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Background Since the COVID-19 pandemic has occurred, nations showed their unpreparedness to deal with a mass casualty incident of this proportion and severity, which resulted in a tremendous number of deaths even among healthcare workers. The World Society of Emergency Surgery conceived this position paper with the purpose of providing evidence-based recommendations for the management of emergency surgical patients under COVID-19 pandemic for the safety of the patient and healthcare workers. Method A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) through the MEDLINE (PubMed), Embase and SCOPUS databases. Synthesis of evidence, statements and recommendations were developed in accordance with the GRADE methodology. Results Given the limitation of the evidence, the current document represents an effort to join selected high-quality articles and experts’ opinion. Conclusions The aim of this position paper is to provide an exhaustive guidelines to perform emergency surgery in a safe and protected environment for surgical patients and for healthcare workers under COVID-19 and to offer the best management of COVID-19 patients needing for an emergency surgical treatment. We recommend screening for COVID-19 infection at the emergency department all acute surgical patients who are waiting for hospital admission and urgent surgery. The screening work-up provides a RT-PCR nasopharyngeal swab test and a baseline (non-contrast) chest CT or a chest X-ray or a lungs US, depending on skills and availability. If the COVID-19 screening is not completed we recommend keeping the patient in isolation until RT-PCR swab test result is not available, and to manage him/she such as an overt COVID patient. The management of COVID-19 surgical patients is multidisciplinary. If an immediate surgical procedure is mandatory, whether laparoscopic or via open approach, we recommend doing every effort to protect the operating room staff for the safety of the patient.

Acute scrotum is characterized by intense acute scrotal pain, which may be associated with other symptoms and signs such as abdominal pain, inflammation, and fever. Many pathologic conditions can present in this way, most which involve the scrotal contents. Nonscrotal conditions, however, can rarely present clinically only as acute scrotum: among them, renal colic, aneurysm rupture or other causes of retroperitoneal hemorrhage, primary abdominal or pelvic tumors and metastases, pancreatitis, pelvic inflammation, and muscle injuries. The pathophysiologic characteristics of the clinical presentation, clues for diagnosis, and imaging features of a series of nonscrotal lesions presenting clinically with acute scrotal pain are herein reported and illustrated. In patients presenting with acute scrotal symptoms and normal scrotal ultrasound findings, nonscrotal causes of acute scrotal pain should be considered in the differential diagnosis. Therefore, an ultrasound investigation of the abdomen, groin, and thighs is indicated.

The Cherenkov Telescope Array (CTA) is the next-generation ground-based observatory for very-high-energy gamma rays. One candidate design for CTA's medium-sized telescopes consists of the Schwarzschild-Couder Telescope (SCT), featuring innovative dual-mirror optics. The SCT project has built and is currently operating a 9.7-m prototype SCT (pSCT) at the Fred Lawrence Whipple Observatory (FLWO); such optical design enables the use of a compact camera with state-of-the art silicon photomultiplier detectors. A partially-equipped camera has recently successfully detected the Crab Nebula with a statistical significance of 8.6 standard deviations. A funded upgrade of the pSCT focal plane sensors and electronics is currently ongoing, which will bring the total number of channels from 1600 to 11328 and the telescope field of view from about 2.7° to 8° . In this work, we will describe the technical and scientific performance of the pSCT.

Desmoid-type fibromatosis (DF), also known as aggressive fibromatosis, is a locally aggressive benign fibroblastic neoplasm that can infiltrate or recur but cannot metastasize. It is rare, with an estimated annual incidence of two to four new cases per million people. Most DFs occur sporadically, but it may also be associated with the hereditary syndrome familial adenomatous polyposis. Treatment is necessary when the disease is symptomatic, especially in case of compression of critical structures. When possible, surgical resection is the treatment of choice; however, recurrence is common. Due to the high rate of recurrence, imaging plays an important role not only in diagnosis, but also in the management of DF. Although there are a number of studies describing CT and MRI findings of DF, there is no description of contrast-enhanced ultrasound findings.

The Acute Abdomen Decision Making course® (AADM®) was developed by the World Society of Emergency Surgeons (WSES) members with the purpose to teach a systematic and concise method for approaching acute abdomen patient. It was first introduced in 2016. The course explains step by step the clinical reasoning to follow for immediate managing of the acute abdomen in emergency department with a safe and reliable method. We developed this original decision making model AADM following the Advanced Trauma Life Support (ATLS) philosophy in evaluating non-traumatic abdominal pain patient. The A-B-C-D-E-F management of non-traumatic acute abdominal pain is conceived by WSES to make easy and systematic the evaluation of patients in Emergency Department. AADM course teaches how to assess an acute abdomen patient’s diagnosis and determine the therapeutic approach to reduce unnecessary exams and hospitalizations.

Patients with acute abdominal pain due to acute colonic diverticulitis are a frequent cause of hospital admission. Diverticuar disease increases with age. In Western populations, diverticular disease is diagnosed in 50% individuals over 70 years and 80% over 85 years of age. The identification of patients with acute diverticulitis is a considerable challenge, since numerous other acute abdominal conditions mimic its clinical characteristics. Another problem is the atypical presentation in older patients. A high index of suspicion in the setting of a compatible history and physical examination serves as the cornerstone of early diagnosis. The purpose of this review is to underline the importance of an intimately integrate multidisciplinary approach between emergency physicians, radiologists and surgeons.

OBJECTIVE: To investigate the role of strain elastography using calculated strain ratio and visual elastography score in differentiating nonneoplastic, benign, and malignant neoplastic intratesticular lesions. MATERIALS AND METHODS: The study was approved by the hospital review board as a retrospective review of 86 patients examined with gray scale, color Doppler ultrasonography and strain elastography (visual elastography score and strain ratio). Sensitivity, specificity, and positive and negative likelihood ratio of color Doppler and stain elastography were documented. Receiver operator characteristic curves assessed the diagnostic accuracy of strain elastography to discriminate nonneoplastic, benign, and malignant neoplasms. Histology or follow-up ultrasonography determined lesion character. RESULTS: Thirty-one of 86 (36.0%) intratesticular malignant neoplasms, 17 of 86 (19.8%) benign neoplasms, and 38 of 86 (44.2%) nonneoplastic lesions were confirmed with histology (n = 52) or follow-up sonography (n = 34); 89.5% of intratesticular lesions were heterogeneous or hypoechoic on gray scale, with no difference between benign and malignant. Sensitivity, specificity, positive and negative likelihood ratio for nonneoplasm versus neoplasm were documented: color Doppler: 68.8%, 97.4%, 26.5, 0.32; visual elastography score: 81.3%, 57.9%, 1.93, 0.32; strain ratio: 68.8%, 81.6%, 3.73, 0.38. Neoplastic lesions showed a higher strain ratio than nonneoplastic lesions (P

On cross-sectional imaging studies performed for other indications, incidental discovery of renal lesions is not uncommon. In daily use, grey-scale ultrasonography (US) and conventional Doppler modes are often the modality of choice for the initial assessment. While simple cysts are fully characterized with US, other lesions require further characterization, which is traditionally obtained by multiphase imaging, such as contrast-enhanced CT and MRI. Contrast-enhanced ultrasound (CEUS) has become a powerful additional tool for imaging renal lesions. With its lack of nephrotoxicity, the absence of ionizing radiation, and the ability to evaluate the enhancement pattern of renal lesions quickly and in real- time, CEUS has unique advantages over traditional modes. Established applications are differentiation between solid tumours, pseudolesions, and complex cysts; characterization of complex cysts with different malignant potential, and evaluation of tumor ablation. Microbubble contrast agents are safe. Adverse reactions are rare. This article provides an overview of the current clinical applications of CEUS in characterizing renal masses, discussing advantages and limitations. The aim is to provide the framework for sonologists to make informed decisions regarding this emerging imaging test in appropriate circumstances.

Ultrasound (US) is recognized as a useful first-line imaging modality, being esteemed its characteristics such as real-time scanning, no radiation, easy performance, and cost-effectiveness. However, it is regarded inferior to computed tomography and magnetic resonance because of its low ability to depict organ vascularization especially for tumor characterization.

Scrotum is a superficial anatomical structure and it can be easily assessed with clinical examination. Ultrasonography (US) is the initial imaging modality for evaluating pathologic conditions of the scrotum. However, magnetic resonance (MR) imaging is useful in case of equivocal sonographic findings.

Purpose Defining the site of recurrent disease early after definitive treatment for a localized prostate cancer is a critical issue as it may greatly influence the subsequent therapeutic strategy or patient management.

Scrotal cystic lesions are common incidental findings at ultrasonography. Most of them are located in the epididymis, but the testis and the cord are also involved. Testicular, albugineal, and epidermoid cysts; cystic dysplasia of the rete testis; cysts of the spermatic cord; and cystic appendages are easily detected at ultrasonography, which is the modality of choice to differentiate benign cysts from cystic tumors. Other imaging modalities such as CEUS and MR imaging may have a role for characterization of complex cystic lesions.

Penile traumas can result from penetrating or non-penetrating injuries. Diagnosis of albugineal disruption must be obtained as soon as possible since early surgical repair reduces significantly the rate of posttraumatic curvature and fibrosis. MR imaging is the modality of choice to investigate the integrity of the tunica albuginea. In expert hands, however, ultrasonography can be as informative as MR. It is able to detect the exact site of the tear as an interruption of the thin echogenic line of the tunica albuginea.

Ultrasound features of solid scrotal tumors are often nonspecific, and most of them have no special character to help identification of their nature. Ultrasonography, however, identifies lesions in virtually all cases. Moreover, it allows differentiation between intratesticular and extratesticular masses and gives an accurate estimate of their local extent and of the relationship with adjacent tissues.

Contrast-enhanced ultrasound (CEUS) is a new technique that employs microbubble contrast agents and complementary harmonic pulse sequences to demonstrate parenchymal perfusion.

In the clinical practice, there is an increasing incidence of small, non-palpable testicular lesions identified with an ultrasonographic investigation performed for other purposes. Many of these lesions are benign tumours or non-neoplastic conditions. In this context, the old axiom that every testicular mass should be considered a malignant tumour and the testis must be removed is no longer valid. Lesions can either undergo active surveillance or testis-sparing surgery, which allows maximal preservation of testicular parenchyma and its vasculature. To provide for the possibility of testis-sparing surgery for non-palpable nodules, precise intraoperative ultrasonographic localisation of the lesion is necessary. Our technique includes ultrasonographic localisation of the nodule within the exposed testicle and placement of a localising needle while the patient is on the operating table.

The increased use of ultrasound in patients with urological and andrological symptoms has given an higher detection of intra-testicular nodules. Most of these lesions are hypoechoic and their interpretation is often equivocal. Recently, new ultrasound techniques have been developed alongside of B-mode and color-Doppler ultrasound. Although not completely standardized, contrast-enhanced ultrasound (CEUS) and tissue elastography (TE), added to traditional ultrasonography, can provide useful information about the correct interpretation of incidentally detected non-palpable testicular nodules. The purpose of this review article is to illustrate these new techniques in the patient management.

Objective Chest auscultation and chest x-ray commonly are used to detect postoperative abnormalities and complications in patients admitted to intensive care after cardiac surgery. The aim of the study was to evaluate whether chest ultrasound represents an effective alternative to bedside chest x-ray to identify early postoperative abnormalities. Design Diagnostic accuracy of chest auscultation and chest ultrasound were compared in identifying individual abnormalities detected by chest x-ray, considered the reference method. Setting Cardiac surgery intensive care unit. Participants One hundred fifty-one consecutive adult patients undergoing cardiac surgery. Interventions All patients included were studied by chest auscultation, ultrasound, and x-ray upon admission to intensive care after cardiac surgery. Measurements and Main Results Six lung pathologic changes and endotracheal tube malposition were found. There was a highly significant correlation between abnormalities detected by chest ultrasound and x-ray (k = 0.90), but a poor correlation between chest auscultation and x-ray abnormalities (k = 0.15). Conclusions Chest auscultation may help identify endotracheal tube misplacement and tension pneumothorax but it may miss most major abnormalities. Chest ultrasound represents a valid alternative to chest x-ray to detect most postoperative abnormalities and misplacements.

In the present article, we present the experimental results concerning the fine-tuning and optimization of superconducting quantum interference device (SQUID) parameters by thermal annealing. This treatment allows for the modification of the parameters in order to meet a specific application or to adjust the device parameters to prevent the increase of magnetic field noise and work instability conditions due to a different critical current with respect to the design value. In particular, we report the sensor critical current, the voltage&ndash, flux (V&ndash, &Phi, ) characteristics and the spectral density of the magnetic field of SQUID magnetometers for different annealing temperatures. The measurements demonstrate that it is possible to achieve a fine control of the most important device parameters. In particular, we show that thermal annealing allows for the reduction of SQUID noise by more than a factor of 5 and makes the device working operations very stable. These results are very useful in view of quantum technology applications related to superconducting quantum computing where the correct functioning of the quantum bit depends on the fine control of the superconducting quantum device parameters and selectable annealing is possible by using a suitable laser as a thermal source.

Branchial cleft cysts are benign lesions caused by anomalous development of the brachial cleft. This report describes a 20-year-old girl with swelling on the right lateral aspect of the neck, which expanded slowly but progressively. The clinical suspicion was that of a branchial cleft cyst. Sonography revealed a homogeneously hypo- to anechoic mass with well-defined margins and no intralesional septa. Color Doppler reviewed no internal vascularization. The ultrasound examination confirmed the clinical diagnosis of a second branchial cleft cyst, demonstrating the cystic nature of the mass and excluding the presence of complications. For superficial lesions like these, ultrasound is the first-level imaging study of choice because it is non-invasive, rapid, low-cost, and does not involve exposure to ionizing radiation.Le cisti branchiali sono lesioni benigne dovute ad anomalie di sviluppo degli archi branchiali. Viene presentato il caso di una Paziente, 20 anni, con tumefazione laterocervicale a lenta e progressiva crescita, sospetta clinicamente per cisti branchiale. Ecograficamente la lesione mostrava struttura omogenea ipo- anecogena, con margini ben definiti, priva di setti intralesionali e di patologica vascolarizzazione alla valutazione color-Doppler. L’ecografia confermava quindi il sospetto clinico di cisti del II arco branchiale, dimostrando la sua natura cistica ed escludendo possibili complicanze. Trattandosi di lesioni superficiali l’ecografia rappresenta la metodica di imaging di primo livello essendo non invasiva, di rapida esecuzione, poco costosa, non esponendo il paziente a radiazioni ionizzanti.

Introduction Differentiation among the many clinical situations that can present with acute scrotal pain is a significant diagnostic problem in clinical practice. A firm diagnosis is often difficult based on clinical history and physical examinations alone, and imaging is usually requested for this purpose. However, imagingfindings alonemaynot clarify the diagnosis as imaging studies have to be interpreted in close correlation with clinical information and with knowledge of the possible pathologic situations underlying the clinical presentation of the specific patient. In this article we describe and discuss the most common problems encountered when performing diagnostic studies for acute scrotal symptoms and the solutions for, possibly, avoiding them.

Digital radiography technology has replaced conventional screen-film systems in many hospitals. Despite the different characteristics of new detector materials, frequently, the same radiological protocols previously optimised for screen film are still used with digital equipment without any critical review. This study addressed optimisation of exposure settings for chest examinations with digital systems, considering both image quality and patient dose. Images acquired with direct digital radiography equipment and a computed radiography system were analysed with specially developed commercial software with a four-alternative forced-choice method: the most promising protocols were then scored by two senior radiologists. Digital technology offers a wide dynamic range and the ability to postprocess images, allowing use of lower tube potentials in chest examinations. The computed radiography system showed both better image quality and lower dose at lower energies (85 kVp and 95 kVp) than those currently used (125 kVp). Direct digital radiography equipment confirmed both its superior image quality and lower dose requirements compared with the storage phosphor plate system. Generally, lowering tube potentials in chest examinations seems to allow better image quality/effective dose ratio when using digital equipment.

We present the case of an 80-year-old man with two renal solid masses found at sonography, which were imaged by contrast-enhanced ultrasound, CT, and MRI and confirmed histologically. Contrast-enhanced ultrasound findings suggested a benign mass and a CT-guided biopsy yielded a diagnosis of extramedullary hematopoiesis.

The rate of resolution of a first episode of pulmonary embolism (PE) is uncertain. A baseline test indicating any residual PE is pivotal in aiding a more accurate diagnosis of recurrent PE. This study aimed to assess the rate and risk factors of residual PE with either multidetector computed tomography imaging (MDCT) or lung perfusion scan (LPS) using a cross-sectional study in which consecutive patients were enrolled with a first objectively documented episode of symptomatic PE, and who were considered for possible treatment withdrawal after at least 3 months of anticoagulation. A first cohort of patients (n = 80) underwent MDCT, while the subsequent cohort (n = 93) underwent LPS. The two cohorts had similar characteristics, and 98.3% of patients had non high-risk index PE. MDCT detected residual PE in 15% of subjects (12/80, 95% CI 8-25%) after a mean of 9 months of anticoagulation. No clinical characteristics were significantly associated with residual PE at MDCT. LPS detected residual PE in 28% (26/93, 95% CI 19-38%) of patients after a period of a mean of 9 months of anticoagulation with a significant association with increasing age and known pulmonary disease. Resolution of PE was high after a first episode of non high-risk PE treated with heparin followed by at least 3 months of anticoagulation. Age and coexistent pulmonary disease influence the presence of residual PE detected by LPS, but not by MDCT. Further studies are warranted in which the presence of residual embolism is detected by repetition of the same test that had been initially carried out.

To evaluate the use of contrast-enhanced ultrasonography (CEUS) in patients with blunt abdominal trauma.A total of 133 hemodynamically stable patients were evaluated using ultrasonography (US), CEUS and multislice Computer Tomography (CT) da eliminare.In 133 patients, CT identified 84 lesions: 48 cases of splenic injury, 21 of liver injury, 13 of kidney or adrenal gland injury and 2 of pancreatic injury. US identified free fluid or parenchymal abnormalities in 59/84 patients positive at CT and free fluid in 20/49 patients negative at CT. CEUS revealed 81/84 traumatic injuries identified at CT and ruled out traumatic injuries in 48/49 negative at CT. Sensitivity, specificity, positive and negative predictive values for US were 70.2%, 59.2%, 74.7% and 53.7%, respectively; for CEUS the values were 96.4%, 98%, 98.8% and 94.1%, respectively.The study showed that CEUS is more accurate than US and nearly as accurate as CT, and CEUS can therefore be proposed for the initial evaluation of patients with blunt abdominal trauma.Sommario INTRODUZIONE: Descrivere l’impiego dell’ecografia con mezzo di contrasto (CEUS) nella valutazione dei pazienti con trauma chiuso dell’addome. MATERIALI E METODI: 133 pazienti con trauma addominale chiuso emodinamicamente stabile sono stati esaminati con ecografia (US), CEUS e Tomografia Computerizzata multistrato (TC) da eliminare. RISULTATI: I 133 pazienti avevano alla TC 84 lesioni, di cui 48 spleniche, 21 epatiche, 13 renali o dei surreni e 2 del pancreas. L’US ha identificato versamento libero o alterazioni parenchimali in 59/84 pazienti positivi alla TC e versamento libero in 20/49 pazienti negativi alla TC. La CEUS ha riconosciuto 81/84 lesioni traumatiche identificate dalla TC e ha escluso lesioni traumatiche in 48/49 pazienti negativi alla TC. Sensibilità, specificità, valore predittivo positivo e negativo per l’US sono stati rispettivamente 70.2%, 59.2%, 74.7% e 53.7%; per la CEUS sono stati 96.4%, 98%, 98.8% e 94.1%. CONCLUSIONI: Lo studio ha dimostrato che la CEUS ha una accuratezza diagnostica maggiore dell’US e quasi sovrapponibile alla TC e può quindi essere proposta nella valutazione iniziale del paziente traumatizzato.

While acute scrotal pain is a common clinical problem in both children and adults, symptoms are often vague and clinical findings are nonspecific. Ultrasound (US) allows for accurate differentiation of many causes of scrotal pain, including prompt diagnosis of testicular torsion. Use of color Doppler US made US the ideal imaging modality for evaluation of the acute scrotum in urgency. The authors review proper US technique and anatomy for testicular studies and findings of the main pathologies causing acute scrotal pain presenting at emergency department.

The aim of the study was to evaluate the diagnostic capability of contrast-enhanced ultrasonography (CEUS) in a large series of patients with blunt abdominal trauma. We studied 133 haemodynamically stable patients with blunt abdominal trauma. Patients were assessed by ultrasonography (US), CEUS and multislice computed tomography (MSCT) with and without administration of a contrast agent. The study was approved by our hospital ethics committee (clinical study no. 1/2004/O). In the 133 selected patients, CT identified 84 lesions; namely, 48 splenic, 21 hepatic, 13 renal or adrenal and two pancreatic. US identified free fluid or parenchymal alterations in 59/84 patients with positive CT and free fluid in 20/49 patients with negative CT. CEUS detected 81/84 traumatic lesions identified on CT and ruled out traumatic lesions in 48/49 patients with negative CT. The sensitivity, specificity and positive and negative predictive values of US were 70.2%, 59.2%, 74.7% and 53.7%, respectively, whereas those of CEUS were 96.4%, 98%, 98.8% and 94.1%, respectively. Our study showed that CEUS is an accurate technique for evaluating traumatic lesions of solid abdominal organs. The technique is able to detect active bleeding and vascular lesions, avoids exposure to ionising radiation and is useful for monitoring patients undergoing conservative treatment.

Patients with adhesive small intestine obstruction (ASIO) are difficult to evaluate and to manage and their treatment is still controversial. The diagnostic and therapeutic role of water-soluble contrast medium (Gastrografin) in ASIO is still debated. This study was designed to determine the therapeutic role of Gastrografin in patients with ASIO. The study was a multicenter, prospective, randomized, controlled investigation. The primary end points were the evaluation of the operative rate reduction and shortening the hospital stay after the use of Gastrografin. A total of 76 patients were randomized into two groups: the control group received traditional treatment (TT), whereas the study group (GG) received in addition a Gastrografin meal and follow-through study immediately. Patients with Gastrografin in the colon within 36 hours were considered to be partially obstructed and submitted to nonoperative management. If after 36 hours, the Gastrografin had not entered the colon, the subjects were submitted to laparotomy. No significant differences were found in age, sex, intravenous administration of prokinetics, incidence and characteristics of the previous procedures in surgical history of the patients, previous episodes of ASIO and surgery for adhesiolysis, or duration of symptoms before admission. In the GG group obstruction resolved subsequently in 31 of 38 cases (81.5%) after a mean time of 6.4 hours. The remaining seven patients were submitted to surgery, and one of them needed bowel resection for strangulation. In the control group, 21 patients were not submitted to surgery (55%), whereas 17 showed persistent untreatable obstruction and required laparotomy: 2 of them underwent bowel resection for strangulation. The difference in the operative rate between the two treatment groups reached statistical significance (p = 0.013). The time from the hospital admission for obstruction to resolution of symptoms was significantly lower in the GG group (6.4 vs. 43 hours; p

The objective of this study was to evaluate the concordance of US and contrast-enhanced US (CEUS) with CT in the assessment of solid organ injury following blunt trauma. Patients underwent complete US examination, including free fluid search and solid organ analysis. CEUS followed, using low-mechanical index techniques and SonoVue. CT was performed within 1 h. Among 156 enrolled patients, 91 had one or more abnormalities (n = 107) at CT: 26 renal, 38 liver, 43 spleen. Sensitivity, specificity, and accuracy for renal trauma at baseline US were 36%, 98%, and 88%, respectively, after CEUS values increased to 69%, 99%, and 94%. For liver baseline US values were 68%, 97%, and 90%; after CEUS were 84%, 99%, and 96%. For spleen, results were 77%, 96%, and 91% at baseline US and 93%, 99%, and 97% after CEUS. Per patient evaluation gave the following results in terms of sensitivity, specificity and accuracy: 79%, 82%, 80% at baseline US; 94%, 89%, and 92% following CEUS. CEUS is more sensitive than US in the detection of solid organ injury, potentially reducing the need for further imaging. False negatives from CEUS are due to minor injuries, without relevant consequences for patient management and prognosis.

In the last 20 years the increasing use of Computed Tomography, Magnetic Resonance and Ultrasonography has decreased the role of conventional radiology in the assessment of acute abdominal diseases. Nevertheless, in clinical practice, serial plain abdominal film remains the first diagnostic procedure, providing important diagnostic information, extremely useful in the emergency setting, and still of value if correctly performed and carefully interpreted. In this paper the current fields of application of serial abdominal plain film are presented, starting from a correct technique of performance and some basic knowledge of its interpretation.

To evaluate the diagnostic performance of ultrasonography using second-generation contrast agent in the study of patients with focal prostate lesions and increased serum prostate-specific antigen (PSA) level.SIX CONSECUTIVE PATIENTS (AGE RANGE: 72-87 years) with increased PSA (≥4 ng/ml) underwent transrectal ultrasonography (TRUS) followed by contrast-enhanced ultrasonography (CEUS) with injection of second-generation contrast agent. All patients showed areas of abnormal echostructure suspicious for neoplastic lesions. On the basis of CEUS, a time/intensity curve of the suspected area was compared to that of a normal-appearing distant area of the gland and to the results of biopsy of the hypoechoic area.AT CEUS TWO DIFFERENT PATTERNS OF ENHANCEMENT WERE IDENTIFIED AND CONSIDERED TO BE SIGNIFICANT: pattern 1 characterized by a rapid rise in the time/intensity curve of the suspected area compared with the normal gland. Two out of six patients had this pattern and biopsy showed cancer in the biopsied area. Pattern 2 was characterized by a similar rise in the time/intensity curve of the suspected area compared with the normal gland. Four out of six patients had this pattern and biopsy showed prostatitis in the biopsied area.CEUS using second-generation contrast agent can on the basis of time/intensity curves show differences in vascularization in normal and pathological tissue. Evaluation of the two patterns seems to be useful for identifying areas requiring biopsy, particularly when peripheral hypoechoic areas are observed at TRUS. Our data need to be confirmed in a larger patient population.Sommario SCOPO: Determinare la performance diagnostica dell'ecografia con mezzo di contrasto di seconda generazione nello studio delle lesioni focali della prostata nei pazienti con elevati valori sierologici di antigene prostatico specifico. MATERIALI E METODI: Sei pazienti consecutivi (età 72–87 anni) con elevati valori di antigene prostatico specifico (≥4 ng/ml) sono stati sottoposti a ecografia transrettale tradizionale seguita da ecografia con mezzo di contrasto. In ogni paziente sono state identificate le aree periferiche di alterata ecostruttura sospette per lesione neoplastica. Queste aree sono state valutate con ecografia con mezzo di contrasto mediante curve di intensità/tempo. I dati ottenuti sono stati confrontati con la biopsia dell'area sospetta. RISULTATI: L'ecografia con mezzo di contrasto ha consentito di identificare due pattern distinti: pattern 1 caratterizzato da rapida elevazione della curva calcolata a livello della lesione rispetto all'intensità di impregnazione del parenchima adiacente. Due dei sei pazienti con questo pattern hanno dimostrato presenza di lesione neoplastica nell'area sottoposta a biopsia. Pattern 2 caratterizzato da scarsa elevazione della curva rispetto all'intensità dell'impregnazione del parenchima adiacente. I rimanenti 4 dei 6 pazienti esaminati avevano questo pattern e l'area bioptizzata ha dimostrato assenza di lesione neoplastica. CONCLUSIONI: L'ecografia con mezzo di contrasto di seconda generazione, attraverso le curve di intensità/tempo può identificare differenze di comportamento tra tessuto normale e patologico. Queste caratteristiche possono risultare utili soprattutto nel caso di aree ipoecogene all'ecografia basale per identificare le aree da sottoporre a biopsia.

Objective: To evaluate the inflammatory involvement of cervical interspinous bursae in patients with polymyalgia rheumatica (PMR) using magnetic resonance imaging (MRI). Methods: Twelve consecutive, untreated new patients with PMR were investigated. Five patients with fibromyalgia, 2 patients with cervical osteoarthritis and 6 patients with spondyloarthritis with neck pain served as controls. MRI of the cervical spine was performed in all 12 PMR case-patients and in 13 control-patients. Two of the 4 PMR patients with pelvic girdle pain also had MRI of the lumbar spine. Results: MRI evidence of interspinous cervical bursitis was found in all patients with PMR, and in 3 patients with fibromyalgia, in 2 with psoriatic spondylitis and 1 with cervical osteoarthritis. A moderate to marked (grade >2 on a semiquantitative 0-3 scale) cervical bursitis occurred significantly more frequently in patients with PMR than in control-patients (83.3% compared with 30.7%, p=0.015). In all patients and controls with cervical bursitis the involvement was found at the C5-C7 cervical interspaces. MRI of the lumbar spine showed lumbar interspinous bursitis at the L3-L5 lumbar interspaces in the 2 patients with PMR and pelvic girdle pain examined. Conclusions: Cervical interspinous bursitis is a likely basis for discomfort in the neck of patients with PMR. The prominent inflammatory involvement of cervical bursae supports the hypothesis that PMR is a disorder of prominent involvement of extra-articular synovial structures.

Acute renal failure is a sudden and sustained decrease in the glomerular filtration rate associated with a loss of excretory function and the accumulation of metabolic waste products and water. It leads to an increase in serum urea and creatinine, usually with a decrease in urine output. Although routine surveillance of patients by means of laboratory examinations has been well defined, very little is known about renal imaging. Modern technology has provided a large number of sophisticated monitoring systems. Ultrasonography with color-Doppler study of the kidneys may be indicated as a possible monitor of renal perfusion. Ultrasonography is often used as the initial imaging procedure in the examination of patients with renal failure. Aside from excluding hydronephrosis, it is well recognized in characterizing the type of renal disease, especially in an acute setting. This article describes the use of ultrasound to achieve the proper diagnosis of acute renal diseases and to enable the appropriate and early assessment of these patients in intensive care units.

Peyronie’s disease (PD) is a benign disease of the penis of unknown cause. First fully described almost 300 years ago by François de La Peyronie, although “nodus penis” has been already described centuries before by Fallopius and Vesalius (Fornara and Gerbershagen 2004). Peyronie’s disease is defined as an acquired disorder of the tunica albuginea with the development of a plaque of fibrous tissue, associated with progressive penile bending and shortening. Pain on erection can be the first symptom of the disease in about 10–15% of the patients. As the result of progressive penile deformity, difficulties of penetration can develop with impairment of erectile capacity

Testicular cancer accounts for about 1 % of all cancers in men. Malignant testicular tumors are divided into two main groups: germ cell tumors and non-germ cell tumors. Germ cell tumors are subdivided into two groups: seminomas and nonseminomatous germ cell tumors such as embryonal carcinoma, yolk sac tumor, teratoma, choriocarcinoma, and mixed germ cell tumor. Non-germ cell tumors consist of Leydig cell tumor, Sertoli cell tumor, granulosa cell tumors, fibroma–thecoma tumors, mixed sex cord–stromal tumors, lymphoma, leukemia, and metastases. Radiological evaluation of testicular tumors is mainly based on ultrasound findings. The main role of ultrasound examination is to distinguish intratesticular from extratesticular lesions, because the majority of the extratesticular masses are benign and intratesticular masses are more likely to be malignant. MRI has an advantage over ultrasound in distinguishing an intratesticular hematoma from a testicular neoplasm.

Rising life expectancy has swollen the ranks of men of middle age and beyond. These individuals have a 43 % risk of symptoms of benign prostatic hyperplasia (BPH) and a 9 % chance of being diagnosed with prostate cancer. Although not always life-threatening, prostate diseases are often associated with a significant reduction in quality of life not only for the sufferer but also for his partner. Men beyond middle age are increasingly reluctant to accept restrictions on their day-to-day activities as they grow older. As a consequence, prostate diseases are now acknowledged as an important determinant of men’s health and therefore worthy of proper scrutiny, treatment, and enhanced research. In this chapter, the role of imaging modalities in evaluation of prostate disorders in elderly is illustrated, with emphasis both on current clinical practice and on the evolving imaging modalities that will affect treatment in the future

Urethral cancer is a rare disease which may occur at any age but is observed more often during the seventh decade. It is usually considered more common in females, but a recent study shows in the United States an annual age-adjusted incidence rate of 4.3 per million men and 1.5 per million women. The incidence is higher in African Americans. Different histologic patterns of urethral tumors are recognized. The most common type of urethral malignancy is squamous cell carcinoma which accounts for about 80 % of cases in men and 60 % of cases in women. Transitional cell carcinoma is the second most common urethral malignancy in both sexes. In males, this lesion accounts for 15 % of total cases, in females for 20 % of patients. Other primary malignant tumors of the urethra are rare. Only sporadic cases of lymphoma, melanoma, and neuroendocrine tumors have been reported in the literature.

A broad spectrum of congenital and acquired nonneoplastic disorders of the penis and scrotum can be encountered in clinical practice. The most conspicuous are those with ambiguity of the external genitalia such as true hermaphroditism, male pseudohermaphroditism, and female pseudohermaphroditism. The most common isolated abnormality of the penis is hypospadias. Other rare anomalies include epispadias, penile agenesis, diphallia, microphallus, penoscrotal transposition, penile cysts and webs, and complete penile corporal septation. Acquired nonneoplastic disorders of the penis include erectile dysfunction, Peyronie’s disease, priapism, penile scar and fibrosis, penile inflammation, and penile cysts.

Clinical history and physical examination do not always allow a firm differential among the different possible cause of acute scrotum, and imaging is needed to provide a diagnosis. Differentiating torsion from infection is a clinical emergency. Inflammatory conditions of the scrotum are the most frequent cause of acute scrotal pain in the adult population. The acute scrotum has several less common causes. This article outlines the ultrasonographic and Doppler findings in patients with acute scrotum of nontraumatic origin.

The scrotum is a fibromuscular sac divided into two compartments by a median raphe. Its wall is composed (from superficial to deep) by skin, superficial fascia, dartos muscle, external spermatic fascia, cremasteric fascia, and internal spermatic fascia. The raphe is continuous with the dartos muscle. Beneath the internal spermatic fascia, there is the tunica vaginalis, a mesothelial layer which outlines a sac containing a testis, epididymis, and spermatic cord, usually together with a small amount of fluid. The layer of the tunica vaginalis lining the scrotal wall is defined as the parietal layer; the one extending over the testis and epididymis is called the visceral one. The two layers join at the posterolateral aspect of the testis, where the tunica attaches to the scrotal wall. Beneath the visceral layer of the tunica vaginalis is the tunica albuginea, an inelastic structure which covers the testis and, at its posterior surface, projects into the inner part to form an incomplete septum, the mediastinum; from there, multiple thin fibrous septa extend into the testicular parenchyma, dividing it into 200–400 lobules. Each lobule contains one to three seminiferous tubules which, at the mediastinum, open via the tubuli recti into dilated spaces called the rete testis and then drain into the epididymis through 10–15 efferent ductules. The epididymis, a tubular structure consisting of a head, body, and tail, is located superior to and contiguous with the posterior aspect of the testis. After entering the epididymal head, the ductules from the rete testis form a single duct, the ductus epididymis, which has very tortuous course from the head to the tail (up to 6 m). The ductus finally becomes the vas deferens and continues in the spermatic cord

Neoplasms of the penis represent a significant health problem in developing countries. Primary malignant neoplasms of the penis include squamous cell carcinomas, sarcomas, melanoma, basal cell carcinoma, and lymphoma. Hemangioma, neurilemmoma, leiomyoma, neurofibroma, and schwannoma constitute benign neoplasms of the penis. Tumors of the tunicae and scrotal wall are rare. Malignant mesothelioma of the tunica vaginalis testis, scrotal hemangioma, and granulosa cell tumor of the tunica albuginea may arise from tunica and scrotal wall.

Purpose: Ultrasound (US) is the main imaging technique in the assessment of testicular masses, as it has proved to be highly accurate in the visualization of these pathologies. Identification of a Leydig cell tumor is essential since the lesion is benign in 90 % of cases. The aim of this multicenter study is to assess the effectiveness of contrast-enhanced ultrasound (CEUS) in differentiating Leydig cell tumors from seminoma using qualitative and quantitative features. Materials and Methods: From February 2011 to December 2013, 31 patients (mean age: 34 years; range: 25 – 52) were recruited for this prospective study. Three of them were monorchid. Therefore, a total of 59 testicles were assessed. All patients underwent grayscale US, color Doppler ultrasound (CDUS), CEUS and orchiectomy. The paired one-tailed Student‘s t -test was carried out to differentiate between Leydig cell tumors and seminomas. Results: 31 lesions suspicious for malignancy were hypoechoic on grayscale US while they did not show a typical pattern on CDUS. CEUS qualitative analysis, based on contrast enhancement pattern, during the arterial and venous phases, did not allow discrimination of Leydig cell tumors from seminoma. Quantitative analysis of time-intensity curves (TICs) demonstrated that only three parameters presented statistical significance, i. e. wash-in rate (WiR) p = 0.014, peak enhancement (PE) p = 0.001 and time to peak (TTP) p = 0.003. Conclusion: The vascular bed of a Leydig cell tumor is wider and the blood flow velocity is higher than that of a seminoma due to more regular neovascularization. In contrast, a seminoma presents large areas of necrosis due to irregular neovascularization. This explains the different PE and WiR values. Further studies involving larger patient populations are mandatory to confirm these encouraging preliminary results.

To describe the imaging findings in a series of patients with mesothelioma of the tunica vaginalis testis.We reviewed clinical data, imaging findings and follow-up information in a series of 10 pathology-proven cases of mesothelioma (all had US; 2 had MR) of the tunica vaginalis.A variety of patterns could be observed, the most common (5/10) being a hydrocele with parietal, solid and hypervascular vegetations; one patient had a septated hydrocele with hypervascular walls; one had multiple, solid nodules surrounded by a small, physiological quantity of fluid; one a cystic lesion with thick walls and vegetations compressing the testis; two had a solid paratesticular mass. MR showed multiple small nodules on the surface of the tunica vaginalis in one case and diffuse thickening and vegetations in the other one; lesions had low signal intensity on T2-w images and were hypervascular after contrast injection.A preoperative diagnosis of mesotheliomas presenting as solid paratesticular masses seems very difficult with imaging. On the contrary, the diagnosis must be considered in patients in whom a hydrocele with parietal vegetations is detected, especially if these show high vascularity.Mesotheliomas of the tunica vaginalis are rare, often challenging to diagnose preoperatively. Most common finding is a complex hydrocele with hypervascular parietal vegetations. Septated hydrocele, nodules without hydrocele, a thick-walled paratesticular cyst are less common. Preoperative diagnosis may allow aggressive surgical approach and, possibly, a better prognosis.

Pooled data from 16 radiology centers were retrospectively analyzed to seek patients with pathologically proven testicular lymphoma and grayscale and color Doppler images available for review. Forty-three cases were found: 36 (84%) primary and 7 (16%) secondary testicular lymphoma. With unilateral primary lymphoma, involvement was unifocal (n = 10), multifocal (n = 11), or diffuse (n = 11). Synchronous bilateral involvement occurred in 6 patients. Color Doppler sonography showed normal testicular vessels within the tumor in 31 of 43 lymphomas (72%). Testicular lymphoma infiltrates through the tubules, preserving the normal vascular architecture of the testis. Depiction of normal testicular vessels crossing the lesion is a useful adjunctive diagnostic criterion.

Extramedullary haematopoiesis (EMH) is the development of haematopoietic tissue outside the bone marrow and it most often occurs in the liver and spleen. Renal EMH is quite rare and there are very few case reports concerning the kidney. We describe two cases of ‘renal histologically documented EMH’ and, in particular, in the second of these two, the EMH tissue coexists with a clear cell renal carcinoma. Although rare, these clinical pictures raise some questions about the role of needle biopsy in the management of renal masses that present a diagnostic dilemma, especially in cases without involvement of other abdominal or intrathoracic organs.

Gastrointestinal perforation is diagnosed by demonstrating air or intestinal content in the peritoneum or retroperitoneum. The diagnosis of free air in the abdominal cavity is usually made with x-ray. However, in clinical practice, x-ray may not detect small amount of air on radiography and CT is often requested. Recently, ultrasonography has emerged as an useful diagnostic technique in patients with acute abdomen also for detecting pneumoperitoneum. US is routinely performed to investigate patients with abdominal pain, including those having gastrointestinal perforation as final diagnosis. In case of gastro-intestinal perforation, a correct interpretation of the artifact due to free air eventually present can lead to the correct diagnosis. Direct and indirect signs of pneumoperitoneum at US are reported with a short report of the commonest causes of gastro-intestinal perforation .

Computed tomography (CT) still represents the preferred imaging method in the assessment of patients presenting with multiple trauma. Nevertheless, in patients with low-energy abdominal trauma, the use of CT is debated because of the possible unnecessary radiation exposure. Accordingly, conventional ultrasound (US) imaging has been increasingly employed as the initial imaging modality in the workup of minor traumatic emergency conditions. Focused assessment with sonography for trauma is widely used to detect free intra-abdominal fluid, but its role is controversial, because the absence of free fluid does not exclude the presence of injuries to abdominal organ. Injection of an ultrasound contrast agent (UCA) may give the radiologist relevant additional information to that obtained with conventional US. Thus, in trauma patients, following early assessment with conventional US imaging, a contrast-enhanced US (CEUS) can provide a more reliable evaluation of solid organ injuries and related vascular complications, including active bleeding, pseudoaneurysms, and artero-venous fistulas. CEUS cannot replace abdominal CT, but it represents a noninvasive and repeatable imaging tool capable of providing a reliable assessment of trauma severity and expedite the patient’s treatment.

Varicocele is defined as abnormally dilated scrotal veins. It is present in 15 % of normal males and in 40 % of males with infertility. This disorder is a challenge for the physicians involved in the diagnosis and treatment, as the pathophysiology of varicocele is not yet completely understood. For this reason, accurate diagnostic criteria and clear indications for treatment in asymptomatic adolescents or adults with clinical or subclinical varicocele are still not defined. Ultrasonography (US) is considered the best method for calculating the volume of the testicles, measuring vein diameter and monitoring the growth of the testis in adolescent patients. Color-Doppler US is the method of choice for detecting spermatic vein reflux and for classifying the grade of varicocele. Various classification systems have been published with recommendations on how to perform US imaging of the scrotum. Currently, color-Doppler US and spectral analysis are the most effective, non-invasive diagnostic procedures as they allow detection of subclinical varicocele associated with infertility. Various techniques are used in the treatment of varicocele including open surgery, laparoscopic procedures and interventional radiology. However, there is no consensus among physicians on which technique is the most effective in terms of outcome and complication rates. This review shows that color-Doppler US is currently the most widely employed diagnostic method for detection and classification of varicocele caused by venous reflux, as it is reliable and easily performed. The review also highlights the role of varicocelectomy in the management of adult male infertility.Il varicocele è una dilatazione abnorme delle vene scrotali. Esso si riscontra nel 15 % degli uomini normali e nel 40 % dei soggetti che presentano infertilità. Rappresenta ancora oggi un problema clinico per gli specialisti che sono coinvolti nella diagnosi e nel trattamento di questa affezione, in quanto i meccanismi fisiopatologici che stanno alla base di questa patologia non sono stati ancora chiariti in maniera completa. Per questi motivi non esistono ancora indicazioni condivise tra i medici sulle possibilità diagnostiche e sulle scelte terapeutiche da applicare negli adolescenti asintomatici o negli adulti con varicocele clinico o subclinico. L’esame ultrasonografico dello scroto viene considerato attualmente come la metodica migliore per calcolare il volume dei testicoli, per misurare il diametro dei vasi venosi e per seguire l’accrescimento testicolare negli adolescenti. Il Color-Doppler è il metodo più semplice e preciso per studiare e documentare l’inversione del flusso nelle vene spermatiche e serve per una precisa classificazione del varicocele. Sono state proposte numerose classificazioni cliniche ed ecografiche del varicocele e sono state pubblicare raccomandazioni su come condurre l’esame ecografico dello scroto per l’identificazione del varicocele. Attualmente il color-Doppler associato all’analisi spettrale è la procedura diagnostica più valida e non invasiva, in quanto consente di evidenziare anche i varicoceli subclinici associati ad infertilità. Per il trattamento del varicocele sono state proposte diverse procedure chirurgiche, a cielo aperto o laparoscopiche e procedure di radiologia interventistica. Non esiste però un consenso su quale è la tecnica migliore in termini di risultati e di complicanze. Questa revisione evidenzia come l’ecografia color-Doppler sia attualmente la procedura diagnostica più diffusa, semplice ed affidabile per la ricerca del varicocele refluente e come la varicocelectomia rappresenti la terapia iniziale negli adulti con infertilità.

Grey-scale ultrasound has an important diagnostic role in nephrology. The absence of ionizing radiations and nephrotoxicity, rapidity of execution, excellent repeatability, the possibility to perform the test at the patient’s bed and the low cost represent important advantages of this technique. Paired with real-time sonography and colour-power-Doppler contrast-enhanced ultrasound (CEUS) reduces the diagnostic gap with computed tomography (CT) and magnetic resonance (MR) and represents a major step in the evolution of clinical ultrasound. Although there are several situations in which contrast-enhanced CT and MR are indicated (i.e. evaluation of cystic or ischemic lesions, traumatisms and ablative therapies of the native and transplanted kidney), the use of CT contrast media presents a high risk of contrast-induced nephropathy (i.e. in elderly people, subjects with comorbidities and those with renal dysfunction), while gadolinium-based RM contrast agents are contraindicated for the risk of nephrogenic systemic fibrosis (i.e. in patients with severe renal dysfunction). In these situations, CEUS may be a viable alternative, however, as any technique associated with the infusion of pharmacological substances, the potential advantages and risks of CEUS should be critically evaluated. In this regard, the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) has published the guidelines for the use of CEUS for the kidney imaging and the International Contrast Ultrasound Society (ICUS) has been recently founded. The aim of this review is to offer an updated overview of the potential applications of CEUS in nephrology, reporting some indications and possible risks associated to its use.