Lumbar Puncture: Creation and Resident Acceptance of a Low-Cost, Durable, Reusable Fluoroscopic Phantom with a Fluid-Filled Spinal Canal for Training at an Academic Program.

Simulation-based medical training provides learners a method to develop technical skills without exposing patients to harm. Although fluoroscopic phantoms are already adopted in some areas of radiology, this has historically not been for lumbar puncture. Commercially available phantoms are expensive. We report a cost-effective, accessible solution by creation of an inexpensive phantom for resident training to perform fluoroscopically guided lumbar puncture, as well as instructions on how to make a phantom for residency education. An anthropomorphic ballistics-gel phantom that contains a plastic lumbar vertebral column and simulated CSF space was created. Radiology residents with minimum or no experience with fluoroscopically guided lumbar punctures were given a brief education and practiced fluoroscopically guided lumbar punctures on the phantom. A survey from the residents was then done. The phantom was qualitatively quite durable and deemed adequate for educational purposes. All the residents surveyed expressed the desire to have this phantom available and it increased comfort, knowledge, and perceived likelihood of success. Few articles have been published that focused on low-cost phantom creation for fluoroscopic-procedure training. This study supports the benefits of using phantoms for fluoroscopic training as well as step-by-step instructions for creation of this phantom. The residents responded positively and felt more confident in their fluoroscopically guided techniques. The ability to make a long-term training device for resident education would be inexpensive and relatively easy to implement in academic programs.

Single-phase dual-energy CT urography in the evaluation of haematuria.

AIM: To assess the value of a single-phase dual-energy computed tomography (DECT) urography protocol with synchronous nephrographic-excretory phase enhancement and to calculate the potential dose reduction by omitting the unenhanced scan. MATERIALS AND METHODS: Eighty-four patients referred for haematuria underwent CT urography using a protocol that included single-energy unenhanced and dual-energy contrast-enhanced with synchronous nephrographic-excretory phase scans. DECT-based images [virtual unenhanced (VUE), weighted average, and colour-coded iodine overlay] were reconstructed. Opacification degree by contrast media of the upper urinary tract, and image quality of virtual unenhanced images were independently evaluated using a four-point scale. The diagnostic accuracy in detecting urothelial tumours on DECT-based images was determined. The dose of a theoretical dual-phase single-energy protocol was obtained by multiplying the effective dose of the unenhanced single-energy acquisition by two. Radiation dose saving by omitting the unenhanced scan was calculated. RESULTS: The degree of opacification was scored as optimal or good in 86.9% of cases (k = 0.72); VUE image quality was excellent or good in 83.3% of cases (k = 0.82). Sensitivity, specificity, positive predictive value, and negative predictive value for urothelial tumours detection were 85.7, 98.6, 92.3, and 97.1%. Omission of the unenhanced scan led to a mean dose reduction of 42.7 ± 5%. CONCLUSION: Single-phase DECT urography with synchronous nephrographic-excretory phase enhancement represents an accurate "all-in-one'' approach with a radiation dose saving up to 45% compared with a standard dual-phase protocol.

CT-MR integrated diagnostic imaging of the oral cavity: neoplastic disease.

The oral cavity is a complex anatomical region consisting of different anatomical sites and subsites. Cancer undoubtedly represents the most frequent and relevant disease of this region. Clinical examination is often the first approach to oral cavity tumours. Cross-sectional computed tomography (CT) and magnetic resonance imaging (MRI) play a key role in staging locoregional disease by demonstrating submucosal spread and involvement of deep layers; evaluation of specific pathways of spread to peculiar anatomical subsites is also fundamental information that can be obtained with these techniques. The purpose of this paper is to illustrate CT and MRI findings of anatomical subsites involved by tumours of the oral cavity.

Atrial lipomatous hypertrophy causing reduction in systemic venous return.

Lipomatous hypertrophy of the interatrial septum (LHIAS) is a benign condition characterized by an abnormal deposition of adipose tissue in the interatrial septum which appears as a pseudomass with a bilobed shape. We present the case of a 68-year-old obese female patient. LHIAS is an infrequent finding, but with recent improvements in imaging it is increasingly recognized. Cardiac MRI may prove useful in its diagnosis in terms of tissue characterization, as well as for the evaluation of disease extension and haemodynamic compromise.

Effects of a long-term treatment with raloxifene on insulin sensitivity in postmenopausal women.

AIMS/HYPOTHESIS: Our aim was to investigate the effect of long-term administration of raloxifene, a selective estrogen receptor modulator, on insulin sensitivity, glucose tolerance and plasma lipid concentrations in a group of postmenopausal women. METHODS: A total of 24 women with postmenopausal osteoporosis were consecutively enrolled and randomly assigned to take raloxifene, 60 mg/day for 12 months or placebo. At baseline and after 6 and 12 months, in each subject insulin sensitivity (M-index) was assessed by means of an euglycaemic hyperinsulinaemic clamp. Plasma concentrations of total cholesterol, triglycerides and HDL-cholesterol were also measured and glucose tolerance was evaluated. RESULTS: In the raloxifene-treated group, the M index decreased after 6 and 12 months with respect to the placebo group (-21%, p=0.042 and -23%, p=0.018, respectively). Neither fasting plasma glucose nor glucose tolerance changed in the raloxifene-treated group, compared to the placebo group. Low density lipoprotein cholesterol concentrations decreased at 12 months (-13%, p=0.047). CONCLUSION/INTERPRETATION: A long-term treatment with raloxifene in osteoporotic, otherwise healthy post-menopausal women can reduce insulin sensitivity without affecting glucose tolerance.

Non invasive assessment of cardiac function in patients with bronchial asthma (BA) or chronic obstructive pulmonary disease (COPD).

BACKGROUND: Most respiratory diseases involve the heart and can lead to acute or chronic pulmonary heart in the most serious cases. The common pathogenetic element is pulmonary arterial hypertension which es secondary to the resistance of the pulmonary circulation together with hypertrophy and/or dilatation of the right ventricle, caused mainly by chronic hypoxia. METHODS AND RESULTS: In order to verify the effects induced on pulmonary circulation and right heart by BA or COPD the cardiac function was assessed by mono and bidimensional Doppler echocardiography in 10 patients with BA (group A), 10 with COPD (group B) and 10 healthy control subjects (group C). At the M-mode echocardiography examination no significant difference was observed among the three study groups. By Doppler pw the peak velocity of early tricuspidal flow (VmaxE) was significantly higher in the group A when compared to the group B (p = 0.03). No subject had pulmonary hypertension. The pulmonary acceleration time (PAT) using pw Doppler technique was similar in groups A and B but it was significantly different when compared to group C (p = 0.006:A vs C; p = 0.03:B vs C). CONCLUSIONS: Our results suggest in patients either with BA or COPD, an early involvement of the right heart even if they had a clinical stable condition and no pulmonary hypertension.

Acute cardiovascular effects of salmeterol in subjects with stable bronchial asthma.

The airway response and cardiovascular effects of salmeterol (SM) and salbutamol (SB) given as a single dose from metered-dose inhalers were studied in 10 patients with mild asthma. In a double-blind, randomized, cross-over, placebo-controlled study, the subjects received SM 100 micrograms (four puffs, 25 micrograms per actuation), SB 200 micrograms (four puffs, 50 micrograms per actuation) or placebo (P) (four puffs). SM caused a greater and longer lasting increase of peak expiratory flow rate (PEFR) value than SB and P. There was no significant difference either with P or the study drugs in heart rate, PR interval, QT interval corrected for heart rate (QTc), incidence of ventricular and supraventricular ectopics, and in echocardiogram evaluation. These findings show that at dosages based on those used in clinical practice salmeterol causes cardiovascular effects comparable to those induced by salbutamol and confirm the favourable cardiac safety profile of this drug.

Effects of gallopamil on epinephrine and norepinephrine plasmatic levels and on TxB2 and beta-tg release in patients with coronary artery disease during adrenergic stimulus with cold pressor test.

We investigated the effect of gallopamil administration during a cold pressor test (CPT) in 18 patients suffering from chronic angina (CA) and in 21 healthy subjects. CA patients showed increased basal levels of beta-thromboglobulin and thromboxane B2 compared to control patients and normal plasma levels of catecholamines. CPT caused plasma catecholamines, beta-thromboglobulin and TxB2 levels to rise. This rise was greater in CA patients than in control patients. Administration of gallopamil (50 mg kg-1 three times a day for 30 days) reduced plasma levels of catecholamines, beta-thromboglobulin and TxB2 blood concentrations either under basal conditions or after CPT. Our data suggest that gallopamil is able to modulate the response induced by adrenergic stress.

[Evaluation of the anti-arrhythmic action of propafenone treatment and its influence on left ventricular function]. / Valutazione dell'azione antiaritmica di un trattamento con propafenone e sua influenza sulla funzione ventricolare sinistra.

Twelve patients (9 males, 3 females, mean age 59.2 +/- 7.0 years) with hyperkinetic ventricular arrhythmias were treated for 30 days with 150 mg propafenone three times daily; the daily dosage was raised to 900 mg in non responders (< 85% reduction of ectopic ventricular beats/h). A 24-hour ECGD and mono- and bidimensional echocardiography were carried out at baseline, after 30 days on 450 mg, 30 days on 900 mg propafenone, and one week after drug withdrawal. Propafenone treatment was found to reduce significantly ectopic ventricular beats, especially with the higher dosage (44.9% reduction under 450 mg; 88.8% reduction under 900 mg). At the lower dosage, 25% of patients responded, under the higher dosage 88.9%; the latter dosage also induced a significant reduction of Lown class. Propafenone treatment was also accompanied by a reduction of maximum and mean heart rate, and by a lengthened PR interval which was almost always within the normal range, without changes of QTc. The two months of propafenone treatment did not induce significant changes of cardiac volume or left ventricular function; on the contrary, at the end of the treatment period an increase, albeit not a significant one, of the ejection fraction and a shortening of the circumference inversely proportional to the reduction in ectopic ventricular beats could be noted. In conclusion, propafenone was found to have a valid antiarrhythmic effect, especially at the 900 mg/day dosage without interfering with left ventricular function which was even found to improve under chronic treatment, probably as a result of improved compliance thanks to the reduction of ventricular ectopic beats.

Left ventricular diastolic function and responses to adrenergic stimuli in borderline arterial hypertension.

OBJECTIVE: To detect the existence of a possible relationship between arterial hypertension and adrenergic reactivity to pressure stimuli, and changes in left ventricular diastolic function (LVDF). PATIENTS: Fifty-nine young subjects with borderline arterial hypertension and ten sex- and age-matched controls were investigated. After three medical examinations, the subjects were divided into hypertensive and borderline groups on the basis of the blood pressure reading at visit 3. A complete echocardiographic study was performed in 25 of the 59 subjects. DESIGN: Blood pressure was measured in baseline conditions and during pressure stimuli (mental stress, handgrip and cold pressor tests). LVDF was evaluated primarily by means of filling velocities during diastolic phases taken from the left ventricular volume curve (obtained from a complete echocardiographic study). RESULTS: No significant changes in blood pressure responses were observed for the borderline or hypertensive groups during the adrenergic test. The echocardiographic indices of diastolic function were statistically different for the two groups when compared with the control group. The LVDF parameters correlated significantly with systolic blood pressure and diastolic blood pressure measured at the time of the echocardiogram, but not with blood pressure measured occasionally. CONCLUSIONS: Blood pressure increases similarly during adrenergic stimuli in both the hypertensive and borderline groups. The correlation between systolic blood pressure, diastolic blood pressure and LVDF parameters may indicate a very early onset of reduced compliance of the left ventricle, even in a preclinical phase of hypertension.

[Evaluation of arteriolar reactivity and blood coagulation parameters during picotamide treatment]. / Valutazione della reattività arteriolare e di alcuni parametri emocoagulativi durante trattamento con picotamide.

Thirty-two patients, nineteen males and thirteen females, mean age 59.4 +/- 11.9 years, 18 with peripheral arteriopathy Fontaine stage II and 14 with cerebral vasculopathy were submitted to treatment with picotamide, 900 mg/die. In basal conditions and after 30 and 60 days of treatment, we evaluated some blood clotting parameters concerning both platelets (circulating platelet aggregates, beta-thromboglobulin, TxB2, 6-keto-pgF1 alpha) and plasma (fibrinogen, plasminogen, ATIII, Factor VIII-C and VIII Ag, prothrombin time, activated thromboplastin time) and some instrumental parameters such as walking distance and Doppler with a post-ischaemic hyperaemia test in patients with peripheral arteriopathy and Doppler of epiaortic vessels with resistance and pressure-perfusion index evaluation in patients with cerebral vasculopathy. Treatment with picotamide significantly reduced circulating platelet aggregates, beta-TG and TxB2 levels, without change of 6-keto-PGF-alpha values, with reduction of F VIII-C and slight increase of plasminogen and ATIII levels. In patients with peripheral arteriopathy after two months, a significant increase in distance and an improvement of arteriolar reactivity were observed, as shown by increase of the perfusion-index and by reduction of the post-ischaemic recovery time. These observations, together with the good tolerance of the drug, justify the use of picotamide in the treatment of patients with atherosclerotic vasculopathy at different localizations.

[Changes in the QT interval caused by autonomic cardiovascular involvement in diabetes mellitus]. / Modificazione dell'intervallo QT da compromissione autonomica cardiovascolare nel diabete mellito.

The aim of the study was to assess the role of altered autonomic regulation on changes in the QT interval. Fifty-three diabetic patients, comprising 32 men and 21 women with a mean age of 49.4 +/- 15.9 years (range 13-73 years), underwent sympathetic and parasympathetic stimulatory tests (changes in heart rate between clino- and orthostatism, lying to standing, while deep breathing, Valsalva's manoeuvre, changes of arterial pressure related to posture) to study cardiovascular reflexes. Patients who were positive for at least two of the tests were considered to be affected by autonomic neuropathy. Ten non-diabetic age-matched subjects (44.8 +/- 14.8 years) with no cardiovascular diseases were included in the study as a control group. The QTc interval was measured in basal conditions and during sympathetic and parasympathetic stimulatory tests, in clino- and orthostatism, during deep breathing and Valsalva's manoeuvre. A significantly greater QTc interval (p less than 0.05) was found in neuropathic patients compared to controls and non-neuropathic patients both in basal conditions and following stimulatory tests at the lowest heart rate (phase IV of Valsalva's manoeuvre and slow exhalation during deep breathing), while at a higher heart rate (orthostatism, L-S, deep inhalation during deep breathing, phase II of Valsalva's manoeuvre) there was no difference in QTc between controls, and neuropathic and non-neuropathic patients due to a lesser extension of the QTc in neuropathic patients. This difference appears to be the expression of autonomic dysregulation in neuropathic patients, given the lack of correlation with diabetes or duration of disease, and is only conditioned by the presence or absence of autonomopathic damage. Among other causes, the observed extension of the QT interval might therefore justify the increased frequency of sudden death in diabetic patients with cardiovascular autonomic neuropathy.

[Clinical-instrumental evaluation of the effects of quinapril treatment in mild-to-moderate hypertension]. / Valutazione clinico-strumentale degli effetti di un trattamento con quinapril nell'ipertensione lieve-moderata.

Eleven patients with uncomplicated mild-to-moderate hypertension (diastolic pressure 95-115 mmHg) were treated for four weeks with daily single quinapril doses of 20-40 mg. Already during the second week a significant reduction in blood pressure was observed without increase of heart rate; 27.3% of patients responded to the lower dose (diastolic blood pressure [90 mmHg], and 54.6% responded to the higher dose. Drug treatment led to reduced pressure increase in response to cold stimulation without influencing the adrenergic response both in basal conditions and after cold pressor test. The drug brought about peripheral vasodilatation as shown by increased perfusion index during Doppler ultrasound examination, and improved arterial reactivity with increased perfusion index and reduced recovery time after ischemia. The reduction of angiotensin and aldosterone plasma levels during treatment was not correlated to diminished blood pressure values, indicating that the antihypertensive effect can occur via pathways different from ACE inhibition. Tolerance was excellent as shown both by clinical and laboratory evidence.

[Systemic cardiorespiratory effects induced by doxofylline]. / Effetti sul sistema cardio-respiratorio indotti dalla doxofillina.

The authors evaluated the clinical effectiveness and tolerability of doxofylline, a new methyl-xanthinic derivative with peculiar pharmacodynamic properties. 13 patients affected with chronic obstructive lung disease (mean age +/- 54 years) were studied. Doxofylline (200 mg) and theophylline (240 mg) were randomly administered by intravenous route in 60'. Arterial haemogasanalysis, FEV1 and ECG data were obtained after the infusion. Doxofylline proved to possess an equal therapeutic efficacy in comparison to theophylline, with a better clinical tolerability. In conclusion, doxofylline is a new and effective drug for the treatment of bronchostructive disorders.

Local infection following aesthetic rhinoplasty.

Local infection is a rare complication after aesthetic rhinoplasty. In the past serious complications and 1 death have been reported. We present 5 cases of local infection after primary and secondary procedures. Infection seems to have more to do with technical details during an operation, such as the external lateral osteotomy, than with the presence of saprophytic bacteria. Care must be taken in the management of cartilage grafts. There is not enough support for the use of prophylactic antibiotics. Usually the organism implicated is Staphylococcus aureus. Once the infection has developed, treatment should be aggressive in view of the grave complications reported in the literature.