Baricitinib as rescue therapy in a patient with COVID-19 with no complete response to sarilumab.

A patient with COVID-19-related severe respiratory failure, with insufficient response to an antiretroviral therapy, hydroxychloroquine and Interleukin-6 (IL-6) antagonist therapy, presented a prompt resolution of the respiratory function and improvement in the radiological picture after baricitinib at an oral dose of 4 mg per day for 2 weeks.

Detection of bone erosions in early rheumatoid arthritis: 3D ultrasonography versus computed tomography.

Three-dimensional (3D) volumetric ultrasonography (US) is an interesting tool that could improve the traditional approach to musculoskeletal US in rheumatology, due to its virtual operator independence and reduced examination time. The aim of this study was to investigate the performance of 3DUS in the detection of bone erosions in hand and wrist joints of early rheumatoid arthritis (ERA) patients, with computed tomography (CT) as the reference method. Twenty ERA patients without erosions on standard radiography of hands and wrists underwent 3DUS and CT evaluation of eleven joints: radiocarpal, intercarpal, ulnocarpal, second to fifth metacarpo-phalangeal (MCP), and second to fifth proximal interphalangeal (PIP) joints of dominant hand. Eleven (55.0%) patients were erosive with CT and ten of them were erosive also at 3DUS evaluation. In five patients, 3DUS identified cortical breaks that were not erosions at CT evaluation. Considering CT as the gold standard to identify erosive patients, the 3DUS sensitivity, specificity, PPV, and NPV were 0.9, 0.55, 0.71, and 0.83, respectively. A total of 32 erosions were detected with CT, 15 of them were also observed at the same sites with 3DUS, whereas 17 were not seen on 3DUS evaluation. The majority of these 3DUS false-negative erosions were in the wrist joints. Furthermore, 18 erosions recorded by 3DUS were false positive. The majority of these 3DUS false-positive erosions were located at PIP joints. This study underlines the limits of 3DUS in detecting individual bone erosion, mostly at the wrist, despite the good sensitivity in identifying erosive patients.

Role of 3D-CT for orthodontic and ENT evaluation in Goldenhar syndrome.

Goldenhar syndrome is a congenital condition that includes anomalies of the derivatives of the first and second brachial arches, vertebral defects and ocular abnormalities. It is also known as oculo-auriculo-vertebrale syndrome (OAVS), hemifacial microsomia, or first or second brachial arch syndrome. It was first described by Van Duyse in 1882 and better studied by M. Goldenhar in 1952. Its treatment requires a multidisciplinary approach. Herein, we describe the value of 3D-CT evaluation in a patient with Goldenhar syndrome, with particular regard to planning diagnostic and therapeutic approach. A 7-year-old boy with Goldenhar syndrome with definite post-natal genetic diagnosis was referred to our Department of Radiology for neuroimaging of the temporal bone. By 3D-CT evaluation of this young patient we observed the asymmetry of the condyles with the right one dysmorphic, short and wide; the auricle of the right ear was replaced by a dysmorphic rough; the right middle ear had a hypoplastic tympanic cavity and the internal auditory canal of right ear was atresic. In our experience, 3D-CT is a powerful diagnostic instrument and offers many advantages: volumetric reproduction of cranium and soft tissues, no overlap of anatomic parts that limits the visibility of various structures, high precision and assurance of images, and a constant and easily reproducible reference system. In our case, 3D-CT offered a very complete evaluation of all malformations of mandibular and temporal bone that characterize this syndrome and representing an important step for ENT and orthodontic therapeutic approaches.

Interobserver variability of dynamic MR imaging of the temporomandibular joint.

PURPOSE: This study investigated the interobserver variability of dynamic magnetic resonance (MR) imaging of the temporomandibular joint (TMJ). MATERIALS AND METHODS: Sixty-two patients with internal derangement of the TMJ (124 TMJs) were investigated with a 1.5-T MR imaging system during physiological opening and closing of the mouth. Two readers evaluated independently the quality of the dynamic examination (Q: nondiagnostic, diagnostic, optimal), condylar motion (CM: limited, suboptimal, optimal), condylar orientation (CO: in-plane, through-plane shift), disc visibility and movement (DV: visible, nonvisible; DM: normal, reducing, nonreducing dislocation) and joint effusion (JE: present, absent). For each TMJ, the condylar path was measured by tracing the position of the condyle in the frames of the dynamic acquisition. Agreement between the two readers was assessed with Cohen's Kappa and the Bland-Altman method. RESULTS: Interobserver agreement was almost perfect for Q (nondiagnostic, diagnostic, optimal: 0.8%, 4.9%, 94.3%; κ=1), CM (limited, suboptimal, optimal: 14%, 26.4%, 59.5%; κ=0.84) and DV (visible, nonvisible: 100%, 0%). Substantial agreement was found for DM (normal, reducing, nonreducing: 66.1%, 14.8%, 19.1%; κ=0.64) and JE (present, absent: 41.3%, 58.7%; κ=0.67). Moderate agreement was found for CO (in-plane, through-plane shift: 94.2%, 5.8%; κ=0.41). As for the condylar path, the means of the percentage differences and limits of agreement (LA) were -3% (LA: -34.5%, 28.3%) on the right and -1.2% (LA: -35%, 32.6%) on the left. CONCLUSIONS: In dynamic imaging of the TMJ, qualitative assessment of condyle-disc movement and joint effusion is minimally dependent on the reader's evaluation. Measurement of the condylar pathway shows an interobserver variability of ±30%.

Chest pain caused by tracheostomy tube malposition: the importance of choosing the right tube.

We describe a case of chest pain caused by tracheostomy tube malposition in a 65-year old woman with chronic respiratory failure due to chronic obstructive pulmonary disease. This report highlights the importance of the correct choice of tracheostomy tube devices for mechanically ventilated and/or spontaneously breathing patients.

Density-based MDCT quantification of lobar lung volumes: a study of inter- and intraobserver reproducibility.

PURPOSE: The authors assessed the reproducibility of multidetector-row computed tomography (MDCT) volumetry of the total and emphysematous parenchyma of pulmonary lobes. MATERIALS AND METHODS: Two observers analyzed 23 MDCT examinations of patients with emphysema during two sessions held 3 months apart. Both lungs and all lobes were delimited by a combination of semiautomated and manual segmentation. Emphysematous parenchyma was obtained by applying density thresholds of -1,024/-950 HU. To assess the reproducibility of total volume (V), volume of emphysema (VE) and emphysema index (EI), intra- and interobserver differences of those measurements were assessed. RESULTS: Total volumetry of the lungs was highly reproducible (intra- and interobserver variability of +/-3.4%). Variability between measurements was slightly greater or emphysema volume and index (EI). Lobar analyses showed large ranges of intra- and interobserver variability (intraobserver V=+/-3.7%-10.6%; VE=+/-17.3%-32.9%; EI=+/-17.8%-34%; interobserver V=+/-13.3%-98.3%; VE=+/-11%-137.6%; EI=+/-28.9%-96.4%). CONCLUSIONS: MDCT quantification of total and emphysematous lung volume and emphysema index is overall reproducible. Quantitative assessment of those parameters performed on single lobes is affected by variability. An improvement of the reproducibility of q-MDCT is expected from the use of advanced methods for lobar segmentation.

New insights on COPD imaging via CT and MRI.

Multidetector-row computed tomography (MDCT) can be used to quantify morphological features and investigate structure/function relationship in COPD. This approach allows a phenotypical definition of COPD patients, and might improve our understanding of disease pathogenesis and suggest new therapeutical options. In recent years, magnetic resonance imaging (MRI) has also become potentially suitable for the assessment of ventilation, perfusion and respiratory mechanics. This review focuses on the established clinical applications of CT, and novel CT and MRI techniques, which may prove valuable in evaluating the structural and functional damage in COPD.

Advanced giant cell reparative granuloma of the mandible: radiological features and surgical treatment.

Giant cell reparative granuloma accounts for 1%-7% of all benign lesions of the jaw. Giant cell reparative granuloma often arises in the mandible and in the maxilla and affects children and young adults. It is usually a slow-growing lesion, fast-growing lesions having rarely been reported. The latter, despite the innocent histological appearance, has an aggressive behaviour mimicking a malignant lesion. In the present report the clinical features of an aggressive variety of giant cell reparative granuloma in a 21-year-old female are described focusing on the dental findings at computed tomography and surgical treatment.

Simultaneous surgical treatment of chronic post-traumatic aneurysm of the thoracic aorta, diaphragmatic hernia and giant emphysema bulla.

Thoraco-abdominal blunt trauma can lead to multiple injuries of several organs. We report a case of a patient in whom, 10 years after a trauma, a chest X-ray showed visceral herniation into the left thorax. Angio computed tomographic scan (CTS) and magnetic resonance imaging (MRI) confirmed these lesions and also showed a saccular thoracic aortic aneurysm. During the surgical procedure a giant post-traumatic emphysema bulla of the left lower pulmonary lobe was discovered and repaired. In the presence of diaphragmatic injuries, CTS and MRI are mandatory for excluding other organ involvement, and during the surgical procedure, careful inspection of left thorax and abdomen should always be done to repair other possible injuries not seen before.

Thymic lesions and myasthenia gravis. Diagnosis based on mediastinal imaging and pathological findings.

PURPOSE: To achieve a better understanding of the role of CT and MR imaging in the study of the mediastinum in patients with myasthenia gravis (MG). MATERIAL AND METHODS: Mediastinal CT and MR findings were correlated with the histopathological results in 104 thymectomized MG patients. RESULTS: CT was performed in 104 patients; in 11 of them, MR was also carried out. 44 patients had hyperplasia at histology. On CT, thymic hyperplasia was confirmed in 16 cases, thymoma was diagnosed in 10 and a normal thymus in 18 (sensitivity 36%, specificity 95%). Of 52 patients with thymoma at histology, CT showed thymoma in 46, hyperplasia in 1, and normal thymus in 5. CT showed 88.5% sensitivity and 77% specificity for thymoma. In 10 patients with invasive thymoma, CT was indiscriminate, while invasiveness was detected in 7 cases at MR (70% sensitivity) and at CT in 1 case. Both CT and MR detected tumor recurrence in 5 cases, but the exact localization and degree of invasion were best defined by MR. CONCLUSION: In MG patients CT is a sensitive, specific and efficient modality for detecting thymoma, but is less so for detecting thymic hyperplasia. MR was shown to be accurate in detecting invasive thymoma both preoperatively and in postoperative follow-up.

Nosocomial bacterial pneumonia in human immunodeficiency virus infected subjects: incidence, risk factors and outcome.

The presented study examined the incidence, risk factors and outcome of nosocomial bacterial pneumonia (NBP) in human immunodeficiency virus (HIV)-infected subjects. Forty-two cases of NBP were ascertained by a 5-yr prospective surveillance and were matched to 84 controls. NBP incidence was 10.8 per 10,000 hospital patient-days. In particular, the incidence of NBP was 13.9 per 10,000 patient-days in the period 1994-1996 and 5.6 per 10,000 patient-days in the period 1997-1998 (p=0.01). By using regression analysis, predictors for developing NBP were an increasing value of Acute Physiology and Chronic Health Evaluation (APACHE) III score (p<0.01) and the presence of acquired immune deficiency syndrome (AIDS)-related central nervous system (CNS) diseases (p=0.01). The additional hospital stay attributable to NBP was 15 days. The attributable mortality rate was estimated to be 29%. Nosocomial bacterial pneumonia is more common in patients with advanced human immunodeficiency virus infection, high Acute Physiology and Chronic Health Evaluation III score and central nervous system diseases. Although the incidence of nosocomial bacterial pneumonia, as well of other opportunistic infections, decreased considerably in the era of highly active antiretroviral therapy, it still represents an important cause of mortality.

[Evaluation of the "N" factor in nonsmall cell lung cancer. Correlation between computerized tomography and pathologic anatomy]. / Valutazione del fattore "N" nel carcinoma polmonare non a piccole cellule. Correlazione tra Tomografia Computerizzata e anatomia patologica.

PURPOSE: To evaluate the role of CT in identifying other morphological signs of metastatic lymph node involvement from non small cell bronchogenic carcinoma. This is done to improve N staging, a critical step in this disease. In fact, since diameter is the only criterion used to distinguish normal form abnormal lymph nodes, medistinal CT only has 80% diagnostic accuracy. MATERIAL AND METHODS: 137 patients with known or suspected lung cancer were examined with Helical CT during early and late arterial phases (2 min delay, 3 mm thickness, 5 mm interslice gap) to depict node characteristics. Mediastinal lymph nodes, located according to the American Thoracic Society mapping, were considered normal when they were not visible or, if visible, less than 1 cm in diameter and of homogeneous density; lymph nodes over 1 cm in diameter and homogeneous density were considered reactive. A lymph node was considered metastatic when, independent of size, the following signs were found: central hypodensity; hyperdense thin/thick rim, with nodules within; hyperdense strands or diffuse hyperdensity in perinodal adipose tissue. The tumor site was also considered. RESULTS: Seventy patients were excluded because they were inoperable. Sixty-five of the remaining 67 patients were operated on, 1 underwent mediastinoscopy and another one mediastinoscopy followed by surgery. Based on the above CT signs, 46 patients were staged as N0, 61 as N1 and 15 as N2. In 44/46 N0 patients there was agreement between anatomical and pathologic findings; 3 of the 44 patients had lymph nodes over 1 cm in diameter and with homogeneous density. Micrometastases to mediastinal lymph nodes (N2) were found at histology in 2/46 patients (CT false negatives). In the 6 N1 and the 15 N2 patients there was complete agreement between anatomical and pathologic findings; in particular, 9 N2 patients had lymph nodes less than 1 cm in diameter with signs of metastasis and 4 had lymph nodes over 1 cm in diameter with signs of metastasis and 2 had lymph nodes either over or less than 1 cm. In all N2 patients the tumor histotype and the mediastinal location were also considered relative to the lesion site. DISCUSSION: A closer correlation was found with node morphology and density than with size. Indeed, CT sensitivity, specificity and diagnostic accuracy were 97, 100 and 97%, respectively, for the former versus 52, 93 and 77% for the latter. Adenocarcinoma was the predominant histotype (70.5%) in N2 patients. Metastases to node region 4 were predominant in right upper lobe carcinomas while node region 5 was predominant in left upper lobe lesions. CONCLUSIONS: Other criteria can be associated with size to improve CT diagnostic accuracy in N staging. Technique optimization plays a major role particularly in the late, thin slice, examination phase.

Combined diagnostic imaging of mediastinal lymphadenopathy in lung cancer.

The identification and characterization of lymphadenopathies is one of the fascinating challenges of modern diagnostic imaging. At present, the real problem is the distinction between normal and pathologic signs. For twenty years, the differentiation was based on the dimensional criterion, namely a short axis < 1 cm, however it was shown to be inadequate. After an overview of the anatomy, ATS classification, the role of N factor in lung cancer (60% of N0 patients survive at 5 years) while only 20% of N2 patients survive), the new signs evidenced on CT are analyzed and interpreted. With thin section, late phase CT, a retrospective study and a perspective study were carried out on densitometric changes in lymph nodes correlated with histology findings. The role of intranodal hypodensity, peripheral rim and adipose tissue was stressed. The results of these studies were concordant with histology findings and confirmed the better accuracy in staging and the impact on survival of extranodal spread detected, based on radiologic criteria.

[Bacterial pneumonia in HIV-infected patients] / Polmoniti batteriche in corso di infezioni da HIV.

This case-control study assessed risk factors and prognostic indicators of 350 episodes of bacterial pneumonia in 285 HIV-infected patients. On univariate analysis, intravenous drug abuse (p<0.001), regular cigarette smoking (p<0.001), cirrhosis (p=0.04), and history of a previous episode of pneumonia (p=0.04), were risk factors for community-acquired episodes of bacterial pneumonia, whereas length of hospitalization (p=0.01) was a risk factor only for nosocomial bacterial pneumonia. The small amount of circulating T CD4+ cells, (<100/mmc) was a risk factor in both groups of pneumonia (p<0.05). Stepwise logistic regression analysis revealed that IVDA in community-acquired episodes and low levels of circulating T CD4+ cells, both in community-acquired and hospital-acquired episodes, were independent risk factors for the development of bacterial pneumonia. The case-fatality rate observed in our study was 27%. On stepwise logistic regression analysis, T CD4+ cell counts >100/mmc (p<0.02), neutropenia (p=0.04), PO2 arterial level <70 mmHg (p=0.01), and Karnofsky score <50 (p=0.04) were independent indicators of mortality. According to a personally developed prognostic score, 211 episodes of pneumonia (60%) were classified as mild, 63 (18%) as moderate, and 76 (22%) as severe. Clinicians must carefully evaluate those variables that can influence the prognosis of bacterial pneumonia to make early identification of affected patients and to promptly establish the most appropriate therapeutic strategy in each case.

Diagnostic imaging of primitive neuroectodermal tumour of the chest wall (Askin tumour).

OBJECTIVES: To describe the radiological features of primitive neuroectodermal tumour (PNET) of the chest wall (Askin tumour) at diagnosis and to analyse the radiological changes occurring as a consequence of treatment and during follow-up. MATERIALS AND METHODS: Nine children with histologically proven PNET were studied. At diagnosis, all patients underwent chest X-ray (CXR), chest CT and bone scintigraphy; three patients also had MR and three had US. During treatment and follow-up, CT was performed in all patients. RESULTS: CT demonstrated a solid heterogeneous chest wall mass in all children at diagnosis and six had a rib lesion. Small nodular densities in the extra-pleural fat were identified in three patients at diagnosis. US, performed in three patients, excluded tumour infiltration of the lung or diaphragm, which had been suspected on CT. On MR, the lesions showed high signal intensity in T1-weighted/proton-density images and intermediate/high signal intensity in T2-weighted images compared with muscle. Minimal chest wall involvement was demonstrated in one case by MRI. Extensive necrosis of tumour mass with pseudo-cystic appearance was documented in the five patients who underwent chemotherapy. Macroscopically complete resection was performed in five patients but there was early local recurrence after surgery in two, identified by CT in one and by MR in the other. CONCLUSIONS: PNET of the chest wall should be considered in a child with a chest wall mass. CT is valuable for evaluating tumour extension at diagnosis, the effects of chemotherapy and assessing tumour recurrence after surgery. However, CT can overestimate pleural, lung or diaphragmatic infiltration, which are better evaluated by US. MR was superior to CT in the evaluation of tumour extension in one of three patients and may be considered complementary to CT, particularly in very large chest wall tumours.

Automated scheduling of radiologic procedures.

The dramatic advances in radiology have increased the number and type of machines and of daily performed exams. Consequently, workload and management organization problems have also markedly increased. Automated, computerized scheduling of radiologic exams is certainly a step forward in a modern rational management of a Diagnostic Imaging service: the relationship with the patient is improved with the optimization of care delivered and of the radiologist's work, who with the new technology is able to rapidly consult the previous exams as well as the list of exams to be performed. The advances in health care information technology imply communications at a distance. From each ward of the hospital, requests for radiologic exams can be automatically scheduled or kept on a dynamic waiting list for automated input in future work shifts. Via the same system, reports (and also radiologic images) can by rapidly transmitted to the wards. At the "Università Cattolica del S. Cuore" from several years, an integrated information system has been implemented for management of patient data, exams and care delivered. Radiology represents one of major departmental systems of the network for the number of machines installed and the amount of information supplied. The system will be soon able to store images from all digital and nondigital machines, and visualize on dedicated workstations the images of ongoing exams or stored previous ones.

Excellence in diagnostic imaging service management.

The identification of promoting factors of excellence improvement in radiology service management means to clearly assess how the different aspects of the service are managed. The key elements for intervention are sharply differentiated according to the service managerial level. The approach to continuous improvement should be a useful tool of assessment even when all its potentialities have been exhausted and new promoting factors are necessary to move to the subsequent stage.