An Innovative Approach to Scalp Segmentation in Pediatric Brain Radiotherapy: An Atlas-Based Study

PURPOSE/OBJECTIVE(S)

This study aims to develop an atlas-based method for segmentation of the scalp in pediatric patients that received brain radiotherapy. The study focuses on the development of a model that utilizes CT scans of pediatric medulloblastoma (MB) patients who underwent craniospinal-irradiation (CSI) and a boost in the posterior cranial fossa (PCF).

MATERIALS/METHODS

A team of experts created the Alopecia_Hope (A_H) contouring protocol on the CT scan using the 2018 EPTN consensus-based atlas and by defining for the manual adjustments the anatomic bone landmarks to differentiate between the scalp and the facial and neck skin. Using RayStation version 12A-SP1, the system was running his latest available software version at the time of study. Automated scripts were created to identify bone tissue and skin as a subtraction volume between bone and body. The soft tissue CT window was then manually used to increase or decrease the thickness of the skin, following the landmarks outlined in the protocol. The entire head scalp was defined as WScalp (WS), and a duplicate and reduced version was also defined as PCFScalp (PCFS). We randomly chose 40 patients to create both WS and PCF atlas with RayStation and 8 patients were used as testers for both volumes, the patients with major bone changes after neurosurgery were excluded. The contouring time was recorded, the mean time was calculated, and the contouring results were analyzed by experts. Standard similarity metrics of 3D DICE similarity coefficient and mean distance to agreement (MDA) were calculated.

RESULTS

A total of 52 patients were selected for the study, with a median contouring time of 19 minutes using the guidelines, the A_H protocol and automatic scripting. Three patients were excluded. Of the 8 testers, including both volumes (WS and PCFS), the mean contouring time for the expert operator was 17.5 min. While the contouring undergone by the automatic atlas was 11 min and the mean time of the expert correction was 4.5 min. Considering the work done by the atlas is in background, this resulted in a time savings of 80% for the operator. Table 1 contains mean and one standard deviation data for the metric, both WS and PCFS tested.

CONCLUSION

Atlas-based self-segmentation and the Alopecia_Hope protocol offer a more efficient and accurate method to identify specific areas of the scalp that may be affected by post-radiotherapy hair loss. This study demonstrates the effectiveness and efficiency in reducing radiotherapy workload and improving accuracy, with possible future application in the prevention of permanent alopecia and in improving the quality of life of patients undergoing whole brain radiotherapy.

Results of current endovascular treatments for visceral artery aneurysms

OBJECTIVE

This single-centre retrospective cohort study was aimed to analyse the early and long-term results of endovascular treatment for true visceral artery aneurysms. Moreover, a comparison with the results of our previously published historical series of open surgical procedures was performed.

MATERIALS AND METHODS

From January 2008 to December 2021, 78 consecutive patients were treated at our institution for true visceral artery aneurysms. All demographic data, procedural details, perioperative outcomes, and follow-up data were prospectively collected from a dedicated database. A retrospective analysis identified 72 patients who underwent endovascular surgery. Early results were analysed in terms of technical success, conversion to open surgery, mortality, and local and systemic morbidities. Follow-up results were analysed in terms of survival, need for open or endovascular reintervention, and freedom from complications at the level of the treated visceral artery. These results were then compared with those of our historical open surgical group (1982-2007), which included 54 interventions.

RESULTS

In four cases, the planned endovascular procedure could not be completed, and the overall technical success rate was 94.5%. No deaths occurred during the hospital stay or 30 days after surgery. Overall, the 30-day perioperative complication rate was 5.8%, with an early reintervention rate of 2.9%. The median follow-up time was 29 months (1-132 months). The estimated 7-year survival rate was 88% (standard error, SE 0.05). The estimated 7-year aneurysm-related complication-free rate was 85.5% (SE 0.06), with reintervention-free and aneurysm-related complication-free survival rates of 93.3% (SE 0.04) and 75.6% (SE 0.07), respectively. At the 7-year follow-up, the survival rate was similar between the endovascular and open groups. There was a trend towards a higher aneurysm-related complication rate in the endovascular group than in the open group (14.5% vs. 6.4%, p=0.07). However, no significant differences in reintervention-free and overall estimated aneurysm-related complication-free survival rates were found between the two groups.

CONCLUSIONS

Endovascular repair is safe and effective in patients with visceral artery aneurysms, with low perioperative complication rates. The long-term outcomes were satisfactory and comparable with those of the historical series of open surgical repairs. Even if there is a trend towards a higher risk of late aneurysm-related complications among endovascular patients, it does not imply an increased need for late reinterventions.

Psychogenic non-epileptic seizures and functional motor disorders in developmental age: A comparison of clinical and psychopathological features

BACKGROUND

Psychogenic Non-Epileptic Seizures (PNES) and Functional Motor Disorders (FMDs) commonly represent the main clinical manifestations of Functional Neurological Disorders (FNDs). Despite their high prevalence in pediatric neurological services, literature on this topic is still spare for this population. The present study aimed to deepen the clinical knowledge of a pediatric FNDs sample through a demographic and clinical characterization of the most recurrent clinical patterns during the pediatric age. Moreover, a comparison of neuropsychological and psychopathological profiles of PNES and FMD patients was carried out to identify specific vulnerabilities and therapeutic targets linked with these different clinical manifestations.

MATERIALS AND METHODS

A total of 43 FNDs patients (age range 7-17 years old) were retrospectively included in our study, enrolled in two subgroups: 20 with FMDs and 23 with PNES diagnosis. They were inpatients and outpatients referred over a period of 5 years and a standardized neurological, neuropsychological (WISC-IV/WAIS-IV), and psychiatric (CDI-2, MASC-2, ADES, DIS-Q, PID-5) evaluation was assessed.

RESULTS

In PNES patients the most common clinical phenotypes were functional tonic-clonic (52%) and atonic (32%) manifestations while in the FMDs group were gait alterations (60%), functional myoclonus (35%), and tremor (35%). A higher frequency of cognitive impairment was reported in PNES patients with higher anxiety-depressive symptom rates than FMDs patients.

CONCLUSIONS

Notably, specific neurocognitive and psychopathological profiles were described in PNES and FMDs, highlighting higher cognitive and psychiatric vulnerabilities in PNES, suggesting as well different strategy for therapeutic approaches.

Real-time colorectal polyp detection using a novel computer-aided detection system (CADe): a feasibility study

BACKGROUND AND AIMS

Colonoscopy aims to early detect and remove precancerous colorectal polyps, thereby preventing development of colorectal cancer (CRC). Recently, computer-aided detection (CADe) systems have been developed to assist endoscopists in polyp detection during colonoscopy. The aim of this study was to investigate feasibility and safety of a novel CADe system during real-time colonoscopy in three European tertiary referral centers.

METHODS

Ninety patients undergoing colonoscopy assisted by a real-time CADe system (DISCOVERY; Pentax Medical, Tokyo, Japan) were prospectively included. The CADe system was turned on only at withdrawal, and its output was displayed on secondary monitor. To study feasibility, inspection time, polyp detection rate (PDR), adenoma detection rate (ADR), sessile serrated lesion (SSL) detection rate (SDR), and the number of false positives were recorded. To study safety, (severe) adverse events ((S)AEs) were collected. Additionally, user friendliness was rated from 1 (worst) to 10 (best) by endoscopists.

RESULTS

Mean inspection time was 10.8 ± 4.3 min, while PDR was 55.6%, ADR 28.9%, and SDR 11.1%. The CADe system users estimated that < 20 false positives occurred in 81 colonoscopy procedures (90%). No (S)AEs related to the CADe system were observed during the 30-day follow-up period. User friendliness was rated as good, with a median score of 8/10.

CONCLUSION

Colonoscopy with this novel CADe system in a real-time setting was feasible and safe. Although PDR and SDR were high compared to previous studies with other CADe systems, future randomized controlled trials are needed to confirm these detection rates. The high SDR is of particular interest since interval CRC has been suggested to develop frequently through the serrated neoplasia pathway.

CLINICAL TRIAL REGISTRATION

The study was registered in the Dutch Trial Register (reference number: NL8788).

Acute limb ischemia due to ONYX 34 migration during embolization of a traumatic pseudoaneurysm of the superficial femoral artery

Pseudo-aneurysms of the arteries of the lower limbs are a possible complication of leg trauma. Complications include rupture, infection, pain and distal embolization. This is a case of a 24-year-old man hospitalized after a car accident, in which we discovered a 1-cm large pseudo-aneurysm of the right superficial femoral artery. The pseudo-aneurysm in first place was treated by the interventional-radiologist for an endovascular repair by embolization with ONYX 34, but during the procedure the copolymer embolized in the arterial axe with complete obstruction of blood-flow in the lower limb. An urgent open surgical revascularization was then attempted by our team with the result of complete patency of the femoro-popliteal axis and of the tibial vessels. Embolization with ONYX is an effective and safe method, but it is susceptible to this type of complication for larger pseudo-aneurysms, where it is required an introduction of a larger quantity of polymer.

Quality of life in Klinefelter patients on testosterone replacement therapy compared to healthy controls: an observational study on the impact of psychological distress, personality traits, and coping strategies

PURPOSE

We aimed to verify if 1 year-testosterone-replacement therapy could produce a psychopathological recovery and a satisfactory quality of life in Klinefelter syndrome (KS) patients compared to matched healthy controls. Further, we analyzed personality traits and coping strategies, an issue not yet examined in androgen-treated KS patients. We also enquired whether any of the sociodemographic and psychological variables might predict a patient's general and sexual life satisfaction.

METHODS

The Quality of Life Enjoyment and Satisfaction Questionnaire and the Temperament and Character Inventory-Revised were administered to both 23 KS patients and matched healthy subjects. Psychopathology was investigated by the Symptom Checklist-90-Revised (SCL-90-R) and the Mini-mental State Examination. The COPE Inventory was used to identify cognitive and behavioral strategies to manage disease-related distress.

RESULTS

In testosterone-treated KS patients, when compared with controls, SCL-90-R subscales analysis evidenced high psychological distress, mainly presented as obsessive thoughts, hanger-hostility, phobias, and psychoticism. Self-directedness and self-transcendence, along with the prevalent use of emotion-focused coping strategies, outlined the personality of our KS patients. Depression and somatization proved to be predictors of general life dissatisfaction. Depression, anger-hostility, and paranoid ideation, instead, emerged as predictors of sexual life dissatisfaction.

CONCLUSION

Endocrinologists should cooperate with mental health providers to foster a better outcome of the disease in KS patients.

BROX haploinsufficiency in familial nonmedullary thyroid cancer

BACKGROUND

The familial nonmedullary thyroid cancer (FNMTC) is suspected to be a Mendelian condition in up to 3-8% of thyroid cancers. The susceptibility chromosomal loci and genes of 95% of FNMTC cases remain to be characterized. The inheritance of FNMTC appears to be autosomal dominant with incomplete penetrance and variable expressivity. The finding of the causative gene of FNMTC and the identification of patients at risk that need genetic testing were our aim.

METHODS

We analyzed by whole-exome sequencing patients and non-affected relatives of five families with at least two family members affected by papillary thyroid cancer, selecting for new or extremely rare variants with predicted pathogenic value.

RESULTS

A family showed, in all three affected members, a new loss-of-function variant (frameshift deletion) in BROX gene at 1q41 that was absent from all internal and external databases. In a second family with three affected relatives, we found an additional new BROX variant. The smaller families presented no variants in BROX or in the other causative genes studied.

CONCLUSIONS

BROX could be a new causative gene for FNMTC. Variants in BROX may result in the haploinsufficiency of a key gene involved in the morphogenesis of MVBs, in the endosomal sorting of cargo proteins, and in EGFR. Functional studies are needed to support this result. The thorough genomic analysis by NGS in all families with three or more affected members should become a routine approach to obtain a comprehensive genetic view and find confirmative second cases.

KRD (carfilzomib and lenalidomide plus dexamethasone) for the treatment of relapsed or refractory multiple myeloma in the real-life: a retrospective survey in 123 patients

From April 2016, carfilzomib, in combination with lenalidomide and dexamethasone (KRD), became available for use in the daily practice in Italy for patients with relapsed or refractory multiple myeloma (RRMM). We performed a retrospective survey at 14 different institutions from Southern Italy in order to evaluate patient characteristics and treatment results from an unselected series of patients treated accordingly so far. One hundred and twenty-three consecutive patients were included, with a median of 2 previous lines of therapy (range 1-9) and a median age of 63 years (range 39-82). At the time of analysis, median number of courses administered is 11 (range 1-34), and all patients are evaluable for response. Overall response rate including complete remission, very good partial remission, and partial remission is 85%. After a median follow-up of 27 months, median overall and progression-free survival are 33 and 23 months, respectively. Sixty-three patients are alive and between them, 45 (37%) are in continuous remission. Sixty patients have died (49%), mainly from progressive disease. There were 6 treatment-related deaths (5% of the whole patient population). Overall, hematological and non-hematological toxicity were manageable, mostly on outpatient basis. Arterial hypertension has been observed in 43 cases (35%) but did not lead to treatment interruption. Our data demonstrate that in real life, KRD is highly effective and well tolerated in the majority of patients with RRMM.

Wearable Sensors for Prodromal Motor Assessment of Parkinson's Disease using Supervised Learning

Parkinson's disease (PD) is a common neurodegenerative disorder characterized by disabling motor and non-motor symptoms. Idiopathic hyposmia (IH), a reduced olfactory sensitivity, is a preclinical marker for the pathology and affects >95% of PD patients. In this paper, SensHand V1 and SensFoot V2, two inertial wearable sensors for upper and lower limbs, were developed to acquire motion data in ten tasks of the MDS-UPDRS III. Fifteen healthy subjects of control, 15 IH people, and 15 PD patients were enrolled. Seventy-one parameters per side were computed by spatiotemporal and frequency data analysis, and the most significant were selected to distinguish among the different classes. Performances of supervised learning algorithms (i.e., Support Vector Machine (SVM), and Random Forest (RF)) were compared on two-group and three-group classification and considering upper and lower limbs separately or together as a full system. Excellent results were obtained for healthy vs. patients classification (accuracy 1.00 for RF, and 0.97 for SVM), and good results were achieved by including IH subjects (0.92 F-measure with RF) within a three-group classification. Overall, the best performances were obtained using the full system with an RF classifier. The system is, thus, suitable to support an objective PD diagnosis. Furthermore, combining motion analysis with a validated olfactory screening test, people at risk for PD can be appropriately analyzed, and subtle changes in motor performance that characterize the prodromal phase and the early PD onset can be identified.

Thyroid function in Klinefelter syndrome: a multicentre study from KING group

PURPOSE

The prevalence and the etiopathogenesis of thyroid dysfunctions in Klinefelter syndrome (KS) are still unclear. The primary aim of this study was to evaluate the pathogenetic role of hypogonadism in the thyroid disorders described in KS, with the scope to distinguish between patients with KS and hypogonadism due to other causes (Kallmann syndrome, idiopathic hypogonadotropic hypogonadism, iatrogenic hypogonadism and acquired hypogonadotropic hypogonadism after surgical removal of pituitary adenomas) called non-KS. Therefore, we evaluated thyroid function in KS and in non-KS hypogonadal patients.

METHODS

This is a case-control multicentre study from KING group: Endocrinology clinics in university-affiliated medical centres. One hundred and seventy four KS, and sixty-two non-KS hypogonadal men were enrolled. The primary outcome was the prevalence of thyroid diseases in KS and in non-KS. Changes in hormonal parameters were evaluated. Exclusion criterion was secondary hypothyroidism. Analyses were performed using Student's t test. Mann-Whitney test and Chi-square test.

RESULTS

FT4 was significantly lower in KS vs non-KS. KS and non-KS presented similar TSH and testosterone levels. Hashimoto's thyroiditis (HT) was diagnosed in 7% of KS. Five KS developed hypothyroidism. The ratio FT3/FT4 was similar in both groups. TSH index was 1.9 in KS and 2.3 in non-KS. Adjustment for differences in age, sample size and concomitant disease in multivariate models did not alter the results.

CONCLUSIONS

We demonstrated in KS no etiopathogenic link to hypogonadism or change in the set point of thyrotrophic control in the altered FT4 production. The prevalence of HT in KS was similar to normal male population, showing absence of increased risk of HT associated with the XXY karyotype.

Fine Motor Assessment With Unsupervised Learning For Personalized Rehabilitation in Parkinson Disease

Parkinson disease (PD) is a common neurodegenerative disorders characterized by motor and non-motor impairments. Since the quality of life of PD patients becomes poor while pathology develops, it is imperative to improve the identification of personalized rehabilitation and treatments approaches based on the level of the neurodegeneration process. Objective and precise assessment of the severity of the pathology is crucial to identify the most appropriate treatments. In this context, this paper proposes a wearable system able to measure the motor performance of PD subjects. Two inertial devices were used to capture the motion of the lower and upper limbs respectively, while performing six motor tasks. Forty-one kinematic features were extracted from the inertial signals to describe the performance of each subjects. Three unsupervised learning algorithms (k-Means, Self-organizing maps (SOM) and hierarchical clustering) were applied with a blind approach to group the motor performance. The results show that SOM was the best classifier since it reached accuracy equal to 0.950 to group the instances in two classes (mild vs advanced), and 0.817 considering three classes (mild vs moderate vs severe). Therefore, this system enabled objective assessment of the PD severity through motion analysis, allowing the evaluation of residual motor capabilities and fostering personalized paths for PD rehabilitation and assistance.

Neutron spin rotation measurements

The neutron spin rotation (NSR) collaboration used parity-violating spin rotation of transversely polarized neutrons transmitted through a 0.5 m liquid helium target to constrain weak coupling constants between nucleons. While consistent with theoretical expectation, the upper limit set by this measurement on the rotation angle is limited by statistical uncertainties. The NSR collaboration is preparing a new measurement to improve this statistically-limited result by about an order of magnitude. In addition to using the new high-flux NG-C beam at the NIST Center for Neutron Research, the apparatus was upgraded to take advantage of the larger-area and more divergent NG-C beam. Significant improvements are also being made to the cryogenic design. Details of these improvements and readiness of the upgraded apparatus are presented. We also comment on how recent theoretical work combining effective field theory techniques with the 1/Nc expansion of QCD along with previous NN weak measurements can be used to make a prediction for dϕ/dz in 4He.

An experiment using the same apparatus with a room-temperature target was carried out at LANSCE to place limits on parity-conserving rotations from possible fifth-force interactions to complement previous studies. We sought this interaction using a slow neutron polarimeter that passed transversely polarized slow neutrons by unpolarized slabs of material arranged so that this interaction would tilt the plane of polarization and develop a component along the neutron momentum. The results of this measurement and its impact on the neutron-matter coupling gA2 from such an interaction are presented. The NSR collaboration is also preparing a new measurement that uses an upgraded version of the room-temperature target to be run on the NG-C beamline; and it is expected to constrain gA2 by at least two additional orders of magnitude for λc between 1 cm and 1 μm.

Development of a Novel Wearable Ring-Shaped Biosensor

We report on the preliminary results obtained out of a wearable module designed to be encompassed within a ring-shaped system aimed at providing healthcare services. The module is composed of two sensors for the measuring of Galvanic Skin Response (GSR) and Heart Rate Variability (HRV). A first device validation was carried out by involving four subjects who were asked to perform tasks providing different stress-related statuses. A comparison of physiological parameters measured by the module with those measured by a commercial HRV-GSR sensor chosen as gold standard was made. Two out of the three HRV parameters and all of the GSR parameters measured with the module resulted consistent (mostly differing less than 10%) with the same parameters measured by the gold standard. The work reported in this paper set a milestone for the realization of a system exploiting sensor fusion to provide active ageing, stress detection, activity recognition and e-health services has been achieved.

Combining olfactory test and motion analysis sensors in Parkinson's disease preclinical diagnosis: a pilot study

OBJECTIVES

Preclinical diagnosis of Parkinson's disease (PD) is nowadays a topic of interest as the neuropathological process could begin years before the appearance of motor symptoms. Several symptoms, among them hyposmia, could precede motor features in PD. In the preclinical phase of PD, a subclinical reduction in motor skills is highly likely. In this pilot study, we investigate a step-by-step method to achieve preclinical PD diagnosis.

MATERIAL AND METHODS

We used the IOIT (Italian Olfactory Identification Test) to screen a population of healthy subjects. We identified 20 subjects with idiopathic hyposmia. Hyposmic subjects underwent an evaluation of motor skills, at baseline and after 1 year, using motion analysis sensors previously created by us.

RESULTS

One subject showed significant worsening in motor measurements. In this subject, we further conducted a dopaminergic challenge test monitored with the same sensors and, finally, he underwent [¹²³ I]-FP/CIT (DaTscan) SPECT brain imaging. The results show that he is probably affected by preclinical PD.

CONCLUSIONS

Our pilot study suggests that the combined use of an olfactory test and motor sensors for motion analysis could be useful for a screening of healthy subjects to identify those at a high risk of developing PD.

Unintentional recurrent laryngeal nerve injuries following thyroidectomy: Is it the surgeon who pays the bill?

BACKGROUND

Thyroidectomy is one of the most common intervention in general surgery and, after the turn of the century, its rate has sharply increased, along with a worldwide increased incidence of differentiated thyroid cancers. Therefore, injuries of the recurrent laryngeal nerve have become one of the most frequent cause of surgical malpractice claims, mostly following surgery for benign pathology.

MAIN BODY

Even if the incidence of definitive paralysis is generally lower than 3%, during the last 20 years in Italy, the number of claims for damages has sharply raised. As a consequence, a lot of defensive medicine has been caused by this issue, and a witch-hunt has been accordingly triggered, so determining mostly a painful and lasting frustration for the surgeons, who sometimes are compelled to pay a lot of money for increasing insurance premiums and lawyers fees. Recurrent laryngeal nerve injury should be considered as a potentially catastrophic predictable but not preventable event, rather than the result of a surgical mistake.

CONCLUSION

Purposes of the Authors are analyzing incidence, conditions of risk, and mechanisms of recurrent laryngeal nerve injuries, underlining notes of surgical technique and defining medical practice recommendations useful to reduce the risk of malpractice lawsuits and judgments against surgeons.

TET2 binds the androgen receptor and loss is associated with prostate cancer

Genetic alterations associated with prostate cancer (PCa) may be identified by sequencing metastatic tumour genomes to identify molecular markers at this lethal stage of disease. Previously, we characterized somatic alterations in metastatic tumours in the methylcytosine dioxygenase ten-eleven translocation 2 (TET2), which is altered in 5-15% of myeloid, kidney, colon and PCas. Genome-wide association studies previously identified non-coding risk variants associated with PCa and melanoma. We perform fine-mapping of PCa risk across TET2 using genotypes from the PEGASUS case-control cohort and identify six new risk variants in introns 1 and 2. Oligonucleotides containing two risk variants are bound by the transcription factor octamer-binding protein 1 (Oct1/POU2F1) and TET2 and Oct1 expression are positively correlated in prostate tumours. TET2 is expressed in normal prostate tissue and reduced in a subset of tumours from the Cancer Genome Atlas (TCGA). Small interfering RNA-mediated TET2 knockdown (KD) increases LNCaP cell proliferation, migration and wound healing, verifying loss drives a cancer phenotype. Endogenous TET2 bound the androgen receptor (AR) and AR-coactivator proteins in LNCaP cell extracts, and TET2 KD increases prostate-specific antigen (KLK3/PSA) expression. Published data reveal TET2 binding sites and hydroxymethylcytosine proximal to KLK3. A gene co-expression network identified using TCGA prostate tumour RNA-sequencing identifies co-regulated cancer genes associated with 2-oxoglutarate (2-OG) and succinate metabolism, including TET2, lysine demethylase (KDM) KDM6A, BRCA1-associated BAP1, and citric acid cycle enzymes IDH1/2, SDHA/B, and FH. The co-expression signature is conserved across 31 TCGA cancers suggesting a putative role for TET2 as an energy sensor (of 2-OG) that modifies aspects of androgen-AR signalling. Decreased TET2 mRNA expression in TCGA PCa tumours is strongly associated with reduced patient survival, indicating reduced expression in tumours may be an informative biomarker of disease progression and perhaps metastatic disease.

Influence of short-term selenium supplementation on the natural course of Hashimoto's thyroiditis: clinical results of a blinded placebo-controlled randomized prospective trial

BACKGROUND

The real efficacy of selenium supplementation in Hashimoto's thyroiditis (HT) is still an unresolved issue.

OBJECTIVES

We studied the short-term effect of L-selenomethionine on the thyroid function in euthyroid patients with HT. Our primary outcome measures were TSH, thyroid hormones, thyroid peroxidase antibody (TPOAb), thyroglobulin antibody (TGAb) levels and thyroid echogenicity after 6 months of L-selenomethionine treatment. The secondary outcome measure was serum CXCL10 levels.

METHODS

In a placebo-controlled randomized prospective study, we have enrolled untreated euthyroid patients with HT. Seventy-six patients were randomly assigned to receive L-selenomethionine 166 µg/die (SE n = 38) or placebo (controls n = 38) for 6 months. TSH, free T₄ (FT₄), free T₃ (FT₃), TPOAb and CXCL10 serum levels were assayed at time 0, after 3 and 6 months. An ultrasound examination of the left and right thyroid lobe in transverse and longitudinal sections was performed. A rectangular region, the region of interest, was selected for analysis.

RESULTS

TSH, FT4, FT3, TPOAb, thyroid echogenicity and CXCL10 were not statistically different between SE and control groups at time 0, after 3 and 6 months. In the SE group, FT₄ levels were significantly decreased (P < 0.03) after 3 months, while FT₃ increased (P < 0.04) after 3 and 6 months versus baseline values. In the control group, the FT₃ decreased after 3 and 6 months (P < 0.02) compared to baseline.

CONCLUSION

The short-term L-selenomethionine supplementation has a limited impact on the natural course in euthyroid HT. Our results tip the balance toward the ineffectiveness of short-term L-selenomethionine supplementation in HT.

The current status of lymph node dissection in the treatment of papillary thyroid cancer. A literature review

AIM

Cervical lymph node micrometastases are observed in up to 90% of papillary thyroid cancers (PTC), showing that lymph nodal involvement is very common. Nevertheless, during the last years, the role of lymph node dissection in the treatment of PTC has been controversial and, at present, the best indications to the routine or therapeutic neck dissection remain subject of research. In order to better analyze the current role of lymph node dissection in the surgical treatment of PTC, an analysis of the most recent literature data was performed.

STUDY DESIGN

By using as keywords lymph node dissection, selective, lateral or central lymph node dissection, modified radical neck dissection, prophylactic or therapeutic lymph node dissection, papillary thyroid cancer, a Pub Med data base research was carried out. The most recent guidelines of different referral endocrine societies, inhering neck dissection for PTC, were also evaluated.

RESULTS

The role of neck dissection in PTC management remains controversial regarding routine or therapeutic indications, surgical extension, and its impact on local recurrence and long term survival. Due to inhomogeneous literature data, the current status of node dissection is still subject of research.

CONCLUSIONS

There is agreement between endocrine and neck surgeons about the extension of therapeutic lymph node dissection in N+ PTC patients , and also in the prophylactic treatment of N0 "high risk" patients. Considering a recent trend toward routine central lymphadenectomy avoiding radioactive treatment, prospective randomized trials are needed to evaluate the benefits of different approaches.

In vivo assessment of tumour angiogenesis in colorectal cancer: the role of confocal laser endomicroscopy

AIM

Tumour neoangiogenesis is a key factor in tumour progression and metastatic spread and the possibility to assess tumour angiogenesis might provide prognostic information. The aim of this study was to establish the role of probe-based confocal laser endomicroscopy (p-CLE) in the identification of vascular architecture and specific morphological patterns in normal colorectal mucosa and malignant lesions during routine endoscopy.

METHOD

Fourteen consecutive patients with colorectal cancer were included. The following features were identified and then compared between normal and neoplastic mucosa on p-CLE images: vessel shape (straight vs irregular) vessel diameter the 'branching patterns' vessel permeability (fluorescein leakage) and blood flow (normal vs defective flux). Immunohistochemistry was used to confirm the presence and to study the morphology of vascular structures (CD-34 staining) and 'neo-vessels' (WT-1 staining) on tumour and normal mucosal sections.

RESULTS

Tumour vessels appeared as irregular, ectatic and with a highly variable calibre and branching patterns on p-CLE images. The mean diameter of tumour vessels was significantly larger than those in normal mucosa (weighted mean difference 3.38, 95% CI 2.65-4.11, P = 0.01). Similarly, 'vessel branching' (OR 2.74, 95% CI 1.23-6.14, P = 0.01), fluorescent dye 'extravasation' (OR 3.46, 95% CI 1.39-8.57, P = 0.01) were significantly more frequent in colorectal cancer than in normal colorectal mucosa. Immunohistochemistry corroborated the p-CLE findings, showing higher vascularity in tumour sections due to neoformed vessels, presenting irregular patterns.

CONCLUSION

Probe-based confocal laser endomicroscopy provides a noninvasive characterization of the microvascular architecture of colonic mucosa. Different morphological patterns have been described, discriminating normal and malignant microvascular networks in colorectal mucosa.

Minimally invasive approach for adrenal lesions: Systematic review of laparoscopic versus retroperitoneoscopic adrenalectomy and assessment of risk factors for complications

In the last decades, minimally invasive transperitoneal laparoscopic adrenalectomy has become the standard of care for surgical resection of the adrenal gland tumors. Recently, however, adrenalectomy by a mininvasive retroperitoneal approach has reached increasingly popularity as alternative technique. Short hospitalization, lower postoperative pain and decrease of complications and a better cosmetic resolution are the main advantages of these innovative techniques. In order to determine the better surgical management of adrenal neoplasms, the Authors analyzed and compared the feasibility and the postoperative complications of minimally invasive adrenalectomy approaches. A systematic research of the English literature, including major meta-analysis articles, clinical randomized trials, retrospective studies and systematic reviews was performed, comparing laparoscopic transperitoneal adrenalectomy versus retroperitoneoscopic adrenalectomy. Many studies support that posterior retroperitoneal adrenalectomy is superior or at least comparable to laparoscopic transperitoneal adrenalectomy in operation time, pain score, blood loss, hospitalization, complications rates and return to normal activity. However, laparoscopic transperitoneal adrenalectomy is up to now a safe and standardized procedure with a shorter learning curve and a similar low morbidity rate, even for tumors larger than 6 cm. Nevertheless, further studies are needed to objectively evaluate these techniques, excluding selection bias and bias related to differences in surgeons' experiences with this approaches.

A slow neutron polarimeter for the measurement of parity-odd neutron rotary power

We present the design, description, calibration procedure, and an analysis of systematic effects for an apparatus designed to measure the rotation of the plane of polarization of a transversely polarized slow neutron beam as it passes through unpolarized matter. This device is the neutron optical equivalent of a crossed polarizer/analyzer pair familiar from light optics. This apparatus has been used to search for parity violation in the interaction of polarized slow neutrons in matter. Given the brightness of existing slow neutron sources, this apparatus is capable of measuring a neutron rotary power of dϕ/dz = 1 × 10(-7) rad/m.

Compounds leached from quinoa seeds inhibit matrix metalloproteinase activity and intracellular reactive oxygen species

OBJECTIVE

Quinoa (Chenopodium quinoa Willd.) is a seed crop rich in bioactive compounds including phytoecdysones (especially 20-hydroxyecdysone, 20HE), polyphenols, proteins and essential fatty acids. We previously reported a method to leach and concentrate quinoa bioactives into a complex phytochemical mixture termed quinoa leachate (QL). Here, we aimed to determine the effect of QL and its chemically distinct fractions on five biochemical endpoints relevant to skin care applications: (i) cell viability, (ii) matrix metalloproteinase (MMP) mRNA expression, (iii) MMP enzymatic activity, (iv) tyrosinase enzymatic activity and (v) intracellular reactive oxygen species (ROS) production.

METHODS

Quinoa leachate was fractionated and chemically characterized using column chromatography and liquid chromatography-mass spectrometry (LC-MS). Cell viability was determined using a MTT assay in four mammalian cell lines. MMP-1 mRNA expression was assessed in human dermal fibroblasts (HDF) via qRT-PCR. The enzymatic activity of MMP-9 and tyrosinase was measured using fluorometric and colorimetric in vitro assays, respectively. Lipopolysaccharide (LPS)-induced ROS production was determined in human dermal fibroblasts by fluorescence intensity of an oxidant-sensitive probe.

RESULTS

Quinoa leachate was separated into three fractions: (i) carbohydrate-rich fraction (QL-C; 71.3% w/w of QL); (ii) phytoecdysone, polyphenol and protein-rich fraction (QL-P, 13.3% w/w of QL); (iii) oil-rich fraction (QL-O, 10.8% w/w of QL). QL did not reduce cell viability in any of the four cell lines tested. QL, QL-P and QL-O each significantly inhibited MMP-1 mRNA expression in HDF at a concentration of 5 μg mL(-1) . QL and QL-P also significantly inhibited MMP-9 enzymatic activity, whereas QL-P demonstrated significant tyrosinase enzymatic inhibition. Furthermore, QL, QL-P, QL-O and 20HE significantly inhibited intracellular ROS production.

CONCLUSION

This study is the first to demonstrate the MMP, tyrosinase and ROS inhibiting properties of multiple different phytochemical components derived from quinoa seeds. Our work indicates that quinoa phytochemicals may play a role in the treatment and prevention of skin ageing through a multiplicity of effects.

Female sexual dysfunction in women with thyroid disorders

BACKGROUND

Few data exist on the prevalence of female sexual dysfunction (FSD) in thyroid disorders.

AIM

We evaluated FSD in women with thyroid diseases and in control age-matched healthy women to investigate the relationship between sexual function and thyroid hormones.

METHODS

One hundred and four women with thyroid diseases and 53 controls participated in the study. Eighteen with hyperthyroidism (Group 1), 22 hypothyroidism (Group 2), 45 Hashimoto's thyroiditis (Group 3), 19 nodular goiter (Group 4) underwent thyroid function evaluation and sonography. The Female Sexual Function Index (FSFI) assessed sexual function.

RESULTS

The prevalence of FSD was 46.1% in thyroid diseases and 20.7% in controls. Only in Group 4, the prevalence (68.4%) was significantly higher than in controls (p<0.005). The mean total FSFI score was 20.1 ± 7.1 in women with thyroid diseases and 25.6 ± 4.7 in the controls (p<0.001). Compared with controls, there was a significant decrease of desire in Group 2; desire, arousal and lubrication in Group 3; desire, arousal, lubrication, orgasm and satisfaction in Group 4. In thyroid diseases the prevalence of FSD was 53% and 42%, while in the controls was 55% and 20%, in menopausal and pre-menopausal groups, respectively. We found a significant inverse correlation between TSH and FSFI (r=-0.7, p=0.01) in Group 4, which showed the lowest FSFI score (17.8 ± 5.7) and the highest body mass index (28.4 ± 7.1 kg/m(2)).

CONCLUSIONS

Women with thyroid diseases present a higher prevalence of FSD than controls. Although our findings suggest a higher impairment of sexual function in Group 4 and a role for TSH in FSD, further researches are needed.

Hashimoto's Thyroiditis and Entero-Chromaffin-like Cell Hyperplasia: Early Detection and Somatostatin Analogue Treatment

Type IIIb polyglandular autoimmune disease comprises autoimmune thyroid disease (HT) and chronic atrophic gastritis (AIG). Hypergastrinemia, secondary to AIG, predisposes to gastric enterochromaffin-like cell (ECL) hyperplasia, a preneoplastic condition. We evaluated the prevalence of AIG, hypergastrinemia and ECL hyperplasia in HT patients. A secondary end-point was to assess the efficacy of treatment with a somatostatin analogue in HT patient with ECL hyperplasia. From 2009 to 2011, 146 HT patients were enrolled in a prospective study. All cases underwent hormonal profile, and parietal cell antibody (PCA), gastrin, and chromogranin A (CgA) serum level assays. Selected patients with elevated gastrin and CgA levels underwent gastro esophageal endoscopy (EGDS). Patients positive for ECL hyperplasia received Octreotide LAR 30 mg/28 days for 12 months. Gastrin and CgA assays were repeated every three months and EGDS after one year. The results show that gastrin and CgA were significantly higher than normal in 17/115 (14.7%) patients. Seven more HT had isolated PCA positivity and in the 17 PCA positive patients histology diagnosed AIG, corpus prevalent, with mild to moderate atrophy. Diffuse ECL hyperplasia of the gastric body was present in three subjects, one of them presenting a type-1 carcinoid. Gastrin and CgA levels were significantly reduced (p<0.01) after 3 months of therapy with a somatostatin analogue and returned to normal after 1 year. ECL hyperplasia regressed in all three patients. We suggest that selected HT patients may need a more accurate surveillance for early signs of gastric EC risk. In the case of altered values of gastrin and in the presence of PCA positivity, EGDS and histology should be performed for an early diagnosis of AIG and treatment of ECL hyperplasia.

Multiple endocrine neoplasia, the old and the new: a mini review

Multiple endocrine neoplasia syndromes have since been classified as types 1 and 2, each with specific phenotypic patterns. MEN1 is usually associated with pituitary, parathyroid and paraneoplastic neuroendocrine tumours. The hallmark of MEN2 is a very high lifetime risk of developing medullary thyroid carcinoma (MTC) more than 95% in untreated patients. Three clinical subtypesdMEN2A, MEN2B, and familial MTC (FMTC) have been defined based on the risk of pheochromocytoma, hyperparathyroidism, and the presence or absence of characteristic physical features). MEN2 occurs as a result of germline activating missense mutations of the RET (REarranged during Transfection) proto-oncogene. MEN2-associated mutations are almost always located in exons 10, 11, or 13 through 16. Strong genotype-phenotype correlations exist with respect to clinical subtype, age at onset, and aggressiveness of MTC in MEN2. These are used to determine the age at which prophylactic thyroidectomy should occur and whether screening for pheochromocytoma or hyperparathyroidism is necessary. Specific RET mutations can also impact management in patients presenting with apparently sporadic MTC. Therefore, genetic testing should be performed before surgical intervention in all patients diagnosed with MTC. Recently, Pellegata et al. have reported that germline mutations in CDKN1B can predispose to the development of multiple endocrine tumours in both rats and humans and this new MEN syndrome is named MENX and MEN4, respectively. CDKN1B. A recent report showed that in sporadic MTC, CDKN1B V109G polymorphism correlates with a more favorable disease progression than the wild-type allele and might be considered a new promising prognostic marker. New insights on MEN syndrome pathogenesis and related inherited endocrine disorders are of particular interest for an adequate surgical and therapeutic approach.

MicroRNA-106b-25 cluster expression is associated with early disease recurrence and targets caspase-7 and focal adhesion in human prostate cancer

The miR-106b-25 microRNA (miRNA) cluster is a candidate oncogene in human prostate cancer. Here, we report that miRNAs encoded by miR-106b-25 are upregulated in both primary tumors and distant metastasis. Moreover, increased tumor miR-106b expression was associated with disease recurrence and the combination of high miR-106b and low CASP7 (caspase-7) expressions in primary tumors was an independent predictor of early disease recurrence (adjusted hazard ratio=4.1; 95% confidence interval: 1.6-12.3). To identify yet unknown oncogenic functions of miR-106b, we overexpressed it in LNCaP human prostate cancer cells to examine miR-106b-induced global expression changes among protein-coding genes. The approach revealed that CASP7 is a direct target of miR-106b, which was confirmed by western blot analysis and a 3'-untranslated region reporter assay. Moreover, selected phenotypes induced by miR-106b knockdown in DU145 human prostate cancer cells did not develop when both miR-106b and CASP7 expression were inhibited. Further analyses showed that CASP7 is downregulated in primary prostate tumors and metastatic lesions across multiple data sets and is by itself associated with disease recurrence and disease-specific survival. Using bioinformatics, we also observed that miR-106b-25 may specifically influence focal adhesion-related pathways. This observation was experimentally examined using miR-106b-25-transduced 22Rv1 human prostate cancer cells. After infection with a miR-106b-25 lentiviral expression construct, 22Rv1 cells showed increased adhesion to basement membrane- and bone matrix-related filaments and enhanced soft agar growth. In summary, miR-106b-25 was found to be associated with prostate cancer progression and disease outcome and may do so by altering apoptosis- and focal adhesion-related pathways.

Efficacy of recombinant human follicle stimulating hormone at low doses in inducing spermatogenesis and fertility in hypogonadotropic hypogonadism

BACKGROUND

Recombinant-FSH (rFSH) added to hCG at dose of 450 IU weekly is effective in inducing spermatogenesis in patients with hypogonadotropic hypogonadism (HH), but there are no data on the use of lower doses.

AIM

This observational retrospective study evaluated whether 150-225 IU of rFSH weekly were able to induce spermatogenesis in HH men who failed to start it with hCG alone.

SUBJECTS AND METHODS

Thirty-four patients with pre-pubertal onset HH (20-44 yr old) without adverse fertility factors were considered for this study. After hCG pre-treatment they received also either rFSH (Group 1) or highly purified urinary FSH (hpFSH) (Group 2) 75 IU sc 2 or 3 times weekly. Semen analysis was performed every 3 months during pre-treatment and the 1st yr of combined therapy. Patients were also invited to refer pregnancies in their partners during the subsequent 12 months.

RESULTS

Total sperm count/ejaculate did not show significant difference between 2 groups, while a significantly higher forward motility was observed in Group 1 (p<0.05). The median times to achieve sperm output thresholds (first sperm appearance, sperm concentration >1.5 or >5 mil/ml) were significantly lower in Group 1 (p<0.04, 0.03, and 0.001, respectively). A tendency to a shorter time to pregnancy was shown in partners of Group 1.

CONCLUSIONS

Our data indicate that lower rFSH week dose than that so far used was able to induce potentially fertilizing sperm output in HH men previously treated with hCG. The rFSH effects are comparable to those of hpFSH but with a trend to a faster outcome achievement.

Direct growth of individual carbon nanotubes on a flexible plastic substrate via selective heating

The deficiency of carbon nanotube (CNT) growth on temperature-sensitive substrates such as plastic tapes impedes the further progress in CNT electronics. We report a novel method that is able to offer the solution by selectively delivering energy via high radio frequency heating to carbon atoms for their catalytic assembly into individual CNTs. Direct growth of CNTs on a flexible kapton substrate was demonstrated. A mechanism of selective heating was discussed.

In vitro expression of osteoblastic phenotype on titanium surfaces

AIM

Differentiation toward the osteoblastic phenotype is a complex phenomenon regulated by means of several factors. Numerous studies in vitro et in vivo showed that surface properties of titanium dental implants modulate cell proliferation and osteoblastic differentiation, affecting bone healing processes. Optimal superficial morphology is still controversial. The aim of the present study was to evaluate in vitro the effects of two different titanium surfaces on biological behaviour of human osteoblast-like cells SaOS-2 with regard to production of extra-cellular matrix (ECM) proteins.

METHODS

Human osteoblast-like cells SaOS-2, cultured on commercially pure titanium disks with two different surface topographies, smooth and microstructured with sand-blasting and acid-etching treatment, were evaluated by investigating adhesion, proliferation and deposition of extra-cellular matrix (ECM) proteins Fibronectin, Tenascin and Collagen I.

RESULTS

The different values of cellular adhesion at three hours and the increase of SaOS-2 proliferation values at the different experimental times on both evaluated surfaces didn't result statistically significant. ECM deposition analysis showed that Fibronectin, Tenascin and Collagen I were gradually produced, with not statistically significant differences for Fibrone-ctin and Tenascin and statistically significant differences for Collagen I.

CONCLUSION

Implant surface properties modulate in vitro the biological behavior of osteoblasts-like cells SaOS-2. SaOS-2 cells proliferate on both evaluated surfaces, showing a more organized differentiation towards an osteoblastic phenotype in ECM proteins production when cultured on microstructured surface.

[Implementation of methods for detection of perceived quality: the application of the Picker's method in ASL Napoli 1 DS 50]

The evaluation of the patient satisfaction in primary care is quite difficult to evaluate for lack of appropriate indicators. The objectives of this study were the validation of the method, using the Picker Institute's Inpatient Questionnaire, and the assessment of patient judgment about the quality of primary care in the DS 50. The indicators that have been used included 3 areas: communication, organization and patient-staff relationship. The results showed that the patient-staff relationship area was indicated as the most important for the patients and they pointed out several problem either for human (self-reference of the professional, lack of emotional relationship) and or for organizational aspects (waiting time). The study highlight that in order to improve the utility of such method, the health organization must be able to appropriately evaluate the patients' need, setting them in a specific organizational vision.

The Efficacy of the PECS for Improving the Communicative, Relational and Social Skills in Children with Autistic Disorder: Preliminary Results

The aim in the current study was to investigate the efficacy of the PECS (Picture Exchange Communication System) in a sample of children with Autistic Disorder (AD) in the development of the communication, alternating gaze and pointing in children with Autistic Disorder (AD).

The sample included 5 children diagnosed with AD (DSM-IV-TR), no verbal language, followed by the team of the Rehabilitation Centre belonging to Scientific Institute “E. Medea”, Association “La Nostra Famiglia” Branch of Ostuni (Italy). The children were tested on their ability with neuropsychiatric, psycholinguistics and psychological assessment at the pre and post of the trial.

The treatment PECS has gone on for two years with a frequency of three times a week (45 minutes each one).

The observed behavioral variables were: spontaneous request of objects using the notebook PECS, alternating gaze, pointing, and possible vocalizing and verbalizing on imitation.

The data were collected at the beginning and at the end of the trial, using play-interaction videotapes, lasting 20 minutes each. Segments (10 min) of videos were randomly selected for coding.

The behaviours were coded using the Observer XT. 7 and the results were analyzed statistically with the SPSS programme.

The results show a significant increase in the number of spontaneous requests, in the capacity of alternating gaze, pointing, vocalizing and verbalizing on imitation.

Finally the PECS seems to allow not only to develop a functional communication in AD, but also to increase social communicative behaviours of children with AD. Nevertheless further studies are necessary.

Replacement therapy and cardiovascular diseases

It is known that hypopituitarism reduces life expectancy and increases the risk of death for cardio- and cerebrovascular disease. Many studies report this phenomenon due to vascular diseases, and GH deficiency (GHD) seems to significantly contribute to the higher mortality. Aim of this article is to review the relationship between GH and cardiovascular risk factors to evaluate the beneficial effects of therapy in the adult GHD. GH replacement therapy (GHRT) improves insulin sensitivity, and reduces LDL cholesterol and triglyceride levels. Several studies also documented a decrease in the intima-media thickness at major arteries and improvement in microvascular and endothelial function. Other studies showed a decrease of inflammatory markers and the normalization of coagulation parameters. Finally, some authors have reported improvements in cardiac performance as well. These data evidence the positive effects of GHRT in the prevention of premature atherosclerosis in adults with GHD, and encourage the early administration of replacement therapy.

[Gastric cancer: surgical treatment and prognostic score]

AIM

Gastric cancer is the fifth most common cause of tumor-related death in Western countries. Surgery is the only effective treatment but only 50-60% of patients can receive a curative treatment because of absent or aspecific symptoms. The aim of this study was to develop a scale for gastric cancer patients that takes into account factors related to the tumor and to the patient.

METHODS

Fifty-seven patients with gastric adenocarcinoma admitted to the Department of General, Geriatric Surgery and Diagnostic and Operative Endoscopy of the University ''Federico II'' in Naples, and treated by gastrectomy from January 1998 until December 2002, were included in this retrospective cohort. The prognostic score was created according to the variables identified in Cox analysis as statistically significant (P 0.1).

RESULTS

The 5-year mortality rate was 61%. Cox analysis identified these variables with a significant effect on mortality: age ?60 (odds ratio (OR) 4.16; P=0.015), smoking or alcoholism (OR 2.66; P=0.057), pTNM I (OR 0.04; P=0.003), pTNM II (OR 0.18; P=0.029), pTNM III (OR 0.27; P=0.023), pTNM IV (OR 3.28; P=0.012), lymph node ratio (LNR) <20% (OR 0.15; P=0.01), LNR 20% (OR 3.83; P=0.002), Lauren diffuse histotype (OR 2.41; P=0.1) and location of the neoplasm at superior third (OR 6.70; P=0.003), middle third (OR 5.60; P=0.003), or inferior third (OR 0.32; P=0.008). Patients have been randomized into three groups according to their scores (3-40.5; 41-78.5; 79-115.5) and the 5-year mortality rate was 46%, 59%, 90% in group 1, 2 and 3 respectively.

CONCLUSION

It is necessary to consider in prognostic stratification of gastric cancer patients not only pTNM staging but also other factors such as age, smoking or alcoholism, Lauren histotype, location and linfonodal involvement. It is possible to design a more effective prognostic score predicting the individual risk and addressing the therapy and the follow-up.

Object-based neglect for the near peripersonal space in drawing tasks

We report a patient with a right cortical and subcortical temporo-occipital lesion who showed spatial neglect mainly involving the left and the near peripersonal space. In drawing tasks the patient omitted the elements closer to him within each figure. A copying task with pairs of radially aligned line drawings demonstrated that the patient's radial neglect was based on within-object coordinates. This novel observation extends the egocentric-allocentric distinction to the radial dimension.

[Diagnostic and therapeutic guidelines for entero-cutaneous fistulas. Personal experience and literature review]

The entero-cutaneous fistulas (ECF) are abnormal communications between intestine and abdominal skin. They can occur spontaneously, or after an injury or a surgical procedure. They are associated with a high rate of morbidity and mortality. Spontaneous fistulas can mainly occur in patients affected by cancer, inflammatory bowel disease, diverticulitis, appendicitis, as a result of radiotherapy or injuries. Surgical procedures, carried out in case of neoplastic diseases, inflammatory bowel disease, adhesions removal, represent the primary cause in the development of a postoperative fistulas. Malnourishment, poor general conditions of the patient, high output fistula along with anatomical site of development, and the presence of abscesses, represent the negative factors influencing the spontaneous healing of fistulas. The experience reported here is about three ECF cases occurred after surgery and treated only with medical therapy. The first case is a woman in good general conditions who underwent surgery to remove a recurrent retroperitoneal myxoid liposarcoma situated in the right lower quadrant. The patient had never undergone surgery for an intestinal resection. The other two patients analyzed were affected by sepsis and metabolic unbalance and had developed a fistula after colonic resection. Fluids and electrolytes adjustments and sepsis management have preceded any other kind of therapy. Continuous infusion with somatostatin, fast, proton pump inhibitors and loperamide have been taken up to decrease secretions and intestinal motility. Total parenteral nutrition has been essential to recover nutritional status and improve patients' general conditions. In order to heal and protect peri-fistula skin we have used sterile washing solutions, absorbable ionic exchange resin, silver and polyurethanes based medications and colostomy bags adhesive systems. Since surgical treatment of ECF is associated with high rates of morbidity and mortality, conservative treatment should always be taken into consideration. When conservative treatment fails, delayed surgical intervention has been related to a higher rate of success. The purpose of this study is to describe diagnostic and therapeutic guidelines to general surgeons, like ourselves, whenever they have to deal with ECF cases.

[Evaluation of the effectiveness of a nutrition education intervention performed by primary school teachers]

This study values the effectiveness of nutrition education interventions carried out by teachers with active didactic methodologies. The research was carried out by administering a frequency of food intake questionnaire, before and after the intervention. To compare the answers given before and after the educational intervention the Wilcoxon-test was applied to dependent data. Our research confirmed that a substantial percentage of children do not show a correct nutrition and therefore nutrition education interventions are opportune and necessary. In the group with "insufficient execution" particular variations are not taken place. In the group with "sufficient execution" increase the number of subjects having breakfast, particularly with milk and biscuits, and decrease the snakes intake. Moreover there is a general decrease of intake food as meat, fish, vegetables, salami and legumes. So this educational intervention seems to have only partial effectiveness.