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Background To assess diagnostic performance of lung ultrasound (LUS) in identifying ARDS morphology (focal vs non-focal), compared with the gold standard computed tomography. Methods Mechanically ventilated ARDS patients undergoing lung computed tomography and ultrasound were enrolled. Twelve fields, were evaluated. LUS score was graded from 0 (normal) to 3 (consolidation) according to B-lines extent. Total and regional LUS score as the sum of the four ventral (LUSV), intermediate (LUSI) or dorsal (LUSD) fields, were calculated. Based on lung CT, ARDS morphology was defined as (1) focal (loss of aeration with lobar distribution); (2) non-focal (widespread loss of aeration or segmental loss of aeration distribution associated with uneven lung attenuation areas), and diagnostic accuracy of LUS in discriminating ARDS morphology was determined by AU-ROC in training and validation set of patients. Results Forty-seven patients with ARDS (25 training set and 22 validation set) were enrolled. LUSTOT, LUSV and LUSI but not LUSD score were significantly lower in focal than in non-focal ARDS morphologies (p TOT, LUSV, LUSI and LUSD for identification of non-focal ARDS morphology were 0.890, 0.958, 0.884 and 0.421, respectively. LUSV value ≥ 3 had the best predictive value (sensitivity = 0.95, specificity = 1.00) in identifying non-focal ARDS morphology. In the validation set, an LUSV score ≥ 3 confirmed to be highly predictive of non-focal ARDS morphology, with a sensitivity and a specificity of 94% and 100%. Conclusions LUS had a valuable performance in distinguishing ARDS morphology.

To evaluate the accuracy of 3D models of the aortic-root generated from non-contrast cardiac magnetic resonance (CMR). Data were retrospectively collected from 30 consecutive patients who underwent surgical aortic valve replacement and had available records of both intra-operative assessment and pre-surgery annulus assessment by cardiovascular computed tomography (CCT) and CMR. The 3D models were independently segmented, modelled and printed by two blinded “manufacturers”. The measurements on the models were carried out by two cardiac surgeons with Hegar dilator. Data were analyzed with non-parametric tests. There was no significant intra- or inter-observer variability (p ≥ 0.13). The agreement between the diameter of the 3D model derived from CMR images and either the anatomical reference of the intraoperative measurement (p = 0.10, r = 0.97) or the radiological reference of the 3D model generated from CCT (p = 0.71, r = 0.92) was very good. The process of segmentation plus the post-processing was about 17 ± 2 min for a model created by CMR, significantly higher than a model created from CCT (7 ± 2 min; p

Guidelines recommend chest radiography (CR) in the workup of suspected acute aortic syndromes (AASs) if the pretest clinical probability is low. However, the diagnostic impact of CR integration for the rule-in and rule-out of AASs is unknown.We performed a secondary analysis of the ADvISED multicenter study. Emergency department outpatients were eligible if an AAS was clinically suspected. Clinical probability was defined with the aortic dissection detection risk score (ADD-RS). CR was evaluated blindly by a radiologist, who judged on mediastinum enlargement (ME) and other signs.In 2014 through 2016, a total of 1,129 patients were enrolled and 1,030 were analyzed, including 48 (4.7%) with AASs. ADD-RS/ME and ADD-RS/any CR sign (aCRs) integration were more accurate than ADD-RS alone (area under the curve = 0.8 and 0.78 vs. 0.66, p 0.001). The sensitivity and specificity of the integrated strategies were 66.7% (95% confidence interval [CI] = 51.5% to 79.9%) and 82.5% (95% CI = 79.9% to 84.8%) for ADD-RS/ME and 68.8% (95% CI = 53.6% to 80.9%) and 76.5% (95% CI = 73.7% to 79.1%) for ADD-RS/aCRs, respectively. The sensitivity and specificity of CR per se were 54.2% (95% CI = 39.2% to 68.6%) and 92.4% (95% CI = 90.5% to 93.9%) for ME and 60.4% (95% CI = 45.3% to 74.2%) and 85.2% (95% CI = 82.9% to 87.4%) for aCRs. The agreement (κ) between attending physicians and radiologists for ME was 0.44 (95% CI = 0.35 to 0.54). ADD-RS/ME rule-in (ADD-RS ≤ 1 and ME-present, or ADD-RS 1) applied to 204 versus 130 patients with ADD-RS 1, including 14 with AAS and 60 false-positives (FP). ADD-RS/aCRs rule-in (ADD-RS ≤ 1 and aCRs-present, or ADD-RS 1) applied to 264 patients, including 15 with AAS and 119 FP. ADD-RS/ME rule-out (ADD-RS ≤ 1 and ME-absent) applied to 826 (80.2%) patients, including 16 with AAS (33.3% of cases). ADD-RS/aCRs rule-out (ADD-RS ≤ 1 and aCRs-absent) applied to 766 patients (74.4%), including 15 with AAS (31.3% of cases).CR integration with clinical probability assessment showed modest rule-in efficiency and insufficient sensitivity for conclusive rule-out.

To assess the accuracy and reproducibly of cardiovascular magnetic resonance (CMR) in the measurement of the aortic annulus and in process of valve sizing as compared to intra-operative sizing, cardiovascular computed tomography (CCT) and transesophageal echocardiography (TEE). Retrospective study on 42 patients who underwent aortic valve replacement from September 2010 to September 2015, with available records of pre surgery annulus assessment by CMR, CCT and TEE and of peri-operative assessment. In CCT and CMR, the annular plane was considered a virtual ring formed by the lowest hinge points of the valvular attachments to the aorta. In TEE the annulus was measured at the base of leaflet insertion in the mid-esophageal long-axis view using the X-plane technique. Two double-blinded operators performed the assessments for each imaging technique. Intra-operative evaluation was performed using Hegar dilators. Continuous variables were studied with within-subject ANOVA, Bland-Altman (BA) plots, Wilcoxon's and Friedman's tests; trends were explored with scatter plots. Categorical variables were studied with Fisher's exact test. The intra- and inter-operator reliability was satisfying. There were no significant differences between the annulus dimensions measured by CMR and either one of the three references. Valve sizing for CoreValve by CMR had the same good agreement with CCT and TEE, with a 78 % match rate; for SAPIEN XT the agreement was slightly better (82 %) for CCT than for TEE (66 %). MR performs well when compared to the surgical reference of intra-operative sizing and stands up to the level of the most used imaging references (CCT and TEE).

A 73-year-old man with a history of smoking, alcohol abuse, hypertension and diabetes was brought to the Emergency Department after a sudden loss of consciousness. Blood pressure was 80/60 mm Hg, heart rate was 100/min, respiratory rate was 30/min, pulse oximetry was 80% on ambient air and temperature was 36°C. On physical examination, he was unresponsive, his skin was mottled, no signs of trauma were evident, respiratory sounds were reduced on the left hemithorax and pulses were symmetrical. The ECG showed sinus tachycardia with diffuse ST segment depression. A portable chest X-ray (CXR) was performed …

Background to determine reliability and reproducibility of measurements of aortic annulus in 3D models printed from cardiovascular computed tomography (CCT) images. Methods Retrospective study on the records of 20 patients who underwent aortic valve replacement (AVR) with pre-surgery annulus assessment by CCT and intra-operative sizing by Hegar dilators (IOS). 3D models were fabricated by fused deposition modelling of thermoplastic polyurethane filaments. For each patient, two 3D models were independently segmented, modelled and printed by two blinded “manufacturers”: a radiologist and a radiology technician. Two blinded cardiac surgeons performed the annulus diameter measurements by Hegar dilators on the two sets of models. Matched data from different measurements were analyzed with Wilcoxon test, Bland-Altmann plot and within-subject ANOVA. Results No significant differences were found among the measurements made by each cardiac surgeon on the same 3D model (p = 0.48) or on the 3D models printed by different manufacturers (p = 0.25); also, no intraobserver variability (p = 0.46). The annulus diameter measured on 3D models showed good agreement with the reference CCT measurement (p = 0.68) and IOH sizing (p = 0.11). Time and cost per model were: model creation ∼10–15 min; printing time ∼60 min; post-processing ∼5min; material cost ∼1€. Conclusion 3D printing of aortic annulus can offer reliable, not expensive patient-specific information to be used in the pre-operative planning of AVR or transcatheter aortic valve implantation (TAVI).

The purpose of this study was to optimize an aorta angiographic CT protocol, by investigating the best combination of tube current modulation, iterative algorithm strength and kV reduction. Anthropomorphic phantoms of three sizes were imaged by CT with different values of noise index, of iterative algorithm ASIR percentages and kV in the range 80–120. Quantitative noise and contrast noise ratios were evaluated at different phantom locations. Three radiologists assessed the subjective image quality by comparing the image series with the one acquired with the reference protocol (120 kV, slice thickness 0.625, noise index 28, ASIR 40 %). Although the highest CNR values were obtained for the 80 kV acquisitions, qualitative scores were higher for 100 and 120 kV at the same noise index. An optimized protocol was established with a NI of 39.2, ASIR 60 %, 100 kV for small- and medium-sized patients and 120 kV for large-sized patients, with a dose reduction of 47 %. When different dose reduction parameters are available, anthropomorphic phantoms of different sizes help to find the optimal combination. For aorta studies, 100 kV with relative high values of noise indexes and iterative levels provides the best balance between dose reduction and image quality.

Evaluate Magnetic Resonance (MR) and Magnetic Resonance Angiography (MRA) sensibility in the diagnosis and follow-up of dissection of Internal Carotid and Vertebral Artery (ICA/VA). We revalued MR examination of 36 patients, 24 men, 12 women, aged 18-69 years. All patients underwent brain TC and MR (GE 1 Tesla); in 16 subjects 3D Time-of-Flight (TOF-3D) MRA was performed and in 20 subjects a Contrast-Enhanced MRA (CEMRA) of neck and head arteries. Thirty-one patients underwent a MRA follow-up. Dissection involved ICA in 30 and VA in 8. MR showed ischemic signs in 25 cases, wall hematoma in 19, and was normal in 11. MRA showed 25 vessels stenosis, 12 occlusions, and 9 aneurysm. Follow-up MRA showed 6 cases of complete resolution of stenosis, 17 partial resolution, 2 aneurysmal dissecanting, 6 luminal alteration unchanged, 1 aneurysma enlarged. MRA represented a non-invasive technique as investigation in suspected cervicocephalic arteries dissection.

Dysraphism embraces a heterogeneous series of spinal abnormalities. Diastematomyelia is a rare malformation characterized by partial division of the spinal cord (SC) into two parts. Diastematomyeli...

Introduction Asymptomatic patients with human immunodeficiency virus (HIV) infection are at increased risk of vascular disease. Whether asymptomatic HIV patients have increased prevalence or structural differences in coronary artery plaques is not clear. Methods Pubmed, Cochrane and Google Scholar were searched for articles evaluating asymptomatic HIV patients evaluated with coronary computed tomography. The prevalence of coronary stenosis (defined as >30% and >50%), of calcified coronary plaques (CCP) viewed as more ‘stable' plaques, and of non-calcified coronary plaques (NCP) viewed as more ‘vulnerable' plaques were the end points of interest. Results 9 studies with 1229 HIV patients and 1029 controls were included. No significant differences were detected about baseline cardiovascular risk profile. The prevalence of significant coronary stenosis >30% or >50% did not differ between HIV+ and HIV- patients (42% [37–44] and 46% [35–52] with an Odds Ratio [OR] of 1.38 [0.86–2.20] for >30% stenosis) and (15% [9–21] and 14% [7–22] with an OR of 1.11 [0.81–1.52]), respectively. The prevalence of calcified coronary plaques (CCP) (31% [24–32] and 21% [14–30] with an OR of 1.17 [0.63–2.16]) also did not differ among HIV+ and HIV- patients. On the contrary rates of NCP were >3-fold higher in HIV-positive patients [58% (48–60) and 17% (14–27) with an OR of 3.26 (1–30-8.18)], with an inverse relationship with CD4 cell count at meta-regression (Beta −0.20 [-0.35-0.18], p 0.04). Conclusion Asymptomatic HIV patients present a similar burden of coronary stenosis and calcified coronary artery plaques but significantly higher rates of non-calcific coronary plaques at computed tomography. The association between HIV infection, reduced CD4 cell counts and higher prevalence on non-calcific coronary artery plaques may shed light into the pathogenesis in HIV-associated coronary artery disease, stressing the importance of primary prevention in this population.

Purpose: We present the technique and the preliminary results of percutaneous implantation of intraarterial catheters connected to a subcutaneous infusion reservoir for prolonged regional chemotherapy of hepatic and extrahepatic tumors. Methods: Two hundred patients with primary or secondary hepatic neoplasms, pelvic, pancreatic, renal, lingual, and breast cancer underwent the procedure. The access was the left axillary artery (188 patients) and the femoral artery (12 patients). The catheter tip was placed in the hepatic (170 patients), hypogastric (18), splenic (4), internal thoracic (2), gastroduodenal (3), renal (2) or the external carotid artery (1). The catheter was connected to a subcutaneous reservoir and filled with heparin: chemotherapeutic infusion was subsequently started. Results: One hundred percent immediate technical success was obtained. Forty-three of 200 (21.5%) patients had a complication: 29 patients had a catheter dislodgment, nine had arterial thrombosis, three had a pseudoaneurysm of the left axillary artery and two had a port pocket hematoma. Most complications (37/43, 86%) were treated percutaneously without interruption of chemotherapy. In only six cases (3% of the total population) was chemotherapy discontinued due to the complication itself. The mean duration of catheter patency was 7.2 months. Conclusion: Percutaneous placement of an intraarterial catheter is feasible and causes less discomfort to the patient than the surgical approach. The technique has an acceptable complication rate (21.5%), similar to that for surgical implantation (17.8%), with the advantage that in most cases the complications can be resolved percutaneously. This technique represents an alternative to surgical implantation in the treatment of liver metastases from colorectal cancer and opens new therapeutic possibilities for the local prolonged treatment of other kinds of tumor, though its clinical efficacy must be assessed in selected trials.