Ambulatory peri-bulbar implantation, revision and replacement of Artificial Urinary Sphincter in neurogenic and non-neurogenic male patients: A preliminary feasibility study over a one-year experience

INTRODUCTION

Our goal was to determine the rate of complications, early revision and removal after full ambulatory implantation of bulbar AUS in men; secondly, to describe satisfaction and short-term continence rate.

MATERIAL AND METHODS

Between April 2018 and April 2019, 28 consecutive patients underwent AUS implantation in a newly organised ambulatory setting. A prospective database of all included patients was established with comprehensive data collected on medical history, aetiology and severity of SUI, surgical procedures, postoperative complications and patient satisfaction.

RESULTS

Twenty-eight patients were included (30 consecutive procedures: 22 primary AUS placement, 6 complete revisions, 2 partial revisions), with a mean follow up of 223±220.5 days. Fourteen patients had prior radiotherapy. Readmission rate was 6.7% in the first 30 days after surgery. Both revision and removal rates were 6.7%. Complications were reported in 26.7% of procedures, mainly Clavien-Dindo I. Patient satisfaction of ambulatory surgery organisation and experience was high (87/5% satisfied or very satisfied). Full continence & social continence were achieved for, respectively, 55.6% and 88.9% of procedures.

CONCLUSION

Ambulatory placement of AUS is safe and can be performed successfully. Larger patient cohorts and randomised trials are crucial to improve knowledge on non-indications for full ambulatory AUS implantation in men.

LEVEL OF EVIDENCE: 3

Retention Modelling of Phenoxy Acid Herbicides in Reversed-Phase HPLC under Gradient Elution

Phenoxy acid herbicides are used worldwide and are potential contaminants of drinking water. Reversed phase high-performance liquid chromatography (RP-HPLC) is commonly used to monitor phenoxy acid herbicides in water samples. RP-HPLC retention of phenoxy acids is affected by both mobile phase composition and pH, but the synergic effect of these two factors, which is also dependent on the structure and pKa of solutes, cannot be easily predicted. In this paper, to support the setup of RP-HPLC analysis of phenoxy acids under application of linear mobile phase gradients we modelled the simultaneous effect of the molecular structure and the elution conditions (pH, initial acetonitrile content in the eluent and gradient slope) on the retention of the solutes. In particular, the chromatographic conditions and the molecular descriptors collected on the analyzed compounds were used to estimate the retention factor k by Partial Least Squares (PLS) regression. Eventually, a variable selection approach, Genetic Algorithms, was used to reduce the model complexity and allow an easier interpretation. The PLS model calibrated on the retention data of 15 solutes and successively tested on three external analytes provided satisfying and reliable results.

Socioeconomic differences in prevalence of biochemical, physiological, and metabolic risk factors for non-communicable diseases among urban youth in Delhi, India

This study examined whether the distribution of biochemical, physiological, and metabolic risk factors for non-communicable diseases (NCDs) among children and youth in urban India vary by socioeconomic status (SES). Data were derived from a cross-sectional survey of students enrolled in the 2nd and 11th grades in 19 randomly selected schools in Delhi (N = 1329) in 2014-15. Mixed-effect regression models were used to determine the prevalence of risk factors for NCDs among private (higher SES) and government (lower SES) school students. After adjusting for age, gender, and grade we found the percentage of overweight (13.16% vs. 3.1%, p value < 0.01) and obese (8.7% vs. 0.3%, p value < 0.01) students was significantly higher among private relative to government school students. Similarly, significantly higher percentage of private school students had higher waist circumference values (7.72% vs. 0.58%, p value < 0.01) than government school students. Furthermore, similar trend was observed across schools in the distribution of other NCD risk factors: raised blood pressure, raised total cholesterol, and low-density lipoprotein. Surprisingly, despite a higher prevalence of all risk factors, significantly higher percentage of private school students had adequate/ideal levels of high-density lipoprotein. Overall, the risk profile of private school students suggests they are more vulnerable to future NCDs.

Authentication of an Italian PDO hazelnut ("Nocciola Romana") by NIR spectroscopy

Common hazelnuts are widely present in human diet all over the world, and their beneficial effects on the health have been extensively investigated and demonstrated. Different in-depth researches have highlighted that the harvesting area can define small variations in the chemical composition of the fruits, affecting their quality. As a consequence, it has become relevant to develop methodologies which would allow authenticating and tracing hazelnuts. In the light of this, the present work aims to develop a non-destructive method for the authentication of a specific high-quality Italian hazelnut, "Nocciola Romana," registered with a protected designation of origin (PDO). Thus, different samples of this fruit have been analyzed by near-infrared (NIR) spectroscopy and then classification models have been built, in order to distinguish between the PDO fruits and the hazelnuts not coming from the designated region. In particular, two different classification approaches have been tested, a discriminant one, partial least squares-discriminant analysis, and a class-modeling one, soft independent modeling of class analogies. Both methods led to very high prediction capability in external validation on a test set (classification accuracy in one case, and sensitivity and specificity in the other, all higher than 92%), suggesting that the proposed methodologies are suitable for a rapid and non-destructive authentication of the product.

Mutations in codons 12 and 13 of K-ras exon 2 in colorectal tumors of Saudi Arabian patients: frequency, clincopathological associations, and clinical outcomes

Mutations in codons 12/13 of K-ras exon 2 are associated with reduced benefit from anti-epidermal growth factor receptor antibody treatment for metastatic colorectal cancer (CRC). Here, we evaluated the frequency of K-ras mutations and their relationship with clinicopathological features and treatment outcomes in Saudi Arabian patients with CRC. The genetic status of K-ras was determined in 300 patients diagnosed with CRC. Clinical information was collected retrospectively. K-ras was wild-type in 58% and mutated in 42% of the tumors. Most mutations were at codon 12 (89%) and were associated with metastasis [odds ratio (OR) = 1.38 (95%CI = 1.14-1.67] and occurrence of >40 µg/L carcinoembryonic antigen (CEA) [OR = 1.33 (1.1-1.74)] during diagnosis. Patients in stages I-III of the disease with wild-type K-ras tumors had a median relapse free survival (RFS) of 29 months in contrast to 22 months for those with the mutated K-ras tumor (P = 0.0357). In multivariate analysis, only the stage of the disease significantly predicted RFS (P = 0.001). Patients in stage IV of CRC with the wild-type K-ras tumor did not reach the median overall survival (OS), whereas patients with the mutated K-ras tumor survived for 23.5 months (P = 0.044). CEA level >40 µg/L (P = 0.004) and status of K-ras (P = 0.044) were independent predictors of OS. This is the largest study investigating K-ras mutations in patients with CRC in the Middle East. Mutations were associated with advanced stage of CRC, higher serum CEA, shorter RFS and OS.

Oral D-mannose in recurrent urinary tract infections in women: a pilot study

Background:

In recurrent urinary tract infections (UTIs) usual prophylactic antibiotic regimes do not change the long-term risk of recurrence. Our aim was to evaluate the efficacy of D-mannose in the treatment and prophylaxis of recurrent UTIs.

Methods:

In this randomized cross-over trial female patients were eligible for the study if they had an acute symptomatic UTI and three or more recurrent UTIs during the preceding 12 months. Suitable patients were randomly assigned to antibiotic treatment with trimethoprim/sulfamethoxazole or to a regimen of oral D-mannose 1 g 3 times a day, every 8 hours for 2 weeks, and subsequently 1 g twice a day for 22 weeks. They received the other intervention in the second phase of the study, with no further antibiotic prophylaxis. The primary endpoint was evaluation of the elapsed time to recurrence; secondary endpoints were evaluation of bladder pain (VASp) and urinary urgency (VASu).

Results:

The results for quantitative variables were expressed as mean values and SD as they were all normally distributed (Shapiro–Wilk test). In total, 60 patients aged between 22 and 54 years (mean 42 years) were included. Mean time to UTI recurrence was 52.7 days with antibiotic treatment, and 200 days with oral D-mannose ( p < 0.0001).

Conclusions:

Mean VASp, VASu score, and average numbers of 24-hour voidings decreased significantly. D-mannose appeared to be a safe and effective treatment for recurrent UTIs in adult women. A significant difference was observed in the proportion of women remaining infection free versus antibiotic treatment.

The ventriculocholecystic shunt: two case reports and a review of the literature

We describe the re-siting of ventriculoperitoneal shunts to the gallbladder in two children. The first child had a rare case of hydrocephalus associated with plasminogen deficiency. She had had multiple VP shunt revisions due to non-absorption of CSF from the peritoneum. The second had craniopharyngioma-related hydrocephalus with once again a non-absorbing peritoneum. We report no surgical complications in the revisions for both the cases, and there has been a subsequent follow-up of 46 and 28 months, respectively, without incident. A review of the relevant literature describing the use and the performance of ventriculocholecystic shunts in comparison with other ventricular shunts is considered.

MetaBase--the wiki-database of biological databases

Biology is generating more data than ever. As a result, there is an ever increasing number of publicly available databases that analyse, integrate and summarize the available data, providing an invaluable resource for the biological community. As this trend continues, there is a pressing need to organize, catalogue and rate these resources, so that the information they contain can be most effectively exploited. MetaBase (MB) (http://MetaDatabase.Org) is a community-curated database containing more than 2000 commonly used biological databases. Each entry is structured using templates and can carry various user comments and annotations. Entries can be searched, listed, browsed or queried. The database was created using the same MediaWiki technology that powers Wikipedia, allowing users to contribute on many different levels. The initial release of MB was derived from the content of the 2007 Nucleic Acids Research (NAR) Database Issue. Since then, approximately 100 databases have been manually collected from the literature, and users have added information for over 240 databases. MB is synchronized annually with the static Molecular Biology Database Collection provided by NAR. To date, there have been 19 significant contributors to the project; each one is listed as an author here to highlight the community aspect of the project.

Extradural spinal cord compression by rheumatoid nodule

Rheumatoid disease is a systemic disorder affecting multiple organs. It is known to affect the nervous system in a variety of ways, but its presentation with spinal cord compression by a rheumatoid nodule is rare. We report two cases presenting with cord compression by a rheumatoid nodule who underwent surgical decompression with good recovery.

First results of long-term rituximab maintenance treatment in follicular lymphoma: Safety analysis of the randomized phase III trial SAKK 35/03

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Background: Rituximab maintenance has been shown to be effective in patients with follicular lymphoma. The optimal duration of maintenance remains unknown. Methods: We prospectively registered 270 patients with untreated, chemotherapy resistant or relapsed follicular lymphoma. All patients received rituximab induction consisting of 4 weekly doses (375 mg/m2). Responding patients (PR and CR) were randomized to a short maintenance consisting of four doses of rituximab (375 mg/m2) every two months (arm A) or prolonged maintenance consisting of rituximab every two months for a maximum of five years or until progression or unacceptable toxicity (arm B). Primary endpoint was event-free survival. Here we present the safety analysis. Results: From October 2004 to November 2007 165 patients were randomized, 82 in arm A and 83 in arm B. The median follow up is 22.7 months. A total of 442 hematological and non-hematological adverse events were observed, 27 of grade 3 and 6 of grade 4. Five subsequent cancers and 9 grade 3 and 4 infections were reported. Grade 3 and 4 neutropenia occurred in 5 patients, decreased levels of IgG were observed in 19 patients. Four grade 3 infections occurred after 2 years of maintenance. In arm B, maintenance was stopped due to unacceptable toxicity (fever) in 1 patient after 18 months and due to subsequent breast cancer in 1 patient after 20 months. One patient died 4 months after randomization because of ileus and consecutive peritonitis; considered to be unrelated to therapy. Twenty-nine patients are on maintenance for two or more years of which 6 patients are on for three or more years. In this analysis, median duration of the prolonged maintenance is 23.7 months. Conclusions: Rituximab maintenance beyond two years is feasible. We do not have evidence for increased toxicity after 2 years of maintenance. However, close follow up of patients under prolonged rituximab maintenance is necessary. The trial has been closed for accrual but there are still patients on treatment.

[Table: see text]

Prognostic role of interim 18FDG-PET in Hodgkin lymphoma: A single-center experience

e19520

Background: The role of FDG-PET for staging and response assessment in Hodgkin lymphoma (HL) is still evolving. We report our experience with the intent of evaluate prognostic role of 18FDG-PET in terms of long term complete remission (CR). Methods: We retrospectively analysed 65 consecutive pts affected by newly diagnosed HL. Median age was 36 yrs. Histology included 50 classical and 10 lymphocyte predominance HL. According to Hasenclever index, 58 out of 65 pts were considered at low risk, 5 at intermediate and 2 at high risk. 30/65 pts showed good prognosis (defined as IA-IIA, < 3 nodal sites, ERS < 50) and received 4 cycles of VBM followed by involved field (IF) radiotherapy (RT); the remaining 35 pts received hybrid ChlVPP/ABVVP for 6 cycles followed by IF RT in case of bulky disease. All patients underwent 18FDG-PET scans at diagnosis, after the fourth cycle in the VBM group, after the third cycle in the ChlVPP/ABVVP (interim 18FDG-PET), at the end of treatment in all patients. Fisher exact test was used to compare percentages between groups. Results: CR was recorded in 60 (92%) pts. Interim 18FDG-PET was negative in 52 out of 65 pts (80%), all in CR at the end of treatment. Eight out of 13 pts with positive interim 18FDG-PET obtained a CR at the end of treatment (100% versus 62%, Fisher exact text p<0.01). Six out of 65 pts relapsed: interim 18FDG-PET was negative in 5 of them, positive in 1 case. Two deaths occurred, one among pts with negative and one with positive interim 18FDG-PET. After a median follow-up of 30 months, 3-year freedom from treatment failure was 83% and 62% in pts with negative and positive interim 18FDG-PET, respectively (Log-rank test p<0.01, Hazard Ratio 4.9 (95%CI 1.4–16.1)). Conclusions: In our experience interim 18FDG-PET demonstrate a predictive role regarding the achievement of CR and treatment failure, at least as relevant as Hasenclever index, but failed to predict clinical result in 12 (18%) pts. Its role in defining the best therapeutical approach in HL pts must be further investigated in randomized clinical trials.

No significant financial relationships to disclose.

Closed cranial meningocele with no communication to the CNS

We present a case of two separate closed parietal meningoceles without communication to the CNS and not in the midline. This is the first such case reported in the literature.

Phase II trial of cladribine (2-CdA) and rituximab in patients with CLL and SLL: Preliminary report of a single institution

7093

Background: Byrd et al (Blood 2003) confirmed the synergistic effect of Rituximab and Fludarabine in the treatment of CLL patients (pts). The choice of purine analogue still remains controversial. We evaluated feasibility, efficacy, and toxicity of 2-CdA-Rituximab combination in the treatment of CLL and SLL pts requiring treatment. Methods: The combination therapy consisted of intravenous Rituximab at a dose of 375 mg/m2 on Day 1 and 2-CdA at a dose of 0.1 mg/kg (sc injection) per day on Days 2 through 6. The course was repeated at 4-week intervals for 4 times. 31 pts (21 CLL and 10 SLL) was enrolled in the study and the median age was 59 years (31–73); 42% of pts were pre-treated. A CT scan was abnormal in 95% of CLL pts. Immunophenotypic evaluation by ZAP-70 was positive in 70% of pts while no evaluable pts showed an adverse prognostic cytogenetic features by FISH. Minimal residual disease (MRD) assessment was performed by flow-cytometry and PCR methods. Results: 2 pts had to discontinue therapy after 2 cycle: one due to herpes zoster reactivation and the other one to the progression disease (PD). We observed grade 3 and 4 neutropenia in 4 pts (12%), major infections in 4 pts (12%) and no episodes of grade 3–4 thrombocytopenia. 24 pts were evaluable for response with an ORR of 96%. At the end of therapy 10 pts (42%), 7 CLL and 3 SLL, achieved a CR, with negative MRD (by PCR) in 4 pts (3 untreated); 13 pts (54%) obtained a PR and 1 patient had no response. With a median follow-up of 12 months (range 3–34) 7 pts (2 pts with MRD+CR and 5 pts with PR after treatment) experimented a PD; 5 of these pts were pre-treated and 2 died because of PD. Conclusions: The combination of 2- CDA and Rituximab seems to be tolerable and active principally for untreated pts and able to induce a molecular clearance also in pre-treated pts. The achieving of a CR with negative MRD seems to be the most important issue to improve the outcome.

No significant financial relationships to disclose.

Bronchial-associated lymphoid tissue (BALT) lymphoma: a retrospective analysis

17547

Background: Systemic CT in BALT lymphoma is the accepted therapy for those pts where surgery isn’t radical or possible. There is not a standard systemic treatment for this uncommon lymphoma however its indolent behavior and the relative asymptomatic outcome, allows on systemic therapy delay and may justify the use of less toxic CT agents. Methods: Here we reported our experience on 19 pts (10 men and 9 women) with biopsy-proven BALT lymphoma, median age was 61 yrs; 8 pts presented a symptomatic disease at diagnosis. 15 pts had a localized pulmonary disease (stage IE); 4 pts had stage IVE disease for peripheral blood and bone marrow involvement (3 pts) and gastric involvement (1 pt). Of 16 pts valuable for response, 3 pts received radical surgery (1 wedge resection and 2 lobectomy) as definitive treatment and 13 pts received systemic treatment (Chl containing regimen in 6, Rituximab ± Chl in 6; CVP regimen in 1) because of symptomatic disease or relapse after major surgery. Results: 6/13 pts achieved CR: 5/6 are still alive and disease free: 1 pt in CR died for other causes. 3 pts in asymptomatic PR don’t need further therapy while the additional 4 pts in PR need subsequent treatment because of symptomatic progression after a median TTP of 40 months. With a median follow up of 39 months, the OS and RFS observed are 85% and 63% respectively. Hematology and non-hematology toxicity was in general mild: transient G3 neutropenia occurred in only two pts; no pt discontinued the treatment because of treatment-related toxicity and no toxic death was recorded. Conclusions: Our analysis seem to confirm that surgery could be considered as unique treatment only for minority of pts with BALT lymphoma. Systemic chemotherapy with Chl containing regimen may achieve a clinical control of disease with about 50% of CR as well as other reported with more aggressive CT regimen. A larger retrospective analysis on pathological figure and clinical outcome is planned on behalf of IELSG.

No significant financial relationships to disclose.

Growing skull fracture in the absence of a dural tear

A case of growing skull fracture associated with unrecognized extradural haematoma is presented together with the relevant radiology. The pathophysiology of growing skull fracture is reviewed in light of this previously unreported case.

Pencil is mightier than the sword!

Penetrating injuries involving the spinal cord are not common. The incidence is, however, much higher in armed conflict. In a civilian population, gunshot wounds and stabbings account for the majority of such injuries. A pencil causing penetrating injury involving the spinal cord is very rare. We present the case of a young boy who accidentally suffered a penetrating injury involving the spinal cord from a pencil in his coat pocket.

Right ventricular infarction complicated by right to left shunting through an atrial septal defect: successful treatment with an Amplatzer septal occluder

A 68 year old woman presented with right ventricular myocardial infarction complicated by refractory hypoxaemia. She was found to have a significant right to left shunt at the atrial level through a previously undiagnosed ostium secundum atrial septal defect. Percutaneous closure of the atrial septal defect with an Amplatzer septal occluder resulted in prompt improvement in her oxygenation and clinical state. Such closure should be considered for patients with right ventricular infarction and refractory hypoxaemia caused by a right to left interatrial shunt.

A phase II study of alpha-interferon and oral arabinosyl cytosine (YNK01) in chronic myeloid leukemia

YNK01 (Starasid) is a prodrug that is adsorbed in the gut and is transformed in the liver in arabinosyl cytosine (AC). Low-dose AC (LDAC) is useful for the treatment of Philadelphia positive (Ph+) chronic myeloid leukemia (CML), especially in combination with alpha-interferon (alphaIFN). The use of YNK01 can avoid the daily s.c. injection of conventional AC. To assess the safety and the efficacy of alphaIFN and YNK01, we enrolled 86 consecutive previously untreated chronic phase Ph+ CML patients in a phase II study of alphaIFN (Intron-A) 5 MIU/m(2) daily and YNK01 600 mg daily 14 days a month. The 6-month complete hematologic response and the 12-month major cytogenetic response rates were 78 and 28%, respectively. In a prior study of alphaIFN and conventional LDAC, they were 62 and 22%, respectively. However, the compliance to the treatment was poor, with 25% of cases discontinuing the treatment within the first year. This was not because of the severity of the side effects but because of the frequency, duration and repetition of the side effects, for an overall frequency of 13.17 adverse events, mostly grade 1 and 2, per patient per year. Therefore, the study of this effective combination is being pursued, testing lower doses of alphaIFN and YNK01.

Anterior sacral meningocoele presenting as a peri-anal abscess

Anterior sacral meningoceole is a rare occurrence and presentation as a perianal abscess has not been previously reported. The case is presented and the condition discussed. The potential risks of failing to establish the diagnosis, prior to surgery, are outlined.

Ultrasound aspects of fetal and extrafetal structures in pregnant cats

Prenatal feline fetal growth and utero-placental development were ultrasonographically evaluated using an ultrasound scanner with a 10 MHz sector probe. Uterus, placenta, embryo, fetus and fetal membranes in 16 pregnant cats were monitored during the course of pregnancy; 13 subjects underwent an ovariectomy on specific days while three subjects went to term. Various anatomic structures, fixed in Carson-buffered formalin, were sectioned and then compared to ultrasound images. By ultrasound examination it is possible to evaluate every stage of the fetal development; the gestational chamber can be seen on the 10th and the embryo inside the chamber on the 14th day. By the 20th day it is possible to evaluate all the fetal membranes, and later it is possible to appreciate organs and structures such as the stomach, intestine, eyes (crystalline lens), kidneys and the cerebral choroid plexi, on the 30th, 40th, 50th, 39th and 40th day respectively. Based on our observations, it will be simpler to locate anomalies of development or pathologies during ultrasound examination of pregnant queens.

A subdural haematoma following 'reverse' bungee jumping

Bungee jumping has been exploited commercially for 13 years and proprietors claim a good safety record. However, published case reports document a wide variety of possible injuries. To this list, we add a report of a subdural haematoma sustained during a variant of the sport, the 'reverse' bungee jump.

Correlation between the age of the conceptus and various ultrasonographic measurements during the first 30 days of pregnancy in domestic cats (Felis catus)

We ultrasonographically evaluated the prenatal development in cats, from the early phases to Day 30 of pregnancy, subjecting a group of pregnant cats (n = 12) to a daily ultrasonographic exam. The ultrasonographic images allowed us to measure the minor diameter of the gestational sac and the crown-rump length of the embryo/fetus. Ten subjects underwent ovariohysterectomy at specific intervals during the pregnancy, with the aim of comparing the ultrasonographic data with real data; only two subjects brought their pregnancy to term. The earliest ultrasonographic observation of the gestational sac was on Day 10 after mating, while the embryo could be measured only beginning with Day 18. This study allowed to gather useful new data in order to clinically monitor the normal course of pregnancy in cats and to date the gestational age.

[Meniscal injuries of the knee. Diagnostic imaging]

Nowadays, treatment of meniscal tears is conservative with removal only of the broken part of meniscus. For this reason, before arthroscopy, the orthopaedic surgeon needs for an accurate preoperative diagnosis that could be obtained with computed tomography (CT) and magnetic resonance (MR). Our purpose is to value the actual role of CT and MR in diagnosis of meniscal tears. We retrospectively evaluated CT and MR images of 128 patients (average age 32 years) who then underwent arthroscopy. On the basis of our findings CT and MR have been shown to be very accurate to detect meniscal tears, even if with both methodics false positives and false negatives are possible. Nevertheless, MR is able to give high resolution multiplanar images without using ionising radiations and is preferable because of its high accuracy in recognising associated lesions of ligaments or articular cartilage.

[Cervical spine injuries: diagnostic imaging]

In past few years, traumas of cervical spine have increased, chiefly owing to rise of road accidents. Nevertheless, only in a small percentage of cases lesions of cervical spine occur and, in order to reduce many negative radiographs, a careful clinical examination is required. Our purpose is to verify the value of radiology in evaluation of acute trauma of cervical spine and to propose an adequate radiological protocol. In the course of two years (1998-99), 376 patients were admitted in consequence of cervical trauma of different degree of gravity. In all patients, conventional radiographs were obtained, in 93 a computed tomography (CT) examination was executed and only in 18 patients with neurological symptoms a magnetic resonance (MR) was required. Fractures of cervical spine wee identified in 91 cases and in patients in which MR images were obtained, neurological lesions of various severity were diagnosed. On the basis of our results, we think that, in a clinical suspicion of cervical spine lesions, a conventional radiographic study has first to be performed even if often good radiographs aren't obtained for technical difficulties. If doubts persist on conventional radiographs or a fractures has already been diagnosed on radiographs but we want to verify its stability, a CT needs to be performed. MR is required if neurological symptoms are present in order to diagnose lesions of spinal marrow, nerve roots or ligaments.

[Rotator cuff rupture. Diagnostic imaging]

Conventional radiography, ultrasound, Magnetic Resonance (MR), Arthrography Computed Tomography (Arthro-CT) and Arthrography Magnetic Resonance (Arthro-MR) are available for diagnosis of rotator cuff tears. Our purpose is to assess the specificity and sensitivity of these examinations and if they could give to the surgeon all the informations to select the more accurate treatment. We have evaluated retrospectively the images of 68 patients, 43 male and 25 female (average age 51 years), which then have been surgically treated for rotator cuff pathology. On the basis of our findings, we think that conventional radiography and ultrasound are excellent in a first evaluation. MR images, particularly in the coronal and sagittal oblique planes, are able to demonstrate partial or complete rotator cuff tears. The use of intra-articular contrast medium (arthro-CT, arthro-MR) should be reserved for partial lesions on specific cases.

The intracranial complications of rhinosinusitis: can they be prevented?

OBJECTIVES/HYPOTHESIS

Reference textbooks on the intracranial complications of rhinosinusitis imply that many of the intracranial complications of rhinosinusitis can be prevented. We sought to examine whether or not this is true.

STUDY DESIGN

A retrospective case series.

METHODS

The study included 47 consecutive patients presenting with intracranial complications secondary to rhinosinusitis between 1992 to 1999 with a mean follow-up of 5 years and 1 month.

RESULTS

The most common presenting symptoms of intracranial involvement were an altered mental state, headache, fever, seizure, vomiting, a unilateral weakness or hemiparesis, or a cranial nerve sign. These justify an urgent magnetic resonance imaging or computed tomography scan. The importance of imaging before a lumbar puncture cannot be overemphasized. Of particular note was the finding that 21 patients (45%) presented with a periorbital cellulitis or frontal swelling. Therefore, it does not follow that because a collection of pus presents anteriorly it precludes any intracranial involvement. More than half of our patients (55%) had visited their primary care physician with an upper respiratory tract infection and had been treated appropriately. Once any central symptoms or signs developed, there was little evidence of any significant delay in referral to our unit. Only six patients had a history of nasal disease, three having had recent sinus surgery and three having had nasal polyps. Nine patients had significant long-term morbidity, seven patients had epilepsy, one patient had dysphasia, and one patient had right arm weakness. The single death in our series was associated with a cavernous sinus thrombosis.

CONCLUSIONS

The report emphasizes the need for surgeons to be alert to the diagnosis, particularly in patients with a periorbital abscess or frontal swelling. Sinus surgery has a role in obtaining pus for culture, as well as draining the sinus if it is in continuity with an intracranial collection. Intracranial infections secondary to rhinosinusitis occur sporadically and, although it appears that this cannot be prevented, early recognition and treatment are essential to reduce any subsequent morbidity or mortality.

Sildenafil (Viagra)-induced spontaneous intracerebral haemorrhage

Sildenafil (Viagra) has been developed as a drug to help male impotence. It has a direct effect on the vasculature of the corpus cavernosum. A case of spontaneous intracerebral haemorrhage (ICH) following the illicit use of Viagra is reported. A discussion of drug-induced ICH is included.

Real-time quantification of different types of bcr-abl transcript in chronic myeloid leukemia

BACKGROUND AND OBJECTIVES

The most common translocation in chronic myeloid leukemia (CML) t(9;22) (q34;q22) produces the BCR/ABL fusion gene. We set up and evaluated a rapid and reliable real-time reverse-transcription-polymerase chain reaction (RT-PCR) approach using TaqMan technology for detection and quantification of bcr-abl transcripts in CML patients at diagnosis and during therapy.

DESIGN AND METHODS

A pair of primers and probe complementary to ABL exon 2 were designed, enabling detection of the most frequent bcr-abl transcripts, and also of the normal ABL-Ia transcript as an internal control. Conditions were established to amplify less than 1(-10) target molecules/reaction and detect one CML cell in 10(6) cells from healthy donors. To determine the utility of the assay, we quantified the bcr-abl/ABL-Ia ratio in 59 bone marrow samples (45 samples with evidence of different Ph+ chromosome percentages and 14 samples in complete cytogenetic remission) from 48 CML patients, 34 of them at diagnosis and 14 in clinical remission (CR). In 14 cases, this ratio was compared with results obtained by a competitive-quantitative RT-PCR/capillary electrophoresis method from contemporary specimens.

RESULTS

By real-time RT-PCR, the median value of bcr-abl/ABL-Ia ratio at diagnosis was 15.334 (range 3.3-28.81) and fell to 0.9 (range 0.003-26.1) in CR. The median value of bcr-abl/ABL-Ia ratio at cytogenetic remission was 0.7 (range 0.003-2.83). The real-time bcr-abl/ABL-Ia ratios correlated with those obtained by competitive RT-PCR (p < 0.0001) and the percentage of Ph+ metaphases (p < 0.0001). The high sensitivity and specificity of the real-time RT-PCR procedure was confirmed in all 14 patients with minimal residual disease. INTERPRETATION AND CONCLUSIONS. We conclude that this real-time RT-PCR procedure is a reliable and sensitive method of monitoring CML patients after therapy, and that the bcr-abl/ABL-Ia ratio correlates strongly with cytogenetic analysis.

[Radiologic diagnosis of spondylodiscitis: role of magnetic resonance]

PURPOSE

To report the Magnetic Resonance Imaging (MRI) features of acute and chronic spontaneous spondylodiscitis as well as any typical patterns which can be useful for the differential diagnosis between pyogenic and tuberculous forms.

MATERIAL AND METHODS

Eleven patients affected with spontaneous spondylodiscitis were selected for the study; they were 7 men and 4 women ranging in age 33-87 years (mean: 64). We excluded the patients with iatrogenic spondylodiscitis. MR images were acquired with a superconductive magnet at 1.5, with the following sequences: sagittal PD and T2-weighted TSE, sagittal T1-weighted SE, axial PD and T2-weighted TSE for the lumbar spine, axial T2-weighted GRE for the cervical and dorsal spine and axial and sagittal T1-weighted SE after contrast agent (gadolinium DTPA) injection. MR images were reviewed by three experienced radiologists and morphological and signal intensity changes of vertebral body and disk were recorded on a standard form. In 9 patients it was possible to compare MR to CT findings.

RESULTS

At the time of our observation all patients reported pain at the spine level, associated with fever and weight loss in 50% of cases and with increased values of the inflammatory markers. Three patients had infectious diseases in other organs and 2 were diabetics. Biopsy was performed in two cases only and demonstrated Staphylococcus aureus in one and Mycobacterium tuberculosis in the other patient. MRI allowed the correct diagnosis to be made in all cases, demonstrating the pathological involvement of the paravertebral structures and into the spinal canal earlier and more accurately than CT. A common finding in pyogenic and tuberculous spondylodiscitis was the low signal of the subcortical bone marrow on T1-weighted sagittal images, which enhanced after Gd-DTPA administration and became intermediate or high on T2-weighted images. Moreover, the steady high signal intensity of the disk on T2-weighted images and its contrast enhancement on T1-weighted images is typical for an acute inflammatory process.

CONCLUSIONS

Based on our personal experience and literature data, we believe MRI to be the most sensitive technique for the diagnosis of spondylodiscitis in the acute phase, whereas it is comparable to CT in the chronic stage of the disease. At present MRI does not allow to differentiate pyogenic from tuberculous forms.

Evaluation of tests employed in serological diagnosis of brucellosis caused by Brucella ovis

A survey was carried out to verify the sensitivity and specificity of various tests (complement fixation test--CF; agar gel immunodiffusion--AGID; indirect enzyme linked immunosorbent assay--ELISA; immunoblotting--IB) employed in the serological diagnosis of brucellosis caused by Brucella ovis. The tests were executed on 44 blood serum samples of rams coming from B. ovis-free flocks, 75 of B. ovis experimentally infected rams and 1139 from rams living in flocks where B. ovis had been previously isolated. All tests were performed using B. ovis hot saline extract (HS) as antigen. Sensitivity results were 97.4% for IB, 98.68% for CF, 100% for AGID and ELISA; specificity was 100% for all methods. Concordance values were 89.62% (CF-AGID), 78.77% (CF-ELISA), 77.74% (AGID-ELISA), 65.45% (IB-CF), 62.93% (IB-ELISA), 67.24% (IB-AGID). IB identified antibodies to antigenic components with molecular weight of 67, 63, 58, 55, 38, 35, 32, 30, 28, 25, 23, 21, 20-18 kDa (proteins) and 15-12 kDa (rough lipopolysaccharide).

[Upper cervical spine fracture: sources of misdiagnosis]

PURPOSE

Missing cervical spine fractures during the initial plain film study may lead to severe neurological complications for patients and to medicolegal responsibilities for the physician. The upper cervical spine tract (C1-C2) is considered to be at high risk for misdiagnoses. We decided to investigate the possible causes of mistake in the cases of missed fractures on the initial plain film, performed in the emergency room.

MATERIAL AND METHODS

We retrospectively reviewed the radiological reports, the original plain films and the CT findings, of 32 patients with upper cervical (C1-C2) fractures, admitted January 1994 to December 1998. Twenty-eight of these patients (87.5%) had multisystem trauma, 4 (12.5%) had minor craniocervical trauma. None of these patients had neurological signs correlated to the cervical injuries, 30 of them had normal consciousness and reported only neck pain, 2 of them were unconscious for the associated head trauma and were hospitalized in the intensive care unit. All the patients with normal consciousness underwent conventional three-view cervical spine radiography; the two unconscious patients in the intensive care unit were submitted to bedside examination with an anteroposterior and a lateral views of the cervical spine. All patients underwent spiral CT of the upper cervical tract.

RESULTS

In 9 of 32 patients (28%) a cervical fracture was missed on the plain film and CT was performed only because of persistent neck pain. We found 2 Jefferson's fractures, 2 type II dens fractures, one type I dens fracture and 4 hangman's fractures. In 8 of the 9 patients (89%) the fracture was potentially unstable. Misdiagnoses resulted from overlapping bone structures (3%), suboptimal film quality (3%), satisfaction of search phenomenon (3%), missed mild tilting of the dens (6%), missed double cortex sign (16%), missed C1-C2 lateral subluxation (6%) and marked osteoporosis (3%). Prevertebral soft tissue swelling was not seen in any of the 9 cases of missed fractures. Considering the group of patients with C1-C2 fractures separately, the false negative rate is 28%, which corresponds to 10.7% of the total number of patients with cervical fractures and dislocations examined during the same period.

CONCLUSIONS

Among the causes of false-negative interpretation, osteoporosis, suboptimal film quality due to associated fractures and overlapping bone structures must be considered unavoidable. On the other hand these possibilities should be indicated on the X-ray report because, if painful symptoms persist, a CT exam is strongly advised. Subtle alterations like dens tilting, double cortex sign, lateral subluxation of C1 and prevertebral soft tissue swelling should be regarded as highly suspicious for fracture. Missing these lesions might be considered a true diagnostic mistake with possible legal consequences, which may also expose the patient to the risk of neurological complications. The satisfaction of search phenomenon can be avoided only by trying to use a search pattern for every film, which includes checking all the visible anatomical structures even in the presence of a particularly evident lesion. In all questionable cases or high-risk fracture patients, even with an apparently negative plain film, it is advisable to perform CT instead of additional plain films. Finally, in all the patients treated in the intensive care unit for head trauma, an upper cervical CT scan should be routinely carried out at the same time as the brain scan.

[Mesenchymal tumors of the pancreas: computed tomography patterns]

PURPOSE

To report the CT patterns of pancreatic mesenchymal lesions and to investigate the capabilities and limitations of this technique in terms of characterization.

MATERIAL AND METHODS

We selected the CT examinations of 23 patients from all CT examinations of the pancreas performed from 1986 to 1998. The patients were 10 to 85 years old and all lesions but two (1 lipoma and 1 lymphoma) had pathologic confirmation. Two lymphangiomas, 2 lipomas, 4 Schwannomas (SCH), 1 plexiform neurofibroma, 1 cystic teratoma, 1 pancreatoblastoma, 9 non-Hodgkin's lymphomas (NHL), 1 undifferentiated sarcoma and 2 leiomyosarcomas were diagnosed.

RESULTS

Lipomas had typically homogeneous negative HU values, and NHL a homogeneous hypodense pattern with mild contrast enhancement, with no necrosis or calcifications in both diffuse and nodular forms; SCH had variable appearance, with water/slightly negative HU numbers or highly enhanced patterns with a central necrotic core depending on the main Antoni A or B histology. Lymphangiomas appeared as complex cysts, with thin and regular or calcified walls and intracystic septa, while the plexiform neurofibroma had near-water homogeneous density with mild contrast enhancement and an infiltrating growth pattern. Our teratoma had multiple calcifications, mucinous and lipid components. The pancreatoblastoma, sarcomas, and leiomyosarcomas exhibited no specific findings.

CONCLUSIONS

In selected cases, CT can provide virtually diagnostic information (lipoma and teratoma), or at least highly suggestive findings (NHL, plexiform neurofibroma, lymphangioma). Moreover, knowledge of the variable morphostructural patterns of mesenchymal histotypes (SCH, sarcoma etc.) permits to include them in the differential diagnosis of pancreatic masses.