Development and machine learning-based calibration of low-cost multiparametric stations for the measurement of CO2 and CH4 in air

The pressing issue of atmospheric pollution has prompted the exploration of affordable methods for measuring and monitoring air contaminants as complementary techniques to standard methods, able to produce high-density data in time and space. The main challenge of this low-cost approach regards the in-field accuracy and reliability of the sensors. This study presents the development of low-cost stations for high-time resolution measurements of CO2 and CH4 concentrations calibrated via an in-field machine learning-based method. The calibration models were built based on measurements parallelly performed with the low-cost sensors and a CRDS analyzer for CO2 and CH4 as reference instrument, accounting for air temperature and relative humidity as external variables. To ensure versatility across locations, diversified datasets were collected, consisting of measurements performed in various environments and seasons. The calibration models, trained with 70 % for modeling, 15 % for validation, and 15 % for testing, demonstrated robustness with CO2 and CH4 predictions achieving R2 values from 0.8781 to 0.9827 and 0.7312 to 0.9410, and mean absolute errors ranging from 3.76 to 1.95 ppm and 0.03 to 0.01 ppm, for CO2 and CH4, respectively. These promising results pave the way for extending these stations to monitor additional air contaminants, like PM, NOx, and CO through the same calibration process, integrating them with remote data transmission modules to facilitate real-time access, control, and processing for end-users.

Slideflow: deep learning for digital histopathology with real-time whole-slide visualization

Deep learning methods have emerged as powerful tools for analyzing histopathological images, but current methods are often specialized for specific domains and software environments, and few open-source options exist for deploying models in an interactive interface. Experimenting with different deep learning approaches typically requires switching software libraries and reprocessing data, reducing the feasibility and practicality of experimenting with new architectures. We developed a flexible deep learning library for histopathology called Slideflow, a package which supports a broad array of deep learning methods for digital pathology and includes a fast whole-slide interface for deploying trained models. Slideflow includes unique tools for whole-slide image data processing, efficient stain normalization and augmentation, weakly-supervised whole-slide classification, uncertainty quantification, feature generation, feature space analysis, and explainability. Whole-slide image processing is highly optimized, enabling whole-slide tile extraction at 40x magnification in 2.5 s per slide. The framework-agnostic data processing pipeline enables rapid experimentation with new methods built with either Tensorflow or PyTorch, and the graphical user interface supports real-time visualization of slides, predictions, heatmaps, and feature space characteristics on a variety of hardware devices, including ARM-based devices such as the Raspberry Pi.

Evaluation of Major Pathologic Response and Pathologic Complete Response as Surrogate End Points for Survival in Randomized Controlled Trials of Neoadjuvant Immune Checkpoint Blockade in Resectable in NSCLC

INTRODUCTION

Controversy remains as to whether pathologic complete response (pCR) and major pathologic response (MPR) represent surrogate end points for event-free survival (EFS) and overall survival (OS) in neoadjuvant trials for resectable NSCLC.

METHODS

A search of PubMed and archives of international conference abstracts was performed from June 2017 through October 31, 2023. Studies incorporating a neoadjuvant arm with immune checkpoint blockade alone or in combination with chemotherapy were included. Those not providing information regarding pCR, MPR, EFS, or OS were excluded. For trial-level surrogacy, log ORs for pCR and MPR and log hazard ratios for EFS and OS were analyzed using a linear regression model weighted by sample size. The regression coefficient and R2 with 95% confidence interval were calculated by the bootstrapping approach.

RESULTS

Seven randomized clinical trials were identified for a total of 2385 patients. At the patient level, the R2 of pCR and MPR with 2-year EFS were 0.82 (0.66-0.94) and 0.81 (0.63-0.93), respectively. The OR of 2-year EFS rates by response status was 0.12 (0.07-0.19) and 0.11 (0.05-0.22), respectively. For the 2-year OS, the R2 of pCR and MPR were 0.55 (0.09-0.98) and 0.52 (0.10-0.96), respectively. At the trial level, the R2 for the association of OR for response and HR for EFS was 0.58 (0.00-0.97) and 0.61 (0.00-0.97), respectively.

CONCLUSIONS

Our analyses reveal a robust correlation between pCR and MPR with 2-year EFS but not OS. Trial-level surrogacy was moderate but imprecise. More mature follow-up and data to assess the impact of study crossover are needed.

Multimodal Use of Contact Endoscopy in Neurosurgery: Case Series with Technical Note and Literature Review

BACKGROUND

Originally adopted for the cytological screening of cervical and uterine cancer, contact endoscopy (CE) is now widely used in several fields of oncological surgery. The CE method, with magnification power up to 150x, was designed to enhance visualization and identify microscopic changes indicative of precancerous and cancerous lesions at early stages. In this pilot study, we evaluated the multimodal applications of CE during different endoscopic intracranial neurosurgical procedures.

METHODS

Twenty patients with skull base lesions underwent surgery using different minimally invasive endoscopic approaches (endonasal, transorbital, and supraorbital). CE was used to distinguish the pathology from the surrounding healthy tissue by positioning the endoscope either in proximity or directly onto the target tissue. Special attention was given to the visualization of the margins of the lesion to differentiate compression/displacement from infiltration of the normal surrounding tissue.

RESULTS

With its unprecedented range of magnification, CE could clearly identify the microvascular pattern and cytological architecture of a tissue not detectable by simple white light endoscopy, with no reported damage due to heat transmission or iatrogenic injuries. All the lesions diagnosed as "presumed neoplastic tissue" by CE were confirmed by histopathology. The most promising results were observed in surgeries for meningioma and pituitary adenoma, as these lesions exhibit distinctive microvascular networks.

CONCLUSIONS

CE represents a new and effective technique for the in vivo identification of pathological microvascular and tissue features, allowing preservation of normal tissue during different endoscopic approaches. The use of CE could improve diagnostic accuracy and assist in intraoperative decision-making, becoming a key tool in various applications in neurosurgical field.

Primary Anaplastic-Lymphoma-Kinase-Positive Large-Cell Lymphoma of the Central Nervous System: Comprehensive Review of the Literature

BACKGROUND

Primary anaplastic-lymphoma-kinase (ALK)-positive large-cell lymphoma of the central nervous system (PCNS ALK-positive ALCL) is a rare entity, with a limited consensus reached regarding its management. While this pathology often presents as solitary lesions, the occurrence of multiple tumors within the brain is not uncommon. The lack of distinctive radiological features poses a diagnostic challenge, leading to delays in initiating targeted therapy.

METHODS

We conducted a comprehensive literature search, identifying seventeen publications for qualitative analysis.

RESULTS

The management options and reported patient outcomes in the literature varied significantly, emphasizing the need for a patient-specific approach. The emergence of ALK-specific inhibitors represents a new frontier in this field, demonstrating promising results.

CONCLUSION

PCNS ALK-positive ALCL necessitates a comprehensive understanding and optimized management strategies. A tailored therapeutic approach, integrating surgical intervention with radiotherapy and chemotherapy, appears pivotal in addressing this pathology. The implementation of a therapeutic protocol is anticipated for further advancement in this field.

The Transorbital Approach, A Game-Changer in Neurosurgery: A Guide to Safe and Reliable Surgery Based on Anatomical Principles

During the last few years, the superior eyelid endoscopic transorbital approach has been proposed as a new minimally invasive pathway to access skull base lesions, mostly in ophthalmologic, otolaryngologic, and maxillofacial surgeries. However, most neurosurgeons performing minimally invasive endoscopic neurosurgery do not usually employ the orbit as a surgical corridor. The authors undertook this technical and anatomical study to contribute a neurosurgical perspective, exploring the different possibilities of this novel route. Ten dissections were performed on ten formalin-fixed specimens to further refine the transorbital technique. As part of the study, the authors also report an illustrative transorbital surgery case to further detail key surgical landmarks. Herein, we would like to discuss equipment, key anatomical landmarks, and surgical skills and stress the steps and details to ensure a safe and successful procedure. We believe it could be critical to promote and encourage the neurosurgical community to overcome difficulties and ensure a successful surgery by following these key recommendations.

Concomitant, Single Burr Hole Endoscopic Third Ventriculostomy and Tumor Biopsy for Pineal Lesions: Feasibility, Safety, and Benefits

Obtaining a prompt diagnosis, avoiding indwelling ventriculoperitoneal shunt, and enhancing the predictive value of pathologic examinations are only some of the advantages conferred by a simultaneous third ventriculostomy and tumor biopsy in patients with pineal region tumors. The objective of this study was to retrospectively search the literature on concomitant, single burr hole endoscopic third ventriculostomy (ETV) and tumor biopsy (TB) for pineal region tumors and to analyze the feasibility, surgical safety, and benefits of these 2 combined procedures. Consequently, a comprehensive, systematic literature search was performed in compliance with the updated PRISMA 2020 guidelines within electronic databases MEDLINE/PubMed, EMBASE, PLOS, and Cochrane Library. Statistical analysis was performed with IBM SPSS 28.0.1.1(14), using Kendall's and Spearman's tests, with a P < 0.05 considered significant. A total of 25 studies were selected and included in this review, for a total of 368 patients (mean age 20.6 years; range 1-86 years; SD 17.5). More than two-thirds of the procedures were operated with a rigid endoscope and 27.6% were performed with either a flexible endoscope, a combination of the 2, or not otherwise specified. Germinoma represented the most frequent diagnosis (20.1%) followed by astrocytoma (12.9%) and pineocytoma (9.9%). The single-entry approach allowed a correct histologic diagnosis in 88.7% of the examined cases. Summing up, concomitant ETV and TB represent a valuable option for the management of non-communicating hydrocephalus and the initial assessment of pineal region tumors. The histologic confirmation rate was 88.7% in the examined cohort, with only 10% of the biopsies yielding inconclusive results.

The feasibility of three port endonasal, transorbital, and sublabial approach to the petroclival region: neurosurgical audit and multiportal anatomic quantitative investigation

PURPOSE

The petroclival region represents the "Achille's heel" for the neurosurgeons. Many ventral endoscopic routes to this region, mainly performed as isolated, have been described. The aim of the present study is to verify the feasibility of a modular, combined, multiportal approach to the petroclival region to overcome the limits of a single approach, in terms of exposure and working areas, brain retraction and manipulation of neurovascular structures.

METHODS

Four cadaver heads (8 sides) underwent endoscopic endonasal transclival, transorbital superior eyelid and contralateral sublabial transmaxillary-Caldwell-Luc approaches, to the petroclival region. CT scans were obtained before and after each approach to rigorously separate the contribution of each osteotomy and subsequentially to build a comprehensive 3D model of the progressively enlarged working area after each step.

RESULTS

The addition of the contralateral transmaxillary and transorbital corridors to the extended endoscopic endonasal transclival in a combined multiportal approach provides complementary paramedian trajectories to overcome the natural barrier represented by the parasellar and paraclival segments of the internal carotid artery, resulting in significantly greater area of exposure than a pure endonasal midline route (8,77 cm² and 11,14 cm² vs 4,68 cm² and 5,83cm², extradural and intradural, respectively).

CONCLUSION

The use of different endoscopic "head-on" trajectories can be combined in a wider multiportal extended approach to improve the ventral route to the most inaccessible petroclival regions. Finally, by combining these approaches and reiterating the importance of multiportal strategy, we quantitatively demonstrate the possibility to reach "far away" paramedian petroclival targets while preserving the neurovascular structures.

Multicentric Italian case-control study on 25OH vitamin D levels in children and adolescents with Prader-Willi syndrome

PURPOSE

25OHD levels in patients with Prader-Willi Syndrome (PWS), the most frequent cause of genetic obesity with a peculiar fat mass distribution, are still debated. Insulin resistance (IR), Body Mass Index-SDS (BMI-SDS), Growth Hormone Therapy (GHT), and puberty onset seem to interact with 25OHD levels. The objectives of the study are: (1) To analyze 25OHD levels in pediatric PWS patients in comparison with a control group (CNT) (2) To evaluate a possible correlation between BMI-SDS, HOMA-IR, puberty, GHT, and 25OHD levels.

METHODS

This is a retrospective case-control, multicenter study. Data were collected among 8 different Italian Hospitals (outpatient clinics), over a period of four years (2016-2020). We included 192 genetically confirmed PWS and 192 CNT patients, aged 3-18 years, matched 1:1 for age, gender, BMI-SDS, Tanner stage, sun exposure, and month of recruitment.

RESULTS

No statistically significant differences in 25OHD levels were observed between the PWS population and the CNT (PWS 24.0 ng/mL vs CNT 22.5 ng/mL, p > 0.05), OR = 0.89 (95% CI 0.58-1.35). We observed a slight, although non-significant, reduction in 25OHD levels comparing NW and OB populations. HOMA-IR, puberty onset, genotype and GHT (previous or ongoing) did not show statistically significant correlation with 25OHD levels.

CONCLUSIONS

Our findings could be useful for clinicians to optimize the therapeutic management as well as to increase awareness of PWS.

Functional and clinical outcomes after superior eyelid transorbital endoscopic approach for spheno-orbital meningiomas: illustrative case and literature review

The pattern of growth of spheno-orbital meningiomas accounts for the main presenting symptoms, such as proptosis, eye motility deficit, visual impairment, diplopia. As these are benign tumors, the postoperative patient's quality of life is an important factor to consider during the preoperative planning. A detailed literature review of superior eyelid transorbital endoscopic approach for spheno-orbital meningiomas, including our own case, was made. A Medline search up to March 2022 in PubMed online electronic database was made using the following key phrases: "superior eyelid endoscopic transorbital approach spheno-orbital meningiomas," "superior eyelid endoscopic transorbital approach," "spheno-orbital meningiomas endoscopic approach." The inclusion criteria were surgical series, reviews, and case reports in English language, as well as papers written in other languages, but including the abstract in English. Cadaveric studies, multiportal combined approaches for SOM, were excluded. The literature review has disclosed five studies for a total of 65 patients, whose demographic, clinical, pathological, surgical, complications, and outcome data were analyzed. Functional and esthetic outcome data after superior eyelid transorbital approach are the following: improvement of proptosis (100%), of visual deficits (66.66%) and of ocular paresis (75%), with only 11 complications (4 trigeminal dysesthesia, 2 CSF leak, 2 wound complications, 1 upper eyelid necrosis, 1 hemorrhage of surgical field, 1 keratitis) reported, but at the expense of extent of resection (gross total resection 33.39%). Based on the outcome data, the superior eyelid transorbital endoscopic approach results in a suitable operative technique for selected spheno-orbital meningiomas.

Solitary fibrous tumor/hemangiopericytoma of the cervical spine: A systematic review of the literature with an illustrative case

Background:

In the WHO 2016 classification of central nervous system tumors, solitary fibrous tumors (SFT) and hemangiopericytomas (HPC) were considered part of the same category given a shared mutation. Nevertheless, since the new 2021 WHO classification, the term “hemangiopericytoma” has been retired, and SFT is considered an independent pathological entity.

Methods:

We reviewed the literature following preferred reporting items for systematic reviews and meta-analyses guidelines focusing on the treatment options and prognosis of patients with cervical SFT. We also present a 68-year-old female with spinal intradural extramedullary SFT complicated by diffuse extension into paravertebral tissues and muscles.

Results:

We found 38 cervical SFT in the literature. Patients averaged 47.3 years of age and 47.4% were female. Typically, these lesions spanned two spinal levels resulting in cord compression and most frequently exhibited benign features (i.e., diagnosed as Grade I SFTs). Interestingly, two patients exhibited distant metastases and had initial pathology consistent with grade II SFT.

Conclusion:

SFT of the cervical spine is rare and its management varies according to the histological grade and the clinical behavior, generally warranting surgical excision and adjuvant radiation therapy and/or systemic chemotherapy.

Effect of low-dose rivaroxaban with low-dose aspirin vs low-dose aspirin on platelet and oxidative biomarkers: a randomized study in diabetes patients with stable peripheral or coronary artery disease

Background

Rivaroxaban (Riva), a direct FXa inhibitor, at 2.5 mg twice-daily (bid) combined with low-dose aspirin (ASA, 100 mg once daily-od) reduced major vascular events vs. ASA alone in subjects with stable coronary artery (CAD) or symptomatic peripheral artery disease (PAD). Whether this benefit is due to the anticoagulant effect or additional FXa-mediated effects through the platelet and endothelial cell thrombin receptors is unknown. Type 2 diabetes mellitus (T2DM) is characterized by high platelet activation and oxidative stress that may contribute to increased cardiovascular risk.

Purpose

We investigated the effects of Riva (2.5 mg bid) + ASA (100 mg od) vs. ASA (100 mg od) alone on platelet and oxidative biomarkers in subjects with T2DM and stable vascular disease (stable CAD, symptomatic PAD and/or significant carotid stenosis).

Methods

In this randomized, open-label, cross-over trial, patients were randomized to continue ASA for 4 weeks and then add Riva for 4 weeks, or add Riva in the first 4 weeks and then continue with ASA alone for 4 weeks. Primary endpoints were: in vivo platelet activation and lipid peroxidation, assessed by the urinary excretion of 11-dehydro-TXB2 (TXM) and 8-iso-PGF2alpha (ISOP), respectively. Secondary endpoints included: routine coagulation tests, D-dimer, thrombin generation, serum TXB2, and Riva plasma concentrations.

Results

Seventy-6 subjects (10 females) were recruited: age 68±7 years (mean±SD); BMI 27.1±3.5 kg/m2; fasting glucose 129±31 mg/dL; HbA1c 6.8±0.9%; serum creatinine 1±0.25 mg/dL; LDL-cholesterol 77±31 mg/dL. Two patients dropped out: one for benign, self-limiting hematuria, one for unwillingness to continue, 8 subjects are completing the study leaving 66 who completed the 8-week randomized treatment and showed no sequence effect. Urinary TXM and ISOP were significantly reduced by Riva+ASA vs. ASA alone: TXM was 260 [195–398] vs. 335 [225–441] pg/mg creatinine and ISOP 722 [601–991] vs. 827 [648–1350] pg/mg creatinine (median [IQR]) on Riva+ASA vs. ASA alone, respectively (p&lt;0.001 for paired samples). Riva plasma concentrations were 48±1.9 ng/ml at peak and 21±1.4 ng/ml at trough. The velocity of thrombin formation significantly decreased with Riva+ASA vs. ASA alone (velocity index, 46±3% vs. 83±3%; peak-height, 66±2% vs. 83±1%, respectively). aPTT levels were slightly but significantly prolonged by Riva vs. ASA alone (44±1 vs. 39±1 sec). Serum TXB2, D-dimer, von Willebrand factor, PT, fibrinogen and endogenous thrombin potential values were similar between treatments.

Conclusions

In ASA-treated subjects with T2DM and stable vascular disease, the addition of very low-dose Riva restrained incompletely-suppressed lipid peroxidation and platelet activation and modified the kinetics of thrombin formation. These changes may contribute to the beneficial effects of the Riva+ASA combination.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Investigator-initiated study funded by Bayer AG

Recurrent Glioblastoma Treatment: State of the Art and Future Perspectives in the Precision Medicine Era

Current treatment guidelines for the management of recurrent glioblastoma (rGBM) are far from definitive, and the prognosis remains dismal. Despite recent advancements in the pharmacological and surgical fields, numerous doubts persist concerning the optimal strategy that clinicians should adopt for patients who fail the first lines of treatment and present signs of progressive disease. With most recurrences being located within the margins of the previously resected lesion, a comprehensive molecular and genetic profiling of rGBM revealed substantial differences compared with newly diagnosed disease. In the present comprehensive review, we sought to examine the current treatment guidelines and the new perspectives that polarize the field of neuro-oncology, strictly focusing on progressive disease. For this purpose, updated PRISMA guidelines were followed to search for pivotal studies and clinical trials published in the last five years. A total of 125 articles discussing locoregional management, radiotherapy, chemotherapy, and immunotherapy strategies were included in our analysis, and salient findings were critically summarized. In addition, an in-depth description of the molecular profile of rGBM and its distinctive characteristics is provided. Finally, we integrate the above-mentioned evidence with the current guidelines published by international societies, including AANS/CNS, EANO, AIOM, and NCCN.

Solitary metastasis from renal cell carcinoma to the choroid plexus: A case illustration and review of the literature

Background:

Metastatic renal cell carcinoma (RCC) of the choroid plexus is an exceedingly rare condition, with only 35 reported cases to date. Surgical resection of these tumors poses a unique challenge to neurosurgeons since evidence-based treatment guidelines are yet to be designed.

Case Description:

The authors describe the case of a 58-year-old woman presenting with progressive neurological deterioration 5 years after a right nephrectomy for a WHO 2016 Stage I RCC. A head, contrast-enhanced, and magnetic resonance revealed signs of obstructive hydrocephalus and a homogeneously contrast-enhancing 5 cm mass located in the trigone of the right lateral ventricle. Furthermore, a search of the literature was performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. After screening for duplicates, 35 publications met the eligibility criteria. Finally, 17 manuscripts were included for analysis. Moreover, a detailed description of an illustrative case is provided. The median age at diagnosis for intraventricular metastasis from RCC was 62.9 years, showing a slight female prevalence. The lateral ventricles were reported as the most frequent location with only one patient presenting with obstructive hydrocephalus caused by the obliteration of Monro foramen. Management options included either open craniotomy or radiosurgery.

Conclusion:

The management of choroid plexus metastasis from RCC is still controversial with various authors proposing different treatment strategies. In this article, in addition to an in-depth case description, a qualitative review of the literature on metastatic RCCs of the choroid plexus using the PRISMA is provided.

Solitary subdural osteomas: Systematic review of the literature with an illustrative case

Background

Subdural osteomas represent an extremely rare entity with only 20 cases described to date. Despite the typical benign behavior, these tumors can grow to compress the brain and occasionally detach from the dura mater.

Methods

A systematic search of the literature was performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. After screening for duplicates, 179 publications met the eligibility criteria. Finally, 18 manuscripts were included in this review. Moreover, a detailed description of an illustrative case is provided.

Results

The median age at diagnosis was 43.2 years, showing a female prevalence. The inner table of the frontal bone was reported as the most frequent location, and in six cases, the lesions did not show any relation with the dura, which appeared intact. Surgical resection appears to be an effective and safe management option. In the present work, the case of a 60-year-old female who presented with persistent, diffuse headaches which had first occurred 6 months earlier is described. On admission, the physical and neurological examinations were unremarkable, and her medical history disclosed no systemic disease, meningitis, or head injury. Computed tomography showed a homogeneous, high-density nodule attached to the inner table of the left middle cranial fossa.

Conclusion

In addition to an in-depth case description, the first systematic and qualitative review of the literature on intracranial subdural osteomas using the PRISMA is provided.

Intradural extramedullary cavernous hemangioma of the cervicothoracic junction: A case report and review of the literature

Background:

Intradural extramedullary cavernous hemangiomas of the spine are rare, benign lesions with only 40 published cases to date.

Case Description:

The authors report a rare case of a histologically diagnosed intradural extramedullary cavernous hemangioma of the spine involving the cervicothoracic junction and causing sudden gait disturbances and urinary retention in a 24-year-old male. Gross total tumor removal allowed complete spinal decompression and sensible improvement of the clinical condition with no evidence of tumor relapse at 12-month follow-up examination.

Conclusion:

More frequently found in the lower thoracic and lumbar spine, these tumors often cause subtle clinical manifestations including sensory and motor dysfunction secondary to nerve root compression; nonetheless, occasional cases of rapidly progressive worsening of the neurological condition with evidence of myelopathy and autonomic dysfunction have been described. In such cases, urgent surgical resection is crucial since the degree of neurological impairment and the time spanned from the onset of the symptoms are paramount for a good recovery.

Cerebrospinal fluid leak as a driving factor in chronic subdural hematoma formation: A histological study

Background:

Chronic subdural hematoma (CSDH) represents the most common neurosurgical disease. Given the demographic shift toward an aging population, the overall incidence of this condition is increasing. Nevertheless, clarity in the pathophysiological process is yet to be made. Several etiological mechanisms have been proposed to initiate and consequently promote fluid collection in the subdural space. Traumatic injury of the bridging veins has long been considered the primum movens of the pathology but increasing evidence shows that trauma is not the only factor involved. Along with recent advances we sought to understand the role of the cerebrospinal fluid (CSF) in the buildup of the intense inflammatory reaction that characterizes CSDH.

Methods:

In the present study, we examined histological features of reactive membranes secondary to extracranial CSF leakage with CSDH-related membranes. Similarity and differences between the specimens were examined by means of light microscopy.

Results:

Histological similarities were consistently found between CSDH membranes and reactive membranes secondary to CSF leakage in the extracranial space. Activated histiocytes were highlighted in all specimens along with an intense inflammatory reaction.

Conclusion:

CSDH is most likely the result of a complex interaction among different pathophysiological events resulting from both traumatic and inflammatory etiologies. In the present work, we highlight how CSF leakage could be an early factor that leads to a cascade of events that culminates in CSDH formation.

Isolated lumbar intradural tailgut cyst: A case report and review of the literature

Tailgut cysts are rare developmental cysts arising from remnants of the embryological postnatal gut. Despite being frequently located in the presacral space, isolated cases of aberrant locations have been reported, including, perirenal, perianal, and subcutaneous sites, with only two cases of subdural tailgut cysts reported to date. The clinical course is often marked by linear growth, causing compression of the adjacent structures, however malignant transformation with carcinomatous features has been previously described. Hereby the authors describe a case of an intradural extramedullary tailgut cyst in a 33-year-old man presenting with progressive low back pain and signs of autonomic dysfunction, including urinary retention and bowel incontinence. Whole-spine MRI revealed an intrathecal cystic lesion located at L2-L3 level exhibiting hyperintensity on T2-weighted images not enhancing when contrast was administered. Laminectomy followed by tumor excision was performed and pathological analysis confirmed the diagnosis of tailgut cyst.

Diffuse vertebral metastases from glioblastoma with vertebroepidural diffusion: A case report and review of the literature

Background:

The occurrence of extraneural metastasis in patients diagnosed with glioblastoma (GBM) is rare with an estimated incidence ranging from 0.4% to 2.0%. Short clinical history is believed to be a possible explanation of the paucity of such cases. Furthermore, to date, only few papers describe cases of vertebral metastases from GBM without evidence of synchronous visceral involvement.

Case Description:

The authors report on the case of a 46-year-old woman presenting with a history of surgically treated GBM who developed multiple metastases located in the posterior laminae and vertebral bodies with a single dural metastasis at D6-D8 level 5 years after the initial diagnosis. Total-body computed tomography did not show signs of either intracranial recurrence or visceral involvement. Postoperative pathological examination confirmed the diagnosis of the World Health Organization-2016 Grade IV GBM metastases.

Conclusion:

From a clinical point of view, the awareness of the possibility of spinal and vertebral metastasis from intracranial GBM is crucial. The present case demonstrates that distant dissemination from the primary tumor is possible despite the absence of intracranial recurrence.

Infratentorial abscess secondary to dermal sinus associated with dermoid cyst in children: Review of the literature and report of a rare case

Background:

Dermal sinus is usually located at either end of neural tube but most commonly lumbosacral. When occipital, it extends caudally and is mostly localized in the midline position or in the cavity of the fourth ventricle. It could communicate with the skin through a fistula with potential risk of deeper abscesses. Posterior fossa abscess secondary to dermal sinus associated with intracranial dermal cyst is an uncommon pathology.

Case Description:

A 24-month-old girl was admitted to our institution with a cutaneous fistula in the midline of the occipital region. Brain imaging showed an infratentorial intradiploic cyst with peripheral enhancement to contrast medium. The mass showed hyperintensity on T1-weighted sequences, with the lower signal on T2-weighted images. A suboccipital craniotomy was performed with evacuation of the abscess and excision of the capsule. Contextually a 3 cm whitish and encapsulated cystic mass with hair component was extracted. Histology confirmed the diagnosis of abscess associated with dermal cyst and dermal sinus. The patient condition improved and 15 days after excision, was discharged. The postoperative MRI showed total removal of the lesion. A 36-month follow-up highlighted no evidence of recurrence.

Conclusion:

Posterior fossa dermoid cyst should be considered in all children with a cutaneous fistula. Early neurosurgical treatment of these benign tumors should be performed to prevent the development of severe intracranial infection. Best results are associated with early diagnosis and complete removal of the abscess. The present work further reviews the few similar cases that have been reported in the literature confirming the need for future research.

Virtual reality for COPD rehabilitation: a technological perspective

Virtual Reality (VR) is a promising technology for implementing personalized, motivating and controlled rehabilitation scenarios. Although its clear potential benefits, VR has been poorly investigated in pulmonary rehabilitation. This review analyses the state of the art, by searching the scientific and grey literature, regarding the use of VR for the rehabilitation of patients with chronic obstructive pulmonary disease, providing a technological perspective. First, the main characteristics of the included systems are presented in terms of visualization devices, way of interaction and type of feedback they provide. Then, results of the selected studies are reported considering feasibility, safety, usability and user experience as outcomes. Finally, the main findings are discussed and future directions for research are outlined.

Lymphadenectomy for gastric cancer at European specialist centres

BACKGROUND AND AIMS

The aim of this project was to evaluate the current practice of D2 in Europe.

MATERIALS AND METHODS

In the first part of the study, 18 European high volume gastric cancer centres completed a questionnaire, designed to evaluate their preferred lymphadenectomy in a series of clinical scenarios. Surgeon compliance with international guidelines for lymphadenectomy was evaluated. In the second part, information on 381 gastrectomies performed for primary gastric cancer by participating surgeons from January to December 2015, was retrospectively collected.

RESULTS

Surgical choice in clinical scenarios was affected by tumour stage and to a lesser extent, site and histotype. In particular, in early gastric cancer with diffuse histology D2 was recommended by >70% of surgeons, while this percentage dropped to 44% in intestinal histotypes. When surgeons selected a D2 dissection, the procedure was rarely fully compliant with the Japanese guidelines. In the review of gastrectomy experience an adequate number of nodes (≥15 nodes) was retrieved in 97% after D2. The number of retrieved nodes varied with median values ranging from 17 to 35 (p < 0.001) after D2. D2/D2+ was more frequently performed in mixed (80%) and diffuse (78%) cases than in intestinal cases (69%) (p = 0.016).

CONCLUSIONS

Although an adequate lymphadenectomy was achieved in almost all cases in dedicated centres, there is still variation in the number of retrieved nodes. Tumor histology largely affects surgeon's choice as regards the extent of lymphadenectomy; however, the role of histology in planning surgical procedures needs to be verified in prospective trials.

Spontaneous cerebrospinal fluid rhinorrhea in a patient with Pallister–Hall syndrome

Pallister-Hall syndrome (PHS) is extremely rare autosomal dominant disorder with typical clinical features such as presence of polydactyly, hypothalamic hamartoma, bifid epiglottis, anal, renal, genitourinary and pulmonary abnormalities, mainly located in the midline of the body. Spontaneous cerebrospinal fluid (CSF) rhinorrhea is also a rare condition, and it is used to describe nasal discharge of CSF unrelated to previous trauma, localized tumour, surgery, or previous radiation therapy. The exact cause is not yet fully understood. We report a case of adult female patient previously diagnosed with PHS and late onset of spontaneous nasal liquorrhea, due to defect in the anterior skull base. Although it can be incidental finding, we believe that described defect in the body midline can be another presentation of congenital craniofacial abnormality which are common in PHS.

Vitom 3D: preliminary experience with intradural extramedullary spinal tumors

BACKGROUND

In the last decade, application of the high-definition exoscope to different neurosurgical procedures has been reported in the literature. We describe the first experience with the VITOM®-3D for the surgical treatment of intradural extra-medullary tumors.

METHODS

Five neurosurgical procedures for the removal of intradural extra-medullary tumors were performed with the VITOM®-3D. Patients' population, feasibility of surgery under the exoscope visualization, VITOM®-3D's technical and optical characteristics, and surgical outcome were analyzed.

RESULTS

All surgeries were performed following the common steps of spinal neurosurgical intradural procedures. The exoscope offered excellent, magnified and brilliantly illuminated high definition images of the surgical field in all the described cases. All the reported surgical operations were successfully completed under exoscope magnification from both the technical as well as the clinical points of view. No complications potentially related to the use of the exoscope occurred. Working environment ergonomics and trainees learning experience were the most relevant benefits associated with the use of exoscope.

CONCLUSIONS

VITOM®-3D may represent a valid visualization tool in spinal procedure for intradural extra-medullary tumors. Our preliminary experience can be useful in better define the role of VITOM®-3D in neurosurgery.

Daily Low-dose Carboplatin and Standard Radiotherapy in Unresectable Head and Neck and Lung Cancers: A Pilot Study

A total of 14 patients with locally advanced and unresectable head and neck (SCCHN) or non small cell lung cancer were treated with a definitive course of radiation therapy with conventional fractionation and 30 mg/m2 carboplatin (CBDCA) given daily as an i.v. infusion during the 1st, 3rd, 5th and 7th weeks of the combined treatment. The planned tumor dose of at least 7000 cGy was reached in all SCCHN patients except 1 (6600 cGy). The 2 NSCLC patients received 6320 and 5980 cGy, respectively. The planned total CBDCA-dose of 600 mg/m2 was administered in all patients. No treatment delays were required in 10 patients. Interruptions for severe mucositis or myelosuppression occurred in 4 patients (28.6%), but in no case did the delay exceed 1 week. Complete response was obtained in 8 patients (57.1%); 7 of the 12 with SCCHN and 1 of the 2 with NSCLC. The other 6 patients achieved a partial response. Granulocytopenia of WHO grade 3 occurred in 1 patient; apart from vomiting and mucositis, toxicities above grade 2 were not observed.

Inappropriate Doses of Chemotherapy in Italian Breast Cancer Patients Enrolled in Clinical Trials

Aims and background

The dose of delivered chemotherapy is important to evaluate the appropriateness of the anticancer treatment. This aspect has been scarcely studied in Italy. About 7 years ago, the Italian Group for Antiemetic Research (IGAR) published a large controlled study on the effectiveness of different antiemetic prophylaxis in patients submitted to moderately emetogenic chemotherapy, where the prescribed chemotherapy was recorded. The aim of our study was to evaluate the incidence of undertreatment and to detect clinical and nonclinical factors able to explain its variability.

Methods

An observational study on the IGAR databank was performed to evaluate the incidence of undertreatment in the prescription in conditions of clinical trial, where the doses belonged to the eligibility criteria, and to analyze the importance of clinical and nonclinical factors using multifactorial logistic models.

Results

317 patients receiving cyclophosphamide, methotrexate, and fluorouracil (CMF) and 224 anthracycline-based chemotherapy were considered. In the CMF-treated patients, 22.4% received full doses, whereas in 53.6% all three drugs of the schedule were down-dosed. In the anthracycline-treated group, 38.6% and 3.4% of patients submitted to chemotherapy containing epirubicin and doxorubicin, respectively, were undertreated. Logistic models showed that undertreatment in CMF-treated patients depended significantly on the geographic area and setting of chemotherapy administration. Although not significant, differences between age class and Karnofsky performance status were also detected. In the epirubicin-treated group, all these factors were significant.

Conclusions

The undertreatment of cancer patients is a relevant problem, because it could give, in daily clinical practice, worse results than those reported in clinical studies. Considering the setting of a clinical trial where our study was carried out, the incidence of undertreatment is surprisingly high. We do not know whether today, about 8 years after the IGAR study was carried out, the inappropriate dose of chemotherapy is still as frequent as we reported, but surely the topic deserves more attention.

Response to Alpha-Interferon Treatment of the Congenital Dyserythropoietic Anemia type I in Two Sicilian Beta Thalassemia Carriers

Congenital dyserythropoietic anemia type I (CDAI) is an autosomal recessive inherited haematological disorder associated with moderate-to-severe anemia characterized by ineffective erythropoiesis with distinct morphological abnormalities in erythroid precursors. We present two case of congenital dyserythropoietic anemia type I in two Sicilian patients heterozygous for β⁰ 39 globin gene cod 39 C > T with marked bone marrow abnormalities, responding to treatment with alpha interferon. The diagnosis was established using routine haematological and biochemical test, light and electron microscopy; molecular analysis of the CDAN1 gene associated to the CDAI disease was performed. The response to the treatment was monitored using the hemoglobin levels, the red cell count, the reticulocyte count and the transfusional requirement. This report points out the usefulness of the treatment with interferon alpha in two Sicilian beta thalassemia carriers, in which the therapy was well tolerated without producing any side effects; in these patients the transfusion requirements after the initiation of interferon therapy decreased.

Microwave-ultrasound simultaneous irradiation: a hybrid technology applied to ring closing metathesis

Glycerol micelles were suitable nanoreactors for ring-closing metathesis reaction activated by a hybrid microwave-ultrasound reactor. Nine different Ru-catalysts were investigated.

Stable isotope ratio analysis for verifying the authenticity of balsamic and wine vinegar

In this paper, we investigate whether the analysis of stable isotope ratios D/H and ¹³C/¹²C in ethanol and acetic acid and of ¹⁸O/¹⁶O in water can be applied to the ingredients of "aceto balsamico di Modena IGP" (ABM) to evaluate their authenticity. We found that impurities in the extraction solution do not affect the ¹³C/¹²C of acetic acid and the D/H values of acetic acid are not affected under a composite NMR experiment. The standard deviation of repeatability and standard deviation of reproducibility are comparable in wine vinegar and ABM and generally lower than those quoted in the official methods. This means that the validation parameters quoted in the official methods can also be applied to the ingredients of ABM. In addition, we found no changes in the isotopic values from wine to vinegar and to ABM, and from the original must to the ABM must, providing experimental evidence that reference data from wine databanks can also be used to evaluate the authenticity of vinegar and ABM.

Chronic pain management in pregnancy and lactation

During pregnancy most of women will experience some kind of pain, either as a result of a pre-existing condition (low back pain, headache, fibromyalgia, and rheumatoid arthritis) or as a direct consequence of pregnancy (weight gain, postural changes, pelvic floor dysfunction, hormonal factors). However, chronic pain management during pregnancy and lactation remains a challenge for clinicians and pregnant women are at risk of undertreatment for painful conditions, because of fear about use of drugs during pregnancy. Few analgesic drugs have been demonstrated to be absolutely contraindicated during pregnancy and breastfeeding, but studies in pregnant women are not available for most of pain medications. The aim of this paper is to review the safety profile in pregnancy or lactation of the commonly prescribed pain medications and non-pharmacological treatments. In addition to the conventional classifications from the Food and Drug Administration and the American Academy of Paediatrics, authors analyzed the currently available clinical data from literature.

Metabolic syndrome in children with Prader-Willi syndrome: the effect of obesity

BACKGROUND AND AIMS

Prader-Willi syndrome (PWS), the most frequent syndromic obesity, is associated with elevated morbidity and mortality in pediatric and adult ages. In PWS, the presence of metabolic syndrome (MS) has not yet been established. The aim of the study was to estimate the frequency of MS and its components in pediatric subjects according to obesity status.

METHODS AND RESULTS

A cross-sectional study was performed in 109 PWS children aged 2-18 years (50 obese and 59 non-obese) and in 96 simple obese controls matched for age, gender, and also for BMI with obese PWS. Obesity was defined when SDS-BMI was >2. Non-obese PWS showed significantly lower frequency of hypertension (12%) than obese PWS (32%) and obese controls (35%)(p=0.003). The same was observed for low HDL-cholesterol (3% vs 18% and 24%, p=0.001) and high triglycerides (7% vs 23% and 16%, p=0.026). Frequency of altered glucose metabolism was not different among groups (2% vs 10% and 5%), but type 2 diabetes (four cases) was present only in obese PWS. Non-obese PWS showed lower insulin and HOMA-index respect to obese PWS and obese controls (p ≤ 0.017). Overall MS frequency in PWS was 7.3%. None of the non-obese PWS showed MS compared with 16% of obese PWS and controls (p<0.001). When obesity was excluded from the analysis, a significantly lower frequency for clustering of ≥ 2 factors was still found in non-obese PWS (p=0.035).

CONCLUSION

Non-obese PWS showed low frequency of MS and its components, while that observed in obese PWS was very close to those of obese controls, suggesting the crucial role of obesity status. Prevention of obesity onset remains the most important goal of PWS treatment. Early identification of MS could be helpful to improve morbidity and mortality in such patients.

[Traumatic rupture of hepatic hydatid cyst]

Hydatid disease is endemic in some areas of the world. It is located mostly in the liver. The cysts rupture is possible after a trauma, or spontaneously by the increase of intracystic pressure. Rupture of the hydatid cyst requires urgent surgical intervention. We report our experience in treatment of traumatic rupture of hepatic hydatid cyst.

Prevalence of coronary artery intramyocardial course in a large population of clinical patients detected by multislice computed tomography coronary angiography

BACKGROUND

Intramyocardial course, an inborn coronary anomaly, is defined as a segment of a major epicardial coronary artery that runs intramurally through the myocardium; in particular, we distinguish myocardial bridging, in which the vessel returns to an epicardial position after the muscle bridge, and intramyocardial course, which is described as a vessel running and ending in the myocardium.

PURPOSE

To evaluate the prevalence of myocardial bridging and intramyocardial course of coronary arteries as defined by multidetector computed tomography (MDCT) angiography.

MATERIAL AND METHODS

The study population consisted of 242 consecutive patients (211 men, 31 women; mean age 59+/-6 years) with atypical chest pain admitted to our hospital between December 2004 and September 2006. All MDCT examinations were performed using a 16-detector-row scanner (Aquilion 16 CFX; Toshiba Medical System, Tokyo, Japan). Patients with heart rate above 65 bpm received 50 mg atenolol orally for 3 days prior to the MDCT scan, or they increased their usual therapy with beta-blockers, in order to obtain a prescan heart rate <60 bpm. Curved multiplanar and 3D volume reconstructions were performed to explore coronary anatomy.

RESULTS

In 235 patients, the CT scan was successful and images were appropriate for evaluation. The prevalence of myocardial bridging and intramyocardial course of coronary arteries was 18.7% (47 cases) in our patient population. In 30 segments (63.8%), the vessels ran and ended in the myocardium. In the remaining 17 segments (36.2%), the vessels returned to an epicardial position after the muscle bridge. We found no difference in the prevalence of this inborn coronary anomaly when comparing different clinical characteristics of the study population (sex, age, body-mass index [BMI], etc.). The mean length of the subepicardial artery was 7 mm (range 5-12 mm), and the mean depth in the diastolic phase was 1.9 mm (range 1.2-2.3 mm). There was no significant difference of diameter in these segments between the different R-R phases examined.

CONCLUSION

Our study is in agreement with major angiographic literature reporting a prevalence of myocardial bridging and intramyocardial course between 0.5% and 33%. MDCT technology represents a useful, noninvasive imaging method to assess and evaluate the location, depth, and length of this anatomical variation.

Self-monitoring of blood glucose in non-insulin-treated diabetic patients: a longitudinal evaluation of its impact on metabolic control

AIMS

In the framework of a nationwide outcomes research programme, we assessed the impact of self-monitoring of blood glucose (SMBG) on metabolic control over 3 years in patients with Type 2 diabetes mellitus (DM2) not treated with insulin.

METHODS

The study involved 1896 patients who completed, at 6-month intervals for 3 years, a questionnaire investigating SMBG practice. Clinical information was collected by participating clinicians at the same time intervals. The predictive value of SMBG frequency on long-term metabolic control was estimated using multilevel analysis. The impact of SMBG on metabolic control was also evaluated in distinct and homogeneous subgroups of patients showing different likelihood of performing SMBG, identified using a tree-growing technique (RECPAM).

RESULTS

Overall, 22% of the patients were on diet alone and 78% were treated with oral agents; 41% practiced SMBG > or = 1/week (10.3% > or = 1/day). The analysis of metabolic control according to the frequency of SMBG failed to show any significant impact of this practice on HbA1c levels over 3 years. Similarly, changes in SMBG frequency during the study were not related to significant changes in HbA1c levels. RECPAM analysis led to the identification of eight classes, characterized by substantial differences in the likelihood of performing SMBG with a frequency of at least 1/week. Nevertheless, in none of the RECPAM classes identified, did SMBG predict a better metabolic control over 3 years of follow-up. In those RECPAM classes indicating that SMBG was mainly performed to avoid hypoglycaemic episodes, SMBG was associated with a decrease in the frequency of hypoglycaemic episodes during the study.

CONCLUSIONS

In a large sample of non-insulin-treated Type 2 diabetic patients, the performance and frequency of SMBG did not predict better metabolic control over 3 years. We could not identify any specific subgroups of patients for whom SMBG practice was associated with lower HbA1c levels during the study.

Multimodal management of stages III–IVa malignant thymoma

PURPOSE

The optimal therapy for locally advanced malignant thymoma is controversial. We review our experience with a multimodal approach in 63 consecutive cases.

PATIENTS AND METHODS

Forty-three patients had stage III and 20 stage IVa disease. Surgery with radical intent was initially performed in 30 cases, while 33 cases not amenable to radical surgery underwent neoadjuvant treatment (radiotherapy in 8 and chemotherapy in 25) before surgical reassessment. All patients, whether or not surgically resected, received radiation therapy.

RESULTS

Radical resection (RR) was performed in 20 patients ab initio (all stage III) and in 12 patients after neoadjuvant treatment (eight stage III and four stage IVa). With the addition of patients radically operated with neoadjuvant treatment, the radical resection rate increased from 46 to 65% in stage III patients, and from 0 to 20% in those with stage IVa disease, respectively. Radical surgery was associated with longer progression free survival and overall survival according to both univariate analysis ( P< 0.001 and P<0.01, respectively) and multivariate analysis after adjustment for age, gender, histology and disease stage ( P<0.001 and <0.02, respectively). Progression free survival (median 56.9 months) was slightly lower in patients undergoing radical surgery after neoadjuvant approaches than in those radically resected ab initio (median not achieved), but overall survival (median not achieved) was similar in both groups. Subtotal surgical resection promoted complete response to subsequent radiation therapy. This condition significantly correlated with a better outcome.

CONCLUSIONS

Complete surgical resection is an independent prognostic parameter in locally advanced thymoma treated with a multimodal approach. Preoperative treatment to increase the complete resection rate could improve the overall survival of these patients.

Randomized trial of 2 versus 5 years of adjuvant tamoxifen for women aged 50 years or older with early breast cancer: Italian Interdisciplinary Group Cancer Evaluation Study of Adjuvant Treatment in Breast Cancer 01

PURPOSE

To compare 2 with 5 years of adjuvant tamoxifen therapy in the treatment of early breast cancer.

PATIENTS AND METHODS

Women with breast carcinoma T1-3, N0-3, M0, who were between 50 and 70 years of age, were eligible irrespective of menopausal status, tumor grade, or estrogen receptor (ER) status. Patients who were event-free after 2 years of tamoxifen therapy were randomly assigned to stop or continue tamoxifen therapy for an additional 3 years. The primary end point was length of disease-free survival (DFS). Secondary end points included overall survival (OS) and toxicity.

RESULTS

From 1989 through 1996, 1,901 patients were randomly assigned either to stop treatment (n = 958) or to receive tamoxifen for 3 additional years (n = 943). The median duration of postrandomization follow-up was 52 months. We found no statistically significant differences between the 5-year arm and the 2-year arm in terms of DFS (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.76 to 1.08) and OS (HR, 1.16; 95% CI, 0.92 to 1.46). In ER-positive patients, a statistically significant prolongation of DFS related to longer treatment duration was observed (HR, 0.74; 95% CI, 0.59 to 0.93), whereas no difference in OS could be detected (HR, 0.98; 95% CI, 0.72 to 1.32). No differences in terms of endometrial cancers, cardiac or cerebrovascular events, or fractures were detected, whereas a doubling in the risk of thromboembolic events was found in the 5-year arm.

CONCLUSION

Our results confirm previous research that shows that 5 years of tamoxifen decreases recurrence compared to 2 years in patients with ER-positive tumors.

Portal vein thrombosis after variceal endoscopic sclerotherapy in cirrhotic patients: role of genetic thrombophilia

BACKGROUND AND STUDY AIMS

Portal vein thrombosis is a rare event in patients with liver cirrhosis in the absence of a related neoplasm. Endoscopic sclerotherapy of esophageal varices has been anecdotally associated with the development of portal vein thrombosis. We tested the hypothesis that genetic thrombophilia plays a role in the development of portal vein thrombosis in patients with liver cirrhosis undergoing endoscopic sclerotherapy.

PATIENTS AND METHODS

From June 1998 to December 1999, 61 consecutive patients underwent multiple sessions of endoscopic sclerotherapy for bleeding esophageal varices. Doppler ultrasound of the portal vein was performed before sclerotherapy and every 3 months thereafter. Antiphospholipid antibodies, factor V Leiden (FVL) mutation, prothrombin mutation G20210A (PTHRA20210) and mutation TT677 of methylenetetrahydrofolate reductase (MTHFR C677T) were evaluated in all patients.

RESULTS

Portal vein thrombosis developed in 16 % of the patients (10 of 61) after a mean follow-up period of 16 months. A genetic cause for thrombosis was found in 70 % of patients with liver cirrhosis who developed portal vein occlusion, but only in 8 % of patients without this complication.

CONCLUSIONS

Endoscopic sclerotherapy of esophageal varices may represent a trigger factor for portal vein thrombosis in cirrhotic patients with genetic thrombophilia.