ENT involvement and orobuccal movements' disorders in Pandas patients: assessment and rehabilitations tools.

OBJECTIVE: PANDAS are known as the spectrum of autoimmune pathologies related to a previous or current infection by group A beta-hemolytic streptococcus (SBEGA), dealing with several neuropsychiatric manifestations that mainly affect pediatric age. The main features consist of behavioral disease or movement disease characterized by acute-onset, presenting especially through infant period or adolescence. Specific manifestations, occurring during the progression of the disease, are the presence of otorhinolaryngologic symptoms (ENT) and orofacial movement disorders associated with temporomandibular joint pain. PATIENTS AND METHODS: We enrolled 130 children (5-15 years) with a clinical diagnosis of PANDAS between 2012 and 2018. Participants were assessed using ENT specific parameters, PSG to examine respiratory disorders and conventional audiological evaluation. Descriptive and comparative statistical analyses were performed with a control group of 51 healthy patients. RESULTS: The prevalence of ENT symptoms associated was significantly detected in 88 patients of 130 in Group A (relative frequency (%) 67.6; p=0.041) and in 51 patients of 130 in the control Group B (relative frequency (%) 39.2; p=0.063). In relation to prevalence of SDB, 54 subjects have presented nocturnal respiratory obstructive symptoms from mild to severe (relative frequency (%) 61.3; p=0.033) vs. 20 patients of Group B (relative frequency (%) 39.2; p=0.055). The obstructive severity average type was correlated to the consensual adenotonsillar development (size 3-4), (relative frequency (%) 45.4; p=0.047). The audiological deficits found were mostly of transmissive type with OME correlated and linked to the presence of occasional episodes of AOM. The four PANDAS patients who presented orobuccal dystonia (relative frequency (%) 4.54; p=0.091) achieved an improvement of the algic symptoms through the exercises of self-rehabilitation. CONCLUSIONS: Findings from our study show that respiratory diseases, characterizing a group of patients with pandas, are the direct consequences of the malformed or hypertrophic condition and suggesting in these conditions surgical therapy as an approaching tool.

[Radiologic assessment of femoro-patellar instability. Personal experience and review of the literature]. / Valutazione radiologica dell'instabilità femoro-rotulea. Esperienza personale e revisione della letteratura.

PURPOSE: To propose a simple and reproducible radiological evaluation of patellofemoral instability to enable the orthopaedic surgeon to choose the best therapy. MATERIAL AND METHODS: We have evaluated retrospectively the radiographs and CT examinations of 25 patients, 15 female and 10 male, aged between 18 and 32 years. They underwent surgical treatment for patellar instability in the past 4 years. Lateral retinacular release has been performed in every patient, medial transposition of the anterior tibial tuberosity has been performed in 23 patients and in 5 of them also its distal replacement, proximal Insall's realignement was performed in 20 cases and only 1 patient underwent trochleoplasy. Preoperative conventional radiographs included antero-posterior view, true lateral view (exact superimposition of the posterior trochlear edges) and axial views at 30 degrees of knee flexion. On lateral view, the patellar height was evaluated based on Caton-Deshamps index and trochlear dysplasia assessed using the methods suggested by Dejour. A CT examination of both knees was performed: the images were taken first with knees in extension, with and without quadriceps contraction, then in flexion at 20 degrees. Patellar "bascùle" angles were measured both with quadriceps relaxed and contracted as an index of quadriceps dysplasia; the TAGT in extension was evaluated as an index of the degree of lateral position of the anterior tibial tuberosity. Preoperative conventional and CT findings were compared with those obtained postoperatively at 30.4 months from the surgical intervention. RESULTS: All patients were free from complaints after surgery. In 5 patients a high patella was corrected by distal realignement of anterior tibial tuberosity. A trochlear dysplasia with different degrees of severity was present in all cases and it was not modified by surgical treatment, with the exception of the patient who underwent trochleoplasty. In the 20 patients who underwent proximal Insall's realignment, patellar "bascùle" angles--pathological before surgery--were restored to normal values with the exception of 3 cases. In 23 patients who underwent medial transposition of anterior tibial tuberosity, the values of the TAGT were all normalized: nevertheless, in three patients low values of the TAGT were found after surgery and this condition may predispose to the development of medial patellofemoral by iperpression syndrome. CONCLUSIONS: In patients suffering from patellofemoral instability, a radiological protocol which includes conventional radiographs in two projections and a CT examination both in extension, with and without quadriceps contraction, and in flexion at 20 degrees supplies all the information needed for evaluating patellar height and mobility, trochlear dysplasia, valgism of the knee and the degree of excessive lateral position of the anterior tibial tuberosity. Careful evaluation of such abnormalities is important for selecting the best surgical treatment for each patient. It's a simple, quick, and accurate protocol that may be reproduced, even using different radiographic equipment. The collaboration between the radiologist and the orthopaedic surgeon is crucial for the correct interpretation of radiological findings, which must be evaluated together with clinical findings so that an adequate therapeutical plan could be proposed.

Neuropsychological assessment in children with absence epilepsy.

OBJECTIVE: To define cognitive deficits in children with absence epilepsy. BACKGROUND: Cognitive deficits have often been reported in children with epilepsy, but have rarely been characterized in patients with a specific epileptic syndrome. METHODS: Detailed neuropsychological testing was carried out on 16 right-handed children with absence epilepsy with similar clinical and EEG findings, and the findings were compared to 16 well-matched right-handed children without absence epilepsy. RESULTS: The authors found lower scores of measures of general cognitive functioning and visuospatial skills in patients with absence epilepsy, as compared to controls. Memory disturbances were also detected in absence epilepsy patients, with selective involvement of nonverbal memory and delayed recall. In contrast, verbal memory and language skills were relatively preserved. Patients whose seizures began at an earlier age seemed to have more severe cognitive deficits. CONCLUSION: Language skills tend to be relatively well preserved in children with generalized epilepsy, with more dysfunction seen in global terms rather than specific lateralizing deficits. Patients with absence epilepsy seem to show a similar neurocognitive profile that may be a reflection of the underlying epilepsy syndrome.

[Shoulder diseases in throwing athletes: radiologic assessment and surgical correlation]. / Patologie della spalla del lanciatore: valutazione radiologica e correlazioni chirurgiche.

Lesions of the shoulder, especially rotator cuff tears and glenoid labrum (SLAP) lesions, are commonly caused by traumatic episodes in athletes such as repeated trauma from throwing. The available radiological methods are MRI, CT and MR arthrography. Twelve athletes suffering from shoulder pain or instability have been studied and then underwent successful treatment in arthroscopy. On the basis of our results and experience, we think that MR, especially with intra-articular injection of contrast medium, is the best examination because it offers an accurate evaluation of both rotator cuff and glenoid labrum. Nevertheless difficulties are often encountered and definitive diagnosis sometime rests on arthroscopic exploration.

[Femoro-patellar instability: radiologic assessment]. / Instabilità femoro-rotulea: valutazione radiologica.

To propose a simple and reproducible radiological evaluation of the patellofemoral instability that enables the orthopaedic in choosing the best therapy. The radiographs and CT examinations of 55 patients, 38 female and 17 male (range 18-32 years) have been evaluated retrospectively. Twenty-height of them underwent surgical treatment for patellar instability. A radiological protocol which includes conventional radiographs in two projections and a CT examination both in extension, with and without quadriceps contraction, and in flexion at 20 degrees allows to give all the informations one's need for evaluating patellar height and mobility, trochlear dysplasia, valgism of the knee and the degree of excessive lateral position of the anterior tibial tuberosity. It's a simple, quick, accurate and reproducible protocol to do, even with different radiological systems.

High resolution computed tomography (HRCT) assessment of beta 2-agonist induced bronchodilation in chronic obstructive pulmonary disease patients.

The evaluation of airway obstruction reversibility in chronic obstructive pulmonary disease (COPD) patients is currently performed by means of an indirect assessment of drug inducing variations in pulmonary function tests. Imaging techniques, especially high resolution computed tomography (HRCT), usually provide a complete evaluation of lung parenchyma (bronchial and vascular structures), but so far they have never been applied to visualize the effects on the bronchopulmonary tree of some pharmacologic stimuli (beta 2 adrenergic agonist), currently used in clinical practice to disclose the presence of airway reversibility. In order to assess the possible role of HRCT in this setting, five COPD patients have been subjected to a double functional radiologic evaluation before and after salbutamol-induced broncho-dilation, with a rigorous assessment of bronchial diameter changes by means of "bronchus-vessel" ratio, currently used for diagnosing bronchiectasis in COPD patients. The results of this experimental study enable us to visualize drug induced broncho-dilation, with a direct assessment of airway reversibility in these patients, and to show a good correlation between functional and HRCT findings, raising the possibility of evaluation COPD patients with abnormal spirometric results or with early signs of lung involvement.

Pancreatic adenocarcinoma: combination of MR imaging, MR angiography and MR cholangiopancreatography for the diagnosis and assessment of resectability.

The purpose of this study was to determine the possibility of integrating MR cholangiopancreatography (MRCP) and MR angiography (MRA) to conventional MR images in the diagnosis and assessment of resectability of pancreatic adenocarcinoma. Twenty-three patients with pancreatic adenocarcinoma were prospectively examined with MR. Conventional MR images were acquired in all patients. Three-dimensional MRCP and MRA images were acquired in all patients with suspected biliary and vascular involvement. Acquisition time was less than 45 min in all cases. Images were independently evaluated by two radiologists, with final reading decided by consensus among readers. Diagnosis was confirmed with surgery in 16 patients and with percutaneous biopsy in 7. Concordance among readers was high with a kappa value of 0.83. Pancreatic adenocarcinoma was observed in all patients. Correct assessment of unresectability due to vascular involvement was found in 22 of 23 patients. Biliary obstruction was evident in 13 patients, involving the biliary and pancreatic ducts in 9 and the biliary ducts only in 4. Technical advances permit extensive use of MRI in the evaluation of abdominal pathologies. The combination of MR imaging, MRCP, and MRA can provide sufficient information for the diagnosis and assessment of resectability of pancreatic adenocarcinoma, which otherwise would require three different exams.

[Cholangiopancreatography with magnetic resonance in the assessment of pancreatic ducts]. / La colangiopancreatografia con Risonanza Magnetica nella valutazione del dotto pancreatico.

We investigated MR cholangiopancreatography (MRCP) findings in patients with pancreatic conditions, which are mainly diagnosed based on US and CT morphologic findings. Sixty-three patients were submitted to MRCP using a .5T magnet. MRCP was performed with non-breath-hold fat-suppressed 3D turbo spin echo sequences (TR = 3000 ms, TE = 700 ms, ETL = 128, NEX = 6) with 3 min acquisition time. For better depiction of Wirsung duct and secondary ducts in the last 11 patients, a high resolution technique with a 128 x 256 matrix, 8 NEX and 8 min 36 s acquisition time was developed. MRCP images were studied both on MIP reconstructions and on single slices as well as T1- and T2-weighted TSE axial images. The diagnosis was compared with endoscopy, percutaneous procedure or CT findings in all cases. A hypointense focal mass was observed on T1-weighted TSE images in 39 pancreatic carcinoma patients (100%) and parenchymal atrophy was shown in 13 patients (33%); a sudden obstruction of the Wirsung duct was observed in 16 cases (41%) with homogeneous dilatation in 11 cases (28%). A tapered appearance of the distal Wirsung duct was demonstrated in 19 chronic pancreatitis patients, with diffuse patchy signal changes in 12 patients (63%); bead-like appearance of the Wirsung duct was shown in 6 cases (32%) and pseudocysts in 7 cases (37.3%). MRCP is the only imaging method demonstrating pancreatic conditions between carcinoma and pancreatitis, similarly to ERCP.

[Assessment with magnetic resonance of laryngeal and oropharyngeal movements during phonation]. / Valutazione con Risonanza Magnetica dei movimenti della laringe e della cavità faringo-buccale durante la fonazione.

The latest MR units are provided with the Turbo-Field-Echo technique which permits gradient-echo imaging with very short TE and TR and is optimized to yield the highest possible image quality within a very short acquisition time--i.e., less than 5 seconds. This dynamic study was aimed at depicting normal laryngeal and oropharyngeal movements during maximal inspiration and the prolonged uttering of vowels, in both a normal and a loud voice. We examined 10 healthy volunteers (7 men and 3 women) with an 0.5-T superconductive unit (Gyroscan T5 III, Philips Medical System). We used Turbo-Field-Echo sequences with the following acquisition parameters: TR 12 ms, TE 6 ms, flip angle 30 degrees, 4 acquisitions, acquisition time: 5 seconds. A single coronal scan was acquired at the larynx, while a midsagittal scan and 2 coronal scans were acquired at the oropharynx. The volunteers were asked to breathe in long and deep, to prolong the emission of the vowel [i] during laryngeal studies and to prolong the emission of the fundamental vowels [a], [i] and [u] in a normal (50 db) and a loud (70 db) voice during oropharyngeal studies. The movements of true and false vocal cords were clearly depicted in all the volunteers, and the activity of the different anatomical structures of the oropharyngeal cavity (lips, tongue, hard and soft palate, pharynx and epiglottis) was also demonstrated. During vowel production in a loud voice, the vocal tract was enlarged at the oral cavity for the vowels [a] and [u] and at the pharynx for the vowel [i]. To conclude, fast MRI with midsagittal scans is the best imaging modality to study different vocal tract patterns during speech and can thus replace midsagittal radiography and xeroradiography in the study of vowel production.

[Pancreatic assessment by magnetic resonance imaging: an improvement in the diagnostic results with new study technics]. / Valutazione del pancreas con Risonanza Magnetica: miglioramento dei risultati diagnostici con nuove tecniche di studio.

Magnetic resonance imaging of the pancreas has been, limited by a series of artifacts with a resulting poor contrast to noise ratio. Nevertheless, technological progress has allowed to reduce not only scanning time but also the number of artifacts, by increasing the number of excitations and matrix size. Moreover, tissue contrast can now be modified. In our study performed on 5 normal volunteers and 20 patients with different pancreatic diseases conditions, fast SE sequences with and without fat suppression were used, with an overall increase in contrast to noise ratio. In all patients MR images allowed the accurate definition of the lesions: in 8 adenocarcinoma patients the lesion could be depicted, including the 2 lesions CT had poorly demonstrated. Also in the 3 patients with endocrine tumors, MRI depicted small tumors which were later confirmed at surgery. This new protocol makes MRI a very sensitive and accurate tool in the study of neoplastic and inflammatory pancreatic diseases thus, MRI is not only a complementary tool to CT but an even better study technique. In particular, its higher contrast to noise ratio allows a dramatic improvement in the depiction of small solid lesions, especially those not altering pancreatic outline. This study proves that MRI, when adequately performed, is a very accurate tool to study, in a very short time, the pancreas and peripancreatic region, yielding much better results than all the other diagnostic imaging modalities.

[Assessment of renal function using low doses of paramagnetic contrast media]. / Valutazione della funzionalità renale mediante impiego di basse dosi di mezzo di contrasto paramagnetico.

Dynamic MR techniques with Gd-DTPA bolus administration can be used to study renal perfusion and function. In previous studies, the concentration of Gd-DTPA injected was never lower than 0.1 mmol/kg: as a result, depending on the magnetic susceptibility effect, renal signal intensity reduced in the early phases, right after contrast agent injection. To prevent signal intensity from reducing in the early phases, in our study we used a concentration of 0.05 mmol/kg. Qualitative and quantitative evaluations were performed. Seven healthy subjects and 14 patients with different degrees of renal insufficiency were enrolled in the study. All exams were performed using an 0.5-T magnet (Philips Gyroscan T5, II), with 15 mT/m gradient power. Signal intensity measurements at the cortical, external medullary and internal medullary levels, allowed the drawing of curves typical of each degree of renal insufficiency which correlated well with nuclear medicine (scintigraphy) findings. The qualitative evaluation provided results comparable with scintigraphic findings in all 7 normal subjects, in 3 of 4 cases of moderate renal insufficiency, in all 7 cases of moderate/severe renal insufficiency and in the only case of severe renal insufficiency. To conclude, this trial demonstrates the feasibility of MR studies of renal function, which provide morphological and functional pieces of information. Low concentration Gd-DTPA is decisive to avoid the magnetic susceptibility artifacts observed in previous studies.

Detailed evaluation of angiographic findings in the surgical assessment of resectability for pancreatic cancer.

The role of angiography as a diagnostic approach and surgical assessment of resectability in pancreatic cancer patients is considered. Pre-operative arteriography of the celiac axis and superior mesenteric artery was performed in 27 patients with surgically proved pancreatic cancer. The operatibility of each patient was assessed according to arteriographic findings. The arteriographic features considered to establish tumor unresectability included: neoplastic arterial encasement or displacement, multiple involvement of pancreatic arteries, involvement of portal, splenic or superior mesenteric veins, liver metastasis. Nineteen angiographically predicted unresectable lesions proved to be unresectable at surgery. Of the eight additional patients who showed no remarkable unresectable angiographic features, 6 were confirmed resectable, while 2 were unresectable. Angiography was shown to be very accurate in differentiating resectable from unresectable cancer of the pancreas.