Adhesions small bowel obstruction in emergency setting: conservative or operative treatment?

Adhesions small bowel obstructions (aSBO) are among the leading causes of emergency operative intervention. About the 80% of aSBO cases resolve without a surgical treatment. It's important to identify which patients could undergo a conservative treatment to prevent an useless surgery The aim of this study is to determine findings that can indicate whether patients with aSBO should undergo a conservative or a surgical treatment. 313 patients with diagnosis of submission of aSBO were restudied. Patients were divided into two groups based on the different type of treatment received, 225 patients who underwent surgical treatment within 24 hours after admission, 88 patients which underwent conservative treatment successfully. For each patient, clinical, hematochemical and radiological findings have been analysed. The treatment of aSBO should be, at the beginning, conservative except that cases that presents clinical and/or CT-scan findings predictive for a surgical treatment (free peritoneal fluid, mesenterial edema, transitional point) or a peritonitis (pneumatosis intestinalis, pneumoperitoneum).

Is incidentally detected pulmonary embolism in cancer patients less severe? A case-control study.

Incidental pulmonary embolism (PE) in cancer patients is usually thought to be of mild degree. We investigated the severity of PE and evaluated the potential of raising the suspicion of PE in such patients. The computed tomography (CT) extent of PE was evaluated in 19 consecutive unsuspected and 19 randomly selected symptomatic patients. A clinical pattern useful for suspecting PE was also searched. On CT, number of embolized vessels, location of emboli, and simple instrumental findings were not different in the two groups. PE is not less severe in unsuspected cancer patients; moreover, PE may be clinically suspected in such patients.

Effect of intravenous tirofiban and aspirin in reducing short-term and long-term neurologic deficit in patients with ischemic stroke: a double-blind randomized trial.

BACKGROUND: Thrombolysis with rt-PA is the only approved pharmacological therapy for acute ischemic stroke presently administrable in a 3-hour window (very recently extended to 4.5 h). After this time, the choice is limited to endovascular treatment and antiplatelet drugs, mainly aspirin (ASA), the efficacy of which in the acute phase of stroke has poorly been evaluated. We compared the efficacy of tirofiban, a GP-IIb/IIIa inhibitor, and ASA, with both drugs being administered within 6 h. METHODS: 150 patients were randomly assigned to treatment with tirofiban or ASA, both given for 3 days in a double-blind regimen. Major inclusion criteria were stroke onset within 6 h and a baseline National Institute of Health Stroke Scale (NIHSS) score of 5-25. Outcome variables were the proportion of patients with a NIHSS score reduction of > or =4 points after 72 h, and the proportion of patients with an mRS score of 0-1 at 3 months. RESULTS: The trial, originally planned to enroll 300 patients, was halted after enrollment of 150 patients at interim analysis due to the lack of a trend difference between the 2 treatment groups. Neurological improvement at 72 h was observed in 56% of the patients in each group. At the 3-month follow-up, minimal or absent disability was seen in 45% of the patients in the tirofiban group and 53% in the ASA group; these differences were not statistically significant. Three-month mortality was the same in both groups (10.6%); the rates of symptomatic intracranial hemorrhage were 1% (tirofiban) and 4% (ASA). CONCLUSION: In spite of the fact that the null hypothesis was not supported by our data, we found results supporting the safety (and potential efficacy) of ASA and tirofiban when used in the first hours of acute ischemic stroke. However, this needs to be confirmed by further studies.

Value of chest radiography in phenotyping chronic obstructive pulmonary disease.

The objectives of the present study were to reappraise chest radiography for the diagnosis of emphysema, using computed tomography (CT) as the reference standard, and to establish whether or not chest radiography is useful for phenotyping chronic obstructive pulmonary disease (COPD). Patients (n = 154) who had undergone posteroanterior and lateral chest radiography and CT for diagnostic purposes were studied. CT data were scored for emphysema using the picture-grading method. Chest radiographs were examined independently by five raters using four criteria for emphysema that had been validated against lung pathology. These criteria were then used to assess the prevalence of emphysema in 458 COPD patients. Patients with and without evidence of emphysema were compared with regard to age, sex, smoking history, body mass index (BMI), forced expiratory volume in one second (FEV(1)), diffusing capacity of the lung for carbon monoxide (D(L,CO)) and health status. Chest radiography yielded a sensitivity of 90% and a specificity of 98% for emphysema. Of the 458 COPD patients, 245 showed radiological evidence of emphysema. Emphysemic patients had a significantly lower BMI, FEV(1) and D(L,CO), greater restriction of physical activity and worse quality of life than nonemphysemic patients. There was no difference across the two groups with regard to age, sex or smoking history. Chest radiography is a simple means of diagnosing moderate-to-severe emphysema. It is useful in phenotyping chronic obstructive pulmonary disease and may aid physicians in their choice of treatment.

Low-density lipoprotein oxidation in essential hypertension.

OBJECTIVES: To investigate the occurrence of enhanced low-density lipoprotein (LDL) oxidation as an additional factor promoting atherosclerosis progression in hypertensive patients. DESIGN: The oxidation of plasma LDL was investigated in a group of untreated patients with mild-to-moderate essential hypertension without clinically evident target organ damage and in a group of control subjects. METHODS: LDL oxidation was evaluated as both the susceptibility to oxidation in vitro and the presence of plasma anti-oxidized LDL antibodies (as an index for oxidation in vivo). RESULTS: LDL from hypertensive subjects exhibited enhanced susceptibility to oxidation in vitro as revealed by early and accelerated generation of conjugated dienes after exposure to CuSO4. Vitamin E concentration in LDL from hypertensive subjects was slightly but significantly decreased and its efficiency in protecting LDL from oxidation was impaired. Furthermore, a higher plasma anti-oxidized LDL titre was found in hypertensive patients. Subclass analysis revealed that the contemporary presence of hypercholesterolaemia did not significantly modify either the increased susceptibility of LDL to oxidation or the presence of plasma anti-oxidized LDL antibodies detected in hypertensive patients. Moreover, no correlation was found between LDL oxidation parameters and blood pressure values. CONCLUSIONS: LDL from hypertensive patients is more susceptible to oxidation in vitro and is more promptly oxidized in vivo. These findings suggest a possible participation of LDL oxidation in promoting and accelerating the atherosclerosis that often develops in hypertensive patients.

Aortobronchial fistula after coarctation repair and blunt chest trauma.

A 34-year-old man had development of an aortobronchial fistula 17 years after patch aortoplasty for correction of aortic coarctation and 5 years after blunt chest trauma, an unusual combination of predisposing factors. The clinical presentation, characterized by dysphonia and recurrent hemoptysis, and the surgical findings suggested the posttraumatic origin of the fistula, which was successfully managed by aortic resection and graft interposition under simple aortic cross-clamping, associated with partial pulmonary lobectomy. When hemoptysis occurs in a patient with a history of an aortic thoracic procedure, the presence of an aortobronchial fistula should be suspected. Early diagnosis offers the only possibility of recovery through a lifesaving surgical procedure.

Metabolic risk factors in white coat hypertensives.

Metabolic disturbances such as hyperinsulinaemia, dislipoproteinaemia and glucose intolerance are often associated with essential hypertension and markedly affect cardiovascular morbidity in hypertensive patients. In order to shed some light on the prognostic significance of white coat hypertension (raised clinic and normal ambulatory blood pressure), we compared the metabolic profile in a group of white coat and sustained previously untreated hypertensives. We studied 84 newly detected hypertensive patients (49 men, 35 women, 47 +/- 8 years, range 28-59 years). Subjects with obesity (BMI > 30), NIDDM and target organ damage were excluded. Ambulatory blood pressure monitoring was performed by SpaceLabs 90207-31. Total cholesterol and triglycerides, LDL-cholesterol, HDL-cholesterol (HDL-C) and subclasses HDL2 and HDL3 cholesterol as well as apolipoprotein A1 and B were measured in fasting plasma. Glucose and insulin were determined in fasting and postload (glucose 75 g plasma. Twenty patients (24%, 8 men and 12 women) were classified as white coat hypertensives. No differences in age, BMI and waist to hip ratio were observed between white coat and sustained hypertensive patients. Plasma glucose and lipoprotein levels were similar in the two groups. Fasting and postload insulin levels were significantly lower in white coat hypertensives (fasting insulin 7.1 +/- 2.9 vs. 12 +/- 8.6 microU/ml, P < 0.02; insulin 120 minutes 48 +/- 27 vs. 65 +/- 41 microU/ml, P < 0.05); glucose/insulin rate was higher in white coat than in sustained hypertensive patients (15 +/- 7 vs. 11 +/- 7, P = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Digital subtraction radiography in voiding cystourethrography.

Digital subtraction radiography (DRS) was utilized to evaluate the anatomy and function of the bladder and urethra. Images were obtained in 30 patients, following urography or retrograde cystography, with full bladder distention and during different phases of micturition. The technique permits good demonstration of several anatomical and functional parameters (lowering of bladder base; dynamic origin of trigonal canal; rotation of the urethra; bladder wall motion).

Influence of bulla volume on postbullectomy outcome.

OBJECTIVE: To quantify the contribution of the resected volume and the presence of associated, functionally significant emphysema to the postoperative improvement of pulmonary function after resection of giant lung bullae. DESIGN: Patients undergoing elective surgery for giant bullae who had had complete pulmonary function and radiographic studies performed were reviewed retrospectively. SETTING: All 25 patients underwent surgery at the thoracic surgery unit of the University of Pisa, Pisa, Italy. METHODS: Pulmonary function was assessed before and 12 months after surgery. On the chest radiograph, the location of bullae, and the signs of compression and emphysema were evaluated. The radiographic total lung capacity (TLC(x-ray)) and the volume of bullae were measured according to the ellipse method. Postoperatively, functional and radiographic changes were analyzed. The percentage change in forced expiratory volume in 1 s (Delta FEV(1)%) after surgery was the main outcome measure. The influence of factors related to emphysema and bulla volume on the functional improvement postbullectomy was assessed by stepwise multiple regression. RESULTS: Before surgery, the TLC(x-ray) overestimated the TLC measured by nitrogen washout, with a mean difference between the two measurements of 1.095 L. A close relationship was found between the TLC(x-ray) and the plethysmographic TLC (n=6; r=0.95). After surgery, dyspnea lessened (P<0.05) and FEV(1) increased (P<0.01). Statistically, the radiographic bulla volume was the single most important factor determining the Delta FEV(1)% (r=0.80, P<0.0001). CONCLUSIONS: These findings suggest that the preoperative size of bullae is the most important contributor to the improvement in ventilatory capacity after bullectomy, and that it is possible to predict the expected increase of postoperative FEV(1) from preoperative bulla volume.

Ischemic-type biliary lesions in liver transplant recipients: evaluation with magnetic resonance cholangiography.

We assessed the diagnostic value of magnetic resonance cholangiography (MRC) when evaluating ischemic-type biliary lesions in the follow-up of liver transplant patients. We retrospectively reviewed magnetic resonance imaging and MRC of 28 liver transplant recipients with ischemic changes of the biliary tree. The MR examinations were performed at 1.5 T. After the acquisition of axial T1w and T2w sequences, MRC involved a coronal respiratory-triggered, fat-suppressed, two-dimensional, thin-slab, heavily T2w fast spin-echo sequence, and/or a coronal breath-hold, thin- and thick-slab, single-shot T2w sequence. Eleven patients underwent either surgical reconstruction of the biliary system (n = 4) or liver retransplantation (n = 7); the pathologic specimens were employed as standard of reference. The final diagnosis was obtained through direct cholangiography in the remaining cases. Without knowledge of the surgical, pathologic, and cholangiographic findings, two experienced investigators evaluated in conference the MR images to determine the presence of biliary tract abnormalities. MRC demonstrated strictures involving the hepatic bifurcation and the extrahepatic bile duct of the graft in 26 patients; a concomitant thickening of the biliary wall was described in 18 out of these 26 subjects. MRC also showed sludge or stones formation in the donor common bile duct in 16 out of these patients. In conclusion, MRC allows noninvasive, reliable, assessment of ischemic-type biliary lesions in liver transplant recipients.

Low-density lipoprotein oxidation and antioxidized LDL antibodies in peritoneal dialysis patients.

Due to the potential atherogenic effects of oxidized low-density lipoproteins (LDLs), LDL oxidation was studied in a group of uremic patients on chronic peritoneal dialysis. The results were compared with those obtained in a group of 70 controls, 10 uremic patients on predialytic conservative therapy, and 11 patients on repetitive hemodialysis. LDL oxidation was evaluated in all subjects as the susceptibility to in vitro oxidation (monitoring the resistance to Cu(2+)-induced formation of conjugated dienes, lag-phase minutes) and the presence of plasma antioxidized LDL antibodies, expressed as the ratio anti-ox-LDL/antinative LDL antibodies. Vitamin E (main antioxidant agent) content in LDLs was also measured and the lipid profile studied. No significant changes in vitamin E concentration were found, although LDLs from uremic patients appeared more susceptible to in vitro and in vivo oxidation (as demonstrated by an earlier production of conjugated dienes and by the presence of a higher antibody ratio), as compared to control subjects. Analysis of the different groups of uremic patients revealed that peritoneal dialysis, not hemodialysis, significantly ameliorated the oxidation markers. However, prolonged treatment with peritoneal dialysis caused a decrease in vitamin E concentration in LDLs and increased their susceptibility to oxidation.

Chloroquine versus pyrimethamine/sulphadoxine in the treatment of uncomplicated P. falciparum malaria in northern Kenya.

The response of P. Falciparum to chloroquine (CQ) and pyrimethamine-sulphadoxine (PSD) in vivo was investigated in 173 indigenous uncomplicated malaria patients at Sololo Hospital, Moyale district in northern Kenya. All the patients were symptomatic and parasitaemic. They were divided in two age groups (children < 10 years, adults > 10 years). They were randomly assigned to receive either CQ or PSD standard treatment and then followed up at 7 and 14 days. In the child group, out of 91 patients enrolled, 65 (71.4%) completed the seven-day study; among these 38 (17 females and 21 males with mean age of 41.9 months) were treated with CQ and 27 (11 females and 16 males with mean age 39.1 months) with PSD. Parasites were significantly (p < 0.001) more resistant to CQ (18/38, 47.4%) than PSD (0/27, 0%). In the adult group, out of 82 patients enrolled, 54 (65.9%) completed the 7-day-study, and among these 27 (10 females and 17 males with mean age of 22.5 years) were treated with CQ and 27 (11 females and 16 males with mean age of 23.2 years) with PSD. Parasites were significantly (p = 0.01) more resistant to CQ (7/20, 25.9%) than PSD (0/27, 0%). Overall, considering the 119 patients who completed the follow-up, the resistance of P. falciparum was significantly higher (p < 0.001) to CQ (25/65, 38.5%) than to PSD (0/54, 0%). Out of the 94 patients with negative slide at day 7, fifty seven came at the control of the day 14 (30 children and 27 adults). Among them, 22 were in CQ group and five were found positive (22.7%), while the 35 patients in PSD group all tested negative (p = 0.006). The resistance to CQ in the children group was 25% (p = 0.05) and 20% in the adult group (p = 0.13). We conclude that the significant parasitological resistance to CQ in the area under study questions the continued use of CQ as first line antimalarial treatment. On the contrary, PSD can still be considered a very effective drug against P. falciparum in northern Kenya.

Tumoral calcinosis: case report.

Tumoral calcinosis (TC) is a rare disease of obscure aetiology. In its classic form, it is characterised by solitary or multiple large foci of mineralisation in the soft tissue adjacent to the bone around large joints in the absence of disorders of calcium metabolism and visceral calcification. A case is presented of TC in a 75-year old Kenyan woman.

[Oxidation of low-density lipoproteins. Correlation between reduced resistance in vitro and increased oxidation in vivo]. / Oxydation des lipoprotéines de basse densité. Corrélation entre une résistance réduite in vitro et une oxydation augmentée in vivo.

OBJECTIVES: The oxidation of low-density lipoproteins has been recently proposed as one of the critical factors in promoting atherogenesis. This process results from the balance between the prooxidant stimuli and the endogenous antioxidants present in LDL and strictly depends on the concentration of oxidizable substrates, namely unsaturated fatty acids. METHODS: Twelve male hypertriglyceridaemic patients were investigated before and after oral supplementation with omega-3 polyunsaturated fatty acids (PUFA) and compared with eighteen untreated healthy matched control subjects. The plasma lipid profile was measured in all patients. LDL oxidation was evaluated as both the susceptibility to in vitro oxidation and the presence of plasma anti-oxidized LDL antibodies (as a marker for in vivo oxidation). RESULTS: Omega-3-fatty acid supplementation caused a significant reduction in plasma triglyceride level (267 +/- 38 vs 375 +/- 33 mg/dl, p < 0.01) and decreased the resistance of LDL to oxidation as revealed by an early and accelerated generation of conjugated dienes following exposure to CuSO4 (105.3 +/- 7 vs 133 +/- 9.3 min, p < 0.01). Moreover, the concentration of the antioxidant vitamin E in LDL was slightly but significantly decreased at the end of the treatment (2.59 +/- 0.19 vs 2.89 +/- 0.17 nmol/mg LDL, p < 0.05), but its efficiency in preventing LDL oxidation was unaltered. Furthermore, a marked increase of the plasma anti-oxidised LDL antibody titre was found in nearly all patients at the end of the treatment (2.08 +/- 0.48 vs 1.37 +/- 0.2 anti-oxidised/anti-native LDL antibody ratio, p < 0.001). CONCLUSION: These results indicate that PUFA supplementation decreases the resistance of LDL to in vitro oxidation and that this decreased resistance is accompanied by an enhanced LDL oxidation in vivo.

[Autoantibodies against oxidised low density lipoproteins in patients with coronary disease]. / Autoanticorps contre les lipoprotéines de basse densité oxydées chez des patients coronariens.

OBJECTIVES: Evidence has been obtained indicating that oxidation of low-density lipoproteins (LDL) plays a relevant role in the pathogenesis of atherosclerosis and it has been proposed that, due to the antigenic properties of oxidized LDL, the anti-oxLDL antibody titre could represent a useful index of in vivo LDL oxidation. METHODS: Sixty-nine control subjects and 64 patients scheduled for selective coronary revascularization were investigated before surgery. RESULTS: The coronary disease patients had a higher level of total plasma cholesterol, LDL cholesterol and triglycerides, and a lower level of HDL cholesterol. Plasma anti-oxLDL antibody titre was measured as the ratio of antibody binding to CuSO4-oxidised LDL versus native LDL. The antibody ratio was higher in coronary patients as compared with control subjects (1.56 +/- 0.5 vs 1.0 +/- 0.3, p < 0.01). A ratio higher than 1.34 (mean of controls +/- one standard deviation) was present in 60% of the coronary patients. Subclass analysis indicated that the presence of diabetes mellitus and hypercholesterolaemia (but not of hypertension, generalized arteriosclerosis, myocardial infarction and cigarette smoking) increased the anti-oxLDL antibody ratio to 1.72 +/- 0.4 and 1.68 +/- 0.3 respectively. CONCLUSION: The results obtained indicate that a) a high titre of anti-oxLDL antibodies is present in plasma of patients with coronary atherosclerosis, b) in these patients LDL oxidation takes place in vivo and probably plays a critical role in the development and progression of atherosclerosis.

[Effectiveness and tolerability of simvastatin in subjects with primary hypercholesterolemia. Multicenter study]. / Efficacia e tollerabilità della simvastatina in soggetti con ipercolesterolemia primitiva. Studio policentrico.

The efficacy and safety of simvastatin were evaluated in an open multicenter study over a 24-week period. One hundred seventy-two patients (91 men, 81 women) with primary hypercholesterolemia (mostly polygenic) were enrolled in 14 Centers in Northern Italy. The mean age was 55.8 +/- 9.7 years and the mean baseline total cholesterol level was 305 +/- 59 mg/dL. After 4 weeks on an AHA step 1 diet, patients who met the inclusion criterion (total cholesterol > or = 250 mg/dL) were given simvastatin 10 or 20 mg in the evening. The dose could be titrated up to a maximum of 40 mg o.d. at week 6 and 12. No dose titration was allowed after week 12. One hundred forty-nine patients (86.6%) completed the study according to the protocol, 2 (1.2%) were withdrawn from the study because of adverse events not related to the drug, 21 (12.2%) were unavailable for follow-up. Simvastatin treatment was associated with a sustained dose-related reduction in total and LDL cholesterol (-28% and -39% respectively at the end of the study). Triglycerides showed a significant descending trend (-16% at week 24) and HDL-C increased by 9%. Apolipoproteins were measured in only 25 patients: apo B was reduced by 30% and apo A1 increased by 9%. Clinical side effects were not relevant. Mean levels of GOT, GPT and CPK significantly increased after 6 weeks on simvastatin, but remained stable and at any rate ioitlin the normal range thereafter. Eight patients (5.4%) experienced small transaminase level elevations (< 3ULN) and six (4%) small CPK elevations.(ABSTRACT TRUNCATED AT 250 WORDS)

[Asbestos-related lesions detected by high-resolution CT scanning in asymptomatic workers. Specificity, relation to the duration of exposure and cigarette smoking]. / Lesioni correlate ad asbesto rilevate mediante TC ad alta definizione di immagine in lavoratori asintomatici. Specificità, relazione con la durata di esposizione e con l'abitudine al fumo di sigarette.

The possibility to detect initial "preclinical" pulmonary lesions related to asbestos is under debate. The aim of this study is to report our experience. We have submitted to HRCT 70 shipyard workers with chest X-ray judged "normal" by "outside" readers (mean age 44.5 +/- 6.1 ys) with a similar grade of (low-level) exposure to amosite (mean duration of "direct"/"heavy" exposure was 4.2 +/- 4.9 ys; "environmental"/"light" exposure was 8.4 +/- 5.9 ys). Among the 70 workers, in 34 pleural plaques were shown, in 6 subjects parenchymal abnormalities alone and in 13 parenchymal and pleural abnormalities were found; in the last 17 workers no pathological finding was shown. In six subjects the presence of a combination of parenchymal abnormalities permitted us to diagnose asbestosis. The difference in the duration of exposure to asbestos for the subjects with both pleural and parenchymal involvement compared to all other groups of workers was statistically significant; also the difference in duration of exposure between workers with or without parenchymal involvement resulted significant. In a control group (20 subjects without any known professional exposure to asbestos) HRCT permitted us to identify 5 cases with small pleural plaques while only one case presented parenchymal bands; lesion frequency was significantly lower in comparison with the exposed group. Calcified plaques have been proved to be more common in the workers with heavier exposure, and no one of the reference group had calcified plaques. The CT-determined emphysema score was found to optimally correlate with smoking habit (pack/years). In conclusion our study suggests that pulmonary or pleural involvement can be shown by HRCT before the onset of any clinical symptomatology with high sensitivity and specificity. Furthermore the results seem to indicate that the prevalence of HRCT-shown parenchymal lesions and the severity of lung involvement among asbestos-exposed workers are related to the duration of exposure, as in most of clinically evident asbestos-related lung disorders, in contrast with previous observations.

Determinants of the prognosis of idiopathic pulmonary fibrosis.

OBJECTIVE: Fibrotic idiopathic interstitial pneumonias are chronic and progressive lung diseases with different prognosis, with idiopathic pulmonary fibrosis (IPF) having the worst prognosis. Many patients need a surgical lung biopsy for the definite diagnosis of IPF but age and the clinical context often contraindicate this procedure. The aim of this study is to identify predictors of survival, apart from lung biopsy, in patients with definite and possible IPF. PATIENTS AND METHODS: We studied 42 patients with HRCT pattern of definite or possible IPF, by assessing the mortality in relationship with baseline HRCT and functional findings. HRCT was assessed both as prevalent pattern (definite vs possible UIP) and as score of the different abnormalities (in particular, honeycombing (HC) and total fibrotic score). Pulmonary function was assessed as baseline FVC, TLC and DLCO values, as well as change over 6 months of follow-up. Both univariate and multivariate analyses were performed in order to detect predictors of mortality. RESULTS: During follow-up, 10 out of 42 patients died. Mortality rate was not different according to the qualitative pattern of fibrosis at HRCT. Among the different HRCT scores, a cut-off of 15% in the HC score differentiated patients with higher mortality rate. A lower baseline FVC, and a greater decrease in pulmonary function after 6 months, were both associated with higher mortality. In a logistic analysis taking in consideration clinical, radiological and functional findings, only baseline FVC and FVC change after 6 months resulted significant predictors of mortality. CONCLUSIONS: Functional evaluation at the baseline and during follow-up is more relevant than HC score for the prognosis of patients with definite and possible IPF.

Dose exposure in the ITALUNG trial of lung cancer screening with low-dose CT.

Few data are available on the effective dose received by participants in lung cancer screening programmes with low-dose CT (LDCT). We report the collective effective dose delivered to 1406 current or former smokers enrolled in the ITALUNG trial who completed 4 annual LDCT examinations and related further investigations including follow-up LDCT, 2-[(18)F]flu-2-deoxy-d-glucose positron emission tomography (FDG-PET) or CT-guided fine needle aspiration biopsy (FNAB). Using the air CT dose index and Monte Carlo simulations on an anthropomorphic phantom, the whole-body effective dose associated with LDCT was determined for the eight CT scanners used in the trial. A value of 7 mSv was assigned to FDG-PET while the measured mean effective dose of CT-guided FNAB was 1.5 mSv. The mean collective effective dose in the 1406 subjects ranged between 8.75 and 9.36 Sv and the mean effective dose to the single subject over 4 years was between 6.2 and 6.8 mSv (range 1.7-21.5 mSv) according to the cranial-caudal length of the LDCT volume. 77.4% of the dose was owing to annual LDCT and 22.6% to further investigations. Considering the nominal risk coefficients for stochastic effects after exposure to low-dose radiation according to the National Radiological Protection Board, International Commission on Radiological Protection (ICRP) 60, ICRP103 and Biological Effects of Ionizing Radiation VII, the mean number of radiation-induced cancers ranged between 0.12 and 0.33 per 1000 subjects. The individual effective dose to participants in a 4-year lung cancer screening programme with annual LDCT is very low and about one-third of the effective dose that is associated with natural background radiation and diagnostic radiology in the same time period.