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BACKGROUND AND STUDY AIMS The mortality rate from upper gastrointestinal bleeding (UGIB) remains high, at 5 % - 10 %. The aim of the current study was to describe the epidemiological characteristics, prognostic factors, and actual practice in a cohort of patients with UGIB admitted to French general hospitals. METHODS From March 2005 to February 2006, a prospective multicenter study was conducted at 53 French hospitals. A total of 3298 patients admitted for UGIB were enrolled consecutively. Patient data were collected up to the date of discharge from hospital. RESULTS Data were available for 2130 men and 1073 women (mean age 63 ± 18 years), one-third of whom were taking drugs that would increase the risk of UGIB. The two main causes of bleeding were peptic ulcers (38 %) and esophagogastric varices (EGV) or portal hypertensive gastropathy (24.5 %). Mean Rockall score was 5.0 ± 2.3. Endoscopy was performed on 96 % of patients (within 24 hours in 79 %), and 66 % of those with ulcers and 62.5 % of the EGV patients underwent hemostatic therapy when indicated. Rebleeding occurred in 9.9 % of the patients, and 8.3 % died. Independent predictors of rebleeding were: need for transfusion (odds ratio [OR] 19.1; 95 % confidence interval [95 %CI] 10.1 - 35.9); hemoglobin < 10 g/dL (OR: 1.7; 95 %CI 1.1 - 3.3); Rockall score (OR: 1.4 for each 1 point score increase; 95 %CI 1.0 - 1.9), systolic blood pressure < 100 mmHg (OR: 1.9; 95 %CI 1.4 - 2.5), and signs of recent bleeding (OR: 2.4; 95 %CI 1.7 - 3.5). Independent predictors of mortality were: Rockall score (OR: 2.8; 95 %CI 2.0 - 4.0), co-morbidities (OR: 3.6 for each additional co-morbidity; 95 %CI 2.0 - 6.3), and systolic blood pressure < 100 mmHg (OR: 2.1; 95 %CI 1.8 - 2.8). Rockall score, blood pressure and co-morbidities were taken as continuous variables meaning that the OR was 1.4 for every point increase, it was the same for blood pressure. CONCLUSION UGIB still occurs mainly as a result of peptic ulcers and portal hypertension in France, and causes significant rates of mortality. There is scope for improvement via better prevention (better use of UGIB-facilitating drugs), endoscopic therapy, and management of co-morbidities.

To assess the accuracy and torerability of gadolinium-enhanced thoracic CTA using a 64 MDCT compared to a 16 MDCT. Because this study was started prior to the description of NSF, particular attention was paid to long-term follow-up of the patient population.The study protocol was approved by the ethics committee of our institution and informed consent was obtained from all patients. Fourteen patients (Group 1) (9 males and 5 females; mean age: 64.3 years) with contraindication to the administration of iodinated contrast material underwent thoracic CTA (collimation: 32 x 2 x 0.6 mm; pitch: 1.2) with gadolinium administration (0.5 mml/ml) at 0.4 mmol/kg injected at 6 ml/sec with evaluation of clinical and biological tolerability of the gadolinium based contrast agent. Results from this patient population were compared to results from a population of 31 patients (21 males; 10 females; mean age: 63.2 years) (Group 2) imaged on a 16 MDCT. All patients were folloowed-up for a mean time of 22.6 months.Using a mean contrast volume (standard deviation) that was not significantly different (Group 1: 54.8+/-11 ml; Group 2: 53.4+/-6.9 ml) (p=0.94), patients in Group 1 underwent complete thoracic CTA whereas patients in Group 2 underwent CTA of only the middle third of the thoracic region. All CTA examinations were diagnostic for Group 1 and Group 2 patients; however, evaluation of subsegmental vessels was possible in a significantly larger proportion of patients in Group 1 (10/14; 72%) compared to Group 2 (6/31; 19%) (p=0.003). Mean attenuation values within pulmonary arterial branches were similar for Groups 1 and 2 (central arteries: 194.5+/-51.3 HU vs 180.6+/-53.8 HU; p=0.38) (lobar arteries: 208.5+/-52.5 HU vs 189.9+/-60.1 HU; p=0.33) (segmental arteries: 220.4+/-50.4 HU vs 201.5+/-54.7 HU; p=0.42). Transient alteration of renal function was recorded in one patient from Group 1 with severe pre-existing chronic renal failure. No change in renal function was observed for Group 2 patients. No case of NSF was reported in patients with pre-existing renal failure at the time of enrollment.The use of gadolinium-based contrast agent for thoracic CTA using a 64 MDCT provides diagnostic quality examinations in all patients with improved image quality compared to a 16 MDCT. No complication other than transient alteration of renal function was observed. Because the likelihood of developing NSF may vary with the type of gadolinium-based contrast agent used, the least toxic agent should be used.

Today pulmonary nodules are commonly detected by spiral CT but their evaluation and management remain a difficult task. The traditional approach, based on the principles of decision analysis, relies on estimating the probability of malignancy from risks factors assessed by history and morphological characteristics on chest radiographs and CT examinations. Use of non-invasive techniques such as PET and contrast-enhanced CT may decrease the number of invasive procedures performed for obtaining a histological diagnosis. A precise evaluation of nodule growth can be obtained from recent improvements in CT technology and may shorten the follow-up. The goal of this review, based on the consensus obtained in a multidisciplinary group, is to emphasize the recent advances on the topic and to propose guidelines.

The authors report two cases of portopulmonary anastomosis to show the value of multidetector CT with MPR MIP reformations in the diagnosis of portopulmonary venous anastomosis. This diagnosis has consequences in the treatement of hypoxemia in patients with chronic liver disease and embolization of bleeding esophageal varices in these patients.

This review consists in three main topics. At this time, technology does not allow for optimal functional and morphological evaluation of the cardiac chambers. However, a precise pretherapeutic map of the systemic supply of the lung can be non invasively obtained.

To our knowledge, conventional chest radiography is not likely to become obsolete or disappear from the daily practice of medical imaging. As such, it is important to insure that chest radiographs are acquired using optimal technique. Evaluation of chest radiograph findings must be comprehensive and the art of reading chest radiographs must be well thought to physicians in training. Chest radiography is characterized by the projection of tridimensional anatomical structures and disease processes onto a two-plane radiographic film. Correlation with cross-sectional data obtained from CT may greatly enhance the understanding and interpretation of conventional chest radiographs. Indeed, review of CT images facilitates anatomical understanding of the segmental and subsegmental anatomy, of the superior segments of the lower lobes and of the three dimensional orientation of the fissures. CT also has improved the understanding of some chest radiography findings. Careful review of findings at chest radiography is helpful to optimize CT acquisition protocols in order to reduce some of the pitfalls of CT and improve detection of specific processes that could otherwise be poorly demonstrated or overlooked. Chest radiographs can sometimes detect diseases or abnormalities that are difficult to demonstrate at CT.

There are good reasons to believe that screening of lung parenchymal diseases by CT is superior to chest radiographs. Nevertheless, conventional chest radiography often remains the first examination performed for evaluation of thoracic diseases and, irrespective of clinical indication, it plays an important role in screening procedures. The interpretation methodology of a chest radiograph in a screening condition is reviewed. Specific attention to poor detectability zones is emphasized and a check-list is proposed, mainly to reduce the risk of overlooking lesions. Techniques, indications and respective diagnostic values for both chest radiography and CT scan are analyzed and applied to the screening of lung cancer, asbestos exposure and tuberculosis.

After characterization of a novel odorant-binding protein (OBP) variant isolated from the rat nasal mucus, the corresponding cDNA was cloned by RT-PCR. Recombinant OBP-1F, the sequence of which is close to that of previously reported rat OBP-1, has been secreted by the yeast Pichia pastoris at a concentration of 80 mg.L-1 in a form identical to the natural protein as shown by MS, N-terminal sequencing and CD. We observed that, in contrast with porcine OBP-1, purified recombinant OBP-1F is a homodimer exhibiting two disulfide bonds (C44-C48 and C63-C155), a pairing close to that of hamster aphrodisin. OBP-1F interacts with fluorescent probe 1-aminoanthracene (1-AMA) with a dissociation constant of 0.6 +/- 0. 3 microM. Fluorescence experiments revealed that 1-AMA was displaced efficiently by molecules including usual solvents such as EtOH and dimethylsulfoxide. Owing to the large OBP-1F amounts expressed, we set up a novel biomimetic assay (volatile-odorant binding assay) to study the uptake of airborne odorants without radiolabelling and attempted to understand the odorant capture by OBP in the nasal mucus under natural conditions. The assay permitted observations on the binding of airborne odorants of different chemical structures and odors (2-isobutyl-3-methoxypyrazine, linalool, isoamyl acetate, 1-octanal, 1-octanol, dimethyl disulfide and methyl thiobutyrate). Uptake of airborne odorants in nearly physiological conditions strengthens the role of OBP as volatile hydrophobic odorant carriers in the mucus of the olfactory epithelium through the aqueous barrier towards the chemo-sensory cells.

The acquisition techniques, including some important dosimetric considerations, and the reconstruction methods reviewing the tomographic, bronchographic and endoscopic rendering techniques are first taken into consideration. They are applied to the most usual problems and diseases encountered in the daily activityThe main purpose of this review, which merges the modern technology of spiral (helical) CT with the multislice acquisition in the very near future, consists in delivering, whenever possible, an integrated diagnostic and therapeutic approach of imaging, endoscopy and surgery.

Clinical applications of spiral CT angiography are mainly based on transverse CT scans which can be completed by several categories of additional reformations in order to provide the most accurate evaluation of the vessel(s)-of-interest. Two-dimensional reformations are the second most frequent category of reconstructions generated from a spiral data set, enabling the creation of planar (frontal, sagittal or oblique) or curved views of given vessel. Three-dimensional displays can also be generated from most post-processing consoles, namely surface shaded displays (SSD), maximum intensity projections (MIP) and images using the volume rendered technique (VRT). Shaded surface displays are based on a binary selection of voxels using a single or double thresholding whereas MIP images result from the selection of the voxels of highest attenuation value. Volume rendered images are generated by means of a probabilistic classification of voxels consisting of a systematic estimation of the amount of the tissue-of-interest in each voxel. In addition, a variable degree of opacity (or transparency) can be chosen for the vascular structures and/or the surrounding anatomical structures, thus avoiding interpretive difficulties due to superimposition. A fourth category of reconstruction, STS-MIP (i.e., sliding-thin-slab MIP) can be applied to the evaluation of peripheral intraparenchymal vasculatures.

To evaluate the accuracy of spiral CT angiography in the diagnosis of central pulmonary embolism (PE).A retrospective study was undertaken in a population of 90 patients who were evaluated with spiral CT angiography (acquisition: 12 to 24 s with or without strict apnea; injection of 90 cm3 of 12, 20 or 30% contrast material at a rate of 4 to 7 cm3, selective pulmonary angiography of each lung (n = 55) and/or ventilation-perfusion (VP) scanning (n = 35).Among the 55 patients evaluated with both spiral CT and angiography, central pulmonary embolism was excluded in 19 patients (34%), assessed in 29 patients (53%) whereas CT examination was considered as inconclusive in 7 patients (13%) due to interpretive difficulties at the level of obliquely oriented arteries and/or presence of hilar lymph nodes (sensitivity: 90.5%; specificity: 82.6%). With spiral CT, the finding of 95 central emboli (3 main, 61 lobar and 31 segmental) corresponded exactly to the angiographic findings; spiral CT enabled direct visualization of intraluminal filling defects (n = 95) whereas the angiographic recognition of PE was based on direct (n = 57) and indirect (n = 38) signs. Spiral CT angiography was more sensitive and specific than VP scanning.Spiral CT angiography appears as a sensitive and specific noninvasive method for the diagnosis of central PE.

Spiral scanning (BSV) is a newly acquired scanning technique for all or part of the thoracic volume in a single breath-hold. It offers many advantages when compared to conventional CT scanning. The study of the lungs with a single breath-hold avoids the inconvenience of an anatomical discontinuity while acquiring the information. In a population of patients presenting with multiple, or solitary pulmonary nodules, or the absence of nodule, BSV shows 30 to 40% of supplementary nodules when compared to conventional scanning techniques. BSV enables the optimal use of contrast products in which the iodine is poorly concentrated to study the pulmonary vessels. Certainly this technique will not replace pulmonary angiography for the diagnosis of pulmonary emboli. However, it may be used first in certain situations, dispensing with invasive angiography in patients with an increased risk, or in the initial assessment of patients with pulmonary arterial hypertension of unknown aetiology, or to follow a previously documented pulmonary emboli. The correlation between spiral scanning and conventional angiography for the diagnosis of pulmonary emboli is excellent, to the level of segmental arteries. Finally the continuity, both anatomically and for the lesions obtained by BSV is such that it is now possible to apply to thoracic pathology techniques of multiplanar and three dimensional reconstruction. If all the information is contained in conventional transversal imaging slice by slice, not everything is perceived by the observer because the information is inconveniently presented because the anatomical and lesional picture is deconstructed. The reconstruction of the volume inspected in coronal, sagittal, oblique or three-dimensional viewing, furnishes supplementary information and announces the arrival of trachea-bronchography, and non-invasive angiography three-dimensionally. In parallel to the expected progress in IRM angiography, three-dimensional angio-CT of the thoracic vessels after appropriate evaluation is going to be substituted for more invasive techniques which are currently used.

Erdheim-Chester's disease is a rare form of visceral xanthogranulomatosis. We report a case of a patient aged 50 presenting with a diffuse interstitial pneumonia which revealed Erdheim-Chester's disease with localisation in the bones, peri-aortic region and also with neurological involvement. The diffuse interstitial pneumonia which progressed chronically was characterised by a diffuse thickening of the septa with subpleural cysts and bilateral apical bullae with thickening of the pleura. Respiratory function tests showed a restrictive ventilatory defect with resting hypoxaemia which was aggravating by exercise. Broncho-alveolar lavage showed a lymphocytosis (26%) also with polymorpho neutrophils (11%). The pathological diagnosis was confirmed by transbronchial lung biopsy showing an excess of foamy histiocytes in the interstitium which are characteristic of the disease. The progress of this interstitial pneumonia is stabilised without immunosuppressive drugs.

Systemic diseases such as scleroderma (ScI), rheumatoid polyarthritis (PR), Gougerot-Sjögren Syndrome (GS) have a well known propensity for the lungs. Previous studies have shown evidence of disturbed alveolar cell repair as evidence of a sub-clinical alveolitis. The significance of such cases of latent alveolitis remains to be specified. To determine if latent alveolitis was associated with interstitial chest disease which was undetectable by chest X-ray, 36 consecutive patients had an BAL and a high resolution computered tomographic examination (HRTC) (Scl: n = 21; PR: n = 9; GS: n = 6). The patients had normal respiratory function and chest X-ray was normal. Our results showed 17 out of 36 (47%) with a latent alveolitis (the percentage of lymphocytes and of alveolar polymorpho-nuclear neutrophils was superior or equal to 18 and 4% respectively) (Scl: 12/21; PR: 1/9; GS: 4/6). In the cases of scleroderma a neutrophil alveolitis was predominant (9/12) and was associated in 2 cases with a honeycomb lung and evidence of fibrotic lesions using TDM-HR. Those examinations using HRTC which were normal were equally associated with a latent alveolitis (Scl: 6/12; PR: 1/6; GR: 4/5). These results suggest that the alveolitis can preceed the anatomical damages. These results need to be confirmed in a larger series and the value of early treatment should be evaluated.

This study was performed on an experimental porcine model of acute local gamma irradiation to simulate accidents which occurred among humans. It enabled us to determine the development and the physiopathological characteristics of the fibrous tissue which developed in skeletal muscle. In the first month after irradiation, the strong inflammatory reaction which initiated the radiation induced fibrosis was characterized by edema as visualized on MRI imaging and X rays computed tomography and by acute phase reactant proteins changes, associated with elevations of local and general temperatures in irradiated animals. At the margin of the irradiated tissue myofibroblasts isolated among collagen bundles or grouped in nodullary reinforcements, are seen associated with intense capillary neogenesis. Several months after irradiation normal skeletal muscle was replaced by atrophic fibrosis delimited by an inflammatory perifibrotic tissue. The muscular fibrosis was characterized by a high density of myofibroblasts and by an inflammatory distribution pattern of collagen types I, III, IV, laminin, fibronectin and fibrinogen as visualized by immunohistochemical methods. Biochemical results showed an increase in collagen content and synthesis in fibrotic tissue whereas the cells in the perifibrotic zone synthesized more non collagenous proteins as compared with the normal muscle. The contributions of granulation tissue, cellular mediators and inhibition of muscular regeneration in the persistence of the invasive character of the muscular radiation induced fibrosis are discussed.

The non bronchial systemic arterial circulation of the lung may, for more than one good reason, be considered as a third arterial circulation of the lung, after the bronchial and pulmonary circulation. A perfect knowledge of the anatomy of the circulation and the physiopathological mechanisms leading to its development is a vital prelude to angiographic study. A common point in the majority of situations leading to this non bronchial systemic arterial hypervascularization is the existence of a pleural symphysis allowing the pulmonary penetration of these thoracic parietal vessels. In addition to the contribution of the transpleural non bronchial systemic vessels the role of the arteries of the triangular ligament should be discussed. The pathological significance of this non bronchial systemic hypervascularization is threefold. This circulation can be the source of haemoptysis as shown by angiography and is important for considering therapy when haemoptysis needs treatment by percutaneous embolisation. The duration and the risk of catheterisation may be considerably reduced thanks to the precision of the endoscopic examination at the site of bleeding. There are other types of endothoracic haemorrhage which can be qualified as "haemoptysis like" whose treatment, preventative or curative may also be assured by embolisation of this circulation. Besides a certain number of extracardiac shunts both endo and transthoracic, without any haemorrhagic consequence at the time at which they are discovered show evidence of abnormal communication between the three circulations of the lung; certain of these may need therapy by vaso-occlusion.

A mucocele is rarely observed after esophageal exclusion for corrosive burns. It may represent a contra-indication to esophageal conservation in case of a total gastric resection for necrosis and perforation of the stomach. To evaluate this risk, 15 patients, operated between January 1970 and December 1988, were reviewed: they underwent total gastric resection with esophageal exclusion, followed by a secondary colon transplant between the cervical esophagus and the duodenum. A plain chest film was performed for 13 patients and a CT scan for 11 patients. Mean follow-up was 5.7 years (2 months - 17 years). Four patients died, one of them after resection of a compressive esophageal mucocele. Six mucoceles were detected on 13 chest films and 7 were described on 11 CT scans. On the whole, 8 mucoceles were diagnosed on 15 patients; one of them was complicated by tracheal compression. The formation of a secondary esophageal mucocele is a late sign of incomplete destruction of the esophageal wall. It is a frequent complication of esophageal exclusion performed after total gastrectomy for corrosive burns of the stomach. It must be detected on a chest film which shows the largest dilatations or on a CT scan, which is a better investigation. When the diameter of the mucocele is equal of superior to 50 mm, it can be compressive and must be treated by resection of internal diversion.

Forty two pulmonary arteriovenous malformations (PAVM) in seventeen patients were treated by coil vaso-occlusion between 1979 and 1989. The techniques of deposition of coils and spiders and the precautions taken to avoid complications are described. Complete occlusion of the arterial pedicles of the PAVM was immediately obtained in 34/37 pedicles. 3/37 were occluded secondarily. Five PAVM were submitted to surgery demonstrating the reciprocal indications for surgical and per-angiographic techniques. Except in one patient, in the beginning of our experience, the observed complications were minor and we have subsequently modified our techniques to avoid them.