Comparison of Different Telemedicine Services to Pre-Evaluate Their Use in a New "Computational Hospital"

Future healthcare is transitioning toward a decentralization of patient care, in which personal care is increasingly moved at the patient home and surrounding areas, while hospitals concentrate primarily on procedures that cannot be performed elsewhere, such as surgeries or outpatient examinations. The healthcare system in the Liguria region (Italy) is currently developing a new Center for Computational and Technological Medicine (CMCT), which is intended to facilitate and support this transition. As a component of the strategic planning and design process, this study examines the development and organization of telemedicine services across a range of chosen Italian and European institutions that share similarities with CMCT in terms of scope and scale. We specifically focus on telemedicine services - how they are governed, their main fields of application. The analysis confirmed the growing importance of telemedicine as part of the new vision of medicine, in which the patient is at the center.

3D-echocardiography for evaluation of the right ventricle in patients with repaired Tetralogy of Fallot: a comparison study with cardiac magnetic resonance

Background

Patients with repaired Tetralogy of Fallot (ToF) need periodic instrumental assessments, due to complications they can meet during lifetime. Right ventricle (RV) dilation and dysfunction are some examples that explain why those patients regularly undergo Cardiac Magnetic Resonance (CMR), currently the gold standard method to detect these complications.

Purpose

3D-echocardiography is an emerging tool to study RV, but there is little data supporting its use in congenital heart diseases. This study aimed at evaluating its accuracy in assessing RV dimensions and systolic function in ToF patients, in comparison to CMR.

Methods

34 patients were prospectively enrolled after CMR performance. They all underwent standard 2D-echocardiography and Multi-Beat-ECG-triggered 3D Full-Volume acquisition.

RV End Diastolic Volume (RV-EDV), End Systolic Volume and Ejection Fraction (RV-EF) were defined both in 3D-echocardiography and CMR.

Results

Post-hoc analysis of 3D images was performed through a vendor-independent software in 30 patients, resulting in a feasibility of 88%.

A Bland-Altman analysis was performed, showing that 3D-echocardiography underestimates the RV-EDV/BSA of −27.39 mL/m2 on average (CI 95%: −29.46; −25.31, SD: 5.68 mL/m2), compared to CMR, as expected. However, when compared to normality reference, 3D-echocardiography identified RV dilatation with a significant correlation to CMR (V=0.66, p<0.001). Moreover, ROC curves showed that 3D-echo-RV-EDV/BSA is the echocardiographic measure that best correlates to CMR in detecting RV dilatation (AUC 1, CI 95%: 1.00; 1.00), followed by RVOT diameter in PLAX (AUC 0.89, CI 95%: 0.69; 0.99).

Youden analysis suggested 77 mL/m2 (Se 95%, Sp 100%; J 0,95) as optimal limit to define RV dilatation in 3D-echocardiography.

Regarding the RV-EF, the Bland-Altman analysis showed that 3D-echocardiography overestimates the RV-EF by 1,97% on average (CI 95%: 0.01; 3.95, SD: 5.43), compared to CMR.

Secondly, accuracy of different echocardiographic parameters (both 2D and 3D) in detecting a RV systolic impairment was analyzed: ROC curves showed that RV-EF in 3D echocardiography is the measurement that best correlates to CMR in detecting RV dysfunction (AUC 0.92, CI 95%: 0.79–1.00), followed by Fractional Area Change (FAC) (AUC 0.78, CI 95%: 0.60; 0.96).

Tricuspid Annular Plane Systolic Excursion (TAPSE) and tricuspid valve annular motion velocities in systole (S'-TDI), instead, showed very poor correlation.

Conclusions

3D-echocardiography showed good agreement with CMR in defining RV dimensions and systolic function in ToF patients, even more than the bidimensional measurements cardiologists are used to. This could lead to a wider use of this tool in daily clinical practice, involving a reduction in the execution of the numerous CMR patients usually undergo. Moreover, it could be a valid instrument in patients with contraindication to CMR.

Funding Acknowledgement

Type of funding sources: None.

Criteria for the Evaluation of Italian Scientific Institutes for Research, Hospitalization and Healthcare (IRCCS): Comparison with European Standards and Certification Models

The definition of the title "Istituto di Ricovero e Cura a Carattere Scientifico" (IRCCS) and how this title is given by the Italian Ministry of Health is presented. Specifically, the first assessment of a commission concerning the essential information for the accreditation process is introduced. Moreover, the two years review process that aims to collect last updated information of the IRCCS, to identify level of excellence and critical aspects, is also explained. The present Italian forms and international manuals like Joint Commission, OECI and HCERES were schematized using UML diagrams. The current IRCCS accreditation forms are presented with the suggested updates organized in some levels of structuring. We compared the Italian forms with the manuals required to obtain international certifications (Joint Commission and OECI) and we analyzed the criteria for the evaluation of research units in France (the HCERES standards). Although it is a preliminary study, the use of UML diagrams allows to schematize a new accreditation model, in line with European guidelines and the most important international certifications.

The Impact of the Introduction of the Breast Unit Model in a Northwestern Italian Region

Breast cancer is the most common tumor in middle-aged and older women. In 2003, the European Parliament recommended to Member States that all women with breast cancer should be treated by a multidisciplinary team and that a network of certified breast centers be organized (the centers have been called Breast Units (BUs)). With the present study, we aim to explore the impact of the introduction of the BU organizational model in the Liguria region, Italy, through different outcome indicators. An explorative retrospective analysis was conducted through the period from 2013 to 2019 to assess the impact of the introduction of the BU model in our region. We identified two periods: before (2014–2015) and after (2017–2018) the introduction of this organizational model to assess its value impact through the definition of six measurable outcome indicators. Length of hospitalization, repeated specialist outpatient diagnostic procedures and the rate of subjects who started radiotherapy treatment within 60 days improved after the introduction of BUs. The passive health migration rate only improved significantly for one local health unit (LHU), while reintervention and diagnosis–surgery time did not show any enhancement after the introduction of the BU model. The BU model seems to provide an increase in several aspects of the healthcare offered to breast cancer patients in Liguria, specifically in those areas where a shared guideline could assist healthcare workers. Future research, such as pilot studies, are needed to assess the impact of the introduction of the BU model in our reality.

EU-Funded Telemedicine Projects – Assessment of, and Lessons Learned From, in the Light of the SARS-CoV-2 Pandemic

The SARS-CoV-2 health emergency has demonstrated the need for developing structured telemedicine systems to protect citizens from the spread of the virus. Thereby, their importance and the necessity to tailor their diffusion at large scale for providing services both at a distance and in time has been shown. For these reasons, the European Union advocates the digital transition of health systems for the next 5 years. The main aim of this work is to revisit the telemedicine research projects financed by European Community during the period 2000-2020 with particular respect to the results derived from their application. The analysis showed that some integration of tele-care and tele-health could be obtained with tele-monitoring systems and the implementation of Electronic Personal Record (EPR). Furthermore, telemedicine allows enhancing health care in critical environments, to protect health and life of the most vulnerable patients, and to encourage cross-border dialogue. The criteria of “from distance” and “timely delivered” are granted, but the effectiveness of the overall offered services highly depends on the availability and the quality of the input data. Unfortunately, this remains a relevant problem in the SARS-CoV-2 pandemic.

Molecular tests for SARS-CoV-2: data from Liguria Region (Italy)

The current Covid-19 pandemic makes necessary to identify people affected by SARS-CoV-2. To do this, the most reliable method is the use of the molecular test that is the gold standard to detect positive peoples.Here, we provide a comprehensive review on the diagnostic processes through molecular tests for SARS-CoV-2 infection. First, we have obtained information about the testing technologies in the Liguria region's hospitals to find and describe the most common technologies used and to calculate the molecular test's average cost. Second, we have evaluated the sensitivity, the specificity, the safety with respect to the data reported on scientific literature (Real Word Data VS Registrative Studies) and the organizational aspects of the molecular tests.Clinical Relevance- This study aims to provide support to the decision makers on clinical, economic, organizational, social and ethical issues related to the use of molecular test for SARS-CoV-2.

Use of Electronic Administrative Databases to Measure Quality Indicators of Breast Cancer Care: Experience of Five Regional Oncology Networks in Italy

PURPOSE:

Assuring quality of care, while maintaining sustainability, in complex conditions such as breast cancer (BC) is an important challenge for health systems. Here, we describe a methodology to define a set of quality indicators, assess their computability from administrative data, and apply them to a large cohort of BC cases.

MATERIALS AND METHODS:

Clinical professionals from the Italian Regional Oncology Networks identified 46 clinically relevant indicators of BC care; 22 were potentially computable using administrative data. Incident cases of BC diagnosed in 2016 in five Italian regions were identified using administrative databases from regional repositories. Each indicator was calculated through record linkage of anonymized individual data.

RESULTS:

A total of 15,342 incident BC cases were identified. Nine indicators were actually computable from administrative data (two structure and seven process indicators). Although most indicators were consistent with guidelines, for one indicator (blood tumor markers in the year after surgery, 44.2% to 64.5%; benchmark ≤ 20%), deviation was evident throughout the five regions, highlighting systematic overlooking of clinical recommendations. Two indicators (radiotherapy within 4 months after surgery if no adjuvant chemotherapy; 42% to 83.8%; benchmark ≥ 90%; and mammography 6 to 18 months after surgery, 55.1% to 72.6%; benchmark ≥ 90%) showed great regional variability and were lower than expected, possibly as result of an underestimation in indicator calculation by administrative data.

CONCLUSION:

Despite highlighting some limitations in the use of administrative data to measure health care performance, this study shows that evaluating the quality of BC care at a population level is possible and potentially useful for guiding quality improvement interventions.

The Use of High Resolution Ultrasound in Preoperative Evaluation of Cutaneous Malignant Melanoma Thickness

High resolution ultrasound (HRUS) was tested in 58 cutaneous malignant melanomas to check its validity in evaluating tumor thickness in vivo before surgery. The values obtained with this method were compared with histologic values (measured according to Breslow); a highly significant correlation was found (r = 0.895, p < 0.001). The accuracy of HRUS in distinguishing between low- and high-risk cutaneous malignant melanoma was also found to be quite high. Our data therefore justify the use of such a technique in the preoperative staging procedure.

Alps to Apennines zircon roller coaster along the Adria microplate margin

We have traced the particle path of high-pressure metasedimentary rocks on Elba Island, Northern Apennines, with the help of a U-Pb-Hf detrital zircon study. One quarter of the analysed zircons are surprisingly young, 41-30 Ma, with a main age peak at ca. 32 Ma, indicating an unexpected early Oligocene maximum deposition age. These Oligocene ages with negative εHf indicate a volcanic source region in the central-southern Alps. Though young by geological means, these zircons record an extraordinary geodynamic history. They originated in a volcanic arc, during the convergence/collision of the the Adria microplate with Europe from ca. 65 to 30 Ma. Thereafter, the Oligocene zircons travelled ca. 400 km southward along the Adria margin and the accretionary prism to present-day Tuscany, where they were subducted to depths of at least 40 km. Shortly thereafter, they were brought to the surface again in the wake of hinge roll back of the Apennine subduction zone and the resulting rapid extensional exhumation. Such a zircon roller coaster requires a microplate that has back-to-back subduction zones with opposing polarities on two sides.

Determinants of marital behaviour in five Apennine communities of Central Italy inferred by surname analysis, repeated pairs and kinship estimates

The work makes use of surname analysis, repeated pairs and kinship estimates in 11,009 marriage records celebrated in five communities of the Italian Central Apennine (Celano, Lecce dei Marsi, Ortucchio, Roio, Villavallelonga) from 1802 to 1965 with the objective to deepen knowledge of the relative influence of several determinants on their marital behaviour. These towns are part of the same geographic and economic environment: the slopes of the ancient Fucino Lake. This work further elaborates the results from previous studies on the bio-demographic model of the region. The data were analyzed according to three periods of approximately 50 years. Results show the highest inbreeding coefficients in the pastoral towns of Roio and Villavallelonga. Repeated pair analysis highlights a certain degree of population subdivision which declined in time in Celano, Lecce dei Marsi and Ortucchio. The highest and increasing values of RP-RPr in time in Roio suggest a general reduction in genetic heterogeneity. This is possibly due to the celebration of marriages among families selected on the economic basis of pastoralism, as this town historically has had a leading tradition of sheep-farming. Villavallelonga, excluding isonymous marriages, shows an increase in repeated pair unions in time, thus revealing a substructure with marriages among preferred lineages. This is in line with previous results on consanguineous marriages which indicated the tendency of avoiding unions between close relatives in this small geographic isolate. This study demonstrates the influence of geographical (altitude) and social factors (pastoralism) on the marital structures of the investigated populations.

Witnessing ischemia or proofing coronary atherosclerosis: two different windows on the same or on different pathways precipitating cardiovascular events?

Risk stratification and prevention of future cardiac events is an extremely relevant part of the daily medical practice in the large population of asymptomatic or scarcely symptomatic patients. The strategies available to this purpose encompass programs intended either to reduce progression and complications of atherosclerosis, and revascularization procedures aimed to reduce total ischemic burden. The former represents a primary prevention approach and fights the substrate of ischemic heart disease. The latter, instead, is used to reduce the total ischemic burden and thus implies to identify those patients in whom ischemia can be life threatening because of its severity and extension. Today, at least two imaging methods are available for this task: coronary calcium scoring by x-ray CT and ischemia assessment by myocardial perfusion imaging. Although both approaches can accurately estimate cardiovascular risk, from a theoretical point of view, the assessment of ischemia evaluates the functional consequences of coronary obstructions and thus the target of revascularization procedure, while estimating the total atherosclerotic burden represents an indirect index of it. This difference might appear academic in its nature, given the current model of ischemic heart disease pathophysiology that assumes and predicts a very tight correlation between the severity of a coronary stenosis and its capability to cause ischemia. However, the majority of studies focused on the combined risk assessment with both approaches confirm the relevance of this issue. In fact, among 7785 patients reported in the literature, coronary calcium scoring most often resulted in positive findings (78%). However, this sign of atherosclerosis was associated with inducible ischemia in only one-fifth of patients. In the near future, coronary calcium scoring will be easily and immediately completed by the noninvasive definition of coronary stenoses. At that time we will face a still largely unknown risk: the presence of a stenosis in the absence of symptoms and of ischemia. Evaluating the effectiveness of different protocols will thus be needed to improve our capability to help these patients.

Haptoglobin serum levels are independently associated with insulinemia in overweight and obese women

BACKGROUND

Obesity is associated with a chronic low-grade inflammatory condition. Haptoglobin is a glycoprotein involved in the acute-phase response to inflammation, and it is increased in obese subjects. The possibility that hyperinsulinemia and/or insulin resistance may directly increase haptoglobin levels has never been tested. The aim of this study was to investigate the associations of haptoglobin serum levels with anthropometric parameters, insulin levels, insulin resistance and related metabolic variables in overweight and obese women.

PATIENTS AND METHODS

This is a cross-sectional study of 194 non-diabetic overweight and obese subjects, aged 18-68 yr. Measurements included body mass index (BMI), central fat accumulation [evaluated by waist circumference (WC)], systolic and diastolic blood pressure, and fasting concentrations of haptoglobin, insulin, glucose, lipids (triglycerides, total cholesterol, and HDL-cholesterol), and insulin resistance as estimated by the homeostasis model assessment (HOMAIR).

RESULTS

Haptoglobin serum levels showed a positive association with BMI (p<0.001), WC (p<0.001), HOMAIR (p<0.001), and fasting insulin (p<0.001), triglyceride (p<0.001) and glucose (p<0.05) blood levels. However, only insulin maintained a significant independent association with haptoglobin (p<0.001) when a multiple regression analysis was performed and age, BMI (or WC), blood pressure levels, HOMAIR, and fasting insulin, glucose, and lipid blood concentrations were entered as independent variables.

CONCLUSIONS

Higher haptoglobin serum levels seem to be a strong marker of hyperinsulinemia, independently of BMI, body fat distribution, insulin resistance and related parameters.

Ethnogenomic diversity of Caucasus, Daghestan

Autosomal short-tandem repeats (STRs) were typed in ethnic populations of Kubachians, Dargins, Avars, Lezgins, Kumiks, and Nogais of the Caucasus (Daghestan, Russia) at the University of Utah. Daghestan ethnic populations demonstrated differences in STR allele frequency distributions, but these differences were much lower among these ethnic groups compared to worldwide ethnic groups. The observed genetic diversity was low while F(ST) values were high, both of which provided supporting evidence for small population sizes and high levels of isolation among the ethnic groups. An analysis of genetic distance from the three major continents, encompassing Daghestan populations and groups, reveals three distinct clusters: all populations of African affiliation, European and Daghestan populations except the Nogais, and Asian populations with ethnic Nogais.

Imaging of post-traumatic cardiac rhabdomyolysis with normal coronary arteries

Numerous cases of acute myocardial infarction (AMI) have been reported in the literature following closed chest injuries, due to post-traumatic dissection or thrombosis of a coronary artery. In the follow-up of AMI, wall thickness during diastole and systole provides important information on heart viability. Multidetector computed tomography (MDCT) is currently the only noninvasive instrumental investigation which provides an appreciable assessment of the coronary arteries, as well as heart wall thickness measurements. We describe and discuss the clinical and imaging findings, especially of MDCT, in a case of post-traumatic regional myocardial necrosis with normal coronary arteries.

Direct Thrombin Inhibitors for the Treatment of Acute Coronary Syndromes and During Percutaneous Coronary Interventions

As acute coronary syndromes are principally sustained by plaque complication and subsequent thrombus formation, anticoagulant therapy plays a central role in avoiding ischemic events; its main targets are thrombin activity and generation. Despite its limitations, such as its scarce ability to activate bound thrombin and its unpredictable pharmacological response, heparin is the most widely used drug for this purpose. Direct thrombin inhibitors are biologically superior to heparin principally because they inhibit clot-bound and circulating thrombin without interacting with other plasma proteins. Their clinical role in acute coronary syndromes and during coronary intervention has been tested in several trials. This article overviews the principal trials involving active-site direct thrombin inhibitors in acute coronary syndrome and during coronary intervention and compares their efficacy and safety with unfractionated heparin. It also describes ongoing trials and analyzes further clinical developments such as their use in addition to the glycoprotein IIb/IIIa inhibitors and the potential advantage possible with new agents orally administered.

Y chromosomal haplogroup J as a signature of the post-neolithic colonization of Europe

In order to attain a finer reconstruction of the peopling of southern and central-eastern Europe from the Levant, we determined the frequencies of eight lineages internal to the Y chromosomal haplogroup J, defined by biallelic markers, in 22 population samples obtained with a fine-grained sampling scheme. Our results partially resolve a major multifurcation of lineages within the haplogroup. Analyses of molecular variance show that the area covered by haplogroup J dispersal is characterized by a significant degree of molecular radiation for unique event polymorphisms within the haplogroup, with a higher incidence of the most derived sub-haplogroups on the northern Mediterranean coast, from Turkey westward; here, J diversity is not simply a subset of that present in the area in which this haplogroup first originated. Dating estimates, based on simple tandem repeat loci (STR) diversity within each lineage, confirmed the presence of a major population structuring at the time of spread of haplogroup J in Europe and a punctuation in the peopling of this continent in the post-Neolithic, compatible with the expansion of the Greek world. We also present here, for the first time, a novel method for comparative dating of lineages, free of assumptions of STR mutation rates.

Peopling of three Mediterranean islands (Corsica, Sardinia, and Sicily) inferred by Y-chromosome biallelic variability

An informative set of biallelic polymorphisms was used to study the structure of Y-chromosome variability in a sample from the Mediterranean islands of Corsica and Sicily, and compared with data on Sardinia to gain insights into the ethnogenesis of these island populations. The results were interpreted in a broader Mediterranean context by including in the analysis neighboring populations previously studied with the same methodology. All samples studied were enclosed in the comparable spectrum of European Y-chromosome variability. Pronounced differences were observed between the islands as well as in the percentages of haplotypes previously shown to have distinctive patterns of continental phylogeography. Approximately 60% of the Sicilian haplotypes are also prevalent in Southern Italy and Greece. Conversely, the Corsican sample had elevated levels of alternative haplotypes common in Northern Italy. Sardinia showed a haplotype ratio similar to that observed in Corsica, but with a remarkable difference in the presence of a lineage defined by marker M26, which approaches 35% in Sardinia but seems absent in Corsica. Although geographically adjacent, the data suggest different colonization histories and a minimal amount of recent gene flow between them. Our results identify possible ancestral continental sources of the various island populations and underscore the influence of founder effect and genetic drift. The Y-chromosome data are consistent with comparable mtDNA data at the RFLP haplogroup level of resolution, as well as linguistic and historic knowledge.

The STR-based genetic profile of the population from Corsica island (France)

Short tandem repeats (STR) at loci HumFES/FPS, HumVWA, HumCSF1PO, HumTH01, HumFXIIIA01, HumTPOX, HumCD4, D3S1358 are markers of choice for population genetics and validated systems for forensic use. In this report, we analysed their allele frequency distribution in a sample of native blood donors from the two departments of Corsica island (France). Deviations from the Hardy-Weinberg rule and heterozygosity values consistently suggested a spatial differentiation of allele and genotype frequencies across the island. Pairwise comparisons showed that Corsican gene pool presents a high level of heterogeneity between departments and substantially differs from that of neighbouring and historically-related populations. The results suggest the use of local databases to calculate a priori statistics in human identity testing.

An object oriented fully 3D tomography visual toolkit

In this paper we present a modern object oriented component object model (COMM) C + + toolkit dedicated to fully 3D cone-beam tomography. The toolkit allows the display and visual manipulation of analytical phantoms, projection sets and volumetric data through a standard Windows graphical user interface. Data input/output is performed using proprietary file formats but import/export of industry standard file formats, including raw binary, Windows bitmap and AVI, ACR/NEMA DICOMM 3 and NCSA HDF is available. At the time of writing built-in implemented data manipulators include a basic phantom ray-tracer and a Matrox Genesis frame grabbing facility. A COMM plug-in interface is provided for user-defined custom backprojector algorithms: a simple Feldkamp ActiveX control, including source code, is provided as an example; our fast Feldkamp plug-in is also available.

Hamming clustering techniques for the identification of prognostic indices in patients with advanced head and neck cancer treated with radiation therapy

The aim of the study is to demonstrate the usefulness of a new, non-linear classifier method, called Hamming clustering (HC), in selecting prognostic variables affecting overall survival in patients with head and neck cancer. In particular, the aim is to identify whether tumour proliferation parameters can be predictive factors of response in a set of 115 patients that receive either alternating chemo-radiotherapy or accelerated or conventional radiotherapy. HC is able to generate a set of understandable rules underlying the study objective; it can also select a subset of input variables that represent good prognostic factors. HC has been compared with other standard classifiers, providing better results in terms of classification accuracy. In particular, HC obtains the best accuracy of 74.8% (sensitivity of 51.1% and specificity of 91.2%) about survival. The rules found show that, besides the classical, well-known variables concerning the tumour dimension and the involved lymphonodes, some biological parameters, such as DNA ploidy, are also useful as predictive factors.

Microsatellite variation in Central Africa: an analysis of intrapopulational and interpopulational genetic diversity

As a part of a research project on molecular variation in Central Africa, we have analyzed 10 microsatellites (CD4, CSFO, D3S1358, D18S51, D21S11, F13A1, FES, TH01, TPOX, and VWA) in the Bamileke and Ewondo from Cameroon and the Sanga and Mbenzele Pygmies from the Central African Republic (a total of 390 chromosomes). A statistically significant trend towards heterozygote deficiency was detected in the Mbenzele Pygmies. This was established through the use of powerful exact tests for the Hardy-Weinberg equilibrium. A certain degree of isolation and a small effective size may explain this finding. However, the lack of any substantial reduction in allelic diversity in the Mbenzele does not support the possibility that this group has a smaller effective size in evolutionary terms. A possible explanation based on ethnographic studies suggests that the gene flow from non-Pygmies to Pygmies could have been interrupted only in relatively recent times. The analysis of association between genotypes at pairs of independent loci indicates that the level of subheterogeneity is markedly lower in the Bamileke than in other sampled populations. This may be explained by the combined effect of larger population size, more rigid respect of clanic exogamy, and higher matrimonial mobility of the Bamileke. Finally, we have analyzed interpopulational relationships among our sampled populations and other Central African populations. The results are consistent with a previous study of protein loci (Spedini et al. 1999), which suggests the recent history of the Bamileke and Ewondo has led them to aquire a substantial genetic similarity. Furthermore, the Mbenzele Pygmies diverge from Biaka Pygmies, despite their common origin and geographical proximity. This is probably due to the differentiating effect of genetic drift, which is enhanced by the small effective size of Pygmy populations.

Evidence of cell kinetics as predictive factor of response to radiotherapy alone or chemoradiotherapy in patients with advanced head and neck cancer

PURPOSE

The aim of this study was to investigate the potential clinical relevance of cell kinetics parameters to the locoregional control (LRC) and overall survival of patients affected by head and neck squamous cell carcinoma (HN-SCC) treated by conventional radiotherapy, partly accelerated radiotherapy, or alternating chemoradiotherapy.

METHODS AND MATERIALS

Between January 1993 and June 1996,115 patients with HN-SCC at Stage III and IV entered the study. Multiple primary tumor biopsies were obtained 6 h after in vivo infusion of bromodeoxyuridine (BrdUrd), an analogue of thymidine that is incorporated in DNA-synthesizing cells. In vivo S-phase fraction labeling index (LI), duration of S-phase (Ts), and potential doubling time (Tpot) were obtained by analysis of the flow cytometric content of BrdUrd and DNA. Eighty-two patients were randomly assigned to receive either alternating chemoradiotherapy or partly accelerated radiotherapy, whereas 33 other matching patients received conventional radiotherapy.

RESULTS

Univariate LRC analysis showed that LI value was a prognostically significant factor, independent of type of therapy. Multivariate analysis failed to show cell kinetics parameters as statistically significant factors affecting LRC probability and overall survival. However, subgroup analysis showed that LRC probability at 4 years for fast proliferating tumors characterized by a LI >/= 8% was significantly better for patients treated either with alternating chemoradiotherapy or partly accelerated radiotherapy than it was for those treated with conventional radiotherapy. Conversely, LRC probability for slow proliferating tumors (LI < 8%) treated with the three treatment modalities was similar.

CONCLUSIONS

These results showed that, independent of type of treatment, pretreatment cell kinetics provided only a weak prognostic role of outcome in HN-SCC. However, this report raises the hypothesis that fast growing HN-SCC may be more likely to benefit from intensified therapy, as given in this series. Cell kinetics parameters studied by the in vivo BrdUrd/flow cytometry method might be considered predictive factors of response, providing information on which type of treatment may be selected according to tumor proliferation rate.

The peopling of sub-Saharan Africa: the case study of Cameroon

This study analyzes the distribution of ten protein genetic polymorphisms in eighteen populations from the most densely inhabited areas of Cameroon. The languages spoken belong to three different linguistic families [Afro-Asiatic (AA), Nilo-Saharan (NS) and Niger-Kordofanian (NK)]. The analysis of variation of allele frequencies indicates that the level of genetic interpopulation differentiation is rather low (F(st) = 0.011 +/- 0.006) but statistically significant (p < 0.001). This result is not unexpected because of the relatively small geographic area covered by our survey. This value is also significantly lower than the one estimated for other groups of African populations. Among the factors responsible for this, we discuss the possible role of gene flow. There is a considerable genetic differentiation among the AA populations of north Cameroon as is to be expected because they all originated from the first agriculturists of the farming "savanna complex." The Podowko and Uldeme are considerably different from all the other AA groups, probably due to the combined effect of genetic drift and isolation. In the case of the Wandala and Massa, our analyses suggest that genetic admixture with allogeneous groups (especially with the Kanuri) played an important role in determining their genetic differentiation from other AA speaking groups. The Bantu speaking populations (Bakaka, Bamileke Bassa and Ewondo, NK family, Benué Congo subfamily) settled in western and southern Cameroon are more tightly clustered than AA speaking groups. This result shows that the linguistic affinity among these four populations coincides with a substantial genetic similarity despite their different origin. Finally, the Fulbe are genetically distinct from all the populations that belong to their same linguistic phylum (NK), and closer to the neighboring Fali and Tupuri, eastern Adamawa speaking groups of north Cameroon.

Testing a biochemical model of human genetic resistance to falciparum malaria by the analysis of variation at protein and microsatellite loci

We recently proposed a biochemical model of genetic resistance to falciparum malaria based on the role of oxidant stress (of parasitic origin) in inducing the irreversible oxidation of hemoglobin and its binding to the erythrocyte membrane (Destro-Bisol et al. 1996). To test the model, we analyzed the relationships between the polymorphisms at the hemoglobin beta chain (HBB) and red cell glutathione peroxidase (GPX1) loci in 18 populations that had been subjected to endemic malaria (Cameroon and Central African Republic). The erythrocytes of GPX1*2 heterozygotes should be more efficient in sheltering the cell membrane from irreversible oxidation and binding of hemoglobin caused by the oxidant stress exerted by Plasmodium falciparum. According to our model, the GPX1*2 allele has an epistatic effect on the HBB*A/*S genotype by lowering its protection against falciparum malaria. In turn, this should decrease the fitness of the HBB*A/*S-GPX1*2/*1 genotype. Our predictions were confirmed. In fact, we observed a clear trend toward a dissociation between the HBB*A/*S and GPX1*2/*1 genotypes in the overall data. To test alternative hypotheses, we also analyzed the genetic variation at 9 protein and 10 autosomal microsatellite loci at both the single- and the 2-locus level. We also discuss the possible relevance of an alternative biochemical pathway. The results further support the conclusions of our study because the dissociation between the GPX1*2/*1 and HBB*A/*S genotypes does not appear to be related either to a general decrease in heterozygosity or to an increased risk of sudden death in HBB*A/*S individuals.

Changes over 100 years in degree of isolation of 21 parishes of the Lima Valley, Italy, assessed by surname isonymy

Changes over 100 years (1887-1986) in degree of isolation of 21 parishes of the Lima valley, Italy, were assessed using surname analysis. Crow and Mange's inbreeding coefficients and Lasker and Kaplan's repeated pair values were calculated using 8026 marriage records; temporal changes were assessed by dividing birth cohorts into 4 time periods of 25 years each: 1887-1911, 1912-1936, 1937-1961, and 1962-1986. Analysis was carried out at 2 hierarchical levels: the population of the valley as a whole and the valley's subdivision into 21 parishes. The relationship between population size and level of isonymy during the breakdown of isolates was investigated. The results show that there is a small difference in inbreeding coefficients between the first 2 periods at either hierarchical level of analysis and a substantial decrease in marital isonymy during the study period is mostly due to the change in male random isonymy. Furthermore, the Fn value at the higher hierarchical level almost coincides with the mean F value at the lower hierarchical level, indicating that over time the parish remained the fundamental reproductive unit. Regression analysis showed that geographic isolation became increasingly important in differentiation among the parishes in population size and in levels of inbreeding. The marked deviation from equilibrium between drift and migration that characterizes the breakdown of isolates of almost all the rural populations is an important disturbing factor in assessing the relationship between level of inbreeding and population size. Comparison over time allows us to better describe the evolutionary forces at the basis of the changes in genetic structure of a population.

Total body irradiation correlates with chronic graft versus host disease and affects prognosis of patients with acute lymphoblastic leukemia receiving an HLA identical allogeneic bone marrow transplant

PURPOSE

To investigate whether different procedure variables involved in the delivery of fractionated total body irradiation (TBI) impact on prognosis of patients affected by acute lymphoblastic leukemia (ALL) receiving allogeneic bone marrow transplant (BMT).

METHODS AND MATERIALS

Ninety-three consecutive patients with ALL receiving a human leukocyte antigen (HLA) identical allogeneic BMT between 1 August 1983 and 30 September 1995 were conditioned with the same protocol consisting of cyclophosphamide and fractionated TBI. The planned total dose of TBI was 12 Gy (2 Gy, twice a day for 3 days). Along the 12-year period, variations in delivering TBI schedule occurred with regard to used radiation source, instantaneous dose rate, technical setting, and actual total dose received by the patient. We tested these different TBI variables as well as factors related to patient, state of disease, and transplant-induced disease to investigate their influence on transplant-related mortality, leukemia relapse, and survival.

RESULTS

At median follow-up of 7 years (range 3-15 years) the probabilities of leukemia-free survival (LFS) and overall survival (OS) for the 93 patients were 60% and 41%, respectively. At univariate analysis, chronic graft versus host disease (cGvHd) (p = 0.0005), age (p = 0.01), and state of disease (p = 0.03) were factors affecting LFS whereas chronic GvHd (p = 0.0005), acute GvHd (p = 0.03), age (p = 0.0001), and GvHd prophylaxis (p = 0.01) were factors affecting overall survival. The occurrence of chronic GvHd was correlated with actually delivered TBI dose (p = 0.04). Combined stratification of prognostic factors showed that patients who received the planned total dose of TBI (12 Gy) and were affected by chronic GvHd had higher probabilities of LFS (p = 0.01) and OS (p = n.s.) than patients receiving less than 12 Gy and/or without occurrence of chronic GvHd. Moreover, TBI dose had a significant impact on LFS in patients transplanted in first remission (p = 0.05). At multivariate analysis, TBI dose was an independent factor affecting overall survival (p = 0.05) as well as chronic GvHd (p = 0.001) and age (p = 0.04).

CONCLUSIONS

This retrospective analysis showed that different variables involved in TBI delivery may influence the occurrence of cGvHd and affect prognosis of patients with ALL receiving allogeneic BMT. The total dose of 12 Gy, administered in six fractions over 3 days, appears to be an effective and low toxic regimen for ALL patients transplanted in first remission.

Introducing Quality Assurance in Radiotherapy

Introducing a Quality Assurance methodology appears particularly useful in Radiation Oncology due to the complexity of the procedures involved and the heterogeneity of the standards adopted, if any, in the great majority of the Centers. There are two possible ways of evaluating quality in the Health Environment: a formal, Institutional certification, or a voluntary one obtained through a mechanism of peer review. The European Society for Therapeutic Radiology and Oncology (ESTRO) started in 1994 with the publication of a methodological Report intended to be adopted by the individual national Societies, and this paper is an invitation to do it.

Correlations of quantitative chromosomal heteromorphisms and classic genetic markers to demogeographic data in Garfagnana valley (Tuscany, Italy)

The genetic structure and interrelationships of six populations of the Garfagnana valley (Tuscany, Italy) were examined using chromosomal heteromorphisms concurrently with blood group system, red cell isozyme, and serum protein polymorphisms, secretor status, and surname frequency data. We aimed to evaluate the relationship of cytogenetic polymorphisms to more classical sources of gene frequency data in a population with a well-known demographic scenario. The R matrix technique (Harpending and Jenkins 1973) was used to estimate kinship coefficients, and the Harpending-Ward model (1982) and its extensions for quantitative traits (Relethford and Blangero 1990) were used to detect differential systematic pressure among population subdivisions. Mantel statistics were used to assess the significance of the correlations between cytogenetic, genetic, isonymy, geographic, and migration matrices. The analyses consistently gave similar results for the DA/DAPI cytogenetic heteromorphism and most gene frequency data. Both sets of results depend on migration patterns and on geographic distance among population subdivisions. However, C cytogenetic heteromorphism and some separately analyzed genetic markers did not fit the demogeographic pattern. Overall, it appears that data from different levels of the genetic hierarchy (namely, DNA regions encoding for classical biochemical markers and the noncoding highly variable cytogenetic bands of heterochromatin) can be treated and compared using the same analytical tools.

Study of the matrimonial structure of the population of central Sardinia (Italy)

Temporal changes in the matrimonial structure of four Sardinian populations (Bitti, Lula, Lodè and Gavoi) have been studied. The endogamy rates and the average marriage distances indicate that the four villages experienced a long period of isolation. Only in recent decades endogamous marriages have fallen shortly. The trends of marital isonymy and inbreeding, evaluated both from isonymy and dispensation for consanguineous marriages, are similar to those of endogamy. The kinship values between pairs of populations show some preferential relationship (Bitti-Lodè, Lodè-Lula) and an evident differentiation between Gavoi and Bitti. The results also indicate that the values of kinship are not associated with the geographic distances. The possible impact of the matrimonial structure on the genetic structure and the relationships among the studied populations will be examined in further investigations, in which the genetic markers will be considered.

[An expert system for the planning of whole-body irradiation treatments]

Total body irradiation (TBI) combined with intensive chemotherapy and bone marrow transplantation is used with increasing success for the treatment of hematologic malignancies with severe prognosis. An expert system, developed on the basis of the experience acquired during the last years in our department, has been designed to optimize the different treatment steps. The choice of an expert system is based on its capabilities in reconstructing a rule-based reasoning through the combination of theoretical and empirical knowledge. Particularly, a subsystem dealing with the steps to be taken to optimize treatment in TBI has been designed using medical and physical data. Our system can determine radiation treatment variables together with a sequence of quality control procedures. Moreover, indications are given about short, medium and long term damage probabilities and toxicity estimates, both derived from literature data and our personal series of cases. Treatment quality can be assessed and the different techniques compared using these data. This project is aimed at providing physicians and physicists with useful clinical suggestions for TBI setting for bone marrow transplantation.

Isolation factors and kinship by isonymy in a group of parishes in northern Tuscany (Italy): influence of within-parish similarity level on between-parish similarity pattern

We investigate the influence of within-parish similarity level on between-parish similarity pattern in surname analysis through a study of the relative roles of various isolation factors accounting for the population structure within a municipality (21 parishes) in the hilly part of northern Tuscany. One surname per family was collected (N = 3052), and the pattern of kinship observed by isonymy was compared with the expected patterns based on demogeographic variables. The fit of the isolation by distance model is substantially improved with the inclusion of values at zero geographic distance (i = j). Differentiation in migration rate was clearly shown by the local kinship values, which are highly correlated with the demogeographic features of the parishes under study. Furthermore, the strong heterogeneity of the local kinship values seems to be the major factor responsible for the poor relation of the off-diagonal values of the kinship matrix to the expected isolation pattern. In fact, the kinship matrix weighted on the basis of the local kinship values points to a pattern of similarity among parishes congruent with the demogeographic structure of the population. On the whole, the results indicate that at the low hierarchical level of parishes the extreme localization of surnames is a disturbing factor in population structure analysis. A simple method to overcome this problem has been proposed.

[Imposing "calcium milk" lithiasis in giant hydronephrosis]

The authors report a quite unusual case of "milk of calcium renal Stone" in unilateral giant Hydronephrosis. Radiographic, sonographic, intravenous urographic and TC aspects are described and prominence il given to morphostructural information obtained through digital image techniques of pyeloureteral zone junction and of "milk of calcium renal Stone". The authors discuss the pathogenesis of the renal Stone type and emphasize the convenience of investigative acts to clear up the ethio-pathogenetic role of pyeloureteral infections.

Numerical method for the interpolation of digitized lines (unrolling method)

The proposed method can be used for reconstructing, from n not necessarily equidistant points of a digitized polydrome line, a set of n1 equidistant points (with n1 > n) interpolating the original points. This method is based on a transformation of the original line into a digitized monodrome function D(1i) (unrolling function), where 1i is the line length between the origin and the ith point (i = 1,..., n1). Advantage of this method consists in reducing the two-dimensional interpolation problem to the one-dimensional field. In scintigraphic imaging, it is possible to achieve interpolation and coding of ROI's (Regions Of Interest) edges. For n samples of a monodrome line this method can also be applied, representing a possible alternative to splines. The numerical procedure is developed to reduce the noise on the points.

Genetic polymorphism in the Garfagnana population (Tuscany)

Blood group systems ABO, KEL, MN, RH, secretor status for ABH blood group substances, red cell enzymes ACP1, ESD, AK1, 6-PGD, PGM1 subtypes, serum markers GC, TF, PI, AHSG, ORM1 and chromosomal heteromorphism Q, C, DA/DAPI were examined in a population sample of the Garfagnana, a semi-isolated mountainous area in the province of Lucca (Tuscany, Italy). The total sample was subdivided and analysed according to the more recent historical events which have occurred in Garfagnana. The observed phenotype and gene frequencies were discussed in the context of other population samples from the same province and of the same region. As a whole, the results concur in pointing out a certain degree of heterogeneity within the area and a high differentiation from the rest of Tuscany. Such peculiar genetic features of the population have to be related to the historical, geographic and cultural isolation of the Garfagnana.

Paleoserology of the Christian population at Sayala (Lower Nubia): an evaluation of the reliability of the results

A paleoserological study of human remains from the Christian cemeteries of Sayala (Lower Nubia, 6th-11th centuries A.D.) was carried out by applying two techniques (absorption-elution and haemagglutination-inhibition), on two types of substratum (bones and hair), in separate laboratories (Pisa and Prague). The aim of research was to evaluate the degree of repeatability of the results and the reliability of the final paleoserological diagnoses. The results indicated different degrees of repeatability depending on the differential sensitivity of the two techniques and on the nature of the substratum. The frequencies of concordant and discordant final diagnoses within and between the two laboratories and by the two methods were significantly different from those expected under the conditions of random distribution, indicating a consistency in results from different laboratories and methods. The reliability of the resulting gene and phenotype distributions is also supported by their consistency both with the theoretical Hardy-Weinberg equilibrium and with the present distribution of the ABO gene frequencies in Egyptian, Sudanese, and Nubian populations.

Variability of DA/DAPI and C heterochromatic regions: a population study

DA/DAPI and C chromosomal heteromorphic sites (1q, 9q, 15p, 16q, Yq) in a sample of 136 unrelated individuals from the Garfagnana valley (Tuscany, Italy) have been analyzed quantitatively and qualitatively. The variations in length, between-homolog heteromorphisms, and intensity of fluorescence of the heterochromatic bands have been compared in two subsamples of the population (upper and middle valley) individualized according to geodemographic criteria. DA/DAPI heterochromatin differed significantly from C heterochromatin, showing a lower average amount and a higher variability at each site. This suggests a differential staining of DNA of the two banding systems. Furthermore, DA/DAPI heterochromatin was less uniformly distributed in the population than C heterochromatin and the regions 16q and Yq discriminated better between subsamples. The variations of DA/DAPI fluorescence at the 15p site demonstrated an excess of homomorphic individuals in the upper valley, which could be related to the mating structure of the population living in this area.

Genetic structure in the Garfagnana (Tuscany, Italy): a study of eight protein markers by isoelectric focusing

The genetic structure of the human population in a random sample of 238 unrelated individuals from Garfagnana (Tuscany, Italy) was studied for five highly polymorphic serum proteins (GC, TF, PI, AHSG, ORM1) and three red cell isozymes (ACP, PGM1, ESD) by isoelectric focusing. Comparison with the gene frequencies from other districts of Tuscany has shown no significant deviation in seven out of eight polymorphic protein systems. Subtype allele frequencies of orosomucoid 1 (ORM1), which were not yet determined in Italian populations, are as follow: ORM1*F1 = 0.586, ORM1*F2 = 0.021, and ORM1*S = 0.393. The most striking features of this unique sample were the relatively high frequencies of PGM1*2B (0.093) and PI*I (0.013) alleles.

Surname versus gene structure of a small isolate

A hierarchical partition of the Wright coefficient of inbreeding (F) is shown for an isolated population (about 2000 inhabitants) from a mountainous region of Tuscany (Italy) with regard to both surnames and genes. At total population level surname variation proves substantially consistent with the observed genetic differentiation of the isolate. Analysis of parental isonymy reveals that the population is structured in subunits and it is concluded that the unit population of the region may be very small, practically coinciding with the village (less than 500 inhabitants). The agreement of 'demographic' and genetic structures is less satisfactory at this level, partly because of subsample size, but we conclude that analysis of surnames may give at least a rough idea of the genetic structure of the population.

[Varicography in the preoperative assessment of primary varices. A study of 100 cases]

Primary varicose veins in the lower limb are usually well evaluated by the surgeon, who avails himself of tourniquet tests and Doppler US. However, the operation is often followed by failure or recurrence, or else it requires ugly skin dissection to eradicate an unforeseeably complicated varicose vein. We suggest that, whenever the surgeon considers the information obtained with tests and Doppler US inadequate for planning surgery, varicography be performed to get further morphological (and functional) data about the origin of varicose veins, which is of fundamental importance for an accurate surgical planning (cross-section stripping, ligation, sclerosis). Out of 100 varicographies consecutively carried out on patients in whom clinical examination was not conclusive, 62% allowed an already planned surgical approach to be changed. The figure rose to 100% in case of unusual varicose veins. Such a result allowed the needs of both the surgeon (selectivity, effectiveness, radicality) and the patient (narrow scars, absence of relapse) to be respected. Furthermore, it has been pointed out that some vein segments are often only pathological, and they are to be adequately treated, while others can be undamaged, and they are to be preserved for both their function and an eventual by-pass surgery. Varicography is rapidly performed, without complications, and is well accepted by the patient. It is a fundamental help in the preoperative study of primary varicose veins, especially in case of unusual ones, whenever the surgeon is in the slightest diagnostic--and therefore surgical--doubt.

Rh system in the Lucca province (Italy): temporal and spatial variations

Phenotype and gene frequency distributions of the Rh system in the province of Lucca (Italy) are reported and discussed considering their diachronic and geographic variations. The data were collected in blood transfusion centers and refer to a total of 13,856 individuals. Analysis by chi 2- and R-matrix methods point to a highly significant genetic heterogeneity among the population subsamples through time. The results are discussed in relation to sample representativeness and to the main geographic and demographic characteristics of the province.