Novelties in slipped capital femoral epiphysis imaging: A narrative review

Rationale and objectives

Imaging plays a key role in Slipped Capital Femoral Epiphysis diagnosis and severity assessment. In the last two decades, signs and measurements emerged in literature showed potential to help in SCFE diagnosis and tailoring treatment. The purpose of this review is to collect and discuss new imaging signs, measurements, and techniques according to investigations published after 2000 to improve SCFE diagnosis.

Material and methods

The PubMed, Scopus, and Science Direct databases were used to search for relevant articles related to imaging in SCFE diagnosis from January 2000 to March 2023. Article selection and review was performed by two board-certified radiologists). Article quality assessment were conducted by authors using QUADAS-2 and SANRA evaluation tools.

Results

The research resulted in a total of 2577 articles. After duplicates removal and abstract analysis, 28 articles were finally selected for full-text analysis. Seventeen articles were focused on Radiographs, 6 on CT, 1 on both Radiographs and CT, 4 on MRI. No study focused on ultrasound was selected.

Conclusions

Use of modified Klein's line and S-sign may improve radiographs accuracy in daily routine. Lucency sign may help in early diagnosis on radiographs. Preoperative CT may be useful in planning a tailored treatment predicting SCFE severity and instability. MRI is the most accurate modality to diagnose SCFE at early stage. Nevertheless, it cannot be used to predict the risk of contralateral SCFE. Risk prediction can be assessed with radiographs, using a new rapid mOBS. Further investigation and validation of these sign is needed.

Mediastinal Germ-cell Tumors Relapse in a Male With Klinefelter Syndrome. Is Longer Surveillance Needed?

Germ cell tumors (GCTs) are a heterogeneous group of pediatric cancers. In up to one-third of male patients, a primary mediastinal location is associated with the presence of Klinefelter syndrome (KS). We describe a case of mediastinal GCT in a patient, with unacknowledged KS, that presented a relapse 7 years from diagnosis, that is, 2 years after the end of the follow-up program usually recommended for patients with GCT. There are no recommendations for screening for KS in patients with mediastinal GCT and there are no specific guidelines for surveillance of GCT in KS patients. Our experience suggests that KS should be suspected in patients with mediastinal GCT, and a longer follow-up plan should be implemented when GCT occurs in patients with KS.

Lung relapse pattern in children with metastatic Wilms tumor

Wilms tumor is the most common pediatric renal cancer, and lungs represent the major site of metastasis and recurrence. Relapse occurs in 15%, months or years after treatment; so due to the small sample, acquiring more data about the pattern of lung relapse remains a challenge. The aim of our study was to evaluate if pulmonary relapse, detected by computed tomography (CT), occurred at the initial site of lung metastases or in a different location. According to our data, the CT pattern of lung relapse showed high probability of recurrence at the same site of initial metastasis.

Ankle and Foot: Focus on Inflammatory Disease

The ankle and foot have numerous bones and complex joints that can be affected by several types of inflammatory arthritis with different patterns and various radiologic signs, depending on the phase of the disease. Involvement of these joints is most frequently seen in peripheral spondyloarthritis and rheumatoid arthritis in adults and juvenile idiopathic arthritis in children. Although radiographs are a mainstay in the diagnostic process, ultrasonography and especially magnetic resonance imaging allow early diagnosis and are crucial diagnostic tools. Some diseases have typical features based on target populations (e.g., adults versus children, men versus women), but others may have overlapping imaging characteristics. We highlight key diagnostic features and describe appropriate investigations to guide clinicians toward the correct diagnosis and provide support during disease monitoring.

COVID-19 musculoskeletal involvement in children

Since the early phases of the COVID-19 pandemic, it has become clear that children are affected by mild respiratory symptoms rather than the critical pneumonia typical in adults. Nevertheless, it took longer to understand that pediatric patients with SARS-COV2 may develop a severe multisystem inflammatory response (a.k.a. multisystem inflammatory syndrome in children (MIS-C)), which can include musculoskeletal symptoms, and/or arthritis and myositis independently from MIS-C. Diagnostic imaging significantly contributed to the assessment of pulmonary disease due to COVID-19 but it has been rarely applied to evaluate musculoskeletal involvement in children with or without previous rheumatic diseases. Despite the paucity of radiological literature, muscle edema at magnetic resonance and synovitis at ultrasound have been described. Further use of diagnostic imaging for children with articular and muscular symptoms due to COVID-19 is strongly encouraged.

Metastatic rhabdomyosarcoma with exclusive distant lymph node involvement: A European Pediatric Soft tissue sarcoma Study Group (EpSSG) report

BACKGROUND

The prognosis of patients with metastatic rhabdomyosarcoma (RMS) is not uniformly poor. Tumors with nodal involvement beyond the first lymph node station are currently considered to have distant metastases. The aim of this study is to evaluate the characteristics and outcome of RMS patients with distal nodal involvement as the only site of metastasis.

METHODS

This study included all patients with a diagnosis of RMS and distant nodal involvement as the only metastatic site, enrolled in the European Pediatric Soft tissue sarcoma Study Group (EpSSG) protocols. Treatment comprised chemotherapy, surgery, and/or radiotherapy. The main outcome measures were event-free survival (EFS) and overall survival (OS).

RESULTS

A total of 22 patients (median age 7.1 years, range 1.4-16.7) fit the inclusion criteria. The extremities were the most common primary tumor site (59%). Twenty-one patients had regional and distant nodal involvement, 12 were PAX3/7-FOXO1 positive. Twenty patients had radiotherapy including 16 to the nodal metastatic area. After a median follow-up of 53.9 months (range 22.8-110.5), 15 patients remain in complete remission, seven had progressive disease or relapse, and six of them died. The 3-year EFS and OS were 67.1% (95% confidence interval [CI]: 42.9-82.9) and 71.9% (95% CI: 47.7-86.3), respectively. Patients with fusion-negative tumors had better outcomes than those with fusion-positive tumors (3-year EFS 100% vs. 46.6%; p = .04).

CONCLUSION

In our experience, patients with RMS and distant lymph node involvement as the only site of metastasis present an outcome superior than other metastatic patients and comparable to patients with locoregional nodal involvement. In particular, excellent outcomes were seen in the limited number of patients with fusion-negative tumors.

Predictors of pulmonary sequelae after COVID-19 pneumonia: A 12-month follow-up study

Background

Since the beginning of the SARS-CoV-2 pandemic, over 550 million people have been infected worldwide. Despite these large numbers, the long-term pulmonary consequences of COVID-19 remain unclear.

Aims

The aim of this single-center observational cohort study was to identify and characterize pulmonary sequelae of COVID-19 at 12 months from hospitalization and to reveal possible predictors for the persistence of long-term lung consequences.

Methods

Based on the persistence or absence of radiological changes after 12 months from hospitalization, the whole population was categorized into NOT-RECOVERED (NOT-REC) and RECOVERED (REC) groups, respectively. Clinical and pulmonary function data tests and clinical data were also collected and compared in the two groups. In the NOT-REC group, high resolution computed tomography (HRCT) images were semiquantitatively scored analyzing ground-glass opacities (GGO), interstitial thickening (IT), consolidations (CO), linear and curvilinear band opacities, and bronchiectasis for each lung lobe. Logistic regression analyses served to detect the factors associated with 12-month radiological consequences.

Results

Out of the 421 patients followed after hospitalization for SARS-CoV-2 pneumonia, 347 met inclusion and exclusion criteria and were enrolled in the study. The NOT-REC patients (n = 24; 6.9%) were significantly older [67 (62-76) years vs. 63 (53-71) years; p = 0.02], more frequently current smokers [4 (17%) vs. 12 (4%); p = 0.02], and with more severe respiratory failure at the time of hospitalization [PaO₂/FiO₂ at admission: 201 (101-314) vs. 295 (223-343); p = 0.01] compared to REC group (n = 323; 93.1%). On multivariable analysis, being a current smoker resulted in an independent predictor for lung sequelae after 12 months from hospitalization [5.6 OR; 95% CI (1.41-22.12); p = 0.01].

Conclusion

After 12 months from hospital admission, a limited number of patients displayed persistent pulmonary sequelae with minimal extension. Being a current smoker at the time of SARS-CoV-2 infection is an independent predictive factor to lung consequences, regardless of the disease severity.

Tumor cellularity beyond the visible in soft tissue sarcomas: Results of an ADC-based, single center, and preliminary radiomics study

Purpose

Soft tissue sarcomas represent approximately 1% of all malignancies, and diagnostic radiology plays a significant role in the overall management of this rare group of tumors. Recently, quantitative imaging and, in particular, radiomics demonstrated to provide significant novel information, for instance, in terms of prognosis and grading. The aim of this study was to evaluate the prognostic role of radiomic variables extracted from apparent diffusion coefficient (ADC) maps collected at diagnosis in patients with soft tissue sarcomas in terms of overall survival and metastatic spread as well as to assess the relationship between radiomics and the tumor grade.

Methods

Patients with histologically proven soft tissue sarcomas treated in our tertiary center from 2016 to 2019 who underwent an Magnetic Resonance (MR) scan at diagnosis including diffusion-weighted imaging were included in this retrospective institution review board–approved study. Each primary lesion was segmented using the b50 images; the volumetric region of interest was then applied on the ADC map. A total of 33 radiomic features were extracted, and highly correlating features were selected by factor analysis. In the case of feature/s showing statistically significant results, the diagnostic accuracy was computed. The Spearman correlation coefficient was used to evaluate the relationship between the tumor grade and radiomic features selected by factor analysis. All analyses were performed applying p<0.05 as a significant level.

Results

A total of 36 patients matched the inclusion criteria (15 women; mean age 58.9 ± 15 years old). The most frequent histotype was myxofibrosarcoma (16.6%), and most of the patients were affected by high-grade lesions (77.7%). Seven patients had pulmonary metastases, and, altogether, eight were deceased. Only the feature Imc1 turned out to be a predictor of metastatic spread (p=0.045 after Bonferroni correction) with 76.7% accuracy. The value -0.16 showed 73.3% sensitivity and 71.4% specificity, and patients with metastases showed lower values (mean Imc1 of metastatic patients -0.31). None of the examined variables was a predictor of the overall outcome (p>0.05, each). A moderate statistically significant correlation emerged only between Imc1 and the tumor grade (r=0.457, p=0.005).

Conclusions

In conclusion, the radiomic feature Imc1 acts as a predictor of metastatic spread in patients with soft tissue sarcomas and correlates with the tumor grade.

Forensic applications of micro-computed tomography: a systematic review

Purpose

The aim of this systematic review was to provide a comprehensive overview of micro-CT current applications in forensic pathology, anthropology, odontology, and neonatology.

Methods

A bibliographic research on the electronic databases Pubmed and Scopus was conducted in the time frame 01/01/2001–31/12/2021 without any language restrictions and applying the following free-text search strategy: “(micro-computed tomography OR micro-CT) AND (forensic OR legal)”. The following inclusion criteria were used: (A) English language; (B) Application of micro-CT to biological and/or non-biological materials to address at least one forensic issue (e.g., age estimation, identification of post-mortem interval). The papers selected by three independent investigators have been then classified according to the investigated materials.

Results

The bibliographic search provided 651 records, duplicates excluded. After screening for title and/or abstracts, according to criteria A and B, 157 full-text papers were evaluated for eligibility. Ninety-three papers, mostly (64) published between 2017 and 2021, were included; considering that two papers investigated several materials, an overall amount of 99 classifiable items was counted when referring to the materials investigated. It emerged that bones and cartilages (54.55%), followed by teeth (13.13%), were the most frequently analyzed materials. Moreover, micro-CT allowed the collection of structural, qualitative and/or quantitative information also for soft tissues, fetuses, insects, and foreign materials.

Conclusion

Forensic applications of micro-CT progressively increased in the last 5 years with very promising results. According to this evidence, we might expect in the near future a shift of its use from research purposes to clinical forensic cases.

Thyroid disorders following hematopoietic stem cell transplantation in childhood: the impact of the conditioning regimen on thyroid dysfunction, volume changes and occurrence of nodules

BACKGROUND

Thyroid late effects are among the most frequent sequelae reported after pediatric hematopoietic stem cell transplantation (HSCT). Though the detrimental effects of radiotherapy on the developing thyroid gland have been extensively assessed, the role of chemotherapy-only conditioning regimens is still controversial.

OBJECTIVE

We aimed at describing the occurrence, monitoring and management of thyroid function disorders (i.e. Graves' disease, Hashimoto thyroiditis and non-autoimmune hypothyroidism), nodules and volumetric changes over a 20-year observation period in a single pediatric transplant unit. In addition, we assessed the impact of different conditioning regimens on thyroid health.

STUDY

design Retrospective observational analysis. The study population included 244 patients transplanted for pediatric malignant or non-malignant diseases between 1999 and 2018 and for whom at least four thyroid function tests and one or more thyroid ultrasound(s) assessed sequentially after HSCT were available.

RESULTS

The 15-year cumulative incidence (CI) of either autoimmune or non-autoimmune thyroid dysfunctions (34%, SE 5.3%) did not statistically differ between total body irradiation- (TBI-) and chemo-based regimens (p 0.23). Indeed, the CI after busulfan (BU) was overall superimposable to that recorded after TBI (10-year CI: 22.2% versus 25.9%, respectively). Nevertheless, the CI of non-autoimmune hypothyroidism was statistically higher after BU- (12.4%, SE 3.7%) than after other chemotherapy only-based-conditionings (3.1%, SE 3.1%; p 0.02, 5-year CI), treosulfan included. The overall CI of nodules was low for the first 5 years after HSCT (1.9%, SE 0.9%), but it showed a subsequent steep increase over time, with a 15-year CI as high as 52.1% (SE 7.5%). TBI-conditioned patients experienced a higher 15-year CI of nodules (66.8%, SE 9.1%) compared to those receiving chemo-only regimens (33.6%, SE 9.5%; p 0.02), whereas age > 10 years upon transplantation showed a protective effect (HR 0.42, 95% confidence interval 0.2-0.88). Finally, a systematic sonographic follow-up highlighted a progressive statistically significant reduction in thyroid antero-posterior diameter among patients conditioned with TBI (p 0.005), but not after chemo-only regimens.

CONCLUSIONS

TBI and younger age upon HSCT play a remarkable and statistically demonstrated detrimental role on the occurrence of thyroid nodules, both benign and malignant. TBI and BU expose patients to a higher cumulative incidence of thyroid dysfunctions than other chemo-only regimens, treosulfan included. Accordingly, BU can be regarded as the most thyrotoxic agent among those administered as a part of a chemo-only conditioning regimen. Finally, patients conditioned with TBI, but not with other regimens, show a progressive decrease in thyroid volume over time, as assessed by sequential ultrasounds.

Chest X-ray Does Not Predict the Risk of Endotracheal Intubation and Escalation of Treatment in COVID-19 Patients Requiring Noninvasive Respiratory Support

Forms of noninvasive respiratory support (NIRS) have been widely used to avoid endotracheal intubation in patients with coronavirus disease-19 (COVID-19). However, inappropriate prolongation of NIRS may delay endotracheal intubation and worsen patient outcomes. The aim of this retrospective study was to assess whether the CARE score, a chest X-ray score previously validated in COVID-19 patients, may predict the need for endotracheal intubation and escalation of respiratory support in COVID-19 patients requiring NIRS. From December 2020 to May 2021, we included 142 patients receiving NIRS who had a first chest X-ray available at NIRS initiation and a second one after 48–72 h. In 94 (66%) patients, the level of respiratory support was increased, while endotracheal intubation was required in 83 (58%) patients. The CARE score at NIRS initiation was not predictive of the need for endotracheal intubation (odds ratio (OR) 1.01, 95% confidence interval (CI) 0.96–1.06) or escalation of treatment (OR 1.01, 95% CI 0.96–1.07). In conclusion, chest X-ray severity, as assessed by the CARE score, did not allow predicting endotracheal intubation or escalation of respiratory support in COVID-19 patients undergoing NIRS.

Brief communication: Chest radiography score in young COVID-19 patients: Does one size fit all?

During the SARS-CoV-2 pandemic, chest X-Ray (CXR) scores are essential to rapidly assess patients’ prognoses. This study evaluates a published CXR score in a different national healthcare system. In our study, this CXR score maintains a prognostic role in predicting length of hospital stay, but not disease severity. However, our results show that the predictive role of CXR score could be influenced by socioeconomic status and healthcare system.

Entrapment within an ottoman storage bed: an unusual accidental asphyxial death

Herein, we present an uncommon forensic case of death by asphyxia. The victim was a woman whose body at death scene investigation (DSI) was discovered beside an ottoman storage bed. According to the rescue team, who had moved the body before our arrival, the body was originally found in the prone position and stuck with the neck, thorax and arms within the bed. Examination of the body showed hypostasis that was mainly distributed to the face and the lower chest while sparing the neck and the upper chest. The face was markedly swollen, and the eyes were congested with blood. Dissection and histology revealed pulmonary oedema and emphysema of both lungs. Integrating circumstantial, radiology and autopsy data, it was established that the victim, while trapped between the mattress and the edge of the ottoman storage bed, died by mechanical asphyxia due to cervical-thoracic compression and postural asphyxia acting simultaneously.

Disease Severity and Prognosis of SARS-CoV-2 Infection in Hospitalized Patients Is Not Associated With Viral Load in Nasopharyngeal Swab

Background: The impact of viral burden on severity and prognosis of patients hospitalized for Coronavirus Disease 2019 (COVID-19) is still a matter of debate due to controversial results. Herein, we sought to assess viral load in the nasopharyngeal swab and its association with severity score indexes and prognostic parameters. Methods: We included 127 symptomatic patients and 21 asymptomatic subjects with a diagnosis of SARS-CoV-2 infection obtained by reverse transcription polymerase chain reaction and presence of cycle threshold. According to the level of care needed during hospitalization, the population was categorized as high-intensity (HIMC, n = 76) or low intensity medical care setting (LIMC, n = 51). Results: Viral load did not differ among asymptomatic, LIMC, and HIMC SARS-CoV-2 positive patients [4.4 (2.9-5.3) vs. 4.8 (3.6-6.1) vs. 4.6 (3.9-5.7) log10 copies/ml, respectively; p = 0.31]. Similar results were observed when asymptomatic individuals were compared to hospitalized patients [4.4 (2.9-5.3) vs. 4.68 (3.8-5.9) log10 copies/ml; p = 0.13]. When the study population was divided in High (HVL, n = 64) and Low Viral Load (LVL, n = 63) group no differences were observed in disease severity at diagnosis. Furthermore, LVL and HVL groups did not differ with regard to duration of hospital stay, number of bacterial co-infections, need for high-intensity medical care and number of deaths. The viral load was not an independent risk factor for HIMC in an adjusted multivariate regression model (OR: 1.59; 95% CI: 0.46-5.55, p = 0.46). Conclusions: Viral load at diagnosis is similar in asymptomatic and hospitalized patients and is not associated with either worse outcomes during hospitalization. SARS CoV-2 viral load might not be the right tool to assist clinicians in risk-stratifying hospitalized patients.

Reduced muscle mass as predictor of intensive care unit hospitalization in COVID-19 patients

Purpose

To evaluate if reduced muscle mass, assessed with Computed Tomography (CT), is a predictor of intensive care unit (ICU) hospitalization in COVID-19 patients.

Methods

In this Institution Review Board approved study, we retrospectively evaluated COVID-19 patients treated in our tertiary center from March to November 2020 who underwent an unenhanced chest CT scan within three weeks from hospitalization.We recorded the mean Hounsfield Unit (Hu) value of the right paravertebral muscle at the level of the 12^th thoracic vertebra, the hospitalization unit (ICU and COVID-19 wards), clinical symptoms, Barthel Index, and laboratory findings.Logistic regression analysis was applied to assess if muscle loss (Hu<30) is a predictor of ICU admission and outcome.Fisher’s exact and Student’s tests were applied to evaluate if differences between patients with and without muscle loss occurred (p<0.05).

Results

One-hundred-fifty patients matched the inclusion criteria (46 females; mean age±SD 61.3±15 years-old), 36 treated in ICU. Patients in ICU showed significantly lower Hu values (29±24 vs 39.4±12, p = 0.001). Muscle loss was a predictor of ICU admission (p = 0.004).Patients with muscle loss were significantly older (73.4±10 vs 56.4±14 years), had lower Barthel Index scores (54.4±33 vs 85.1±26), red blood-cell count (3.9±1 vs 4.6±1×10¹²L⁻¹), and Hb levels (11.5±2 vs 13.2±2g/l) as well as higher white blood-cell count (9.4±7 vs 7.2±4×10⁹L⁻¹), C-reactive protein (71.5±71 vs 44±48U/L), and lactate dehydrogenase levels (335±163 vs 265.8±116U/L) (p<0.05, each).

Conclusions

Muscle loss seems to be a predictor of ICU hospitalization in COVID-19 patients and radiologists reporting chest CT at admission should note this finding in their reports.

Is Empowerment of Female Radiologists Still Needed? Findings of a Systematic Review

Considering that radiology is still a male-dominated specialty in which men make up more than two thirds of the workforce, this systematic review aimed to provide a comprehensive overview of the current role of women in radiological imaging, focusing on the main aspects such as career progression, leadership, academic practice, and perceived discrimination. Three electronic databases were searched up to 21 October 2020. To identify additional records, weekly automatic email alerts were set up on PubMed until December 2020 and reference lists of key studies and included papers were screened. Two reviewers independently performed the search, study selection, quality appraisal, data extraction, and formal narrative synthesis. In case of disagreement, a third reviewer was involved. Across the 61 included articles, women worked more often part-time and held fewer positions of power in hospitals, on editorial boards, and at the academic level (associate and full professors). Women were less often in relevant positions in scientific articles, had fewer publications, and had a lower H-index. Discrimination and sexual harassment were experienced by up to 40% and 47% of female radiologists, respectively. Our study highlights that women in radiology are still underrepresented and play a marginal role in the field, struggling to reach top and leading positions.

Validation of a composed COVID-19 chest radiography score: the CARE project

OBJECTIVES

The aim of this study was to validate a composed coronavirus disease 2019 (COVID-19) chest radiography score (CARE) based on the extension of ground-glass opacity (GG) and consolidations (Co), separately assessed, and to investigate its prognostic performance.

METHODS

COVID-19-positive patients referring to our tertiary centre during the first month of the outbreak in our area and with a known outcome were retrospectively evaluated. Each lung was subdivided into three areas and a three-grade score assessing the extension of GG and Co was used. The CARE was derived from the sum of the subscores. A mixed-model ANOVA with post hoc Bonferroni correction was used to evaluate whether differences related to the referring unit (emergency room, COVID-19 wards and intensive care unit (ICU)) occurred. Logistic regression analyses were used to investigate the impact of CARE, patients' age and sex on the outcome. To evaluate the prognostic performance of CARE, receiver operating characteristic curves were computed for the entire stay and at admission only.

RESULTS

A total of 1203 chest radiographs of 175 patients (120 males; mean age 67.81±15.5 years old) were examined. On average, each patient underwent 6.8±10.3 radiographs. Patients in ICU as well as deceased patients showed higher CARE scores (p<0.05, each). Age, Co and CARE significantly influenced the outcome (p<0.05 each). The CARE demonstrated good accuracy (area under the curve (AUC)=0.736) using longitudinal data as well as at admission only (AUC=0.740). A CARE score of 17.5 during hospitalisation showed 75% sensitivity and 69.9% specificity.

CONCLUSIONS

The CARE was demonstrated to be a reliable tool to assess the severity of pulmonary involvement at chest radiography with a good prognostic performance.

Clinical Features and Chest Imaging as Predictors of Intensity of Care in Patients with COVID-19

Coronavirus disease 2019 (COVID-19) has rapidly become a global pandemic with lung disease representing the main cause of morbidity and mortality. Conventional chest-X ray (CXR) and ultrasound (US) are valuable instruments to assess the extent of lung involvement. We investigated the relationship between CXR scores on admission and the level of medical care required in patients with COVID-19. Further, we assessed the CXR-US correlation to explore the role of ultrasound in monitoring the course of COVID-19 pneumonia. Clinical features and CXR scores were obtained at admission and correlated with the level of intensity of care required [high- (HIMC) versus low-intensity medical care (LIMC)]. In a subgroup of patients, US findings were correlated with clinical and radiographic parameters. On hospital admission, CXR global score was higher in HIMCs compared to LIMC. Smoking history, pO2 on admission, cardiovascular and oncologic diseases were independent predictors of HIMC. The US score was positively correlated with FiO2 while the correlation with CXR global score only trended towards significance. Our study identifies clinical and radiographic features that strongly correlate with higher levels of medical care. The role of lung ultrasound in this setting remains undetermined and needs to be explored in larger prospective studies.

Short-term effects of the activator in skeletal class II division 1 patients with different vertical skeletal pattern. A retrospective study

AIM

The aim of this retrospective study was to analyse the effectiveness of Andresen appliance in inducing an increased mandibular dimension and, above all, to test the "null" hypotesis that the patients' vertical skelettofacial morfology could influence this increase using the Ricketts' method of VERT.

METHODS

Cephalometric records of 42 skeletal class II patients treated at the Orthodontic Department of Catania University were randomly selected. The sample was divided for vertical facial patterns, according to the facial classification method of Ricketts (VERT), into three groups: brachyfacial, mesiofacial and dolicofacial. Ten landmarks were located on the lateral cephalometric radiographs; growth in the horizontal-sagittal direction and in the vertical direction was evaluated using the measurements of total mandibular length (Co-Gn, Co-Pg, Ar-Pg, Ar-Gn), mandibular sagittal position (SNB, ANB) and mandibular ramus height (S-Go, Ar-Go, Co-Go). The intragroup comparisons were made using two tailed t-tests, while the intergroup comparisons were analyzed statistically using the Kruskal-Wallis test.

RESULTS

The cephalometric values before (T0) and after (T1) treatment showed significant changes for the majority of the cephalometric variables in each group. Our findings demonstrated a statistically significant greater increase of mandibular dimension in the brachyfacial group, while similar results were found for mesiofacial and dolichofacial groups.

CONCLUSION

The "null" hypothesis, that the skeletal pattern of subjects could influence the increase of mandibular dimension after Andresen treatment, had to be accepted: the brachyfacial patients showed a greater anterior mandibular displacement when compared to mesiofacial or dolichofacial group.

[Buschke Scleredema, case report]

Buschke Scleredema is a rare connective tissue disorder of unknown aetiology, characterized by thickening of the dermis whose characteristics may mainly to mime systemic sclerosis, eosinophilic fasciitis and cutaneous amyloidosis. Scleredema may be associated with a history of an antecedent febrile illness, diabetes mellitus, or blood dyscrasia. Scleredema can be classified into three clinical groups; each has a different history, course, and prognosis. Each one of these share reduction in chest articular movements and limitation of limbs movements. The skin histology is characterised by thickened dermis and increased spaces between large collagen bundles due to increased deposition of mucopolysaccharide in the dermis. Differential diagnosis can be made considering the typical clinical features and the histologic peculiarity. No therapy has been found effective. The authors describe a case of Buschke Scleredema successfully treated by steroids and colchicine. Clinical evaluation of skin induration and thickness as well as ultrasonography were performed at baseline and after treatment.

Unusual presentation of Addison's disease in Schmidt's syndrome

A patient with Schmidt's syndrome and atypical symptoms of Addison's disease is presented. Autoimmune thyroiditis was diagnosed at the age of 12 years and then at 15 years; a diagnosis of migraine was made following 10 days of headache, visual field defects and dysarthria. One week later the patient was admitted to hospital in critical condition. Addison's disease was diagnosed and replacement therapy was introduced which brought about a rapid clinical improvement. Positive adrenal autoantibodies confirmed the diagnosis. We suggest that patients with organ-specific autoimmune disease undergo annual screening for adrenal activity, and in the event of abnormal results, adrenal autoantibody evaluation should be carried out, to avoid a life-threatening crisis caused by Addison's disease, which is often difficult to recognize due to atypical clinical presentation, as in the patient reported here.

A ten-year (1989-1998) perspective study of the incidence of Type 1 diabetes in the district of Catania (Sicily) in a 0-14 year age group

The aim of this report was to evaluate the incidence of Type 1 diabetes mellitus (T1DM) in the district of Catania (eastern Sicily) in children under 15 yr of age over a ten-yr period (01/01/1989 - 31/12/1998) in relation to age, sex, monthly-seasonal variability, calendar yr and spatial clustering. The estimated completeness of our register was 99.2%. The overall incidence rate was 12.38 per 100,000 during the period of the study. Twenty-four percent of cases were 0-4 yr at diagnosis, 42% were 5-9 yr and 34% were 10-14 yr. More males (no. 148) than females (no. 125) were newly diagnosed with a male/female ratio similar to the base population ratio in the range 0-14 yr and within age groups. The study revealed a non-random spatial distribution of T1DM incidence in children not accounted for by known demographic factors. A significant seasonal pattern and temporal trend of incidence were also detected.

Consolidation of passive avoidance learning is associated with transient increases of polysialylated neurons in layer II of the rat medial temporal cortex

Within the rat medial temporal lobe, transient modulations of neural cell adhesion molecule (NCAM) polysialylation have been observed to follow spatial learning. These have been attributed to neuroplastic events associated with the processing of information destined for long term memory consolidation. To determine if similar events are associated with avoidance learning, we investigated change in polysialylated cell number in the entorhinal, perirhinal, and piriform cortex, following acquisition of a passive avoidance task in the rat. Direct quantification of polysialylated neurons in layer II of these cortical regions revealed a significant increase in polysialylated cell frequency at 12 h following passive avoidance training. Unlike spatial learning, the increased expression of polysialylated neurons persisted for up to 24-48 h following training. In the more dorsal aspect of the perirhinal/entorhinal cortex, this increase was found to be specific to learning, as it was not observed in animals rendered amnesic with scopolamine. By contrast, change in polysialylated cell frequency in the ventral aspect of the medial temporal lobe was only partially reduced by amnesic doses of scopolamine. The persisting activation of NCAM polysialylation in the more dorsal aspects of the perirhinal and entorhinal cortex is suggested to reflect the need for more extensive synaptic alterations, as compared to those required for the consolidation of spatial learning. Moreover, the neuroplastic modulations observed in the more ventral regions of the entorhinal and perirhinal cortex appear to be a unique aspect of avoidance conditioning that reflects the activation of alternative learning strategies associated with motivational and/or contextual parameters of the task.

Laparotomic vs. laparoscopic rectopexy in complete rectal prolapse

AIM

The aim of this study was to compare the functional and clinical results of laparotomic and laparoscopic rectopexy in 2 homogeneous groups of patients with complete rectal prolapse and fecal incontinence.

METHODS

Between January 1989 and December 1997, twenty-three patients underwent abdominal rectopexy. Thirteen patients (group A, 12 females and 1 male, mean age 57.3, range 22-76 years), and 10 patients (group B, 10 females, mean age 52.3, range 26-70 years) were submitted respectively to either Wells laparotomic or laparoscopic rectopexy by the same surgical team using the same surgical technique and materials. Before the operation a detailed clinical history was collected, and the patients were studied by inspection and digital examination of the anorectum, proctosigmoidoscopy, pancolonic transit time, dynamic defecography, anorectal manometry and anal electromyography. After the operation all patients underwent perineal physiotherapy, external electric stimulation, and perineal biofeedback. Mean follow-up was 37.1 (range 6-90) months in group A and 25.7 (range 6-49) months in group B. Values were compared by chi(2), Mann-Whitney U, and Wilcoxon tests as appropriate. Differences were considered significant at p < 0.05.

RESULTS

In both groups dyschezia and fecal incontinence improved significantly (p < 0.05) after the operation. The basal pressure of the anal sphincter, squeezing pressure and rectoanal reflex improved without significance, and anal-perineal pain was not significantly reduced. In group B the postoperative hospital stay was lower than in group A, with a reduction in costs.

CONCLUSION

Laparoscopic Wells rectopexy has the same clinical and functional results as laparotomic rectopexy, but with a shorter postoperative hospital stay and lower costs.

Melanoma antigen genes 1 and 2 are differentially expressed in human gastric and cardial carcinomas

BACKGROUND

MAGE genes encode for tumor-rejection antigens and are expressed in tumors of different histologic types but not in normal tissues, with the exception of testis and placenta. The aim of this study was to evaluate the frequency of MAGE-1 and -2 expression in gastric and in cardial carcinomas; these conditions have been described as two distinct diseases, having different etiologies, epidemiologic patterns, and gene mutations.

METHODS

Two groups of patients were studied: patients with distal gastric carcinoma and patients with carcinoma of the cardia. A group of patients with intestinal metaplasia in the gastric mucosa and controls were also included. All of them underwent upper GI endoscopy. Paired biopsy specimens were taken for routine histology and for RNA extraction, to study the expression of MAGE-1 and -2 genes.

RESULTS

None of the intestinal metaplastic samples or controls expressed MAGE-1 and -2 at detectable levels. Whereas 40% of the gastric cancer patients expressed either MAGE-1 or -2, 26.6% transcribed both. In the cardial cancer group, 20% of the cases expressed at least one MAGE, and only 6.6% expressed both genes. These results might reinforce the concept that cancer of the cardia is a distinct neoplastic disease with regard to esophageal and gastric (distal) carcinomas.

CONCLUSIONS

Here we show that MAGE gene expression occurs in advanced stages of gastric and cardial cancer and therefore appears to be a late event. This might point to a reconsideration of their potential role in cancer immunotherapy.

[Acquired deficiency of von Willebrand factor (wWF) associated with intestinal angiodysplasia. An unusual clinical case]

A rare case of acquired von Willebrand's disease associated with intestinal angiodysplasia is described. The case is very interesting because it clinically mimicked an intestinal neoplasm.

The prognostic value of cell proliferation in colorectal adenomas assessed with tritiated thymidine and anti-proliferating cell nuclear antigen

We analyze the cell kinetics of colorectal adenomas by tritiated thymidine (3HTdR) autoradiographic method and anti-proliferating cell nuclear antigen (PCNA) antibodies. A total of 46 patients who underwent prior endoscopic polypectomy for colorectal adenomas were reevaluated by colonoscopy for 4 years. Thymidine labeling index (T-LI) in index adenomas ranged from 1.40 to 38.0% (median value: 10. 75%); PCNA labeling index (PCNA-LI) in index adenomas ranged from 0 to 27.0% (median value: 1.95%). Among the 46 patients studied, 16 developed recurrent adenomas (Group A) and 30 were free of recurrent adenomas (Group B). The T-LI and PCNA-LI comparisons between Groups A and B were statistically significant (p < 0.0001, chi2 test). These results demonstrate that T-LI and PCNA-LI in colorectal adenomas might be helpful to predict the development of metachronous adenomas and hence to plan the follow-up of patients with adenomatous polyps after polypectomy.

Spatial learning activates neural cell adhesion molecule polysialylation in a corticohippocampal pathway within the medial temporal lobe

Transient and time-dependent modulations of neural cell adhesion molecule (NCAM) polysialylation in the dentate gyrus of the rodent hippocampus are a feature of spatial and nonspatial forms of learning. In the hippocampal formation, polysialic acid immunoreactivity was localized to granule-like cells and their mossy fibre axons. We now demonstrate the latter to extend to the CA3 region where apparent recurrent and Schaffer collaterals were labelled. The axons of the CA1 pyramidal cell layer were immunopositive, as was the subiculum that they innervate. Layers I and III of the entorhinal cortex stained intensely for polysialic acid; however, these were not visible in the more lateral aspect of this region and were replaced by a single band of immunopositive neurons that extended to include the perirhinal and piriform cortices. After Morris water maze training, the number of polysialylated neurons within the entorhinal cortex exhibited a two- to threefold increase at the 10-12-h posttraining time with respect to that observed immediately after training. This increase was task specific, as no change was observed in freely swimming animals or those required to locate a visible platform. These results suggest the presence of a corticohippocampal pathway involved in the eventual consolidation of memory.

Expression of the epidermal growth factor receptor gene in human intestinal metaplasia: a preliminary report

BACKGROUND

The role of growth factors/receptors in the etiopathology and/or development of gastric cancer has recently come under scrutiny, since overexpression or amplification of the EGF system has been found in many intestinal type gastric cancers and related to a more aggressive behavior. Since these gastric carcinomas appear to develop from intestinal metaplasia, a study was planned to investigate whether overexpression of the EGF-receptor gene also occurred in intestinal metaplastic mucosa.

METHODS

Patients underwent upper GL endoscopy. Gastric biopsies for routine histology, Helicobacter pylori detection, quantification of intestinal metaplasia and EGF-R expression analysis were performed. A 30mer EGF-R specific oligonucleotide was end-labeled and used to probe a dot blot filter containing the RNA from the bioptic samples.

RESULTS

Though all the gastric samples transcribed the EGF-R gene to a detectable level, overexpression of the EGF-R gene was found in the metaplastic mucosa in a minority of patients.

CONCLUSIONS

These preliminary findings suggest that overexpression of the EGF-R gene is infrequent in the metaplastic gastric mucosa.

[Rhombencephalic tissue in an ovarian teratoma with cerebellar foliation and maturation of the postnatal type]

In a women 32 years old, primipara with pregnancy to term hesitated caesarian birth, a cystic mature teratoma was found on both ovaries. While the content of the cyst of the left ovary appeared deprived of descriptive interest, in that of the right ovary, beyond to locks of hair, tegumental tissue, sebaceous matter and to a bone in miniature, they were structures relatively well diversified belonging to the nervous central system and particularly to the rhombencephalus (hindbrain). At the microscopic examination it was well recognizable a cerebellar structure with a microfolic configuration and with histological maturity of the postnatal type, identified for her neuronal depletion of the layer of the external granules and for the advanced myelination. It is advanced the hypothesis of a correlation between the maturation of the teratoma and the coexisting term pregnancy.

[A rare mesenchymal tumor of the larynx . Case report and anatomo-clinical features]

Laryngeal chondrosarcoma is an uncommon mesenchymal tumor and in the world literature only 220 cases have been reported. We report in this retrospective examination three cases which age ranged from 54 to 65 years; one was a man and two were women. Two of the tumors arose in the thyroid cartilage, one in the cricoid cartilage. All the cases corresponded to low-grade, well-differentiated chondrosarcomas of the hyaline type (grade I) and two of the patients were alive and free from recurrence or metastasis after 6 and 12 years. One had a recurrence 5 years later with a superior histologic grade (grade II) and died 6 months after laryngectomy from metastatic disease. The AA. discusses the importance of assessing location, size, state of the resection borders, histologic grade and recurrence for the correct evaluation of the neoplasia, for therapeutic and prognostic purposes.

[Pleomorphic storiform malignant fibrohistiocytoma of the larynx. Case report and anatomo-clinical considerations]

We have studied a rare case of malignant fibrous histiocytoma of the larynx, of the storiform-pleomorphic variety, diagnosed already as fibrosarcoma on two bioptical examinations performed to distance of a month the one from the other. The second biopsy showed an histological grade superior to the first and the patient came to death for lung metastasis two years later. The immunohistochemical study confirmed the mesenchimal origin of the tumor, excluding the presence of epithelial elements. Given the aggressive course, for the application of the different therapeutic protocols and for prognostic purposes it is underlined the need to make an attentive differential diagnosis also on histogenetic bases as regards the other mesenchimal and epithelial malignancies that they can simulate from near the histologic appearance. It proved very important, to such end, the immunohistochemical investigation, if correctly interpreted.

[Xanthelasma of the sigmo-rectal wall]

Xanthelasma is a benign localized collection of lipid-laden histiocytes, that is usually idiopathic and immunohistochemical studies confirmed the histiocytic nature of the proliferation. It is here reported a case in the sigma-rectum, with a review of the recent literature on the argument. Although it is a well recognized entity already described in various organs, its occurrence in the wall of the sigma-rectal channel is at all uncommon. It is suggested that the lesion could be referred to a local immunological disorder, with a cell mediated mechanism.

[Treatment of obesity with gastric balloon]

The use of inflatable intragastric balloons is a new non-intensive approach in the treatment of obesity when poor results are obtained by more conservative treatment. The intragastric balloons are certainly less hazardous than bariatric surgery but their long term effect on body-weight reduction it is not still proved. Several types of balloons are currently in use. The two used most widely are the Garren-Edwards Gastric Bubble and the Ballobes Balloon. The Authors report their experience with these two types of anti-obesity gastric-balloon in 60 grossly obese patients.

[Psychometric evaluation of the effects of an almitrine-raubasine combination in the intellectual deterioration of aged subjects. A double-blind controlled trial versus placebo]

The clinical and psychometric evaluation of a drug to be used against the intellectual deterioration associated with cerebral aging is of obvious interest when carried out on ambulatory subjects, since the symptoms likely to be reduced are found in elderly people usually living at home. Thirty-six patients (18 male, 18 female; mean age 65.5 +/- 1.7 years) were selected and allocated at random to two treatment groups. They received during 2 months 80 drops per day in two doses of either an almitrine-raubasine combination or a placebo. Patients definitely entered the trial when Hachinski's score for ischaemia was equal or inferior to 7. They were evaluated at zero, 1 and 2 months by means of 3 performance tests (Toulouse-Pieron test, Tapping test, numbers memorization test) and 2 mood tests (Hamilton's scale, Zung's questionnaire). All mean scores of recognition tests were statistically improved in the almitrine-raubasine group after 2 months of treatment. Compared with the placebo group, the improvement in the almitrine-raubasine group was significant at 1 month for 3 medium scores (symbols omitted, taping, numbers in normal order) and for all scores at 2 months. The psycho-behavioural symptoms evaluated by the two mood scores were significantly improved in the almitrine-raubasine group (P less than 0.001) and in comparison to the placebo group after 1 and 2 months (P less than 0.001). These results concerning intellectual performance and mood demonstrate that the almitrine-raubasine combination is useful in the treatment of intellectual deterioration in elderly people living at home.

[Interference of the intestinal ecosystem of mice in the oral administration of lyophilized live bacteria]

Oral vaccines mode by living or killed bacteria are commonly used to restore normal intestinal flora; it's not well know, however, which bacteria play the leading part in this ecosystem. In the present paper Authors have intended to compare the effectiveness of an oral vaccine, made by Bifidobacterium bifidus and Lactobacillus acidofilus, with another of similar use, made by Enterococci, to increase the mouse resistance to lethal Salmonella enteritidis infections. According to collected microbiological data and M.E.S. photos, the association Bifidob./Lactobac. is more effective than Enterococci to enhance resistance to the experimental infection.

[Target cimetidine treatment of peptic ulcer. Considerations and assessment of a new dosage]

32 patients suffering from peptic ulcer have been selected. Of these 12 formed part of a previous series treated with cimetidine and subsequently relapsed; the other 20 were selected on the basis of endoscopic and functional examinations and were treated for the first time with cimetidine. The drug doses used were 1.2 g for 30 days and 0.3 g for a further 60 days. The purpose of the study was to check for possible recurrences by comparing the results obtained and their maintenance in the long term using these doses. 2 months after suspension of maintenance treatment there has not been any recurrence of the acute pain and dyspeptic symptomatology.