Malignant Pleural Mesothelioma and Radiotherapy: Lung Toxicity Results of an Interim Analysis in Prospective Pilot Trial

PURPOSE/OBJECTIVE(S)

Malignant Pleural Mesothelioma (MPM) is a rare but aggressive intrathoracic malignancy with an overall poor prognosis. Neoadjuvant chemotherapy, surgery and then radiotherapy is the standard of care in early-stage disease. Our study aim is to evaluate the feasibility and toxicity of the novel adjuvant RT in accelerated hypofractionation. We report the lung toxicity preliminary results of the first patients entreated.

MATERIALS/METHODS

Starting in 2017, 29 MPM patients were enrolled in the trial (IRST trial 163). All patients were treated with accelerated hypofractionated radiotherapy using a helical 3-D CRT and IMRT system and intensity-modulated arc therapy. We conducted a prospective mono-institutional clinical trial enrolling cyto-histological proven, MPM patients. The major exclusion criteria were: previous thorax radiotherapy, contralateral mediastinum involvement (N3) and/or M1, interstitial pneumopathy, active pneumonitis, and fissural disease. The prescription dose was 30 Gy in five daily fractions, while an inhomogeneous dose escalation to 40 Gy was prescribed based solely upon the presence of gross residual tumor. All patients were treated in a 3-D CRT and IMRT system. Patients underwent functional lung study before to start radiotherapy treatment, 2 months and 6 months after the end of the treatment. The organs at risk dose-volume histograms were converted to a 2-Gy equivalent dose, and we closely adhered to the dose constraints of the literature data. We in particular analyzed lung toxicity of the first 20 patients.

RESULTS

No G3/G4 lung toxicity was found. We reported 65.0% G1 pneumonitis and 10% G2 as acute lung toxicity. The majority of the G1 patients had only mild symptoms and pneumonitis was described only for radiologic features with no need for medical therapy. Other respiratory toxicities were G1-G2 cough in 50% of the patients; G1 dyspnea occurred in 65% of the patients and G2 in the 15%. The total lung mean dose was 18 Gy (range 13 Gy-23 Gy), and the contralateral lung mean dose was 2 Gy (range 1 Gy-2 Gy). The median value of Forced Expired Volume in one second (FEV1) recorded was 75.5% (range: 46%-137%) before the treatment was started, the median value of Forced Vital Capacity (FVC) at baseline was 74 (range 46-123) with progressive decreasing values through time. DLCO has also been reported with a progressive decrease over time after radiotherapy treatment. No case of respiratory failure was reported after treatment.

CONCLUSION

Treatment of the intact lung with pleural intensity-modulated arc irradiation is a novel treatment strategy that appears to be safe, feasible, and without a high grade of lung toxicity. More investigations are mandatory. The protocol is ongoing.

Hyperbaric Oxygen Therapy plus Hypofractionated Stereotactic Radiotherapy in Recurrent Glioblastoma

PURPOSE/OBJECTIVE(S)

Hypoxia is thought to play a role in tumor development, angiogenesis and growth, and resistance to chemotherapy, antiangiogenic therapy and radiotherapy (RT) in a large number of human cancers. Brain tumors, especially highly aggressive GBM with its necrotic tissue, are more likely to be affected by hypoxia. The median partial pressure of oxygen (PO2) of high-grade gliomas in patients under anesthesia was approximately 5-7 mmHg, with a significant proportion of PO2 values <2.5 mmHg. The radiosensitivity of brain tumors could potentially be increased by performing hyperbaric oxygenation (HBO) before the RT session. We propose an innovative approach to improve the efficacy of accelerated hypofractionated Stereotactic Radiotherapy (HSRT) after HBO (HBO-RT) for the treatment of recurrent HGG (rHGG). The primary objective of this study is to evaluate the disease control rate (DCR) at 3 months. The secondary Objectives are: - Safety assessment (acute and late toxicity). - Overall Survival (OS), - Progression Free Survival (PFS).

MATERIALS/METHODS

We enrolled 14 patients (aged >18 years) with rHGG detected using MRI. A total dose of 15-25 Gy was administered in daily 5-Gy fractions for 3-5 consecutive days after daily HBO.

RESULTS

Median follow-up from re-irradiation was 22.8 months (range: 2.0-24.2 months). The disease control rate 3-months after HBO-RT was 50% (23.0-76.9). Six- and 12-month Progression-free survival was 35.7% (95% CI: 13-59.4) and 10.7% (95% CI: 0.8-35.4), respectively. Median overall survival of HBO-RT was 10.7 months (95% CI: 6.6-24.2). No acute or late neurologic toxicity >grade (G)2 was observed.

CONCLUSION

HSRT combined to HBO seems effective and safe in the treatment of rHGG.

Electrical stimulation applied during differentiation drives the hiPSC-CMs towards a mature cardiac conduction-like cells

Human induced pluripotent stem cell derived cardiomyocytes (hiPSC-CMs) resemble fetal cardiomyocytes and electrical stimulation (ES) has been explored to mature the differentiated cells. Here, we hypothesize that ES applied at the beginning of the differentiation process, triggers both differentiation of the hiPSC-CMs into a specialized conduction system (CS) phenotype and cell maturation. We applied ES for 15 days starting on day 0 of the differentiation process and found an increased expression of transcription factors and proteins associated with the development and function of CS including Irx3, Nkx2.5 and contactin 2, Hcn4 and Scn5a, respectively. We also found activation of intercalated disc proteins (Nrap and β-catenin). We detected ES-induced CM maturation as indicated by increased Tnni1 and Tnni3 expression. Confocal micrographs showed a shift towards expression of the gap junction protein connexin 40 in ES hiPSC-CM compared to the more dominant expression of connexin 43 in controls. Finally, analysis of functional parameters revealed that ES hiPSC-CMs exhibited faster action potential (AP) depolarization, longer intracellular Ca2+ transients, and slower AP duration at 90% of repolarization, resembling fast conducting fibers. Altogether, we provided evidence that ES during the differentiation of hiPSC to cardiomyocytes lead to development of cardiac conduction-like cells with more mature cytoarchitecture. Thus, hiPSC-CMs exposed to ES during differentiation can be instrumental to develop CS cells for cardiac disease modelling, screening individual drugs on a precison medicine type platform and support the development of novel therapeutics for arrhythmias.

Structured reporting of chest CT in COVID-19 pneumonia: a consensus proposal

OBJECTIVES

The need of a standardized reporting scheme and language, in imaging of COVID-19 pneumonia, has been welcomed by major scientific societies. The aim of the study was to build the reporting scheme of chest CT in COVID-19 pneumonia.

METHODS

A team of experts, of the Italian Society of Medical and Interventional Radiology (SIRM), has been recruited to compose a consensus panel. They used a modified Delphi process to build a reporting scheme and expressed a level of agreement for each section of the report. To measure the internal consistency of the panelist ratings for each section of the report, a quality analysis based on the average inter-item correlation was performed with Cronbach's alpha (Cα) correlation coefficient.

RESULTS

The overall mean score of the experts and the sum of score were 3.1 (std.dev. ± 0.11) and 122 in the second round, and improved to 3.75 (std.dev. ± 0.40) and 154 in the third round. The Cronbach's alpha (Cα) correlation coefficient was 0.741 (acceptable) in the second round and improved to 0.789 in the third round. The final report was built in the management of radiology report template (MRRT) and includes n = 4 items in the procedure information, n = 5 items in the clinical information, n = 16 in the findings, and n = 3 in the impression, with overall 28 items.

CONCLUSIONS

The proposed structured report could be of help both for expert radiologists and for the less experienced who are faced with the management of these patients. The structured report is conceived as a guideline, to recommend the key items/findings of chest CT in COVID-19 pneumonia.

Critical Transport and Vortex Dynamics in a Thin Atomic Josephson Junction

We study the onset of dissipation in an atomic Josephson junction between Fermi superfluids in the molecular Bose-Einstein condensation limit of strong attraction. Our simulations identify the critical population imbalance and the maximum Josephson current delimiting dissipationless and dissipative transport, in quantitative agreement with recent experiments. We unambiguously link dissipation to vortex ring nucleation and dynamics, demonstrating that quantum phase slips are responsible for the observed resistive current. Our work directly connects microscopic features with macroscopic dissipative transport, providing a comprehensive description of vortex ring dynamics in three-dimensional inhomogeneous constricted superfluids at zero and finite temperatures.

Realization of a high power optical trapping setup free from thermal lensing effects

Transmission of high power laser beams through partially absorbing materials modifies the light propagation via a thermally-induced effect known as thermal lensing. This may cause changes in the beam waist position and degrade the beam quality. Here we characterize the effect of thermal lensing associated with the different elements typically employed in an optical trapping setup for cold atoms experiments. We find that the only relevant thermal lens is represented by the TeO₂ crystal of the acousto-optic modulator exploited to adjust the laser power on the atomic sample. We then devise a simple and totally passive scheme that enables to realize an inexpensive optical trapping apparatus essentially free from thermal lensing effects.

Integrated molecular, biochemical, and physiological assessment unravels key extraction method mediated influences on rat neonatal cardiomyocytes

Neonatal cardiomyocytes are instrumental for disease modeling, but the effects of different cell extraction methods on basic cell biological processes remain poorly understood. We assessed the influence of two popular methods to extract rat neonatal cardiomyocytes, Pre-plating (PP), and Percoll (PC) on cell structure, metabolism, and function. Cardiomyocytes obtained from PP showed higher gene expression for troponins, titin, and potassium and sodium channels compared to PC. Also, PP cells displayed higher levels of troponin I protein. Cells obtained from PC displayed higher lactate dehydrogenase activity and lactate production than PP cells, indicating higher anaerobic metabolism after 8 days of culture. In contrast, reactive oxygen species levels were higher in PP cells as indicated by ethidium and hydroxyethidium production. Consistent with these data, protein nitration was higher in PP cells, as well as nitrite accumulation in cell medium. Moreover, PP cells showed higher global intracellular calcium under basal and 1 mM isoprenaline conditions. In a calcium-transient assessment under electrical stimulation (0.5 Hz), PP cells displayed higher calcium amplitude than cardiomyocytes obtained from PC and using a traction force microscope technique we observed that PP cardiomyocytes showed the highest relaxation. Collectively, we demonstrated that extraction methods influence parameters related to cell structure, metabolism, and function. Overall, PP derived cells are more active and mature than PC cells, displaying higher contractile function and generating more reactive oxygen species. On the other hand, PC derived cells display higher anaerobic metabolism, despite comparable high yields from both protocols.

High dose irradiation after pleurectomy/decortication or biopsy for pleural mesothelioma treatment

PURPOSE

The role played by radiation therapy after pleurectomy/decortication or surgical biopsy in malignant pleural mesothelioma is uncertain. We treated patients with accelerated hypofractionated radiotherapy using helical tomotherapy and intensity-modulated arc therapy in an attempt to keep lung toxicity to a minimum. The present study reports the feasibility and toxicity of this approach.

MATERIAL AND METHODS

Between 2008 and 2012, 36 patients with malignant pleural mesothelioma underwent accelerated hypofractionated radiotherapy to the hemithorax after pleurectomy/decortication (19 patients) or biopsy (17 patients). The prescription dose was 25Gy in five fractions over 5 consecutive days.

RESULTS

We observed three patients with G3 pneumonitis, five cases of grade 2 dyspnea and six cases of grade 2 cough. The median follow-up was 37 months (range: 3-54 months). The median overall survival for patients who underwent pleurectomy/decortication followed by radiotherapy was 21.6 months [95% confidence interval (95% CI): 15.5-24.1] compared to 19.4 months for patients not submitted to surgery.

CONCLUSION

Treatment of intact lung with pleural intensity-modulated arc irradiation in malignant pleural mesothelioma patients with malignant pleural mesothelioma proved safe and feasible, with an acceptable rate of pneumonitis. Survival rates were encouraging for both biopsy-only and pleurectomy/decortication groups. We are currently conducting a phase II dose escalation trial in a similar patient setting to prospectively evaluate the impact of radiotherapy on toxicity, disease-free survival and overall survival.

Large vestibular aqueduct in distal renal tubular acidosis: High-resolution MR in three cases

High-resolution MR of the inner ear performed in 3 consecutive pediatric patients affected by distal renal tubular acidosis (dRTA) and progressive sensorineural hearing loss (SNHL) revealed enlarged vestibular aqueducts (LVA) (bilateral in 1 case and unilateral in 2). LVA is associated to sporadic, progressive SNHL, often secondary to minor head trauma and activities involving the Valsalva maneuver.

We believe that the presence of LVA may have contributed to the onset of SNHL and its progression in our patients, and therefore want to stress the importance of morphological studies of the inner ear in patients affected by dRTA and SNHL.

ESGAR consensus statement on liver MR imaging and clinical use of liver-specific contrast agents

Objectives

To develop a consensus and provide updated recommendations on liver MR imaging and the clinical use of liver-specific contrast agents.

Methods

The European Society of Gastrointestinal and Abdominal Radiology (ESGAR) formed a multinational European panel of experts, selected on the basis of a literature review and their leadership in the field of liver MR imaging. A modified Delphi process was adopted to draft a list of statements. Descriptive and Cronbach’s statistics were used to rate levels of agreement and internal reliability of the consensus.

Results

Three Delphi rounds were conducted and 76 statements composed on MR technique (n = 17), clinical application of liver-specific contrast agents in benign, focal liver lesions (n = 7), malignant liver lesions in non-cirrhotic (n = 9) and in cirrhotic patients (n = 18), diffuse and vascular liver diseases (n = 12), and bile ducts (n = 13). The overall mean score of agreement was 4.84 (SD ±0.17). Full consensus was reached in 22 % of all statements in all working groups, with no full consensus reached on diffuse and vascular diseases.

Conclusions

The consensus provided updated recommendations on the methodology, and clinical indications, of MRI with liver specific contrast agents in the study of liver diseases.

Key points

• Liver-specific contrast agents are recommended in MRI of the liver.

• The hepatobiliary phase improves the detection and characterization of hepatocellular lesions.

• Liver-specific contrast agents can improve the detection of HCC.

iPad-based primary 2D reading of CT angiography examinations of patients with suspected acute gastrointestinal bleeding: preliminary experience

OBJECTIVE

To evaluate the effectiveness of the iPad (Apple Inc., Cupertino, CA) for two-dimensional (2D) reading of CT angiography (CTA) studies performed for suspected acute non-variceal gastrointestinal bleeding.

METHODS

24 CTA examinations of patients with suspected acute gastrointestinal bleeding confirmed (19/24, 79.2%) or ruled out (5/24, 20.8%) by digital subtraction angiography (DSA) were retrospectively reviewed by three independent readers on a commercial picture archiving communication system (PACS) workstation and on an iPad with Retina Display® 64 GB (Apple Inc.). The time needed to complete reading of every CTA examination was recorded, as well as the rate of detection of arterial bleeding and identification of suspected bleeding arteries on both devices.

RESULTS

Overall, the area under the receiver operating characteristic curve, sensitivity, specificity, positive- and negative-predictive values for bleeding detection were not significantly different while using the iPad and workstation (0.774 vs 0.847, 0.947 vs 0.895, 0.6 vs 0.8, 0.9 vs 0.944 and 0.750 vs 0.667, respectively; p > 0.05). In DSA-positive cases, the iPad and workstation allowed correct identification of the bleeding source in 17/19 cases (89.5%) and 15/19 cases (78.9%), respectively (p > 0.05). Finally, the time needed to complete reading of every CTA study was significantly shorter using the iPad (169 ± 74 vs 222 ± 70 s, respectively; p < 0.01).

CONCLUSION

Compared with a conventional PACS workstation, iPad-based preliminary 2D reading of CTA studies has comparable diagnostic accuracy for detection of acute gastrointestinal bleeding and can be significantly faster.

ADVANCES IN KNOWLEDGE

The iPad could be used by on-call interventional radiologists for immediate decision on percutaneous embolization in patients with suspected acute gastrointestinal bleeding.

p-medicine: A Medical Informatics Platform for Integrated Large Scale Heterogeneous Patient Data

Secure access to patient data is becoming of increasing importance, as medical informatics grows in significance, to both assist with population health studies, and patient specific medicine in support of treatment. However, assembling the many different types of data emanating from the clinic is in itself a difficulty, and doing so across national borders compounds the problem. In this paper we present our solution: an easy to use distributed informatics platform embedding a state of the art data warehouse incorporating a secure pseudonymisation system protecting access to personal healthcare data. Using this system, a whole range of patient derived data, from genomics to imaging to clinical records, can be assembled and linked, and then connected with analytics tools that help us to understand the data. Research performed in this environment will have immediate clinical impact for personalised patient healthcare.

HLA-B35, a common genetic trait, in a familial case of Henoch-Schoenlein purpura and Berger's disease

Nephritis characterized by IgA mesangial depositions has been described both in Henoch-Schoenlein purpura (HSP) and in Berger's disease (BD), but common genetic traits are still uncertain. We report here the case of two brothers, the first affected by HSP with persistent nephritis and the second by BD, accidentally discovered as silent microhematuria 1 year after HSP onset in the first brother. HLA genotyping demonstrated the presence of HLA-B35 in both patients. Our findings reinforce the need to screen for urinary abnormalities in family members of patients affected by HSP nephritis to identify a silent IgA nephropathy.

Juxtarenal aortic aneurysms: preliminary experience with fenestrated E-vita abdominal stent-graft

Endovascular aneurysm repair (EVAR) offers a minimally invasive treatment to patients with improved short-term and similar mid-term results compared to conventional, open repair. Approximately 20% of patients have an aneurysm neck morphology inadequate for a standard stent-graft and requires an endograft to cross vital aortic side branches to achieve a seal. This work describes the promising single center preliminary results in the management of juxtarenal aortic aneurysm using E-vita stent-graft.

Adverse effects during specific oral tolerance induction: in-hospital "rush" phase

BACKGROUND

Specific oral tolerance induction (SOTI) is a promising approach in the treatment of severe food allergies. Different protocols have demonstrated its efficacy. Nevertheless, SOTI is still considered an experimental method and should be limited to highly controlled settings.

AIMS

To define the incidence and severity of adverse reactions, possible risk factors, and the safety and effectiveness of nebulized epinephrine as a first-line treatment of respiratory reactions during in-hospital SOTI for cow's milk allergy.

MATERIALS AND METHODS

A retrospective study was conducted by reviewing the medical records of patients admitted for SOTI beginning in 2001. Reactions were classified as mild, moderate and severe on a partially modified Clark scale. Adverse reactions were treated following the International Guidelines with the introduction of nebulized epinephrine for level four reactions.

RESULTS

Of 209 patients, 17 were excluded due to the absence of objective reactions. The remaining 192 were classified as follows: Mild Reactions (Clark Scale 1 to 3): 100 patients received either no treatment, oral antihistamines or nebulized steroids; Moderate Reactions (Clark Scale 4): 87 patients treated with nebulized epinephrine and, depending on their symptoms, oral antihistamines, corticosteroids (nebulized, oral or IV) or nebulized beta 2 agonists; Severe Reactions (Clark Scale 5): 5 children, 4 of whom initially underwent one nebulization of epinephrine and eventually required an IM dose. The fifth patient was immediately treated with IM epinephrine due to hypotension.

DISCUSSION

adverse reactions during this in-hospital SOTI protocol were frequent but easily manageable. Nebulized epinephrine can play a relevant role in the treatment of respiratory reactions.

Double renal chimney graft using only femoral approach

Endovascular aneurysm repair (EVAR) is a minimally invasive treatment that can be offered to most patients with an aortic aneurysm. Patients who are rejected from standard EVAR often have more extensive aortic pathology and more medical comorbidities. The advent of fenestrated and branched stent grafts gives us an opportunity to treat the most demanding aortic aneurysms endovascularly. Fenestrated stent-grafts, however, are costly and time-consuming to manufacture, which limits their applicability, especially in the emergency setting. The chimney graft is a stent placed parallel to the aortic stent-graft to preserve flow to a vital aortic branch that was overstented to obtain an adequate seal. The technique can be used as a planned operation but also as a rescue procedure to salvage a side branch unintentionally covered during EVAR. As visceral branches of the aorta are usually directed caudally these vessels are, therefore, preferably catheterized from a brachial approach. We describe a case of a successful positioning of the chimney graft using only the femoral approach. The only femoral approach to position a renal chimney graft isn't recommended for the routine procedure but it is proved to be useful in selected case and when other treatment options are excluded.

Diagnostic accuracy of CT colonography in patients with positive faecal occult blood test: results of the Italian project Legatumori 2003-2006

PURPOSE

In the framework of the 3-year project of the Italian Legatumori (2003-2006), we evaluated the diagnostic accuracy of computed tomography (CT) colonography in detecting colorectal lesions in a screening population with positive faecal occult blood test (FOBT).

MATERIALS AND METHODS

Two hundred and thirty asymptomatic subjects (age range 45-80 years) were enrolled in the study. CT colonography was performed with standard patient preparation (no faecal tagging) and a 4-detector-row CT scanner. Image analysis was carried out with primary 2D analysis and the use of 3D endoluminal views to solve difficult cases. Patients were referred for conventional colonoscopy in the following situations: detection of three or more suspected lesions with maximum diameter<or=6 mm; evidence of one or more lesions with maximum diameter>6 mm; presence of colonic masses (maximum diameter>3 cm).

RESULTS

CT colonography detected colonic masses in 12 out of 135 subjects (8%). It generated 93 false positives and 19 false negatives in the identification of diminutive lesions (<or=6 mm), and 70 false positives and six false negatives in lesions>6 mm. Sensitivity was 83% in smaller lesions and 93% in lesions>6 mm; specificity was 45% and 59%, respectively.

CONCLUSIONS

In a screening population with positive FOBT, CT colonography without faecal tagging and no definite size threshold for the reporting of polyps showed very low specificity but high sensitivity in the detection of all colorectal lesions.

Video recording of cardiac surgical procedures: what the surgeon needs to know

In the past, rudimentary devices were used to record surgical operations. Currently, the introduction of technologic advances such as high-definition television and the miniaturization of high-resolution digital video cameras provides an opportunity for making significantly enhanced surgical records. These enhancements, coupled with the recent advances in telemedicine and surgical simulation, will improve cardiac surgery training and skill acquisition, decrease operative times and costs, minimize morbidity, and improve overall patient care. The present paper provides a discussion of the media technology offered to surgeons for recording a surgical procedure on video. Hardware technology, including different types of cameras and analogical or digital post processing methods, are reviewed with a surgical ''eye''. This ''how to'' paper provides practical suggestions to surgeons in order to enhance surgical video recording.

Functional interactions between presynaptic NMDA receptors and metabotropic glutamate receptors co-expressed on rat and human noradrenergic terminals

BACKGROUND AND PURPOSE

Electrophysiological studies described potentiation of NMDA receptor function by metabotropic glutamate receptors (mGluRs) of group I occurring postsynaptically. Since release-enhancing NMDA receptors exist on noradrenergic terminals and group I mGluRs have recently been identified on these nerve endings, we have investigated if NMDA receptor-mGluR interactions also can occur at the presynaptic level.

EXPERIMENTAL APPROACH

Rat hippocampus and human neocortex synaptosomes were labelled with [(3)H]noradrenaline and superfused with mGluR agonists and antagonists. NMDA-evoked [(3)H]noradrenaline release was produced by removal of external Mg(2+) or by simultaneous application of NMDA and AMPA in Mg(2+)-containing solutions.

KEY RESULTS

The mGluR1/5 agonist 3,5-DHPG, inactive on its own, potentiated both the release of [(3)H]noradrenaline elicited by AMPA/NMDA/glycine and that evoked by NMDA/glycine following Mg(2+) removal. The effect of 3,5-DHPG on the AMPA/NMDA/glycine-induced release was insensitive to the mGluR1 antagonist CPCCOEt, but it was abolished by the mGluR5 antagonist MPEP; moreover, it was potentiated by the mGluR5 positive allosteric modulator DFB. When NMDA receptors were activated by Mg(2+) removal, both mGluR5 and mGluR1 contributed to the evoked release, the mGluR-mediated release being blocked only by CPCCOEt and MPEP in combination. Experiments with human neocortex synaptosomes show NMDA receptor-mGluR interactions qualitatively similar to those observed in rodents.

CONCLUSIONS AND IMPLICATIONS

Group I mGluRs, both of the mGluR1 and mGluR5 subtypes, co-localize with NMDA receptors on noradrenergic terminals of rat hippocampus and human neocortex. Depending on the mode of activation, NMDA receptors exert differential permissive roles on the activation of presynaptic mGluR1 and mGluR5.

A 3-D CAD tool for CT colonography

Nowadays, biomedical images of the human body are an invaluable source of information that clinicians can use in order to make a correct and final diagnosis. Their use is widespread in almost every branch of medicine. In some cases, computer-aided diagnosis (CAD) tools have received approval for being used without any human intervention and validation, like, for example, in breast cancer detection relying on X-rays mammograms. In this paper we present a framework for building CAD tools based on the well-known software design patterns and an implementation of the first modules of a CAD tool for computed tomography (CT) colonography.

IERAPSI project: simulation of a canal wall-up mastoidectomy

Among the various EU research projects concerning the medical application of virtual reality, the project Ist-1999-12175, called IERAPSI (Integrated Environment for the Rehearsal and Planning of Surgical Interventions), specifically addressed the creation of a virtual and interactive surgical field for the temporal bone using three-dimensional images derived from CT data. We report on the experience obtained in the IERAPSI project in simulating a canal wall-up mastoidectomy. A surgeon with extensive experience in surgery of the petrous bone performed the mastoidectomy. The operative field included the mastoid, with its substantial differences in density between the cortex and the pneumatized bone, together with soft tissue structures, both on the border and inside the bone. The simulation is better in the first part of the operation than in the second part, suffering from a lack of haptic feedback from soft tissue and the surgical tool in deeper contexts, and under-representation of the variability inherent in pneumatized bone. This said, the excellent representation of dust production and removal, 3D simulation through color, and very good visual and haptic feedback in the early stage of the procedure are impressive. IERAPSI represents a potential surgical planning theater for the training of students and young surgeons, but is also expected to aid expert surgeons in the preoperative planning of difficult cases.

CT colonography: contrast enhancement of benign and malignant colorectal lesions versus fecal residuals

We retrospectively reviewed the computed tomographic colonographic datasets of 22 patients. Mean attenuation values of benign polyps before and after contrast administration were 30 +/- 15 HU and 90 +/- 18 HU, respectively. Mean attenuation values of colorectal cancer before and after contrast administration were 43 +/- 15 HU and 124 +/- 18 HU, respectively. The mean attenuation value of solid fecal residuals was 43 +/- 15 HU. The difference in attenuation value between precontrast and postcontrast studies of polyps was statistically significant (mean 60 HU, p < 0.01); the same was true for colorectal cancer (mean 81 HU, p < 0.01). The difference between postcontrast density of polyps and cancer with respect to density of solid fecal residuals was statistically significant (p < 0.01). The use of contrast medium could be of help in computed tomographic colonography for discriminating polypoid benign lesions and colorectal cancer from fecal residuals.

Ileocecal valve imaging on computed tomographic colonography

BACKGROUND

The aim of our study was to describe the visualization, normal anatomy, and variations of the ileocecal valve with computed tomographic (CT) colonography to provide information about its optimal imaging.

METHODS

We analyzed data in two- and three-dimensional rendering mode in 71 consecutive patients who underwent routine CT colonoscopy followed by conventional colonoscopy for confirmation of the radiologic findings.

RESULTS

Complete visualization of the ileocecal valve was better achieved in the supine than in the prone position (82% vs. 62%, respectively); the ileocecal valve appeared in 64% of cases in the supine position when it was invisible in prone position (p < 0.0001). Partial visualization of the ileocecal valve was possible in 94% of cases. The ileocecal valve was of labial type in 76%, papillary type in 21%, and lipomatous in 3% of cases. The orifice was identified in 53% of ileocecal valves; in two cases of cecal carcinoma, the normal ileocecal valve morphology was grossly disrupted.

CONCLUSION

The ileocecal valve was at least partly visualized by CT colonoscopy in 94% of cases, more frequently in the supine position. Its most common normal morphology is the labial type. The absence of orifice visualization alone is not a specific sign for neoplasia, but its presence helps distinguish physiologic bulging from neoplasia.

Enterocyte actin autoantibody detection: a new diagnostic tool in celiac disease diagnosis: results of a multicenter study

OBJECTIVES

This study describes a new method to detect autoantibodies against actin filaments (AAA) as a serological marker of intestinal villous atrophy (IVA) in celiac disease (CD), and reports the results of an Italian double-blind multicenter study.

METHODS

IgA-AAA were analyzed by immunofluorescence using a newly developed method based on intestinal epithelial cells cultured in presence of colchicine. IgA-AAA were blindly evaluated prospectively in 223 antiendomysial antibody (AEA) and/or antitransglutaminase antibody (TGA) positive subjects and in 78 AEA and TGA negative subjects. IgA-AAA positive patients underwent an intestinal biopsy to confirm the diagnosis. Moreover, IgA-AAA were retrospectively investigated in 84 biopsy-proven CD patients and in 2,000 new consecutively collected serum samples from AEA and TGA negative nonbiopsied subjects.

RESULTS

IgA-AAA were positive in 98.2% of the CD patients with flat mucosa, in 89% with subtotal villous atrophy, and in 30% with partial villous atrophy. IgA-AAA were present in none of the AEA and TGA negative nonbiopsied controls. In AEA and/or TGA positive CD patients IgA-AAA positivity significantly correlated with IVA (p < 0.000 in the prospective study, p = 0.005 in the retrospective study). In the prospective study, the values of sensitivity, specificity, the positive predictive value, the negative predictive value, and the efficiency of the IgA-AAA test to identify patients with IVA were, respectively, 83.9%, 95.1%, 97.8%, 69.2%, and 87.0%. Furthermore, a significant correlation (p < 0.0001) was found between the IgA-AAA serum titre and the degree of IVA (rs 0.56).

CONCLUSIONS

The results of this multicenter study show that the new method for IgA-AAA detection could represent a practical diagnostic tool in AEA and/or TGA positive subjects, which would be especially useful when IVA shows a patchy distribution, when the histological picture is difficult to interpret, or when a biopsy could represent a life-threatening risk.

Multidetector CT and virtual endoscopy in the evaluation of the esophagus

In this prospective study, we assessed the diagnostic capabilities of multidetector computed tomography (CT) in various esophageal pathologic conditions. Thirty-three patients underwent a multidetector CT study after esophageal distention by means of effervescent powder administered after induction of pharmacologic esophageal hypotonia. All acquired images were post-processed with two- and three-dimensional software tools. The CT data were compared with the results of conventional radiology (33), endoscopy (28), endoscopy ultrasonography (14), or surgery (14). Follow-up ranged between 4 and 15 months. Esophageal distention in the upper and middle thirds was classified as "good" in 32 of 33 cases (97%); in the lower third, esophageal distention was "good" in 21 of 33 cases (64%). Final diagnoses were leiomyoma (six cases), squamous cell carcinoma (six), adenocarcinoma (four), esophageal infiltration by thyroid cancer (two), benign polyposis (two), chronic esophagitis (five), post-sclerotherapy stenosis (one), no abnormalities (seven). When good distention was achieved, the thickness of unaffected esophageal wall was less than 3 mm (range, 1.5-2.4 mm; mean, 1.9 mm). Pathologic wall thickening was observed in 25 of 33 cases (76%), with values ranging between 3.6 and 36 mm (mean, 9.6 mm). Spiral CT demonstrated 21 true positive cases, and seven true negative cases. There were four false negative cases and one false positive case. Sensitivity was 84%, specificity was 87%, diagnostic accuracy was 85%, positive predictive value was 95%, and negative predictive value was 64%. Evaluation of the esophagus with multidetector CT is a promising technique and easy to use, allowing panoramic exploration, virtual endoluminal visualization, accurate longitudinal and axial evaluations, and simultaneous evaluation of T and N parameters.

Mass screening for coeliac disease using antihuman transglutaminase antibody assay

AIMS

To determine coeliac disease prevalence by an anti-transglutaminase antibody assay in a large paediatric population; to evaluate acceptance of the screening programme, dietary compliance, and long term health effects.

METHODS

Cross-sectional survey of 3188 schoolchildren (aged 6-12) and prospective follow up of diagnosed cases. Main outcome measures were: prevalence of coeliac disease defined by intestinal biopsy or positivity to both human tissue transglutaminase and anti-endomysium antibodies in HLA DQ2-8 positive subjects; percentage of children whose families accepted screening; dietary compliance as defined by negativity for anti-transglutaminase antibodies; and presence of clinical or laboratory abnormalities at 24 month follow up.

RESULTS

The families of 3188/3665 children gave their consent (87%). Thirty biopsy proven coeliacs were identified (prevalence 1:106). Three other children testing positive for both coeliac related autoantibodies and HLA DQ2-8 but refusing biopsy were considered as having coeliac disease (prevalence 1:96). Of 33 cases, 12 had coeliac related symptoms. The 30 biopsy proven coeliacs followed a gluten-free diet. Of 28 subjects completing 18-24 months follow up, 20 (71.4%) were negative for anti-transglutaminase antibodies, while eight were slightly positive; symptoms resolved in all 12 symptomatic children.

CONCLUSIONS

Prevalence of coeliac disease is high in Italian schoolchildren. Two thirds of cases were asymptomatic. Acceptance of the programme was good, as was dietary compliance. Given the high prevalence and possible complications of untreated coeliac disease, the availability of a valid screening method, and evidence of willingness to comply with dietary treatment population mass screening deserves careful consideration.

Multirow CT in the follow-up of pancreas transplantation

PURPOSE

Isolated pancreas or combined kidney-pancreas transplantation represents the only therapeutic weapon for complete resolution of type I diabetes mellitus. The purpose of the present study was to investigate the role of multirow CT in the follow-up of these patients.

MATERIALS AND METHODS

Thirty patients who underwent isolated (n = 13) or combined kidney-pancreas (n = 17) transplantation, using systemic-bladder (n = 7) or enteric-portal (n = 23) drainage, were evaluated with multirow CT (Light Speed Plus, GE Medical System). The CT study included unenhanced, arterial, and portal phases of the isolated pancreas, and a urographic phase for combined kidney-pancreas transplants. The acquisition was done with 1.25-mm collimation, 0.6-mm reconstruction interval, and a pitch of 6. A CT scan of the thorax was included if patients were suspected to have pulmonary complications.

RESULTS

In all cases it was possible to recognize the surgical technique performed for endocrine and exocrine pancreatic drainage, to evaluate the transplanted pancreas, and to identify possible complications. For example, CT identified thrombosis or stenosis of the arterial graft, partial thrombosis of the venous graft, ectasia of the common iliac artery and arterial graft, dehiscence of the duodenal-bladder anastomosis, infected abdominal collections, thrombosis of the internal iliac vein, and pulmonary infections.

CONCLUSIONS

Because multirow CT detects complications it is useful to follow isolated pancreas or combined kidney-pancreas transplants.

Less invasive radial artery harvest

BACKGROUND

Recent studies have sparked a renewed interest in the use of autogenous radial arteries in coronary operations. Some concerns have been found about sequelae of conventional harvesting. A less invasive technique for radial artery harvesting has been proposed by others using endoscopic devices. This technique is time consuming, needs expensive instrumentation and an important learning curve.

METHODS

A new less invasive approach for radial harvesting has been developed with a light assisted retractor under direct vision. A small skin incision, median in the forearm, is followed by dissection of the proper plane of the artery. A subcutaneous tunnel is created around the vessel and all the branches are ligated or clipped. The dissection of the pedicle under the skin is completed with the aid of a modified light assisted retractor, originally designed for the saphenous vein harvesting. The incision is closed after heparin reversal with a small redon as drainage.

RESULTS

A preliminary serie of 15 patients have been operated with this technique. In all patients the radial artery was patent and functional at the postoperative angiography. Morbidity included only a light hematoma at the beginning of our experience.

CONCLUSION

This less invasive technique for the radial artery harvesting appears to be an excellent surgical compromise between the open technique and the endoscopic procedure; it is easy to perform, the learning curve is acceptable and it offers an excellent aesthetic result.

The retrojugular route: the ideal exposure for carotid endarterectomy performed under locoregional anesthesia

BACKGROUND

Scientific evidence exists to support the claim that either general o regional anesthesia can be safely used for CEA: each of the techniques has either theoretical and practical advantages or drawbacks. Since the issue of whether, for CEA, one anesthetic technique is better than another has not yet been explored by randomized trials, any contribution that could reduce the disadvantages of any of the two approaches may contribute to overcome individual diffidence and visceral antagonism. The proposed approach represents a technical improvement of locoregional CEA technique.

METHODS

One hundred consecutive patients undergoing elective or urgent primary CEA under locoregional anesthesia were prospectively randomized in two equal size groups. In group 1 traditional (medial) approach to carotid bifurcation was employed; in group 2 the retrojugular approach (RJA) was used. Surgical and anesthesia scores were developed to assess the differences between the two groups in terms of surgical ease, the quality of exposure, patients comfort, level and quality of anesthesia.

RESULTS

Demographic and clinical characteristics of group 1 and group 2 patients were comparable. No major complication or death was observed in this series. Significant score differences were observed in favour of the retrojugular route. Using this route an improved and wider exposure was obtained, moreover, we achieved a better analgesia, with lesser additional anesthetic doses requirements, a faster approach to the carotid bifurcation, an enhanced patient comfort and a reduced interference on the surgical procedure by deglutition movements.

CONCLUSIONS

The retrojugular route represents the ideal route for locoregional CEA; this exposure, with respect to the traditional approach, minimizes many of the disadvantages commonly considered as major deterrents of regional anesthesia for carotid surgery.

Pretreatment with intravenous ketamine reduces propofol injection pain

BACKGROUND

Paediatric procedural sedation using propofol has been shown to be safe and effective and is widely used. Pain at the injection site is a frequent complaint and can be particularly distressing for children, especially for those undergoing repeated procedures. Ketamine has analgesic properties and can diminish the incidence of propofol infusion pain in adults. The aim of the study was to investigate whether pretreatment with ketamine would reduce infusion line pain in propofol sedation in children.

METHODS

We performed a prospective, randomized, double-blind trial in a paediatric sedation unit of a tertiary referral teaching hospital. A total of 122 children admitted for gastroscopy were randomly allocated into two groups. Group 1 received atropine and ketamine before propofol infusion. Group 2 received atropine, normal saline solution, and a mixture of propofol with lidocaine. The main outcome measure evaluated was pain associated with the infusion and secondary outcome measures were mean medium arterial pressure decrease and desaturation.

RESULTS

The incidence of pain of the infusion was significantly lower in patients pretreated with ketamine (8% vs 37%, P = 0.0001).

CONCLUSIONS

Pretreatment with ketamine (0.5 mg.kg-1) is very effective in preventing propofol infusion pain.

The "Braids Lady" of Arezzo: a case of rheumatoid arthritis in a 16th century mummy

OBJECTIVE

To diagnose a probable case of rheumatoid arthritis in a mummified female body from the 16th century and to backdate the first clinical diagnosis, entering the diatribe regarding the ancientness of the disease.

METHODS

Image techniques such as normal X-ray, X-ray by mammography, total body CT and high resolution CT were used. Microscopic examination by stereomicroscopy was performed. Samples of tissue were submitted to histology. These data and the review of past literary references, of artistic representations and of paleopathological cases provided an interesting contribution to reconstruct the history of the disease.

RESULTS

The body of the "Braids Lady" showed all the "stigmata" of the disease. The left hand revealed large erosions of the metacarpophalangeal joints of both the third and the fourth fingers, volar metacarpophalangeal subluxation of both the third and the fourth fingers and lateral deviation of all the fingers. The carpus showed some minute and marginal erosions of the bones. The bases of the first phalanges were slightly flared. The toes showed partially overlapped fibular deflection. CT evidenced subluxations of the joints. The body showed no involvement of sacroiliac articulation.

CONCLUSIONS

The "Braids Lady" was affected by rheumatoid arthritis. A large number of features typical of the disease were recorded. Differential diagnosis supported the findings. The death of the lady was established at the end of 16th century, namely 200 years before the first clinical diagnosis worked out by Landré Beauvais in the early 1800s.

Surgical treatment of abdominal aortic aneurysms associated with aortic valve incompetence: strategies and outcomes

BACKGROUND

The exact incidence of associated aortic valve incompetence (AVI) and abdominal aortic aneurysm (AAA) in the general population is not known. In recent years, we have observed this association with increasing frequency. This observation is probably due to the extensive preoperative screening of the cardiac and vascular status of patients who are candidates for surgical procedures. The choice of the optimal surgical strategy is needed to achieve low operative morbidity and mortality. The present study reviews our experience with a subset of patients suffering the association of AVI and large AAA. Surgical strategy, clinical management and outcome are presented.

METHODS

Between January 1982 and May 2000, 76 patients with the association of AAA and AVI have been evaluated in our institution. Forty-four patients have been treated for both AAA and aortic valve (AV) regurgitation. These patients have been divided into three groups on the basis of the surgical strategy adopted. Group 1: combined procedure (16 patients); group 2: AAA repair prior to AV surgery (nine patients); group 3: AV surgery prior to aneurysm repair (19 patients).

RESULTS

Hospital mortality was 4.5% (two patients); overall mortality was 6.8% (three patients).

CONCLUSIONS

In patients with AAA and AVI, an accurate and complete preoperative evaluation is essential. Surgical strategy should be individualized on the basis of the cardiac preoperative status.

Noninvasive tests for risk stratification in major vascular surgery

BACKGROUND

The predictive values of noninvasive tests versus perioperative cardiac events in patients undergoing major vascular surgery has not been definitively established.

PATIENTS AND METHODS

According to clinical markers and left ventricular function at rest, 188 patients were assigned to the following groups: 40 low, 115 moderate and 33 high risk. They were then randomly submitted to dipyridamole (n = 64), dobutamine (n = 63) stress echocardiography and dipyridamole perfusion scintigraphy (n = 61).

RESULTS

No events were observed in low-risk patients, whereas 12 (10.4%) and 8 (24%) events in moderate- and high-risk categories occurred, respectively. Only the high-risk category, as a predictive variable, was significantly related to the onset of cardiac complications (p < 0.05). A positive dipyridamole/dobutamine stress test was related to cardiac events, but multivariate analysis showed that only severity and extent of ischemia were the best predictors of events (p < 0.01 for dipyridamole and p < 0.005 for dobutamine). The presence of reversible, but not fixed, perfusion defects at scintigraphy was significantly related to perioperative events; at multivariate analysis, only > 3 reversible perfusion defects represented a strong predictor of events (p < 0.05).

CONCLUSIONS

Among subjects undergoing major vascular surgery, severity and extent of ischemia during dipyridamole/dobutamine stress echocardiography and presence of > 3 reversible perfusion defects are strong predictors of cardiac events, particularly in moderate-risk category of patients.

Kartagener's syndrome and rheumatoid arthritis: an unusual association

We report the case of a 66-year-old caucasian woman affected by Kartagener's syndrome (KS), a genetically transmitted disorder characterised by situs viscerum inversus, bronchiectasis and sinusitis, who also developed rheumatoid arthritis (RA). The impaired mucociliary function typical of KS caused recurrent paranasal sinus and lung infections, as shown by CT scans of the sinuses and chest. The coexistence of KS and RA in our patient was probably accidental. Given the small number of patients in whom an association of the two disorders has been described, it is impossible to establish whether KS might play a role in the pathogenesis of RA.

Perioperative use of tirofiban hydrochloride (Aggrastat) does not increase surgical bleeding after emergency or urgent coronary artery bypass grafting

BACKGROUND

The platelet glycoprotein IIb/IIIa inhibitor tirofiban hydrochloride improves outcome in patients with acute coronary syndrome. Nevertheless, a considerable number of patients require emergency or urgent coronary artery bypass grafting and may be at increased risk of postoperative bleeding after treatment with this molecule. The aim of this study is to evaluate the incidence of bleeding complications among patients undergoing bypass grafting after treatment with tirofiban.

METHODS

We investigated the influence of the molecule on postoperative bleeding after cardiac surgery, comparing 2 groups of patients undergoing emergency or urgent coronary artery bypass grafting: group A (n = 20) received tirofiban, and group B (n = 68) received conventional therapy with intravenous heparin up until the operation. A total of 88 patients underwent coronary artery bypass surgery within 2 hours of ceasing the hemodynamic study. Clinical outcome, chest tube outputs, bleeding complications, transfusion requirements, platelet and hemoglobin counts, and clinical complications were examined.

RESULTS

Bleeding differences were noted between the 2 groups at 8, 16, and 24 hours postoperatively. The incidence of blood, platelet, and fresh frozen plasma transfusions was higher in the control group. Postoperative thrombocytopenia was preserved in group A (199.5 +/- 70.4 vs 150.6 +/- 33.4 10(3)/mL, P <.01). No significant differences were noted between the 2 groups in the incidence of perioperative myocardial infarction, but significant differences were noted in enzyme levels, length of stay in the intensive care unit, and length of stay in the hospital. No deaths were observed. Hospital morbidity was increased in group B because of factors that were not apparently linked with tirofiban infusion.

CONCLUSIONS

Patients may safely undergo coronary artery bypass surgery after treatment with tirofiban hydrochloride. This molecule, administered in the immediate preoperative period, has no adverse clinical effects and does not seem to negatively influence the incidence of perioperative myocardial infarction. Although extracorporeal circulation can modify platelet numbers and function, our ongoing data could show significant reduction in the loss of platelets induced by cardiopulmonary bypass, minor postoperative bleeding, and a minor transfusion requirement in general.