POS1228 THE ROLE OF CHEST CT IN UNDERSTANDING INTERSTITIAL LUNG DISEASE (ILD): SYSTEMIC SCLEROSIS (SSc). VERSUS COVID-19

Background:

COVID-19 pandemic is a global emergency which may overlap on the clinical and radiological scenario of ILD in SSc. In clinical practice, the striking similarities observed at computed tomography (CT) between the diseases make it difficult to distinguish a COVID-19 superinfection from a progression of SSc-ILD.

Objectives:

The aim of our study was to identify the main CT features that may help distinguishing SSc-ILD from COVID-19 pneumonia.

Methods:

22 international readers were included and divided in the radiologist group (RAD) and non-radiologist group (nRAD). The RAD group included non-chest RAD and chest-RAD. A total of 99 patients, 52 with COVID-19 and 47 with SSc-ILD, were included in the study.

Results:

Fibrosis inside focal ground glass opacities (GGO) in the upper lobes; fibrosis in the lower lobe GGO; reticulations in lower lobes (especially if bilateral and symmetrical or associated with signs of fibrosis) were the CT parameters most frequently associated with SSc-ILD. The CT parameters most frequently associated with COVID- 19 pneumonia were: consolidation (CONS) in the lower lobes, CONS with peripheral (both central/peripheral or patchy distributions), anterior and posterior CONS and rounded-shaped GGOs in the lower lobes. After multivariate analysis, the presence of CONS in the lower lobes (p <0.0001) and signs of fibrosis in GGO in the lower lobes (p <0.0001) remained independently associated with COVID-19 pneumonia or SSc-ILD, respectively. These two variables were combined in a predictive score which resulted positively associated with the COVID-19 diagnosis, with 96.1% sensitivity and 83.3% specificity: 3 different risk class for COVID-19 pneumonia may be identified: high risk for COVID-19 pneumonia (5-9 points); probable overlap COVID-19 pneumonia in SSc-ILD (4 points); low risk for COVID-19 pneumonia (0-3 points).

Conclusion:

The CT differential diagnosis between COVID-19 Pneumonia and SSc-ILD is possible and may be fostered in practice by the use of a radiological score. In the case where an overlap of both diseases is suspected, the presence of consolidation in the lower lobes may suggest a COVID-19 pneumonia while the presence of fibrosis inside GGO may indicate a SSc-ILD.

References:

[1]Orlandi M, Landini N, Bruni C, et al. Infection or autoimmunity? The clinical challenge of interstitial lung disease in systemic sclerosis during COVID 19 pandemic. J Rheumatol. 2020 Dec 1: jrheum.200832

[2]Simpson S, Kay FU, Abbara S, et al. Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA [published online ahead of print, 2020 Apr 28]. J Thorac Imaging. 2020;10.1097/RTI.0000000000000524.

[3]Cheng C, Li C, Zhao T, et al. COVID-19 with rheumatic diseases: a report of 5 cases. Clin Rheumatol. 2020;39(7):2025-2029.

[4]Mariano RZ, Rio APTD, Reis F. Covid-19 overlapping with systemic sclerosis. Rev Soc Bras Med Trop. 2020 Sep 21;53:e20200450.

Disclosure of Interests:

None declared

The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice

Novel coronavirus 2019 is a single-stranded, ribonucleic acid virus that has led to an international pandemic of coronavirus disease 2019. Clinical data from the Chinese outbreak have been reported, but experiences and recommendations from clinical practice during the Italian outbreak have not. We report the impact of the coronavirus disease 2019 outbreak on regional and national healthcare infrastructure. We also report on recommendations based on clinical experiences of managing patients throughout Italy. In particular, we describe key elements of clinical management, including: safe oxygen therapy; airway management; personal protective equipment; and non-technical aspects of caring for patients diagnosed with coronavirus disease 2019. Only through planning, training and team working will clinicians and healthcare systems be best placed to deal with the many complex implications of this new pandemic.

Transanal Endoscopic Operation under spinal anaesthesia

Background

Transanal Endoscopic Operation (TEO®) for rectal benign lesions and early rectal cancer may provide better oncological outcomes than flexible endoscopy. The major advantage of flexible endoscopy is that it does not require general anaesthesia. This prospective observational study assessed the feasibility and safety of TEO® performed under spinal anaesthesia.

Methods

The study population comprised eligible consecutive patients who underwent TEO® under spinal anaesthesia with curative or palliative intent for rectal neoplasms larger than 20 mm in diameter or for recurrent lesions of any size. The primary endpoints were feasibility and safety; secondary endpoints were postoperative pain, as measured on a visual analogue scale, heart rate, systolic and diastolic BP, opioid requested, postoperative nausea or vomiting, and urinary retention.

Results

The study included 50 patients (median age 70 years; 29 men and 21 women). No intraoperative complications occurred. The median duration of operation was 60 (range 20–165) min. No opioids were requested during the perioperative or postoperative period. The median postoperative pain score was 0 at 4, 8, 24 and 48 h after surgery. There were no significant fluctuations in heart rate, systolic and diastolic BP up to 48 h after the procedure (P = 0·379, P = 0·386 and P = 0·617 respectively). Postoperative nausea and vomiting occurred in one patient, and urinary retention in four.

Conclusion

TEO® under spinal anaesthesia was safe and feasible with no conversions to general anaesthesia.

Phase transitions in strongly coupled three-dimensional Z(N) lattice gauge theories at finite temperature

We perform an analytical and numerical study of the phase transitions in three-dimensional Z(N) lattice gauge theories at finite temperature for N>4, exploiting equivalence of these models with a generalized version of the two-dimensional vector Potts models in the limit of vanishing spatial coupling. In this limit the Polyakov loops play the role of Z(N) spins. The effective couplings of these two-dimensional spin models are calculated explicitly. It is argued that the effective spin models have two phase transitions of BKT type. This is confirmed by large-scale Monte Carlo simulations. Using a cluster algorithm we locate the position of the critical points and study the critical behavior across both phase transitions in details. In particular, we determine various critical indices and compute the helicity modulus, the average action, and the specific heat. A scaling formula for the critical points with N is proposed.

Phase transitions in two-dimensional Z(N) vector models for N>4

We investigate both analytically and numerically the renormalization group equations in two-dimensional (2D) Z(N) vector models. The position of the critical points of the two phase transitions for N>4 is established and the critical index ν is computed. For N=7 and 17 the critical points are located by Monte Carlo simulations, and some of the corresponding critical indices are determined. The behavior of the helicity modulus is studied for N=5, 7, and 17. Using these and other available Monte Carlo data we discuss the scaling of the critical points with N and some other open theoretical problems.

Inhibition of Notch3 signalling induces rhabdomyosarcoma cell differentiation promoting p38 phosphorylation and p21(Cip1) expression and hampers tumour cell growth in vitro and in vivo

Rhabdomyosarcoma (RMS) is a paediatric soft-tissue sarcoma arising from skeletal muscle precursors coexpressing markers of proliferation and differentiation. Inducers of myogenic differentiation suppress RMS tumourigenic phenotype. The Notch target gene HES1 is upregulated in RMS and prevents tumour cell differentiation in a Notch-dependent manner. However, Notch receptors regulating this phenomenon are unknown. In agreement with data in RMS primary tumours, we show here that the Notch3 receptor is overexpressed in RMS cell lines versus normal myoblasts. Notch3-targeted downregulation in RMS cells induces hyper-phosphorylation of p38 and Akt essential for myogenesis, resulting in the differentiation of tumour cells into multinucleated myotubes expressing Myosin Heavy Chain. These phenomena are associated to a marked decrease in HES1 expression, an increase in p21^Cip1 level and the accumulation of RMS cells in the G1 phase. HES1-forced overexpression in RMS cells reverses, at least in part, the pro-differentiative effects of Notch3 downregulation. Notch3 depletion also reduces the tumourigenic potential of RMS cells both in vitro and in vivo. These results indicate that downregulation of Notch3 is sufficient to force RMS cells into completing a correct full myogenic program providing evidence that it contributes, partially through HES1 sustained expression, to their malignant phenotype. Moreover, they suggest Notch3 as a novel potential target in human RMS.

Impacts of marine aquaculture at large spatial scales: evidences from N and P catchment loading and phytoplankton biomass

While several studies point at off-shore aquaculture as a possible source of impacts on the local marine environment, very few have analysed its effects at large scales such as at the bay, gulf or basin levels. Similar analyses are hampered by the multiple sources of disturbance that may concomitantly affect a given area. The present paper addresses these issues taking the Gulf of Castellammare (Southern Tyrrhenian Sea) as an example. Nitrogen (N) and phosphorous (P) loads were calculated for the period 1970-2007, and compared to chlorophyll-a concentration as measured inside and outside the Gulf over the same period. Results indicate that N and P catchment loading has constantly decreased because of improved environmental management. Nevertheless, nutrient concentration in the Gulf has steadily increased since the establishment of aquaculture facilities in 1999. Chlorophyll-a concentration followed this trend, showing a marked increase from 2001 onwards. In the same period, chlorophyll-a concentrations measured inside and outside the Gulf have significantly diverged. As all the other possible causes can be ruled out, aquaculture remains the sole explanation for the observed situation. This paper demonstrates for the first time ever that off-shore aquaculture may affect the marine ecosystem well beyond the local scale and provides an additional element of concern to be kept into consideration when allocating oceans' space for new fish-farming activities.

Role of chest radiography in the diagnosis of allergic bronchopulmonary aspergillosis in adult patients with cystic fibrosis

PURPOSE

This study aimed to verify the usefulness of chest radiography in the diagnosis of allergic bronchopulmonary aspergillosis (ABPA) in adult patients with cystic fibrosis.

MATERIALS AND METHODS

Eleven patients (with a total of 14 episodes) affected by ABPA were selected from among subjects attending a Regional Cystic Fibrosis Centre. For each episode, we retrospectively reviewed the baseline chest radiographs obtained before the diagnosis of ABPA, those obtained during the course of ABPA and those obtained during follow-up. Radiographs were assessed for the presence of bronchial wall thickening, bronchiectasis, infiltrates, atelectasis, mucoid impaction, lymphadenopathy, pleural effusion and fluid levels. Radiographic findings that had appeared at the time of ABPA diagnosis and disappeared after treatment were considered related to ABPA and thus useful for a correct diagnosis of the disease. Chest radiograph abnormalities were compared with changes on the respiratory function tests [forced expiratory volume in 1 s (FEV1)] during the different stages of the disease.

RESULTS

Radiographic findings at the time of ABPA diagnosis appeared to have deteriorated in 8/14 cases when compared with the baseline films; after treatment, the radiographic findings deteriorated in 6/14 cases and improved in 6/14. The most significant among the radiographic signs considered (infiltrates and mucoid impaction) appeared at the time of ABPA diagnosis in 7/14 and 4/14 cases, respectively, and in some patients, they were also present at baseline and persisted during follow-up. FEV1 values were significantly decreased (>10%) in 9/14 cases at the time of ABPA diagnosis.

CONCLUSIONS

Our results demonstrate the limited usefulness of chest radiography in the diagnosis of ABPA in patients with cystic fibrosis. The most significant abnormalities are nonspecific and commonly seen on baseline films in cystic fibrosis without ABPA and persist after treatment in most cases.

Epirubicin (E) cardiac toxicity: A retrospective analysis of 1,097 patients (pts) treated for metastatic breast cancer (MBC)

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Background: The object of the study was to conduct an analysis and assess a recommended cumulative dose of E corresponding to a 5 % risk for cardiotoxicity taking into account: dose administrations, concurrent risk of dying of MBC and possible predictors of cardiotoxicity. Methods: Data from 1097 consecutive anthracycline naïve pts was retrieved. Pts developing cardiac heart failure according to New York Heart Association (NYHA) Class =II were recorded as having E cardiotoxicity. Statistics: two extended Cox multivariate analysis (events: cardiotoxicity and mortality of MBC) followed by competing risk analysis. Results: 125 pts (11.4%) developed cardiotoxicity. Predictors for increasing the cardiotoxicity hazard ratio (HR) were: 1. cumulative dose of E: as the rate increased with 37% per every 100 mg/m2 E, when given as first line treatment for advanced disease, 2. increasing age as the rate increased with 28.7 % per additional 10 year, 3. x-ray including the heart (HR=2.08), 4. tamoxifen for relapse (HR=1.87), 5. pre-disposition to cardiac disease (HR=3.01). Mortality rate for MBC: the survival was significant lower in pts with increasing tumour burden, poorer performance status, previous adjuvant CMF, and with increasing age. The HR for mortality was significantly increased by increased duration of treatment with E and was highest in the first three months than later on. The risk of cardiotoxicity increased mostly during the first 8 months after cessation of E nearly becoming constant later on. The cumulative dose of E corresponding to a 5 % cardiotoxicity risk was found to be both significantly lower than previously assumed (900 mg/m2) and depend on predictors for mortality and cardiotoxicity. Thus, a pts with no predictors at age 40 the level of 5% risk was 806 mg/m2, at age 50 = 739 mg/m2, at age 60 = 673 mg/m2 and at age 70 = 609 mg/m2. Conclusion: The risk of cardiotoxicity of E was more pronounced than expected and occurred on a much lower cumulative dose of E. Increasing age, x-ray, tamoxifen and pre-disposition to cardiac disease contributed significantly to this.

No significant financial relationships to disclose.

Three-year findings of an early lung cancer detection feasibility study with low-dose spiral computed tomography in heavy smokers

BACKGROUND

Low-dose spiral computed tomography (sCT) showed a four-fold increase in the detection rate in high-risk subjects and a higher percentage of stage I lung cancer in comparison with chest X-ray. However, there is a considerable discrepancy among studies in the percentage of lung nodules, overall lung cancer and stage I detection rate.

SUBJECTS AND METHODS

From April to December 2001, 520 asymptomatic volunteers aged >or=55 years with a history of cigarette smoking >or=20 pack-years and no previous cancer were enrolled to receive an annual sCT of the chest for five consecutive years.

RESULTS

Seventy three per cent were male, median age was 59 years and 91% were current smokers. At baseline, nodules >or=5 mm were detected in 114 (22%) undergoing sCT; the size of lung nodules ranged from 5 to 9.9 mm in 81.5% of the cases. Five (1%) cases of lung cancer were detected. In two additional cases a pathological diagnosis of atypical adenomatous hyperplasia was made. Three new cases of lung cancer were detected in the second and third year of the study. One interval case was detected during the third year.

CONCLUSIONS

Despite some promising data, convincing evidence from ongoing randomized trials is needed to support the routine use of sCT as a recommended tool for screening of lung cancer.

Treatment of blepharospasm with botulinum neurotoxin type A: long-term results

PURPOSE

To describe the long-term efficacy and side effects of treatment of blepharospasm with botulinum neurotoxin type A (Botox).

METHODS

A total of 178 patients with blepharospasm were treated by injections of botulinum toxin in the Eye Clinic of the University of Naples from 1980 to 2001. The severity of spasm for each patient was graded on a four-point scale. Duration of improvement was assessed and reported in months.

RESULTS

Of 178 cases, 10 were lost to follow-up; of the remaining patients, 93% reported improvement after treatments. The mean duration of improvement was 3.6 months. Twelve patients (76%) who underwent more than 14 treatments maintained stable relief. Three patients (1.7%) had a total remission of spasms. Side-effects were local; none of the 168 patients experienced any systemic or toxic reaction.

CONCLUSIONS

Botulinum toxin therapy for blepharospasm can provide long-lasting relief and reduction of spasms in the majority of patients. This therapy has the advantages of being safe, simple, and repeatable.

[Usefulness of chest X-ray during cystic fibrosis exacerbation in adult patients]

PURPOSE

Verify the real usefulness of chest X-ray during clinical exacerbation of cystic fibrosis (FC).

MATERIAL AND METHODS

The study was based on a group of 46 adult patients affected by FC. For every subject we selected one or more pair of chest films, of which the first was used as reference image (To), whereas the second (T1) was selected among the following controls, either in course of clinical obvious exacerbation, or during another routine control. The 64 pairs of chest films (32 representing phases of clinical stability, 32 documenting evolution towards clinical deterioration) were subjected to evaluation by two radiologists, who were first asked to judge if stability, improvement or worsening of the overall radiographic picture could be observed; then to estimate the improvement, worsening, stability or absence of the 12 radiographic signs, selected among those more frequently correlating with the acute phase of disease.

RESULTS

The comprehensive radiological evaluation, which shows a statistically significant difference (p=0.012) between the two groups considered, weakly correlates with the patient clinical status. Among the patients with exacerbation, the radiographic picture appeared worsened in only 18/32 cases (sensibility 56%, specificity 78%), while on the contrary 7/32 clinically stable patients exhibited a radiographic deterioration. Among the considered radiographic-sings, some were exclusively observed during exacerbation (specificity 100%), but with low sensitivity (pneumothorax: 6%, increment of bronchiectasis: 9%, air space disease 22%); the most common alterations (mucoid impactions and bronchial wall thickening) were observed in both groups of patients.

DISCUSSION AND CONCLUSIONS

Our results demonstrate that there is not a precise correlation between the radiographic picture and the clinical manifestations of exacerbation and confirm the poor usefulness of chest X-ray in such a phase of disease. Chest X-ray is needed to exclude pnemothorax or extensive air space disease, rather then to accurately diagnose exacerbation.

[Characterization of non-secreting adrenal nodules (incidentalomas): role of multiphasic spiral computerized tomography]

PURPOSE

To evaluate the diagnostic yield of multiphasic helical CT in the characterization of single non functioning adrenal nodules (incidentalomas) less than 50 mm in diameter. Emphasis was given to the possible replacement of unenhanced with delayed scans in cancer patients undergoing staging procedures.

MATERIAL AND METHODS

Sixty patients with single adrenal nodules (30 of them neoplastic and 30 non-neoplastic) were examined with thin unenhanced scans (5 mm), early scans after administration of a contrast agent (120 mL at 2.5 mL/s with 60 s delay) and late scans (30 min delay).

RESULTS

On both unenhanced and late scans a threshold could be selected on the Hounsfield unit scale which guaranteed absolute specificity in the characterization of adenomas (100% specificity) with very high sensitivity (93% at both scans): this threshold was 19 HU on unenhanced and of 41 HU on late scans. In contrast, at early delayed scanning the threshold which guaranteed 100% specificity was associated with negligible sensitivity (30%). The evaluation of lesion size had no diagnostic value, since the mean diameter of both benign and malignant nodules was of 25 mm.

CONCLUSIONS

Late scans have diagnostic yield comparable to unenhanced scans: at the selected delay (30 min), benign lesions nearly always have lower attenuation values than malignant nodules and can be diagnosed with confidence when they exhibit mean attenuation values lower than 41.

Exhaled nitric oxide in systemic sclerosis: relationships with lung involvement and pulmonary hypertension

OBJECTIVE

To measure nitric oxide (NO) concentration in exhaled air of patients with systemic sclerosis (SSc) and to investigate its relationships with lung involvement, complicated or not by pulmonary hypertension (PH).

METHODS

Exhaled NO was measured by chemiluminescence in 47 patients with SSc (16 with PH) and in 30 controls. All the patients underwent Doppler echocardiography to assess pulmonary artery pressure (PAP), lung function tests, and thin section computed tomographic scans of the lung to quantify the extent of fibrosing alveolitis.

RESULTS

Exhaled NO levels were higher in patients with SSc (16.6 +/- 9.1 ppb), particularly those with interstitial lung disease (ILD) (18.3 +/- 10.4 ppb), compared to controls (9.9 +/- 2.9 ppb; p < 0.0001). In patients with PH, exhaled NO was less than in patients without PH (10.7 +/- 5.9 vs 19.6 +/- 9 ppb, respectively; p < 0.001), and patients with PH without ILD had even lower exhaled NO than patients with PH and ILD (6.6 +/- 1.1 vs 12.6 +/- 6.3 ppb; p = 0.004). There was an inverse correlation between PAP and exhaled NO (r = 04).53, p = 0.004). Exhaled NO was not correlated to age, disease duration, current therapy, or form of disease (limited or diffuse).

CONCLUSION

The increased concentration of exhaled NO in patients with SSc may reflect respiratory tract inflammation. The relatively low value of exhaled NO in patients with PH and the negative correlation between PAP and exhaled NO suggest the important role of NO in regulating pulmonary vascular resistance in patients with SSc.

Determination of serum levels of 2,6 diethylaniline in laboratory animal treated with Alachlor

In order to estimate the environmental risk of the use of Alachlor, experiments on laboratory animals were conducted. Alachlor and 2,6 diethylaniline content in blood serum was quantified. Three groups of male ACI/T rats and C3H/FEJ mice were treated with three different doses of Alachlor. Six hours after the intraperitoneal injection the animals were bled and blood was collected by cardiac puncture. From serum obtained after blood centrifugation, A and DEA were extracted using diethyl ether. 2,6 diethylaniline and Alachlor determinations were carried out by high performance liquid chromatography (HPLC). The HPLC revealed that the metabolic capacity of 2,6 diethylaniline production from Alachlor in rats is dose-dependent; moreover, the animals can be subdivided into at least two groups, according to their Alachlor metabolic capacities. In mice the metabolic release of 2,6 diethylaniline was found to be practically complete at every dose tested.

Induction of humoral immunity toward 2-acetylaminofluorene in mice: modulation of DNA binding after 4 weeks dietary exposure to the carcinogen

In order to investigate the modulatory effect of the immune response induced by recurrent carcinogen exposure, anti-2-acetylaminofluorene (anti-2-AAF) IgG were elicited in Swiss mice before subsequent carcinogen administration. The immunization schedule consisted of three weekly i.p. injections of 2-acetylaminofluorene (2-AAF)-gelatin conjugate, followed by a final immunogen injection 14 days later. At the end of treatment, the presence of specific anti-2-AAF antibodies in blood serum of all immunized animals was demonstrated. The immunization procedure did not affect liver metabolic activities, as evaluated using liver homogenates for the exogenous activation of 2-AAF to mutagen. After immunization, mice were fed 2-AAF pelleted in the diet at 50 and 150 p.p.m. for 4 weeks and killed at the end of treatment. The determination of DNA adducts by ELISA in liver and spleen of treated animals revealed significantly (P < 0.01-0.001) lower 2-AAF adduct levels in both tissues of immunized mice with respect to non-immunized animals (both naive and pretreated with the adjuvant alone). This result suggests that the specific humoral immunity elicited by repeated carcinogen exposure may be able to modulate the genotoxic effect induced by subsequent carcinogen administration.

Modulation of DNA binding in vivo by specific humoral immunological response: a novel host factor in environmental carcinogenesis?

To investigate the possible modulatory effect of the immune response induced by recurrent carcinogen exposure, a specific humoral immune response toward 2-acetylaminofluorene (2-AAF) was elicited in Swiss mice with repeated intraperitoneal injections of a 2-AAF-gelatin conjugate. The immunization procedure resulted in the production of specific anti-2-AAF antibodies in all treated animals. Groups of immunized and nonimmunized mice were subsequently fed 2-AAF pelleted in the diet at 50 and 150 ppm for 4 weeks. At the end of 2-AAF administration, animals were sacrificed and the content of 2-AAF-adducts in liver DNA was determined by enzyme-linked immunoadsorbent assay using a polyclonal rabbit antiserum. The comparison of the adducts levels in immunized and nonimmunized mice (receiving either the vehicle or the adjuvant alone during pretreatment) demonstrates a highly significant (p < 0.001) difference among groups, with far lower adduct levels in immunized animals. No significant difference in food consumption or liver metabolic activities was observed among experimental groups, suggesting the absence of external bias. The mechanism underlying the result observed is not yet clear; however, the experimental data strongly suggest that the specific immunological response induced by recurrent carcinogen exposure may exert a modulatory effect and act as a relevant host factor in chemical carcinogenesis.

[Possible etiologic role of occupational exposure to arsenic anhydride in a case of bladder carcinoma]

It has long been known that occupational or environmental exposure to arsenic (As) may cause skin and lung cancer. Moreover, several epidemiological studies on populations exposed to inorganic As by ingestion indicate an increased risk for cancer at other sites and, particularly, for bladder cancer. We describe the case of a petrol chemical worker, who died of metastasized bladder cancer at the age of 52, after being employed for over 30 years in a hydrogen production unit. Analysis of the technological cycle and biological monitoring data revealed an excessive, prolonged exposure to arsenic trioxide (As2O3) vapours and fumes; a solution of this compound was utilized to absorb the CO2 produced by oxidation of the synthesis gas. Careful anamnesis indicated a prolonged contact between the carcinogen and the bladder mucosa, due to the presence of severe urethral stenosis with chronic urinary obstruction. It also appears likely that synergism between As exposure and smoking (5-10 cigarettes per day until 46 years) occurred. This case suggests the opportunity to extend to the occupational setting future epidemiological research on the relationship between inorganic As exposure and bladder cancer.

[Computerized tomography of cerebrovascular disorders in old age]

The authors present and demonstrate the more typical CT patterns of cerebrovascular diseases in old age, on the basis of literature and of personal experience of more than 1000 CT examinations of old patients in 1991-1992. They stress the basic role of CT in differential diagnosis between hemorrhagic and ischemic lesions. Finally, they propose a protocol for the better use of CT in the early diagnosis and the outcome of cerebrovascular diseases.

[Accuracy of CT in the demonstration of lymph node metastasis in pulmonary carcinoma]

The CT, surgical and histological findings were examined of 350 lymph nodes in a perspective study of 50 patients affected with lung cancer. CT accuracy could thus be evaluated in assessing the size of hilar and mediastinal lymph nodes; the incidence of histologically-proven metastases in nodes more/less than 10 cm in diameter could also be determined, together with CT diagnostic accuracy for nodal metastases. Finally, CT capabilities were also evaluated in distinguishing N0 from N1-N2 patients. CT proved to have high negative predictive value and low positive predictive value, which caused the authors to raise the normal threshold value of CT evaluation of the greatest diameter for hilo-mediastinal nodes from 10 to 20 mm.

[Nasosinus tumors: the problem of orbital invasion]

Neoplasms of the nasal cavity and paranasal sinuses constitute less than 1% of all malignant tumors and account for 3% of those within the E.N.T. field. The course of said pathologies is characterized by scant lymph node metastases and by a marked tendency toward local evolution. Since symptoms are not particularly specific diagnosis is normally arrived at late (approximately 6 months after the first symptoms) when the disease is already in an advanced stage. The orbital area and its contents are quite difficult to study both from a clinical point of view and in terms of testing methodology. Orbital symptoms exist at onset in from 25-30% of the cases. On the other hand, when evaluated upon surgery, orbital invasion is encountered in 40% of the patients. Unfortunately radiology is not always able to provide all the information a surgeon requires in order to establish the proper approach. Although CT is able to provide information regarding extension of the lesion to the soft parts it is not equally able to confidently diagnose initial infiltrations into the bony walls of the orbita. A sampling of 31 patients with tumors of the nasal cavity and paranasal sinuses was studied. All subjects underwent careful radiological examination and were treated with a combination of surgery and radiotherapy. Upon clinical examination orbital invasion was suspected for 50% of the cases. Only in 40% of the cases did radiology confirm this while in 60% it was confirmed by surgery. It is worth noting that during surgery only half of the cases of such invasion were deemed as requiring orbitectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Dosimetry of a Filter for Treating Carcinoma of the Uterine Cervix with Cobalt to Complement Intracavitary Curietherapy

A shaped filter has been designed for treating carcinoma of the uterine cervix with cobalt in cases previously treated with intracavitary curietherapy. The filter is designed so that the dose delivered by cobalt from the midline of the pelvis to the periphery in order to compensate rises the decreasing dose of intracavitary therapy. Since this method rules out the possibility of overdosed areas, the total dose delivered to the pelvis may be increased to levels not formerly allowed.