Contents

Current problems
Carty H, Rangr P - The investigation of urinary tract infections in children

Survey
Gocheva I - Heterotopic ossification - a domain of radiotherapy

Original articles
Zhigrai M, Zhakovich V, Brezinova M, Olozova M, Pavlovichova M - MRI in diagnosing nerve root edema in patients with lumbar disk herniation
Kirova G, Rashkov R, Georgiev O - Comparison between radiological manifestations of thoracic involvement in collagen vascular diseases and idiopathic pulmonary fibrosis
Gagov E, Garvanska G, Totev M, Panov M - Experience with imaging methods in the diagnosis and therapy of invaginations in pediatric patients
Tenchova V, Topalova S, Stefanova D, Kuzova K - Assessment of the radiomodifying effect of the herbal preparation "Elixir-3" in laboratory animals exposed to external whole-body gamma-irradiation

Case report
Jerassy R, Lyubomirova M, Astrukhov E, Nikolova M - Liver abscess in a female patient with chronic calculous cholecystitis and empyema of the gallbladder

Historical facts and events

Continuing education. Corner of nuclear medicine
Locher J Th - Renal cortical scintigraphy

Problems relating to education
Problems relating to radiation protection
News of the EAR
Impressions from congresses
News of the ISR
Abstracts of current literature
Forthcoming scientific events
News items
Instructions to authors
 

The investigation of urinary tract infections in children

H. Carty, P. Rangr
Alder Hey Hospital, Liverpool, UK

Summary. This article outlines the role and methods used in the investigation of urinary tract infections in children. Each modality, whether it has been used in the past or being used currently or in the future, has been discussed, together with its advantages and pitfalls. There are no hard and fast rules in the investigation of UTIs. It really depends on the clinical scenario and the child. This article will hopefully provide a basis of understanding the reasons behind each investigation and their appropriate use in the child depending on their age and clinical history.

Key words: urinary tract infections. children. methods.
 

Urinary tract infections are a common bacterial infection in children. 5% of girls and 0.5% of boys will be affected at least once. The morbidity associated with these infections is substantial but some children get silent infections, which leads to renal damage. Though most cases of UTI associated with vesicoureteric reflux (VUR) are associated with bacteriuria, it is now recognized that sterile reflux seen antenatally may also result in renal scarring. Symptoms of UTI are pain, which is often abdominal, fever, haematuria, smelly urine and failure to thrive.  Risk factors associated with urinary tract infections are, congenital abnormalities of the urinary tract such as vesicoureteric reflux, pelviureteric obstruction, posterior urethral valves, duplex kidney, ectopic ureterocoele and bladder diverticula. The clinical diagnosis of a urinary tract infection is the presence of significant bacteriuria, which is defined as greater than 100,000 cfu/ml (colony forming units per milliliter). The purpose of investigation is to identify:

a. The small group of children who may progress to end stage renal failure from infective episodes
b. A further small group with a surgically correctable condition which when treated, halts further infection and morbidity
c. To identify those children with vesico ureteric reflux, who if treated with prophylaxis, will in most instances prevent further infection and renal damage until the vesico ureteric reflux spontaneously ceases; the natural history of VUR
d. To establish the extent of damage for prognosis

Radiology has therefore two roles in the investigation of urinary tract infections. The first is the identification of the abnormality predisposing to the infection, which when treated, eliminates further infection. The second is the assessment of the damage caused to the kidneys by these repeated infections.
The dilemma for the clinician is to identify who, why and how to investigate. Investigation inevitably leads to inflicting unpleasant tests such as the micturating cysto-urethrogram (MCUG) on the children.
Available imaging techniques are the plain film, ultrasound, fluoroscopy, nuclear medicine, CT and MRI.
The method of imaging a child with a urinary tract infection has long been a complicated and sometimes controversial one.  There are many modalities that can be used but not all of them are the most appropriate or useful. The age and awareness of the child plays an important role, as does the availability of the imaging modalities in each hospital. The Royal College of paediatrics and child health has therefore published guidelines for the investigation of UTIs in children according to the age of the child (table 1). 
This paper will review each of the modalities used in the imaging of the child with a UTI and discuss the relative merits and pitfalls of each. 

PLAIN FILM

The plain film is usually the first modality used in the investigation. It has a low radiation burden and provides a general overview of the patient, especially when the clinical diagnosis is uncertain. Its diagnostic yield is low and in most children, it is normal.
The abdominal film gives an indication of the renal size. A small kidney with an irregular shape indicates scarring. A large smooth kidney may imply a congenital duplex system or PUJ. Bladder size and wall thickness may occasionally but unreliably be assessed. A thick trabeculated bladder may imply the presence of posterior urethral valves. Renal stone formation, a large renal or bladder mass or a spinal anomaly will be visible. Urinary tract calculi often indicate proteus infections (fig 1). More rarely, a partially calcified renal mass is identified, indicating xanthogranulomatous pyleonephritis. Rarely, a relevant spinal anomaly, overlooked clinically, and a partial sacral agenesis will be seen.
The disadvantages of the abdominal radiograph in children are the renal outlines are usually difficult to see due to their lack of intra-abdominal fat, faeces and gas in the bowel from air swallowing when distressed. 

INTRAVENOUS UROGRAM

The IVU was once the most important and widely used investigation of the urinary tract. However, with the development of other imaging techniques, its use has now diminished.
Non-ionic contrast is now used which has eliminated the unpleasant side effects of the older ionic contrast. A minimum dose of 2ml/kg is required to achieve adequate opacification. In most children adequate information can be obtained from a four film series: the control, a three-minute cross kidney nephrographic phase, a full length at fifteen minutes and a full length post micturition film.
The main indications of the IVU are to assess anatomic variations of the kidney suggested by ultrasound or DMSA scan; to demonstrate obstruction of the ureter by a renal stone and confirmation of a duplex system of the kidney (fig 2) when the ultrasound is normal and DMSA indicates smooth kidneys with a discrepancy in size.
The advantage of the IVU is that it is available in almost every hospital. The anatomical detail is excellent. The renal outline in the nephrogram phase shows cortical scarring well (fig 3). Calyceal detail cannot be reproduced by any other image modality. The changes of chronic infection and scarring, clubbed calyces with overlying reduction in renal parenchyma are well demonstrated. The IVU is normal in 75% of patients with acute pyleonephritis. Mucosal striations of the ureter on the contrast film are diagnostic of VUR. Other findings are an enlarged swollen kidney, a delayed or striated nephrogram or renal pelvis.
The IVU is no longer used as part of the routine work up for a child with a UTI since the introduction of ultrasound and radionuclides. It is now reserved to resolve doubt raised by the other techniques. 
The disadvantage of the IVU is that a good series depends on adequate renal function. Scars are not detected in their acute phase and its sensitivity on demonstrating scarring is low compared with scintigraphy. Its use now, as described earlier, is limited. Some studies have therefore called for the abandonment of the routine IVU in UTI1.

ULTRASOUND

Ultrasound is the first investigation of choice in all children with proven UTIs. Images of the bladder (pre and post micturition) and of the kidneys are taken. The purpose of the investigation is to:

a. Identify the presence of two kidneys
b. To identify congenital abnormalities
c. To monitor growth
d. To identify renal scarring

The advantages of ultrasound are well known. It is cheap, freely available, painless, carries no radiation burden and can be repeated frequently. 
Its disadvantages are also well known. It is operator dependant, can be difficult in a fractious child and its sensitivity in demonstrating scarring is low. Pelvic kidneys, small calculi and uncomplicated duplex kidneys may be missed.
In simple, uncomplicated duplex kidneys, there is a division of the central echo- bright sinus within the renal parenchyma, which can be difficult to appreciate and its identification is very operator dependant. Complex duplex systems with a hydronephrotic upper moiety and a ureterocoele will not be missed, but a tortuous dilated ureter can, in cross section, appear as multiple cysts and be misinterpreted as a cystic mass. Reflux in duplex systems is to the lower moiety.
A hydronephrotic kidney is identified by dilatation of the renal pelvis greater than 10mm in the transverse diameter. A measurement of 10mm can be normal in children with a full bladder and post micturition views need to be taken. Renal pelvic dilatation of 1cm, without hydrocalyces, indicates an extra renal pelvis configuration and is not an indication of reflux or hydronephrosis. Over interpretation leads to unnecessary investigation.
Renal and bladder calculi are visualized on ultrasound by an echo-bright focus that has an acoustic shadow behind it. The identification of small calculi can be difficult and are dependent on the operator's experience and child's cooperation. Renal masses and cystic disease are easy to identify on ultrasound and can usually be characterized.  Renal scars can be visualized on US as a decrease in renal parenchymal thickness but the sensitivity for pick up is low compared to other modalities. However, one study suggests that renal scarring detected by ultrasound can have a positive predictive value of 93% and a negative predictive value of 95% if the following criteria are used: 1. Proximity of sinus echo to cortical surface; 2. Loss of pyramids; 3. Irregularity of outline; 4. Loss of definition of capsular echo and 5. Calyceal dilatation.2.
Acute pyleonephritis can be diagnosed by visualizing a large kidney with loss of its cortico-medullary differentation and an altered echogenicity. 
The bladder is visualized for the presence of ureterocoeles (fig 4), trabeculation and calculi. Debris in the bladder suggests infection or chronic obstruction. In boys, the ultrasound examination can be extended to include the area of the urethra, as proximal urethral dilatation is often demonstrable in posterior urethral valves.
Ultrasound is used in most hospitals as the initial investigation in children presenting with UTIs. Technically, the examination should start with bladder views as small infants will frequently micturate once the abdomen is exposed to the atmosphere and jelly applied. If it is impossible to obtain views of the bladder, this should be recorded.

MICTURATING CYSTO-URETHROGRAM  (MCUG)

The gold standard investigation for detecting VUR is the MCUG. The MCUG is done about 6 weeks after the acute episode with prophylactic antibiotic cover. If reflux is demonstrated, the antibiotics should be increased to therapeutic levels.
The advantage of the MCU is that it gives good anatomical detail of the bladder and urethra, and abnormalities associated with them, for example, ureterocoeles. It is very accurate for the assessment of grades of vesicoureteric reflux both during bladder filling and voiding (fig 5). This can then be correlated with the grades of reflux according to the International Reflux Study in Children.  In addition to grading it is helpful to give a narrative description of the findings. In severe reflux, ureteric peristalsis should be commented upon, as reimplantation in children with flabby aperistaltic systems is associated with a poor outcome. In boys, the entire urethra, distended with contrast, must be demonstrated as valves, both anterior and posterior, or polyps may be missed. The image must be in a steep oblique projection (fig 6). A spinning top urethra (fig 7) in girls is a feature of detrusor instability. Vaginal reflux is common and should be noted. Post micturition residue in the bladder can also be assessed with ease.
The major disadvantage of doing a MCU is that it is invasive procedure: children and their parents don't like it! The catheter is a potential source of an infection, particularly if there is vesicoureteric reflux. Insertion of the catheter is uncomfortable and can be distressing to the child (especially in older children). MCUs are therefore not performed as the primary investigation in patients over the age of 2 years but are reserved in whose other tests suggest reflux. It also has the disadvantage of having a relatively high radiation exposure particularly to the reproductive organs. 
Despite these disadvantages, the MCU is commonly performed as it can be done in almost any hospital and provides an excellent demonstration of vesicoureteric reflux. Significant VUR can be missed in both ultrasound and renal scans, thus emphasizing the importance of this imaging technique3.

NUCLEAR MEDICINE SCANS

There are many uses of nuclear medicine examinations in the evaluation of UTIs.

DMSA Scan
This scan is considered to be the most sensitive for the detection of renal scarring (fig 8), particularly when associated with other imaging methods 4, 5, 6. 
Technetium 99 DMSA is injected intravenously. The dose is based on an adult dose of 80MBq and adjusted for the child's weight. Images are acquired after 2 to 3 hours with the patient still. Posterior and posterior oblique views7 are taken using low energy, all-purpose collimators. If the kidneys are not both in the normal renal beds and one lies low or is ectopically placed e.g. pelvis, is rotated or is a horseshoe kidney, an anterior view should also be done and the relative uptakes averaged to a geometric mean.
Both kidneys are compared visually and by their relative function (as assessed by the amount of uptake of the radionuclide by the kidneys). The relative uptake should lie within the range of 45 to 55%. The scan does not give an indication of overall function, for example, both kidneys could be equally damaged and if not scarred, be estimated as normal (fig 9). In children with poor renal function, there is a failure of binding of DMSA and excessive tissue background is present at two hours. Scarring is seen as peripheral defects. The oblique views increase the sensitivity of detection. A dilated system shows central photopenia in the postion of the dilated calyces and an enlarged outline. Photopenic defects are also seen with staghorn calculi or renal abscesses. A small kidney with a smooth outline, a result of renal failure, may also be seen as a manifestation of infection (fig 10).
Advantages of the DMSA scan are that it has been shown to be more sensitive than other modes of imaging and is performed after an acute pyleonephritis to assess permanent scarring 8. Scarring present six months or more after an episode of infection, is permanent. It is also reproducible on ultrasound but is not as sensitive for identifying scars at this stage as the DMSA scan9.
The disadvantage of DMSA scanning is, that although it is classed as the gold standard for renal scar detection, small peripheral scars can be missed. The recommendation in the UK is that the scan is performed 6 weeks after the initial acute infection so not to mistake acute reversible Photopenic lesions as permanent ones 9. Another pitfall is that small shrunken kidneys may give a normal looking scan with equal relative functions, thus emphasizing the need to use the DMSA scan in conjugation with other imaging modalities. Unfortunately nuclear medicine is not available in every hospital and does have a radiation burden. As with planar scintigraphy in other organs, the DMSA scan must always be viewed in conjugation with other image investigations.

DMSA SPECT
This is a relatively new technique where a triple headed gamma camera is used to take images giving a CT like picture of the kidneys. It has been shown to give a superior image quality compared to planar imaging and has improved the sensitivity of renal scar detection 10, 11. However, the availability of SPECT is very limited in the UK currently and is not a feasible option for the near future.

Direct Radionuclide Cystography
This is performed similar to the micturating cysto-urethrogram but sterile saline with technetium 99m pertechnetate is infused into the bladder while the child is lying under the gamma camera. Continuous imaging during filling and micturition is performed. Time activity curves over the renal areas and bladder are generated. Vesicoureteric reflux is seen on the analogue images but the anatomical detail is not as good as the MCU and the reflux cannot be accurately graded. Reflux is also seen on the time activity curves as a peak.  Grade 1 will be missed as the full bladder hides the reflux.
As a screening tool, DRC has the advantages of a low radiation dose and there is evidence that it is more sensitive than the MCUG in detecting reflux in a child under1 year 12, 13. It is an appropriate first examination in girls as the incidence of urethral abnormality is almost non-existent, but not in boys. Structural abnormalities will be missed and detrusor instability cannot be detected. Other disadvantages include the requirement for catherisation and the desire by urologists to see the anatomy is difficult to overcome.

Indirect Radionuclide Cystography
MAG 3 is a hippuran analogue and is excreted by the kidneys by tubular secretion. It is the urographic radiopharmaceutical of choice in renography. Its advantages compared to DTPA, is rapid renal clearance and better imaging statistics. The initial two-minute image gives a reasonable posterior nephrographic image similar to that obtained by DMSA scintigraphy, but oblique views are possible. Because of rapid clearance (about 50 minutes) with normal renal function, it is an ideal radiopharmaceutical for the indirect radionuclide cystography. The injected dose is based on an adult dose of 80MBq adjusted for the child's weight. Following injection, a renogram is performed. The information about perfusion, excretion and relative and absolute renal function is obtained together with a reasonable anatomical image, which will detect gross scarring. Following the renogram, the child is given fluids to drink to encourage washout of radionuclide and to stimulate a desire to micturate. The child is then invited to micturate sitting or standing upright, thus mimicking physiological micturition as there is no intervention. Time activity curves are generated over the kidneys and bladder. A rise in counts during micturition indicates reflux (fig 11). Both counts and the analogue images are vital.
The advantages are no catheterization and information about renal function. 
The disadvantages are patient cooperation and bladder control is needed for this examination. Anatomical detail is poor and the sensitivity for vesicoureteric reflux is low for grade 1 and 2.
This examination is therefore used in older children presenting with a UTI and a normal ultrasound and for the follow up of children with known vesicoureteric reflux 14.

COMPUTED TOMOGRAPHY

CT is not used routinely in the assessment of a UTI in a child. If needed, a post- intravenous contrast scan is used and contiguous scans are obtained. If calculi are being sought, a non- enhanced scan is required.
The advantage of CT in a child with an infection of the kidneys is to differentiate between acute pyleonephritis and xanthogranulomatosis pyleonephritis.  The CT findings of the former are a swollen kidney with sometimes, associated hemorrhage. A post contrast scan shows areas of patchy enhancement with wedge shaped areas of decreased perfusion. In xanthogranulomatosis pyleonephritis, there are multiple areas of soft tissue density in the kidney surrounded by thickened parenchyma. The renal pelvis is contracted and there is usually evidence of calculus. XGP is often mistaken for a malignant tumour.
The disadvantages are the large radiation exposure related to CT. This is increased if a pre and post scan are performed. A post contrast scan alone will mask signs of calcification in the kidney. The child must remain still with a controlled breath hold. 
Therefore, CT is not routinely used in the investigation of UTIs. The main indication in this hospital is the detection of renal stones, which are associated with infection when there is doubt on ultrasound. It is routinely used in XGP and renal abscess assessment (fig 12 & 13).

MAGNETIC RESONANCE IMAGING

There is a limited role of MR scanning in investigating children with UTIs. The main use is in MR urography. A heavily weighted T2 image of the renal tract produces IVU like pictures.
Another potential use is to produce gadolinium enhanced images to diagnose acute pyelonephritis. A recent study has been performed to look at the potential use of MR in the evaluation of renal scarring. Fat saturated T1 weighted and post gadolinium inversion recovery sequences were used and compared with DMSA studies. It was found that the detection rate of scarring by MRI was comparable to that of DMSA 15.
The advantage of using MR is that it is radiation free and multi planar. Disadvantages are limited availability and the potentially long scanning time and lack of co-operation.

CONCLUSION

No single imaging technique is able to give full information and answer all the questions that need answering. As stated earlier, the dilemma is to use minimum invasion consistent with answering the question. The protocol in Table 1 is a practical approach and the one basically employed in this unit. Rigid protocol investigation will inevitably lead to over or under investigation. The protocol covers well over 90% of patients but each patient is still individually assessed to ensure that protocol driven medicine is not used as a substitute for clinical skills. We are fortunate in having all facilities on site. Investigation is therefore planned as a one- stop service where possible, with all investigations being done in a single visit, often on the day of clinical attendance. Investigations are stopped if adequate information is obtained even if the full protocol is not completed.

Address for correspondence: Prof. Helen Carty, Alder Hey Children's Hospital, Eaton Road, Liverpool L12 2AP, UK
 

Heterotopic ossification - a domain of radiotherapy

L.Gocheva
Department of Oncology and Chemotherapy, Medical Faculty - Sofia

Summary. The radiotherapy (RT) in the case of non-malignant diseases is a subject of controversial standpoints. If founds increasingly restricted application in the English-American countries, while it is quite frequently applied treatment in other countries.
 At the present stage the indications for RT for non-malignant diseases are rather diverse. The heterotopic ossification (HO) refers to the clearly established in clinical practice cases. The present review considers in detail the frequency of HO development after endoprosthetics, traumas in the area of the cerebrum and the spinal cord, cauterization. The aetiology, pathogenesis and early diagnostics as well as the basic therapeutic possibilities (non-steroid and anti-inflammatory remedies and radiotherapy) have been considered.
 The radiobiological mechanism of RT action, the type of the used radiation, the time of application (prior-to and post operation RT), doses and schemes of treatment have been analyzed in detail.
 The use of RT is recommended as a simple for performance and effective local treatment of HO, with absent or negligible side effects.
 The one-time prior-to and post operation radiation is more preferable than the fractionated prior-to and post operation one, taking under consideration the comfort of the patients and the possible postoperation complications.

Key words: RADIOTHERAPY.  non-malignant DISEASES.  HETEROTOPIC OSSIFICATIONS.

Address for correspondence: L. Gocheva, MD, Dimitar Nestorov Street, Bl. 120 A, 1612  Sofia, Bulgaria
¥-mail: r.petkov@bgcict.acad.bg

MRI in diagnosing nerve root edema in patients with lumbar disk herniation

M. ³igrai, V. ³?akoviü, M. Brezinov¡, M. Olozov¡, M. Pavloviüov¡
1st Neurological Clinic, Comenius University and Radiological Department, Hospital of St. Cyril and Method - Bratislava 

Summary. Over the period 1995 through 2000, thirty-six patients presenting radicular pains in the lower limbs are subjected to MRI study, with myelography and CT-myelography bein also performed in the same series. The obtained images undergo comparative assessment with electromyographic findings.
 In 73 per cent of the patients edema of nerve roots in the vicinity of disk herniation at L4/L5 level, and in 27 per cent - edema in the region of herniated intervertebral disk L5/S1 are observed. In cases with median disk herniation there are bilateral edematous changes involving the roots of the respective nerves.

Key words: nerve root edema. lumbar disk herniation. Magnetic resonance imaging (MRI).

Introduction

MRI is aÿdiagnostic method yielding detailed information for diagnosis and differential diagnosis in patients with radicular pain in the lower extremities. Those familiar with this problem are aware of the need to overcome many obstacles both before and after treatment in these patients. 
The identification of edema of the cauda equina nerve roots on the basis of clinical features, MRI and electromyographic findings may be very helpful in the management of these cases.

Materials and methods

In the period 1995-2000, MRI investigation was performed  in 36 patients with radicular pain in lower extremities. In this series we made myelography and CT myelography, too. There were 26 men, 10 women, aged between 28-51 years presenting lumbago with radicular pain in the lower extremities with compression of the dural sac with edema of the cauda equina nerve roots.
Patients were evaluated by MRI device Signa 0.5T, scanning was performed by standard procedures without contrast application. The picture of the nerve roots was correlated with EMG findings.
MRI findings were interpreted according to the relation between dural sac and herniated nucleus pulposus, intervertebral disk and root sheaths and the epidural spaces in the area being examined.
The diameters of the roots on the transverse axial section were evaluated in accordance with the diameters of normal roots in two degrees and two fold increase in diameter was deemed a ÿfirst degree edema, three fold increase - a ÿsecond degree edema.

Results

In 36 patients the transversal axial MRI scans of the lumbosacral region disclosed edema of the roots compressed by the herniated nucleus pulposus, with corresponding clinical symptoms on the side of compression in 31 cases and contralateral to the compression in 5 cases, bilateral 5 (with monolateral compression).
On the ipsilateral side first degree edema  was found in 14 cases and second degree - in 17. Edema  affecting more than a  ÿsingle root in 19 patients. Patients with bilateral clinical symptoms presented first degree edema in 4 cases and second degree in 2 cases.
On the myelogram (fig.1) is patient with congenital stenosis of the spinal canal and compression of the dural sac from the ventral part herniated nucleus pulposus and from  the dorsal part is compression with hypertrophic flaval ligaments. on the MRI is edema first aÿsecond degree on the side of compression and second degree on the contralateral side (fig.2). We made CT myelography of these patients. On the figure 3 is CT myelogram in patient with paramedial herniated nucleus pulposus with compression of the dural sac and oedema of the nerve roots on the side of the compression.
These findings correlated with the electromyograms pointing to impaired conductivity. Cerebrospinal fluid had an elevated protein content in 91% of the patients.
We observed 73% edema of the nerve roots near a hernia of the intervertebral disc L4/L5, and 27% edema of the nerve roots in the case of L5/S1 herniated disk. Bilateral edema of the nerve roots was identified in case of centrally located herniation.

Discussion

Early in the last century, it was generally accepted that pain in lumboischial syndromes is caused by compression of the respective nerve root. This view long overshadowed the changes taking place in the compressed root. In 1956 Tarlov et al monitored the changes in compression of the cauda equina nerve roots. their observations were subsequently confirmed by Sharples in 1975 who proved that conductivity is impaired by even aÿslight ÿroot compression [6, 7].
In the late seventies, Ulmaker, Rydevik and Lundberg intensively investigated the changes occurring in the nerve root. Their results as well as our present findings show that functional changes occur in the nerve roots. Root compression is accompanied by root edema on CT myelography and MRI scan and exacerbating clinical symptoms of irritation or destruction [6, 7, 9].
Clinical symptoms on the ipsilateral side upon compression also occur on the contralateral side [10]. There are no findings documenting root investigation correlated to electromyography and hyperproteinorhachia in cerebrospinal fluid [2, 6]. Our results also show that root edema is accompanied by aÿperipheral conductivity lesion in most cases [2, 7].
We made MRI examination without contrast material.   Diagnostic possibilities with gadolinium application are better [1, 3, 4, 5] or in our conditions very pretentious.
In roots lesion L5 and S1, electromyographic findings are most apparent in the distal (extensor digitorum brevis, extensor hallucis longus) and proximal (tibialis anterior) muscles. We think that because edema results from impaired flow of axoplasm, the defect involves the distal and proximal part of the nerve.
 

Two factors should be stressed. Unlike the peripheral nerves, nerve roots in the dural sac an epineurium and perineurium, lying in the subarachnoidal space in the cerebrospinal fluid [6].
The cerebrospinal fluid serves not only to preserve the nerve roots mechanically, but also has aÿmetabolic function [6]. Rydevik using an isotope method, proved that the nerve roots take up some necessary elements from the cerebrospinal fluid [6, 7]. Ukai demonstrated that the partial pressure of the oxygen in the cerebrospinal fluid is higher than in nerve roots [6, 7]. Abundant materials like albumins in the cerebrospinal fluid penetrate the endoneurium through the nerve sheath and then eliminated. If there is material introduced intravenously, they do not penetrate the endoneurium but enter the ganglion where the capillaries differ histologically from those supplying the nerve roots [5, 6]. The dorsal ganglia have fenestrated capillaries supplying the nerve roots [6]. Discontinuity of the capillary wall is sufficient to allow highly molecular material to pass through. Certain "fine conjunction" points of discontinuity are common and allow some material to penetrate the endoneurium [6].
Regarding the influence of the chemical material transported by this process, the main role is played by the P factor present in the nerve fibers of the radicular arteries and affecting plasma extravasation with the release of histamine [8, 9, 10]. 

Conclusion

Most patients in this study with herniation of nucleus pulposus in the lumbar region and severe sciatica also had edema of the affected roots in the dural sac, demonstrated with MRI on the transversal axial scans. The severity of sciatica was closely correlated to nerve root edema. These findings may provide important clues to the mechanisms of sciatic pain accompanying herniation of nucleus pulposus in the lumbar region.

Address for correspondence: M. ³igrai, 1st Neurological Clinic, Comenius University, 81250 Bratislava, Slovak Republic

Comparison between the radiological manifestations of thoracic involvement in collagen vascular diseases and idiopathic pulmonary fibrosis

G. Kirova, R. Rashkov, O. Georgiev
Department of Radiology, National Oncologic Center - Sofia

Summary. The purpose of the study is to compare the presentation and distribution of lung abnormalities seen in Collagen Vascular Diseases (CVD) with those specifics for Idiopathic Pulmonary Fibrosis (IPF).
The HRCT scans of 92 patients fulfilling the ARA criteria's for the diagnosis of four different CVD were reviewed and compared with those of 18 patients with IPF.  The presentations of three main patterns of lung disease were assessed into the both groups. In order to find out the trend distribution in each disease, the grade and severity of presentation for the main abnormalities were assessed, using a scoring system. 
The incidence of reticular lung abnormalities for the group of IPF is 100% versus 57.3 % for the CVD (p<0.0009). At the same time CVD, except for PSS, had a low incidence of reticular diseases (37%). The incidence of alveolar abnormalities in CVD (57.3 %) were similar as these in IPF (66.6 %) (p=NS). The severity of the disease was greatest in IPF and PSS without significant difference between them. Nevertheless of uniform character of the abnormalities in the rest of CVD, they were presented with lesser degree and severity.
The main abnormalities, seen in pulmonary parenchyma in patients with IPF and CVD were similar but with different grade, severity and distribution.

Key words: HRCT. diffuse lung diseases. Collagen Vascular Diseases. Idiopathic Pulmonary Fibrosis.

Address for correspondence: Dr. G. Kirova, Department of Radiology, National Oncologic Center, 6, Plovdivsko pole str., 1756 Sofia, Bulgaria, e-mail: krassi@omega.bg

Experience with imaging methods in the diagnosis 
and therapy of invaginations in pediatric patients

E. Gagov1, G. Garvanska1, M. Totev1, M. Panov2
1Emergency Imaging Diagnostic Clinic, 2Clinic of Pediatric Surgery, Emergency Medicine Institute "Pirogov" - Sofia

Summary. Intussusception is the commonest cause of acquired intestinal obstruction in children. In 60 to 78 % of the cases children up to 2 years of age are involved, and in 10 per cent - children older than 3 years. Etiologically relevant are both mechanical factors, such as Meckel's diverticulum, tumor, polyps, intramural intestinal hematoma, hyperplasia of lymph nodes, foreign bodies and the like, as well as impairment of the intestinal tract innervation, with the combination secondary hyperplastic intestinal lymph nodes plus intestinal hyperperistalsis against the background of infection of the upper airways taken to be the commonest underlying cause. Single and multicylinder invaginations are likewise differentiated with the frequency of their occurrence in the different intestinal tract sections being likewise variable.
The study covers 93 children aged up to 11 years, undergoing treatment in the pediatric Abdominal Surgery Department with the Emergency Institute Pirogov over a 3-year period (1998 - 2000). In all children radiological studies are performed including chest radiography, serial x-rays for acute abdomen in prone and supine position, ultrasound examination of the abdomen, and air-contrast pneumocoloscopy.

Key words: INVAGINATION. PNEUMOCOLOSCOPY. ULTRASOUND.

Address for correspondence: Dr. E. Gagov, Emergency Medicine Institute "Pirogov", 21, Macedonia  blvd., 1606 S(r)fia, Bulgaria

Assessment of the radiomodifying effect of the herbal 
preparation "Elixir-3" in laboratory animals exposed 
to external whole-body gamma-irradiation

V. Tenchova, S. Topalova, D. Stefanova, K. Kuzova
National Center of Radiobiology and Radiation Protection - Sofia

Summary. The study of preparations obtained from natural products, free of any toxic effects on the organism, has important practical implications on the prophylaxis against and correction of eventual sequellae of ionizing radiation. It is the purpose of the study to assay the radiomodifying action of the herbal preparation "Elixir-3 (E-3) on mice exposed to acute whole-body irradiation with 3 and 7 Gy gamma-rays, using a prophylactic-therapeutic scheme of application over 30 days. E-3 represents alcohol-water extract of basil, hops, briar, nettle, walnut and peppermint. Bone marrow femoral and spleen cellularity, endogenous spleen colony-forming units (E-CFUs), overall plasma oxidation activity and phagocytic activity of neutrophils are evaluated. E-3, administered in a prophylactic-therapeutic scheme, promotes post-radiation recovery of hematopoiesis in mice irradiated with non-lethal and median-lethal gamma ray doses, and exerts a favourable effect on the antioxidation status and phagocytic activity of neutrophils in laboratory animals.

Key words: Ionizing radiation. herbal preparation. hematopoiesis. plasma antioxidation activity. neutrophil phagocytic activity.

Address for correspondence: Assoc. Prof. V. Tenchova, National Center of Radiobiology and Radiation Protection, 132, Kliment Ohridski Blvd., Sofia 1756, Bulgaria

Liver abscess in a female patient with chronic calculous cholecystitis and empyema of the gallbladder

R. Jerassy1, M. Lyubomirova1, .... Astrukhov2, Œ. Nikolova1
1Clinic of Nephrology, 2Clinic of Surgery, University Hospital "Alexandrovska" - Sofia 

Summary. This is a report on a female patient aged 60 years with complaints of vague pain in the right lumbar region and heaviness in the right epigastrium, septic fever, accelerated ESR and leukocytosis. Diagnosis chronic calculous cholecystitis and liver abscess is made on the ground of conventional ultrasound (CU) and Doppler Ultrasound (Color - CFM), Pulse (PD) and power Doppler (PWD). In the differential diagnosis infected simple hydatid or parasitic cyst and liver carcinoma as well are considered. The absence of neoangiogenesis and vascularization around the abscess formation direct the diagnostic discussion to pericholecystic liver abscess. The contrast CT study demonstrates chronic calculous cholecystitis and liver abscess involving IV and V hepatic segments. The diagnosis is confirmed intraoperatively. Histological diagnosis: gallbladder fibrosis, with heavily thickened wall, d choledochus narrowing, xanthogranulomatous cholecystitis and pericholecystitis.
Description of the case reported on corroborates the differential diagnostic difficulties faced in inflammatory and neoplastic diseases of the gallbladder and surrounding hepatic structures, as well as the diagnostic relevance of the imaging methods of study.

Key words: LIVER ABSCESS. GALLBLADDER EMPYEMA. CT. CONVENTIONAL ULTRASOUND. DOPPLER ULTRASOUND. IMAGING TECHNIQUES.

Address for correspondence: Assoc. Prof. R. Jerassy, Clinic of Nephrology, University Hospital "Alexandrovska", 1, St. G. Sofiisky str., 1431 Sofia, Bulgaria

40 years Chair of Radiology at the Medical University - Varna

Renal cortical scintigraphy

J. Th. Locher
Department of Nuclear Medicine, Cantonal Hospital Aarau - Switzerland 

Introduction

Urinary reflux predisposes children with lower tract infections to the development of pyelonephritis (PN). Forty percent of cases of acute PN result in a permanent renal scar. Children with high fevers, elevated levels of C- reactive protein and severe vesicoureteral reflux (VUR) are especially susceptible [2]. In experimental work with animals, the degree of loss of cortical function during PN was proportional to the likelihood of formation of permanent renal scar [4]. Therefore, the goal of the management of VUR is to prevent renal scaring. In most children urinary tract infections can be prevented by antibiotic prophylaxis and management of voiding dysfunction. The risk for the development of progressive renal damage increases with the number of documented episodes of PN or scaring. Also, progressive renal scars are much less likely to develop in children without defects at presentation.
PN was once considered to be exclusively a sequel of VUR or obstructive uropathy. However, several recent studies using renal cortical scintigraphy have shown PN without demonstrable VUR in more than 50 % of children with documented renal infection [2]. These children may have PN secondary to hematogenous seeding of the kidneys or intermittent reflux that is not detectable on subsequent imaging.
In the past, the standard method for detecting PN and renal scaring was the intravenous urography (IVU). However, since the mid-1980s studies have demonstrated the superiority of renal cortical scintigraphy for detecting both acute PN and renal scaring when compared with IVU and sonography [1, 2, 7].

Material and protocol

Since the 1970s a series of 99mTc labeled tracers were produced, substances accumulating in the renal parenchyma and allowing static imaging. Dimercaptosuccinic acid (DMSA) was introduced in 1974 by Lin [3] and became a popular agent. Together with 99mTc-glucoheptonate (GH) it is considered today as a first choice tracer for renal cortical imaging. However, the clinical applications as well as the technical modalities have progressively changed during the last 20 years and differ from center to center. An international consensus was published in 1999 [5] by a board of renowned experts to recommend most appropriate rules for the systematic use of DMSA-scintigraphy including indications, methodology of scintigraphic imaging as well as the interpretation of images and quality control. 

Administrated doses

99mTc-DMSA children 3.7 MBq/kg adjusted to body weight with a minimal activity of 18.5 MBq and a maximal activity of 185 MBq (adult dose)
99mTc-GH children 7.4 MBq/kg; adults 370 - 740 MBq
  (Less expensive, but difficulties of image interpretation because of the visualization of the urinary collecting system)

Procedure
1. Sedation should not be given to children or limited to special situations.
2. The tracer solution is best injected through a peripheral catheter and flushed with 5 ml of isotonic NaCl.
3. Start imaging 2 to 3 hours after the tracer injection.
4. Use pinhole collimators in small children (converting collimators can be used in adults).
5. Obtain six planar views (PA, AP, RAO, LAO, RPO, LPO) using a preset counts of 250'000 or a preset time of 10 minutes. Acquire on computer.
6. Calculate in percentage of total activity based on two regions of interest (ROI) drawn around each kidney.
7. SPET- use is discussed controversially. It could provide additional information but seems to increase the number of false positive results. Therefore, it is not widely recommended. 

Interpretation of images

Normal variants
In general, renal cortical images are homogenous, but demonstrate slight physiological differences of activity uptake that are more pronounced with kidney size. One must be aware that the outer part corresponding to the cortex is more active than the inner part, the medulla and the collecting system. Furthermore, normal variants have to be observed such as spleen impression, variances in the shape of the renal contours (renculi), number and size of the columns of Bertin, normal hypoactive poles, and contrasting of underlying hyperactive columns of Bertin.

Pathological images / definitions
The kidney can be small or swollen, and renal contours can be irregular, indistinct or absent. Lesions should be described as single or multiple, small or large, and with or without volume loss. In our hands a four-grade scale describing the grade of parenchymal damage has been practically proven (Table 1).
Clinical examples

Discussion

Unlabeled DMSA was originally used to treat heavy metal poisoning. Its technetium labeled chelate [3] is used for imaging the renal parenchyma, because it binds to renal tubular cells and accumulates in the functioning renal cortex. About one third passes unchanged into urine. Cortical uptake of this tracer is determined by intrarenal blood flow and proximal tubular cell membrane transport function. Any pathologic process that alters these parameters results in areas of diminished uptake. Kidney uptake is greater than for any other available 99mTc-labeled agent amounting to 40% in two kidneys at 3 hours. Therefore, imaging should be delayed for 3 hours after injection, because of the slow transfer of activity from blood to kidney. Although the fraction accumulated by the kidneys is greater with 99mTc-DMSA than with 99mTc-glucoheptonate, this advantage is negated by its slow blood clearance. In presence of renal failure, 99mTc-DMSA activity can be seen in liver, gallbladder, and gut.
Renal cortical scintigraphy is the current "gold standard" for the diagnosis of pyelonephritis. Indeed, animal experiences have demonstrated a high sensitivity and specificity for DMSA scanning when correlated with histopathology [4]. Because of the importance of an early diagnosis of acute pyelonephritis (APN) in children and the lack of performance of other radiology procedures (sonography, intravenous pyelography) and of routine laboratory tests, 99mTc-DMSA scintigraphy became a primary method to detect acute renal damages or renal scars. However, there is much controversial discussion about the clinical applications as well as the technical modalities that have progressively changed during the last years. Differences in imaging techniques used, differences in pathology involved (APN, scars, congenital uropathy), and in particular differences in population studied (infants, children or adults) may explain large differences in the evaluation of inter-observer reproducibility, varying from 51% to 90% of concordance in the evaluation of 99mTc-DMSA scintigraphy. In a recent multiple-center study [6] we found that the inter-observer reproducibility as well as the intra-observer reproducibility could be improved by applying statistical parameters as the Bayesian analysis to diagnostic interpretation of images and decision making. Likelihood ratio enables to weight the results of the scintigraphic test with the pre-test clinical probability of presence of the disease taking into account the performances of the scintigraphic test in terms of sensitivity and specificity. We could also show that the inter-observer reproducibility was due in part to the complexity of the predefined criteria. A simplified code system (table 1) gave a more congruent interpretation of images between different readers. Indeed, most experts participating at the mentioned concensus conference [5] indicated that they are not using any scoring system, some refer to simple distinction between normal, abnormal, or equivalent, and some others were based on the type, number, and the extension of the lesions. Therefore, renal cortical scintigraphy needs to be standardized. Scoring is as mandatory as the use of ultrasound in cases of APN, because new studies are needed for defining optimal strategies for diagnosis and treatment. The following questions have to be answered in the future:
- What is the risk for developing DMSA lesions during an acute episode of renal infection, if, during a previous episode of infection, the DMSA scan was normal? What is the impact of age?
- Are invasive investigations such as micturating cystogram still indicated in case of a normal initial DMSA scan? Is there an influence of age?
- An abnormal initial DMSA scan is probably the best predictor for sequel. What is more helpful, to circumscribe from the beginning a group of risk (those with DMSA scan abnormalities) and not controlling those with a normal early DMSA scan, or to evaluate all patients 6 month later for sequels?
- What is the risk of non-aggressive treatment of children with normal scan? Can the treatment be adapted according to the acute scan? (Cost-benefit calculation!) 
- May DMSA scan influence the decision of treatment in cases of atypical clinical APN with negative or equivocal urine cultures?
There is a lot of work ahead of us!

Address for correspondence: Prof. Dr. Dr.h.c. J. Th. Locher, Dept. of Nuclear Medicine, Cantonal Hospital, CH-5001 Aarau, Switzerland

Course on Nuclear Oncology
Naples, August 22 - 29, 2001

Radiation protection 118
Referral guidelines for imaging 
Adapted by experts representing European radiology and Nuclear medicine

Teaching material on CD-ROMs

The European Congress of Radiology is dedicated to promoting and developing the highest standards of radiology and related sciences through education and research. The intent of the ECR teaching material is to provide radiologists and health professionals in radiology with the most interesting educational materials covering most aspects of today's radiology.
Four new CD-ROMs were recorded at ECR 2001 and are available now:

CT angiography (topic: Vascular)
M. Prokop (AT), M. R(c)my-Jardin (FR), H. Rigauts (BE)

Malignant bone tumor (topic: Musculoskeletal)
D. L. Resnick (US), A.M. Davies (GB)

Chest (1) (topic: Rad.-Path. Correlations)
M. R(c)my-Jardin (FR), D. M. Hansell (GB)

IHE - Integrating the Health Care Enterprise
A multimedia presentation given at ECR 2001

The ECR 2002 Research and Education Fund

The purpose of the fund consists of supporting research and education in radiology and related sciences by awarding scholarships and/or grants to individuals and/or organizations.
The goal of the ECR - Research and Education Fund is to make an impact on radiological practice by encouraging research that will develop new knowledge and improve patient care. To meet that goal, the fund supports young faculty radiologists by freeing at least half of their time for a designated research project. The programmes are targeted to scientists, typically under 45 years of age with rank at, and facility support from, a radiological educational institution.
The ECR Research and Education Fund was founded in 1994 and on the occasions of ECR'97, ECR'99, ECR 2000 and 2001 a total number of 35 grants have been awarded to applicants.
Donations: In addition to the financial support from the ECR Foundation and from the industry, the ECR Research and Education Fund can be supported by individual donations of   ? 60, - (minimum). The donators will be announced publicly during ECR 2002. Please use the registration form A for making a donation or transfer your donation to the ECR Research and Education Fund account no.: 031-93349, at the "Erste Bank", routing code 20111, Vienna, Austria.
Confirmations will be mailed upon receipt of the donation. Donators will have the logo of the ECR Foundation on their badges.
For further information and/or a Fund brochure including application forms and application regulations please contact the
ECR-Office
Neutorgasse 9/2a, AT - 1010 Vienna
Phone: +43 1 533 40 64,
Fax: +43 1 533 40 64 9
E-mail: office@ecr.org
For updates please refer to www.ecr.org

European congress of nuclear medicine
Napoli, August 25 -29, 2001

8th European symposium on urogenital radiology 
Rotterdam, September 14 - 16, 2001

6-th annual meeting of the European Society 
of MusculoSkeletal Radiology (ESSR)
Budapest, October 5-6, 2001

Bone metastases from malignant melanoma: a retrospective review and analysis of 28 cases

Elias Brountzos1, Irene Panagiotou2, Dimitrios Bafaloukos2, Dimitrios Kelekis1

1Second Department of Radiology, Medical School, Athens University, Eugenidion Hospital, Athens, Greece, 2Second Department of Oncology, Metaxa Cancer Hospital, Piraeus, Greece

Radiol Oncol 2001; 35(3): 209 - 14.

Background. The aim of the study was to evaluate the clinical characteristics, the radiological findings, and the treatment effect on the patients with bone metastases from malignant melanoma.
Patients and methods. Retrospective review of 293 stage IV melanoma patients during a 15-year period was made.
Results. Twenty-eight patients (9.5 %) with bone metastases were identified, all patients had a thick or intermediate primary melanoma (Breslow 2.7 - 9.9). Most of the patients presented with multiple (95.6 %), symptomatic (92.6 %) skeletal lesions. Imaging depicted 90 bone lesions. Axial metastases were more common (86 %); 54 % of them were located at the spine. Skeletal radionuclide scintigraphy was non-specific, radiography and computed tomography was diagnostic. Typical bone metastases were osteolytic (92.5 %). Sixty-six lesions were treated with radiotherapy; in 79 % there was a palliative response. There was no correlation between total dose of fraction size and effective palliation. The skeletal lesions did not respond to concurrent chemotherapy and/or biphosphonates. Median response duration to treatment was estimated to 2.6 months and median survival to 4.7 months.
Conclusions. Osseous metastases from malignant melanoma occur in the patients with more advanced primary lesions. They are most frequently osteolytic and located in the axial skeleton. Radiography and computed tomography is diagnostic. Radiotherapy still remains the treatment of choice.
Key words: Bone neoplasms. malignant melanoma. bone metastases. imaging. radiotherapy.
 
 
 

Percutaneous drainage of abdominal fluid collections that require laparotomy or relaparotomy with ultrasound guidance

Damir Miletió1, Miljenko Uravió2, ³eljko Fuükar2, Robert Glava«?3, Dubravka Topljak-Polió1

1Department of Radiology, 2Clinic for Surgery, 3Department of Gastroenterology, Clinical Hospital Rijeka, Croatia

Radiol Oncol 2001; 35(3): 167 - 73.

Background. The aim of the study was to determine efficacy and reliability of percutaneous abdominal drainage in surgical patients and to evaluate intercostal approach to drain subphrenic collections.
Material and methods. Eighty-seven patients aged from 29 to 84 years (mean, 55.5 years) were percutaneously drained under the monographic guidance due to the postoperative or nonoperated abdominal collection that would otherwise require laparotomy. Intercostal, subcostal, lateral and anterior approach with eight to 14 French catheters were used to evacuate abdominal collection.
Results. The intercostal approach was used to drain 31 (60.8 %) of 51 subphrenic collections. The mean duration of drainage was independent of the intercostal or subcostal drainage route, but was significantly prolonged (p < 0. 05, Mann-Whitney U test) for purulent collections (median, 18 days; range 7 - 73 days) in comparison to hematomas, bilomas and other nonpurulent collections (median, 11 and 6 days, respectively). Sonographically guided percutaneous drainage was a definitive method in 92 % patients, with 9.2 % minor complications. Successful rate for subphrenic collections was even greater (96 %).
Conclusions. Sonographically guided percutaneous drainage is the method of choice in the treatment of abdominal collections that require laparotomy. If the puncture site is at least two intercostal spaces lower than the dome of diaphragm and catheter is not introduced through the pleural effusion, intercostal drainage is equally efficient and not less secure than subcostal approach.

Key words: Sonography. abdomen. drainage.
 
 
 

Imaging of the arthritides

Adam Greenspan, M. D.

Musculoskeletal Radiology University of California, Davis School of Medicine Sacramento, California, USA

Osteologiai K¶zlem(c)nyek, 1/2001, 11 - 15.

Abstract. In the imaging of the arthritides, plain-film radiography retains its position as the basic tool for evaluation despite recent advances in imaging technology. It is clearly the procedure of choice for the initial examination because of its effectiveness in evaluating the bone and joint changes associated with arthritic disorders, including diminution of the radiographic joint space, osteopenia, sclerosis, subchondral cysts and erosions, osteophytosis, periosteal reaction, and soft tissue calcifications. Likewise, skeletal scintigraphy remains a fundamental evaluative tool for the arthritides because of its extreme sensitivity in demonstrating the skeletal distribution of arthritic lesions. The newer modalities offering cross-sectional and multiplanar imaging capabilities, nonetheless, play a distinct and invaluable role in allowing further characterization of the changes that the many degenerative, inflammatory, infectious, and metabolic conditions may cause in the joints and adjacent soft tissues. CT has proved to be particularly useful in imaging arthritic the sacroiliac joints and the spine while MRI yields important information about subtle bone and soft tissue abnormalities and spinal complications of rheumatoid arthritis. Gadolinium-enhanced MRI permits the discrimination of joint effusion from hypertrophic synovitis and the identification of inflammatory pannus.
 
 
 

Value of helical CT in Takayasu arteritis

JF Paul (1,2), JL Reny (3), A Hernigou (4), E Mousseaux (2), JN Fiessinger (3), JC Piette (5) et JC Gaux (2)

J Radiol 2001; 82: 967 - 72.

In the past, the diagnosis and course of Takayasu arteritis were monitored by following angiographic findings, in addition to clinical symptoms and biological tests. More recently, cross-sectional imaging techniques especially Computed Tomography (CT) depicted mural changes in aorta and main vessels in this disease.
Within the same acquisition, spiral mode also allows to show luminal changes, similarly to conventional angiography. In addition to its diagnostic value especially in the early phase of the disease, CT seems accurate in the follow-up of treated patients and may be proposed as a therapeutic guide. CT features are presented, according to the stage of the disease and the vessels involved.

Key words: Takayasu arteritis. Computed tomography (CT). Aorta.
 
 
 

Strict anteroposterior straight-beam decubitus view of the shoulder: value in the assessment of rotator cuff tears

JJ Railhac, N Sans, A Rigal, H Chiavassa, D Galy-Fourcade, G Richardi, J Assoun, Y Bellumore et M Mansat

J Radiol 2001; 82: 979 - 85.

Purpose. To compare the contribution of various radiographic projections in the evaluation of impingement syndrome and rotator cuff tears.
Materials and method. We realized a prospective study in 53 patients with suspected rotator cuff tear, evaluated by plain radiographs and arthrography (gold standard). 31 patients were men and 22 were women (mean age 51 years). In all patients, anteroposterior radiograph, strict anteroposterior straight-beam decubitus view and anteroposterior radiograph during Leclercq's maneuver of the affected shoulder were obtained. The population was divided into three groups: group 1: normal arthrography (n = 19), group 2: isolated supraspinatus tendon tear (n = 23), group 3: rupture of the supraspinatus and infraspinatus tendons (n = 11). The acromio-humeral space was measured on all these views and differences between the three groups were statistically analyzed.
Results. There is a significant statistical difference between the height of the acromio-humeral space found in patients with isolated tear of the supraspinatus tendon and those with a tear extending to the infraspinatus tendon (p = 0.0001).
The ROC methodology showed a better accuracy of the strict anteroposterior straight-beam decubitus view in cases of wide ruptures of the rotator cuff, and this for a selected threshold value of 6 mm.
Conclusion. Strict anteroposterior straight-beam decubitus view, seems to be easy to realize, cheap, reproducible and very powerful in the preoperative assessment of patients with suspected rotator cuff tendon tear. It allows an excellent visualization of the acromioclavicular joint.

Key words: Shoulder. Conventional radiographs. Rotator cuff.
 
 
 

Calcific retropharyngeal tendinitis: a rare diagnosis

N Szelei (1), M Tassart (1), C Le Breton (1), S P(c)ri(c) (2), ZE Boumenir (1), M Bazot (1), N Kadi (1) et JM Bigot (1)

J Radiol 2001; 82: 1001 - 4.

Acute calcific retropharyngeal tendinitis is a rare entity that often is initially misdiagnosed a retropharyngeal abscess and treated with IV administration of antibiotics. In our 2 cases, imaging enabled a correct diagnosis to be made. Two patients were admitted to the hospital with dysphagia, severe neck discomfort and fever. Lateral radiographs of the cervical spine and CT were obtained in both cases, while MRI was obtained in one case. Calcification of the prevertebral muscles was demonstrated by CT in both cases, and detected on lateral radiographs in only one case. Soft tissue swelling was noted at CT and MRI.
A clinical diagnosis of calcific retropharyngeal tendinitis may be difficult to achieve and a definitive diagnosis can be confirmed at imaging studies.

Key words: Calcific tendinitis. Prevertebral space. Retropharyngeal space. CT. MRI.
 
 
 

Imaging of primary carcinoid tumor of the pancreas

H Dahan, P Soyer, B Cochand-Priollet, M Abitbol, J Coumbaras, JP Pelage, M Boudiaf et R Rymer

J Radiol 2001; 82: 987 - 90.

Purpose. To describe the imaging features of primary carcinoid tumors of the pancreas.
Materials and Methods. The monographic and computed tomographic examinations of six patients with pathologically proven primary carcinoid tumor of the pancreas were retrospectively reviewed.
Results. In all cases, sonography showed hypoechoic and well circumscribed tumors. CT scan demonstrated hypoattenuating tumors on noncontrast images, with variable enhancement on postcontrast images. Small tumors (less than 2 cm in diameter) were homogeneous whereas larger tumors were heterogeneous with areas of cystic necrosis. In two cases, enlarged lymph nodes were found in association with ascitis. In one case, hepatic metastases were present.
Conclusion. Primary carcinoid tumors of the pancreas display various and non specific imaging features. Small tumors are likely to be homogeneous and hypervascular whereas larger tumors are heterogeneous and hypovascular.

Key words: Abdomen. Neoplasms. Pancreas. Neoplasms. Carcinoid tumor. Imaging.
 
 
 

Correlation of tumor size and survival in patients with stage IA non-small cell lung cancer

Patz EF Jr, Rossi S, Harpole DH Jr, Herndon JE, Goodman PC 

Department of Radiology, Duke University Medical Center, Durham, NC 27710 USA

Chest 2000; 117: 1568 - 71.

Objective. The purpose of this study was to determine the relationship between tumor size and survival in patients with stage IA non-small cell lung cancer (non-small cell lung cancer; ie, lesions < 3 cm). 
Method. Five hundred ten patients with pathologic stage IA (T1N0M0) non-small cell lung cancer were identified from our tumor registry over an 18-year period (from 1981 to 1999). There were 285 men and 225 women, with a mean age of 63 years (range, 31 to 90 years). The Cox proportional model was used to examine the effect on survival. Tumor size was incorporated into the model as a linear effect and as categorical variables. The Kaplan-Meier product limit estimator was used to graphically display the relationship between the tumor size and survival.
Results. The Cox proportional hazards model did not show a statistically significant relationship between tumor size and survival (p = 0.701) as a linear effect. Tumor size was then categorized into quartiles, and again there was no statistically significant difference in survival between groups (p = 0.597). Tumor size was also categorized into deciles, and there was no statistical relationship between tumor size and survival (p = 0.674).
Conclusions. This study confirms stratifying patients with stage IA non-small cell lung cancer in the same TNM classification, given no apparent difference in survival. Unfortunately, these data caution that improved small nodule detection with screening CT may not significantly improve lung cancer mortality. The appropriate prospective randomized trial appears warranted.
 
 
 
 

Outcome of bronchial carcinoma in situ

Venmans BJ, van Boxem TJ, Smit EF, Postmus PE, Sutedja TG

Department of Pulmonary Diseases, University Hospital Vrije Universiteit, Amsterdam, The Netherlands

Chest 2000; 117: 1572 - 6.

Introduction. The proportion of patients with carcinoma in situ in whom invasive cancer will develop is not known. It is important for clinical decision making to know the outcome of these lesions. The same applies for studies assessing the effectiveness of chemoprevention treatment or endobronchial therapy.
Methods. The records of patients with a bronchial carcinoma in situ who had undergone autofluorescence bronchoscopic examinations at regular intervals during a follow-up period for at least 6 months were reviewed. Data were examined for the outcome of carcinoma in situ, and for the detection, course, and bronchoscopic findings of neoplastic lesions at other bronchial sites.
Results. Progression to carcinoma occurred in five of nine patients (56 %) with a carcinoma in situ. Eight neoplastic lesions were detected at other sites in four of the nine patients (44 %). In earlier biopsy specimens of two sites that later showed a severe dysplasia and a carcinoma, only normal epithelium was found. Biopsies had been performed at these sites because they were assessed as suspicious during autofluorescence bronchoscopy.
Conclusions. The majority of sites showing a carcinoma in situ progressed to invasive carcinoma. A considerable portion of the patients had neoplastic lesions at other bronchial sites. The fluorescence pattern of the bronchial mucosa may reflect early changes that are not found at histopathologic examination, but which may progress to neoplastic growth.
Patient preferences regarding possible outcomes of lung resection: what outcomes should preoperative evaluations target?

Cykert S, Kissling G, Hansen CJ

Division of General Internal Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, USA

Chest 2000; 117: 1551 - 9.

Context. Lung resection can lead to significant postoperative complications: Although many reports describe the likelihood of postoperative problems, such as atelectasis, pneumonia, and prolonged ventilator dependence, it is unclear whether patients perceive these outcomes as sufficiently severe to influence their decisions about surgery.
Objective. To assess patients' preferences regarding possible outcomes of lung resection, including traditional complications reported in the lung surgery literature and outcomes that describe functional limitation.
Design. Utility analysis.
Setting. A community hospital internal medicine clinic, a private internal medicine practice, and a private pulmonary practice.
Participants. Sixty-four patients, aged 50 to 75 years, who were awaiting appointments at the designated clinic sites. Main outcome measure: Patients' strength of preference regarding potential outcomes of lung resection as derived from health utility scores.
Results. Common postoperative complications were assigned high utility scores by patients. On a scale for which 1.0 represents perfect health and 0 represents death, postoperative atelectasis, pneumonia and 3 days of mechanical ventilation were all rated > 0.75. Scores describing limited physical function were strikingly low. Specifically, activity limited to bad to chair movement and the need for complete assistance with activities of daily living were all assigned utility scores < 0.2. Twenty-four-hour oxygen dependence was scored at 0.33. Presence or absence of pulmonary illness did not predict scores for any outcome.
Conclusions. Whether patients suffer from chronic lung disease or not, they do not regard the postoperative outcomes reported in the lung surgery literature as sufficiently morbid to forego important surgery. However, physical debility is perceived as extremely undesirable, and anticipation of its occurrence could deter surgery. Therefore, identification of preoperative predictors of postoperative physical debility would be invaluable for counseling patients who face difficult decisions about lung resection.
 
 
 

Long-term results after video-assisted thoracoscopic surgery for first-time and recurrent spontaneous pneumothorax

Hatz RA, Kaps MF. Meimarakis G, Loehe F, Muller C, Furst H

Department of Surgery and General Thoracic Surgery, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Germany

Ann Thorac Surg 2000; 70: 253 - 7.

Background. Few investigators have reported on results after video-assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax (SP) with follow-up periods longer than 24 months. The aim of this study was to evaluate VATS for first-time and recurrent SP and to follow patients long-term.
Methods. One hundred nine patients were followed long-term after treatment of SP by VATS. Ninety-five patients had primary SP and 14 had secondary-SP. Sixty-two patients had a first episode, and 47 had a recurrence. In 72 patients leaks or ruptured blebs were identified and excised without subsequent pleurodesis. In 37 patients showing no ruptured bullae or leaks only pleurodesis was applied.
Results. Median follow-up was 53.2 months. Postoperative complications were rare. Three patients (2.7 %) had a prolonged air leak. The long-term recurrence rate was 4.6 %. Only those patients who had not received pleurodesis at the time of first treatment by VATS experienced recurrence.
Conclusions. Immediate postoperative results show VATS to be a safe and reliable method in first-time and recurrent SP to obtain quick reexpansion of the lung. Long-term recurrence rates are acceptable and compare with results after open thoracotomy. Pleurodesis should be included in each procedure for adequate recurrence prevention.
 
 
 

Primary non-Hodgkin's lymphoma of the lung

Ferraro P, Trastek VF, Adlakha H, Deschamps C, Allen MS, Pairolero PC

Department of Surgery, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA

Ann Thorac Surg 2000; 69: 993 - 7.

Background. Primary non-Hodgkin's lymphoma of the lung is a rare entity. Although the prognosis is favorable, clinical features, prognostic factors, and patient management have not been clearly defined.
Methods. We reviewed retrospectively the records of 48 patients operated on for primary pulmonary non-Hodgkin's lymphoma. The study group consisted of 21 male (44 %) and 27 female (56 %) patients with a mean age of 61.8 years. Thirty-seven and a half percent of patients were asymptomatic, and 62.5 % were seen with pulmonary symptoms, systemic symptoms, or both. A definitive diagnosis was obtained by thoracotomy in 90 % of patients, thoracoscopy in 8 %, and anterior mediastinotomy in 2 %.
Results. Complete surgical resection was possible in 19 patients (40 %). A mucosa-associated lymphoid tissue lymphoma (MALT) was found in 35 patients and lymphoma that was not of this type, in 13. The 1-year, 5-year, and 10-year survival rates were 91 %, 68 %, and 53 %, respectively in the group with mucosa-associated lymphoid tissue lymphoma and 85 %, 65 %, and 64 % in the group with lymphoma that was not of the mucosa-associated lymphoid tissue type. None of the prognostic factors studied (mode of presentation, smoking history, bilateral disease, postoperative stage, complete resection, adjuvant chemotherapy, histology) significantly influenced patient survival.
Conclusions. Primary non-Hodgkin's lymphoma of the lung occurs with nonspecific clinical features. Although patient survival is good, prognostic factors could not be identified.
CT evaluation of periacetabular osteotomies

Haddad FS, Garbuz DS, Duncan CP, Janzen DL, Munk PL

Department of Radiology, Vancouver Hospital and Health Sciences Centre, University of British Columbia, Canada

J Bone Joint Surg Br 2000; 82: 526 - 31.

We have previously described a simple and reproducible three-dimensional technique of CT for the measurement of the cover of the femoral head in acetabular dysplasia in adults. We now describe the application of this technique in ten patients with symptomatic dysplasia to assess the degree and direction of dysplasia and to measure the cover obtained at acetabular osteotomy. The indices obtained gave a useful indication of the degree and direction of the dysplasia and confirmed which components had been used most efficiently to achieve cover. The information is easily presented in graphical form and gives a clearer indication of the cover obtained than the indices derived from plain radiographs.
 
 

Prevalence and predictive factors for regional osteopenia in women with anorexia nervosa

Grinspoon S, Thomas E, Pitts S, Gross E, Mickley D, Miller K, Herzog D, Klibanski A

Neuroendocrine Unit, Bulfinch 457b, Massachusetts General Hospital, Boston, MA 02114, USA

Ann Intern Med 2000; 133: 790 - 4

Background. Anorexia nervosa is highly prevalent among young women.
Objective. To determine prevalence and predictive factors for regional bone loss.
Design. Prospective cohort analysis.
Patients. 130 women with anorexia nervosa.
Setting. University hospital.
Measurement. Dual-energy x-ray absorptiometry.
Results. The prevalence of osteopenia (-1.0 SD >/= T-score > - 2.5 SD) and osteoporosis (T-score </= - 2.5 SD) was 50 % and 13 % for the anterior-posterior spine, 57 % and 24 % for the lateral spine, and 47 % and 16 % for the total hip, respectively. Bone mineral density (BMD) was reduced by at least 1.0 SD at one or more skeletal sites in 92 % of patients and by at least 2.5 SD in 38 % of patients. Weight was the most consistent predictor of BMD at all skeletal sites. Twenty-three percent of patients were current estrogen users, and 58 % were previous estrogen users. Bone mineral density did not differ by history of estrogen use at any site.
Conclusions. Bone mineral density is reduced at several skeletal sites in most women with anorexia nervosa. Weight, but not estrogen use, is a significant predictor of BMD in this population at all skeletal sites.
 
 
 

Magnetic resonance arthrography of the acetabular labrum. Macroscopic and histological correlation in 20 cadavers

Plotz GM, Brossmann J, Schunke M, Heller M, Kurz B, Hassenpflug J

Christian-Albrechts University, Kiel, Germany

J Bone Joint Surg Br 2000; 82: 426 - 32

We studied the sensitivity and specificity of magnetic resonance arthrography (MRa for the diagnosis of lesions of the acetabular labrum in 20 cadaver hips. The MRa results were compared with macroscopic and histological findings. We found that the labrum could be satisfactorily delineated by MRa and that large detachments could be identified satisfactorily. The diagnosis of small detachments and degeneration of the labrum was less reliable.
 
 
 

The pathology of median neuropathy in acromegaly

Jenkins PJ, Sohaib SA, Akker S, Phillips RR, Spillane K, Wass JA, Monson JP, Grossman AB, Besser GM, Reznek RH
Department of Endocrinology, St Bartholomew's Hospital, London, United Kingdom

Ann Intern Med 2000; 133: 197 - 201

Background. Median neuropathy is commonly associated with acromegaly, although its pathology is uncertain. 
Objective. To study the pathology of median neuropathy in acromegaly by using magnetic resonance imaging (MRI). 
Design. Case series.
Settings. Outpatient clinic and MRI unit.
Patients. Nine patients with acromegaly, four of whom had clinical symptoms of neuropathy.
Measurements. At presentation and 6 months after treatment, median nerve size, its signal intensity, and the volume of the carpal tunnel contents were measured.
Results. At presentation, patients with symptoms of neuropathy had increased nerve size and signal intensity compared with asymptomatic patients, but the two groups did not differ in volume of carpal tunnel contents. These measures improved with treatment of acromegaly in symptomatic patients; asymptomatic patients experienced no change or worsening.
Conclusion. The predominant pathology of median neuropathy in acromegaly seems to be increased edema of the median nerve within the carpal tunnel rather than extrinsic compression from increased volume of the carpal tunnel contents.
 
 
 

Joint injury in young adults and risk for subsequent knee and hip osteoarthritis

Gelber AC, Hochberg MC, Mead LA, Wang NY, Wigley FM, Klag MJ

Johns Hopkins University, University of Maryland, and Veterans Affairs Medical Center, Baltimore, USA

Ann Intern Med 2000; 133: 321 - 8
Background. Knee and hip injuries have been linked with osteoarthritis in cross-sectional and case-control studies, but few prospective studies have examined the relation between injuries in young adults and risk for later osteoarthritis. 
Objective. To prospectively examine the relation between joint injury and incident knee and hip osteoarthritis.
Design. Prospective cohort study. 
Setting. Johns Hopkins Precursors Study.
Participants. 1321 former medical students.
Measurement. Injury status at cohort entry was recorded when the mean age of participants was 22 years. Injury during follow-up and incident osteoarthritis were determined by using self-administered questionnaires. Osteoarthritis was confirmed by symptoms and radiographic findings.
Results. Over a median follow-up of 36 years, 141 participants reported joint injuries (knee alone [n = 111], hip alone [n = 16], or knee and hip [n = 14]) and 96 developed osteoarthritis (knee alone [n = 64], hip alone [n = 27], or knee and hip [n = 5]). The cumulative incidence of knee osteoarthritis by 65 years of age was 13.9 % in participants who had a knee injury during adolescence and young adulthood and 6.0 % in those who did not (P = 0.0045) (relative risk, 2.95 [95 % Cl, 1.35 to 6.45]). Joint injury at cohort entry or during follow-up substantially increased the risk for subsequent osteoarthritis at that site (relative risk, 5.17 [Cl, 3.07 to 8.71] and 3.50 [Cl, 0.84 to 14.69] for knee and hip, respectively). Results were similar for persons with osteoarthritis confirmed by radiographs and symptoms.
Conclusions. Young adults with knee injuries are at considerably increased risk for osteoarthritis later in life and should be targeted in the primary prevention of osteoarthritis.

01.03. - 05.03.2002
Vienna, Austria
 

19.03. - 23.03.2002
Barcelona, Spain
 

15.05. - 19.05.2002
Salzburg, Austria
 

12.06. - 16.06.2002
Ohrid, Macedonia
 
 

16.06. - 19.06.2002
Stockholm, Sweden
 
 

24.06. - 28.06.2002
Cancun, Mexico
 

26.06. - 29.06.2002
Paris, France
 

26.06. - 30.06.2002
Warsaw, Poland
 
 

30.06. - 5.07.2002
Oslo, Norway
 

01.07. - 05.07.2002
Cancun, Mexico
 
 

06.07. - 09.07.2002
Madrid, Spain
 
 

18.08. - 24.08.2002
Paris, France
 
 
 

01.09. - 05.09.2002
Athens, Greece
16.09. - 19.09.2002
Prague, Czech Rep.
 
 

19.09. - 22.09.2002
Florence, Italy
 
 

20.09. - 22.09.2002
Ulaanbatar, Mongolia
 

28.09. - 03.10.2002
Luzern, Switzerland
 
 

11.10. - 12.10.2002
Valencia, Spain
 

18.10. - 22.10.2002
Nice, France
 

19.10. - 23. 10.2002
Paris, France
 

01.12. - 06.12.2002
Chicago, USA
 
 

11.12. - 13.12.2002
Manchester, UK
 

26.04. - 30.04.2003
Firenze, Italy
 

14th European Congress of Radiology
Contact: ECR Office, Neutorgasse 9/2A, A-1010 Vienna, Austria. Fax: 43-1-5334064-9, E-mail: office@ecr.org

EBCC 3: 3rd European Breast Cancer Conference 
Contact: Ms Kris Vantongelen, FECS Conference Unit, Av. E. Mounier 83, B-1200 Brussels, Belgium. Fax: 32-2-7750245, E-mail: Kris@fecs.be

7th International Meeting on Progress in Radio-Oncology/ICRO/OGRO 7
Contact: Univ. Prof. Dr. H. D. Kogelnik, Landeskl., St. Johanns-Spital, M¼llner Hauptstr. 48, A-5020 Salzburg, Austria. Fax: 43-662-4482887, E-mail: D.Kogelnik@1kasbg.gv.at

Third Macedonian Congress of Radiology with International Participation
Contact: Congress Secretariat, Institute of Radiology, University Clinical Center, Vodnjanska 17, 1000 Skopje, Republic of Macedonia. Fax: 389-2-236974, E-mail: rentgen@unet.com.mk

7th Meeting of the World Association of Sarcoidosis and other Granulomatous Disorders (WASOG)
Contact: Mr. Chr. Carlsson, Stockholm Convention Bureau, P. O. Box 6911, S- 102 39 Stockholm, Sweden. Fax: 46-8-348441

22nd International Congress of Radiology (ICR)
Contact: Fed. Mexicana de Radiologia e, Imagen, Coahuila No. 35, Col. Roma, C.P. 06700, Mexico, D.F. Fax: 52-5-5745374, E-mail: fmri@compuserve.com

CARS 2002 - Computer Assisted Radiology and Surgery
Contact: Mrs. Franziska Schweikert, CARS 2002 Conference Office, Im Gut 11/15, D-79790 K¼ssaberg, Germany. Fax: 49-7742-922438, E-mail: francis.cars@d-plus.net

EUROSON 2002 - 14th Congress of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB)
Contact: Polish Ultrasound Society, ul. Kondratowicza 8, 03-242 Warszawa, Poland. Fax: 48-22-8119591, E-mail: euroson@euroson.edu.pl

18th International Cancer Congress
Contact: Congrex Sweden AB, P.O. Box 5619, SE-114 86 Stockholm, Sweden. Fax: 46-8-6619125, E-mail: amelie.svanstrom@congrex.se

22nd International Congress of Radiology (ICR)
Contact: B.P. Servimed, S.A. de C.V., Insurgentes Sur, No. 1188-50 piso, Col. del Valle, 03210 Mexico, D.F.
Fax: 52-5-5599497, E-mail: fmricr@servimed.com.mx

EACR XVII - European Association for Cancer Research
Contact: Mr Luc Hendrickx, FECS Conference Unit, Av. E. Mounier 83, B-1200 Brussels, Belgium
Fax: 32-2-7750200, E-mail: EACRXVII@fecs.be

XVII Symposium Neuroradiologicum of the World Federation of Neuroradiological Societies (WFNRS)
Contact: Prof. Luc Picard, Serv. Neurorad., H´p. Central, 29 av. Mar(c)chal de Lattre de Tassigny-CO 34, F-54035 Nancy Cedex, France. Fax: 33-3-83852236/83851391, E-mail: 1.picard@chu-nancy.fr

Annual Congress of the European Association of Nuclear Medicine (EANM)
Contact: Quality Associates, Secretariat EANM, Van Breestraat 156, NL-1071 ZX Amsterdam, The Netherlands. Fax: 31-20-6759410
ESTRO 21 - 21st Annual Meeting of the Eurpoean Society for Therapeutic Radiology and Oncology
Contact: ESTRO office, Av. E. Mounierlaan 83/12
B-1200 Brussels, Belgium. Fax: 32-2-7795494, E-mail: info@estro.be

19th Annual Meeting of the European Society for Magnetic Resonance in Medicine and Biology (ESMRMB)
Contact: Prof. C. Bartolozzi, ESMRMB Office, Neutorgasse 9/2A, A-1010 Vienna, Austria. Fax: 43-1-5357041, E-mail: Office@esmrmb.org

Annual Meeting of the Mongolian Radiological Society
Contact: Dr. D. Gonchigsuren, Dept. of Radiol., Nat. Univ. Hosp., P.O. Box 34, Ulaanbatar 48, Mongolia. Fax: 976-1-321249/302818, E-mail: dgonchigsuren@hotmail.com

CIRSE 2002 - Annual Meeting of the Cardiovascular and Interventional Radiological Society of Europe (CIRSE)
Contact: CIRSE 2002, Bellerivestrasse 42, CH-8008 Z¼rich, Switzerland. Fax: 41-1-3849339
E-mail: cirse@congressorg.ch

9th Annual Meeting of the European Society of Musculoskeletal Radiology (ESSR)
Contact: Dr Francisco Aparisi, C. Dr. Sanchis Sivera 18, E-46008 Valencia, Spain
Fax: 34-96-3177870

27th Congress of the European Society of Medical Oncology (ESMO)
Contact: ESMO Congress Secretariat, Via Soldino 22, CH-6900 Lugano, Switzerland
Fax: 41-91-9500781, E-mail: esmo@dial.eunet.ch

Journ(c)es francaises de radiologie - JFR 2002 
Contact; Prof. Guy Frija, Secr. Gen. SFR, 20, av. Rapp, F-75343, Paris Cedex 07, France
Fax: 33-1-53595960, E-mail: sfr@sfradiologie.or

88th Meeting of the Radiological Society of North America (RSNA)
Contact: Steven T. Drew, Ass. Exec. Director, 320 Jorie Boulevard, Oak Brook, IL 60523-2251, USA
Fax: 1-630-5717837, E-mail: sdrew@rsna.org

34th Annual Scientific Conference of the British Medical Ultrasound Society (BMUS)
Contact: Mrs Elaine Brown, BMUS, 36 Portland Place, London W1B 1LS, UK
Fax: 44-20-73232175, E-mail: BMUS@compuserve.com

6th International Conference on Nuclear Cardiology
Contact: European Society of Cardiology, B.P. 179, Les Templiers, F-06903 Sophia-Antipolis Cedex, France
Fax: 33-4-92947601, E-mail: webmaster@escardio.org
 

Instructions to authors

For publication in the journal "Roentgenologia & Radiologia" are accepted review articles, original papers and case reports which correspond to the thematic scope of the journal (conventional and special roentgenological diagnostic, computer tomography, magnetic resonance, ultrasound, interventional radiology, nuclear medicine, radiotherapy, radiobiology, radiation protection) and are not published anywhere else.
Manuscripts should be submitted in two copies. They must be typewritten on one side only of A4 sheets with 60 characters per line and 30 lines per page, double-spaced with 6 mm between lines. A space has to be left after each period, comma, dash and other character. The margins should be as follows: on the left - 3 cm, on the right - 1 cm, and down - 3 cm.
Review articles should not exceed 8-10 manuscript pages, original papers - 6 pages, case reports - 3 pages, and information for congresses, conferences and symposia - 1-2 pages. The upper limit of the figure for original papers is 10, and for case reports is 4.
The particular parts of the papers are to be set in the following order:
 
 

Title page

Title, names of authors and name of the institute from which the work originates.
 
 

Example

Cerebellar hemangioblastoma in two generations

M. Zhekova, M. Dimitrov, V. Hadjidekov
Department of Radiology,
State University Hospital "Alexandrovska"-Sofia

When the authors are from different institutions use indexes and place them after the surname of the corresponding author and in front of the institution's name. Information on the leaders of the institutions are not needed.

Abstract and key words

It is presented on a separate page. Its size must be about 250 words. The abstracts should reflect clearly and specifically the most essential from the work and should comply with the following structure: 1. object; 2. material; 3. method; 4. results. The key words (3-5) are derived from the text and have the goal to help the future bibliographical processing of the paper.
 

Text of the paper

It is desirable each original paper to have the following parts: introduction, material and methods, results, discussion and conclusion. Use only officially accepted abbreviations. Measurements should be given in the International System of Units (SI). It is recommended to cite the references by number only.
 
 

Illustrations

Illustrations (photocopies, drafts, schemas, graphs, diagrams etc) are submitted in a separate envelope together with an inventory mentioning the title of the paper, author's names and number of figures. Black and white and color illustrations are accepted. They should be of good quality and contrast. Color illustrations are preferably to be on slides. No special place in the manuscript should be left for the figures. Their numbers should be written in the left margin. On the back all figures must be numbered, indicated with "top" and "bottom", the title of the paper and the names of the authors written down. Figure legends must be presented on a separate page. Tables are typed on separate pages and should have separate numbering, which is written down (like the figures) in the left margin of the manuscript.
 

References

They should be presented on a separate page too. The number of references should not exceed 10-15. It is desirable that they cover the last few years. Arrange them in alphabetical order. After the serial number write the author's surname and than the initials (no spaces or punctuation between initials). Put a comma and one space between each name. The last author must have a full-stop after their initial(s).
Where there are 6 or less authors you must list all authors. Where there are 7 or more authors, only the first 6 are listed and add "et al". Write the entire title for the publication, but only the first word of journal articles or book titles (and words that normally begin with a capital letter) is capitalized. Write the name of the journal (or its officially accepted abbreviation according to the style used in Medline), year (and month/day if necessary) of publication, volume number (and issue if necessary), page numbers (from-to). *NOTE: do not repeat digits unnecessarily (e.g. 127-33), if the journal has continuous page numbering through volume, the month/day and issue information can be omitted.
 
 

Citing books:
Name/s of author/s or editor/s (use the word "editor" or "editors" in full after the name/s); title of publication; edition - if other than first edition, abbreviate the word edition to "ed." - do not confuse with editor; place of publication (if the publishers are located in more than one city), write the place name in full; publisher - the publisher's name should be spelt out in full; year of publication; page numbers (if applicable) - abbreviate the word page to "p."

Examples of references

Examples of citing books:
Getzen TE. Health economics: fundamentals of funds. New York: John Wiley & Sons; 1997.
Edition other than first:
Blenkinsopp A, Paxton P. Symptoms in the pharmacy: a guide to the management of common illness. 3rd ed. Oxford: Blackwell Science; 1998.
Chapter of a book
Porter RJ, Meldrum BS. Antiepileptic drugs. In: Katzung BG, editor. Basic and clinical pharmacology. 6th ed. Norwalk, CN: Appleton and Lange; 1995, p. 361-80.
Examples of citing journals:
Non-continuous page numbers - include month/day and issue:
Russell FD, Coppell AL, Davenport AP. In vitro enzymatic processing of radiolabelled big ET-1 in human kidney as a food ingredient. Biochem Pharmacol 1998 Mar 1;55(5):684-92.
Continuous page numbers - omit month/day and issue:

Russell FD, Coppell AL, Davenport AP. In vitro enzymatic processing of radiolabelled big ET-1 in human kidney as a food ingredient. Biochem Pharmacol 1998;55:684-92.
Citing conferences
Conference papers:
Bengtsson S, Solheim BG. Enforcement of data protection, privacy and security in medical informatics. In: Lun KC, Degoulet P, Piemme TE, Reinhoff O, editors. MEDINFO 92. Proceedings of the 7th World Congress on Medical Informatics; 1992 Sep 6-10; Geneva, Switzerland. Amsterdam: North-Holland; 1992. p. 1561-5.
Conference proceedings:
Kimura J, Shibasaki H, editors. Recent advances in clinical neurophysiology. Proceedings of the 10th International Congress of EMG and Clinical Neurophysiology; 1995 Oct 15-19; Kyoto, Japan. Amsterdam: Elsevier; 1996.

Address for correspondence

It should be placed at the end of the manuscript and contains all necessary data, including the zip code.
 

Technical instructions for manuscripts submitted on diskette

Authors who have prepared their manuscript using a  PC word processing software are asked to provide the file(s) on diskette after the manuscript has been accepted for publication. To facilitate the preparation of the file, some basic rules are given bellow:
Please follow the "Instruction to Authors" when structuring the text of your paper.
Submit your file(s) on diskette formatted for PC-DOS or AppleMc for PC.
Store your text in two version:
1. In the file format offered by your word processing software.
2. In one of the following formats:
- DOC - MS DOS Word 5.X, or MS Word for Windows (any version).
Input your text continuously, i.e. use "Enter" key only at the ends of the paragraphs.
Do not use the "Space bar" to make indents or to form columns in lists. The indent command or tabulator ("Tab") should be used in this purpose.
Please delete any annotations or comments from the final text.
Photos, figures, graphs and tables should be submitted on separate files:
- Photos - in TIF format with resolution at least 300x300 dpi (135 lpi);
- Graphs created by CorelChart, MS Excel or other software for drawing graphs - in the file format of the program;
- Diagrams - in TIF, PCX or BMP format;
- Tables created by MS Excel, Aldus Table Editor or other similar software - in the format of the program.
Please write on the diskette label (or on an additional sheet of paper) the title of the paper, the authors, word processing software used for preparation of the text and file format of the second version, file names with the figures, graphs, diagrams and tables and the software used for their preparation.
 
 

The authors are entirely responsible for accuracy of all data  and statements. Manuscripts are not submitted back to authors.

All manuscripts for the journal "Roentgenologia & Radiologia" should be addressed to:
Prof. Dr. Ljubomir Diankov, 6, Damian Gruev Blvd., 
1303 Sofia, Bulgaria, Tel. (359 2) 987-72-01 (226)