Reported and Unreported Potentially Important Incidental Findings in Urgent Nonenhanced Abdominal CT for Renal Colic.

OBJECTIVE: The aim of the study was to retrospectively evaluate the prevalence of reported and unreported potentially important incidental findings (PIFs) in consecutive nonenhanced abdominal CTs performed specifically for renal colic in the urgent setting. METHODS: One radiologist, blinded to the finalized report, retrospectively re-evaluated nonenhanced abdominal CTs performed from January to December 2017 on adult patients from the emergency department with the specific request of urgent evaluation for renal colic, searching for PIFs. RESULTS: The CTs of 312 patients were included in the study. Thirty-eight findings were reported in 38 different CTs, whereas the re-evaluation added 47 unreported findings in 47 different CTs, adding to total of 85 findings (27%). The difference in the proportion of reported and unreported PIFs between the original report and re-evaluation was significant (p < 0.001). No significant difference was found between the age of patients with and without reported findings. The proportion of potentially important findings did not vary significantly among the 3 shifts in the original report and in re-evaluation. The most frequent findings, both reported and unreported, were pleural effusion, lymphadenopathies, and liver nodules. CONCLUSIONS: Potentially important additional findings are frequently present in urgent nonenhanced abdominal CTs performed for renal colic, and many are not described in the finalized reports. Radiologists should take care not to underreport PIFs even in the urgent setting because of the possible consequences on the patient's health and in order to avoid legal issues, while at the same time satisfying the need for timely and efficient reporting.

Radiological exams on end-stage oncologic patients before hospice admission.

PURPOSE: To evaluate frequency, type, and cost of diagnostic and interventional radiological exams performed on end-stage oncologic patients in the 90 days before Hospice admission. MATERIALS AND METHODS: Data of patients admitted to Hospice from January 2012 through June 2013 (18 months) were cross-checked with data from the digital archive of the Radiology Department. Frequency and type of exams performed before admission were analyzed across three 1-month periods, namely M-3, M-2, M-1, corresponding to 90-61, 60-31 and 30-1 days before admission. The Regional Range of Fees was used to determine the costs. RESULTS: A total of 389 patients were admitted to Hospice. Before admission, 335 patients (86%) underwent 1543 radiological exams: 919 X-rays, 555 CTs, 39 MRs, and 30 interventional procedures. The cost of these services was € 106,988 (€ 19,918 for X-rays, € 73,956 for CTs, € 9502 for MRs, and € 3612 for interventional procedures). Across the pre-Hospice periods, the proportions of examined patients increased as admission approached: 36% in M-3, 43% in M-2 (P = .038), 65% in M-1 (P < .001). The mean number of exams increased significantly, too (P < .001). CONCLUSIONS: A substantial number of end-stage oncologic patients underwent radiological exams in the 90 days before Hospice admission, and these numbers grew as Hospice access approached. In the end-of-life span, diagnostic excesses should be avoided.

Odontogenic-Like Pain in Partial Edentulism: An Unusual Presentation of Diffuse Large B-Cell Lymphoma of the Mandible.

Primary bone lymphoma is a rare entity and it usually occurs in long bones. Primary mandibular involvement is very rare, and it usually shows unspecific features, mimicking odontogenic inflammatory lesions. We present the unusual case of a diffuse large B-cell lymphoma (DLBCL) of the right mandibular body in a 91-year-old woman, who presented with acute pain in the mandibular region initially suspicious for odontogenic abscess. No significant findings were seen on orthopantomography (OPG) and her almost complete edentulism made the diagnosis of abscess unlikely. Computed tomography and magnetic resonance images showed an expansive mass around the right mandibular body with erosion of cortical bone and involving the right mandibular canal and nerve. Final diagnosis of DLBCL was pathologically proven. The presence of odontogenic-like pain in nearly complete edentulism should be suspicious for malignancy, and it needs further diagnostic workup despite the absence of signs on OPG.

sABLATE: a simplified ABLATE score for prediction of complications and outcome in percutaneous thermal ablation of renal lesions.

The aim of the study is to evaluate the performance of a simplified ABLATE score (sABLATE) in predicting complications and outcome with respect to RENAL, mRENAL, and ABLATE scores. This study included 136 renal lesions in 113 patients (M:F ratio = 2.5; mean age 70.8 years). 98 tumors underwent cryoablation at San Raffaele hospital between 01/2015 and 03/2020, while 37 underwent microwave ablation at San Paolo or Policlinico hospitals between 07/2016 and 03/2020. RENAL, mRENAL, ABLATE, and sABLATE scores were calculated using pre-procedural imaging. Data regarding complications and follow-up were registered. Mann-Whitney U test, ROC analyses, and logistic regression analyses were used for complications. Cox-regression analyses were performed for outcome. Mean tumor diameter was 23.2 mm. Mean and median RENAL, mRENAL, ABLATE, and sABLATE scores were 6.8 and 7, 6.9 and 7, 5.3, and 5, and 3.5 and 3, respectively. During a mean follow-up of 21.9 months (range 1-73), we registered 7 complications, 3 cases of residual disease, and 10 local tumor progressions. Mann-Whitney U test p values for complications for RENAL, mRENAL, ABLATE, and sABLATE were 0.51, 0.49, 0.66, and 0.056, respectively. ROC analyses for complications showed an AUC for RENAL, mRENAL, ABLATE, and sABLATE of 0.57, 0.57, 0.55, and 0.71, respectively. Regarding outcome, HR and p values of Cox-regression analyses were 1.30 and 0.36 for RENAL, 1.33 and 0.35 for mRENAL, 2.16 and 0.01 for ABLATE, 2.29 and 0.004 for sABLATE. sABLATE was the only score close to significance for complications, representing a progress even if not definitive. Regarding outcome, ABLATE confirmed its value, and sABLATE maintained validity despite being a simplification.

Paediatric gastric trichobezoar: the Rapunzel syndrome A report of two cases.

Rapunzel syndrome is a rare case of bowel obstruction resulting from hair ingestion (Trichobezoar). The obstruction can occur in any level of intestinal tract, but usually the stomach is primary involved. This syndrome is usually reported in patients affected by Trichotillomania or Pica syndrome, an obsessive-compulsive disorder that are characterized by an irresistible need to eat body hairs or non-digestible substances 1. When bowel obstruction occurs, it may be treated conservatively, but sometimes surgery is required. We reported two cases of Rapunzel Syndrome in two pediatric patients with different clinical presentation. Both patients were initially treated conservatively but eventually they underwent surgery. KEY WORDS: Bowel obstruction, Rapunzel syndrome, Trichobezoar.

Patient Perception of Musculoskeletal MR: A Survey Research.

BACKGROUND: When undergoing magnetic resonance (MR) exams, patients need to lie still in a noisy and enclosed environment for a long time. This condition, together with the anxiety burden related to the possible implications of the scan results, can entail a diagnostic outcome of poor quality. OBJECTIVE: The aim of the study was to evaluate the personal perception and experience of adult patients undergoing unenhanced musculoskeletal MR. METHODS: Consecutive outpatients undergoing unenhanced MR of spine, knee or shoulder were asked to respond to a 10-item questionnaire at the end of the exam. RESULTS: 263 patients (54% males, mean age 50.6 ±15.8 years, range 18-83 years) completed the questionnaire. Patients declared that the most disturbing elements of the exam were forced immobility and noise (30% in both cases). Females perceived significantly higher degree of anxiety than males (56% vs. 21%, p<0.001). Exam duration was correctly perceived by 83% of the population. Patients' satisfaction was generally high (mean above 9 over 10). CONCLUSION: Explanations and clarifications given before the exam were considered satisfactory by the patients. Despite some negative aspects such as noise, immobility and anxiety especially in females, patients' satisfaction with our service was high, as well as the willingness to return.

Iatrogenic Coagulopathy and the Development of Posterior Reversible Encephalopathy Syndrome after L-asparaginase Chemotherapy.

Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological syndrome mostly related to hypertension, eclampsia, renal failure, or to chemotherapy and/or immunosuppressive drugs. Although the PRES pathophysiology is multifactorial, hypertension and endothelial dysfunction are hypothesized to be the pivotal factors. Here we report a case of PRES in an adult patient after chemotherapy (Escherichia coli L-asparaginase [L-ASP], daunorubicin, vincristine, and intrathecal methotrexate) for acute lymphoblastic leukemia. The development of the PRES was strictly associated with an iatrogenic coagulopathy induced by L-ASP, which inhibits the biosynthesis of hepatic coagulation factors. The nadir of platelet count, antithrombin III (ATIII) and fibrinogen curve was coincident with the onset of the PRES neurological picture; subsequently, the normalization of the ATIII and fibrinogen levels seemed to parallel the good clinical evolution. This case seems to provide new insights into the PRES pathophysiological mechanisms.

Current perspective on the pathogenesis of central diabetes insipidus.

Diabetes insipidus is a heterogeneous condition characterised by polyuria and polydipsia caused by a lack of secretion of vasopressin, its physiological suppression following excessive water intake, or kidney resistance to its action. The clinical and laboratory diagnosis is confirmed by standard tests, but recent advances in molecular biology and imaging techniques have shed new light on the pathophysiology of this disease. In many patients, central diabetes insipidus is caused by a germinoma or craniopharyngioma; Langerhans' cell histiocytosis and sarcoidosis of the central nervous system; local inflammatory, autoimmune or vascular diseases; trauma from surgery or accident; and, rarely, genetic defects in vasopressin biosynthesis inherited as autosomal dominant or X-linked recessive traits. Thirty to fifty percent of cases are considered idiopathic. Tumour-associated central diabetes insipidus is uncommon in children younger than 5 years old. Biopsy of enlarged pituitary stalk should be reserved for patients with hypothalamic-pituitary mass and progressive thickening of the pituitary stalk since spontaneous recovery may occur. Molecular biology in selected patients may identify those with apparently idiopathic diabetes insipidus carrying the vasopressin-neurophysin II gene mutation.

Large bilateral internal auditory meatus associated with bilateral superior semicircular canal dehiscence.

Superior semicircular canal dehiscence and an abnormally wide internal auditory meatus are clinical entities characterized by vestibular and cochlear symptoms. These symptoms are induced by hypersensitivity of labyrinthine receptors secondary to a bone defect of the otic capsule. We report the case of a 41-year-old man with congenital right-sided hearing loss who presented with bilateral superior semicircular canal dehiscence that was associated with wide, bulbous internal auditory meatus and a loss of the bony wall separating the lateral end of the meatus from the cochlea. The patient was experiencing vestibular and cochlear symptoms in the right ear and disabling tinnitus in the left ear. However, he refused all treatment and was lost to follow-up.

Varicella zoster virus meningo-encephalo-myelitis in an immunocompetent patient.

OBJECTIVE: To describe clinical, MRI and cerebrospinal fluid (CSF) features of a varicella zoster virus (VZV) related meningo-encephalo-myelitis (MEM) without rash in an immunocompetent female. PATIENT: An 85 year old immunocompetent woman with mild hyperthermia and acute, severe MEM. INTERVENTION: Serum antibodies and CSF PCR were searched for several viruses. Brain and spinal cord MRI were performed. Immunological profile. TREATMENTS: i.v. acyclovir 30 mg/kg/day; i.v. 6-MP 125 mg/day. RESULTS: Marked CSF lymphomonocytic pleocytosis, blood-brainbarrier damage, and PCR detection of 3.05 X 10 6 copies of VZV DNA. MRI revealed lesions of the meninges, brain and spinal cord. No evidence of immunosuppression. CONCLUSION: We highlight the importance of considering the possibility of VZV related MEM, even in immunocompetent patients. We also provide a MRI description of VZV related multifocal myelitis, not previously available. As supported by other reports, we underline the necessity of a prompt therapeutic intervention in this life-threatening condition.

Contrast-enhanced versus conventional and color Doppler sonography for the detection of thrombosis of the portal and hepatic venous systems.

OBJECTIVE: We conducted a prospective study to compare sonography, color Doppler sonography, and contrast-enhanced sonography for the detection and characterization of portal and hepatic vein thrombosis complicating hepatic malignancies. SUBJECTS AND METHODS: Three hundred sixteen patients with biopsy-proved hepatic tumors were studied at baseline and 3 months later with sonography, color Doppler sonography, and contrast-enhanced sonography. Thrombosis was defined as the presence of intraluminal echogenic material at sonography, absence of intraluminal color signals at color Doppler sonography, and presence of nonenhancing intraluminal area at contrast-enhanced sonography. Thrombi were considered malignant if they displayed continuity with tumor tissue at sonography, intrathrombus color signals at color Doppler sonography, and enhancing signals at contrast-enhanced sonography, both having arterial waveforms at Doppler spectral examination. Definitive diagnoses were obtained by sonographically guided biopsy except for thrombi displaying at conventional sonography unequivocal continuity with tumor tissue. RESULTS: Thrombosis was detected in 79 (25.0%) of 316 patients at baseline and in 83 (26.3%) of 316 patients after 3 months. Eighty-one (97.6%) of the 83 thrombi were malignant. Definitive diagnosis was performed by imaging in 60 (72.3%) of the 83 cases and by biopsy in 23 cases (27.7%). For thrombus detection, contrast-enhanced sonography displayed significantly higher sensitivity than color Doppler sonography (p = 0.004) and borderline superiority over sonography (p = 0.058). For thrombus characterization, contrast-enhanced sonography was significantly more sensitive than color Doppler sonography (p < 0.0005) and conventional sonography (p = 0.02). CONCLUSION: Contrast-enhanced sonography is superior to sonography and color Doppler sonography for the detection and characterization of portal and hepatic vein thrombosis complicating hepatic malignancies.