Adrenal vein sampling is safe; increasing the selectivity index cutoffs lowers the number of usable adrenal vein samplings; higher lateralization index cutoff values lead to missing a proportion of aldosterone-producing adenomas. The improved selectivity rate provided by adrenocorticotropic hormone stimulation should be weighed against the loss of correct lateralization.

No abstract

Imaging examination suggests a characteristic pattern of muscle involvement. MRI represents an important diagnostic technique useful in differential diagnosis, thanks to the distinctive patterns observed in the distribution of muscular changes between the different muscular diseases.

Dysphagia in motor neuron disease (MND) may lead to dangerous complications such as cachexia and aspiration pneumonia. Functional evaluation of the oropharyngeal tract is crucial for identifying specific swallowing dysfunctions and planning appropriate rehabilitation. As part of a multidisciplinary study on the treatment of dysphagia in patients with neuromuscular diseases, 23 MND patients with different degrees of dysphagia underwent videofluoroscopy, videopharyngolaryngoscopy and pharyngo-oesophageal manometry. The results of the three instrumental investigations were analysed in order (1) to define the pattern of swallowing in MND patients complaining of dysphagia; (2) to evaluate whether subclinical abnormalities may be detected; and (3) to assess the role of videofluoroscopy, videopharyngolaryngoscopy and manometry in the evaluation of MND patients with deglutition problems. Correlations between the instrumental findings and clinical features (age of the patients, duration and severity of the disease, presence and degree of dysphagia) were also assessed. The results of our study showed that: (1) The oral phase of deglutition was compromised most often, followed by the pharyngeal phase. (2) In all patients without clinical evidence of dysphagia, subclinical videofluoroscopic alterations were present in a pattern similar to that found in the dysphagic group. (3) Videofluoroscopy was the most sensitive technique in identifying oropharyngeal alterations of swallowing. Impairment of the oral phase, abnormal pharyngo-oesophageal motility and incomplete relaxation of the upper oesophageal sphincter were the changes most sensitive in detecting dysphagia. Videofluoroscopy was also capable of detecting preclinical abnormalities in non-dysphagic patients who later developed dysphagia. Practical guidelines for the use of instrumental investigations in the assessment and management of dysphagia in MND patients are proposed.

Diaphragmatic sulci in the superior surface of the liver were found in 40% of cases at autopsy. All sulci were located in the right lobe and in 47% they were multiple. In order to evaluate possible predisposing factors for these accessory sulci, their topography and characteristics were observed in unfixed livers; moreover, intravenous injections of radio-opaque resins were performed in the portal and hepatic veins (HVs). After formalin fixation, the livers underwent CT and MR scans and a three-dimensional (3D) elaboration of the images was performed. Radiological examination revealed a correspondence between the topography of the sulci and the course of the right and middle HVs and their main tributaries in 67%. The corrosion casts showed the location of the sulci at the level of the boundaries between the ramifications of the terminal branches of the portal triad, where the HVs are located, in 73%. These findings suggest that, rather than the action of 'special' or hypertrophied muscle bundles, the pressure exerted by the diaphragm as a whole may be responsible for the production of sulci at the level of weak zones, represented by the portal fissures, where the watershed superficial hepatic parenchyma, owing to the absence of all but the smallest vascular branches, exhibits a lower resistance to external pressure.

Estimation of the firing range is often critical for reconstructing gunshot fatalities, where the main measurable evidence is the gunshot residue (GSR). In the present study intermediate-range gunshot wounds have been analysed by means of a micro-computed tomography (micro-CT) coupled to an image analysis software in order to quantify the powder particles and to determine the firing distance. A total of 50 shootings were performed on skin sections obtained from human legs surgically amputated for medical reasons. For each tested distance (5, 15, 23, 30 and 40 cm), firing was carried out perpendicularly at the samples using a 7.65-mm pistol loaded with jacketed bullets. Uninjured skin sections were used as controls. By increasing the firing distance, micro-CT analysis demonstrated a clear decreasing trend in the mean GSR percentage, particularly for shots fired from more than 15 cm. For distances under 23 cm, the powder particles were concentrated on the epidermis and dermis around the hole, and inside the cavity; while, at greater distances, they were deposited only on the skin surface. Statistical analysis showed a nonlinear relationship between the amount of GSR deposits and the firing range, well explained by a Gaussian-like function. The proposed method allowed a good discrimination for all the tested distances, proving to be an objective, rapid and inexpensive tool for estimating the firing range in intermediate-range gunshot wounds

1. Low-to-normal renin renovascular hypertension (RVH) and the accuracy of renal vein renin ratios were investigated in 129 consecutive patients referred for suspected RVH. Forty-nine had essential hypertension, 24 unilateral renoparenchymal hypertension and 56 renal artery obstruction. Of the latter, 86% were diagnosed retrospectively as RVH, based on fall in blood pressure with correction of renal ischaemia. We measured baseline, captopril-stimulated and renal vein plasma renin activity (PRA) levels, as well as several other parameters. 2. PRA was low-to-normal in 37% of the RVH patients [low-to-normal renin (LNR-) RVH group] and elevated in the remaining 63% [high-renin (HR-) RVH group]. In the LNR-RVH group, low-to-normal renin levels, by immunoreactive active renin and plasma renin concentration measurements, and a blunted response of PRA to captopril, were seen. As compared with HR-RVH, LNR-RVH patients had a longer duration of hypertension (P < 0.05), higher serum K+ (P = 0.04) and lower diastolic blood pressure (P = 0.02). However, they did not differ for the other variables, including the fall in blood pressure after correction of renal ischaemia. Although the number of bilateral stenoses was similar in the two groups, no patient in the LNR-RVH group had total renal artery occlusion compared with 53% in the HR-RVH group (P = 0.00015). The accuracy of renal vein renin indices were high enough to justify their use only in the patients with total occlusion of a renal artery. 3. Thus LNR-RVH is common in patients with longstanding hypertension without a totally occluded renal artery. Since the sensitivity of renin measurements is low, cure of hypertension would be precluded for more than one third of RVH patients, if these tests were a prerequisite for identifying RVH.

Incineration or extensive burning of the body, causing changes in the content and distribution of fluids, fixation and shrinking processes of tissues, can alter the typical macroscopic and microscopic characteristics of firearm wounds, hampering or at least complicating the reconstruction of gunshot fatalities. The present study aims at evaluating the potential role of micro-computed tomography (micro-CT) for detecting and quantifying gunshot residue (GSR) particles in experimentally produced intermediate-range gunshot wounds severely damaged by fire. Eighteen experimental shootings were performed on 18 sections of human calves surgically amputated for medical reasons at three different firing distances (5, 15 and 30 cm). Six stab wounds produced with an ice pick were used as controls. Each calf section underwent a charring cycle, being placed in a wood-burning stove for 4 min at a temperature of 400 °C. At visual inspection, the charred entrance wounds could not be differentiated from the exit lesions and the stab wounds. On the contrary, micro-CT analysis showed the presence of GSR particles in all burnt entrance gunshot wounds, while GSR was absent in the exit and stab wounds. The GSR deposits of the firearm lesions inflicted at very close distance (5 cm) were mainly constituted of huge particles (diameter >150 μm) with an irregular shape and well-delineated edges; at greater distances (15 and 30 cm), agglomerates of tiny radiopaque particles scattered in the epidermis and dermis layers were evident. Statistical analysis demonstrated that also in charred firearm wounds the amount of GSR roughly correlates with the distance from which the gun was fired. The obtained results suggest that micro-CT analysis can be a valid screening tool for identifying entrance gunshot wounds and for differentiating firearm wounds from sharp-force injuries in bodies severely damaged by fire.