JOURNAL CLUB: Four-Dimensional Flow MRI-Based Splenic Flow Index for Predicting Cirrhosis-Associated Hypersplenism.

OBJECTIVE: The objective of this study is to evaluate the ability of spleen volume, blood flow, and an index incorporating multiple measures to predict cirrhosis-associated hypersplenism. MATERIALS AND METHODS: A total of 39 patients (14 women and 25 men; mean [± SD] age, 52 ± 10 years) with cirrhosis and sequelae of portal hypertension underwent 4D flow MRI and anatomic 3-T MRI performed before and after contrast administration. Unenhanced 4D flow MRI was used to assess abdominal hemodynamics, and splenic volumes were measured on T1-weighted gradient-recalled echo MRI. Relationships among demographic characteristics, blood component counts, splenic volume, arterial flow, venous flow, and the percentage of shunted portal flow were assessed in 29 consecutive patients (i.e., the derivation group), to develop a splenic flow index. This index was assessed along with splenic volume and blood flow alone in 10 additional consecutive patients (i.e., the validation group) via ROC curve analysis, to identify platelet counts of less than 50 × 103 cells/µL, leukocyte counts of less than 3.0 × 103 cells/µL, or both. RESULTS: In the derivation cohort (platelet count, 129 ± 76 × 103 cells/µL), splenic volume, arterial flow, venous flow, and the percentage of shunted portal flow were inversely correlated with platelet counts (ρ = -0.68, -0.68, -0.56, and -0.36, respectively; p < 0.05). Adding splenic volume to arterial flow and the product of venous flow and the percentage of shunted portal flow indexed to the body surface area yielded superior correlations with platelet counts, leukocyte counts, and the degree of severity of hypersplenism (ρ = -0.75, -0.48, and -0.75, respectively; p ≤ 0.001) and predicted severe hypersplenism (sensitivity, 100%; specificity, 100%) in the validation cohort (platelet count, 93 ± 71 × 103 cells/µL). CONCLUSION: A splenic flow index that incorporates both splenic volume and blood flow is a better indicator of hypersplenism than is splenic volume alone.

Reproducibility of 24-h heart rate variability in children.

BACKGROUND: Over the last decades, time domain heart rate (HR) variability analysis has been explored in different pediatric clinical settings to obtain information on the cardiac autonomic tone. However, the consistency over time of 24 h time domain HRV measurements in children is not well-known. METHODS: We investigated the reproducibility of 24 h HRV time-domain indices (1 day apart), from 39 healthy children (9.5 ± 5.3 years, 56.4% girls). The parameters analysed included: standard deviation of all the adjacent NN intervals, standard deviation of the averages of NN intervals (the intervals between normal R-peaks) in all 5-min segments, and square root of the mean of the sum of the squares of the differences between adjacent NN intervals, uncorrected and corrected for HR. Reproducibility between two 24-h ECG recordings was evaluated by intraclass correlation coefficients, standard error of measurement, coefficients of variation and Bland-Altman plots. RESULTS: For the analyzed time-domain indices, standard deviation of all the adjacent NN intervals corrected for HR showed best reproducibility with the highest intraclass correlation coefficient (0.987), the lowest coefficients of variation (5.5%) and the best level of agreement between two recordings as assessed by Bland-Altman plots. CONCLUSIONS: Our results indicate that the standard deviation of all the adjacent NN intervals corrected for the HR parameter obtained from 24-h ambulatory recordings in children is consistent and reproducible over time, thus allowing reliable identification of cardiac autonomic tone in this age group.

Contraception for adolescents after abortion.

INTRODUCTION: Preventing repeated unplanned pregnancy among adolescents is still a challenge because many of them fail to use effective contraception after abortion. OBJECTIVE: To review currently recommended options of methods and counselling for effective prevention of repeat pregnancies in adolescents. METHODS: Review of the literature that was identified through the Medline, ScienceDirect, Google and Popline databases and relevant expert opinions. RESULTS: Counselling needs to be adapted to the needs, values and lifestyle of adolescents. The best results are achieved with nondirective or active contraceptive counselling, followed by regular check-ups and cautious and attentive approach in the management of doubts, prejudices and side effects related to the contraceptive chosen. Adolescents should initiate contraception immediately after abortion: the motivation for choosing an efficacious method is highest at that time; resumption of ovulation following induced abortion occurs on average after three weeks; more than half of these girls will resume sexual activity within two weeks after pregnancy termination. Long-acting reversible contraception use during adolescence is safe and most effective. However, achieving a high long-term continuation rate is especially challenging in adolescents; this is due to developmental and environmental characteristics that influence their contraceptive behaviour. CONCLUSION: Adolescents should immediately after abortion initiate a reliable contraceptive method, preferably one whose efficacy is not user-dependent. Providing an appropriate health care would contribute to achieving continuity in the prevention of repeat pregnancy.

Effect of TIPS placement on portal and splanchnic arterial blood flow in 4-dimensional flow MRI.

OBJECTIVES: To assess changes in portal and splanchnic arterial haemodynamics in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) using four-dimensional (4D) flow MRI, a non-invasive, non-contrast imaging technique. METHODS: Eleven patients undergoing TIPS implantation were enrolled. K-t GRAPPA accelerated non-contrast 4D flow MRI of the liver vasculature was applied with acceleration factor R = 5 at 3Tesla. Flow analysis included three-dimensional (3D) blood flow visualization using time-resolved 3D particle traces and semi-quantitative flow pattern grading. Quantitative evaluation entailed peak velocities and net flows throughout the arterial and portal venous (PV) systems. MRI measurements were taken within 24 h before and 4 weeks after TIPS placement. RESULTS: Three-dimensional flow visualization with 4D flow MRI revealed good image quality with minor limitations in PV flow. Quantitative analysis revealed a significant increase in PV flow (562 ± 373 ml/min before vs. 1831 ± 965 ml/min after TIPS), in the hepatic artery (176 ± 132 ml/min vs. 354 ± 140 ml/min) and combined flow in splenic and superior mesenteric arteries (770 ml/min vs. 1064 ml/min). Shunt-flow assessment demonstrated stenoses in two patients confirmed and treated at TIPS revision. CONCLUSIONS: Four-dimensional flow MRI might have the potential to give new information about the effect of TIPS placement on hepatic perfusion. It may explain some unexpected findings in clinical observation studies. KEY POINTS: • 4D flow MRI, a non-invasive, non-contrast imaging technique, is feasible after TIPS. • Provides visualization and quantification of hepatic arterial, portal venous, collateral and TIPS haemodynamics. • Better understanding of liver blood flow changes after TIPS and patient management.

K-t GRAPPA-accelerated 4D flow MRI of liver hemodynamics: influence of different acceleration factors on qualitative and quantitative assessment of blood flow.

OBJECTIVE: We sought to evaluate the feasibility of k-t parallel imaging for accelerated 4D flow MRI in the hepatic vascular system by investigating the impact of different acceleration factors. MATERIALS AND METHODS: k-t GRAPPA accelerated 4D flow MRI of the liver vasculature was evaluated in 16 healthy volunteers at 3T with acceleration factors R = 3, R = 5, and R = 8 (2.0 × 2.5 × 2.4 mm(3), TR = 82 ms), and R = 5 (TR = 41 ms); GRAPPA R = 2 was used as the reference standard. Qualitative flow analysis included grading of 3D streamlines and time-resolved particle traces. Quantitative evaluation assessed velocities, net flow, and wall shear stress (WSS). RESULTS: Significant scan time savings were realized for all acceleration factors compared to standard GRAPPA R = 2 (21-71 %) (p < 0.001). Quantification of velocities and net flow offered similar results between k-t GRAPPA R = 3 and R = 5 compared to standard GRAPPA R = 2. Significantly increased leakage artifacts and noise were seen between standard GRAPPA R = 2 and k-t GRAPPA R = 8 (p < 0.001) with significant underestimation of peak velocities and WSS of up to 31 % in the hepatic arterial system (p <0.05). WSS was significantly underestimated up to 13 % in all vessels of the portal venous system for k-t GRAPPA R = 5, while significantly higher values were observed for the same acceleration with higher temporal resolution in two veins (p < 0.05). CONCLUSION: k-t acceleration of 4D flow MRI is feasible for liver hemodynamic assessment with acceleration factors R = 3 and R = 5 resulting in a scan time reduction of at least 40 % with similar quantitation of liver hemodynamics compared with GRAPPA R = 2.

Reproducibility study of four-dimensional flow MRI of arterial and portal venous liver hemodynamics: influence of spatio-temporal resolution.

PURPOSE: To evaluate influence of variation in spatio-temporal resolution and scan-rescan reproducibility on three-dimensional (3D) visualization and quantification of arterial and portal venous (PV) liver hemodynamics at four-dimensional (4D) flow MRI. METHODS: Scan-rescan reproducibility of 3D hemodynamic analysis of the liver was evaluated in 10 healthy volunteers using 4D flow MRI at 3T with three different spatio-temporal resolutions (2.4 × 2.0 × 2.4 mm(3), 61.2 ms; 2.5 × 2.0 × 2.4 mm(3), 81.6 ms; 2.6 × 2.5 × 2.6 mm(3), 80 ms) and thus different total scan times. Qualitative flow analysis used 3D streamlines and time-resolved particle traces. Quantitative evaluation was based on maximum and mean velocities, flow volume, and vessel lumen area in the hepatic arterial and PV systems. RESULTS: 4D flow MRI showed good interobserver variability for assessment of arterial and PV liver hemodynamics. 3D flow visualization revealed limitations for the left intrahepatic PV branch. Lower spatio-temporal resolution resulted in underestimation of arterial velocities (mean 15%, P < 0.05). For the PV system, hemodynamic analyses showed significant differences in the velocities for intrahepatic portal vein vessels (P < 0.05). Scan-rescan reproducibility was good except for flow volumes in the arterial system. CONCLUSION: 4D flow MRI for assessment of liver hemodynamics can be performed with low interobserver variability and good reproducibility. Higher spatio-temporal resolution is necessary for complete assessment of the hepatic blood flow required for clinical applications.

k-t GRAPPA accelerated four-dimensional flow MRI in the aorta: effect on scan time, image quality, and quantification of flow and wall shear stress.

PURPOSE: The purpose of this study was to evaluate the utility of k-t parallel imaging for accelerating aortic four-dimensional (4D)-flow MRI. The aim was to systematically investigate the impact of different acceleration factors and number of coil elements on acquisition time, image quality and quantification of hemodynamic parameters. METHODS: k-t accelerated 4D-flow MRI (spatial/temporal resolution = 2.1 × 2.5 × 2.5 mm/40.0 ms) was acquired in 10 healthy volunteers with acceleration factors R = 3, 5, and 8 using 12- and 32-channel receiver coils. Results were compared with conventional parallel imaging (GRAPPA [generalized autocalibrating partial parallel acquisition], R = 2). Data analysis included radiological grading of three-dimensional blood flow visualization quality as well as quantification of blood flow, velocities and wall shear stress (WSS). RESULTS: k-t GRAPPA significantly reduced scan time by 28%, 54%, and 68%, for R = 3, 5, and 8, respectively, while maintaining image quality as demonstrated by overall similar image quality grading. Significant differences in peak WSS (diff12ch = -5.9%, diff32ch = 18.5%) and mean WSS (diff32ch = 13.9%) were found at the descending aorta for both receiver coils for R = 5 (PWSS < 0.04). Peak velocity differed for R=8 at the aortic root (-7.4%) and descending aorta (-12%) with PpeakVelo < 0.03. CONCLUSION: k-t GRAPPA acceleration with a 12- or 32-channel receiver coil and an acceleration of 3 or 5 can compete with a standard GRAPPA R = 2 acceleration.

Aortic wall shear stress in Marfan syndrome.

The aim of this study was to quantify changes in thoracic aortic wall shear stress (WSS) in asymptomatic patients with Marfan syndrome (MFS) compared with healthy controls. WSS in the thoracic aorta was quantified based on time-resolved 3D phase contrast MRI with three-directional velocity encoding (4D flow MRI, temporal resolution ∼44 ms, spatial resolution ∼2.5 mm) in 24 patients with confirmed MFS (age = 18 ± 12 years) and in 12 older healthy volunteers (age = 25 ± 3 years). Diameters of the thoracic aorta normalized to body surface area were similar for both groups. Peak systolic velocity, absolute WSS, time-averaged WSS, circumferential WSS, peak systolic WSS, and WSS eccentricity were calculated in eight analysis planes distributed along the thoracic aorta. Plane-wise comparison revealed significant differences between MFS patients and volunteers in the proximal ascending aorta for peak systolic velocities (1.11 ± 0.23 m/s vs. 1.34 ± 0.18 m/s, P = 0.004) and circumferential WSS (0.14 ± 0.03 N/m(2) vs. 0.11 ± 0.02 N/m(2), P = 0.007). WSS eccentricity was altered in most of the ascending aorta and proximal arch (P = 0.009-0.020). MFS patients demonstrated segmental differences in peak systolic WSS with a significantly higher WSS at the inner curvature in the proximal ascending aorta and at the anterior part in the more distal ascending aorta (P < 0.01). These findings indicate differences in WSS associated with MFS despite similar aortic dimensions compared to controls.

K-t GRAPPA accelerated phase contrast MRI: Improved assessment of blood flow and 3-directional myocardial motion during breath-hold.

PURPOSE: To evaluate spatiotemporal parallel imaging with R = 5 in comparison to conventional parallel imaging with R = 2 applied to phase contrast (PC) magnetic resonance imaging (MRI). This was motivated by the fact that scan times for PC imaging often exceed breath-hold capabilities of patients even with standard parallel imaging using typical reduction factors of R = 2. MATERIALS AND METHODS: K-t generalized autocalibrating partially parallel acquisition (GRAPPA) acquisition was validated in phantom measurements and then applied in 10 volunteer and three patient examinations. Due to the higher reduction factor compared to conventional GRAPPA, k-t GRAPPA measurements could be performed during breath-hold with high spatial and temporal resolution. K-t GRAPPA scans were compared to GRAPPA acquired during free-breathing with navigator respiration control. In addition, spatiotemporally accelerated PC imaging was acquired during free-breathing for comparison of k-t-accelerated breath-held scans. RESULTS: Substantial improvements in image quality for the breath-hold measurements were observed. Significantly reduced peak velocities were found for the GRAPPA protocol compared to the k-t-accelerated breath-hold scans for both flow (8%) and myocardial motion (up to 30%) measurements. CONCLUSION: Spatiotemporal acceleration allows the performance of high temporal or spatial resolution PC imaging during breath-hold while providing high image quality and robust acquisition of functional information that cannot be achieved during breath-hold with standard techniques.

Normal and altered three-dimensional portal venous hemodynamics in patients with liver cirrhosis.

PURPOSE: To compare time-resolved three-dimensional (3D) phase-contrast magnetic resonance (MR) imaging with three-directional velocity encoding (flow-sensitive four-dimensional [4D] MR imaging), with Doppler ultrasonography (US) as standard of reference, for investigating alterations in 3D portal venous hemodynamics in patients with liver cirrhosis compared with healthy age-matched control subjects and healthy young volunteers. MATERIAL & METHODS: This prospective study was approved by the local ethics committee, and written informed consent was obtained from all participants. Three-dimensional portal venous hemodynamics was assessed, employing flow-sensitive 4D MR imaging with a 3-T MR system (spatial resolution, approximately 2 mm(3); temporal resolution, approximately 45 msec) in 20 patients with hepatic cirrhosis, 20 healthy age-matched control subjects, and 21 healthy young volunteers. Flow characteristics were analyzed by using 3D streamlines and time-resolved particle traces. Quantitative analyses were performed by retrospectively evaluating regional peak and mean velocities, flow volume, and vessel area. Doppler US was used as standard of reference. Independent-sample t tests or Wilcoxon-Mann-Whitney tests were applied for comparing each subject group. Paired-sample t tests or Wilcoxon tests were applied when comparing MR imaging and US. RESULTS: Three-dimensional visualization of portal venous hemodynamics was successful, with complete visualization of the vessels in 18 patients and 35 volunteers, with limitations in the left intrahepatic branches (87%, reader A; 89%, reader B). A moderate but significant correlation was observed between 4D MR imaging and Doppler US in nearly all maximum and mean velocities, flow volumes, and vessel areas (r = 0.24-0.64, P = .001-.044). With MR imaging, significant underestimation was observed of intrahepatic flow velocities and flow volumes, except vessel area, which Doppler US represented as even lower (P < .001 to P = .045). Six patients had collateralization with reopened umbilical vein, while one had flow reversal in the superior mesenteric vein visible at MR imaging only. CONCLUSION: Flow-sensitive 4D MR imaging may constitute a promising, alternative technique to Doppler US for evaluating hemodynamics in the portal venous system of patients with liver cirrhosis and may be a means of assessing pathologic changes in flow characteristics.

Evaluation of 3D blood flow patterns and wall shear stress in the normal and dilated thoracic aorta using flow-sensitive 4D CMR.

BACKGROUND: The purpose of this study was to investigate 3D flow patterns and vessel wall parameters in patients with dilated ascending aorta, age-matched subjects, and healthy volunteers. METHODS: Thoracic time-resolved 3D phase contrast CMR with 3-directional velocity encoding was applied to 33 patients with dilated ascending aorta (diameter≥40 mm, age=60±16 years), 15 age-matched normal controls (diameter≤37 mm, age=68±7.5 years) and 15 young healthy volunteers (diameter≤30 mm, age=23±2 years). 3D blood flow was visualized and flow patterns were graded regarding presence of supra-physiologic-helix and vortex flow using a semi-quantitative 3-point grading scale. Blood flow velocities, regional wall shear stress (WSS), and oscillatory shear index (OSI) were quantified. RESULTS: Incidence and strength of supra-physiologic-helix and vortex flow in the ascending aorta (AAo) was significantly higher in patients with dilated AAo (16/33 and 31/33, grade 0.9±1.0 and 1.5±0.6) than in controls (2/15 and 7/15, grade 0.2±0.6 and 0.6±0.7, P<.05) or healthy volunteers (1/15 and 0/15, grade 0.1±0.3 P<.05). Greater strength of the ascending aortic helix and vortex flow were associated with significant differences in AAo diameters (P<.05). Peak systolic WSS in the ascending aorta and aortic arch was significantly lower in patients with dilated AAo (P<.0157-.0488). AAo diameter positively correlated to time to peak systolic velocities (r=0.30-0.53, P<.04), OSI (r=0.33-0.49, P<0.02) and inversely correlated to peak systolic WSS (r=0.32-0.40, P<.03). Peak systolic WSS was significantly lower in AAo aneurysms at the right and outer curvature within the AAo and proximal arch (P<.01-.05). CONCLUSIONS: Increase in AAo diameter is significantly correlated with the presence and strength of supra-physiologic-helix and vortex formation in the AAo, as well with decrease in systolic WSS and increase in OSI.

MR-based visualization and quantification of three-dimensional flow characteristics in the portal venous system.

PURPOSE: To evaluate the feasibility of time-resolved flow-sensitive MRI for the three-dimensional (3D) visualization and quantification of normal and pathological portal venous (PV) hemodynamics. MATERIALS AND METHODS: Portal venous hemodynamics were evaluated in 18 healthy volunteers and 5 patients with liver cirrhosis. ECG- and adaptive respiratory navigator gated flow-sensitive 4D MRI (time-resolved 3D MRI with three-directional velocity encoding) was performed on a 3 Tesla MR system (TRIO, Siemens, Germany). Qualitative flow analysis was achieved using 3D streamlines and time-resolved particle traces originating from seven emitter planes precisely placed at anatomical landmarks in the PV system. Quantitative analysis included retrospective extraction of regional peak and mean velocities and vessel area. Results were compared with standard 2D flow-sensitive MRI and to the reference standard Doppler ultrasound. RESULTS: Qualitative flow analysis was successfully used in the entire PV system. Venous hemodynamics in all major branches in 17 of 18 volunteers and 3 of 5 patients were reliably depicted with good interobserver agreement (kappa = 0.62). Quantitative analysis revealed no significant differences and moderate agreement for peak velocities between 3D MR and 2D MRI (r = 0.46) and Doppler ultrasound (US) (r = 0.35) and for mean velocities between 3D and 2D MRI (r = 0.41). The PV area was significantly (P < 0.01) higher in 3D and 2D MRI compared with US. CONCLUSION: We successfully applied 3D MR velocity mapping in the PV system, providing a detailed qualitative and quantitative analysis of normal and pathological hemodynamics.

A Near Miss and Salvage Management of Aortoesophageal Fistula Secondary to Cell Battery Ingestion.

We report a case of an infant surviving aortoesophageal fistula secondary to lithium cell battery ingestion. In the setting of a delayed vascular complication, computed tomography and magnetic resonance imaging are essential to establishing the correct diagnosis and surgical management. Management of children after battery ingestion must be guided by a high index of clinical suspicion.

The future of paediatric and adolescent gynaecology in Europe.

Paediatric and Adolescent Gynaecology (PAG) is a subspecialty under the umbrella of Obstetrics and Gynaecology but linked to other branches of medicine including Paediatrics, Surgery, Endocrinology and Urology. Therefore future developments in clinical care and education requires a multidisciplinary approach combining aspects of all the above medical specialties, and also with inputs from Public Health, Genetics, Radiology and Psychology. A multidisciplinary collaboration among different specialists is as important as the establishment and adoption of standards in education, training and management. PAG in Europe has evolved from its first steps and it is still growing with the aim of providing increasing protection of the gynaecological and reproductive health of female children and adolescents. In fact, without proper advice and care, inappropriate management of gynaecological issues in childhood and adolescence can be expected to have significant repercussions throughout later years, and into adulthood. The aim of this third paper in this mini-symposium is to explore how PAG should develop in Europe in the near future.

Detection of pulmonary nodules with move-during-scan magnetic resonance imaging using a free-breathing turbo inversion recovery magnitude sequence.

PURPOSE: Detection of pulmonary metastases is still a challenging task for magnetic resonance imaging (MRI). It was the aim of this study to evaluate the potential of a free-breathing move-during-scan turbo inversion recovery magnitude sequence for the detection of pulmonary nodules. MATERIALS AND METHODS: The sensitivities and positive-predictive values of 2 radiologists to detect pulmonary nodules in 41 move-during-scan MRI examinations of 38 patients with different malignancies were calculated and subgroup analyses according to lesion size and localization were performed. Multidetector computed tomography served as the standard of reference. Additionally, 6 radiologists rated the confidence for the presence of nodular lesions in 212 regions-of-interest, which were randomly selected to represent lesions of various sizes as well as negative findings. Receiver-operator-characteristic was performed. RESULTS: Three hundred twenty-one nodules were found in 30 patients by multidetector computed tomography. Sensitivity and specificity of MRI to detect pulmonary nodules larger than 3 mm on a per-patient basis were 81.8% and 94.7%, respectively. On a per-lesion basis, MRI revealed a sensitivity of 79.0% to 80.7% for lesions larger than 3 mm, if high conspicuity ratings were counted as positive, and 84.6%, if medium and high conspicuity ratings were counted as positive. Sensitivity increased uniformly with lesion size, and all lesions larger than 12 mm were detected. Receiver-operator-characteristic analysis revealed a mean accuracy of 0.90 and sensitivities over 90% for lesions larger than 3 mm with a specificity of 96.1%. For lesions larger than 6 mm the accuracy was 0.99. CONCLUSION: Detection of pulmonary nodules with a move-during-scan turbo inversion recovery magnitude sequence is feasible. Excellent detection of lesions larger than 6 mm is achievable with free-breathing moving-table MRI.

Torsion of malignant ovarian tumors in childhood and adolescence.

AIM: To investigate the frequency of torsion of malignant ovarian tumors in children and adolescents. METHODS: We evaluated all patients treated for adnexal torsion in a tertiary care referral pediatric institution during the last 20 years. Presentation, tumor markers and pathology reports were evaluated. We reviewed the literature on torsion of malignant ovarian tumors. RESULTS: Ninety-two girls (age 6 months to 19 years), 41 of them premenarchal, were surgically treated for adnexal torsion. Symptoms and signs that led to clinical investigation and subsequent surgery were not specific. Histological findings of torsioned masses showed 69 non-neoplasms and 23 tumors, including five malignant. Origin of the malignant disease included four germ cell tumors and one sex-cord stromal tumor. The morphology index score for malignant tumors was > or = 7 in all five patients. Tumor markers were elevated in 12 patients, including four of the patients with malignant tumors. Complete staging was performed in three adolescents with stage Ia, IIa and IIIa of disease. We found tumor origin for 11 previous reported patients with torsion of malignant ovarian tumor, including seven germ cell and four granulosa cell tumors. CONCLUSION: Torsion of malignant ovarian tumors in pediatric and adolescent patients occurs very rarely, but it is nevertheless possible at any stage of disease. The most common torsioned malignant ovarian tumors were of germ cell origin, in both premenarchal and postmenarchal girls. A torsioned adnexal mass with index > or = 7 needs to be considered as a potential malignant tumor.

Beneficial long term effect of a phosphodiesterase-5-inhibitor in cirrhotic portal hypertension: A case report with 8 years follow-up.

Non-selective beta-blockers are the mainstay of medical therapy for portal hypertension in liver cirrhosis. Inhibitors of phosphodiesterase-5 (PDE-5-inhibitors) reduce portal pressure in the acute setting by > 10% which may suggest a long-term beneficial effect. Currently, there is no available data on long-term treatment of portal hypertension with PDE-5-inhibitors. This case of a patient with liver cirrhosis secondary to autoimmune liver disease with episodes of bleeding from esophageal varices is the first documented case in which a treatment with a PDE-5-inhibitor for eight years was monitored. In the acute setting, the PDE-5-inhibitor Vardenafil lowered portal pressure by 13%. The portal blood flow increased by 28% based on Doppler sonography and by 16% using MRI technique. As maintenance medication the PDE-5-inhibitor Tadalafil was used for eight consecutive years with comparable effects on portal pressure and portal blood flow. There were no recurrence of bleeding and no formation of new varices. Influencing the NO-pathway by the use of PDE-5 inhibitors may have long-term beneficial effects in compensated cirrhosis.

Glutathione S-transferase (GST) polymorphism could be an early marker in the development of polycystic ovary syndrome (PCOS) - an insight from non-obese and non-insulin resistant adolescents.

INTRODUCTION: It has been supposed that endocrine disturbances might be responsible for polycystic ovary syndrome (PCOS)-associated oxida-tive stress, with special emphasis on hyperandrogenism. Considering the potential relationship between hyperandrogenism and increased free radical production, parameters of oxidative stress were determined in non-obese normoinsulinemic adolescent girls newly diagnosed with PCOS. MATERIALS AND METHODS: Nitrotyrosine, thiol group concentrations, glutathione peroxidase, and superoxide dismutase activities were determined under fasting conditions and during oral glucose tolerance test (OGTT) in 35 PCOS patients and 17 controls. Insulin resistance was assessed by the homeostasis model (HOMA-IR), HOMA ß, insulinogenic index (IGI), Matsuda insulin sensitivity index (ISI), and AUC for glucose. Glutathione S-transferases (GSTs) polymorphisms were determined by PCR. RESULTS: Under fasting conditions, no significant difference of oxidative stress parameters was found between PCOS and controls. Acute hyperglycaemia during OGTT induced significant alteration in parameters of oxidative protein damage in PCOS patients. Alteration in nitrotyrosine concentrations correlated with testosterone, DHEAS, androstenediones, FAI, and LH, while changes in thiol groups cor-related with DHEAS. Significant inverse association was found between LH and ISI, as well as AUC glucose and thiol groups. PCOS girls, carriers of GSTM1-null genotype, had significantly lower testosterone in comparison to ones with GSTM1-active genotype. CONCLUSIONS: PCOS girls exhibited high free radical production together with unchanged antioxidant enzymatic capacity, independently from obesity and insulin resistance. Based on associations between oxidative stress parameters and testosterone, DHEAS, and androsten-edione, it can be suggested that increased free radical production, probably as a consequence of hyperandrogenaemia, is an early event in the development of PCOS.

Ovarian Preservation from Tumors and Torsions in Girls: Prospective Diagnostic Study.

STUDY OBJECTIVE: To develop a new decision tree system (DTS) for the management of adnexal masses in prepubertal and adolescent girls, aimed to improve the distinction between benign and malignant masses, help preserve affected ovaries during surgery, and reduce the rate of surgical management of uncomplicated functional ovarian cysts. DESIGN: A prospective diagnostic study using clinical and ultrasound data collected for all patients younger than 19 years of age with adnexal masses managed between 2006 and 2015. SETTING: Mother and Child Health Institute of Serbia 'Dr Vukan Cupic' (Belgrade, Serbia). PARTICIPANTS: Patients (N = 1499) with adnexal masses, of whom 318 were surgically treated. INTERVENTIONS AND MAIN OUTCOME MEASURES: Ultrasonographic characteristics (Ueland's Morphology Index [MI] and the ovarian crescent sign [OCS]). Patients were managed expectantly or surgically, in line with 3 rules of the DTS. Rule 1: asymptomatic patients having a mass with MI of 4 or less and OCS present, were managed expectantly. Rule 2 (emergency): malignancy was suspected if the MI was 7 or more and no edema of the OCS was present. Rule 3 (nonemergency): malignancy was suspected if the OCS was absent and MI was 5 or more. The diagnostic accuracy was assessed using sensitivity and specificity (P < .05). RESULTS: No malignancy was found in the group of 1236 patients selected according to the DTS rule 1. Torsion was confirmed in 36% of surgically treated masses (n = 115). The OCS was present in 96% of benign masses in the non-emergency group (n = 149) and in three with microscopic malignancy. In predicting malignancy, the DTS (rules 2 and 3) showed a sensitivity of 93 (95% confidence interval [C.I.]: 82-98); and a specificity of 97 (C.I.: 95-99). Ovarian tissue was preserved from benign (n = 254, 93%) and malignant tumors (n = 3, 7%). Only five (2%) uncomplicated ovarian cysts were surgically treated. CONCLUSION: The DTS with 3 rules is a very accurate diagnostic tool in the differentiation between benign and malignant ovarian masses. The DTS rule 1 reduces the number of surgical procedures on functional cysts, rules 2 and 3 are very useful in choosing the optimal treatment of adnexal masses, whether or not they are twisted.