Osteochondritis dissecans of the patella in a XVII century player of the Florentine historic kickball.

We report a case of osteochondritis dissecans in the patella of Francesco de' Medici, Prince of Capistrano, who lived from 1594 to 1614. He was known to play Florentine kick ball, a precursor of Rugby and American football, and speculate that trauma from this activity may have led to the lesion.

Diffuse idiopathic skeletal hyperostosis in the Medici, Grand Dukes of Florence (XVI century).

Diffuse idiopathic skeletal hyperostosis (DISH) is a common systemic disorder characterised by the ossification of the anterior longitudinal spinal ligament involving at least three contiguous vertebrae and by diffuse extraspinal enthesopathies. The condition is associated with the male sex and with advanced age; its aetiology is uncertain, but seems to be related to obesity and diabetes. The most recent studies in archaeological series demonstrated a relation between high social status and the incidence of DISH. The present study examines two cases of DISH found amongst the members of the Medici family buried in the Basilica of San Lorenzo in Florence. The skeletons of the Grand Dukes Cosimo I (1519-1574) and his son Ferdinand I (1549-1609) showed the typical features of the condition. This result is related to the obesity of the Grand Dukes, attested by the written and artistic sources, and to the protein-based alimentation demonstrated by a paleonutritional study, thus furnishing further evidence to the significance of DISH as a life style.

Scenes from the past: the Medici Project: radiographic survey.

The remains of 12 members of the grand ducal (junior) branch of the Florentine Medici family were exhumed in 2003 as part of the Medici Project, a multidisciplinary study whose aim was to investigate the lifestyles, health status, and possible causes of death of members of one of the richest, most powerful families of the Italian Renaissance. Digital radiography and orthopantomography were performed on the skeletal remains of individuals who lived between 1562 and 1666. The observed bone malformations, deformities, and changes (degenerative, metabolic, and dental) challenge traditional views, based on portraits and historical accounts, about the appearance and lifestyle of some family members. Moreover, the occurrence of a constellation of bone changes related to diabetes (osteoporosis, osteoarthritis, diffuse idiopathic skeletal hyperostosis, cranial hyperostosis, and crystalline arthropathy) suggests that this metabolic disease was common in the grand ducal branch of the Medici family.

Transient hepatic attenuation differences and focal liver lesions: sump effect due to primary arterial hyperperfusion.

OBJECTIVE: To analyze at computed tomography (CT) examination the "sump effect," a particular type of transient hepatic attenuation differences, related primarily to an increase in arterial flow without any accompanying decrease in portal flow. METHODS: We retrospectively evaluated all biphasic upper abdomen CT examinations (1283 in 807 patients) performed from the year 2003 to the year 2006 and selected and organized those with at least 1 transient hepatic attenuation differences. Of these, we enrolled patients with lobar/multisegmental arterializations surrounding focal lesion(s), without CT portal hypoperfusion signs, in the study group. We assessed histology, number, site, diameter, and volume of causing focal lesion(s); site, extension, and attenuation of arterial area; greater visibility of feeding artery branches ipsilateral to causal focal lesion; and presence of aberrant left hepatic artery. Thirty patients with normal liver represented the control group. RESULTS: Fifteen of the 99 patients with transient hepatic attenuation differences presented with sump effect. In our series, this phenomenon was always related to hypervascular inflammatory and benign lesion(s) with overall average diameter of 8 +/- 4 cm inscribed in arterial area. Attenuation of arterial enhanced areas were significantly higher than the contralateral parenchyma and control patients' parenchyma, with frequent hypertrophy of ipsilateral arterial feeding branches and/or aberrant left hepatic artery visibility. CONCLUSIONS: Siphonage seems to be primary hyperperfusion area determined by arterial bed enlargement, induced by inscribed large hypervascular inflammatory/benign lesion(s).

The 'gout' of the Medici, Grand Dukes of Florence: a palaeopathological study.

OBJECTIVE: According to the written sources several members of the famous Medici family of Renaissance Florence suffered from an arthritic disease, called 'gout' by contemporary physicians; a palaeopathological study allowed verification of the true nature of the 'gout of the Medici' referred by archive document data. METHODS: The skeletal remains of the Grand Dukes and their families, buried in the Basilica of San Lorenzo in Florence, were examined macroscopically and submitted to X-ray investigation. RESULTS: Out of 15 investigated individuals, two cases of diffuse idiopathic skeletal hyperostosis (DISH), with ossification of the anterior longitudinal ligament and massive hyperostotic changes of the extra-spinal ligaments, were detected in the skeletons of the Grand Dukes Cosimo I (1519-74) and his son Ferdinand I (1549-1609). The left foot of Ferdinand also revealed typical lesions of the uratic gout, confirming the archive data, which describe the disease in detail. CONCLUSIONS: The association between DISH and elite status, highlighted in recent research, receives further confirmation in the present study, furnishing evidence to the significance of this disorder as a lifestyle indicator, linked specifically with a high-caloric diet, consequent obesity and type II diabetes mellitus. Furthermore, the coexistence between DISH and gout observed in Ferdinand represents the first documentation of this association in the palaeopathological literature.

CT colonography after incomplete colonoscopy in subjects with positive faecal occult blood test.

AIM: To report our experience with computed tomography colonography (CTC) systematically performed in subjects with positive faecal occult blood test (FOBT) and an incomplete colonoscopy in the setting of a population-based screening for colorectal cancer (CRC). METHODS: From April 2006 to April 2007, 43290 individuals (age range 50-70) who adhered to the regional screening program for the prevention of CRC underwent immunochemical FOBT. FOBT was positive in 1882 subjects (4.3%). 1463 (77.7%) of these subjects underwent colonoscopy, 903 performed in a single center. Of 903 colonoscopies 65 (7.2%) were incomplete. Forty-two of these subjects underwent CTC. CTC was performed with a 16-MDCT scanner after standard bowel prep (polyethyleneglycole) in both supine and prone position. Subjects whose CTC showed polyps or masses were referred to the endoscopist for repeat colonoscopy under sedation or underwent surgery. Per-lesion and per-segment positive predictive values (PPV) were calculated. RESULTS: Twenty-one (50%) of 42 CTCs showed polyps or masses. Fifty-five of these subjects underwent a repeat colonoscopy, whereas 2 subjects underwent surgery for colonic masses of indeterminate nature. Four subjects refused further examinations. CTC correctly identified 2 colonic masses and 20 polyps. PPV for masses or polyps greater than 9 mm was of 87.5%. Per-lesion and per-segment PPV were, respectively, 83.3% and 83.3% for polyps greater or equal to 10 mm, and 77.8% and 85.7% for polyps of 6-9 mm. CONCLUSION: In the context of a screening program for CRC based on FOBT, CTC shows high per-segment and per-lesion PPV for colonic masses and polyps greater than 9 mm. Therefore, CTC has the potential to become a useful technique for evaluation of the non visualized part of the colon after incomplete colonoscopy.

The influence of diffusion- and relaxation-related factors on signal intensity: an introductive guide to magnetic resonance diffusion-weighted imaging studies.

In magnetic resonance diffusion-weighted imaging, signal intensity is influenced simultaneously by temperature, diffusivity, b value, pseudodiffusion, macroscopic motion, and T2-weighted intensity value. The purpose of this pictorial essay is to discuss and exemplify the influence that such factors and the related modifications have on signal intensity. Apparent diffusion coefficient, shine-through and pseudodiffusion will also be examined to show how T2-weighted signal intensity value and nondiffusional intravoxel incoherent motion can affect the diffusion-weighted imaging.

Bodies of stone: Girolamo Segato (1792-1836).

The life, activity and specimens of Girolamo Segato (Sospirolo 1792--Firenze 1836), as well as the mystery still surrounding his petrifaction method are outlined in this paper with the aim of shedding some light on one of the most controversial naturalists of the 19th century. Even if after his death many preparations became scattered or even destroyed, the greatest nucleus of them is now collected and exhibited in the Museum of the Department of Anatomy in Florence. Special attention has been given to the description of one of the most famous "pieces", a female head, recently added to the collection, coming from Museo Civico of Belluno. This sample, submitted to conventional Rx analysis and CT Scan Tomography, displays an outstanding injection of the thinnest peripheral blood vessels.

The Medici Project first anthropological and paleopathological results of the exploration of the Medici tombs in Florence.

Within the framework of the Medici Project, a paleopathological team of experts from the University of Pisa, the University of Florence and the Superintendence for Florentine Museums, is carrying out a study on 49 tombs of some of the Medici family members (16th-18th centuries) housed in the so-called Basilica of San Lorenzo in Florence. The project involves disciplines such as paleopathology, funerary archeology, physical anthropology, paleonutrition, parasitology, histology, histochemistry, immuno-histochemistry, electron microscopy, molecular biology, and identification of ancient pathogens. The most recent biomedical imaging technologies have been employed to obtain as much information as possible about the genetic make-up, eating habits, life styles and diseases of these important rulers of Renaissance Florence. The first anthropological and paleopathological results are presented here.

Subcortical damage and cortical functional changes in men and women with Fabry disease: a multifaceted MR study.

PURPOSE: To prospectively compare brain magnetic resonance (MR) imaging and hydrogen 1 (1H) MR spectroscopy findings and to use functional MR imaging to explore the patterns of brain activation in men and women with Fabry disease (FD). MATERIALS AND METHODS: Eight men and eight women with FD (mean age, 38.8 years +/- 13.9 [standard deviation]) with absent or mild neurologic deficit and 16 healthy control subjects (eight men and eight women; mean age, 42.7 years +/- 15.3) gave informed consent to participate in the study, which was approved by the local ethical committee. Patients and control subjects underwent MR imaging, 1H MR spectroscopy of the frontal cortex and subcortical white matter, and functional MR imaging during repetitive flexion-extension of the last four fingers of the right hand. Extent of cerebral white matter damage was rated on fluid-attenuated inversion recovery MR images by using a visual score. Areas of activation were identified by using statistical parametric mapping software and the adoption of a height threshold of P < .001 (uncorrected) and an extent threshold of P < .05 (corrected). RESULTS: Men and women with FD showed a similar distribution of cerebral white matter changes, lacunar and cortical infarcts, small hemorrhages, and vertebrobasilar dolichoectasia. No significant (P > .05) difference was observed between patients with FD and control subjects for concentration of N-acetylaspartate, creatine, and choline. During the motor task, patients showed recruitment of additional cortical areas in comparison with control subjects. Increased activation of the contralateral sensorimotor area correlated (P = .002) with extent of white matter damage. CONCLUSION: Subcortical ischemic changes in men and women with FD are similar and are associated with increased recruitment of the sensorimotor network during a simple motor task, which might limit the functional effect of the white matter small-vessel disease.

Operator-dependent reproducibility of size measurements of small phantoms and lung nodules examined with low-dose thin-section computed tomography.

OBJECTIVE: We sought to assess the reproducibility of size measurements of small lung nodules examined with low-dose thin-section computed tomography (LDTSCT). MATERIALS AND METHODS: Three radiologists measured volume with a semiautomatic tool and diameters manually of 20 (equivalent diameter range, 5.3-11 mm) phantom nodules and 37 (mean diameter range, 5-8.5 mm) lung nodules in subjects undergoing LDTSCT. RESULTS: In phantoms, the worst 95% limits of agreement (95% LA) for volume were -3.0% and 3.0% within operator and -3.1% and 2.8% between operators. The coefficient of repeatability (CR) for diameter ranged between 0.51 and 0.67 mm within operator and the 95% LA were from -0.71 to 0.71 mm between operators. In nodules, the worst intraoperator 95% LA for volume were -14.4% and 17.6% within operator and -13.1% and 14.2% between operators. The CR for diameter ranged between 0.48 and 0.73 mm within operator and the 95% LA were from -1.16 to 1.16 mm between operators. CONCLUSION: Operator-dependent variability of size measurements of small nodules examined with LDTSCT is not negligible and should be considered in lung cancer-screening studies.

Thin-section and low-dose volumetric computed tomographic densitometry of the lung in systemic sclerosis.

OBJECTIVE: To correlate lung density measurements with the results of visual assessment of thin-section computed tomography (CT) and of pulmonary function tests (PFT) in Systemic Sclerosis (SSc). METHODS: Thirty-nine SSc patients underwent sequential thin-section CT and spiral low-dose whole-lung acquisitions. The thin-section CT scans were evaluated with a dedicated visual scale. Mean lung density, skewness, and kurtosis were calculated from the lung density histogram. In addition from the spiral low-dose acquisition, the lung volume was computed. The visual score, the densitometric parameters, and the lung volume were correlated with the PFT. RESULTS: Mean lung density, skewness, and kurtosis computed from thin-section (R = 0,66; R = -0,74; R = -0,75) and low-dose volumetric (R = 0,72; R = -0,71; R = -0,71) CT and the lung volume (R = -0.54) correlated with the visual score. Densitometric values and lung volume consistently better correlated with PFT than the visual score. CONCLUSIONS: In SSc the histogram results are more closely correlated to PFT than the visual score. The low-dose spiral CT seems ideal for longitudinal studies.

Risk-benefit analysis of X-ray exposure associated with lung cancer screening in the Italung-CT trial.

OBJECTIVE: Prior analyses of X-ray exposures in lung cancer screening with CT considered the basic acquisition technique in single-detector scanners and the effects of a lifetime screening regimen, whereas the potential benefit in terms of lives saved was not addressed. MATERIALS AND METHODS: We determined the total-body effective dose of different acquisition techniques for one single-detector and one MDCT scanner and made projections about the cumulative radiation exposure to smokers undergoing four annual CT examinations on the same scanners in the Italung-CT Trial. Combining these data with estimates of radiation-induced fatal cancer and of the benefit of screening, we calculated the risk-benefit ratio for participants in the trial, ex-smokers, and never-smokers. RESULTS: The cumulative effective doses per 1,000 subjects were 3.3 Sv using an MDCT scanner and 5.8 or 7.1 Sv using a single-detector scanner. Potential fatal cancers associated with radiation exposure were 0.11 per 1,000 subjects for MDCT scanners and 0.20 or 0.24 for single-detector scanners, which is about 10-100 times lower than the number of expected lives saved by screening assuming a 20-30% lung cancer-specific mortality reduction in current smokers. They were, however, of similar magnitude to the lives saved by screening in never-smokers and former smokers assuming a 10% efficacy of screening. CONCLUSION: MDCT is associated with lower radiation doses than single-detector CT technology. The risk of radiation dose in the Italung-CT Trial is compensated for by the expected benefit. CT screening for lung cancer should not be offered to never-smokers, whereas its recommendation in former smokers is debatable.

Detection and assessment of coronary artery anomalies by three-dimensional magnetic resonance coronary angiography.

BACKGROUND: Coronary artery anomalies (CAAs) are a relatively rare condition usually diagnosed in vivo by conventional angiography. In the past few years Magnetic resonance coronary angiography (MRCA) has been used to detect CAAs and found to be highly accurate. No data is available regarding the ability of MRCA to detect previously not suspected anomalies. METHODS: We prospectively analyzed the origin and course of 336 patients undergoing a diagnostic Cardiovascular magnetic resonance (CMR) study. After the completion of a standard examination a navigator-echo 3D-MRCA low-quality scan was used in all the cases to rule out CAAs. The high-quality MRCA was applied only if an abnormal coronary arterial tree was seen. RESULTS: Nineteen patients with CAAs (12 men, 7 women; mean age, 53+/-18 years) were identified by MRCA. Six out of the 19 CAAs subjects had already been detected by other means (coronary angiography in 5, and transesophageal echocardiography in 1 case). However in none of them a complete anatomical assessment was achieved. In 13 patients CAAs were an unexpected and new finding. MRCA was able to assess the origin and proximal course of the anomalous artery in all the cases. CONCLUSIONS: MRCA is able to detect the presence and anomalous course of CAAs. Besides offering precise information about already suspected CAAs, MRCA can identify anomalies previously not suspected. This study suggests a potential role for MRCA as a screening tool for CAAs in young patients with angina, ventricular arrhythmias, or unexplained syncope as well as in highly competitive athletes.

Diffusion-weighted MR of the brain: methodology and clinical application.

Clinical diffusion magnetic resonance (MR) imaging in humans started in the last decade with the demonstration of the capabilities of this technique of depicting the anatomy of the white matter fibre tracts in the brain. Two main approaches in terms of reconstruction and evaluation of the images obtained with application of diffusion sensitising gradients to an echo planar imaging sequence are possible. The first approach consists of reconstruction of images in which the effect of white matter anisotropy is averaged -- known as the isotropic or diffusion weighted images, which are usually evaluated subjectively for possible areas of increased or decreased signal, reflecting restricted and facilitated diffusion, respectively. The second approach implies reconstruction of image maps of the apparent diffusion coefficient (ADC), in which the T2 weighting of the echo planar diffusion sequence is cancelled out, and their objective, i.e. numerical, evaluation with regions of interest or histogram analysis. This second approach enables a quantitative and reproducible assessment of the diffusion changes not only in areas exhibiting signal abnormality in conventional MR images but also in areas of normal signal. A further level of image post-processing requires the acquisition of images after application of sensitising gradients along at least 6 different spatial orientations and consists of computation of the diffusion tensor and reconstruction of maps of the mean diffusivity (D) and of the white matter anisotropic properties, usually in terms of fractional anisotropy (FA). Diffusion-weighted imaging is complementary to conventional MR imaging in the evaluation of the acute ischaemic stroke. The combination of diffusion and perfusion MR imaging has the potential of providing all the information necessary for the diagnosis and management of the individual patient with acute ischaemic stroke. Diffusion-weighted MR, in particular quantitative evaluation based on the diffusion tensor, has a fundamental role in the assessment of brain maturation and of white matter diseases in the fetus, in the neonate and in the child. Diffusion MR imaging enables a better characterisation of the lesions demonstrated by conventional MR imaging, for instance in the hypoxic-ischaemic encephalopathy, in infections and in the inherited metabolic diseases, and is particularly important for the longitudinal evaluation of these conditions. Diffusion-weighted MR imaging has an established role in the differential diagnosis between brain abscess and cystic tumour and between epidermoid tumour and arachnoid cyst. On the other hand, the results obtained with diffusion MR in the characterisation of type and extension of glioma do not yet allow decision making in the individual patient. Diffusion is one of the most relevant MR techniques to have contributed to a better understanding of the pathophysiological mechanisms of multiple sclerosis (MS). In fact, it improves the specificity of MR in characterising the different pathological substrata underlying the rather uniform lesion appearance on the conventional images and enables detection of damage in the normal-appearing white and grey matter. In MS patients the ADC or D values in the normal-appearing white matter are increased as compared to control values, albeit to a lesser degree than in the lesions demonstrated by T2-weighted images. In addition, the D of the normal appearing grey matter is increased in MS patients and this change correlates with the cognitive deficit of these patients. Histogram analysis in MS patients shows that the peak of the brain D is decreased and right-shifted, reflecting an increase of its value, and the two features correlate with the patient's clinical disability. Ageing is associated to a mild but significant increase of the brain ADC or D which is predominantly due to changes in the white matter. Region of interest and histogram studies have demonstrated that D or ADC are increased in either the areas of leukoaraiosis or the normal-appearing white matter in patients with inherited cerebral autosomal dominant arteriopathy with subcortical infarcts and stroke or sporadic ischaemic leukoencephalopathy. Diffusion changes might be a more sensitive marker for progression of the disease than conventional imaging findings. In neurodegenerative diseases of the central nervous system such as Alzheimer's disease, Huntington's disease, hereditary ataxias and motor neuron disease, quantitative diffusion MR demonstrates the cortical and subcortical grey matter damage, which is reflected in a regional increase of D or ADC, but also reveals the concomitant white matter changes that are associated with an increase in D or ADC and decrease in FA. In all these diseases the diffusion changes are correlated to the clinical deficit and are potentially useful for early diagnosis and longitudinal evaluation, especially in the context of pharmacological trials.

Chronic obstructive pulmonary disease: thin-section CT measurement of airway wall thickness and lung attenuation.

PURPOSE: To prospectively evaluate airway wall thickness and lung attenuation at spirometrically gated thin-section computed tomography (CT) in patients with chronic obstructive pulmonary disease (COPD) and to correlate gated CT findings with pulmonary function test (PFT) results. MATERIALS AND METHODS: The ethical committee approved the study, and all patients gave informed consent. Forty-two consecutive patients with COPD (20 with and 22 without chronic bronchitis [CB]) underwent gated thin-section CT and PFTs on the same day. The percentage wall area (PWA) and the thickness-to-diameter ratio (TDR) for all depicted bronchi that were round and larger than 2 mm in diameter, the mean lung attenuation (MLA), and the pixel index (PI) at -950 HU were determined. The reproducibility of the airway measurements was preliminarily tested by performing a five-trial examination in a patient with COPD and in a control patient. Differences in airway and lung attenuation measurements between the patients with and those without CB were evaluated at Mann-Whitney U testing. Simple and multiple regression analyses were used to assess the correlation between thin-section CT and PFT measurements. RESULTS: The mean intraoperator coefficient of variation for airway measurements was 7.8% (range, 3.8%-13.4%). An average of nine bronchi per patient were assessed. Patients with CB had significantly higher PWAs, TDRs, and MLAs and significantly lower PIs than patients without CB (P < .05 for all values). The combination of PWA, TDR, and PWA normalized to body weight correlated significantly (P < .05) with the forced expiratory volume in 1 second-to-slow vital capacity ratio and the diffusing capacity of the lung for carbon monoxide in patients with but not in patients without CB. PFT results correlated better with MLA and PI in patients without CB. CONCLUSION: Bronchial wall measurements differ between patients who have COPD with CB and those who have COPD without CB. The correlation between airway dimensions and indexes of airway obstruction in patients with COPD and CB indicates that the bronchial tree is the site of anatomic-functional alterations in this patient group.

Spirometric-gated computed tomography quantitative evaluation of lung emphysema in chronic obstructive pulmonary disease: a comparison of 3 techniques.

OBJECTIVE: To compare the quantitative assessment of pulmonary emphysema with spirometric-gated computed tomography (gated CT) using 3 different acquisition techniques and to determine if low-current spiral CT could be used effectively to quantitate emphysema. METHODS: Eleven patients with chronic obstructive pulmonary disease (COPD) underwent gated CT and pulmonary function tests (PFTs). Spiral whole-lung 10-mm collimation acquisitions at standard (146 mAs) and low (43 mAs) current and sequential 3-slice 1-mm collimation high-resolution computed tomography (HRCT) acquisitions at standard current were obtained at 90% of the patient's vital capacity. The mean lung density (MLD) and the pixel index (PI) derived from the 3 data sets were compared using one-way analysis of variance and correlated with PFTs using linear regression. Moreover, the radiation dose associated with each technique was measured. RESULTS: The MLDs were not significantly different. The PIs calculated from the standard- and low-current spiral acquisitions were similar, and both were significantly different from that of HRCT. The MLDs correlated with the PFTs in standard-current spiral and HRCT but not in low-current spiral acquisitions, whereas the PIs correlated with the PFTs in all 3 techniques. High-resolution computed tomography implied the lowest dose (0.08 mSv) compared with low-current (1.2 mSv) and standard-current (4 mSv) spiral techniques. CONCLUSIONS: Low- and standard-dose spiral CT provides similar lung density data in COPD. The combination of low-dose whole-lung spiral CT and 3-slice HRCT represents the best compromise between the amount of information provided and radiation exposure to the patient and could be substituted for standard-dose spiral CT for quantitative evaluation of COPD.