Guidelines for the Diagnostic Cross Sectional Imaging and Severity Scoring of Chronic Pancreatitis.

The paper presents the international guidelines for imaging evaluation of chronic pancreatitis. The following consensus was obtained: Computed tomography (CT) is often the most appropriate initial imaging modality for evaluation of patients with suspected chronic pancreatitis (CP) depicting most changes in pancreatic morphology. CT is also indicated to exclude other potential intraabdominal pathologies presenting with symptoms similar to CP. However, CT cannot exclude a diagnosis of CP nor can it be used to exclusively diagnose early or mild disease. Here magnetic resonance imaging (MRI) and MR cholangiopancreatography (MRCP) is superior and is indicated especially in patients where no specific pathological changes are seen on CT. Secretin-stimulated MRCP is more accurate than standard MRCP in the depiction of subtle ductal changes. It should be performed after a negative MRCP, when there is still clinical suspicion of CP. Endoscopic ultrasound (EUS) can also be used to diagnose parenchymal and ductal changes mainly during the early stage of the disease. No validated radiological severity scoring systems for CP are available, although a modified Cambridge Classification has been used for MRCP. There is an unmet need for development of a new and validated radiological CP severity scoring system based on imaging criteria including glandular volume loss, ductal changes, parenchymal calcifications and parenchymal fibrosis based on CT and/or MRI. Secretin-stimulated MRCP in addition, can provide assessment of exocrine function and ductal compliance. An algorithm is presented, where these imaging parameters can be incorporated together with clinical findings in the classification and severity grading of CP.

A potential therapeutic pitfall in the treatment of venous reflux due to variant planar anatomy of varicose segments.

Purpose To elaborate on a planar anatomic variant of great saphenous vein as a potential therapeutic pitfall in the treatment of venous reflux. Materials and methods Lower extremity veins in 568 limbs with great saphenous vein insufficiency were sonographically mapped. A rather overlooked variation, the saphenous bow, was studied with emphasis on anatomic clarification and its involvement in venous insufficiency. Results This variation, observed in 5.1% (n = 29) of limbs, comprised two segments; one uninterrupted great saphenous vein proper coursing throughout saphenous compartment and one extra-compartmental segment originating distally from and proximally fusing with it. Venous arch remains within compartment only briefly during take-off and re-entry. Extra-compartmental venous arch had reflux either alone (10.3%) or together with intra-compartmental segment (75.9%). Conclusion This variation, part of saphenous segmental aplasia/hypoplasia complex, is associated with venous insufficiency. Meticulous mapping of great saphenous vein territory and identification of such variants during planning stage is indispensable for optimal clinical outcomes of treatment.

Comparison of Long-Term Results of Percutaneous Treatment Techniques for Hepatic Cystic Echinococcosis Types 2 and 3b.

OBJECTIVE: The purpose of this study was to determine the long-term results of a modified catheterization technique for percutaneous treatment of hepatic cystic echinococcosis (CE) types 2 and 3b and to retrospectively compare the results of puncture, aspiration, injection, and reaspiration (PAIR); standard catheterization; and the modified catheterization technique. MATERIALS AND METHODS: Seventy-three patients (37 male, 36 female; 75 cysts) with CE types 2 and 3b who underwent percutaneous treatment from March 1991 to August 2008 were included. Informed consent from all patients and approval of the ethics board were obtained. Patients were 6-79 years old. Twenty-three cysts (30.6%) were treated with PAIR, 26 (34.7%) with standard catheterization, and 26 (34.7%) with the modified catheterization technique. The results of the three techniques were statistically compared. RESULTS: Among all patients, the cysts decreased in volume by 61.1% (range, 5-100%). Cysts recurred in 11 (47.8%) patients treated with PAIR, three (11.5%) treated with standard catheterization, and one (3.8%) treated with the modified catheterization technique. The recurrence rate was not significantly different between standard catheterization and the modified catheterization technique (p > 0.05), whereas significantly more recurrences developed after PAIR than with the other two techniques (p < 0.05). Twelve (16.4%) major and 16 (21.9%) minor complications developed. Significantly fewer major complications occurred with PAIR than with the modified catheterization technique, but the difference between standard catheterization and the other two techniques was not significant. CONCLUSION: Treatment of CE types 2 and 3b with the modified catheterization technique was associated with a recurrence rate lower than what is seen with other techniques, and therefore it appears to be a safe, reliable, and efficient alternative.

Percutaneous Treatment of Splenic Cystic Echinococcosis: Results of 12 Cases.

PURPOSE: Cystic echinococcosis (CE) in the spleen is a rare disease even in endemic regions. The aim of this study was to examine the efficacy of percutaneous treatment for splenic CE. MATERIALS AND METHODS: Twelve patients (four men, eight women) with splenic CE were included in this study. For percutaneous treatment, CE1 and CE3A splenic hydatid cysts were treated with either the PAIR (puncture, aspiration, injection, respiration) technique or the catheterization technique. RESULTS: Eight of the hydatid cysts were treated with the PAIR technique and four were treated with catheterization. The volume of all cysts decreased significantly during the follow-up period. No complication occurred in seven of 12 patients. Abscess developed in four patients. Two patients underwent splenectomy due to cavity infection developed after percutaneous treatment, while the spleen was preserved in 10 of 12 patients. Total hospital stay was between 1 and 18 days. Hospital stay was longer and the rate of infection was higher in the catheterization group. Follow-up period was 5-117 months (mean, 44.8 months), with no recurrence observed. CONCLUSION: The advantages of the percutaneous treatment are its minimal invasive nature, short hospitalization duration, and its ability to preserve splenic tissue and function. As the catheterization technique is associated with higher abscess risk, we suggest that the PAIR procedure should be the first percutaneous treatment option for splenic CE.

Percutaneous Treatment of Simple Hepatic Cysts: The Long-Term Results of PAIR and Catheterization Techniques as Single-Session Procedures.

PURPOSE: The purpose of our study is to evaluate results of percutaneous aspiration with alcohol sclerotherapy in symptomatic patients with simple hepatic cysts by employing single-session techniques either by a needle or a catheter. MATERIALS AND METHODS: We retrospectively included 39 simple hepatic cysts in 35 patients treated via percutaneous aspiration and single-session alcohol sclerotherapy between years 1993 and 2012. Indications were pain (n = 28) or ruling out cystic echinococcus (CE) disease (n = 7). 29 cysts in 26 patients were treated by needle technique (Group A) and ten cysts in nine patients were treated by single-session catheter technique (Group B). Patients were followed for 4-173 months (median: 38 months). RESULTS: All patients were successfully treated. Before procedure, cyst volumes were 21-676 cc (median: 94 cc). Post-procedure cyst volumes at last follow-up were 0-40 cc (median: 1 cc). The mean decrease in cyst volume was 95.92 ± 2.86 % in all patients (95.96 ± 3.26 % in Group A and 95.80 ± 6.20 % in Group B). There was no statistically significant difference between the volume reduction rates of Group A and Group B. Only one patient, in Group B, developed a major complication, an abscess. Hospitalization period was 1 day for all patients. CONCLUSIONS: For patients with symptomatic simple hepatic cysts smaller than 500 cc in volume by using puncture, aspiration, injection, and reaspiration (PAIR) technique with only needle, single-session alcohol sclerotherapy of 10 min is a safe and effective procedure with high success rate.

Unusual presentation of a pancreatic cyst resulting from osteosarcoma metastasis.

Pancreatic metastases are uncommon. They have been reported in lung cancer, gastrointestinal malignancies, breast cancer, renal cell carcinoma, melanoma, lymphoma and sarcoma, and usually have solid morphology. Cystic metastasis to the pancreas is even more rare with few case reports in the literature. However, with the increasing use of computed tomography and magnetic resonance imaging as well as endoscopic ultrasound, more such lesions may be detected. Metastasis to the pancreas from osteosarcoma is highly unusual, but can be seen with the increasing survival of patients with osteosarcoma. We present an extremely rare case of a predominantly cystic lesion of the pancreas, which was diagnosed as metastasis from osteosarcoma. The pathophysiology of the cystic component of the metastasis of osteosarcoma is unknown. Cystic necrotic degeneration of the solid metastasis or pancreatitis secondary to the metastasis with development of associated fluid collection can be considered. Metastasis should remain a differential consideration even for primarily cystic lesions of the pancreas.

Embolic infarct presented with bilateral thalamic lesions possibly initiated by an emboli to the artery of Percheron.

Bilateral thalamic infarcts are rare and present with varying symptoms. Cardioembolism and small artery disease are the most common etiologic factors. The occlusion of a rare arterial variant called the artery of Percheron results in bilateral thalamic infarcts. Herein, we present the imaging findings of an embolic infarct starting from bilateral thalami, probably due to an emboli to the artery of Percheron first.

Effects of gender on burden among caregivers of Alzheimer's patients.

PURPOSE: This study was conducted to determine the effects of gender on caregiver burden among caregivers of persons with Alzheimer's disease. DESIGN: Comparative descriptive study. METHODS: Factors affecting the burden of female and male caregivers (age, total duration of caregiving, mean duration of daily caregiving, education, income, employment status, age of the patients cared for, and Mini-Mental State Examination [MMSE] and Neuropsychiatric Inventory [NPI] scores) were similar (p > .05). The sample consisted of 120 female and 72 male caregivers of patients with Alzheimer's disease. Data were collected from patients by means of the MMSE and demographic variables, and data from the Caregiver Burden Inventory [CBI] and NPI were obtained from caregivers, as well as from face-to-face interviews using a questionnaire. Descriptive statistics and t-tests were used to describe and analyze data. FINDINGS: Female caregivers had significantly higher scores for caregiver burden than their male counterparts (p= .002). Subscale analysis on the CSI revealed that female caregivers had significantly higher scores for caregiver burden than male caregivers on time dependence (p= .040), developmental (p= .002), physical (p= .001), and social burdens (p= .045). No difference was found with respect to emotional burden (p= .718). CONCLUSIONS: Results of this study suggest that female caregivers are subjected to a higher level of caregiver burden than male caregivers in Turkey. In subscales, female caregivers experienced more burden than male caregivers in the time dependence, developmental, physical, and social burdens. Emotional burden was similar in both genders. CLINICAL RELEVANCE: Although caregiver burden has been a much debated issue for many years, it is a relatively new topic in Turkey. In order to provide appropriate care for the patient's and family's cultural values and needs, more studies are needed to be conducted on family members giving care to Alzheimer's patients. It is thought that the findings of the present study will facilitate cross-cultural comparisons and culture-oriented care planning.

Reliability and validity of Turkish version of attitudes toward old people scale.

AIMS AND OBJECTIVES: To assess the reliability and validity of a Turkish version of Kogan's Attitudes Toward Older People Scale. BACKGROUND: To explore nursing students' attitudes towards older people, standardised, well-tested instruments are needed. Kogan's Attitudes Toward Older People is a comprehensive instrument for assessment of attitudes toward older adults and has been validated in several languages. However, a validated Turkish version has not been available until now. DESIGN: The study used psychometric testing to establish reliability and validity of the Turkish version of Kogan's Attitudes Toward Older People Scale. METHODS: A convenience sample of 237 nursing students in Turkey was used to collect data regarding attitudes towards older people. Content validity, construct validity, internal consistency and stability reliability of the Kogan's Attitudes Toward Older People were assessed. RESULTS: Kogan's Attitudes Toward Older People scores were between 74-224. All of the 34 items were found to have significant item-to-total correlations (p < 0·05). Results of the confirmatory factor analysis established that the scale had a two-factor construct and was appropriate use in this student population. The Cronbach's alpha was 0·89 for the total scale (0·82 for negative, 0·85 for positive). In addition, test-retest correlation was 0·83 (negative subscale 0·77, positive subscale 0·73) (p < 0.001). CONCLUSIONS: The Turkish version of the Kogan's Attitudes Toward Older People was found to be a reliable and valid tool for assessing Turkish nursing students' attitudes toward older adults. RELEVANCE TO CLINICAL PRACTICE: This study provided evidence that the Kogan's Attitudes Toward Older People is a reliable and valid instrument for assessing Turkish nursing student's positive and negative attitudes toward older adults. It is easy and practical to use for both informants and investigators and acceptable for Turkish Culture.

Dual-echo TFE MRI for the assessment of myocardial iron overload in beta-thalassemia major patients.

PURPOSE: Cardiac failure due to myocardial iron overload is the most common cause of death in beta-thalassemia patients. Multi/ two echo times-turbo field echo (TE-TFE) magnetic resonance imaging (MRI) is considered the gold standard technique in the evaluation of myocardial iron accumulation. However, multi TE-TFE technique is not available in all scanners. The aim of our study was to show the role of black blood dualecho cardiac triggered TFE in the assessment of myocardial iron overload. MATERIALS AND METHODS: Sixteen beta-thalassemia major patients (10 males) with a mean age of 19 years who were receiving parenteral deferoxamine and oral deferiprone treatment were included in this study. Baseline measurement of myocardial T2* values were < 20 ms in all patients. Cardiac MRI was performed after 6 months, 12 months, and 18 months with the same technique. RESULTS: The average baseline value of T2* was 8.2 +/- 3.6 ms. After treatment of combined deferoxamine and deferiprone, the average measurements of myocardial T2* at 6, 12, and 18 months were 11.3 +/- 6.0, 13.6 +/- 7.5, and 15.7 +/- 7.4 ms, respectively (P < 0.05). The basal ejection fraction (EF) value was 49 +/- 8.7%. The EFs were 54.4 +/- 11% at 6 months, 54.8 +/- 6.9% at 12 months, and 58.6 +/- 3.6% at 18 months of followup (P > 0.05). CONCLUSION: Cardiac MRI with dual TE-TFE technique can be used to determine myocardial iron accumulation and response to the chelation treatment.

Iliac vascular complication after spinal surgery: immediate endovascular repair following CT angiographic diagnosis.

Iliac arterial injuries are rare but important complications that can develop after spinal surgery. The presentation of these injuries is usually late, with symptoms such as leg swelling or cardiac failure. However, acute massive bleeding may be a sign of early presentation as in our patient. Herein, we present a case of life-threatening bleeding with early computed tomography angiographic diagnosis of common iliac artery pseudoaneurysm and iliac arteriovenous fistula secondary to spinal surgery which was successfully managed by endovascular stent graft treatment.

Value of Dual Energy Computed Tomography for detection of myocardial iron deposition in Thalassaemia patients: initial experience.

PURPOSE: The aim of our study was to compare the value of cardiac DECT (cDECT) for detection of myocardial iron deposition to T2*w cardiac MRI (cMRI). MATERIAL AND METHODS: Nineteen patients with clinical history of Thalassaemia underwent T2*-weighted cardiac MRI (cMRI) with a 1.5 T MR scanner (MAGNETOM Symphony, Siemens Medical Solutions, Erlangen, Germany) and cardiac dual energy CT (cDECT) with a DSCT scanner (SOMATOM Definition, Siemens Medical Solutions, Erlangen, Germany) on the same day. HU values obtained from cDECT scans and T2*-values from cMRI were statistically correlated to calculate significance levels. Table times were measured for both cDECT and cMRI and compared. Patients were asked to grade their subjective comfort during the examination. RESULTS: In all patients cDECT scans were successfully acquired. HU values of septal muscle correlated strongly with T2*-values, whereas no correlation was found for paraspinal muscle. Table time was significantly shorter for cDECT compared to cMRI (mean: 3.7 min vs. 11.2 min) and subjective patient comfort was rated comfortable for cDECT and average to poor for cMRI. Mean radiation dose was 0.71 mSv. CONCLUSION: cDECT scans seem to be possible for evaluation of myocardial iron load in pediatric Thalassaemia patients.

Non-invasive evaluation of voiding function in asymptomatic primary school children.

This study aimed to evaluate the voiding characteristics of primary school children by using questionnaires and non-invasive diagnostic tools. The voiding characteristics of 212 healthy children in two primary schools were evaluated with ultrasound for bladder wall thickness (BWT) in association with the Pediatric Lower Urinary Tract Symptom Score (PLUTSS), familial questionnaire, uroflowmetry (UF) and urinalysis. Most of the children (70%) had achieved urinary and fecal continence between the ages of 18 months and 36 months. Twenty-five per cent of healthy children void fewer than four times or more than seven times per day. Ninety percent of children had a PLUTSS within normal ranges (< 9). Fifteen percent of patients had a uroflowmetric pattern other than bell-shaped. The peak and average flow rates were higher in girls. Enuresis nocturna was detected in 10% of children. None of the children had documented urinary tract infection. The average BWT from posterior wall at full bladder in healthy children was 1.1 mm. The anterior and posterior BWT measurements before and after micturition were found to be thicker in boys. Regarding the UF pattern, in post-voiding measurements in children with abnormal UF pattern, the bladder walls were thicker. Non-invasive tests in non-symptomatic children showed a range of variability, and these deviations should be kept in mind during the evaluation of voiding characteristics of a child. The symptom scoring system, with the high sensitivity and specificity rates it possesses, is one of the promising tools for this purpose.

PVOD suggested by MDCT and clinical findings in a pregnant woman.

Pulmonary hypertension secondary to pulmonary venoocclusive disease (PVOD) is increasingly recognized (Wagenvoort, Chest 69:82-86, [20]; Scully et al., N Engl J Med 308:823-834, [21]). The clinical presentation is usually progressive pulmonary hypertension. It should be kept in mind when there is pulmonary arterial hypertension, pulmonary edema, and a normal pulmonary artery wedge pressure. Importance of diagnosing this condition is to protect patient from fatal pulmonary edema when using prostacyclins that are effective for treatment of primary pulmonary hypertension. Herein, we present multidetector computed tomography findings of PVOD in a pregnant woman that presented with pulmonary hypertension.