How large is the lung recruitability in early acute respiratory distress syndrome: a prospective case series of patients monitored by computed tomography

Introduction: The benefits of higher positive end expiratory pressure (PEEP) in patients with acute respiratory distress syndrome (ARDS) have been modest, but few studies have fully tested the "open-lung hypothesis". This hypothesis states that most of the collapsed lung tissue observed in ARDS can be reversed at an acceptable clinical cost, potentially resulting in better lung protection, but requiring more intensive maneuvers. The short-/middle-term efficacy of a maximum recruitment strategy (MRS) was recently described in a small physiological study. The present study extends those results, describing a case-series of non-selected patients with early, severe ARDS submitted to MRS and followed until hospital discharge or death. Methods: MRS guided by thoracic computed tomography (CT) included two parts: a recruitment phase to calculate opening pressures (incremental steps under pressure-controlled ventilation up to maximum inspiratory pressures of 60 cmH(2)O, at constant driving-pressures of 15 cmH(2)O); and a PEEP titration phase (decremental PEEP steps from 25 to 10 cmH2O) used to estimate the minimum PEEP to keep lungs open. During all steps, we calculated the size of the non-aerated (-100 to +100 HU) compartment and the recruitability of the lungs (the percent mass of collapsed tissue re-aerated from baseline to maximum PEEP). Results: A total of 51 severe ARDS patients, with a mean age of 50.7 years (84% primary ARDS) was studied. The opening plateau-pressure was 59.6 (+/- 5.9 cmH(2)O), and the mean PEEP titrated after MRS was 24.6 (+/- 2.9 cmH(2)O). Mean PaO2/FiO(2) ratio increased from 125 (+/- 43) to 300 (+/- 103; P < 0.0001) after MRS and was sustained above 300 throughout seven days. Non-aerated parenchyma decreased significantly from 53.6% (interquartile range (IQR): 42.5 to 62.4) to 12.7% (IQR: 4.9 to 24.2) (P < 0.0001) after MRS. The potentially recruitable lung was estimated at 45% (IQR: 25 to 53). We did not observe major barotrauma or significant clinical complications associated with the maneuver. Conclusions: MRS could efficiently reverse hypoxemia and most of the collapsed lung tissue during the course of ARDS, compatible with a high lung recruitability in non-selected patients with early, severe ARDS. This strategy should be tested in a prospective randomized clinical trial.

Assessment of variations of the mandibular canal through cone beam computed tomography

The neurovascular bundle may be vulnerable during surgical procedures involving the mandible, especially when anatomical variations are present. Increased demand of implant surgeries, wider availability of three-dimensional exams, and lack of clear definitions in the literature indicate that features of anatomical variations should be revisited. The objective of the study was to evaluate features of anatomical variations related to mandibular canal (MC), such as bifid canals, anterior loop of mental nerve, and corticalization of MC. Additionally, bone trabeculation at the submandibular gland fossa region (SGF) was assessed and related to visibility of MC. Cone beam computed tomography exams from 100 patients (200 hemimandibles) were analyzed and the following parameters were registered: diameter and corticalization of MC; trabeculation in SGF region; presence of bifid MC, position of bifurcations, diameter, and direction of bifid canals; and measurement of anterior loops by two methods. Corticalization of the MC was observed in 59% of hemimandibles. In 23%, MC could be identified despite absence of corticalization. Diameter of MC was between 2.1 and 4 mm for nearly three quarters of the sample. In 80% of the sample trabeculation at the SGF was either decreased or not visible, and such cases showed correlation with absence of MC corticalization. Bifid MC affected 19% of the patients, mostly associated with additional mental foramina. Clinically significant anterior loop (> 2 mm of anterior extension) was observed in 22-28%, depending on the method. Our findings, together with previously reported limitations of conventional exams, draw attention to the unpredictability related to anatomical variations in neurovascularization, showing the contribution of individual assessment through different views of three-dimensional imaging prior to surgical procedures in the mandible.

Comparative study of cone beam computed tomography and intraoral periapical radiographs in diagnosis of lingual-simulated external root resorptions

Background: Owing to a lack of symptoms and difficult visualization in routine intraoral radiographs, diagnosis of external root resorptions can be challenging. Aim: The goal of this study was to compare two image acquisition methods, intraoral radiographs and cone beam computed tomography (CBCT), in the diagnosis of external resorption. Material and Methods: Thirty-four maxillary and mandibular bicuspids were divided into three groups. Perforations measuring 0.3 and 0.6 mm in diameter and 0.15 and 0.3 mm in depth, respectively, were made on the lingual root surfaces in thirty teeth, and four were used as controls. Next, teeth were mounted on an apparatus and radiographed at mesial, distal, and orthoradial angulations. CBCT images were also taken. The analysis of the intraoral radiographic and tomographic images was carried out by two experts using standardized scores. Data were then compared statistically. Results: A strong agreement between the examiners was observed in both diagnosis methods, the intraoral radiographic (r = 0.93) and the tomographic analysis (r = 1.0). Tomography had higher statistically significant detection values than intraoral radiography (P < 0.05). In intraoral radiographs, the detection was significantly greater (P < 0.05) in the mandibular bicuspids, compared with their maxillary counterparts. The ability to detect 0.6-mm perforations by intraoral radiography was significantly higher than that of 0.3-mm perforations (P < 0.05). Conclusion: Cone beam computed tomography showed better diagnostic ability compared with intraoral radiography, regardless of the tooth or the dimensions of the resorption evaluated.

Root and Root Canal Morphology of Four-rooted Maxillary Second Molars: A Micro-Computed Tomography Study

Introduction: This study examined the anatomy of 4-rooted maxillary second molars by using micro computed tomography. Methods: Twenty-five 4-rooted maxillary second molars were scanned to evaluate the size and curvature of the roots; the distance and spatial configuration between some anatomical landmarks; the number of root canals and the position of apical foramina; the occurrence of fusion of roots and enamel pearls; the configuration of the canal at the apical third; the cross-sectional appearance, the volume, and surface area of the root canals. Data were compared by using analysis of variance post hoc Tukey test (alpha = 0.05). Results: The specimens were classified as types I (n = 16), II (n = 7), and III (n = 2). The size of the roots was similar (P > .05), and most of them presented straight with 1 canal, except the mesiobuccal that showed 2 canals in 24% of the samples. The configuration of the pulp chamber was mostly irregular quadrilateral-shaped. The lowest mean distance of the orifices was observed between the buccal roots (P < .05). Accessory canals were present mostly in the apical third. Location of the apical foramina varied considerably. Fusion of roots and enamel pearls occurred in 44% and 8% of the samples, respectively. Mean distance from the pulp chamber floor to the furcation was 2.15 +/- 0.57 mm. No statistical differences were found in the bi-dimensional and 3-dimensional analyses (P > .05). Conclusions: All analyzed parameters showed differences between roots, except for the length of the roots, the configuration of the canals at the apical third, cross-sectional appearance, volume, and surface area of the canals. (J Endod 2012;38:977-982)

Accuracy of positron emission tomography/computed tomography and clinical assessment in the detection of complete rectal tumor regression after neoadjuvant chemoradiation Long-Term Results of a Prospective Trial (National Clinical Trial 00254683)

BACKGROUND: Neoadjuvant chemoradiation (CRT) therapy may result in significant tumor regression in patients with rectal cancer. Patients who develop complete tumor regression have been managed by treatment strategies that are alternatives to standard total mesorectal excision. Therefore, assessment of tumor response with positron emission tomography/computed tomography (PET/CT) after neoadjuvant treatment may offer relevant information for the selection of patients to receive alternative treatment strategies. METHODS: Patients with clinical T2 (cT2) through cT4NxM0 rectal adenocarcinoma were included prospectively. Neoadjuvant therapy consisted of 54 grays of radiation and 5-fluorouracil-based chemotherapy. Baseline PET/CT studies were obtained before CRT followed by PET/CT studies at 6 weeks and 12 weeks after the completion of CRT. Clinical assessment was performed at 12 weeks after CRT completion. PET/CT results were compared with clinical and pathologic data. RESULTS: In total, 99 patients were included in the study. Twenty-three patients were complete responders (16 had a complete clinical response, and 7 had a complete pathologic response). The PET/CT response evaluation at 12 weeks indicated that 18 patients had a complete response, and 81 patients had an incomplete response. There were 5 false-negative and 10 false-positive PET/CT results. PET/CT for the detection of residual cancer had 93% sensitivity, 53% specificity, a 73% negative predictive value, an 87% positive predictive value, and 85% accuracy. Clinical assessment alone resulted in an accuracy of 91%. PET/CT information may have detected misdiagnoses made by clinical assessment alone, improving overall accuracy to 96%. CONCLUSIONS: Assessment of tumor response at 12 weeks after CRT completion with PET/CT imaging may provide a useful additional tool with good overall accuracy for the selection of patients who may avoid unnecessary radical resection after achieving a complete clinical response. Cancer 2012;35013511. (C) 2011 American Cancer Society.

Upper airway expansion after rapid maxillary expansion evaluated with cone beam computed tomography

Objective: Cone-beam computed tomography (CBCT) is a reliable method of assessing the oral cavity and upper airways. We conducted this study to examine the changes introduced by rapid maxillary expansion in the nasal cavity, nasopharynx, and oropharynx as seen with images obtained by CBCT. Materials and Methods: We evaluated 15 patients with maxillary width deficiency treated with RME. Patients were subjected to CBCT at the beginning of RME and after the retention period of 4 months. Results: The nasal cavity presented a significant transverse increase in the lower third, in the anterior (1.08 mm +/- 0.15), medium (1.28 mm +/- 0.15), and posterior regions (0.77 mm +/- 0.12). No significant change occurred in the nasopharynx in volume (P = .11), median sagittal area (P = .33), or lower axial area (P = .29) resulting from the RME. A significant change was noted in the oropharynx in volume (P = .05), median sagittal area (P = .01), and lower axial area (P = .04) before and immediately after the RME. Conclusions: RME is able to increase the transverse width of the nasal cavity, but it does not have the same effect in the nasopharynx. Changes noted in the oropharynx may be due to the lack of a standardized position of the head and tongue at the time of image acquisition. (Angle Orthod. 2012;82:458-463.)

Alveolar Bone Morphology in Patients With Bilateral Complete Cleft Lip and Palate in the Mixed Dentition: Cone Beam Computed Tomography Evaluation

Objectives: To verify the thickness and level of alveolar bone around the teeth adjacent to the cleft by means of cone beam computed tomography (CBCT) in patients with complete bilateral cleft lip and palate prior to bone graft surgery and orthodontic intervention. Method: The sample comprised 10 patients with complete bilateral cleft lip and palate (five boys and five girls) in the mixed dentition. The mean age was 9.5 years, and all subjects showed a G3 interarch relationship according to the Bauru index. The thickness of alveolar bone surrounding the maxillary incisors and the maxillary canines was measured in CBCT axial section using the software iCAT Xoran System. The distance between the alveolar bone crest and the cement-enamel junction (CEJ) was measured in cross sections. Results: The tomography images showed a thin alveolar bone plate around teeth adjacent to clefts. No bone dehiscence was observed in teeth adjacent to clefts during the mixed dentition. A slight increase in the distance between the alveolar bone crest and the CEJ was observed in the mesial and lingual aspects of canines adjacent to cleft. Conclusion: In patients with BCLP in the mixed dentition, teeth adjacent to the alveolar cleft are covered by a thin alveolar bone plate. However, the level of alveolar bone crest around these teeth seems to be normal, and no bone dehiscence was identified at this age.

Computed tomography to evaluate the association of fragmented heterolog cortical bone and methylmethacrylate to repare segmental bone defect produced in tibia of rabbits

A 6mm segmental defect was performed on the metaphyseal region of the tibia of 12 rabbits and the autoclaved fragmented heterolog cortical bone conserved in glycerin (98%) and methylmethacrylate was used as a bone graft for the reconstruction. The graft was placed in the receptor bed and its integration was evaluated by computed tomography after 30, 60 and 90 days. There was gradual bone graft incorporation in the receptor bed during the time in 100% of the cases. Fragmented cortical bone heterograft and methylmethacrylate was biologically compatible and promotes bone defect reparation without signs of infection, migration and or rejection, featuring a new option of osseous substitute to fill in bone defects.

Spontaneous combined rupture of a pelvicalyceal cyst into the collector system and retroperitoneal space during the acquisition of computed tomography scan images: a case report

Abstract Introduction Pelvicalyceal cysts are common findings in autopsies and can manifest with a variety of patterns. These cystic lesions are usually a benign entity with no clinical significance unless they enlarge enough to cause compression of the adjacent collecting system and consequently obstructive uropathy. Few cases of the spontaneous rupture of pelvicalyceal renal cysts have been published and to the best of our knowledge there is no report of a combined rupture to collector system and retroperitoneal space documented during a multiphase computed tomography. Case presentation We report a case of a ‘real-time’ spontaneous rupture of a pelvicalyceal cyst into the collecting system with fistulization into the retroperitoneum. The patient was a 78-year-old Caucasian man with a previous history of renal stones and a large pelvicalyceal renal cyst who was admitted to our Emergency department with acute right flank pain. A multiphase computed tomography was performed and the pre-contrast images demonstrated a right pelvicalyceal renal cyst measuring 12.0 × 6.1cm in the lower pole causing moderate dilation of the upper right renal collection system. In addition, a partially obstructive stone on the left distal ureter with mild left hydronephrosis was noted. The nephrographic phase did not add any new information. The excretory phase (10-minute delay) demonstrated a spontaneous rupture of the cyst into the pelvicalyceal system with posterior fistulization into the retroperitoneal space. Conclusion In this case study we present time-related changes of a rare pelvicalyceal cyst complication, which to the best of our knowledge has fortunately not been previously documented. Analysis of the sequential images and comparison with an earlier scan allowed us to better understand the physiopathological process of the rupture, the clinical presentation and to elaborate hypotheses for its etiopathogenesis.

Hepatobiliary diseases in small animals: a comparison of ultrasonography and multidetector-row computed tomography

Ultrasonography (US) is an essential imaging tool for identifying abnormalities of the liver parenchyma, biliary tract and vascular system. US has replaced radiography as the initial imaging procedure in screening for liver disease in small animals. There are few reports of the use of conventional and helical computed tomography (CT) to assess canine or feline parenchymal and neoplastic liver disease and biliary disorders. In human medicine the development of multidetector- row helical computed tomography (MDCT), with its superior spatial and temporal resolution, has resulted in improved detection and characterization of diffuse and focal liver lesions. The increased availability of MDCT in veterinary practice provides incentive to develop MDCT protocols for liver imaging in small animals. The purpose of this study is to assess the rule of MDCT in the characterization of hepatobiliary diseases in small animals; and to compare this method with conventional US. Candidates for this prospective study were 175 consecutive patients (dogs and cats) referred for evaluation of hepatobiliary disease. The patients underwent liver US and MDCT. Percutaneous needle biopsy was performed on all liver lesions or alterations encountered. As for gallbladder, histopatological evaluation was obtained from cholecystectomy specimens. Ultrasonographic findings in this study agreed well with those of previous reports. A protocol for dual-phase liver MDCT in small animals has been described. MDCT findings in parenchymal disorders of the liver, hepatic neoplasia and biliary disorders are here first described in dogs and cats and compared with the corresponding features in human medicine. The ability of MDCT in detection and characterization of hepatobiliary diseases in small animals is overall superior to conventional US. Ultrasonography and MDCT scanning, however, play complementary rules in the evaluation of these diseases. Many conditions have distinctive imaging features that may permit diagnosis. In most instances biopsy is required for definitive diagnosis.

Anatomic study of the feline bronchial and vascular structures with a 64 detector-row computed tomography

Multidetector row computed tomography over the last decade is commonly used in veterinary medicine. This new technology has an increased spatial and temporal resolution, could evaluate wider scanning range in shorter scanning time, providing an advanced imaging modality. Computed tomography angiographic studies are commonly used in veterinary medicine in order to evaluate vascular structures of the abdomen and the thorax. Pulmonary pathology in feline patients is a very common condition and usually is further evaluating with computed tomography. Up to date few references of the normal computed tomographic aspects of the feline thorax are reported. In this study a computed tomographic pulmonary angiography (CTPA) protocol is reported in normal cats and is compared with the up to date anatomical references. A CTPA protocol using a 64 MDCT in our study achieved high resolution images of the pulmonary arteries, pulmonary veins and bronchial lumen till the level of minor segmental branches. Feline pulmonary bronchial parenchyma demonstrates an architecture of mixed type with a monopedial model observed in the most anatomical parts and the dichotomic aspect is seen at the accessory lobe. The arterial and venous architecture is similar to the bronchial. Statistical analysis demonstrates the linear correlation of tracheal diameter to the felines weight. Vascular variations were noticed. The pulmonary venous system enters into the left atrium through three ostia (left cranial ostia: consisted of the anastomosis of the cranial and caudal portion of the left cranial pulmonary vein; right ostia: consisted of the anastomosis of the right cranial and middle pulmonary vein; and the caudal ostia: consisted of the anastomosis of the right and left caudal pulmonary vein). In conclusion CTPA is applicable in feline patients and provides an excellent imaging of the pulmonary arterial, venous and bronchial system till the level of minor segmental branches.

Teos-based consolidants for stone conservation: evaluation of the effects and testing by x-ray imaging

Natural stones have been widely used in the construction field since antiquity. Building materials undergo decay processes due to mechanical,chemical, physical and biological causes that can act together. Therefore an interdisciplinary approach is required in order to understand the interaction between the stone and the surrounding environment. Utilization of buildings, inadequate restoration activities and in general anthropogenic weathering factors may contribute to this degradation process. For this reasons, in the last few decades new technologies and techniques have been developed and introduced in the restoration field. Consolidants are largely used in restoration and conservation of cultural heritage in order to improve the internal cohesion and to reduce the weathering rate of building materials. It is important to define the penetration depth of a consolidant for determining its efficacy. Impregnation mainly depends on the microstructure of the stone (i.e. porosity) and on the properties of the product itself. Throughout this study, tetraethoxysilane (TEOS) applied on globigerina limestone samples has been chosen as object of investigation. After hydrolysis and condensation, TEOS deposits silica gel inside the pores, improving the cohesion of the grains. X-ray computed tomography has been used to characterize the internal structure of the limestone samples,treated and untreated with a TEOS-based consolidant. The aim of this work is to investigate the penetration depth and the distribution of the TEOS inside the porosity, using both traditional approaches and advanced X-ray tomographic techniques, the latter allowing the internal visualization in three dimensions of the materials. Fluid transport properties and porosity have been studied both at macroscopic scale, by means of capillary uptake tests and radiography, and at microscopic scale,investigated with X-ray Tomographic Microscopy (XTM). This allows identifying changes in the porosity, by comparison of the images before and after the treatment, and locating the consolidant inside the stone. Tests were initially run at University of Bologna, where characterization of the stone was carried out. Then the research continued in Switzerland: X-ray tomography and radiography were performed at Empa, Swiss Federal Laboratories for Materials Science and Technology, while XTM measurements with synchrotron radiation were run at Paul Scherrer Institute in Villigen.

Valutazione della qualità delle immagini e della dose in multi-slice computed tomography per l'ottimizzazione dei protocolli clinici che impiegano sistemi di modulazione automatica

In questo studio ci siamo proposti di investigare i sistemi di modulazione automatica della dose sui sistemi TC Multislice (Automatic Exposure Control – AEC) da tre diversi produttori, aventi differenti indicatori di qualità delle immagini. Il presente lavoro è stato svolto presso il Servizio di Fisica Sanitaria dell’Azienda Ospedaliera Universitaria - Policlinico Sant’Orsola-Malpighi di Bologna e consiste in un’analisi quantitativa della dose impiegata durante esami di Tomografia Computerizzata Multi-Slice (TCMS) e delle rispettive immagini radiologiche. Le immagini sono state acquisite con : GE LightSpeed VCT 64 e GE LightSpeed 16 (AEC AutomA 3D longitudinale e angolare), Siemens Sensation 16 (AEC CARE Dose 4D combinato), Philips Brilliance 16 e iCT 64 (separati in AEC ZDOM longitudinale e AEC DDOM angolare). Le acquisizioni TCMS sono state effettuate a differenti kV e mA di riferimento, al fine di investigarne gli effetti sulla modulazione, impiegando algoritmi di ricostruzione standard presenti su ogni macchina. Due fantocci antropomorfi simulanti la zona del torace e dell’addome sono stati utilizzati per simulare un paziente standard posizionato come in un esame clinico di routine ; a questo proposito, sono stati impiegati protocolli elicoidali standard con e senza modulazione. Sono inoltre stati testati differenti valori di indice di qualità delle immagini. Il profilo dei mA lungo la lunghezza è stato ottenuto utilizzando ImageJ, un programma open source comunemente utilizzato per l’elaborazione di immagini; i mAs sono stati normalizzati ad un fattore che tiene conto delle differenti geometrie e delle filtrazioni dei diversi scanner tomografici analizzati nell’esperienza. Il rumore è stato valutato tramite la scelta di determinate ROI (Region Of Interest) localizzate in aree il più possibili uniformi disponibili lungo i fantocci. Abbiamo registrato che una variazione del Noise Index o dei mAs di riferimento a seconda della tipologia di macchina analizzata risulta in uno shift dei profili di dose; lo stesso si è verificato quando sono stati cambiato kV o mA nella scout di acquisizione. Sistemi AEC longitudinali e combinati hanno mostrato profili di mAs normalizzati simili tra loro, con valori elevati evidenziati nella zona delle spalle e zona pelvi; sono state osservate differenze del 30-40% tra i differenti scanner tomografici. Solo in un caso di macchina analizzata si è verificato un comportamento opposto rispetto alle altre due tipologie di macchina in esame. A dispetto della differente natura dei sistemi AEC, i risultati ottenuti dai protocolli combinati e longitudinali sono simili tra loro. Il rumore presente nelle immagini è aumentato ad un livello accettabile e la sua uniformità lungo la direzione di scan è migliorata.

Image quality and dose evaluation of filtered back projection versus iterative reconstruction algorithm in multislice computed tomography.

Il presente lavoro di tesi è stato svolto presso il servizio di Fisica Sanitaria del Policlinico Sant'Orsola-Malpighi di Bologna. Lo studio si è concentrato sul confronto tra le tecniche di ricostruzione standard (Filtered Back Projection, FBP) e quelle iterative in Tomografia Computerizzata. Il lavoro è stato diviso in due parti: nella prima è stata analizzata la qualità delle immagini acquisite con una CT multislice (iCT 128, sistema Philips) utilizzando sia l'algoritmo FBP sia quello iterativo (nel nostro caso iDose4). Per valutare la qualità delle immagini sono stati analizzati i seguenti parametri: il Noise Power Spectrum (NPS), la Modulation Transfer Function (MTF) e il rapporto contrasto-rumore (CNR). Le prime due grandezze sono state studiate effettuando misure su un fantoccio fornito dalla ditta costruttrice, che simulava la parte body e la parte head, con due cilindri di 32 e 20 cm rispettivamente. Le misure confermano la riduzione del rumore ma in maniera differente per i diversi filtri di convoluzione utilizzati. Lo studio dell'MTF invece ha rivelato che l'utilizzo delle tecniche standard e iterative non cambia la risoluzione spaziale; infatti gli andamenti ottenuti sono perfettamente identici (a parte le differenze intrinseche nei filtri di convoluzione), a differenza di quanto dichiarato dalla ditta. Per l'analisi del CNR sono stati utilizzati due fantocci; il primo, chiamato Catphan 600 è il fantoccio utilizzato per caratterizzare i sistemi CT. Il secondo, chiamato Cirs 061 ha al suo interno degli inserti che simulano la presenza di lesioni con densità tipiche del distretto addominale. Lo studio effettuato ha evidenziato che, per entrambi i fantocci, il rapporto contrasto-rumore aumenta se si utilizza la tecnica di ricostruzione iterativa. La seconda parte del lavoro di tesi è stata quella di effettuare una valutazione della riduzione della dose prendendo in considerazione diversi protocolli utilizzati nella pratica clinica, si sono analizzati un alto numero di esami e si sono calcolati i valori medi di CTDI e DLP su un campione di esame con FBP e con iDose4. I risultati mostrano che i valori ricavati con l'utilizzo dell'algoritmo iterativo sono al di sotto dei valori DLR nazionali di riferimento e di quelli che non usano i sistemi iterativi.