In Vivo Analysis of Urinary Stones With Dual-Energy Computed Tomography.

OBJECTIVE: Formation mechanisms and treatment of the urinary stones are different, depending on their chemical structure. Therefore, determining the stone type plays a key role in planning treatment and preventive measures. Computed tomography (CT), with the use of dual-energy technology in recent years, has made it possible to do in vivo analysis of urinary stones. In this study, we aimed to evaluate the diagnostic efficacy of dual-energy CT (DECT) and compare its results with in vitro analysis, which is accepted as a gold standard for analysis of urinary stones. MATERIALS AND METHODS: The DECT examinations were performed on 373 patients using 128-slice dual-source CT scanner. Analysis of attenuation ratios in the high and low kilovoltage peak values of the stone was performed at workstation, and stones were classified as hydroxyapatite, calcium oxalate, cystine, and uric acid. On follow-up, the stone was obtained in 35 patients as a result of surgery or passed spontaneously. The DECT analysis and in vitro analysis results were compared and statistically evaluated. RESULTS: In all patients, 136 hydroxyapatite, 160 calcium oxalate, 57 uric acid, and 20 cystine stones were detected with DECT. In vitro analyses of the stones were performed in 35 patients, and 8 hydroxyapatite, 18 calcium oxalate, 6 uric acid, and 3 cystine stones were revealed. When DECT analysis results were compared with in vitro analysis results, stone types were detected correctly in 32 (91.4%) patients and incorrectly in 3 (8.6%) patients. Especially all uric acid and cystine stones were correctly detected with DECT. CONCLUSIONS: With advanced postprocess analysis methods, DECT is able to analyze urinary stones. The DECT is found superior especially in detecting uric acid and cystine stones. Its success in detecting hydroxyapatite and calcium oxalate stones is also high. When in vivo analyses of the stones are performed with DECT, it will be possible to make a contribution to the personalization and optimization of the treatment.

Assessment of Ten-Year-Long Results of Kidney Biopsies Performed on Children in the Thrace Region of Turkey.

BACKGROUND: Many children with kidney diseases can be diagnosed and treated without a biopsy. However, biopsy is a valuable method for the diagnostic and prognostic evaluation of children with kidney diseases. AIMS: To evaluate the clinical and pathological profiles of the kidney biopsies in our department to provide epidemiological data for clinical practice. STUDY DESIGN: Retrospective cross-sectional study. METHODS: Kidney biopsies and patient's charts in pediatric patients performed between May 2005 and February 2015 at the Pediatric Nephrology Department, Trakya University School of Medicine were assessed retrospectively. RESULTS: A total of 100 patients were examined. Their mean age was 9.62±4.26 years (range: 1-17 years); 54% of the patients were girls and 46% were boys. The most frequent indication for kidney biopsy was nephrotic syndrome (33%). The most common kidney disease was primary glomerulonephritis, which was observed in 65% of cases. IgA nephropathy (24%) was the most frequently observed subtype in primary glomerulonephritis groups. Secondary glomerulonephritis was diagnosed in 35% of cases. Systemic lupus erythematosus (51%) was the most frequently observed subtype in the secondary glomerulonephritis groups. CONCLUSION: IgA nephropathy and systemic lupus erythematosus were the most frequent primary and secondary glomerulonephritis in our region among children, respectively.

A novel modified PAIR technique using a trocar catheter for percutaneous treatment of liver hydatid cysts: a six-year experience.

PURPOSE: We aimed to demonstrate the success and reliability of a novel puncture, aspiration, injection, and reaspiration (PAIR) technique in liver hydatid cysts. METHODS: Percutaneous treatment with ultrasonographic guidance was performed in 493 hepatic hydatid cysts in 374 patients. Patients were treated with a new PAIR technique by single puncture method using a 6F trocar catheter. The results of this novel technique were evaluated with regards to efficacy and safety of the procedure and complication rates. RESULTS: Out of 493 cysts, 317 were Gharbi type I (WHO CE 1) and 176 were Gharbi type II (WHO CE 3A). Of all cysts, 13 were referred to surgery because of cystobiliary fistulization. Recurrence was observed in 11 cysts one month later. Therefore, the success rate of the PAIR technique was 97.7% (469/480). Minor complications (fever, urticaria-like reactions, biliary fistula) were seen in 44 treated patients (12%, 44/374); the only major complication was reversible anaphylactic shock which was observed in two patients (0.5%, 2/374). CONCLUSION: This novel modified PAIR technique may be superior to catheterization by Seldinger technique due to its efficiency, easier application, lower severe complication rate, and lower cost. Further comparative studies are required to confirm our observations.

Fibroblast Growth Factor-23 and Carotid Artery Intima Media Thickness in Chronic Kidney Disease.

BACKGROUND: The cause of early-accelerated atherosclerosis development observed in Chronic Kidney Disease (CKD) is not fully understood. The determination of the relationship between the levels of fibroblast growth factor 23 (FGF-23) and the development of endothelial dysfunction, left ventricular hypertrophy, and myocardial infarction lends support to the possibility that FGF-23 plays a role in the development of atherosclerosis in CKD. Only a few studies, however, have been conducted that analyze the relationship between FGF-23 levels in the progression of CKD and the development of atherosclerosis, and these studies have generally been limited to those patients receiving dialysis therapy due to end stage renal disease (ESRD). METHODS: In the present study, carotid artery intima-media thicknesses (IMT) were measured ultrasonically as a marker of atherosclerosis in 91 patients with CKD stage 3 - 4 (61 female and 30 male, age between 19 - 65 years, glomerular filtration rate [GFR] 15 - 60 mL/min 1.73 m2, CKD was not related to diabetes mellitus, and without cardiovascular-cerebral disease) in contrast to 36 healthy volunteers (26 female and 10 male, age between 19 - 65 years, GFR > 90 mL/min 1.73 m2, and without any diagnoses of acute or chronic disease), and a possible role of FGF-23 on atherosclerosis was analyzed. RESULTS: Patients were similar to controls with respect to age, gender, smoking status, body mass index, and plasma glucose and lipid profile. On the other hand, IMT measurements (p < 0.00001) and FGF-23 levels (p = 0.00012) were significantly higher in patients than controls. IMT was measured above the subclinical atherosclerosis limit of 0.750 mm in 54% of the patients. Multivariate regression analysis showed that patients' age, high sensitive c-reactive protein (hsCRP), and FGF-23 levels were independent predictors of IMT (p < 0.00001, r = 0.559). Independent of other variables, every 1 µmol/L increase in FGF-23 levels resulted in 0.444 mm increase of IMT measurements in patients with CKD. CONCLUSIONS: Our findings suggest that monitoring serum FGF-23 may be useful as a non-invasive indicator of subclinical atherosclerosis in patients with chronic kidney disease.

Carotid intima media thickness is independently associated with urinary sodium excretion in patients with chronic kidney disease.

Atherosclerosis-induced premature vascular diseases are the leading cause of mortality among patients with chronic kidney disease (CKD). The pathogenetic mechanism of atherosclerosis in patients with CKD has not been fully explained. Experimental studies have demonstrated that high dietary sodium intake not only increases circulatory volume and blood pressure, but also facilitates development of atherosclerosis by reducing production-bioavailability of nitric oxide due to oxidative stress and accordingly by enhancing endothelial and arterial stiffness. In this study, we investigated the relationship between sodium consumption and carotid artery intima-media thickness, which is the indicator of atherosclerosis, by determining daily urinary sodium excretion, which is a reliable indicator of sodium consumption, in our patient group. Our patient group included 193 patients with stage 2-4 non-diabetic CKD and without a history of atherosclerotic disease. We determined that 77% of our patients have been consuming more than 2 g of sodium per day, which is the upper limit of sodium consumption recommended for patients with CKD. We determined a positive linear correlation between carotid artery intima-media thickness and patient age (p < 0.001), C-reactive protein (p < 0.001), urinary sodium excretion (p < 0.001), body mass index (p = 0.002), systolic blood pressure (p = 0.002), hemoglobin (p = 0.030), triglycerides (p = 0.043), and diastolic blood pressure (p = 0.049). We also found a negative linear correlation between carotid artery intima-media thickness and glomerular filtration rate (p = 0.008). We found that urinary sodium excretion is the determinant of intima-media thickness even if all factors associated with intima-media thickness are adjusted, and that intima-media thickness increases by 0.031 (0.004-0.059) mm per 2 g increase in daily sodium excretion, independent from overall factors (p = 0.025). Our results reveal a relation between urinary sodium excretion and carotid artery intima-media thickness and suggest that excessive sodium consumption predisposes development of atherosclerosis in patients with CKD.

Ultrasound validation of Trendelenburg positioning to increase internal jugular vein cross-sectional area in chronic dialysis patients.

BACKGROUND AND AIM: Trendelenburg positioning (TP) is a common approach used during internal jugular vein (IJV) cannulation. No evidence indicates that TP significantly increases the cross-sectional area (CSA) of the IJV or decreases the overlap between the carotid artery (CA) and the IJV in dialysis patients. The primary aim of this study was to investigate the effects of the TP on the CSA of the right IJV and on its relationship to the CA. METHODS: Thirty-seven consecutive hemodialysis patients older than 18 years of age were enrolled. We measured the CSA of the right IJV and overlap rate (at end-expiration at the level of the cricoid cartilage) between the CA and the IJV in two positions: State 0, table flat (no tilt), with the patient in the supine position; State T, in which the operating table was tilted to 15° of TP. RESULTS: Data were collected for all of the 37 patients enrolled in the study. The change in CSA and overlap between the CA and the IJV from the supine to the TP was not significantly different. The CSA was paradoxically decreased in 11 of 37 patients when changed from State 0 to State T. CONCLUSIONS: TP does not significantly increase the CSA of the right IJV or decrease the overlap between the CA and the IJV in dialysis patients. In fact, in some patients, it reduces the CSA. Therefore, the use of the TP for IJV cannulation in dialysis patients can no longer be supported.

Diffusion Weighted Magnetic Resonance Imaging for the Characterization of Solitary Pulmonary Lesions.

BACKGROUND: We evaluated the differential diagnosis of solitary pulmonary lesions on magnetic resonance imaging. AIMS: To investigate the value of diffusion weighted imaging on the differential diagnosis of solitary pulmonary lesions. STUDY DESIGN: Randomized prospective study. METHODS: This prospective study included 48 solitary pulmonary nodules and masses (18 benign, 30 malignant). Single shot echo planar spin echo diffusion weighted imaging (DWI) was performed with two b factors (0 and 1000 s/mm(2)). Apparent diffusion coefficients (ADCs) were calculated. On diffusion weighted (DW) trace images, the signal intensities (SI) of the lesions were visually compared to the SI of the thoracic spinal cord using a 5-point scale: 1: hypointense, 2: moderately hypointense, 3: isointense, 4: moderately hyperintense, 5: significantly hyperintense. For the quantitative evaluation, the lesion to thoracic spinal signal intensity ratios and the ADCs of the lesions were compared between groups. RESULTS: On visual evaluation, taking the density of the spinal cord as a reference, most benign lesions were found to be hypointense, while most of the malignant lesions were evaluated as hyperintense on DWI with a b factor of 1000 s/mm(2). In contrast, on T2 weighted images, it was seen that the distinction of malignant lesions from benign lesions was not statistically significant. The ADCs of the malignant lesions were significantly lower than those of benign lesions (mean ADC was 2.02×10(-3) mm(2)/s for malignant lesions, and 1.195×10(-3)±0.3 mm(2)/s for benign lesions). Setting the cut-off value at 1.5×10(-3), ADC had a sensitivity of 86.7% and a specificity of 88.9% for the differentiation of benign lesions from malignant lesions. CONCLUSION: DWI may aid in the differential diagnosis of solitary pulmonary lesions. (ClinicalTrials.gov Identifier: NCT02482181).

Two-detector Computed Tomography Map of the Inferior Epigastric Vessels for Percutaneous Transabdominal Intervention Procedures.

BACKGROUND: It is crucial to know anatomic variations and the exact course of an inferior epigastric artery (IEA) to prevent any complications during percutaneous abdominal interventions. AIMS: The aim of this study was to map the inferior epigastric vessels using reconstructed two-detector computed tomography images and measure the distance from the inferior epigastric artery (IEA) to the midline to determine a safe route for percutaneous abdominal interventions. STUDY DESIGN: Retrospective comparative study. METHODS: Coronal reconstructed two-detector computed tomography images of 200 patients were evaluated to measure the distances between the IEA and midline at three levels (origin, middle, and distal). Vein and artery arrangements were documented. RESULTS: The most frequently encountered arrangement (41.5%) was a single vein and artery on both sides. Mean distances on the right and left sides were 4.01 and 4.47 cm at the umbilical level, 3.81 and 4.26 cm at the midlevel, and 5.62 and 5.51 cm at the origin level. On both sides, measurement differences between the three levels were highly significant (p<0.05). In addition, a total of 56 IEA bifurcations were depicted in all 200 patients. Thirteen of the 56 bifurcations occurred only on the right side, 11 only on the left side, and 32 on both sides. CONCLUSION: It is important to be attentive to the IEA's course, at different midline levels, when attempting percutaneous interventions via an abdominal approach.

Prognostic value DCE-MRI parameters in predicting factor disease free survival and overall survival for breast cancer patients.

PURPOSE: The aim of the study is to assess the predictive power of DCE-MRI semi-quantitative parameters during treatment of breast cancer, for disease-free (DFS) and overall survival (OS). MATERIALS AND METHODS: Forty-nine women (age range, 28-84 years; mean, 50.6 years) with breast cancer underwent dynamic contrast enhancement MRI at 1.0T imaging, using 2D FLASH sequences. Time intensity curves (TICs) were obtained from the regions showing maximal enhancement in subtraction images. Semi-quantitative parameters (TICs; maximal relative enhancement within the first minute, E (max/1); maximal relative enhancement of the entire study, E(max); steepest slope of the contrast enhancement curve; and time to peak enhancement) derived from the DCE-MRI data. These parameters were then compared with presence of recurrence or metastasis, DFS and OS by using Cox regression (proportional hazards model) analysis, linear discriminant analysis. RESULTS: The results from of the 49 patients enrolled into the survival analysis demonstrated that traditional prognostic parameters (tumor size and nodal metastasis) and semi-quantitative parameters (E(max/1), and steepest slope) demonstrated significant differences in survival intervals (p<0.05). Further Cox regression (proportional hazards model) survival analysis revealed that semi-quantitative parameters contributed the greatest prediction of both DFS, OS in the resulting models (for E(max/1): p=0.013, hazard ratio 1.022; for stepest slope: p=0.004, hazard ratio 1.584). CONCLUSION: This study shows that DCE-MRI has utility predicting survival analysis with breast cancer patients.

Spontaneous fistulization of a pancreatic abscess to colon and duodenum treated with percutaneous drainage.

Pancreatic fistulas are rare clinical entities associated with severe pancreatitis. A 39-year-old man who had been diagnosed and treated for severe pancreatitis 2 months ago presented with abdominal pain, fever, and vomiting. The abdominal computed tomography (CT) demonstrated a peripancreatic abscess and a duodenal fistula communicating the first part of duodenum, which was also verified with fluoroscopy. A size 14-French catheter with pig-tail tip was inserted primarily with a Seldinger 2-step technique through percutaneous route under CT-guidance to avoid intervening bowels or solid organs. The patient's clinic improved and treatment was stopped on the 18th day. On the 26th day of the first intervention, the patient had fever and abdominal pain and his clinic was deteriorated. A second fluoroscopic examination revealed that the duodeno pancreatic fistula was closed while a new 1 has developed into the ascending colon. With aggressive nutrition support, antibiotics and repeated drainage of the abscess pouch a dramatic clinical improvement was observed. Control abdominal CT demonstrated the resolution of pancreatic abscess on the 62nd day.

Inflammatory myofibroblastic tumor presenting as an abdominal wall mass in an adult patient.

Inflammatory myofibroblastic tumor of the abdominal wall is a rare soft-tissue tumor presentation in adults. A 50-year-old woman was referred with abdominal pain and a palpable mass in the left lower quadrant. Computed tomography scan and magnetic resonance investigation revealed an 8-cm heterogeneous abdominal wall mass. Tumor markers were within normal limits. Fine-needle aspiration cytology and tru-cut biopsies yielded necrotic material. A preoperative diagnosis of a resectable rhabdomyosarcoma was suggested. On exploration a tumor measuring 8 x 8 x 6 cm was resected along with the involved structures. Histopathologic examination of specimen revealed an inflammatory myofibroblastic tumor of the abdominal wall. The patient has been followed up for the last 12 months without clinical or radiographic evidence of recurrence. Inflammatory myofibroblastic tumor arising from the anterior abdominal wall in adults is an unusual manifestation of soft-tissue tumors, which can be managed by a multidisciplinary team of surgeons, oncologists, radiologists and pathologists.

Validity of serum tau protein levels in pediatric patients with minor head trauma.

BACKGROUND: The aim of this study was to investigate the relationship between intracranial injury and serum tau protein levels in pediatric patients with minor head trauma (MHT). METHODS: We included 60 pediatric patients with MHT (Glasgow Coma Scale [GCS], 14-15) and 28 control patients. The patients were divided into 3 groups as follows: those without (group 1) and with (group 2) intracranial lesions shown on cranial computed tomography (CCT) and the control group (group 3). RESULTS: The mean serum tau protein level was 96.06 +/- 70.36 pg/mL in group 1, whereas it was 112.04 +/- 52.66 pg/mL in group 2, with no statistically significant difference between the groups (p = .160). The mean serum tau protein levels between the study groups (group 1 and group 2) and control (38.52 +/- 29.01) were statistically significant (P < .001 and P < .001, respectively). The GCS score and pathologic condition in CCT were only influential variables on tau protein levels. CONCLUSIONS: We found that serum tau protein increased after MHT but did not distinguish between those with and those without intracranial lesions demonstrable on CCT.

Incidental pancreatic lipomas: computed tomography imaging findings with emphasis on diagnostic challenges.

PURPOSE: The purpose of this study was to describe the computed tomography (CT) findings of pancreatic lipomas of 9 cases, with emphasis to diagnostic challenges. METHODS: Between March 2006 and April 2008, 9 patients with pancreatic lipomas that were diagnosed by CT were reviewed in the present study. Clinical data and CT features of these 9 cases were retrospectively analysed. The patient population included 5 men and 4 women, aged 42-81 years (mean age, 65.8 years). The patients were followed up for at least 2 years with control CTs. RESULTS: In all 9 cases, a well-bordered nodular fat density lesion was incidentally detected in the pancreas. Four of the lesions had a lobulated contour, and 2 of them had septations. Two of the lipomas were located in the head, 3 in the neck, 3 in the corpus, and 1 in the tail. The CT densitometric values were between -90 and -120 HU, with a mean value of -106 HU. No pancreatic or biliary dilatation or compression to the adjacent structures was seen. All the cases had control CTs, and the lipomas remained unchanged during the follow-up period. Histopathologic confirmation of the diagnosis was not planned for the cases. CONCLUSION: Lipomas are rarely encountered in the pancreas. They often are diagnosed coincidentally as small, well-circumscribed, encapsulated, homogeneous, mature adipose masses on imaging studies. Imaging follow-up strategy or histopathologic confirmation is not necessary in asymptomatic patients.

The effect of celiac plexus block in critically ill patients intolerant of enteral nutrition: a randomized, placebo-controlled study.

BACKGROUND: In this study, we evaluated the efficacy of celiac plexus block for the treatment of feeding intolerance in critically ill patients. METHODS: Nineteen mechanically ventilated medical patients intolerant of enteral nutrition and receiving metoclopramide underwent bilateral celiac plexus block. The anterior procedure was accomplished under sonographic guidance with the injection of either 25 mL bupivacaine 0.25% (celiac group, n = 10) or saline (control group, n = 9) bilaterally. Gastric emptying was assessed by the acetaminophen absorption method. After the block, nasogastric feeding was commenced, and nasogastric aspirates were collected once every 24 hours. Successful feeding was defined as 24-hourly gastric residual volume <250 mL with a feeding rate > or = 40 mL/h. RESULTS: Demographic data were similar for the 2 groups. The area under the plasma paracetamol absorption curve (383.8 +/- 248.1 mg . min . L(-1)) and the peak plasma paracetamol concentration (C(max); 3.28 +/- 2.15 mg/L) in the celiac group were significantly lower than the area under the curve value (1233.5 +/- 771.2) and C(max) value (10.14 +/- 6.04) in controls (P < 0.001 for all). After treatment, celiac plexus block reduced the mean gastric residual volume (celiac group: 430 +/- 32 mL to 205 +/- 30 mL, P < 0.001; control group: 450 +/- 33 mL to 461 +/- 19 mL, P > 0.05) and improved the proportion of patients with successful feeding (celiac block 80% vs controls 0%, P < 0.001). CONCLUSION: In critical illness, celiac plexus block is effective for treating feeding intolerance when IV drug therapy has failed to improve gastrointestinal dysfunction.

CT-angiographic demonstration of hepatic collateral pathways due to superior vena cava obstruction in Behçet disease.

Behçet disease (BD) is a chronic multisystemic inflammatory disorder, mainly characterized by recurrent oral and genital ulcers, skin lesions, and uveitis. Large vein thrombosis in BD is unusual; when present, it is most frequently seen in the inferior or superior vena cava (SVC). The authors describe an unusual hepatic pseudolesion caused by abnormal focal enhancement through collateral pathways to the liver in two BD patients with SVC occlusion on three-dimensional multi-detector computed tomography, using volume rendering and maximum intensity projection techniques. BD should be suspected in patients presenting a focal increased hepatic enhancement area with collaterals caused by occlusion of the SVC without evidence of a hypercoagulable state or malignant mediastinal or thoracic venous inlet obstruction.

Digital subtraction angiography of a persistent trigeminal artery variant.

Persistent trigeminal artery variants are described as cerebellar arteries that directly originate from the precavernous segment of the internal carotid artery. This has been observed in 0.18% of cerebral catheter angiograms. On the other hand, a persistent trigeminal artery variant feeding both the anterior inferior cerebellar artery and the posterior inferior cerebellar artery territory is very rare. We present this uncommon anomalous artery along with digital subtraction angiography findings and discuss its clinical significance in light of the literature.

Prevalence and MDCT characteristics of asymptomatic Bochdalek hernia in adult population.

PURPOSE: To determine the frequency of asymptomatic incidental Bochdalek hernias in adults, using multidetector computed tomography (MDCT), and to ascertain any possible relationship between Bochdalek hernia and age, gender, or body mass index (BMI). MATERIALS AND METHODS: Seven hundred and forty-eight abdominal, and 602 chest MDCT scans, which had been performed for a variety of reasons on 1350 adults, were investigated retrospectively. Location and size of Bochdalek hernias seen on these scans were correlated with age, gender, and BMI. On the basis of BMI, patients with Bochdalek hernia were classified as group A (BMI < 25) and group B (BMI > or =25). RESULTS: A total of 171 Bochdalek hernias were identified in 142 of 1350 patients, ranging in age from 25 to 90 years (median age, 57.2), representing a prevalence of 10.5%. Sixty leftsided unilateral Bochdalek hernias (42.2%), 53 (37.4%) rightsided unilateral Bochdalek hernias, and 29 (20.4%) bilateral Bochdalek hernias were detected. Forty-five (31.6%) were categorized as small, 82 (57.8%) were medium-sized, and 15 (10.5%) were large. BMI was < 25 in 62 patients (43.7%), and > or =25 in 80 patients (56.3%). Fourteen patients (9.9%) were young adults, while 86 (60.6%) were middle aged, and 42 (29.6%) were elderly. No statistically significant relationship was found between dimensions or hernia locations and age, gender, or BMI of patients with Bochdalek hernia. CONCLUSION: In view of the high prevalence of Bochdalek hernia in our study (10.5%), the multiplanar and reconstruction features of MDCT seem to facilitate the diagnosis of asymptomatic incidental Bochdalek hernia. No relationship was found between asymptomatic incidental Bochdalek hernia and age, gender, or BMI in adults.