Sonographic classification of gallstones and outcome of extracorporeal shock wave lithotripsy.

The success of extracorporeal shock wave lithotripsy (ESWL) for gallstone elimination is dependent on the lithotripter's ability to reduce the stone to fragments less than 5 mm in diameter, but wide variation in successful fragmentation rates have been reported even with the same instrument. This variation is probably due in part to differences in stone composition. Tsuchiya et al. have recently related the pre-operative ultrasound properties of gallstones to their chemical compositions. In the present study, 138 patients with cholecystolithiasis were treated with ESWL and results were evaluated in light of the pre-treatment sonogram patterns as classified by the aforementioned authors. Complete fragmentation (CF), i.e., fragments less than 5 mm, was achieved in 90% of patients with type I a patterns (pure cholesterol stones); stone number, diameter, and volume had no effects on fragmentation. Significantly lower CF rates were obtained with I b and I c (mixed cholesterol), and type II (combination) stones (p less than 0.0003). No fragmentation at all was achieved in the six stones with type III (bilirubinate) patterns. Twelve months after treatment, 45%, 25%, and 9% of the patients with type 1 a, type I b, and types I c or II (the latter two combined), respectively, were stone-free. Pure and mixed cholesterol gallstones without calcification seem to respond best to ESWL; effective treatment can be expected even when stones are numerous (4-10) or large ( greater than 35 mm). We recommend the inclusion of ultrasound properties of gallstones in the selection criteria for candidates for ESWL.

[Ultrasonography in diseases of lymph nodes and soft tissues of the neck]. / L'ecotomografia nelle affezioni dei linfonodi e dei tessuti molli del collo.

A study of 55 patients affected by neoplasia of the head and neck or clinically evident laterocervical swellings was carried out in order to evaluate the diagnostic value of ultrasonography in the study of cervical lymph nodes and soft tissues, excluding thyroid or salivary pathologies. The analysis of results confirmed that, in line with previously published findings, ultrasonography is a reliable method of diagnosing lesions and correctly identifying the affected organ, but then it is considerably less reliable in defining the type of lesion. In view of this, it is reasonable to propose a more widespread use of ultrasonographically guided needle biopsy which, in addition to being a rapid and non-traumatic method, would allow precisely target samples to be taken from those lesions with a doubtful or unusual clinical or ultrasonic appearance.

Is magnetic resonance imaging more sensitive than computed tomography in the location of corticotropin secreting pituitary adenomas?

Two cases of pituitary-dependent Cushing's syndrome are described in which the computed tomography (CT) examination was negative; as the hormone dynamic investigations were directed towards the presence of corticotropin (ACTH) secreting pituitary formations, magnetic resonance imaging (MRI) of the pituitary was performed, which evidenced the presence of such lesions; subsequent neurosurgery confirmed in both cases the location indicated by MRI. In conclusion, the higher sensitivity of MRI compared to CT in the diagnosis of ACTH secreting pituitary adenomas can be noted.

[The clinical prognostic importance of routine study of the aorta during abdominal echotomography in the elderly patient]. / Significato clinico-prognostico dello studio "di routine" dell'aorta in corso di ecotomografia addominale nel paziente anziano.

Aneurysm of the abdominal aorta (AAA) is encountered with increasing frequency and is often observed at fixation or rupture, events which can be treated surgically but suffer from high operative mortality. Given the current tendency to extend the surgical indication to increasing sectors of patients, the clinico-prognostic significance of routine study of the abdominal aorta with echotomography has been investigated. This examination is reliable in all elderly patients who undergo ultrasound examination for different clinical indications. In the 147 patients considered, aged more than 60 and of both sexes, 12 AAA not suspected clinically were observed. For this the surgical indication or echotomographic monitoring was discussed in relation to age and clinical condition and with due consideration for the morphologic volumetry of the lesion. The finding of the 12 cases of AAA is an indicator of the usefulness of a routine study of the aorta in elderly patients, for awareness of the lesion means that the best therapeutic decisions can be taken and makes it possible to act effectively in emergency situations such as fixation, rupture and distal embolism.

[A possible role of magnetic resonance in the follow-up of renal transplants]. / Possibile ruolo della RM nel follow-up del trapianto renale.

The authors discuss the possible role of Magnetic Resonance Imaging (MRI) in the follow-up of renal transplants. Its diagnostic accuracy is compared with Ultrasounds (US), which is considered the method of choice in postoperative monitoring of renal transplants. Thirty-two patients (transplant life ranging from 5 days to 37 months) were examined in the same day with both MRI and US. Sonographic evaluation is based on a group of signs related to renal alterations and unanimously ascertained; the identification of MR patterns of normally functioning kidney or renal rejection might give way to more extensive clinical applications of the method, with the advantages of multiplanarity and no X-ray use. MR diagnostic accuracy in the diagnosis of normally functioning transplant or renal rejection was 82.7% (vs. US: 68.9%); even though specificity was the same (84.6%). MRI had higher sensibility than US (82.25% vs. 656.25%). MRI is more sensitive in demonstrating renal pathology in transplanted kidneys, and its diagnostic accuracy is superior. Still, US must be considered the methodology of choice in instrumental research when there is a clinical suspicion of renal rejection, due to its sufficient diagnostic accuracy, to its being easy to perform in continuous follow-up, to its low cost and to the short execution time. MRI is nevertheless suggested in the follow-up of renal transplants both in questionable cases and when biopsy cannot be performed.

[Ultrasonic evaluation of primary hyperparathyroidism]. / Valutazione ecotomografica dell'iperparatiroidismo primitivo.

The authors evaluated the diagnostic reliability of echotomography in detecting parathyroid masses: 37 patients were studied with primary hyperparathyroidism, in four cases recurrent. They all underwent surgical ablation of the mass, identification of all glands, and biopsy of an apparently normal parathyroid. Echotomography was accurate in 91.4% of cases: it identified 27 out of 39 pathological glands (sensibility 69.2%) and gave no false-positive results (specificity 100%). Since parathyroid is often ectopic, oblique scans are suggested, i.e. of jugulum while the patient is swallowing. Such scans were always used in our study, in order to identify lesions even in case of "difficult" locations, such as the superior mediastinum.

[Magnetic resonance in renal transplants]. / La risonanza magnetica nel trapianto renale.

The authors report their experience in the study of renal transplant recipients by MR, in order to determine its clinical potentials. The main purpose of this work is to focus on MR patterns in relation to clinical findings of rejected or normally functioning kidney. Twenty-four patients were examined with a 0.5 T superconductive magnet, body coil, spin-echo pulse sequence (SE) and inversion-recovery (IR). MRI patterns could be seen in normally functioning kidneys and transplant rejections, while variable MRI findings were observed in transplants with acute tubular necrosis (ATN). In the normally functioning transplanted kidney there is a clear corticomedullary differentiation (CMD), and the extent of vascular penetration into the renal parenchyma is clearly seen. In transplant rejection, CMD is either diminished or absent, and there is no vascular penetration into the parenchyma; to differentiate acute from chronic rejections, the increase/decrease in renal size and the change in renal shape (spherical shape in acute transplant rejection) respectively must be observed. MRI proves thus to be useful in the study of renal transplants, even in case of questionable clinical findings, and in patients in whom renal biopsy is contraindicated.

[Disorders of heart rhythm during urography studied with Holter monitoring. Comparison of ionic and non-ionic contrast media]. / Le turbe del ritmo cardiaco in corso di urografia studiate con monitoraggio Holter. Raffronto tra mdc ionico e non ionico.

Given the disagreements in the literature over the extent of cardiac complications during urography it was decided to assess any arrhythmias following the injection of ionic and non-ionic contrast media and a placebo by means of 24 hours dynamic Holter monitoring. The results were subjected to meticulous statistical analysis and showed no connection between electrocardiographic alterations and the substance injected. The absence of statistical significance and the variability of the results suggest that alterations in the physiological parameters and/or arrhythmias arising during the administration of contrast media should be assessed with extreme caution.

[Magnetic resonance in the study of the adrenal glands]. / La risonanza magnetica nello studio dei surreni.

Current usage of MR in the clinical study of adrenal pathology is assessed with a review of the advantages and limitations of this new imaging technique and a critical analysis of data deriving both from the literature and from personal experience. The possibility of a multiplanar study offered by MR permits a more accurate anatomical-topographical definition of the adrenal masses though it is not yet capable of the tissue characterisation that would diagnose the nature of the lesion, though it can differentiate between inert adenomas and metastases.

[Diagnostic accuracy of sequential angio-urography with the spot-camera in clinical practice]. / Accuratezza diagnostica dell'angiourografia sequenziale (AUS) con spot-camera nella practica clinica.

In this perspective study the authors examined 57 patients to evaluate diagnostic accuracy of sequential angiourography (AUS) using spot-camera and image subtraction for the visualization of the vascular phase of the renal arteries. All the subjects underwent surgery or follow-up with other clinical and radiological methods. The results obtained with this technique, of low cost and simple execution, were satisfactory: accuracy 98%, sensitivity 100%, specificity 98%.

Methyl-TER-butyl ether (MTBE) and endoscopic sphincterotomy. A possible solution for dissolving gallstones.

MTBE was instilled in 6 cases of lithiasis (1 intrahepatic, 5 giant common bile duct stones following EPT). The nasobiliary route (3 cases) and a percutaneous biliary drain (3 cases) were used for this purpose. Complete stone dissolution was achieved in four cases. In the other two, volume reduction was sufficient to allow spontaneous elimination after EPT. A full clinical recovery was obtained in all cases. Further investigation is required in cases of intrahepatic and common bile duct stones when their removal by EPT is not enough to lead to clinical resolution. Follow-up is indispensable.

[Clinical evaluation of chemical cholelitholysis using methyl tertiary butyl ether in lithiasis of the bile ducts]. / Valutazione clinica della colelitolisi chimica con MTBE nella litiasi delle vie biliari.

Personal experience is reported in the treatment of calculosis of the biliary ways using MTBE and injected through percutaneous biliary drainage catheters placed surgically or endoscopically in 11 patients in whom surgery appeared to be contraindicated or particularly dangerous. In 10 out of the 11 cases chemical cholelitholysis was successful and the technique is therefore proposed as a valid alternative to surgery in ductal cholelitholysis when sphincterotomy and endoscopic removal of the stones cannot cure the conditions.

[Transcutaneous chemical cholelitholysis with methyl tert-butyl ether (MTBE). lst results in man]. / Colelitolisi chimica transcutanea con metil-ter-butil etere (MTBE). Primi risultati nell'uomo.

Three patients have been treated, with instillation of MTBE through a transcutaneous biliary drainage after transduodenal sphincterotomy. The first had gallbladder stones, the second common bile duct stones and the last intrahepatic stones (V segment). While in the first case there has been only a partial success in the other two we have obtained a total dissolution of the stones, with complete clinical recovery. This treatment has not caused immediate side effects but the absence of long term damage has not yet been proven. We think that the use of MTBE is not indicated in gallbladder stone disease. Its major indication is the dissolution of ductal gallstones when transduodenal sphincterotomy and endoscopic removal of the stones have failed.

[Possibility of using the spot camera in the documentation of the arterial phase in urography]. / Possibilità di utilizzazione della spot-camera per la documentazione della fase arteriosa dell'urografia.

32 patients have been examined with sequential angiourography (AUS) and image subtraction, utilizing a spot-camera instead of a rapid seriograph, for the visualization of the vascular phase of the renal artery. Satisfactory results have been obtained since in 96.9% of the cases (31/32) it has been possible to obtain representation of those structures sufficient for a clinical evaluation. This technique for its low cost and simplicity of execution can therefore be proposed as a routine examination in the suspect of vascular renal pathology. This method and the more diffuse AUS with rapid seriograph offer, with respect to digital subtraction angiography (DSA), the advantage of a better nephrographic and urographic phase due to the higher quantity of contrast medium injected.

Direct interaction between polymorphonuclear neutrophils and cuprophan membranes in a plasma-free model of dialysis.

Plasma-free, purified, normal, human polymorphonuclear neutrophils (PMN) were recirculated for 60 minutes in an experimental model of dialysis using cuprophan membranes and acetate or bicarbonate dialysate. At different time intervals, the intracellular contents of PMN-derived cationic proteins (NCP), the release of lysosyme, beta-glucuronidase and PAF as well as the occurrence of PMN and platelet aggregating activities in the supernatants were evaluated. The formation of PMN aggregates, the depletion of intracellular contents of NCP together with the release of lysosomal constituents occurred early (5-10 min) in the course of recirculation. These events were concomitant with the occurrence of PMN aggregating activity in the supernatants due to the release of NCP, as it was antagonised (30-40%) by a rabbit anti-human NCP, and to the release of PAF which also accounted for the platelet aggregating activity that was independent from both adenosine diphosphate and cyclo-oxygenase inhibitors. These data suggest that direct interaction occurs between human PMN and cuprophan in in vitro conditions in the absence of plasma factors and point to a role for cellular mediators in the pathogenesis of the intravascular alterations occurring early in haemodialysis.