Clinical significance of vesicoureteral reflux after kidney transplantation.

In this study 103 out of our 125 CsA-treated patients who received between January 1985 and December 1989 a first cadaver kidney transplant that functioned for at least one year were studied with voiding cystography (VC) for vesicoureteral reflux (VUR). All patients had an external uretero-neo-cystostomy. VUR occurred in 89 (86.4%) patients. Patients were grouped according to VUR: absence of VUR (group 0), VUR grade I-II (group 1-2), and VUR grade III (group 3). The 3 groups were comparable for male/female ratio, cause of renal failure, cause of donor death, recipient and dialytic age, immunosuppressive therapy, follow-up, time of VC performance after transplantation. At 6 months and 1, 2, 3, 4, and 5 years after transplantation graft function, number of rejection episodes, and number of urinary tract infections (UTIs) were similar in the 3 groups. In groups 1-2 and 3 hypertension was more frequent than in group 0 and occurred even after the 6th month (whereas this did not happen in group 0), but the differences between the 3 groups were not significant. However, when only the 13 patients who were followed for 5 years were considered, the prevalence of hypertension after 5 years was significantly higher in groups 1-2 and 3 (both 100.0%) than in group 0 (33.3%) (chi-square = 7.88; p < 0.02). Finally, 4.5% of patients with VUR and no patients without VUR had septic episodes linked to UTIs, but the difference was not significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Vesicoureteral reflux after kidney transplantation: clinical significance in the medium to long-term.

103 patients who received a cyclosporine-treated primary cadaver kidney transplant (TX) at our center between 1985 and 1989, whose graft survived for more than 1 year and who accepted to undergo voiding cystography after TX were analyzed and grouped according to the highest grade (regardless to whether active or passive) of vesicourteral reflux (VUR): group 0, absent (n = 14); group 1-2, grade I or II (n = 62); group 3, grade III (n = 27). Patient follow-up ranged from 5 to 10 (median 7) years. Patient and graft survivals and prevalence of hypertension (defined as the persistent need of antihypertensive therapy), did not differ significantly between groups (Mantel-Cox test p: n.s. in all cases). GFR (Cockroft and Gault) and proteinuria were evaluated with ANOVA for repeated measures at 1, 2, 3, 4 and 5 years in the 96 patients (group 0: 13, group 1-2: 56, group 3: 27) whose grafts lasted for 5 years or more. Neither GFR values (p: n.s.) nor GFR behaviour over time (p: n.s.) differed between groups, although a progressive decline of GFR was noted in all groups (p < 0.002). Proteinuria neither showed any significant differences between groups in values (p: n.s.) or behaviour over time (p: n.s.), nor any trend in behaviour over time in all groups as a whole (p: n.s.). Finally, in the first 5 years after TX the 3 groups did not differ for number of urinary tract infections (UTIs) (mean value for all patients: 2.5, range 0-22, episodes/pt/5 years) (p: n.s.), or for number of UTIs with leukocyturia (mean 0.6, range 0-6, episodes/pt/5 years) (p: n.s.), or for number of febrile UTIs (mean 0.3, range 0-5, episodes/pt/5 years) (p: n.s.), or for number of UTIs with sepsis (mean 0.1, range 0-2, episodes/pt/5 years) (p: n.s.). The same results were obtained when, instead of episodes/ pt/5 years, percentages of patients without or with 1 or more of such episodes in the same period were considered. In conclusion, VUR does not seem to be hazardous for the transplanted kidney in the medium to long-term.

[The elbow: normal and pathologic patterns]. / Il gomito: quadri normali e patologici.

The elbow is an anatomically complex joint, which is nonetheless quite easy to investigate by means of US thanks to the superficial location and relative abundance of periarticular structures--i.e., tendons, muscles, bursae, vessels and nerve. Thus, US allows lateral, medial, anterior and posterior musculo-tendinous joints to be demonstrated, together with vasculonervous structures--i.e., arteries, veins, nerves. Linear or convex US probes (at 7.5 or 10 MHz) are employed. The examination must be performed with either a flexed or an extended elbow. US shows typical patterns in traumas (joint and periarticular conditions), in degenerative disorders (chondromatosis), inflammations (epicondylitis, bursitis, hygromas, rheumatoid nodules and joint effusions) and finally in tumors. The US patterns of the above conditions are quite typical and often allow a diagnosis to be made. Therefore, US proves to be a reliable first-choice technique in the evaluation of the periskeletal elbow.

[Utility of the Doppler technique in the uro-nephrologic field]. / Utilità delle tecniche Doppler in campo uro-nefrologico.

Doppler techniques (echo Doppler, Color Doppler) may be useful in many urologic and nephrologic applications. Renal vein thrombosis can be determined by discovering a combination of a distended, thrombus-filled renal vein and the absence of detectable flow. The use of Doppler as screening technique for suspected renal artery hypertension remains controversial. Although patency of the renal artery can be assessed by Doppler, it is difficult to evaluate always the entire course of the vessel and it is impossible to detect multiple renal arteries. In the renal masses Doppler can investigate the vascularity: most malignant lesions gives rise to abnormal, high frequency, Doppler shifted signals that can aid the differential diagnosis of benign and malignant conditions. Doppler has recently been shown to help distinguish between the dilated renal pelvis and renal obstruction. A Resistive Index (RI) of 0.70 or greater is suspicious for obstruction, while a value of less than this virtually rules out the diagnosis in most cases. The use of Doppler techniques in renal transplants has become routine. Doppler assesses the presence of blood flow in the main renal arteries and veins, the presence of post-surgical abnormalities such as pseudo-aneurysms, stenoses, A-V fistulas and has proven useful in the evaluation of flow waveforms associated with variety of different abnormalities which can produce a decrease in renal function. Acute vascular rejection produces an increased resistance to flow with decreased, absent or reversed diastolic flow within the transplant kidney. Severe rejection produces abnormalities of the RI which are non-specific; severe acute tubular necrosis, infections, obstructions, peri-renal collections can also produce elevated RI.(ABSTRACT TRUNCATED AT 250 WORDS)

[Extrarenal ultrasound and color Doppler: renal artery stenosis]. / Eco e color Doppler extrarenale: la stenosi dell'arteria renale.

There is a long term interest in noninvasive Doppler (Duplex Doppler, Color Doppler) methods to screen patients with reno-vascular hypertension resistant to medical therapy. Doppler criteria for the diagnosis of renal artery stenosis in native kidneys vary (peak systolic velocity exceeding 100 cm/sec; RAR (Renal Aortic Ratio) exceeding 3.5; Doppler shift frequency exceeding 6-8 KHz; dampened peripheral waveform; lack of signal in complete occlusion). When the vessels are adequately visualized (about 40% of cases) sensitivity and specificity are quite good (80-90%). In the transplanted kidney Doppler diagnosis of renal artery is easier (diagnostic accuracy about 90%). The diagnostic criteria have been well codified (Doppler shift of 7.5 KHz at an insonating frequency of 3 MHz).

[White and black in nuclear magnetic resonance (NMR). Impulse sequences and their significance in the NMR image]. / Bianco e nero in risonanza nucleare magnetica (RNM). Sequenze di impulsi e loro significato nell'immagine RNM.

In order to understand how pulse sequences affect what is black and what is white in Nuclear Magnetic Resonance (NMR) images, the tissue parameters (proton density; relaxation times T1 and T2) are related to the operator selectable controls (type of pulse sequence; repetition time TR; interpulse delay TI; echo delay TE). The pulse sequences "Saturation Recovery"; "Inversion Recovery"; "Spin Echo" are discussed. The authors also analyze the effect of flowing blood on NMR images.

[Diagnostic errors in the echography of the hip in newborns]. / Errori nell'ecografia dell'anca neonatale.

Neonatal hip sonography according to Graf employs a standardized image in a frontal section plane ("3-point system") and a good scanner adjustment (the femoral head must be anechoic, like the hyaline cartilage roof triangle). Pathologic conditions can change some of these parameters. The authors examined 6,000 neonatal hips in order to point out the commonest causes of diagnostic error. Two types of error were considered: method errors and interpretation errors. Method errors: they are due to the choice of transducer and frequency, to scanner adjustment and definition of the standard section plane. Their incidence was 2.25% and supported by an uncorrect definition of the standard section plane. Interpretation errors: they come from the wrong localization of some reference points--i.e., lower iliac margin, labrum--, uncorrect evaluation of increased echogenicity of the cartilaginous roof, infant age, application of radiographic criteria and uncorrect measurements of alpha and beta angles. Interpretation errors had 5.5% incidence; they were all due to the uncorrect measurement of alpha (3.18%) and beta (2.33%) angles, especially in pathological hips (68%). To reduce the number of errors, the authors suggest to strictly apply Graf's method, to make a diagnosis based on the morphological changes of the cartilaginous and osseous acetabular roof and, only later on, to measure alpha and beta angles to confirm the diagnosis or in the follow-up.

[Ultrasonography of the borderline between normal and pathological state of the hip in newborn infants (borderline hip)]. / Reperti al confine fra normale e patologico nell'ecografia dell'anca neonatale (anca "borderline").

Infant hips are classified, according to Graf, in 4 US types on the basis of the morphologic changes in both the cartilaginous and the bony roofs (type I, II, III, IV). Out of 6,000 examined hips, 170 (2.8%) were considered, which could be classified neither as type I (mature) nor as type II (delayed/immature ossification). These hips were called borderline hips. They exhibited some characteristic US features: good bone modeling, rounded cotyle, and alpha angle 60 degrees +/- 2. They were always observed during the first month of the patients' life. Anamnestic data were not specific (27.5% breech delivery, and 13% oligohydramnios); clinics sometimes overestimated the actual anatomic development (64/170 cases with positivity of Ortolani's sign and/or restricted abduction; 25% of patients presented with no suspicious signs). Dynamic hip examination showed only physiological cranial deflection of the cartilaginous roof. Finally, borderline hips developed into type I hips in 99% of cases, within the third month of the patients' life.

[The echo-guided fine-needle biopsy of thoracic and abdominal masses]. / Agobiopsia ecoguidata con ago sottile su masse toraciche e addominali.

Five hundred and seventy-two US-guided fine-needle biopsies were performed on 561 patients (1.2 puncture/patient); in two cases only minor complications were observed. The patients were 12 to 86 years old--most of them ranging 40 to 75. In 5.42% of cases FNAB proved inadequate; 1.75% of the diagnoses was questionable, 28.89% was negative, and 63.98% positive. A comparison with histology was possible in 218 cases: 2 false positives and 5 false negatives were observed. The low rate of false-positive findings demonstrates US-guided FNAB to have high positive predictive value. The method had 95% sensitivity, 98.4% specificity and 84.3% accuracy. The high reliability of FNAB depends on the possibility of centering the lesion through the direct US visualization of the needle tip. This characteristic, together with the presence of the cytologist, who immediately evaluates the aspirated material, helps reduce the number of unnecessary biopsies and, consequently, complications.

[The intraoperative echography of malignant hepatic lesions]. / Ecografia intraoperatoria nelle lesioni maligne epatiche.

IOU (intraoperative ultrasound) is nowadays an indispensable technique for the surgeon to confirm the information collected from preoperative tests or to gain further information that may modify surgical strategy. A series of 350 patients were studied with IOU: in 67 cases the liver was involved, with 23 malignant lesions. In the latter group, 10 lesions were found which had been missed even at palpation; the size of 9 of them could be correctly assessed, which had been overestimated in 8 cases and underestimated in 1 before surgery. Moreover, in 39.1% of the cases, the information yielded by IOU determined a change in surgical strategy, favoring a more accurate dissection of the lesion. Surgery was modified depending on the recognition of: nonpalpable lesions (5 cases); portal thrombosis (1 case); lesions bigger (2 cases)--smaller (2 cases) than preoperatively diagnosed. Moreover, IOU was a useful tool to guide the surgeon during intervention, by yielding accurate anatomical information on the segment/segments hosting the lesion.

[The hypothesis of a diagnostic-prognostic assessment of intestinal invagination with the aim of treatment by echo-guided pneumatic reduction]. / Ipotesi di valutazione diagnostico-prognostica della invaginazione intestinale finalizzata al trattamento con riduzione pneumatica ecoguidata.

The authors investigated the role of US in the diagnostic-prognostic evaluation of enteric intussusception, for the use of US-guided pneumatic reduction (RPEG). In the last 5 years, 59 young patients were examined; 44 of them had clinically suspected enteric intussusception which was confirmed by US. US allowed site and nature of the condition to be demonstrated (sensitivity and specificity: 100%), while supplying helpful predictive prognostic elements as to the extent of intussuscepted loop involvement (predictive prognostic value: 100%). On the contrary, its etiological screening capabilities were poor (11%) in the identification of secondary forms (5 ileal diverticula). A grading score was introduced to select the patients undergoing RPEG. Six clinical and US parameters were considered, with values increasing according to severity of the condition. The higher the score, the lower the chances of therapeutical success with RPEG. In 3 cases (2 loop necroses and 1 severe intestinal obstruction) with US score greater than 6 [9] and clinical score greater than 11 [15], RPEG, was replaced by surgery. Fourteen patients underwent RPEG: positive results were obtained in 12 cases (85%). In one case, a short-term relapse (within 6 hours) was observed.

[Magnetic resonance (MR) imaging of the normal mediastinum]. / Imaging del mediastino normale con risonanza magnetica (RM).

Magnetic Resonance (MR) cross sectional images of the normal mediastinum are presented and discussed. In normal subjects most mediastinal structures visible on Computed Tomography (CT) are also visible using MR. The primary advantages of MR over CT in the evaluation of mediastinum are the greater soft tissues contrast resolution, the multiplanar (axial, coronal and sagittal) display of the mediastinal anatomy and its ability to distinguish vascular from nonvascular structures without injection of contrast media.