarges the FOV of the upconversion system when compared to using narrowband laser illumination. A model is presented to predict the angular acceptance of the upconverter in terms of focusing and ASE spectral width and allocation. The model is experimentally checked in case of 1550-630 nm upconversion.

Intra-cavity upconversion to 631 nm of images illuminated by an eye-safe ASE source at 1550 nm.

We report an image wavelength upconversion system. The system mixes an incoming image at around 1550 nm (eye-safe region) illuminated by an amplified spontaneous emission (ASE) fiber source with a Gaussian beam at 1064 nm generated in a continuous-wave diode-pumped Nd(3+):GdVO(4) laser. Mixing takes place in a periodically poled lithium niobate (PPLN) crystal placed intra-cavity. The upconverted image obtained by sum-frequency mixing falls around the 631 nm red spectral region, well within the spectral response of standard silicon focal plane array bi-dimensional sensors, commonly used in charge-coupled device (CCD) or complementary metal-oxide-semiconductor (CMOS) video cameras, and of most image intensifiers. The use of ASE illumination benefits from a noticeable increase in the field of view (FOV) that can be upconverted with regard to using coherent laser illumination. The upconverted power allows us to capture real-time video in a standard nonintensified CCD camera.

Variations in the size of focal nodular hyperplasia on magnetic resonance imaging.

OBJECTIVE: To evaluate the changes in the size of focal nodular hyperplasia (FNH) during long-term magnetic resonance imaging (MRI) follow-up. MATERIAL AND METHODS: We reviewed 44 FNHs in 30 patients studied with MRI with at least two MRI studies at least 12 months apart. We measured the largest diameter of the lesion (inmm) in contrast-enhanced axial images and calculated the percentage of variation as the difference between the maximum diameter in the follow-up and the maximum diameter in the initial study. We defined significant variation in size as variation greater than 20%. We also analyzed predisposing hormonal factors. RESULTS: The mean interval between the two imaging studies was 35±2 months (range: 12-94). Most lesions (80%) remained stable during follow-up. Only 9 of the 44 lesions (20%) showed a significant variation in diameter: 7 (16%) decreased in size and 2 (4%) increased, with variations that reached the double of the initial size. The change in size was not related to pregnancy, menopause, or the use of birth control pills or corticoids. CONCLUSION: Changes in the size of FNHs during follow-up are relatively common and should not lead to a change in the diagnosis. These variations in size seem to be independent of hormonal factors that are considered to predispose.

[Magnetic resonance enterography: technique and indications. Findings in Crohn's disease]. / Enterografía por resonancia magnética: técnica e indicaciones. Hallazgos en la enfermedad de Crohn.

Radiology with oral contrast, or enteroclysis, have traditionally been the techniques of choice in the examination of the small intestine, due to the excellent visualisation of the mucosal pattern. However, the absence of extra-luminal information and the use of ionising radiation have replaced these examinations with sectional techniques which enable the abdominal cavity to be viewed with good resolution. Magnetic resonance enterography is a simple technique, with no ionising radiation, provided quality images, distends the intestinal lumen well by the administration of non-reabsorbable oral substances, minimises peristalsis, and establishes a protocol which includes sequences with intravenous contrast. These properties can be used in patients with Crohn's disease, achieving good diagnostic precision in the assessment of activity and monitoring of treatment, in intestinal obstruction, in the suspicion of small intestine tumours, and in paediatric patients due to it being harmless.

Electro-optic control of a PPLN-unpoled LiNbO3 boundary for low-voltage Q switching of an intracavity frequency-doubled Nd3+:YVO4 laser.

We present a simple technique to integrate an electro-optic Q switch in a periodically poled bulk lithium niobate crystal bounded by two unpoled (monodomain) regions. The technique exploits the high sensitivity to low applied electric fields of the total internal reflection condition in the periodic poled-unpoled boundary for the small grazing incidence angles associated with the diffraction of a focused Gaussian beam that propagates in the periodically poled region with its axis parallel to the boundary. When the arrangement is placed intracavity to a 1064 nm diode-pumped Nd(3+):YVO(4) laser, it performs simultaneously as a Q switch and as a second-harmonic generator, with Q switching starting at applied voltages as low as 1 V over a 500 microm thickness and with no additional optical elements.

Dual-wavelength green laser with a 4.5 THz frequency difference based on self-frequency- doubling in Nd3+ -doped aperiodically poled lithium niobate.

We report a dual-wavelength continuous-wave laser at 542.4 and 546.8 nm based on an Nd(3+)-doped aperiodically poled lithium niobate crystal. Two fundamental infrared (IR) wavelengths at 1084.8 and 1093.6 nm are simultaneously oscillated and self-frequency-doubled to green. The aperiodic domain distribution patterned in the crystal allows for quasi-phase matched self-frequency-doubling of both IR fundamentals while avoiding their sum-frequency mixing.

Estado actual de la formación de residentes de cirugía general en Colombia / Current state of general surgical training programs in Colombia

Introducción: La formación y certificación de Cirujanos es una preocupación creciente en los programas de Cirugía en Colombia, sin embargo no existe un diagnostico de la situación actual que permita un ajuste a los cambios constantes. Describimos en términos de carga académica y laboral el estado actual de los programas de residencia de Cirugía General inicialmente en la ciudad de Bogotá y en una segunda fase extenderlo al resto del país, desde la perspectiva de los residentes. Materiales y métodos: Se aplicó una encuesta a los residentes activos de Cirugía General en Bogotá y se tabularon los resultados en una base de datos Excel. Resultados: Se obtuvo información completa del 97.6 porciento de la población de residentes de Cirugía General en Bogotá, Clasificándola en cuatro variables: Datos sociodemográficos, información asistencial y académica, satisfacción y expectativa laboral. Conclusiones: El análisis de los datos muestra que los residentes de cirugía General se encuentran satisfechos con el programa donde realizan su especialización, sin embargo, no disponen de facilidades para que la investigación clínica termine en publicaciones, y el bienestar de los residentes no es una prioridad.

[Maternal-fetal staphylococcal toxic shock syndrome with chorioamniotitis]. / Choc toxique staphylococcique maternofoetal sur chorioamniotite.

We report a rare case of mother-infant pair with Staphylococcal Toxic Shock Syndrome (TSS). A term neonate was born by caesarean section for maternal septic syndrome during per-partum. He presented with respiratory distress complicated by pulmonary hypertension, skin rash, and multiple organ system involvement. Staphylococcus aureus was isolated from placenta, surface swabs and gastric aspirate. He received adapted antibiotics, respiratory support by high frequency ventilation and NO. The mother had shock, skin rash and inflammatory syndrome. Outcome was good in both cases. The isolate produced enterotoxin C and L. Shock, exanthematous disease and multi-organ involvement complicating a staphylococcal infection in neonate must lead to suspect a TSS.

Tumores Gástricos Estromales / Stromal gastric tumors

Los tumores gástricos de origen estromal constituyen un grupo especial de lesiones cuya definición patológica se ha establecido recientemente dada la evolución en las técnicas de análisis patológico. A pesar de su infrecuente presentación, es importante para el cirujano conocer su clasificación, características biológicas y las modalidades de tratamiento existente...

[The relation between the clinical symptoms and the findings on magnetic resonance in children with periventricular leukomalacia]. / Relación entre los síntomas clínicos y los hallazgos en resonancia magnética en niños con leucomalacia periventricular.

OBJECTIVES: To assess whether there is a relationship between the various clinical symptoms and imaging findings on MR in children with periventricular leukomalacia (PVLM). PATIENTS AND METHODS: We made a retrospective study of 41 consecutive paediatric patients, 19 boys and 22 girls, with an average age of 30.5+/-19 months (range 8 84 months) who had been diagnosed as having PVLM and studied using MR, recording imaging, clinical and epidemiological data. RESULTS: The MR images showed areas of gliosis in all the children (few foci in 68.3% and multiple foci in 31.7%), with cysts in 22%. The changes were seen mainly in the parietal and occipital regions, were bilateral and symmetrical in 80.5%, with ventricular dilatation in 75.6%, atrophy of the parenchyma in 48.8%, Wallerian degeneration in 7.3%, delay in myelination in 31.7%, lesions in the optic radiations in 9.8%, thalamus 12.2% and anomalous venous drainage in 2.4%. The overall degree of involvement on MR was severe in 43.9%, moderate in 31,7% and mild in 24.4%. There was a history of perinatal foetal distress in 56.8%, hyaline membrane disease in 40.5%, intracranial hemorrhage in 35.1%, psychomotor retardation in 58.5%, motor retardation in 29.3%, and squint in 22%. A significant relationship was found only between acute foetal distress and lateralization of the lesions (p= 0.038) and the presence of parenchymatous cysts (p= 0.024). CONCLUSION: The patients with a history of foetal distress had a greater tendency to symmetrical, bilateral involvement with cysts in the white matter of the brain. It was not possible to establish a model for classification of the overall involvement using MR and the data recorded. The imaging findings were not related overall to the patients symptoms.

Metastasis to the breast from extramammary malignancies: a report of four cases and a review of literature.

Breast metastases from extramammary tumours are rare with few cases reported. Four cases of metastasis to the breast are presented and the diagnostic problems of this condition are reviewed. Correlation between the histology of primary tumour and the cytology of breast metastatic tumour can avoid the surgical breast biopsy and unnecessary mastectomy. Metastasis to the breast has poor prognosis.

Redefining the significance of aneuploidy in the prognostic assessment of colorectal cancer.

The aberrant content of DNA, or aneuploidy, is a hallmark of tumor cells and may be associated with malignant potential. Based on the hypothesis that aneuploidy, as a form of genetic instability, results in an increased capability to generate cell heterogeneity, we investigated whether a comprehensive assessment of aneuploidy extent and degree might be a reliable indicator of tumor aggressiveness. DNA content was determined by flow cytometry in the infiltrating front of 131 paraffin-embedded primary colorectal carcinomas collected in a prospective design. Enrichment of tumor cells by sample microdissection resulted in neoplastic cell contents above 75%. An estimate of aneuploidy, the aneuploidy index (AI), was calculated as the tumor DNA content adjusted by the percentage of diploid and aneuploid cells in G0/G1. Thirty-nine tumors were diploid, 90 hyperdiploid, and 2 hypodiploid. The mean AI in aneuploid tumors was 1.20+/-0.17 and correlated with Dukes' stage and metastasis (p < 0.05). A high AI (receiver operating characteristic curve cutoff value greater than 1.14) predicted a poorer outcome in univariate (p = 0.004) and multivariate (p = 0.01) analyses. Based on these results, we postulate that aneuploidy is the molecular engine of progression in a subset of colorectal cancers, in which the AI seems to be a sensible and independent gauge of malignant potential. The AI determination may have prognostic application in colorectal cancer, especially in low-grade tumors, which might benefit from coadjuvant therapies.

A mitochondrial tRNA(Lys) gene mutation (T8316C) in a patient with mitochondrial myopathy, lactic acidosis, and stroke-like episodes.

We studied a patient with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes who had morphologically and biochemically abnormal muscle mitochondria. Molecular analysis revealed a T8316C transition in the mitochondrial DNA tRNA(Lys) gene. The mutation was homoplasmic in muscle from the proposita, heteroplasmic in her blood, and still less abundant in blood from her asymptomatic maternal relatives. The T8316C mutation affects a highly conserved base pair and was not found in controls, thus satisfying the accepted criteria for pathogenicity. Our data document the genetic heterogeneity in mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes syndrome, underlining that the same syndrome may be associated with mutations of different genes.

Klippel-Trenaunay syndrome: frequency of cerebral and cerebellar hemihypertrophy on MRI.

We examined 11 patients, clinically and radiographically diagnosed as having the Klippel-Trenaunay syndrome (KTS) by MRI. There were four females and seven males, aged 3-51 years (mean 21 years). Two had clear asymmetry of the cerebral and cerebellar hemispheres. The thickness of the grey matter was normal, without sulcation abnormalities, but the thickness of the white matter was increased; the size of the ipsilateral ventricle was normal. These patients had hypertrophy of the leg and a cutaneous haemangioma on the same side as the brain abnormality. No patient had an intracranial vascular malformation, unilateral megalencephaly, cerebral atrophy or hydrocephalus. The prevalence of cerebral hemihypertrophy in our series of patients with KTS was thus 18%.

Prognostic value of the expression of E-cadherin and beta-catenin in bladder cancer.

The purpose of this study was to assess the prognostic effect of the expression of E-cadherin, beta-catenin and CD44 adhesion molecules in bladder carcinoma. 22 superficial and 18 invasive bladder tumour samples were studied by immunohistochemistry. The median follow-up was 24 months (range: 1-50 months). Loss of E-cadherin and beta-catenin immunoreactivity was found in 14 (35%) and 17 (43%) tumours, respectively, and was significantly associated with invasiveness, high grade and p53 overexpression. There was no correlation between CD44 variant expression and clinicopathological findings. Loss of E-cadherin expression was an independent predictor of poor survival in a multivariate analysis, when assessed with age, grade, stage and p53 status (hazards ratio adjusted (HRa)=4.45 [95% confidence interval (CI), 1.06-18.63]). This effect was particularly augmented in patients with invasive bladder cancer. When expression of E-cadherin and beta-catenin were evaluated simultaneously, loss of immunoreactivity of both proteins was a strong predictor of poor survival (HRa=13.06 [95% CI, 0.95-178.55]). The same pattern was found when progression-free survival in relation to these variables was assessed. In conclusion, assessment of E-cadherin and beta-catenin immunoreactivity may be a useful prognostic marker in bladder cancer complementary to established prognostic factors.