Determinants of acute kidney injury during high-power mechanical ventilation: secondary analysis from experimental data.

BACKGROUND: The individual components of mechanical ventilation may have distinct effects on kidney perfusion and on the risk of developing acute kidney injury; we aimed to explore ventilatory predictors of acute kidney failure and the hemodynamic changes consequent to experimental high-power mechanical ventilation. METHODS: Secondary analysis of two animal studies focused on the outcomes of different mechanical power settings, including 78 pigs mechanically ventilated with high mechanical power for 48 h. The animals were categorized in four groups in accordance with the RIFLE criteria for acute kidney injury (AKI), using the end-experimental creatinine: (1) NO AKI: no increase in creatinine; (2) RIFLE 1-Risk: increase of creatinine of > 50%; (3) RIFLE 2-Injury: two-fold increase of creatinine; (4) RIFLE 3-Failure: three-fold increase of creatinine; RESULTS: The main ventilatory parameter associated with AKI was the positive end-expiratory pressure (PEEP) component of mechanical power. At 30 min from the initiation of high mechanical power ventilation, the heart rate and the pulmonary artery pressure progressively increased from group NO AKI to group RIFLE 3. At 48 h, the hemodynamic variables associated with AKI were the heart rate, cardiac output, mean perfusion pressure (the difference between mean arterial and central venous pressures) and central venous pressure. Linear regression and receiving operator characteristic analyses showed that PEEP-induced changes in mean perfusion pressure (mainly due to an increase in CVP) had the strongest association with AKI. CONCLUSIONS: In an experimental setting of ventilation with high mechanical power, higher PEEP had the strongest association with AKI. The most likely physiological determinant of AKI was an increase of pleural pressure and CVP with reduced mean perfusion pressure. These changes resulted from PEEP per se and from increase in fluid administration to compensate for hemodynamic impairment consequent to high PEEP.

Dual-Energy CT in Oncologic Imaging.

Dual-energy CT (DECT) is an innovative technology that is increasingly widespread in clinical practice. DECT allows for tissue characterization beyond that of conventional CT as imaging is performed using different energy spectra that can help differentiate tissues based on their specific attenuation properties at different X-ray energies. The most employed post-processing applications of DECT include virtual monoenergetic images (VMIs), iodine density maps, virtual non-contrast images (VNC), and virtual non-calcium (VNCa) for bone marrow edema (BME) detection. The diverse array of images obtained through DECT acquisitions offers numerous benefits, including enhanced lesion detection and characterization, precise determination of material composition, decreased iodine dose, and reduced artifacts. These versatile applications play an increasingly significant role in tumor assessment and oncologic imaging, encompassing the diagnosis of primary tumors, local and metastatic staging, post-therapy evaluation, and complication management. This article provides a comprehensive review of the principal applications and post-processing techniques of DECT, with a specific focus on its utility in managing oncologic patients.

Leiomyoma or sarcoma? MRI performance in the differential diagnosis of sonographically suspicious uterine masses.

PURPOSE: To assess the diagnostic performance of MRI in distinguishing between leiomyomas and malignant/potentially malignant mesenchymal neoplasms in patients with rapidly enlarging/sonographically suspicious uterine masses. METHODS: IRB-approved retrospective study including 88 patients (51 ± 11 years) who underwent MRI for rapidly enlarging/sonographically suspicious uterine mass at our Institution between January 2016 and December 2021, followed by surgery or >12 months follow-up. Qualitative image analysis was independently performed by 2 radiologists and included lesion's margins (sharp/irregular), architecture (homogeneous/inhomogeneous), presence of endometrial infiltration (yes/no), necrotic areas (yes/no), hemorrhagic areas (yes/no), predominant signal intensity on T1-WI, T2-WI, CE T1-WI, DWI, and ADC map. The same radiologists performed quantitative image analysis in consensus, which included lesion's maximum diameter, lesion/myometrium signal intensity ratio on T2-WI and CE T1-weighted images, lesion/endometrium signal intensity ratio on DWI and ADC map and necrosis percentage. Lesions were classified as benign or malignant. Imaging findings were compared with pathology and/or follow-up. RESULTS: After surgery (52/88 patients) or follow-up (36/88 patients, 33 ± 20 months), 83/88 (94.3%) lesions were classified as benign and 5/88 (5.7%) as malignant/potentially malignant. Presence of necrotic areas, high necrosis percentage, hyperintensity on DWI and high lesion/endometrium DWI signal intensity ratio were significantly associated with malignant/potentially malignant lesions (p = 0.027, 0.002, 0.008 and 0.015, respectively). The two readers identified malignant/potentially malignant lesions with 95.5% accuracy, 80.0% sensitivity, 96.4% specificity, 57.1 % PPV, 93.3% NPV. CONCLUSION: MRI has high accuracy in identifying malignant/potentially malignant myometrial masses. In everyday practice, however, MRI positive predictive value is relatively low given the low pre-test malignancy probability.

Budget impact analysis: comparing the costs of nusinersen and risdiplam in the treatment of type 3 spinal muscular atrophy patients.

OBJECTIVES: The aim of the budget impact analysis (BIA) was to determine the economic impact of introducing risdiplam in the treatment of type 3 spinal muscular atrophy (SMA) patients in a rare diseases reference centre on a 3-year time horizon, as compared with nusinersen. METHODS: Public databases were used to estimate the target population. Two market scenarios were assessed over a 3-year time horizon: with nusinersen and with the introduction of risdiplam. Drug acquisition and administration costs were considered. BIA is calculated as the difference between scenarios with nusinersen - scenario with risdiplam. RESULTS: The introduction of risdiplam would generate a 3-year saving of €3411.50. There could be a saving in the administration of risdiplam in the treatment of patients under the age of 2 with a weight of 5 kg (€26 382.08). CONCLUSION: The BIA shows the overlapping costs of these therapies, although the oral administration of risdiplam could be a decisive factor for the therapeutical switch from nusinersen.

Machine learning predicts lung recruitment in acute respiratory distress syndrome using single lung CT scan.

BACKGROUND: To develop and validate classifier models that could be used to identify patients with a high percentage of potentially recruitable lung from readily available clinical data and from single CT scan quantitative analysis at intensive care unit admission. 221 retrospectively enrolled mechanically ventilated, sedated and paralyzed patients with acute respiratory distress syndrome (ARDS) underwent a PEEP trial at 5 and 15 cmH2O of PEEP and two lung CT scans performed at 5 and 45 cmH2O of airway pressure. Lung recruitability was defined at first as percent change in not aerated tissue between 5 and 45 cmH2O (radiologically defined; recruiters: Δ45-5non-aerated tissue > 15%) and secondly as change in PaO2 between 5 and 15 cmH2O (gas exchange-defined; recruiters: Δ15-5PaO2 > 24 mmHg). Four machine learning (ML) algorithms were evaluated as classifiers of radiologically defined and gas exchange-defined lung recruiters using different models including different variables, separately or combined, of lung mechanics, gas exchange and CT data. RESULTS: ML algorithms based on CT scan data at 5 cmH2O classified radiologically defined lung recruiters with similar AUC as ML based on the combination of lung mechanics, gas exchange and CT data. ML algorithm based on CT scan data classified gas exchange-defined lung recruiters with the highest AUC. CONCLUSIONS: ML based on a single CT data at 5 cmH2O represented an easy-to-apply tool to classify ARDS patients in recruiters and non-recruiters according to both radiologically defined and gas exchange-defined lung recruitment within the first 48 h from the start of mechanical ventilation.

Langerhans cell histiocytosis: unusual dorsal spine localization in an adult male.

This case report describes the clinical, imaging, and pathological features of a case of Langerhans cell histiocytosis affecting a patient suffering from chronic thoracic spine pain. Spinal localizations of Langerhans cell histiocytosis have been rarely described and they are usually characterized by involvement of vertebral bodies with osteolytic lesions. Our case presented with several unusual features that delayed the diagnosis, including the age of patient and the involvement of left T10 costovertebral junction with relative sparing of vertebral body and costal bone. The clues for diagnosis were represented by increased signal intensity both on T 2W fat-saturated and T 1W images after administration of gadolinium. The diagnosis was finally confirmed by means of percutaneous biopsy with subsequent histological/immunohistochemical study.

Imaging of paraduodenal pancreatitis: A systematic review.

BACKGROUND: Paraduodenal pancreatitis (PP) represents a diagnostic challenge, especially in non-referral centers, given its potential imaging overlap with pancreatic cancer. There are two main histological variants of PP, the cystic and the solid, with slightly different imaging appearances. Moreover, imaging findings in PP may change over time because of disease progression and/or as an effect of its risk factors exposition, namely alcohol intake and smoking. AIM: To describe multimodality imaging findings in patients affected by PP to help clinicians in the differential diagnosis with pancreatic cancer. METHODS: The systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-analyses 2009 guidelines. A Literature search was performed on PubMed, Embase and Cochrane Library using (groove pancreatitis [Title/Abstract]) OR (PP [Title/Abstract]) as key words. A total of 593 articles were considered for inclusion. After eliminating duplicates, and title and abstract screening, 53 full-text articles were assessed for eligibility. Eligibility criteria were: Original studies including 8 or more patients, fully written in English, describing imaging findings in PP, with pathological confirmation or clinical-radiological follow-up as the gold standard. Finally, 14 studies were included in our systematic review. RESULTS: Computed tomography (CT) findings were described in 292 patients, magnetic resonance imaging (MRI) findings in 231 and endoscopic ultrasound (EUS) findings in 115. Duodenal wall thickening was observed in 88.8% of the cases: Detection rate was 96.5% at EUS, 91.0% at MRI and 84.1% at CT. Second duodenal portion increased enhancement was recognizable in 76.3% of the cases: Detection rate was 84.4% at MRI and 72.1% at CT. Cysts within the duodenal wall were detected in 82.6% of the cases: Detection rate was 94.4% at EUS, 81.9% at MRI and 75.7% at CT. A solid mass in the groove region was described in 40.9% of the cases; in 78.3% of the cases, it showed patchy enhancement in the portal venous phase, and in 100% appeared iso/hyperintense during delayed phase imaging. Only 3.6% of the lesions showed restricted diffusion. The prevalence of radiological signs of chronic obstructive pancreatitis, namely main pancreatic duct dilatation, pancreatic calcifications, and pancreatic cysts, was extremely variable in the different articles. CONCLUSION: PP has peculiar imaging findings. MRI is the best radiological imaging modality for diagnosing PP, but EUS is more accurate than MRI in depicting duodenal wall alterations.

Pathophysiology of COVID-19 pneumonia and respiratory treatment.

COVID-19 pandemic has seen an unprecedented number of patients presenting with acute respiratory distress syndrome to the intensive care units all over the world. Between August and November 2022, we performed research on PubMed screening all publications on COVID-19 disease and respiratory failure and its treatment. In this review we focused on COVID-19 most common manifestations concerning lung function. The respiratory infection develops in three broad phases: early, intermediate, and late. The mainstay of the disease is the frequent presence of severe hypoxemia associated - at least at the beginning - to a near normal lung mechanics and PaCO2 tension. The management of symptomatic patients, progressing through these temporal phases, is not possible without understanding the pathophysiology underlying the respiratory manifestation.

High- versus Low-Flow Extracorporeal Respiratory Support in Experimental Hypoxemic Acute Lung Injury.

Rationale: In the EOLIA (ECMO to Rescue Lung Injury in Severe ARDS) trial, oxygenation was similar between intervention and conventional groups, whereas [Formula: see text]e was reduced in the intervention group. Comparable reductions in ventilation intensity are theoretically possible with low-flow extracorporeal CO2 removal (ECCO2R), provided oxygenation remains acceptable. Objectives: To compare the effects of ECCO2R and extracorporeal membrane oxygenation (ECMO) on gas exchange, respiratory mechanics, and hemodynamics in animal models of pulmonary (intratracheal hydrochloric acid) and extrapulmonary (intravenous oleic acid) lung injury. Methods: Twenty-four pigs with moderate to severe hypoxemia (PaO2:FiO2 ⩽ 150 mm Hg) were randomized to ECMO (blood flow 50-60 ml/kg/min), ECCO2R (0.4 L/min), or mechanical ventilation alone. Measurements and Main Results: [Formula: see text]o2, [Formula: see text]co2, gas exchange, hemodynamics, and respiratory mechanics were measured and are presented as 24-hour averages. Oleic acid versus hydrochloric acid showed higher extravascular lung water (1,424 ± 419 vs. 574 ± 195 ml; P < 0.001), worse oxygenation (PaO2:FiO2 = 125 ± 14 vs. 151 ± 11 mm Hg; P < 0.001), but better respiratory mechanics (plateau pressure 27 ± 4 vs. 30 ± 3 cm H2O; P = 0.017). Both models led to acute severe pulmonary hypertension. In both models, ECMO (3.7 ± 0.5 L/min), compared with ECCO2R (0.4 L/min), increased mixed venous oxygen saturation and oxygenation, and improved hemodynamics (cardiac output = 6.0 ± 1.4 vs. 5.2 ± 1.4 L/min; P = 0.003). [Formula: see text]o2 and [Formula: see text]co2, irrespective of lung injury model, were lower during ECMO, resulting in lower PaCO2 and [Formula: see text]e but worse respiratory elastance compared with ECCO2R (64 ± 27 vs. 40 ± 8 cm H2O/L; P < 0.001). Conclusions: ECMO was associated with better oxygenation, lower [Formula: see text]o2, and better hemodynamics. ECCO2R may offer a potential alternative to ECMO, but there are concerns regarding its effects on hemodynamics and pulmonary hypertension.

Myosteatosis as an independent predictor of short-term mortality in successfully reperfused acute ischemic stroke.

BACKGROUND AND PURPOSE: Poor clinical outcomes are still common in successfully reperfused acute ischemic stroke patients. The aim of our study was to assess the impact of sarcopenia and myosteatosis on neurological outcomes and mortality in successfully reperfused acute ischemic stroke patients. MATERIALS AND METHODS: We included in our retrospective observational study 166 consecutive patients who underwent technically successful mechanical thrombectomy for anterior circulation acute ischemic stroke between Jan 2016 and Dec 2019. ASPECTS and collateral score were assessed on pre-operative CT/CTA. Masseter muscles area and attenuation were measured on CTA images. Clinical and radiological variables were tested in multivariate logistic models to predict the probability of death and, among survivors, of incurring poor outcome. RESULTS: At admission, mean NIHSS was 19 (SD = 6.5), mean body mass index 25.5 (SD = 4.4) kg/m2, and mean ASPECTS 8.0 (SD = 1.9). Of all, 48.2% patients showed good collaterals, 38.5% intermediate collaterals, and 13.3% poor collaterals. Overall, 90 days mRS was ≤2 in 48.2% of the patients, 3-5 in 30.7%, and 6 in 21.1%. At multivariate logistic regression, age (OR = 1.08, p = 0.036), ASPECTS (OR = 0.59, p = 0.013), and masseter muscles attenuation (OR = 0.93, p = 0.010) were independent predictors of mortality, whereas sex (OR = 7.15, p = 0.043), age (OR = 1.05, p = 0.042), body mass index (OR = 1.35, p = 0.013), NIHSS (OR = 1.12, p = 0.012), and ASPECTS (OR = 0.64, p = 0.024) were independent predictors of poor neurological outcome (mRS 3-5). CONCLUSION: Beyond other well-known variables, low masseter attenuation, indicating myosteatosis, represents an independent negative prognostic factor for 90 days mortality in patients successfully reperfused after anterior circulation stroke.

Management of vertebral compression fractures: the role of dual-energy CT in clinical practice.

PURPOSE: To evaluate the role of dual-energy computed tomography (DECT) in the management of vertebral compression fractures in clinical practice. MATERIALS AND METHODS: This retrospective IRB-approved study included 497 consecutive patients with suspected acute vertebral fractures, imaged either by DECT (group 1) or MRI (group 2) before vertebroplasty. The site, number and type of fractures at imaging findings, and clinical outcome based on any change in pain (DELTA-VAS), before (VAS-pre) and after treatment (VAS-post), were determined and compared. Two radiologists evaluated DECT and MRI images (15 and 5 years of experience, respectively), and inter-observer and intra-observer agreement were calculated using k statistics. RESULTS: Both in the control group (n = 124) and in the group of patients treated by vertebroplasty (n = 373), the clinical outcome was not influenced by the imaging approach adopted, with a DELTA-VAS of 5.45 and 6.42 in the DECT group and 5.12 and 6.65 in the MRI group (p = 0.326; p = 0.44). In the group of treated patients, sex, age, lumbar fractures, multiple fractures, previous fractures, Genant grade, involvement of anterior apex or superior endplates, and increased spinal curvatures were similar (p = ns); however, dorsal fractures were more prevalent in group 1 (p = 0.0197). Before treatment, the mean VAS-pre was 8.74 in group 1 (DECT) and 8.65 in group 2 (MRI) (p = 0.301), whereas after treatment, the mean VAS-post value was 2.32 in group 1 (p = 0.0001), and 2.00 in group 2 (p = 0.0001). The DELTA-VAS was 6.42 in the group of patients imaged using DECT and 6.65 in the group imaged using MRI (p = 0.326). Inter-observer and intra-observer agreement were 0.85 and 0.89 for DECT, and 0.88 and 0.91 for MRI, respectively. CONCLUSION: The outcome of vertebral compression fracture management was no different between the two groups of patients studied.

Role of CT colonography in differentiating sigmoid cancer from chronic diverticular disease.

PURPOSE: To evaluate the accuracy of computed tomography colonography (CTC) in differentiating chronic diverticular disease from colorectal cancer (CRC), using morphological and textural parameters. MATERIALS AND METHODS: We included 95 consecutive patients with histologically proven chronic diverticular disease (n = 53) or CRC (n = 42) who underwent CTC. One radiologist, unaware of histological findings, evaluated CTC studies for the presence of potential discriminators including: maximum thickness, involved segment length, shouldering phenomenon, growth pattern, diverticula, fascia thickening, fat tissue edema, loco-regional lymph nodes, mucosal pattern. Another radiologist performed volumetric texture analysis on the involved segment. RESULTS: Several qualitative imaging parameters resulted to significantly correlated with colorectal cancer, including absence of diverticula in the affected segment, straightened growth pattern and shouldering phenomenon. A maximum wall thickness/involved segment length ratio < 0.1 had 98% specificity and 47% sensitivity in identifying diverticular disease. Regarding first-order texture analysis parameters, kurtosis resulted to be significantly different between the two groups. CONCLUSIONS: Absence of diverticula, straightened growth pattern and shouldering phenomenon are significantly associated with CRC (71-91% sensitivity; 82-91%).

Accuracy of unenhanced CT in the diagnosis of cerebral venous sinus thrombosis.

OBJECTIVES: To evaluate the diagnostic performance of unenhanced brain CT (NECT) in identifying patients with cerebral venous sinus thrombosis (CVT). METHODS: Forty-eight consecutive patients with CVT and 48 healthy controls were included in our retrospective study. All patients underwent NECT and CT/MR angiography within 24 h. Two radiologists independently evaluated NECT images for the presence of sinus hyperdensity; discrepancies were solved by consensus. Sinus attenuation was measured in seven sites. The obtained data were compared with the presence of CVT at CT/MR angiography and with patients' hematocrit. RESULTS: Interobserver agreement in sinus hyperdensity detection was good (k = 0.64). The presence of sinus hyperdensity at NECT enabled to detect patients with CVT with 81% sensitivity, 77% specificity, 78% PPV, and 80% NPV. Mean attenuation was significantly higher in sinus segments involved by CVT than in patent ones (62.4 ± 10 versus 55.6 ± 6 HU, p < 0.0001). ROC analysis showed that a cutoff value of 63 HU enables to detect patients with CVT with 52% sensitivity and 88% specificity. Hematocrit values were significantly correlated with patent sinus segments attenuation (r = 0.19). CONCLUSIONS: The presence of sinus hyperdensity at NECT enables to detect patients with CVT with 81% sensitivity and 77% specificity. A sinus attenuation cutoff value of 63 HU can be used in order to increase specificity, but lowering sensitivity.

Liver enhancement during hepatobiliary phase after Gd-BOPTA administration: correlation with liver and renal function.

OBJECTIVES: To assess the influence of liver and renal function on liver relative enhancement during hepatobiliary phase MRI after Gd-BOPTA administration. METHODS: In this IRB-approved retrospective cohort study, we included 326 patients who underwent Gd-BOPTA-enhanced 1.5T liver MRI, including hepatobiliary phase (HBP) acquired 90-150 min after injection, in two centres between Jan 2016 and Dec 2019. Liver signal intensity was measured on native and HBP phases and normalized to paraspinal muscles. Liver normalized relative enhancement (NRE) in HBP was calculated and compared with eGFR, total serum bilirubin and HBP acquisition delay by means of Spearman r correlation test and Mann-Whitney U test. RESULTS: 221/326 patients received 0.05 mmol/Kg Gd-BOPTA (group A), whereas 105/326 received 0.1 mmol/Kg (group B). Liver NRE in HBP was significantly higher in group B than in group A (0.55vs.0.33, p < 0.0001). In both groups, liver NRE in HBP had a negative correlation with total serum bilirubin level (r = - 0.32, p < 0.0001, group A; r = - 0.36, p = 0.0002, group B). Patients with total bilirubin > 1.2 mg/dl showed significantly lower NRE in HBP compared with those with total bilirubin ≤ 1.2 mg/dl (p < 0.0001, group A; p = 0.04, group B). Patients with impaired liver function in group B showed a NRE during HBP comparable with those with normal liver function in group A. No statistically significant correlation between liver NRE and eGFR or acquisition delay was observed. CONCLUSIONS: The degree of liver enhancement during HBP is not correlated with eGFR or acquisition delay, but it is significantly reduced in patients with impaired liver function. 0.1 mmol/kg Gd-BOPTA dose might be useful in patients with total serum bilirubin > 1.2 mg/dl. KEY POINTS: • The degree of liver enhancement during hepatobiliary phase after Gd-BOPTA administration has a negative correlation with total serum bilirubin level (r = - 0.32, p < 0.0001). • The degree of liver enhancement during HBP after Gd-BOPTA administration is not significantly correlated with renal function and acquisition delay (comprised between 90 and 150 min after contrast injection). • 0.1 mmol/Kg Gd-BOPTA dose might be preferable in patients with increased total serum bilirubin levels.

Role of diffusion tensor imaging of sciatic nerve in symptomatic patients with inconclusive lumbar MRI.

OBJECTIVE: To assess fractional anisotropy (FA) of sciatic nerve roots within the pelvis by using diffusion tensor imaging (DTI) in patients suffering from sciatica with inconclusive lumbar MRI. METHODS: This IRB-approved prospective study included 32 consecutive subjects (11 males and 21 females; mean age 32.2 years) between September 2019 and February 2020. All patients underwent DTI (TR/TE 5800/97 ms; b = 1000; slice thickness 3,5 mm; directions = 20) on a 1.5 T scanner (Siemens Aera). Seventeen patients were symptomatic, whereas 15 patients served as control group. DTI data were analyzed by two radiologists (25 and 11 years of experience, respectively) blinded to clinical data. Each radiologist placed two ROIs on the nerve roots at three different levels. Diagnostic accuracy values of FA numbers were calculated by using receiver operator curves (ROC) and relative area under the curve (AUC), by using clinical findings as standard of reference. Inter-observer agreement was calculated with k-statistics. Paired T-test and Mann-Whitney test were used for comparison accordingly to data distribution. A value of p < 0.05 was considered statistically significant. RESULTS: Among the 17 symptomatic patients, FA values were significantly lower in the affected side at all levels (p < 0.05). The FA ratio (FA affected side/FA unaffected side) of symptomatic patients was significantly lower compared to control group at level 1 (p = 0.0005) and level 2 (p = 0.0006). Using a threshold of 0.90 for level 1 and 0.73 for level 2, 76 % and 71 % sensitivity and 100 % and 87 % specificity were achieved, respectively. CONCLUSION: DTI can quantitatively demonstrate sciatic nerve roots impairment within the pelvis.

Dislocation of intra-abdominal drains after pancreatic surgery: results of a prospective observational study.

PURPOSE: The use of intra-abdominal drains after major surgical procedures represents a well-established but controversial practice. No data are available regarding both the occurrence and the potential impact of their postoperative accidental dislocation. The aim of this study is to assess the actual rate of dislocation of intra-abdominal drains postoperatively and to evaluate its clinical impact. METHODS: This is a prospective observational study using major pancreatic surgery as a model. Ninety-one consecutive patients undergoing pancreatoduodenectomy (PD) or distal pancreatectomy (DP) underwent low-dose, non-enhanced computed tomography (LDCT) on postoperative days (POD) 1 and 3 in a blinded fashion to assess the position of drains. We compared the outcomes of patients with dislocated and correctly placed drains. RESULTS: Overall, drains were dislocated in 30 patients (33%), without differences between PD and DP. Most of dislocations were already present on POD 1 (77%). Postoperative complications occurred in 57% of patients, and the rate of postoperative pancreatic fistula (POPF) was 27%. The dislocated cohort had lesser morbidity (40% vs. 66%; relative risk (RR), 0.35; 95% CI, 0.14-0.86; P = 0.020), and the rate of POPF (3% vs. 39%, respectively; RR, 0.05; 95% CI, 0.01-0.42; P < 0.001). After PD, patients with dislocated drains had a shorter hospital stay (12 vs. 20 days; P = 0.015). No significant differences in terms of need for percutaneous drainage procedures, abdominal collections, or grade C POPFs were found between the groups. CONCLUSIONS: Dislocation of intra-abdominal drains is an early and frequent event after major pancreatic resection. Its occurrence might protect against the negative effects of maintaining drainage, eventually leading to better postoperative outcomes. This data reinforces the knowledge that surgical drains might be detrimental in selected cases.

Ascites relative enhancement during hepatobiliary phase after Gd-BOPTA administration: a new promising tool for characterising abdominal free fluid of unknown origin.

OBJECTIVES: To correlate the degree of ascites enhancement during hepatobiliary phase after gadobenate dimeglumine (Gd-BOPTA) administration with ascites aetiology. METHODS: IRB-approved retrospective study, need for informed consent was waived. We included 74 consecutive ascitic patients who underwent Gd-BOPTA-enhanced liver MRI including hepatobiliary phase (HBP) images between January 2014 and December 2017. Ascites appearance on unenhanced and HBP images was classified as hypo-, iso- or hyperintense in comparison to paraspinal muscles. Ascites signal intensity on unenhanced and HBP images was measured using round ROIs and was normalised to paraspinal muscles (NSI). Normalised relative enhancement (NRE) between native phase and HBP was calculated. The results were related to ascites aetiology using Wilcoxon and Mann-Whitney tests. RESULTS: On native images, ascites appeared hypointense in 95.9% of the cases and isointense in 4.1%, whereas on HBP images, it appeared hyperintense in 59.4% of the cases, isointense in 36.5% and hypointense in 4.1%. Mean ascites NSI was 0.52 on unenhanced images and 1.50 on HBP ones (p < 0.0001). Mean ascites NRE was 201 ± 133%. Ascites of non-malignant aetiology showed mean NRE of 210 ± 134%, whereas malignant ascites showed mean NRE of 92 ± 20% (p = 0.001). ROC analysis showed that a NRE < 112.5% correlates with malignant aetiology with 100% sensitivity and 83.4% specificity (LR = 5.667). NRE did not show any significant correlation with ascites thickness, eGFR and time interval between contrast administration and HBP acquisition (p > 0.05). CONCLUSIONS: Ascites NRE in HBP after Gd-BOPTA administration is significantly lower in patients with ascites secondary to peritoneal carcinomatosis than in patients with non-malignant ascites. KEY POINTS: • Ascites enhancement in the hepatobiliary phase after Gd-BOPTA administration may determine false positive findings when looking for biliary leaks. • Ascites enhancement in the hepatobiliary phase after Gd-BOPTA administration is lower in patients with peritoneal carcinomatosis than in patients with portal hypertension or congestive heart failure. • None of the patients with peritoneal carcinomatosis showed an ascites enhancement of more than 112% as compared with unenhanced images.

Prediction of histological grade of endometrial cancer by means of MRI.

OBJECTIVES: To evaluate the ability of MRI in predicting histological grade of endometrial cancer (EC). METHODS: IRB-approved retrospective study; requirement for informed consent was waived. 90 patients with histologically proven EC who underwent preoperative MRI and surgery at our Institution between Sept2011 and Nov2016 were included. Myometrial invasion (50%) was assessed. Neoplasm and uterus volumes were estimated according to the ellipsoid formula; neoplasm/uterus volume ratio (N/U) was calculated. ADC maps were generated and histogram analysis was performed using commercially available software. MRI parameters were compared with the definitive histological grade (G1 = 28 patients, G2 = 29, G3 = 33) using ANOVA and Tukey-Kramer tests. RESULTS: Deep myometrial invasion was significantly more frequent in G2-G3 lesions than in G1 ones (p < 0,005). N/U ratio was significantly higher for high-grade neoplasms (mean 0,08 for G1, 0,16 for G2 and 0,21 in G3; P = 0,002 for G1 vs. G2-G3); a cut off value of 0,13 enabled to distinguish G1 from G2-G3 lesions with 50% sensibility and 89% specificity. ADC values didn't show any statistically significant correlation with tumour grade. CONCLUSIONS: N/U ratio >0.13 and deep myometrial invasion are significantly correlated with high grade EC, whereas ADC values are not useful for predicting EC grade.

Solid non-functioning endocrine tumors of the pancreas: correlating computed tomography and pathology.

BACKGROUND: Since prognosis and treatment of pancreatic endocrine tumors (pNET) are based on tumor grade, contrast-enhanced multidetector computed tomography (MDCT) features of solid non-functioning pNETs were studied and correlated with pathology tumor grading. METHODS: MDCTs of diagnosed pNETs were reviewed retrospectively. Each tumor was analyzed for location, size, homogeneity, margins, arterial and venous phase enhancement, main pancreatic duct diameter, calcifications, vascular invasion, lymph-nodes enlargement, and liver metastases. RESULTS: Of 154 pNETs presenting between January 2000 and May 2016 with available histology from resected specimen or biopsy, there were 65 G1, 72 G2 and 17 G3 pNETs. Tumor diameter varied significantly between the three groups. Tumors >20 mm were more frequently malignant and non-homogeneous than smaller tumors. G1 tumors were more commonly hypervascular and G3 tumors more often non-hypervascular in the arterial phase. Arterial phase non-hyperdensity and tumor non-homogeneity had a higher rate of metastatic lesions. Vascular invasion correlated with presence of metastases and histological grade. G3 tumors were all >20 mm (p = 0.007), more often non-hypervascular in the arterial phase (p = 0.0025), and non-hyperdense in the venous phase (p = 0.009), and showed more often vascular invasion (p = 0.0198). CONCLUSION: CT correlated with tumor grade; differentiating low-grade and high-grade pNETs through routine CT imaging might improve patient management.

Gallbladder adenomyomatosis: imaging findings, tricks and pitfalls.

Gallbladder adenomyomatosis (GA) is a benign alteration of the gallbladder wall that can be found in up to 9% of patients. GA is characterized by a gallbladder wall thickening containing small bile-filled cystic spaces (i.e., the Rokitansky-Aschoff sinuses, RAS). The bile contained in RAS may undergo a progressive concentration process leading to crystal precipitation and calcification development. A correct characterization of GA is fundamental in order to avoid unnecessary cholecystectomies. Ultrasound (US) is the imaging modality of choice for diagnosing GA; the use of high-frequency probes and a precise focal depth adjustment enable correct identification and characterization of GA in the majority of cases. Contrast-enhanced ultrasound (CEUS) can be performed if RAS cannot be clearly identified at baseline US: RAS appear avascular at CEUS, independently from their content. Magnetic resonance imaging (MRI) should be reserved for cases that are unclear on US and CEUS. At MRI, RAS can be identified with extremely high sensitivity, but their signal intensity varies widely according to their content. Positron emission tomography (PET) may be helpful for excluding malignancy in selected cases. Computed tomography (CT) and cholangiography are not routinely indicated in the suspicion of GA. TEACHING POINTS: 1. Gallbladder adenomyomatosis is a common benign lesion (1-9% of the patients). 2. Identification of Rokitansky-Aschoff sinuses is crucial for diagnosing gallbladder adenomyomatosis. 3. Sonography is the imaging modality of choice for diagnosing gallbladder adenomyomatosis. 4. Intravenous contrast material administration increases ultrasound accuracy in diagnosing gallbladder adenomyomatosis. 5. Magnetic resonance is a problem-solving technique for unclear cases.