Relevant incidental findings at abdominal multi-detector contrast-enhanced computed tomography:A collateral screening?

AIM: To investigate the prevalence of relevant incidental findings(RIFs) detected during routine abdominal contrast-enhanced computed tomography(Ce CT).METHODS: We retrospectively evaluated the reports of a consecutive series of abdominal Ce CT studies performed between January and May 2013. For each report, patients' age and sex, admission as inpatient or outpatient, clinical suspicion as indicated by the requesting physician, availability of a previous abdominal examination, and name of the reporting radiologist were recorded. Based on the clinical suspicion, the presence and features of any RIFs(if needing additional workup) was noted.RESULTS: One thousand forty abdominal Ce CT were performed in 949 patients(528 males, mean age 66 ±14 years). No significant difference was found between inpatients and outpatients age and sex distribution(P > 0.472). RIFs were found in 195/1040(18.8%) Ce CT [inpatients = 108/470(23.0%); outpatients = 87/570(15.2%); P = 0.002]. RIFs were found in 30/440(6.8%) Ce CT with a previous exam and in 165/600(27.5%) without a previous exam(P < 0.001). Radiologists' distribution between inpatients or outpatients was significantly different(P < 0.001). RIFs prevalence increased with aging, except for a peak in 40-49 year group. Most involved organs were kidneys, gallbladder, and lungs.CONCLUSION: A RIF is detected in 1/5 patients undergoing abdominal Ce CT. Risk of overdiagnosis should be taken into account.

Reporting rotator cuff tears on magnetic resonance arthrography using the Snyder's arthroscopic classification

AIM To determine diagnostic performance of magnetic resonance arthrography(MRA) in evaluating rotator cuff tears(RCTs) using Snyder's classification for reporting.METHODS One hundred and twenty-six patients(64 males, 62 females; median age 55 years) underwent shoulder MRA and arthroscopy, which represented our reference standard. Surgical arthroscopic reports were reviewed and the reported Snyder's classification was recorded. MRA examinations were evaluated by two independent radiologists(14 and 5 years' experience) using Snyder's classification system, blinded to arthroscopy. Agreement between arthroscopy and MRA on partial-and fullthickness tears was calculated, first regardless of their extent. Then, analysis took into account also the extent of the tear. Interobserver agreement was also calculated the quadratically-weighted Cohen kappa statistics.RESULTS On arthroscopy, 71/126 patients(56%) had a fullthickness RCT. The remaining 55/126 patients(44%) had a partial-thickness RCT. Regardless of tear extent, out of 71 patients with arthroscopically-confirmed fullthickness RCTs, 66(93%) were correctly scored by both readers. All 55 patients with arthroscopic diagnosis of partial-thickness RCT were correctly assigned as having a partial-thickness RCT at MRA by both readers. Interobserver reproducibility analysis showed total agreement between the two readers in distinguishing partial-thickness from full-thickness RCTs, regardless of tear extent(k = 1.000). With regard to tear extent, in patients in whom a complete tear was correctly diagnosed, correct tear extent was detected in 61/66 cases(92%); in the remaining 5/66 cases(8%), tear extent was underestimated. Agreement was k = 0.955. Interobserver agreement was total(k = 1.000).CONCLUSION MRA shows high diagnostic accuracy and reproducibility in evaluating RCTs using the Snyder's classification for reporting. Snyder's classification may be adopted for routine reporting of MRA.

Pioglitazone does not modify ANP levels of type 2 diabetic patients

Background: The atrial natriuretic peptide (ANP) regulates fluid volume redistribution between heart and the pulmonary vessels. In diabetic patients the physiological action of ANP appears to be seriously altered. Methods: 12 subjects (gender 6M/6F, age 47 ± 2 years, BMI 29.1 ± 0.1 kg/m2), with type 2 diabetes and under stable conditions, were studied after one month of pioglitazione treatment (30 mg/die) by means of isotonic blood volume expansion. Results: After one month of pioglitazone treatment the meta- bolic profile of the subjects improved (decrease dia- stolic blood pressure: p = 0.05, total cholesterol: p = 0.01, triglycerides: p = 0.03 and blood glucose: p = 0.01) as the expansion of their plasma volume was found associated with the decrease of hematocrit (p < 0.05). The statistical comparison before versus after pioglitazone showed a significant decrease in the ba- sal aldosterone levels post-treatment (p < 0.04). Nonetheless ANP plasma levels were similar before and after therapy. Conclusions: The inappropriately high concentrations of ANP induced by hyperglyce-mia and the abnormal responses to a physiological sti- mulus like an isotonic blood volume expansion are not reverted by one month of pioglitazone. This is in contrast with the brisk improvement of the metabolic profile seen for the same period of treatment. ANP secretion is modified by fluid load in diabetic patients. This anomaly is not reverted by pioglitazone.

Therapeutic and clinical aspects of portal vein thrombosis in patients with cirrhosis

Portal vein thrombosis(PVT) is a frequent complication in cirrhosis, particularly in advanced stages of the disease. As for general venous thromboembolism, risk factors for PVT are slow blood flow, vessel wall damage and hypercoagulability, all features of advanced cirrhosis. Actually, the old dogma of a hemorrhagic tendency in cirrhosis has been challenged by new laboratory tools and the clinical evidence that venous thrombosis also occurs in cirrhosis. The impaired hepatic synthesis of both pro- and anticoagulants leads to a rebalanced hemostasis, more liable to be tipped towards thrombosis or even bleeding. Conventional anticoagulant drugs(low molecular weight heparin or vitamin K antagonists) may be used in cirrhosis patients with PVT, particularly in those eligible for liver transplantation, to prevent thrombosis progression thus permitting/facilitating liver transplant. However, several doubts exist on the level of anticoagulation achieved as estimated by coagulation tests, on the efficacy of treatment monitoring and on the correct timing for discontinuation in non-transplant candidates, while in transplant candidates there is expert consensus on continuing anticoagulation until transplantation. The recent introduction of direct acting oral anticoagulant drugs(DOACs) in other clinical settings generates much interest on their possible application in patients with cirrhosis and PVT. However, DOACs were not evaluated yet in patients with liver disease and cannot be recommended for the present time.

Use of non-selective beta blockers in cirrhosis:The evidence we need before closing(or not) the window

Non selective beta blockers(NSBBs)are used in primary and secondary prophylaxis of portal hypertensionrelated bleeding in patients with cirrhosis.The efficacy of NSBBs treatment is predicted by hemodynamic response in term of reduction of the hepatic venouspressure gradient(HVPG)below 12 mm Hg or at least20%of the basal value.Nevertheless a relevant number of patients who do not achieve this HVPG reduction during NSBBs therapy do not bleed during follow up;this evidence suggests an additional non-hemodynamic advantage of NSBBs treatment to modify the natural history of cirrhosis.Recent studies have questioned the efficacy and safety of NSBBs in patients with advanced stage of liver disease characterized by refractory ascites and/or spontaneous bacterial peritonitis.These studies have suggested the existence of a defined and limited period to modify the natural history of cirrhosis by NSBBs:the"window hypothesis".According with this hypothesis,patients with cirrhosis benefit from the use of NSBBs from the appearance of varices up to the development of an advanced stage of cirrhosis.Indeed,in patients with refractory ascites and/or spontaneous bacterial peritonitis the hemodynamic effects of NSBBs may expose to a high risk of further complications such as renal insufficiency and/or death.Methodological concerns and contrasting results counterbalance the evidence produced up to now on this issue and are the main topic of this editorial.

Azacarbazole n-3 and n-6 polyunsaturated fatty acids ethyl esters nanoemulsion with enhanced efficacy against Plasmodium falciparum

Alternative therapies are necessary for the treatment of malaria due to emerging drug resistance.However,many promising antimalarial compounds have poor water solubility and suffer from the lack of suitable delivery systems,which seriously limits their activity.To address this problem,we synthesized a series of azacarbazoles that were evaluated for antimalarial activity against D10(chloroquine-sensitive)and W2(chloroquine-resistant)strains of P.falciparum.The most active compound,9H-3-azacarbazole(3),was encapsulated in a novel o/w nanoemulsion consisting of ethyl esters of polyunsaturated fatty acids n-3 and n-6 obtained from flax oil as the oil phase,Smix(Tween 80 and Transcutol HP)and water.This formulation was further analyzed using transmission electron microscopy,dynamic light scattering and in vitro and in vivo studies.It was shown that droplets of the 3-loaded nanosystem were spherical,with satisfactory stability,without cytotoxicity towards fibroblasts and intestinal cell lines at concentrations corresponding to twice the IC50 for P.falciparum.Moreover,the nanoemulsion with this type of oil phase was internalized by Caco-2 cells.Additionally,pharmacokinetics demonstrated rapid absorption of compound 3(tmax=5.0 min)after intragastric administration of 3-encapsulated nanoemulsion at a dose of 0.02 mg/kg in mice,with penetration of compound 3 to deep compartments.The 3-encapsulated nanoemulsion was found to be 2.8 and 4.2 times more effective in inhibiting the D10 and W2 strains of the parasite,respectively,compared to non-encapsulated 3.Our findings support a role for novel o/w nanoemulsions as delivery vehicles for antimalarial drugs.