Medical professional values and education: a survey on italian students of the medical doctor school in medicine and surgery

Background:

The values such as participation/empathy, communication/sharing, self-awareness, moral integrity, sensitivity/trustfulness, commitment to ongoing professional development, and sense of duty linked to the practice of the medical professionalism were defined by various professional oaths.

Aims:

The aim of this study was to evaluate how these values are considered by the students of the degree course of medicine.

Materials and Methods:

Four hundred twenty three students (254 females, 169 males) taking part of the first, fourth, and fifth years of the degree course in medicine were asked to answer seven questions. Pearson's Chi-square, Wilcoxon rank sum test, and Kruskal–Wallis test were used for the statistical analysis.

Results:

The survey showed a high level of knowledge and self-awareness about the values and skills of medical profession. In particular, the respect, accountability, and the professional skills of competence were considered fundamental in clinical practice. However, the students considered that these values not sufficiently present in their educational experience.

Conclusions:

Teaching methods should be harmonized with the contents and with the educational needs to ensure a more complex patient-based approach and the classical lectures of teachers should be more integrated with learning through experience methods.

¹⁸F-FDG-PET/CT in malignant mesothelioma

It is well known the useful role of ¹⁸F-FDG-PET/CT for differential diagnosis between benign and malignant disease, for staging, for monitoring response and for prognosis regarding mesothelioma. Recently, literature was enriched with new interesting studies regarding the potential applications of ¹⁸F-FDG-PET/CT in this field. The purpose of this review is to evaluate articles published on line (PubMed) from January 2011 until October 2012 in order to obtain an overview of recent progress of molecular imaging in malignant mesothelioma. The main topics concern the use of ¹⁸F-FDG-PET/CT in radiation therapy planning, monitoring of treatment (surgery/chemotherapy) response and prognosis assessment.

Fifteen different 18F-FDG PET/CT qualitative and quantitative parameters investigated as pathological response predictors of locally advanced rectal cancer treated by neoadjuvant chemoradiation therapy

PURPOSE

The aim of this study was to correlate qualitative visual response and various PET quantification factors with the tumour regression grade (TRG) classification of pathological response to neoadjuvant chemoradiotherapy (CRT) proposed by Mandard.

METHODS

Included in this retrospective study were 69 consecutive patients with locally advanced rectal cancer (LARC). FDG PET/CT scans were performed at staging and after CRT (mean 6.7 weeks). Tumour SUVmax and its related arithmetic and percentage decrease (response index, RI) were calculated. Qualitative analysis was performed by visual response assessment (VRA), PERCIST 1.0 and response cut-off classification based on a new definition of residual disease. Metabolic tumour volume (MTV) was calculated using a 40 % SUVmax threshold, and the total lesion glycolysis (TLG) both before and after CRT and their arithmetic and percentage change were also calculated. We split the patients into responders (TRG 1 or 2) and nonresponders (TRG 3-5).

RESULTS

SUVmax MTV and TLG after CRT, RI, ΔMTV% and ΔTLG% parameters were significantly correlated with pathological treatment response (p < 0.01) with a ROC curve cut-off values of 5.1, 2.1 cm(3), 23.4 cm(3), 61.8 %, 81.4 % and 94.2 %, respectively. SUVmax after CRT had the highest ROC AUC (0.846), with a sensitivity of 86 % and a specificity of 80 %. VRA and response cut-off classification were also significantly predictive of TRG response (VRA with the best accuracy: sensitivity 86 % and specificity 55 %). In contrast, assessment using PERCIST was not significantly correlated with TRG.

CONCLUSION

FDG PET/CT can accurately stratify patients with LARC preoperatively, independently of the method chosen to interpret the images. Among many PET parameters, some of which are not immediately obtainable, the most commonly used in clinical practice (SUVmax after CRT and VRA) showed the best accuracy in predicting TRG.

Aliskiren improves blood pressure control and prevents cardiac damage in high-risk hypertensive subjects

Aim: Longitudinal study aimed to evaluate the antihypertensive efficacy, safety and the effect on cardiac damage of Aliskiren, administered to a group of high-risk hypertensive patients with mild impairment of renal function and uncontrolled blood pressure (BP) despite a two-drug antihypertensive treatment. Methods: One hundred and six patients (56 men and 50 females) aged 61.9±12.7 years, were assigned to receive Aliskiren 150-300 mg once-daily for 12 months. Clinic BP measurements were taken at every follow-up visit (1st, 6th and 12th month), while biochemical tests, estimated glomerular filtration rate (eGFR), 24-hours ambulatory BP measurements (ABMP) and echocardiography were evaluated at baseline and at the end of follow-up. Analysis of variance for repeated measures compared BP, left ventricular mass index (LVMI) and eGFR values changes. Results: A significant reduction (all P<0.0001) of clinic systolic (-28.6 mmHg) and diastolic (-12.8 mmHg) BP values, mean 24h-systolic (-12.3 mmHg) and 24h-diastolic (-6.5 mmHg), day-time systolic (-11.5 mmHg) and diastolic (-6.4 mmHg), night-time systolic (-11.9 mmHg) and diastolic (-7 mmHg) ABPM values and in the use of antihypertensive drugs was observed (3.0±0.9 vs. 2.0±0.7, p=0.01). LVMI was significantly reduced (130.2±36.1 vs. 115.9±33.4 g/m2, P<0.0001); eGFR was steady (75.3±17.3 vs. 73.1±21.5 ml/min/1.73m2, P>0.05). Putative adverse events caused withdrawal of 7 subjects (6 for gastrointestinal disturbances, 1 for alopecia). Conclusion: Aliskiren was effective in decreasing both clinical and ABPM values and in reducing LVMI in both genders without any influence on eGFR. The treatment resulted safe, even in combination with ACE-inhibitors and angiotensin II receptor blockers. A significant reduction in the use of concomitant antihypertensive drugs was observed.

Arterial hypertension, a tricky side of Parkinson's disease: physiopathology and therapeutic features

The role of arterial hypertension (HT) as risk factor for Parkinson's disease (PD) is still debated. Case-control and retrospective studies do not support an association between HT and PD and the risk of PD seems to be lower in hypertensive than in normotensive subjects. In addition, the use of calcium-channel blockers (CCBs) and angiotensin-converting enzyme inhibitors seems to have a protective effect on the risk of developing PD. In clinical practice, a crucial finding in subjects with PD is the high supine systolic blood pressure (SBP) coupled with orthostatic hypotension (OH). It is not clear whether this SBP load could be a risk factor for target organ damage as this load can be largely due to the drugs used to treat OH (i.e., fludrocortisone acetate, midodrine) or PD itself (i.e., monoamine oxidase inhibitors, dopamine D2-receptor antagonists). This blood pressure (BP) load is largely independent of medications as the 40 % of subjects with PD have a non-dipping pattern of BP during 24 h ambulatory monitoring (24-h ABPM). In PD, nocturnal HT is usually asymptomatic and 24-h ABPM should be used to track both supine HT and OH. Treatment of HT in PD is difficult because the reduction of supine BP could worsen OH. To avoid this, short-acting dihydropyridine CCBs, clonidine or nitrates are recommended, assuming between meals, in late afternoon or in the evening in avoiding an aggravation in the post-prandial hypotension characteristic of PD.

Neoadjuvant therapy with weekly docetaxel and cisplatin, 5-fluorouracil continuous infusion, and concurrent radiotherapy in patients with locally advanced esophageal cancer produced a high percentage of long-lasting pathological complete response: a phase 2 study

BACKGROUND

This phase 2 study was aimed at defining the pathological response rate of a neoadjuvant schedule including weekly docetaxel and cisplatin, continuous infusion (c.i.) of 5-fluorouracil (5-FU) and concomitant radiotherapy (RT) in untreated stage II-III adenocarcinoma and squamous cell carcinoma of mid-distal thoracic esophagus.

METHODS

The schedule consisted of a first phase of chemotherapy alone and of a second phase of concurrent chemoradiation. Doses were as follows: docetaxel 35 mg/m(2) and cisplatin 25 mg/m(2) on days 1, 8, 15, 29, 36, 43, 50, and 57 plus 5-FU c.i. (180 mg/m(2) on days 1-21 and 150 mg/m(2) on days 29-63); RT (50 Gy) started at day 29. Surgery was planned 6 to 8 weeks after the completion of chemoradiation.

RESULTS

A total of 74 patients were enrolled; pathological complete remission (pCR) was found in 47% (35 of 74) and near pCR (microfoci of tumor cells on the primary tumor without lymph nodal metastases) (pnCR) in 15% of the patients (11 of 74). Grade 3-4 neutropenia, nonhematological toxicity, and toxic deaths occurred in 13.5%, 32.4%, and 4% of the patients, respectively. Median follow-up was 55 months (range, 3-108 months). Median survival of all 74 patients was 55 months, whereas it was not reached in the pCR subset. The 3- and 5-year survival rates were, respectively, 83% and 77% for pCR, 73% and 44% for pnCR, and 21% and 14% for Residual Tumor subsets (P < .001).

CONCLUSIONS

This study shows that 1) this intensive weekly schedule produced a high pathological response rate, 2) responders had high and long-term durable survival rates.

The widened use of exogenous stimulation with recombinant human TSH to treat metastatic thyroid carcinoma in Italy

Recently, in Italy, the reimbursement for the use of rhTSH in preparing patients for radiometabolic treatment of iodine-avid metastases from differentiated thyroid cancer has been made possible. Intramuscular administration of rhTSH increases the radioiodine uptake and thyroglobulin production by thyroid cells. In addition to the previous indications on the use of rhTSH (mainly: serum thyreoglobulin assay with or without 131I scintigraphy and ablation with 131I of remnants in low risk patients), the reimbursement is now allowed for the treatment with radioiodine of iodine-avid loco-regional and distant metastases, in subjects with inability to reach adequate TSH levels and/or severe clinical conditions which could be potentially worsened by other concurrent diseases (history of stroke or transient ischemic attack, severe cardiac disease, renal failure or major psychiatric disorders). The Italian Medicines Agency (AIFA) approved this use (and added this hormone in the special list of drugs regulated by the D.Lgs 648/96) on the basis of a series of scientific evidences, proposed by a "team of experts". In the present paper we illustrate the scientific background of the use of rhTSH (clinical usefulness, economic considerations, aspects related to a better quality of life) that allowed the modification of the reimbursement and how it was made possible in the Italian legislative context.

Recurrent syncope in a hypertensive subject with vascular cognitive impairment and permanent pacemaker

Syncope following permanent pacemaker (PM) implantation is a nightmare for electrophysiologists. We describe a case of daily recurrent syncope in an 84-year-old man having a dual-chamber pacemaker implanted for complete atrio-ventricular block occurred 4 years before the admission to our department. He had a history of arterial hypertension, parossistic atrial fibrillation, chronic obstructive pulmonary disease, stage-III chronic renal failure, mild vascular cognitive impairment and glaucoma. The initial work-up including electrocardiogram (ECG), repeated PM interrogations, Holter electrocardiogram, blood pressure measurement in orthostatic position, complete blood count, serum glycaemia, electrolytes and thyroid function tests showed normal findings. Syncope occurred in lying position and during 90° left clockwise neck rotation and was associated to pallor, sweating, tonic-clonic seizures and transient self-limited loss of consciousness lasting a few seconds. Electroencephalogram was normal. During continuous ECG monitoring, the right rotation of the head determined a ventricular asystolic pause lasting 9 seconds associated with loss of consciousness. Restoration of sinus rhythm was observed after bringing back the head in axis. The PM interrogation, performed during pacing failure, recorded low impedance of bipolar ventricular lead, suggesting a damage in lead insulation. It is likely that lead movements during clockwise neck rotation produced an intermittent short circuit that prevented sufficient energy delivery to the myocardium with a consequence of sudden loss of capture.

EANM 2012 guidelines for radionuclide imaging of phaeochromocytoma and paraganglioma

PURPOSE

Radionuclide imaging of phaeochromocytomas (PCCs) and paragangliomas (PGLs) involves various functional imaging techniques and approaches for accurate diagnosis, staging and tumour characterization. The purpose of the present guidelines is to assist nuclear medicine practitioners in performing, interpreting and reporting the results of the currently available SPECT and PET imaging approaches. These guidelines are intended to present information specifically adapted to European practice.

METHODS

Guidelines from related fields, issued by the European Association of Nuclear Medicine and the Society of Nuclear Medicine, were taken into consideration and are partially integrated within this text. The same was applied to the relevant literature, and the final result was discussed with leading experts involved in the management of patients with PCC/PGL. The information provided should be viewed in the context of local conditions, laws and regulations.

CONCLUSION

Although several radionuclide imaging modalities are considered herein, considerable focus is given to PET imaging which offers high sensitivity targeted molecular imaging approaches.

Value of FDG PET/CT in patients with treated ovarian cancer and raised CA125 serum levels

PURPOSE

Patients treated for ovarian cancer are usually referred for 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography/computed tomography (FDG PET/CT) in case of increased Carcinoma Antigen 125 (CA125) but negative conventional imaging. However, there is not enough in the literature to support the value of FDG PET/CT in this context. This study aimed to assess role of FDG PET/CT in a cohort of patients with treated ovarian cancer and correlate the results with serum levels of CA125.

PROCEDURES

We retrospectively studied 175 patients, mean age 65.2 years (range 24-88 years) who had radical treatment for ovarian cancer (chemotherapy, surgery or combination). The patients had a standard FDG PET/CT and measurement of serum CA125 within a month of the scan. PET/CT was considered positive if demonstrated areas of abnormally increased metabolic activity unrelated to physiological distribution, on the basis of a visual analysis. The results of PET/CT imaging were compared to the level of CA125, and receiver operating characteristic (ROC) curves were plotted and area-under-the curve (AUC) statistics were computed. Cytologic or histologic data or clinical and imaging follow-up were taken as gold standard.

RESULTS

Patients were divided into five groups based on CA125 values. The average level of CA125 was 107.7 (range 3-867, SD 166.1). PET/CT was positive in 125/175 cases (71.4%), mean value of CA125 132.2 (SD 182.9) and negative in 50/175 (28.6%), mean value of CA125 46.4 (SD 89.3). In descriptive ROC analyses, the discriminatory power of this marker was relatively high (AUC statistics 0.77, range = 0.703-0.8). The optimal cut-off point of CA125 after treatment to reflect active disease on PET/CT was 18 U/mL achieving a detection rate of 85.6%. There was no relation between PET/CT negativity and the histological type of the tumor.

CONCLUSION

PET/CT was able to detect active disease at relatively low levels of CA125, thereby facilitating the early diagnosis of recurrence or residual disease. Also in patients with low CA125 levels (<30), PET/CT had a relatively high detection rate (53%). According to our preliminary results, the use of FDG PET/CT in this setting is justified even with low serum CA125 levels.

Indeterminate pulmonary nodules on CT images in breast cancer patient: the additional value of 18F-FDG PET/CT

AIM

To assess the potential role of 18F-Fluorodeoxiglucose (FDG) Positron Emission Tomography (PET)/Computed Tomography (CT) in characterizing indeterminate lung nodules detected at CT scan in patients previously treated for a breast cancer (BC).

MATERIALS AND METHODS

Twenty-nine consecutive BC patients (28 females, mean age 65 ± 12 years) with evidence of indeterminate lung nodules at contrast-enhanced CT (CECT) scan (lesions with axial diameter ≥8 mm) were retrospectively analysed: all patients underwent 18F-FDG PET/CT within a mean 2 ± 1 months from CECT imaging. PET/CT was considered positive in the presence of abnormal FDG uptake in the pulmonary nodules and/or in other organs. The nature of lung nodules was defined at histopathology and/or imaging follow-up.

RESULTS

Fourteen (48%) patients showed negative and 15 (52%) positive PET/CT scan in the lungs: of these 15 patients, 7 (47%) had pathologic FDG-uptake in lungs only, whereas 8 (53%) showed abnormal FDG-uptake also in sites different from lungs. At histology and/or imaging follow-up, five (17%) patients were considered positive for BC lung metastases while in seven (24%) a second cancer was diagnosed. In this subset of patients, the sensitivity and specificity for FDG PET/CT in revealing lung lesions were 17% and 100%, respectively, for nodules <8 mm in diameter, and 77% and 85%, respectively, for nodules with diameter ≥8 mm. The therapeutic planning was changed to surgery in seven patients, chemotherapy in one patient and continued hormonal therapy in five. The inclusion of PET/CT in the diagnostic algorithm of the evaluated patients helped avoid unnecessary over-treatment in 12 of 29 patients.

CONCLUSION

FDG PET/CT appears useful in characterizing indeterminate lung nodules found at CECT scan in BC patients, with a sensitivity that is proportional to nodule size. In addition, PET/CT helped in avoiding over-treatment in a significant proportion of patients.

[Radiometabolic therapy for metastatic thyroid carcinoma: overview of the literature and rational bases for the use of recombinant human TSH]

The established treatment for differentiated thyroid carcinoma (DTC) is founded on total thyroidectomy and subsequent administration of radioiodine (131I) to ablate the thyroid remnant and to treat the metastatic disease. In the case of metastatic or recurrent disease, further cycles of 131I therapy are often necessary. The condition for maximizing the effectiveness of the treatment is to have an adequate stimulation from TSH, which must be >25-30 mIU/L. This elevation is achieved either discontinuing the hormone suppression therapy for an appropriate period, or administering recombinant human TSH (rhTSH). The latter has shown good clinical efficacy in patients with residual thyroid gland and is nowadays commonly employed since it is easy to use and allows to avoid the side effects of hypothyroidism. It thus represents a good alternative to thyroid hormone withdrawal for the remnant ablation, while is still open the question if its efficacy on the management of metastatic disease is superimposable to thyroid hormone withdrawal. To this purpose, a Panel of expert reviewed the literature, assessing the advantages and disadvantages for the patient, as well as the impact in terms of cost and benefit to the National Health Service. The work of the Panel concluded with a proposal for the use of rhTSH in selected patients with metastatic DTC, in which is considered the efficacy and safety of the product and is examined its use in terms of costs; this proposal was accepted by the Italian Drug Agency resulting in an update of the indications for rhTSH.

Contemporary nuclear medicine imaging of neuroendocrine tumours

Neuroendocrine tumours (NETs) are rare, heterogeneous, and often hormonally active neoplasms. Nuclear medicine (NM) imaging using single photon- and positron-emitting radiopharmaceuticals allows sensitive and highly specific molecular imaging of NETs, complementary to anatomy-based techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI). Somatostatin-receptor scintigraphy is a whole-body imaging technique widely used for diagnosis, staging and restaging of NETs. The increasing availability of hybrid single-photon emission CT (SPECT)/CT cameras now offers superior accuracy for localization and functional characterization of NETs compared to traditional planar and SPECT imaging. The potential role of positron-emission tomography (PET) tracers in the functional imaging of NETs is also being increasingly recognized. In addition to 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG), newer positron-emitting radiopharmaceuticals such as (18)F-dihydroxyphenylalanine (DOPA) and (68)Ga-1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA) peptides, show promise for the future. This article will summarize the role of current and emerging radiopharmaceuticals in NM imaging of this rare but important group of tumours.

Role of 11C-choline PET/CT in the re-staging of prostate cancer patients with biochemical relapse and negative results at bone scintigraphy

AIM

to evaluate the utility of (11)C-choline PET/CT in prostate cancer (PC) patients who have demonstrated a biochemical recurrence and a negative bone scintigraphy (BS).

MATERIALS AND METHODS

123 consecutive PC patients (mean age 67.6 years; range 54-83) with a biochemical relapse (mean PSA value 3.3ng/mL; range 0.2-25.5) after radical prostatectomy (RP) were included in our retrospective study. Patients underwent a BS that resulted negative and a (11)C-choline PET/CT within 4 months from BS (range: 1 day to 4 months; mean: 2.5 months). Validation of results was established by: (1) a positive biopsy, (2) a positive subsequent BS, CT or MR and (3) a normalization of (11)C-choline uptake after systemic therapy or a progression of the disease.

RESULTS

(11)C-choline PET/CT was positive in 42/123 patients (34.1%). (11)C-choline PET/CT detected lesions in: bone (10 patients), lymph-nodes (20 patients), bone and lymph nodes (7 patients), bone and lung (1 patient), lymph-nodes and lung (1 patient), local relapse (3 patients). Overall, (11)C-choline PET/CT showed a total of 30 unknown bone lesions in 18/123 (14.6%) patients.

CONCLUSION

(11)C-choline PET/CT showed a better sensitivity than BS in patients with biochemical relapse after RP: (11)C-choline PET/CT detected unknown bone lesions in 18/123 (14.6%) patients.

Phantom study of the impact of reconstruction parameters on the detection of mini- and micro-volume lesions with a low-dose PET/CT acquisition protocol

PURPOSE

Every PET scanner suffers of the partial volume effect (PVE), that is a loss of contrast in small lesions causing a worsening in standardized uptake value (SUV) accuracy, that is critical if quantitative PET/CT imaging is used for diagnosis and therapy.

METHODS

In order to quantify PVE and optimize our clinical protocols to minimize this effect in a last generation PET/CT scanner, we utilized a cylindrical phantom equipped with ten mini- and micro-volume hollow spheres. The lesion detectability and the SUV accuracy were evaluated at a fixed spheres to background intrinsic contrast (activity concentration ratio 8:1) but in different scan conditions: (a) acquisition modality (3D vs. 2D), (b) number of subset per iteration, (c) type of post-reconstruction filter and (d) activity concentration (i.e. total counts). Also the effect of different absorber thickness was evaluated.

RESULTS

Small lesion detectability resulted better in images acquired in 3D mode rather than 2D, mainly because of the lower noise produced by the fully-3D algorithm. The number of reconstruction iterations and the post-processing filter used affected both the contrast underestimation and the spatial resolution. Decreasing the (18)F activity injected according to the low-dose protocol, the small lesions could be distinguished from the background down to a diameter of 6.2mm and the SUV accuracy did not deteriorate. Adding absorber thickness around the phantom, the image noise slightly increased while SUV accuracy did not change.

CONCLUSIONS

The hybrid PET/CT scanner we evaluated showed good performances, mainly in 3D acquisition modality. The phantom measurements showed that the most appropriate reconstruction protocol derived from a compromise between the contrast accuracy and the noise variance in PET images. The low-dose protocol clinically used demonstrated no loss in SUV accuracy and an adequate lesion detectability for lesions down to 6.2mm in diameter.

Is ⁶⁸Ga-DOTA-NOC PET/CT indicated in patients with clinical, biochemical or radiological suspicion of neuroendocrine tumour?

PURPOSE

In recent years, (68)Ga-DOTA-peptides positron emission tomography (PET)/CT has been increasingly used to study patients with neuroendocrine tumours (NET). However, performing specialized examinations in the appropriate contest is mandatory for both medical and economic reasons. The aim of the study is to evaluate the potential usefulness of (68)Ga-DOTA-NOC PET/CT in patients with suspected NET.

METHODS

Among the patients undergoing (68)Ga-DOTA-NOC PET/CT at our centre, we reviewed those studied for suspected NET based on the presence of either clinical signs/symptoms or imaging or raised biochemical markers or a combination of these conditions. PET/CT results were compared with clinical and imaging follow-up of at least 1 year or pathology.

RESULTS

Overall 131 suspected NET cases were included. The most common condition considered suspicious for NET was the increase of blood markers (66), followed by inconclusive findings at conventional imaging (CI, 41), clinical signs/symptoms (10), equivocal (18)F-fluorodeoxyglucose (FDG) PET (7) or somatostatin receptor scintigraphy (SRS, 4), or a combination of the above (3). PET/CT results were true-positive in 17 cases, true-negative in 112 and false-negative in 2 (overall sensitivity 89.5 %, specificity 100 %). Interestingly, increased blood markers and clinical signs/symptoms were associated with the lowest frequency of true-positive findings (1/66 and 1/10, respectively), while CI findings were confirmed in one third of the cases (13/41). Overall, the incidence of NET in the studied population was 14.5 % (19/131).

CONCLUSION

Our data confirm the good accuracy (98 %) of (68)Ga-DOTA-NOC PET/CT in NET lesion detection. However, our results also suggest that (68)Ga-DOTA-NOC PET/CT may not be routinely recommended in patients with a suspicion of NET based on the mere detection of increased blood markers or clinical symptoms. Positive CI alone or in association with clinical/biochemical findings is on the contrary associated with a higher probability of true-positive findings.