INCIDENTAL PARATHYROIDECTOMY DURING TOTAL THYROIDECTOMY AS A POSSIBLE RISK FACTOR OF HYPOCALCEMIA. EXPERIENCE OF A SINGLE CENTER AND REVIEW OF LITERATURE

CONTEXT

Post-operative clinical and biochemical hypocalcemia is a common complication of thyroid surgery and the correlation with incidental parathyroidectomy (IP) remains controversial.

OBJECTIVE

To evaluate the incidence of IP during TT, its correlation to early post-surgery hypocalcemia, and its potential risk factors.

PATIENTS AND METHODS

77 consecutive patients submitted to thyroid surgery between January 2018 and December 2019. Demographic, clinical, biochemical, surgical and histopathological factors were assessed. Statistical multivariate analysis was performed to identify the risk of IP.

RESULTS

IP was evident in 22 (28.5%) patients who underwent TT, TT with lymph node dissection of the central compartment (CLND) and reoperation for previous hemithyroidectomy with CLND. Early symptomatic hypocalcemia 24 hours after TT was demonstrated in 12/22 (54.5%) patients, with PTH value of <14pg/mL in 7/12 (58.3%) patients, and in 6 of these 7 patients (85.7%) the PTH value was <6.3pg/mL. In 5/22 (22.7%) patients the IP was associated with biochemical hypocalcemia <8.4mg/dL, and in 5/22 (22.7%) patients anatomical damage was not associated with a reduction in plasma calcium levels. The severity of early post-op hypocalcemia was not correlated with the number of parathyroid glands left in situ. The multivariate analysis did not show statistically significant values between the clinical-pathological variables and increased risk of IP.

CONCLUSIONS

No IP clinical-pathological risk factors have been identified during thyroid surgery. In all cases of TT, with or without CLND, the meticulous identification of the parathyroid glands, whose incidental removal is frequently associated with clinical and biochemical hypocalcemia, is recommended.

T1 mapping-derived signature of myocardial involvement in idiopathic inflammatory myopathy compared to acute viral myocarditis: a texture-based analysis

Funding Acknowledgements

Type of funding sources: None.

Background. Recent studies revealed the ability of MRI T1 mapping to characterize myocardial involvement in both idiopathic inflammatory myopathy (IIM) and acute viral myocarditis (AVM), as compared to healthy controls. However, neither myocardial T1 nor T2 maps were able to discriminate between IIM and AVM patients, when considering conventional myocardial mean values and derived indices such as lambda and extracellular volume.

Purpose. To investigate the ability of T1 mapping-derived texture analysis to differentiate IIM from AVM.

Methods. Forty patients, 20 with IIM (51 ± 17 years, 9 men) and 20 with AVM (34 ± 13 years, 16 men) underwent 1.5T MRI T1 mapping using a modified Look-Locker inversion-recovery sequence before and 15 minutes after injection of a gadolinium contrast agent. After manual delineation of endocardial and epicardial borders and co-registration of all inversion time images, native and post-contrast T1 maps were estimated. Myocardial texture analysis was performed on native T1 maps. Textural features such as: autocorrelation, contrast, dissimilarity, energy and sum entropy were used to build a least squares-based linear regression model. Finally, receiver operating characteristic (ROC) analysis was used to investigate the ability of such texture features score to classify IIM vs. AVM patients, compared to the performance of mean myocardial T1. A Wilcoxon rank-sum test was also used to test difference significance between groups.

Results. Both native and post-contrast mean myocardial T1 values were comparable between IIM (native: 1022 ± 43 ms; post-contrast: 319 ± 44 ms) and AVM (1056 ± 59 ms, p = 0.07; 318 ± 35 ms, p = 0.90, respectively) groups. Results of ROC analyses are provided in the Table, indicating that a better discrimination between IIM and AVM patients was obtained when using texture features, with higher AUC and accuracy than mean T1 values (Figure).

Conclusion. Texture analysis derived from MRI T1 maps without contrast agent injection was able to discriminate between IIM and AVM with higher accuracy, sensitivity and specificity than conventional T1 indices. Such analysis could provide a useful myocardial signature to help diagnose and manage cardiac alterations associated with IIM in patients presenting with myocarditis and primarily suspected of AVM.

Table Area under curve (AUC) Accuracy Sensitivity Specificity Native T1 0.67 0.70 0.65 0.75 Post-contrast T1 0.49 0.60 0.25 0.95 Texture features score 0.85 0.82 0.90 0.75 ROC analyses for classification between IIM and AVM patients Abstract Figure

Wave decomposition applied to LA phasic longitudinal strain evaluated from MRI feature tracking to estimate a true LA booster strain index

Funding Acknowledgements

Type of funding sources: None.

Background. Feature tracking (FT) is an emerging approach for the evaluation of both left atrium (LA) and left ventricular (LV) myocardial strain from the same cine MRI dataset. We hypothesized that the LA active contraction longitudinal strain, is a merge of an intrinsic LA booster contraction with the early diastolic LA emptying, especially when this latter is extended because of a poor LV relaxation (Figure 1, bottom). Such index can be estimated through LA phasic strain wave-decomposition as conventionally done for pressure curves to estimate forward and reflected components.

Purpose. To compare the newly proposed LA intrinsic or "true" booster index (Sla_fit) against the conventional index (Sla) in terms of associations with LV remodeling (LV mass/ LV volume), LV systolic longitudinal strain (LV_GLS), and transmitral LV filling indices in healthy controls and aortic valve stenosis (AVS) patients with preserved LV ejection fraction.

Methods. We studied 55 patients (34 AVS:71 ± 11years, 21 controls:66 ± 9years) who had an MRI exam with cine SSFP and phase contrast (PC) images. FT was applied to cine images to extract LV and LA phasic longitudinal strain and strain rates. Transmitral flow early (E, cm/s) and late (A, cm/s) filling peak velocities were calculated from PC data. To estimate intrinsic LA booster index, the LA longitudinal strain curve corresponding to the reservoir and conduit phases was fitted using two half cosine waves, to account for an eventual LA filling to LA early emptying asymmetry, while fitting the LA contraction with a full cosine wave (Figure 1). The peak of this latter wave was defined as the intrinsic LA booster strain index (Sla_fit), while the second peak of the measured LA strain was defined as the conventional LA booster strain (Sla).

Results. While conventional Sla was significantly higher than intrinsic LA booster Sla_fit in AVS patients (13.55 ± 4.26 vs. 8.09 ± 6.07, p = 0.0002), it was nearly equivalent in controls (14.34 ± 4.30 vs.13.43 ± 4.23, p =.49). But the newly proposed LA booster strain index was significantly related to LV_GLS (r=-48,p=.0004); to LV remodeling (r=-.44,p = 0.0012) as well as to transmitral flow A wave ( r=-.49, p=.0005) none of these associations were significant when considering conventional LA booster strain. Interestingly our intrinsic LA booster index Sla_fit was significantly associated with LV longitudinal strain in both controls (r=-.55,p = 0.009) and asymptomatic AVS (N = 10) (r=-.77,p = 0.0081) but not in symptomatic AVS (N = 24) (p&gt;.70). This may reveal a maintained LA-LV coupling in the asymptomatic phase and an uncoupling in the symptomatic phase, caused by elevated LV filling pressures.

Conclusions. A promising index for the quantitative evaluation of intrinsic LA booster function was proposed and its consistency was demonstrated through its significant associations with LV remodeling, LV longitudinal strain and transmitral late filling peak.

Abstract Figure.

Application of different DNA extraction procedures, library preparation protocols and sequencing platforms: impact on sequencing results

In this study three DNA extraction procedures, two library preparation protocols and two sequencing platforms were applied to analyse six bacterial cultures and their corresponding DNA obtained as part of a proficiency test. The impact of each variable on sequencing results was assessed using the following parameters: reads quality, assembly and alignment statistics; number of single nucleotide polymorphisms (SNPs), detected applying assembly- and alignment-based strategies; antimicrobial resistance genes (ARGs), identified on de novo assemblies of all sequenced genomes. The investigated nucleic acid extraction procedures, library preparation kits and sequencing platforms do not significantly affect de novo assembly statistics and number of SNPs and ARGs. The only exception was observed for two duplicates, which were associated to one PCR-based library preparation kit. Results from this comparative study can support researchers in the choice toward the available pre-sequencing and sequencing options, and might suggest further comparisons to be performed.

Total thyroidectomy associated to chemotherapy in primary squamous cell carcinoma of the thyroid

Primary squamous cell carcinoma of the thyroid (PSCCT) is a rare malignant disease with rapid fatal prognosis. The onset is generally characterized by sudden bilateral latero-cervical lymphadenopathy. The Authors report patient of 58-year-old who referred for evaluation of rapidly aggravating bilateral latero-cervical lymphadenopathy. The US highlighted the presence of a hypoechoic nodular lesion characterized by peri and intra-nodular vascularization. Multilayer CT showed diffused involvement of mediastinal and bilateral latero-cervical lymph nodes, with no evidence of primary pulmonary neoplasia or elsewhere. The patient underwent total thyroidectomy. The peri-isthmic tissue was removed due to the presence of a small roundish formation, that was due to lymph node metastasis at histological examination. Histological diagnosis: PSCCT. The immunohistochemical panel of the thyroid lesion was indispensable for the differential diagnosis between PSCCT, medullary carcinoma, anaplastic carcinoma, and thyroid metastasis of neoplasia with unknown primitiveness. The patient underwent chemotherapeutic treatment with Carboplatin and Paclitaxel with modest improvement of dysphagia symptoms and reduction of 10-15% of the target lesions. The clinical course was characterized by loco-regional progression of the disease with exitus in 10 months after diagnosis. Survival and quality of life after surgical therapy and chemotherapy were like that of patients undergoing only chemotherapy. Due to the extreme rarity of the neoplasia, 60 cases described in Literature, no exclusive guidelines are reported for PSCCT. More extensive case studies are needed to evaluate the effects of total thyroidectomy with intent R0/R1 on improving survival and quality of life of patients with PSCCT.

A Study of Sentinel Node Biopsy in T1 Breast Cancer Treatment: Experience of 48 Cases

Axillary clearance in breast cancer has been proven to be unnecessary in more than 50% of cases. Sentinel node biopsy (SNB) is a new technique that can be used to avoid unneccesary axillary clearance in breast cancer surgery. Our integrated team, consisting of surgeons, pathologists and nuclear medicine physicians, studied 48 cases of T1 breast cancer with lymphoscintigraphy-guided SNB. Before starting this study, the team performed 20 SNBs as a learning procedure. 500 μCi of 99mTc-nanocoll in 0.2 mL were injected around the lesion, under US or x-ray guidance if necessary. Static images in anterior, lateral and lateral oblique view collected at the end of a 20 min dynamic study were used to mark the SN on the skin. During surgery a gamma probe was used to guide SN resection, and node invasion was assessed with cytokeratin immunohistochemistry. In 14 patients tracer uptake was observed in a single node, in 30 patients in 2–4 nodes, whereas in four patients the nodes were scintigraphically missed. Surgical resection was possible in 42 nodes out of 54. All but two patients with negative immunohistochemistry for cancer cell clusters showed metastasis-free axillary nodes. All patients with positive SNBs (13) showed involved axilla. In four patients the lymphatic drainage was towards the intramammary chain; one node was juxtaclavicular and one node was intramammary in the upper outer quadrant. The overall sensitivity of the method was about 80%, the specificity about 90% with a diagnostic accuracy about 80%. SNB is a promising method for surgical decision-making regarding axillary clearance in breast cancer. Adequate training of an interdisciplinary team is needed in order to successfully perform SNB and assess SN invasion. Its unusual anatomic location can be encountered and technical care is necessary to correctly identify and remove them.

Bilateral hydrocele. Uncommon clinical presentation of primary testicular lymphoma in the elderly

Primary testicular lymphoma (PLT) represents 5% of testis tumors, the incidence increases in patients older than 60 years of age. Bilateral hydrocele is an unusual clinical presentation. Relapse in the central nervous system and in the contralateral testis is often observed. The US shows hypoechoic nodular lesions with a complete structural involvement of didymus and hypervascularization at Color Doppler. Orchiectomy should be performed in all cases as it is indispensable for the histopathological diagnosis and to characterize the immunophenotypic features. The most common histotype is diffuse large-B cell lymphoma. Combined biological approach and chemotherapy with rituximab and doxorubicin has radically changed the prognosis of disease. The authors report two patients of 81 and 82 years-old who referred for evaluation of massive bilateral hydrocele causing severe limitation of deambulation. Negative cytological findings for neoplastic cells in the scrotal effusion made difficult the differential diagnosis between inflammatory and malignant disease. Histopathologic findings made a diagnosis of high grade diffuse large B-cell NHL, respectively stage IV-E and stage III-E. The 82 years old patient was treated with 6 chemotherapy cycles of rituximab, cyclophosphamide, vincristine, prednisone. The exitus was dued to the umbilical hernia complications. In the 81 years old patient, cognitive deficit and severe impairment of general conditions constituted an absolute contraindication to polychemotherapy treatment. Rapid tumor progression led the patient to exitus 2 months after diagnosis. In both patients the delayed diagnosis of PLT was probably due to the reduction of welfare protection in the elderly with adverse social conditions.

Multilocus sequence typing of Arcobacter butzleri isolates collected from dairy plants and their products, and comparison with their PFGE types

AIMS

The present study aimed to determine, by multilocus sequence type (MLST), the heterogeneity level of Arcobacter butzleri isolates and to compare MLST and pulsed-field gel electrophoresis (PFGE) in terms of discriminatory power (DI) as well as unidirectional and bi-directional concordance.

METHODS AND RESULTS

Arcobacter butzleri isolates (N = 133) from dairy products and environmental samples, collected from dairy plants, were characterized by MLST and PFGE with SacII and classified in 29 sequence types (STs), 47 PFGE and 62 type strains (TS). Among the 119 alleles, 19 were previously unreported and the same for all the STs but two. A significant linkage disequilibrium was detected when the complete ST data set was analysed The DIs of MLST, PFGE and their combination were 0·937, 0·953 and 0·965 respectively. The adjusted Wallace coefficients between MLST and PFGE as well as PFGE and MLST were 0·535 and 0·720 respectively; the adjusted Rand coefficient was 0·612.

CONCLUSIONS

The A. butzleri studied population showed recombination to some degree. PFGE showed a DI higher than MLST. Both methods presented good concordance. The TS analysis seems to show persistence of the same strain on time and possible cross-contaminations between food and environmental sites.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study provides insights in the A. butzleri population found in raw milk, cheese, and dairy production plants. The data suggest that MLST and PFGE genotypes correlate reasonably well, although their combination results in optimal resolution.

Thyroid diseases in women with breast cancer

AIM

Several studies have been undertaken to investigate a possible link between breast cancer and thyroid diseases, notably thyroid carcinoma and autoimmune thyroid diseases, but the issue remains unresolved. The aim of this study is to evaluate, in thyropathic women with and without breast cancer, the following effects: the distribution of different thyroid diseases, the breast-cancer-related prevalence of anti-thyroperoxidase and anti-thyroglobulin antibodies and the role in thyroid pathology of breast-cancer post-surgery therapy with tamoxifene.

MATERIALS AND METHODS

One-hundred-ninety thyropathic women with breast cancer (BC group) were recruited, and compared with a control group (C group) of one-hundred-ninety thyropathic women without breast cancer.

RESULTS

Nodular disease is the most frequent pathology in both groups. The difference in the incidence of thyroid carcinoma is also not statistically significant. The biochemical increase in the positivity of autoantibodies in BC-group patients is confirmed, but there is no statistically significant difference in the rate of clinical autoimmune diseases between the two groups. No difference in the frequency of any particular thyroid disease is found between those patients who underwent post-operative tamoxifene therapy and those who did not.

CONCLUSION

It can be concluded, on the basis of these results, that it is advisable to reduce the clinical weight of the issue. A routine thyroid screening is recommended in women with BC for the management of chronic comorbidities, as would be for women in the general population having the same age and coming from the same iodine-intake area.

Evaluation of E6 and E7 mRNA expression in HPV DNA positive breast cancer

Several studies have suggested a possible role for HPV in the pathogenesis of the breast cancer. We investigated the presence of the HPV DNA in breast cancers and non malignant disease breast tissues by the use of a standard HPV detection method (INNO-Lipa HPV), in order to detect HPV DNA in metastatic nodes, to investigate a possible cervical HPV co-infection, and to evaluate the E6/E7 mRNA expression in HPV DNA positive breast cancer tissues. The rate of HPV infection was significantly higher in the cancer group than in controls (9/31 vs. 0/12, p = 0.04). One out of eight metastatic axillary nodes was positive for HPV infection; 2/3 of the positive HPV breast cancer patients were co-infected at the cervical site. The role of the virus in breast oncogenesis is still unclear, since our analysis failed in demonstrating the expression of viral E6 and E7 in positive HPV positive breast tumor tissues.

[Hormone replacement therapy after total thyroidectomy. Can the combined treatment be considered effective to get metabolic adequacy? Preliminary results]

INTRODUCTION

Even if T4 is standard treatment for hypothyroidism after thyroidectomy, a treatment with T4 plus T3 has been proposed as an alternative reproducing carefully the physiology of the thyroid. We performed an observational study about the effects of the combined replacement therapy with T4 and T3 in patients who underwent total thyroidectomy.

PATIENTS AND METHODS

Fifty thyroidectomized patients (not for cancer), in T4 replacement therapy, were included in the study. Such a therapy has been changed by administering T3 and T4 in proportion 1/16. Adverse effects, clinical parameters and general health perceptions (SF36 Questionnaire) have been considered at the time of enrollment (T0), after 30 days (T1) and after 60 days (T2).

RESULTS

No differences in weight, cardiac frequency and blood pression have been found between T0 and T2. A not statistically significant reduction has been found in total cholesterol (3 mg/dL) and triglycerides (3.29 mg/dL) levels. A reduction of complaints referred by the patients at T0 has been revealed in T2: anxiety from 21 to 13 patients; headache from 22 to 13; tiredness from 17 to 8 (p<0.05); sleepiness from 25 to 15 (p<0.05). About the questionnaire, in the General Health Perception sub-score has been found a not significant increase of the parameter.

DISCUSSION AND CONCLUSIONS

T4 replacement therapy is of proved efficacy, notwithstanding some complaints afflict a share of patients. To improve the quality of life of these patients, we consider relevant the reduction of complaints and the improvement of well-being and cognitive function obtained by the combined T4 and T3 treatment. Moreover, even if the production of T3 from T4 usually ensures euthyroidism in all tissues, contemporary pathologies and alterations determined by the oldness can disturb the enzymatic activity, which is the essential requirement of T4 therapy. These preliminary findings in a small group of patients encourage further studies on a larger patient population.

Clostridium perfringens occurrence and ribotypes in healthy broilers reared in different European countries

The main aim of this study was to investigate the occurrence and ribotypes of Clostridium perfringens in broiler flocks reared in 2 European countries that apply European Union Regulation 1831/2003. A total of 1,532 cecum contents were collected between June 2005 and November 2006 from birds belonging to 51 intensively reared flocks produced in the Czech Republic and 41 intensive production, organic, and free-range flocks reared in Italy. Clostridium perfringens was detected in 64.7 and 82.9% of the Czech Republic and Italian flocks, respectively, at mean loads ranging between 3.65 and 4.77 log10 cfu per gram of cecum content. More than 1 ribotype was identified among isolates belonging to the same flock in 57.1 and 76.5% of the Czech Republic and Italian flocks, respectively. Moreover, common ribotypes were identified between strains belonging to 2 up to 8 different flocks. In particular, 4 ribotypes were shared between strains isolated in the 2 European countries. The results of this study report on C. perfringens occurrence and mean populations in broilers reared on diets devoid of antibiotic growth promoters. Moreover, these findings show for the first time the presence of common ribotyping profiles among isolates collected from birds reared more than 1,000 km apart.

[Tissue attenuation in small animals on contrast enhanced ultrasound]

Despite recent advances in contrast-enhanced ultrasound imaging, evaluation of tissue perfusion with contrast-enhanced ultrasound is still impaired by shadowing effects. These effects are particularly relevant in small animal studies due to high frequency imaging. Current methods of tissue attenuation correction are not suited for contrast-enhanced ultrasound examinations, because microbubble acoustic response to ultrasound waves is far more complex than that of tissues. A method allowing in vivo tissue attenuation correction in the presence of contrast agents is presented.

Risk of mortality from cardiovascular and respiratory causes in patients with chronic obstructive pulmonary disease submitted to follow-up after lung resection for non-small cell lung cancer

AIM

Considerable controversy surrounds mortality from non-neoplastic diseases during the postoperative follow-up of patients with non-small cell lung cancer (NSCLC) and chronic obstructive pulmonary disease (COPD). This study investigated the incidence of mortality from cardiovascular and respiratory (CVR) causes in patients with COPD submitted to follow-up after lung resection for NSCLC, and identified preoperative and postoperative risk factors.

METHODS

A total of 398 patients with mild or moderate COPD were followed up in our department after lung resection for NSCLC (median follow-up 61 months). Statistical analysis of the data was carried out to determine the incidence and the prognostic factors of postoperative death from CVR causes.

RESULTS

Of the 398 resected patients, 186 survived without tumor recurrence; 24/186 (12.9%) died of CVR causes (acute respiratory failure, pneumonia, pulmonary embolism, acute pulmonary edema, acute myocardial ischemia or stroke). These 24 patients had a higher frequency of pre-existing coronary artery disease or heart failure (P=0.0003), predicted postoperative FEV1 <1000 mL (P=0.0008), exertional dyspnea (P=0.0000), and 30-day operative cardiopulmonary complications (P=0.001). Protective features were young age (<40 years), early stage disease, and minor resection (lobectomy). Independently significant adverse prognostic factors were stage III-IV disease (cumulative CVR death rate 47% at 5-10 years; P=0.028 vs. stage I-II) and completion pneumonectomy or partial resection of the other lung for a second primary tumor (cumulative CVR death rate 50% and 57%, respectively, at 5-10 years; P=0.0016 vs. all other resections). Older age and tumor histology were significant risk factors only in patients with advanced stage disease.

CONCLUSION

The findings suggest that postoperative CVR death may be expected in patients with COPD and advanced stage NSCLC or in those undergoing completion pneumonectomy or partial resection of the other lung for a second primary tumor. Other risk factors are previous coronary artery disease and/or heart failure, exertional dyspnea and predicted postoperative FEV1 <1000 mL.

Enumeration and identity of Campylobacter spp. in Italian broilers

Transmission of Campylobacter to humans has been prominently associated with mishandling or improperly preparing contaminated poultry carcasses. The number of organisms per carcass represents an important measure of human exposure to the agent. Therefore, we wished to estimate this public exposure over 1 yr among Italian broiler carcasses. We sampled 213 broiler carcasses from rinse water samples collected from a single slaughterhouse. Groups of carcasses had mean processed weights ranging from 1.2 to 2.7 kg. These were produced from 22 commercial broiler chicken flocks collected from 12 different farms, 3 of which were seasonally tested. Carcasses were rinsed with sterile water, and the rinse suspension was then serially diluted and spread-plated directly onto Campy-Cefex agar plates. One to 5 typical Campylobacter colonies per plate were identified by polymerase chain reaction as Campylobacter thermo-tolerant species. The overall estimated mean count per carcass in our study was 5.16 +/- 0.80 log10 cfu. This value increased in summer and autumn, as well as on carcasses collected from farms located > 100 km far from the slaughterhouse. A total of 678 Campylobacter colonies were identified by polymerase chain reaction. The majority of isolates were classified as Campylobacter jejuni (49.2%) or Campylobacter coli (47.5%). The overall number of C. jejuni was significantly higher on 1) carcasses weighing > 2 kg, 2) carcasses belonging to flocks with > 10,000 birds, and 3) carcasses collected from farms located > 100 km from the slaughterhouse. Moreover, among farms tested seasonally, C. jejuni was significantly greater than C. coli in winter. These data provide the first results of a continuing survey on Campylobacter loads and species identification from Italian broiler carcasses and represents an important baseline to estimate the human exposure to Campylobacter in Italy.

Assessment of left ventricular contraction by parametric analysis of main motion (PAMM): theory and application for echocardiography

The computerized study of the regional contraction of the left ventricle has undergone numerous developments, particularly in relation to echocardiography. A new method, parametric analysis of main motion (PAMM), is proposed in order to synthesize the information contained in a cine loop of images in parametric images. PAMM determines, for the intensity variation time curves (IVTC) observed in each pixel, two amplitude coefficients characterizing the continuous component and the alternating component; the variable component is generated from a mother curve by introducing a time shift coefficient and a scale coefficient. Two approaches, a PAMM data driven and a PAMM model driven (simpler and faster), are proposed. On the basis of the four coefficients, an amplitude image and an image of mean contraction time are synthesized and interpreted by a cardiologist. In all cases, both PAMM methods allow better IVTC adjustment than the other methods of parametric imaging used in echocardiography. A preliminary database comprising 70 segments is scored and compared with the visual analysis, taken from a consensus of two expert interpreters. The levels of absolute and relative concordance are 79% and 97%. PAMM model driven is a promising method for the rapid detection of abnormalities in left ventricle contraction.

Phage types, ribotypes and tetracycline resistance genes of Salmonella enterica subsp. enterica serovar Typhimurium strains isolated from different origins in Italy

The tetracycline resistance (tet) gene patterns of 52 tetracycline resistant Salmonella enterica subsp. enterica (S.) serovar Typhimurium isolates collected from animals, food of animal origin, and humans in Italy, were investigated to evaluate whether the tet gene patterns could be used for strain differentiation in addition to phage typing and ribotyping. The detection of tet genes was performed by specific PCR assays. Ribotyping was performed automatically using PvuII as restriction enzyme. Ten different ribotyping patterns were detected. All isolates were positive for at least one of the tet genes studied and six different tet gene patterns were observed. Ribotyping and tet gene patterns showed discriminatory indices of 0.741 and 0.812, respectively. Multiple tet genes were commonly found among tetracycline resistant S. typhimurium isolates from various sources. The resulting tet gene patterns allowed further discrimination of strains which were otherwise indistinguishable by their phage type, ribotype and origin. Thus, the analysis of tet gene patterns might represent an additional tool for the differentiation of S. typhimurium isolates.

Local reconstruction of stenosed sections of artery using multiple MRA acquisitions

A method for reconstructing magnetic resonance angiography (MRA) volumes from successive acquisitions is described. The method is based on double oblique acquisitions of highly anisotropic MRA volumes, each of which corresponds to reduced k-space filling. These partial k-spaces are then combined to obtain a 3D k-space adapted to the frequency spread of the angiographic image of the stenosis. The SNR-resolution compromise of MRA is thus improved by focusing the acquisition on the most relevant k-space regions. The reconstruction is performed directly in k-space by averaging the partial k-spaces. The feasibility of the method was demonstrated in studies on a Lucite stenosis phantom, on MRAs of carotid arteries using three bolus injections, and on MRAs of renal arteries using a single contrast injection.

Subcutaneous metastasis of pancreatic cancer in the site of percutaneous biliary drainage

A subcutaneous metastatic lesion from a carcinoma of the pancreas or common bile-duct along the tract of a percutaneous transhepatic biliary drainage is a rare finding. Prompted by a case that came to our observation by chance, we reviewed the literature and analysed the 29 cases collected. Neoplastic cell seeding along a percutaneous drainage tract, albeit rare, must be kept in mind. The complication can be avoided if patients at risk, whenever possible, undergo endoscopic drainage.

Prognostic significance of primary-tumor extension, stage and grade of nuclear differentiation in patients with renal cell carcinoma

Surgery remains the preferred therapy for renal cell carcinoma. The various adjunctive or complementary therapies currently yield disappointing results. Identifying reliable prognostic factors could help in selecting patients most likely to benefit from postoperative adjuvant therapies. We reviewed the surgical records of 78 patients who had undergone radical nephrectomy with lymphadenectomy for renal cell carcinoma, matched for type of operation and histology. According to staging (TNM), 5.1% of the patients were classified as stage I, 51.3% as stage II, 29.5% as stage III and 14.5% as stage IV. Of the 78 patients 40 were T2N0 and 21 T3aN0. Tumor grading showed that 39.7% of the patients had well-differentiated tumors(G1), 41.1% moderately-differentiated (G2), and 19.2% poorly-differentiated tumors (G3). Overall actuarial survival at 5 and 10 years was 100% for stage 1; 91.3% at 5 years and 83.1% at 10 years for stage II; 45.5% and 34.1% for stage III; and 29.1% and nil for stage IV (stage II vs stage III p = 0.0001). Patients with tumors confined to the kidney (pT2N0) had better 5- and 10-year survival rates than patients with tumors infiltrating the perirenal fat (pT3aN0) (p = 0.000006). Survival differed according to nuclear grading (G1 vs G3 ; p = 0.000005; G2 vs G3; p = 0.0009). In conclusion our review identified tumor stage, primary-tumor extension, and the grade of nuclear differentiation as reliable prognostic factors in patients with renal cell carcinomas.

[Apudoma of Vater's ampulla: case report and review of the literature]

The Authors report a case of Vater's ampulla apudoma and after having examined the characteristics of these neoplasms they discuss clinical presentation, diagnostic and treatment problems of islet cell adenomas. They review the literature and make some remarks.

[Retroperitoneal leiomyosarcoma: clinical case]

The Authors have reported a case of retroperitoneal leiomyosarcoma. The retroperitoneal localization is quite unusual and early diagnosis is difficult. Only surgery operation and radio-chemotherapy can improve the prognosis. Tumor size is the major prognostic factor.

Validation of myocardial perfusion reserve measurements using regularized factor images of H(2)(15)O dynamic PET scans

The use of H(2)(15)O PET scans for the measurement of myocardial perfusion reserve (MPR) has been validated in both animal models and humans. Nevertheless, this protocol requires cumbersome acquisitions such as C(15)O inhalation or (18)F-FDG injection to obtain images suitable for determining myocardial regions of interest. Regularized factor analysis is an alternative method proposed to define myocardial contours directly from H(2)(15)O studies without any C(15)O or FDG scan. The study validates this method by comparing the MPR obtained by the regularized factor analysis with the coronary flow reserve (CFR) obtained by intracoronary Doppler as well as with the MPR obtained by an FDG acquisition.

METHODS

Ten healthy volunteers and 10 patients with ischemic cardiopathy or idiopathic dilated cardiomyopathy were investigated. The CFR of patients was measured sonographically using a Doppler catheter tip placed into the proximal left anterior descending artery. The mean velocity was recorded at baseline and after dipyridamole administration. All subjects underwent PET imaging, including 2 H(2)(15)O myocardial perfusion studies at baseline and after dipyridamole infusion, followed by an FDG acquisition. Dynamic H(2)(15)O scans were processed by regularized factor analysis. Left ventricular cavity and anteroseptal myocardial regions of interest were drawn independently on regularized factor images and on FDG images. Myocardial blood flow (MBF) and MPR were estimated by fitting the H(2)(15)O time-activity curves with a compartmental model.

RESULTS

In patients, no significant difference was observed among the 3 methods of measurement-Doppler CFR, 1.73 +/- 0.57; regularized factor analysis MPR, 1.71 +/- 0.68; FDG MPR, 1.83 +/- 0.49-using a Friedman 2-way ANOVA by ranks. MPR measured with the regularized factor images correlated significantly with CFR (y = 1.17x - 0.30; r = 0.97). In the global population, the regularized factor analysis MPR and FDG MPR correlated strongly (y = 0.99x; r = 0.93). Interoperator repeatability on regularized factor images was 0.126 mL/min/g for rest MBF, 0.38 mL/min/g for stress MBF, and 0.34 for MPR (19% of mean MPR).

CONCLUSION

Regularized factor analysis provides well-defined myocardial images from H(2)(15)O dynamic scans, permitting an accurate and simple measurement of MPR. The method reduces exposure to radiation and examination time and lowers the cost of MPR protocols using a PET scanner.

[Inguinal hernia surgery. Review of a caseload and description of a technique variation]

BACKGROUND

To evaluate the efficacy of the tension free surgical technique for the treatment inguinal hernia.

METHODS

The authors propose personal experience of 172 patients, treated for inguinal hernia in the period from 1986 to 1993, selecting two patients groups. In the first group the patients (80 cases) were treated with traditional hernioplasty, in the second group (92 cases) hernioplasty tension-free was performed.

RESULTS

In the first group 6 cases of recurrence (6.7%), have been observed and in the second group only one case.

CONCLUSIONS

The results obtained, and literature survey show the advantages of hernioplasty tension-free.

Automated ribotyping and random amplified polymorphic DNA analysis for molecular typing of Salmonella enteritidis and Salmonella typhimurium strains isolated in Italy

AIMS

The ability of automated ribotyping and random amplified polymorphic DNA (RAPD) analysis to differentiate Salmonella enteritidis and Salmonella typhimurium isolates in relation to their origin was evaluated.

METHODS AND RESULTS

The restriction enzymes EcoRI, PvuII and PstI, and the random primers OPB17 and P1254, were tested for ribotyping and RAPD analysis, respectively. Seventeen subtypes were identified among the isolates of the two pathogenic Salmonella serovars using the RiboPrinter, and 25 subtypes using RAPD.

CONCLUSIONS

The greatest degree of genetic diversity was observed among Salm. typhimurium isolates using both automated ribotyping (Simpson's index of discrimination 0878) and RAPD (Simpson's index of discrimination 0886).

SIGNIFICANCE AND IMPACT OF THE STUDY

According to the results of this research, automated ribotyping and RAPD are two useful genotyping techniques for identifying unique and common subtypes associated with a specific source and location, and provide powerful tools for epidemiological investigations.

[Lipoma of the small intestine: a rare cause of intestinal invagination]

Lipomas are an uncommon cause of small-bowel obstruction. The symptoms are intermittent and nonspecific. The Authors report a case in which intussusception was diagnosed with echography and the obstruction was treated with resection. They conclude that lipomas must always be considered in the differential diagnosis of intrabdominal neoplasms and in intestinal obstructions.

Automated ribotyping using different enzymes to improve discrimination of Listeria monocytogenes isolates, with a particular focus on serotype 4b strains

To develop improved automated subtyping approaches for Listeria monocytogenes, we characterized the discriminatory power of different restriction enzymes for ribotyping. When 15 different restriction enzymes were used for automated ribotyping of 16 selected L. monocytogenes isolates, the restriction enzymes EcoRI, PvuII, and XhoI showed high discriminatory ability (Simpson's index of discrimination > 0.900) and produced complete and reproducible restriction cut patterns. These three enzymes were thus evaluated for their ability to differentiate among isolates representing the two major serotype 4b epidemic clones, those having ribotype reference pattern DUP-1038 (51 isolates) and those having pattern DUP-1042 (20 isolates). Among these isolates, PvuII provided the highest discrimination for a single enzyme (nine different subtypes; index of discrimination = 0.518). A combination of PvuII and XhoI showed the highest discriminatory ability (index of discrimination = 0.590) for these isolates. A group of 44 DUP-1038 isolates and a group of 12 DUP-1042 isolates were identical to each other even when the combined data for all three enzymes were used. We conclude that automated ribotyping using different enzymes allows improved discrimination of L. monocytogenes isolates, including epidemic serotype 4b strains. We furthermore confirm that most of the isolates representing the genotypes linked to the two major epidemic L. monocytogenes clonal groups form two genetically homogeneous groups.

Adaptive and self-evaluating registration method for myocardial perfusion assessment

With the advent of ultra-fast MRI, it is now possible to assess non-invasively regional myocardial perfusion with multislice coverage and sub-second temporal resolution. First-pass contrast enhanced studies are acquired with ECG-triggering and breath holding. Nevertheless, some respiratory induced movements still remain. Myocardial perfusion can be assessed locally by parametric imaging methods such as Factor Analysis of Medical Image Sequences (FAMIS), provided that residual motion can be corrected. An a posteriori registration method implemented in the image domain is proposed. It is based on an adaptive registration model of the heart combining three elementary shapes (left ventricle, right ventricle and pericardium). The registration procedure is performed on a potential map derived from the distance map. To evaluate the quality of the registration procedure a superimposition score between the registration model and the contour automatically extracted in the sequence is proposed. Rigid transformation hypotheses and registration analysis provide an efficient and automatic method which allows the rejection of outlier images, such as: out of synchronisation images, out of plane acquisitions. When compared to a manual registration method, this approach reduces processing time and requires a minimal intervention from the operator. The proposed method performs registration with a subpixel accuracy. It has been successfully applied to simulated images and clinical data. It should facilitate the use of MR first-pass perfusion studies in clinical practice.

[Biliary-intestinal bypass in the treatment of severe obesity: personal experience with 23 patients]

BACKGROUND

The aim of this study was to determine the efficacy and safety of biliary-intestinal bypass in severely obese subjects (Body Mass Index > 35).

METHODS

From January to December 1999, 23 patients (8 men and 15 women, mean age 36.6 years: range 20-51) affected with primary morbid obesity (BMI >40: range 40.1-64.7), in whom different attempt using conservative medicine have proved non-resolutive, underwent biliary-intestinal bypass. After the operation all the patients have been followed- up for 12 months.

RESULTS

The mean Body Mass Index was reduced to 36.9 (range 27.7-44.1) after 6 months and to 33 (range 24.9-40.1) after 12 months. Peri and postoperative mortality was zero. Excessive malabsorption was efficaciously controlled by adequate replacement therapy. Diarrhoea, common compliance of every operation inducin malabsorbition, was reduced to 2-3 evacuation a day after 2-3 months.

CONCLUSIONS

On the basis of personal experience it is underlined that biliary-intestinal bypass, as surgical treatment of morbid obesity refractory to medical therapy, is today a safe and effective operation (up to 80% of excess body weight lose); the presence of biliary-intestinal anastomosis reduces the post-operative loss of bile acids, choleretic diarrhoea and electrolytic disorders.

Isolated intestinal neurofibromatosis of colon. Single case report and review of the literature

Isolated intestinal neurofibromatosis of the colon is a most unusual disease: from 1937 to 1999 only 12 cases have been reported. The differential diagnosis and treatment of this lesion are very difficult. A review of the literature is made and personal experience in the diagnosis and treatment of a case in a 68-year-old female is described.

Diagnosis controversies for adrenal ganglioneuroma

The authors report a case of adrenal ganglioneuroma which was incidentally diagnosed performing preoperative examination for a sigmoid carcinoma. The authors took this finding as a starting point to underline the rarity of this condition and its chance discovery, this being due to the rare presence of signs and symptoms and its frequent association with other synchronous neoplasms; all this makes differential diagnosis rather difficult.

Small bowel schwannoma with diffuse subcutaneous lipomatosis. Case report and literature review

A case of a small-bowel schwannoma with diffuse familiar lipomatosis is described. This case underlines the rarity of the neoplasm and its probably chance association with subcutaneous lipomatosis. The intestinal neoplasm was diagnosed preoperatively by upper gastrointestinal endoscopy and a small-bowel enema; computed tomography scan confirmed the intestinal lesion. Attention is focused on the morphological features of intestinal schwannomas and their biological behaviour.

Spatial regularization of flow patterns in magnetic resonance velocity mapping

A technique dedicated to spatial regularization of magnetic resonance (MR) velocity data has been implemented to improve flow image quality. It is assumed that neighboring flow-velocity pixels are partially correlated, although large-velocity discontinuities remain possible. Increasing MR signal magnitude due to the in-flow effect also is used to enhance further reliability of the estimated velocity. By using an eight-step Fourier-encoding approach, 162 "reference" velocity images acquired in the ascending aorta from six healthy volunteers were compared with "raw" and "regularized" images that were computed from only two gradient steps. The mean square error decreased from 0.12 m(2) x s(-2) to 0.06 m(2) x s(-2) (P < 10-9) for velocity pixel values and from 1929 ml(2) x s(-2) to 1336 ml(2) x s(-2) (P < 0.01) for instantaneous flow rates. The regularization of two-step data sets provides the same velocity image quality as that found after using three-step data sets without regularization. The method can be applied to phase-velocity data sets of any MR technique to reduce velocity noise. J. Magn. Reson. Imaging 1999;10:851-860.

Neuroendocrine tumors of the gastroenteric canal. Anatomopathological and diagnostic-therapeutic definition. Description of a case with a rare cecal localisation

The authors take the case of a neuroendocrine tumour of the cecum as the starting point for an analysis of the anatomopathological and diagnostic-therapeutic aspects of these neoplasms. Furthermore, the authors underline that neuroendocrine tumours (NET) of the colon represent an extremely rare nosological entity and that they are heterogeneous from a clinical and biochemical point of view, thus making a reliable preoperative diagnosis a problem that is still difficult to resolve today.

Spatial regularization applied to factor analysis of medical image sequences (FAMIS)

Dynamic image sequences allow physiological mechanisms to be monitored after the injection of a tracer. Factor analysis of medical image sequences (FAMIS) hence creates a synthesis of the information in one image sequence. It estimates a limited number of structures (factor images) assuming that the tracer kinetics (factors) are similar at each point inside the structure. A spatial regularization method for computing factor images (REG-FAMIS) is proposed to remove irregularities due to noise in the original data while preserving discontinuities between structures. REG-FAMIS has been applied to two sets of simulations: (a) dynamic data with Gaussian noise and (b) dynamic studies in emission tomography (PET or SPECT), which respect real tomographic acquisition parameters and noise characteristics. Optimal regularization parameters are estimated in order to minimize the distance between reference images and regularized factor images. Compared with conventional factor images, the root mean square error between regularized images and reference factor images is improved by 3 for the first set of simulations, and by about 1.5 for the second set of simulations. In all cases, regularized factor images are qualitatively and quantitatively improved.

[The usefulness and limits of echo-endoscopy in the clinical staging of esophageal cancer]

Endoscopic ultrasonography (EUS) is a diagnostic method of considerable value for the local staging of esophageal cancer, in particular for T and N evaluation. After an extensive review of the literature, the authors underline the possibility of using EUS to improve the treatment and prognosis of esophageal neoplasms based on the use of various stage-dependent therapeutic strategies. EUS is regarded as a gold-standard technique for esophageal cancer staging in order to select appropriate treatment options, but is currently hampered by the intrinsic difficulty and subjectivity of interpreting ultrasonographic images. In order to ensure safe and reliable data, EUS must be carried out by operators who have undergone suitable training at a specialised centre.

[A case of thymoma: histological and diagnostic aspects and surgical considerations]

The histological and diagnostic features of a thymoma case observed recently have been investigated in the present study. Comparing the case under investigation with the literature, the Authors conclude that the proper surgical approach is that indicated by Jaretsky. By means of a longitudinal sternotomy associated with minimal cervical incision, the whole mediastinal cellular tissue together with that of the thyroid inferior poles is easily removed. Moreover oncological and myastenic recurrences have a very low incidence in cases surgically treated with this procedure.

Neuroendocrine tumors of the gastroenteric canal. Anatomopathological and diagnostic-therapeutic definition. Description of a case with a rare cecal localisation

The authors take the case of a neuroendocrine tumour of the cecum as the starting point for an analysis of the anatomopathological and diagnostic-therapeutic aspects of these neoplasms. Furthermore, the authors underline that neuroendocrine tumours (NET) of the colon represent an extremely rare nosological entity and that they are heterogeneous from a clinical and biochemical point of view, thus making a reliable preoperative diagnosis a problem that is still difficult to resolve today.