Inter-fractional monitoring of [Formula: see text]C ions treatments: results from a clinical trial at the CNAO facility

The high dose conformity and healthy tissue sparing achievable in Particle Therapy when using C ions calls for safety factors in treatment planning, to prevent the tumor under-dosage related to the possible occurrence of inter-fractional morphological changes during a treatment. This limitation could be overcome by a range monitor, still missing in clinical routine, capable of providing on-line feedback. The Dose Profiler (DP) is a detector developed within the INnovative Solution for In-beam Dosimetry in hadronthErapy (INSIDE) collaboration for the monitoring of carbon ion treatments at the CNAO facility (Centro Nazionale di Adroterapia Oncologica) exploiting the detection of charged secondary fragments that escape from the patient. The DP capability to detect inter-fractional changes is demonstrated by comparing the obtained fragment emission maps in different fractions of the treatments enrolled in the first ever clinical trial of such a monitoring system, performed at CNAO. The case of a CNAO patient that underwent a significant morphological change is presented in detail, focusing on the implications that can be drawn for the achievable inter-fractional monitoring DP sensitivity in real clinical conditions. The results have been cross-checked against a simulation study.

Reproductive biology and pollinators in two enantiostylous Qualea species (Vochysiaceae) in the Brazilian Cerrado

Enantiostyly is a floral polymorphism in which two floral forms in the same species differ in deflection of the stigma to right or left position. In monomorphic enantiostylous plants, flowers of the two morphs occur within the same individual, usually in the same proportion. In self-compatible species the function of monomorphic enantiostyly is proposed to increase outcrossing rates and offer a reproductive advantage under pollination limitation. Enantiostylous species are usually self-compatible and show heteranthery, with poricide anthers and pollen as pollinator reward; however, there are families, such as Vochysiaceae, that have different characteristics. We analysed the reproductive system and pollination biology of Qualea parviflora and Q. multiflora, two enantiostylous species from the Brazilian Cerrado that have specific morphological and physiological traits. For this, we characterized flower traits, performed hand pollinations and studied floral visitors. We found no differences between morphs in the proportion of flowers, nectar produced or its concentration, pollen quantity and fruit set. Both species were self-incompatible and quite generalist regarding floral visitors. Enantiostyly in self-incompatible plants seems to confer a reproductive advantage by reducing self-interference resulting from stigma clogging. This novel result helps to expand our knowledge on this complex floral polymorphism and opens new avenues for future research on this topic.

Particle beam microstructure reconstruction and coincidence discrimination in PET monitoring for hadron therapy

Positron emission tomography is one of the most mature techniques for monitoring the particles range in hadron therapy, aiming to reduce treatment uncertainties and therefore the extent of safety margins in the treatment plan. In-beam PET monitoring has been already performed using inter-spill and post-irradiation data, i.e. while the particle beam is off or paused. The full beam acquisition procedure is commonly discarded because the particle spills abruptly increase the random coincidence rates and therefore the image noise. This is because random coincidences cannot be separated by annihilation photons originating from radioactive decays and cannot be corrected with standard random coincidence techniques due to the time correlation of the beam-induced background with the ion beam microstructure. The aim of this paper is to provide a new method to recover in-spill data to improve the images obtained with full-beam PET acquisitions. This is done by estimating the temporal microstructure of the beam and thus selecting input PET events that are less likely to be random ones. The PET detector we used was the one developed within the INSIDE project and tested at the CNAO synchrotron-based facility. The data were taken on a PMMA phantom irradiated with 72 MeV proton pencil beams. The obtained results confirm the possibility of improving the acquired PET data without any external signal coming from the synchrotron or ad hoc detectors.

Full-beam performances of a PET detector with synchrotron therapeutic proton beams

Treatment quality assessment is a crucial feature for both present and next-generation ion therapy facilities. Several approaches are being explored, based on prompt radiation emission or on PET signals by [Formula: see text]-decaying isotopes generated by beam interactions with the body. In-beam PET monitoring at synchrotron-based ion therapy facilities has already been performed, either based on inter-spill data only, to avoid the influence of the prompt radiation, or including both in-spill and inter-spill data. However, the PET images either suffer of poor statistics (inter-spill) or are more influenced by the background induced by prompt radiation (in-spill). Both those problems are expected to worsen for accelerators with improved duty cycle where the inter-spill interval is reduced to shorten the treatment time. With the aim of assessing the detector performance and developing techniques for background reduction, a test of an in-beam PET detector prototype was performed at the CNAO synchrotron-based ion therapy facility in full-beam acquisition modality. Data taken with proton beams impinging on PMMA phantoms showed the system acquisition capability and the resulting activity distribution, separately reconstructed for the in-spill and the inter-spill data. The coincidence time resolution for in-spill and inter-spill data shows a good agreement, with a slight deterioration during the spill. The data selection technique allows the identification and rejection of most of the background originated during the beam delivery. The activity range difference between two different proton beam energies (68 and 72 MeV) was measured and found to be in sub-millimeter agreement with the expected result. However, a slightly longer (2 mm) absolute profile length is obtained for in-spill data when compared to inter-spill data.

Endonasal mucosal contact points in chronic migraine

Some anatomo-functional alterations of the nose may be considered as possible causes of headache: deviations of the nasal septum, abnormal turbinates, especially middle or superior, with consequent areas of mucosal contact with the septum. This study was performed on 100 subjects, 27 chronic migraine (CM) sufferers and 73 subjects who never suffered from migraine as control group. In the CM group, a direct endoscopic assessment was carried out in order to search for mucosal points of contact. Following the endoscopy, the patients underwent a computerized tomography (CT) in order to confirm the mucosal contact and for a better evaluation of its localization. The control group (C group) consisted of subjects who underwent a CT of the skull for various reasons. In CM group, a mucosal contact was highlighted in 14 patients (51.8 %); it was unilateral in 50 % of cases. In C group, the contact was present in 27 cases (36.9 %); in 81.5 % of them (n = 22), it was unilateral. A single site of contact was present in 6 (22 %) patients in CM group and 20 (27.3 %) patients in C group; more sites, in 8 (29.6 %) CM group patients and in 7 (9.5 %) patients of the C group. The connection between subjects and the number of single or multiple contacts in the two groups was statistically significant (p = 0.049). Furthermore, the frequency of the septum-middle turbinate was significantly (p = 0.0013) more frequent in CM sufferers (13/14) compared with control subjects (11/27). This study suggests, although with extremely early data, the need to select carefully patients for a possible surgical approach, using various parameters: in particular, the site of the mucosal contact, favoring the cases with multiple areas of contact, mainly between septum-middle turbinate and septum-superior turbinate.

Compatibility between coherent reflective burst-mode PON and TWDM-PON physical layers

We discuss the compatibility between reflective PON architectures and the recently defined ITU-T G.989.1 TWDM-PON. Focusing on the upstream, we experimentally demonstrate that, by using burst-mode coherent detection at OLT, reflective PON can achieve the specification target set for TWDM-PON, without requiring precise wavelength accuracy at ONU. Compared to the companion ECOC 2013 paper, we investigate on the differential optical path loss (DOPL) issue, proposing a simple SOA gain control algorithm to achieve reliable transmission for DOPL up to 17 dB.

Sexual reproduction of the pentaploid, short-styled Oxalis pes-caprae allows the production of viable offspring

Reproduction is a key factor for the successful establishment and spread of introduced species. Oxalis pes-caprae is a tristylous species with a self- and morph-incompatibility sexual system that, in the invaded range of the western Mediterranean Basin, has been found to reproduce asexually because only the pentaploid, short-styled morph (5x S-morph) was introduced. The objective of this study was to test the ability of the 5x S-morph of O. pes-caprae to produce viable offspring in the absence of compatible mates, exploring the hypothesis that new morphs could have emerged by sexual reproduction events of the initially introduced morph. Pollen germination, pollen tube development, fruit and seed production, seed germination and offspring ploidy levels were analysed after controlled hand-pollinations to assess self- and morph-incompatibility and production of viable gametes by the 5x S-morph. The self-incompatibility system is still operating, but a partial breakdown in the morph-incompatibility system combined with the production of viable gametes was observed, allowing sexual reproduction of the 5x S-morph in the invaded range. The ability of the 5x S-morph to reproduce sexually may have major consequences for the dynamics of invasive populations of O. pes-caprae and could be one of the factors involved in the occurrence of new floral morphs in this invaded range.

Quantifying reciprocity in distylous and tristylous plant populations

Reciprocal herkogamy (heterostyly) is an example of extreme relevance of accuracy of the location of the sexual organs within some floral systems. It involves the reciprocal positioning of anthers and stigmas in flowers of different plants within the same population, and the accuracy of this positioning is important to promote out-cross pollination, prevent self-interference, or both. Hence, several indices have been proposed to quantify reciprocity, most of them for populations with two different morphs (distylous). Here, we propose an extension of our index of reciprocity for distylous populations to be applied also to populations with three morphs (tristylous), allowing effective comparisons of reciprocity between tristylous, but also distylous populations. As for the distylous version, the index is based on comparison of the position of every single sexual organ in the sample with each and every organ of the opposite sex, for each of the three possible organ levels. Due to the massive amount of calculations required, a macro was developed that is available as Supplementary Information and at the website of the authors. The index and macro were tested on several hypothetical tristylous and distylous populations with predetermined mean and dispersion of sexual organs at each level, as well as on several actual tristylous and distylous populations. The index proposed is a solid tool for the study of reciprocity in distylous and tristylous populations. Comparisons between distylous and tristylous populations are easily performed and can be readily interpreted. The applicability of the index is facilitated through the software provided.

Optimization of self-coherent reflective PON to achieve a new record 42 dB ODN power budget after 100 km at 1.25 Gbps

We demonstrate a greater than 42 dB optical distribution network power budget in the upstream of a 1.25 Gbps self-coherent reflective PON after 100 km of installed fibers, using off-the-shelf optoelectronic components, improving our previous result by 4 dB. We discuss all system optimizations introduced in the setup in order to reach such a result, including 8B/10B high-pass filtering and Faraday rotation at the ONU.

Characterization of uncooled RSOA for upstream transmission in WDM reflective PONs

We investigate on the uncooled RSOA driving parameters in WDM reflective PONs, focusing on an upstream path at 1.25 Gbit/s using pure binary modulation. We show how the optimal values change using direct-detection or self-coherent receivers. In particular, for the latter, the driving point optimization allows a gain of more than 3 dB in terms of ODN loss compared to a standard On-Off Keying, generating a quasi-PSK modulation. We also address operating temperature and wavelength dependence issues.

Unusual heterostyly: style dimorphism and self-incompatibility are not tightly associated in Lithodora and Glandora (Boraginaceae)

BACKGROUND AND AIMS

Heterostyly is a floral polymorphism characterized by the reciprocal position of stamens and stigmas in different flower morphs in a population. This reciprocal herkogamy is usually associated with an incompatibility system that prevents selfing and intra-morph fertilization, termed a heteromorphic incompatibility system. In different evolutionary models explaining heterostyly, it has been alternately argued that heteromorphic incompatibility either preceded or followed the evolution of reciprocal herkogamy. In some models, reciprocal herkogamy and incompatibility have been hypothesized to be linked together during the evolution of the heterostylous system.

METHODS

We examine the incompatibility systems in species with different stylar polymorphisms from the genera Lithodora and Glandora (Boraginaceae). We then test whether evolution towards reciprocal herkogamy is associated with the acquisition of incompatibility. To this end, a phylogeny of these genera and related species is reconstructed and the morphological and reproductive changes that occurred during the course of evolution are assessed.

KEY RESULTS

Both self-compatibility and self-incompatibility are found within the studied genera, along with different degrees of intra-morph compatibility. We report for the first time extensive variability among members of the genus Glandora and related species in terms of the presence or absence of intraspecies polymorphism and heteromorphic incompatibility. Overall, our results do not support a tight link between floral polymorphism and incompatibility systems.

CONCLUSIONS

The independent evolution of stylar polymorphism and incompatibility appears to have occurred in this group of plants. This refutes the canonical view that there is strong linkage between these reproductive traits.

Reciprocal style polymorphisms are not easily categorised: the case of heterostyly in Lithodora and Glandora (Boraginaceae)

Interest in reciprocal floral polymorphisms, such as heterostyly, has increased in recent decades because they can be used as suitable model systems to study mechanisms of outbreeding and disassortative mating in plants. Heterostylous plants are characterised by the presence of discrete morphs that differ in sex organ position and in some other ancillary traits. As regards sex organ deployment, different types of polymorphisms have been described, depending on number and type of discrete classes present in populations and degree of reciprocity between them. However, a clear-cut characterisation of stylar polymorphisms does not appear to be the best approach when there is great variability among populations because of continuous variation of some of traits examined. A recent study in Lithodora sensu lato (recently split into two separate genera, Lithodora and Glandora) showed a wide variation in sex organ position across species in the genus, which warrants precise population analysis of stylar polymorphism and its reciprocity. We provide a detailed morphometric analysis of flower sexual traits and include those considered to be ancillary characters. We report a wide variation in these traits in populations of Lithodora s.l. and highlight the subjectivity of the former characterisation of style polymorphism based on visual inspection. Ancillary traits appear repeatedly in Lithodora and Glandora, particularly in the latter. The appearance of these traits seems to be related to greater reciprocity between sexual whorls in Glandora, with the exception of G. prostrata. These results agree with evolutionary steps proposed in the build-up of heterostyly according to some evolutionary models. We also examined variation in polymorphisms in light of current models for evolution of heterostyly, and, more specifically, we sought to verify the prediction that flower traits as a whole (i.e., flower integration) respond to selective pressure to assure the exact location of pollen on the pollinator body. Most reciprocal populations and species, where between-morph pollen transfer is expected to be higher, would show greater integration. Our results confirm this hypothesis.

Patterns of style polymorphism in five species of the South African genus Nivenia (Iridaceae)

BACKGROUND AND AIMS

Heterostylous plants have been characterized by the presence of two or three discrete morphs that differ in their sex organ position within populations. This polymorphism is widely distributed among the angiosperms, but detailed studies are limited to few taxonomic groups. Although a small representation, evolutionary meaningful variations of the heterostylous syndrome have been reported when precise measurements of the sexual whorls were taken. A thorough exploration of groups where heterostyly has been reported should offer new opportunities to further testing the evolutionary hypotheses explaining heterostyly. Here, the traits defining heterostyly were explored in half of the species in Nivenia, the only genus of Iridiaceae where heterostyly has been reported.

METHODS

Detailed morphometric analysis of the flower sexual whorls and some traits considered as ancillary are supplied to determine for each population (a) the kind of stylar polymorphism, (b) the morph ratio and (c) the degree of reciprocity between sexual whorls. Also the rates of assortative (within morph) versus disassortative (between morphs) pollen transfer were estimated by analysing pollen loads on stigmas. The association between floral phenotypic integration and the reciprocity between sexual whorls was estimated; both characteristics have been quoted as dependent on the accuracy of the fit between pollinators and flowers and therefore related to the efficiency of pollen transfer.

KEY RESULTS

Different types of polymorphism, differing in their degree of reciprocity, were found in Nivenia. Effective disassortative mating appears to be common, since (a) all dimorphic populations show equal morph-ratios (isoplethy), and (b) the pollen placed on the stigmas of each morph is likely to be coming from the other (complementary) morph. The most reciprocal populations of the heterostylous species have also the highest values of phenotypical integration.

CONCLUSIONS

Stigma height dimorphism, as opposed to distyly, is proven for the first time in Nivenia. The presence of different types of polymorphism within the genus is consistent with hypotheses of the evolution of heterostyly. The role of the pollinators as the leading force of the transition seems to be apparent, since floral integration is related to reciprocity.

Tobacco smoke affects expression of peroxisome proliferator-activated receptor-gamma in monocyte/macrophages of patients with coronary heart disease

BACKGROUND AND PURPOSE

Tobacco smoke represents a relevant risk factor for coronary heart disease (CHD). Although peroxisome proliferator-activated receptor (PPAR)gamma activation reduces inflammation and atherosclerosis, expression of PPARgamma in cells and its modulation by smoking are poorly investigated. We previously reported that monocyte/macrophages from healthy smokers exhibited an enhanced constitutive expression of PPARgamma. Here, we evaluated PPARgamma expression and basal cytokine release in monocytes and monocyte-derived macrophages (MDMs) from 85 CHD patients, classified by their smoking habit (smokers, non-smokers and ex-smokers), and assessed the role of PPARgamma ligands in this context.

EXPERIMENTAL APPROACH

PPARgamma protein was detected by Western blot and semi-quantified by PPARgamma/beta-actin ratio; cytokine release was measured by elisa and nuclear factor-kappaB (NF-kappaB) translocation by electrophoretic mobility shift assays.

KEY RESULTS

As compared to the other groups, MDMs from smoker CHD patients exhibited a reduced PPARgamma/beta-actin ratio and an increased spontaneous release of tumour necrosis factor-alpha (TNF-alpha) and interleukin-6, but with no major variations in monocytes. In cells from selected CHD patients, rosiglitazone inhibited TNF-alpha release and NF-kappaB translocation induced by phorbol-12-myristate 13-acetate. The selective PPARgamma antagonist GW9662 reversed these effects, with some variations related to smoking habit.

CONCLUSIONS AND IMPLICATIONS

In CHD patients, exposure to tobacco smoke profoundly affected PPARgamma expression, and this was related to levels of secretion of pro-inflammatory cytokines. MDMs from CHD smokers showed the lowest PPARgamma expression and released more inflammatory cytokines. Moreover, rosiglitazone's ability to inhibit cytokine release and its reversal by GW9662 clearly indicated PPARgamma involvement in these changes in CHD patients.

Optical Phase locking techniques: an overview and a novel method based on single side sub-carrier modulation

A short overview on Optical Phase locking techniques and a detailed description of the Phase Locking technique based on Sub-Carriers modulation is presented. Furthermore, a novel Single Side Sub-Carrier-based Optical Phase Locked Loop (SS-SC-OPLL), with off the shelf optical components, is also presented and experimentally demonstrated. Our new method, based on continuous wave semiconductor lasers and optical single side sub-carrier modulation using QPSK LiNbO(3) modulator, allows a practical implementation with better performance with respect to the previously proposed OPLL circuits, and permits an easy use in real time WDM signal coherent demodulation.

Cochlear blood flow modifications induced by anaesthetic drugs in middle ear surgery: comparison between sevoflurane and propofol

OBJECTIVE

Because it is necessary to maintain controlled hypotension during middle ear surgery in order to avoid bleeding and as it is known that cochlear blood flow (CBF) is related to blood pressure (BP), it is useful to evaluate CBF modifications induced by anaesthetics in order to prevent cochlear damage. The aim of this paper is to evaluate, using laser Doppler flowmetry, which anaesthetic drug, out of sevoflurane and propofol, has the smallest effect on CBF.

MATERIAL AND METHODS

Twenty consenting adult patients scheduled for myringoplasty under general anaesthesia for simple tympanic membrane perforation were studied. Patients were divided into two groups: the first group was treated with sevoflurane and the second with propofol. For the first group, CBF measurement was carried out on three different occasions: (i) at a basal low drug dosage; (ii) having increased the drug dosage to a higher level; and (iii) having reduced the drug dosage to the basal low level again. For the second group, CBF measurement was carried out on three different occasions: (i) 10 min after injecting a bolus of propofol; (ii) immediately after a second propofol injection; and (iii) 10 min after a third injection of propofol. A probe was placed over the promontory in order to measure CBF levels.

RESULTS

In the subjects treated with sevoflurane, after having increased the drug dosage, BP decreased significantly while CBF did not change significantly. In the subjects treated with propofol we recorded a significant reduction in BP, as well as a decrease in CBF.

CONCLUSION

The results obtained show that sevoflurane has a hypotensive effect without modifying CBF, while propofol, although having a similar effect on BP to sevoflurane, has less of a protective effect on inner ear microcirculation.

Angiographical follow-up after radioactive "Cold Ends" stent implantation: a multicenter trial

BACKGROUND

Radioactive stents with an activity of 0.75 to 12 microCi have shown >40% edge restenosis due to neointimal hyperplasia and negative remodeling. This trial evaluated whether radioactive Cold Ends stents might resolve edge restenosis by preventing remodeling at the injured extremities.

METHODS AND RESULTS

The 25-mm long (15-mm radioactive center and 5-mm nonradioactive ends) Cold Ends stents had an activity of 3 to 12 microCi at implantation. Forty-three stents were implanted in 43 patients with de novo native coronary artery disease. Two procedural, 1 subacute, and 1 late stent thrombosis occurred. A restenosis rate of 22% was observed with a shift of the restenosis, usually occurring at the stent edges of radioactive stents, into the Cold Ends stents. The most severe restenosis occurred at the transition zone from radioactive to nonradioactive segments, a region located in dose fall-off.

CONCLUSION

Cold Ends stents did not resolve edge restenosis.

Surgery of otosclerosis in the elderly

Auditory results following stapes surgery in 26 patients with otosclerosis >60 years of age at the time of surgery were compared with those obtained in 140 patients <60 years undergoing stapes surgery during the same time period. Stapedotomy was performed in all cases. The mean follow-up period was 29 months. Hearing results as judged by postoperative air-bone gaps were as good in the older age group as in the younger patients. Moreover, complications of surgery, such as postoperative formation of perilymphatic fistula, did not occur more frequently in elderly vs younger patients. On the basis of the results obtained, it is concluded that stapes surgery should be offered to elderly patients with the same indications as younger patients with otosclerosis.

Pharyngocutaneous fistula as a complication of total laryngectomy: review of the literature and analysis of case records

Pharyngocutaneous fistula is the most common complication of total laryngectomy. The management of this problem increases hospitalization time and delays initiation of postoperative radiotherapy, where indicated. To identify factors predisposing to the development of pharyngocutaneous fistula, we reviewed the postoperative courses of 293 patients who underwent total laryngectomy at our clinic. General factors taken into account were concurrent diseases such as diabetes, liver diseases, or chronic anemia; local factors included radiotherapy before and after surgery, preoperative tracheostomy, type of cervical lymph node removal, and method of pharyngeal closure. We then compared our data with those reported in the literature by other authors. Last, we applied the Fisher exact test to a correlation we found between the higher incidence of fistula in patients with diabetes, liver diseases, or anemia. The local factor that turned out to be statistically most significant for the development of fistula was preoperative radiotherapy.

Problems in reconstructive surgery in the treatment of carcinoma of the hypopharyngoesophageal junction

BACKGROUND AND OBJECTIVES

Thirty percent of carcinomas of the pyriform sinus manifest generally with infiltrations in the cervical esophagus. In recent years, progress in reconstructive surgery has broadened surgical indications to include tumors previously managed with palliative measures alone. In some cases, radical surgery has been extended to creating safer resection margins, with more and more indications for circular pharyngectomy. Lesions involving the hypopharyngoesophageal junction pose particular problems; furthermore, the high rate of synchronous or metachronous tumors warrants the indication for total esophagectomy, which requires complex reconstructive techniques.

METHODS

We report on a series of 21 patients who underwent pharyngocoloplasties after receiving total pharyngolaryngoesophagectomy.

RESULTS

With regard to the oncologic results, after a follow-up of 2-60 months, 9 patients had no evidence of disease, 5 patients died during the postoperative course, 2 patients survived with disease, 4 died with disease, 1 died from metachronous breast carcinoma, and 7 underwent reintervention.

CONCLUSIONS

In cases in which reconstruction by gastric pull-up is considered risky, if not contraindicated, pharyngocoloplasty represents a particularly reliable treatment option. The limits and advantages of the technique are discussed. The procedure permitted us to reconstruct the digestive tract, without encountering problems any more serious than those a normal gastric pull-up procedure would pose.

Problems in reconstructive surgery in the treatment of carcinoma of the hypopharyngoesophageal junction

BACKGROUND AND OBJECTIVES

Thirty percent of carcinomas of the pyriform sinus manifest generally with infiltrations in the cervical esophagus. In recent years, progress in reconstructive surgery has broadened surgical indications to include tumors previously managed with palliative measures alone. In some cases, radical surgery has been extended to creating safer resection margins, with more and more indications for circular pharyngectomy. Lesions involving the hypopharyngoesophageal junction pose particular problems; furthermore, the high rate of synchronous or metachronous tumors warrants the indication for total esophagectomy, which requires complex reconstructive techniques.

METHODS

We report on a series of 21 patients who underwent pharyngocoloplasties after receiving total pharyngolaryngoesophagectomy.

RESULTS

With regard to the oncologic results, after a follow-up of 2-60 months, 9 patients had no evidence of disease, 5 patients died during the postoperative course, 2 patients survived with disease, 4 died with disease, 1 died from metachronous breast carcinoma, and 7 underwent reintervention.

CONCLUSIONS

In cases in which reconstruction by gastric pull-up is considered risky, if not contraindicated, pharyngocoloplasty represents a particularly reliable treatment option. The limits and advantages of the technique are discussed. The procedure permitted us to reconstruct the digestive tract, without encountering problems any more serious than those a normal gastric pull-up procedure would pose.

[Functional results in the reconstruction of the ossicular chain in partial or total atrophy of the incus. Comparison between reconstruction using a moulded incus and hydroxyapatite PORP]

Ossicular chain defects modifying sound transmission through the middle ear can be treated with (re)implantation of remodeled autologous o homologous ossicles. In recent years, thanks to improved biocompatibility of the materials on the market, prostheses have been increasingly used in the partial or total ossicular chain reconstruction. The present study evaluates auditory ossicle reconstruction as a result of partial or total atrophy of the incus, comparing the use of the remodeled autologous incus with the use of partial hydroxyapatite prostheses (PORP). The study involved 79 patients of which 59 (74.7%) underwent ossicular chain reconstruction using a remodeled, inverted autologous incus while in the remaining 20 cases (25.3%) a hydroxyapatite prosthesis (PORP) was used. The effectiveness of the ossicular chain was evaluated by comparing pre- and postoperative audiometry and evaluating the average thresholds at frequencies of 0.5, 1, 2 and 3 KHz. The average preoperative audiometric gap (understood as the relationship between the air-bone gap) was 23 dB (Standard Deviation 11.2) while postoperatively it was 11 dB (SD 8.5) (p < 0.0001). Therefore the improvement in the air-bone gap was 12 dB (SD 11) for the overall population: 13 dB (SD 10) in those cases where reconstruction was performed using a remodeled incus and 8 dB (SD 11) when PORP was used. The postoperative cumulative gap between the air and bone pathways fell between 0 and 20 dB in 84% of the total population: 89% of those reconstructed with a remodeled incus and 73% of those using PORP. The middle ear ossicular chain reconstruction was performed using remodeled, inverted autologous incus in those cases where ossicular damage did not compromise its use while prostheses made of a biocompatible material (hydroxyapatite PORP) were reserved for those cases where the incus was absent or severely worn. The results obtained are satisfactory, remained stable in time and reflect the average values reported in the Literature.

Angiographic follow-up after coronary implantation of the Multilink stent: a prospective observation

BACKGROUND

A growing variety of coronary stents is becoming available on the market. Results of randomized trials may be difficult to apply to less selected patients, and experience with every device cannot be obtained in every center. Detailed information about the immediate and long-term results achieved with one device can be a helpful reference for interventional cardiologists. The aim of this study was to test the applicability and the clinical and angiographic results, both immediate and at 6 months, of the Multilink coronary stent in a cohort of unselected patients undergoing coronary angioplasty.

METHODS

From March 1997 to June 1998 coronary angioplasty was performed in 391 patients in our center, with the use of stents in 339 patients.

RESULTS

Three hundred and seventeen Multilink stents were successfully implanted in 295 lesions in 277 patients; an acute coronary syndrome was present in 209 cases (75%), and lesion types B2 and C accounted for 30% of lesions. In 7 cases (2.4%) the Multilink stent did not cross the lesion, and another device was implanted. Subacute stent occlusion occurred in 1 patient (0.36%) after primary angioplasty. After 6 months from the procedure, clinical follow-up data were available for 252 out of 254 patients: none had died, and angina or myocardial ischemia occurred in 25 patients (9.9%). A control angiogram was performed in 239 out of 254 patients (94%) at 178 +/- 34 days. Restenosis occurred in 44/239 patients (18.4%) and in 48/247 lesions (19.4%). In patients with vs without restenosis the original lesion was longer (p = 0.009), and diabetes mellitus was more frequent (p = 0.002), as was the use of multiple stents (p = 0.005). In single 15, 25 and 35 mm long stents restenosis occurred in 13.9, 15.5 and 46.2% of cases, respectively (p = NS).

CONCLUSIONS

The Multilink stent showed a low rate of subacute occlusion (0.36%) and could be used safely also in patients with acute coronary syndromes. The use of a single, 15 or 25 mm long Multilink stent was associated with a low angiographic recurrence rate (14-16%).

Pulmonary artery hypertension in adult patients with symptomatic valvular aortic stenosis

Pulmonary hypertension (PH) has been reported in patients with valvular aortic stenosis (AS) and has been found to be associated with a more severe clinical picture and a poor prognosis after aortic valve replacement. The aim of this study was to assess the prevalence of PH in adult patients with symptomatic AS undergoing cardiac catheterization, and to evaluate the relation between pulmonary artery (PA) systolic pressure and hemodynamic and clinical variables to further clarify the pathogenetic mechanisms. We assessed right-sided heart hemodynamics during cardiac catheterization in 388 patients with symptomatic isolated or predominant AS. PA systolic pressure between 31 and 50 mm Hg was used to define mild to moderate PH, whereas PA systolic pressure >50 mm Hg was used to define severe PH. PA systolic pressure showed no significant difference according to age and sex, although it was significantly higher in patients in New York Heart Association functional classes III and IV and in patients with coexistent systemic hypertension than in the others. PH was absent in 136 patients (35%, group 1), mild to moderate in 196 patients (50%, group 2), and severe in 58 patients (15%, group 3). Only the prevalence of overt heart failure was significantly higher in group 3 patients. AS severity was similar among the 3 groups, and PA systolic pressure showed no relation to aortic valve area in the entire population. Also, a poor correlation was found between PA pressure and left ventricular (LV) ejection fraction (r = -0.28), with several patients having moderate or severe PH despite a preserved LV systolic function. PA systolic pressure significantly correlated with LV end-diastolic pressure (r = 0.50) and with PA wedge pressure (r = 0.84). Furthermore, transpulmonary pressure gradient, an index of resistance across the pulmonary vascular bed (obtained as the difference between PA mean and PA wedge pressure), was significantly higher in patients with PH, especially in those with a marked increase in PA systolic pressure, suggesting a reactive component of PH.

Comparison of thrombolytic therapy and primary coronary angioplasty with liberal stenting for inferior myocardial infarction with precordial ST-segment depression: immediate and long-term results of a randomized study

OBJECTIVES

The aim of the study was to compare randomly assigned primary angioplasty and accelerated recombinant tissue plasminogen activator (rt-PA), in patients with "high-risk" inferior acute myocardial infarction (ST-segment elevation in the inferior leads and ST-segment depression in the precordial leads).

BACKGROUND

The ST-segment depression in the precordial leads is a marker of severe prognosis in patients with inferior myocardial infarction. The comparative outcome of treatment with primary angioplasty or lysis with accelerated rt-PA has not been investigated.

METHODS

One hundred and ten patients within 6 h of symptoms were randomized to either treatment. To assess the in-hospital and 1-year outcome of both treatments the following results were compared: death or nonfatal infarction, recurrence of angina, left ventricular ejection fraction (LVEF), and the need for repeat target vessel revascularization (TVR).

RESULTS

In patients treated with angioplasty (55) and rt-PA (55) the rate of in-hospital mortality and reinfarction was 3.6% versus 9.1% (p=0.4). Recurrence of angina was 1.8% versus 20% (p=0.002), new TVR was used in 3.6% versus 29.1% (p=0.0003), and the LVEF (%) at discharge was 55.2+/-9.5 versus 48.2+/-9.9 (p=0.0001). There were no hemorrhagic strokes, no emergency coronary artery bypass graft (CABG) and identical (5.5%) need for blood transfusions. At 1 year, the incidence of death, reinfarction or repeat TVR was 11% in the percutaneous transluminal coronary angioplasty (PTCA) group versus 52.7% in the rt-PA group (log-rank 22.38, p < 0.0001).

CONCLUSIONS

Primary angioplasty is superior to accelerated rt-PA in terms of both myocardial preservation and reduction of in-hospital complications in patients with inferior myocardial infarction and precordial ST-segment depression. Primary angioplasty also yields a better long-term event-free survival.

[Myringoplasty in children: a comparison with an adult population]

The indications for myringoplasty in children has always been a controversial subject since many authors feel the high frequency of the phlogistic auricular processes in children constitute an unfavorable prognostic factor to success of the procedure. The authors present the results obtained in 23 patients under 17 years of age who had undergone myringoplasty for simple perforation of the tympanum. In cases of posterior and inferior perforations, surgery was performed using the underlay technique and a transmeatal approach; in all other cases the overlay technique was used with a retroauricular approach. An average 30 month follow-up (range 12-55 months) revealed new perforations in only 2 cases (9%). From the functional point of view the average air/bone conduction gap was reduced to 10 dB. As a control, the results were compared to those obtained in 150 patients over 16 years of age, again affected by simple perforation of the tympanic membrane and treated by myringoplasty using the same methods. In the adults, 22 new perforations were found (15%) while the functional results were analogous to those obtained in the children group. In this light, it can be asserted that myringoplasty can be considered a safe procedure to be used in children and it does not appear essential to wait until they have finished growing before performing this procedure.

Plasma lipoprotein(a) is not a predictor for restenosis after elective high-pressure coronary stenting

BACKGROUND

Lipoprotein(a) is a risk factor for coronary artery disease. Although it has been implicated in restenosis after balloon angioplasty, its role in restenosis within coronary stents is unknown. The aim of the study was to assess the role of plasma lipoprotein(a) as a predictor for restenosis after elective coronary stenting.

METHODS AND RESULTS

Elective, high-pressure stenting of de novo lesions in native coronary arteries with Palmaz-Schatz stents was performed in 325 consecutive patients. Clinical, angiographic, and biochemical data were analyzed prospectively. Angiographic follow-up was performed at 6 months. Lipoprotein(a) levels were compared in patients with and without restenosis. Angiographic follow-up was obtained in 312 patients (96%); recurrence was observed in 67 patients (21.5%). No clinical or biochemical variable was associated with restenosis. Lipoprotein(a) level was 37.81+/-49. 01 mg/dL (median, 22 mg/dL; range, 3 to 262 mg/dL) in restenotic patients and 36.95+/-40.65 mg/dL (median, 22 mg/dL; range, 0 to 244 mg/dL) in nonrestenotic patients (P=NS). The correlations between percent diameter stenosis, minimum luminal diameter, and late loss at follow-up angiography and basal lipoprotein(a) plasma level after logarithmic transformation were 0.006, 0.002, and 0.0017, respectively. Multiple stents were associated with a higher incidence of restenosis (P=0.006), but biochemical data in these patients were similar to those treated with single stents.

CONCLUSIONS

The basal plasma level of lipoprotein(a) measured before the procedure is not a predictor for restenosis after elective high-pressure coronary stenting.

[Primary angioplasty in acute inferior myocardial infarct with anterior ST-segment depression: the long-term follow-up]

BACKGROUND

Concomitant anterior ST-segment depression is a marker of severe prognosis in inferior myocardial infarction.

PATIENTS AND METHODS

Prospective observational study in patients with inferior acute myocardial infarction and ST-segment depression > or = 4 mm in the anterior leads, who were treated with primary angioplasty. Angiography was performed at hospital discharge and at six months, and a clinical follow-up was obtained at one year after the infarction.

RESULTS

Sixty-three patients were included in the study. Pre-hospital and in-hospital delay were 147 +/- 70 minutes (20-355) and 54 +/- 11 minutes (18-80), respectively. Angioplasty was successful in all patients and 48 stents were implanted in 36 patients (57%). Angiography was performed at hospital discharge in 55 patients (87%) and showed a TIMI grade 3 coronary flow in the infarct-related artery in all cases. The left ventricular ejection fraction was 0.55 +/- 0.09 (0.4-0.8). One patient (1.6%) died before discharge, two (3.2%) had ischemic complications (one had non-fatal reinfarction, another had recurrent angina at rest), and three (4.9%) had local vascular complications. At the six-month follow-up, none of the patients had died. One had suffered reinfarction (1.6%) and another had been readmitted for recurrence of angina at rest (1.6%); none had symptoms of stable angina. The ejection fraction was 0.56 +/- 0.12 and eight patients (14%) showed angiographic restenosis. At twelve months, two patients had died (1.6%) and five (8%) had required readmission to hospital.

CONCLUSIONS

Primary angioplasty yielded favorable results in this group of patients. Our data confirm the efficacy of primary angioplasty for the treatment of acute myocardial infarction, with a low rate of clinical (3.2%) and angiographic (14%) restenosis at six months, and a high rate (87%) of event-free survival at one year follow-up.

Early aggressive treatment of unstable angina without on-site cardiac surgical facilities: a prospective study of acute and long-term outcome

BACKGROUND

The early invasive diagnostic approach with extensive use of myocardial revascularization in patients with unstable angina is a matter of debate. Both the advantages of this strategy and the choice of the best candidates are controversial. The widespread applicability of this approach in Italian hospitals is also questionable, due to limited availability of facilities for interventional cardiology.

METHODS

A prospective, observational study was done on a cohort of consecutive patients, who were admitted with a diagnosis of unstable angina and treated with an early aggressive approach at a center with interventional cardiology facilities without cardiac surgery. The aim of the study was to evaluate both the immediate and long-term clinical outcome of patients and the efficiency of our therapeutic approach.

RESULTS

Two-hundred and two patients were enrolled and 85% were in Braunwald class III. Coronary angiography was performed in 171 patients (85%) at 2.1 +/- 2.4 days after admission: it showed one-, two- and three-vessel disease in 40, 29 and 22% of cases, respectively; 9% of patients had no severe coronary lesion. Left ventricular ejection fraction was 0.58 +/- 0.13. Medical treatment, coronary by-pass surgery and percutaneous myocardial revascularization were chosen in 36, 24 and 40% of cases, respectively. Coronary angioplasty was performed in our center in 58 (73%) of 80 patients at 6.8 +/- 5.6 days after admission and stents were used in 42 cases (74%). Overall hospital stay was 10.4 +/- 4 days. Cumulated adverse events (death and non-fatal myocardial infarction) occurred in 2.5 and 7% of patients during the initial admission and in the following year, respectively.

CONCLUSIONS

An early aggressive approach to patients with unstable angina is feasible in a hospital with interventional cardiology in the absence of cardiac surgical facilities. The immediate favorable clinical results of this strategy in an intermediate-risk cohort seem to persist at one-year follow-up.

Prevalence of late potentials after myocardial infarction treated with systemic thrombolysis or primary percutaneous transluminal coronary angioplasty

BACKGROUND

The presence of late potentials (LP) after myocardial infarction (MI) is related to an occluded infarct-related coronary artery (IRA). However, the effects of the signal-averaged electrocardiogram (SAECG) of systemic thrombolysis are contradicting. Reperfusion in the IRA is more frequently observed after primary percutaneous transluminal coronary angioplasty (PTCA) than after systemic thrombolysis. The aim of this prospective study was to compare the prevalence of LP in survivors of acute MI treated with either systemic thrombolysis or primary PTCA.

METHODS

Between October 1994 and January 1997, 134 patients (pts) with acute MI were treated with reperfusion therapy within 12 hours of the onset of symptoms: seventy-four pts received systemic thrombolysis and 60 underwent primary PTCA. All pts (mean age 61 +/- 10 years, 120 males) had a control coronary angiography 9 +/- 5 and 10 +/- 4 days after acute MI, respectively. The recorded signals were amplified, averaged and filtered with bi-directional Butterworth filtering (band-pass filter range of 40-250 Hz). LPs were defined as the presence of 2 or 3 of the following criteria: filtered duration of the QRS complex > 114 ms, root mean square voltage of signals in the last 40 ms of the QRS < or = 20 mV and duration of the low amplitude signals > 38 ms.

RESULTS

The two groups of pts did not differ significantly with respect to age, gender, presence of either diabetes or hypertension, site of MI, previous MI, Killip class, time to treatment, peak CK-MB level, incidence of reinfarction, extent of coronary artery disease and left ventricular ejection fraction. One hundred pts (75%) had patency (TIMI 3 grade flow) of the IRA at control coronary angiography. Twenty-seven pts (20%) had LP: 16 pts (22%) among those treated with systemic thrombolysis and 11 pts (18%) among those treated with primary PTCA (p = ns). Pts treated with primary PTCA had higher patency rates [95% (57/60) vs 58% (43/74); p = 0.00002] and less severe residual stenosis (19 +/- 15% vs 72 +/- 18%; p = 0.0001) in the IRA. LP were found in 15 pts (15%) with TIMI 3 grade flow and in 12 pts (35%) with TIMI 0-2 grade flow (p = 0.017). By multivariate analysis, including 18 clinical and electrocardiographic variables, an occluded IRA was the only independent predictor of the development of LP (Wald chi 2: 6.1453; p = 0.0132).

CONCLUSION

Results of this prospective study suggest that primary PTCA alone does not reduce the prevalence of LP when compared to systemic thrombolysis. Only the patency of the IRA, as determined before the hospital discharge, affected the development of LP after acute MI.

[Effects on high resolution electrocardiogram of coronary angioplasty in acute myocardial infarct]

BACKGROUND

The lower prevalence of ventricular late potentials (LPs) in signal-averaged electrocardiograms (SAECG) observed in patients (pts) treated with systemic thrombolysis, as compared with SAECGs in conventionally treated pts, has been attributed to the patency of the infarct-related artery. Mechanical reperfusion, achieved by means of either primary or rescue percutaneous transluminal coronary angioplasty (PTCA), is associated with higher permeability rates and reduced residual stenosis in the infarct-related artery, when compared to systemic thrombolysis. The aim of this retrospective study was to assess the prevalence of LPs in pts recovering from a first high-risk acute myocardial infarction (AMI) treated with primary or rescue PTCA.

METHODS

Fifty-nine pts (48 pts with clinical signs or electrocardiographic evidence of high-risk AMI or in whom systemic thrombolysis was inadvisable, and 11 pts in whom systemic thrombolysis failed) underwent emergency PTCA within 10 hours of the onset of symptoms. All pts (mean age 61 +/- 9 years, 48 M) were monitored via coronary angiography 9 +/- 4 days after AMI. The SAECG was obtained 10 +/- 4 days after AMI. LPs were defined as the presence of 2 or 3 of the following criteria: filtered duration of the QRS complex > 114 ms, duration of the low amplitude signals > 38 ms and mean square-root voltage of signals in the last 40 ms of the QRS < or = 20 microV.

RESULTS

Primary and rescue PTCA were performed 3 +/- 1.7 and 6.3 +/- 2 hours after AMI, respectively (p = 0.000). Fifty-six pts (95%) had patency (TIMI 3 grade flow) of the infarct-related artery (mean residual stenosis: 18.3 +/- 14.2%) confirmed by control coronary angiography, while the infarct-related artery was occluded in three pts. Sixteen out of 59 pts (27%) had LPs: 14/56 (25%) with TIMI 3 grade flow and 2/3 (67%) with TIMI 0 grade flow. Pts with and without LPs were comparable for age, sex, infarct location, Killip Class, mean peak CK-MB, time to control coronary angiography, time to SAECG, left ventricular ejection fraction, presence of multivessel disease, infarct-related artery and mean residual stenosis in infarct-related artery. LPs were observed more frequently after rescue PTCA than after primary PTCA (64 vs 19%; p = 0.005). Time to treatment was significantly longer in pts with LPs than in those without (4.9 +/- 2.6 vs 3.2 +/- 1.7 hours; p = 0.025). Multivariate analysis indicated that the type of PTCA (primary vs rescue PTCA) was the only independent predictor for the development of LPs.

CONCLUSION

In this study, the prevalence of LPs in pts with patency of the infarct-related artery after primary or rescue PTCA was surprisingly high. Delay to treatment and type of PTCA affected the presence of LPs. The association between infarct-related artery status and prevalence of LPs has not been analyzed, due to the low number of pts with coronary artery occlusion in the control coronary angiography.

[The use of indwelling phonatory valve in the rehabilitation of laryngectomized patients: preliminary results in 30 patients]

The creation of a tracheo-esophageal fistula, and subsequent positioning of a voice button, has greatly improved the patients' ability to communicate and is the treatment of choice for many. The literature indicates that the success rate for this technique is in the 56-90% range. The present study presents the preliminary results obtained in a group of 30 laryngectomy patients for whom a Provox or Blom-Singer-Indwelling voice button were inserted at a later date. Of these 21 (70%) had undergone pre- or post-operative radiotherapy. On the average insertion of the voice button took place 36 months after the laryngectomy while it was approximately 40 months after radiotherapy. Patient selection was based on widely accepted criteria. In particular, the following factors were take into consideration: patient motivation, positive Taub test, dynamic features of the esophageal wall, video fluoroscopy evaluation. For the Provox voice button the patient was hospitalized for 24 hours while with the Blom-Singer-Indwelling device it was 72 hours. In addition, with the latter device, oral feeding was restored somewhat later although this depends on the difference in positioning. The results of the present study are in line with those presented by other authors. In particular, the immediate success rate was 83% while the long-term success rate reached 96%.

[Annular wedge tympanoplasty: a variation of overlay myringoplasty]

Myringoplasty has been increasingly refined in recent years and today the most frequently employed are the "overlay", the "underlay" and the "interlay". Of these the overlay technique appears to best guarantee graft stability. However, with this technique there is the risk of blunting and neotympanum lateralization which can compromise functional recovery. To obviate these drawbacks, the authors propose a modification of the classical overlay technique. This modification consists of detachment of the anterior portion of the Gerlach annulus and the adjacent protympanum mucosa in order to insert the graft between the bony and fibrous portions of the annulus. This technique is defined as the "Annular Wedge Tympanoplasty" (AWT). From January 1993 to July 1994 a total of 74 tympanoplasties were performed using the AWT technique to reconstruct the tympanic membrane. In 71 (96%) of these, the opening closed completely. As regards incomplete healing, 2 cases showed signs of blunting, 3 showed posterior lateralization and 1 full lateralization with a reduction in the hearing level recovery. The work is not conclusive although it does present a technique which is easy to perform and which provides good functional recovery.

[Cervical mechanical anastomosis by transhiatal approach with a new circular stapler, Ehicon ECS 21]

Authors describe a new technique of mechanical cervical anastomosis using a new, particularly long, stapler, the ECS Ethicon. Mechanical anastomosis at neck level is difficult to perform with stapler now in use, so manual anastomosis is usually preferred. However the percentage of leakage is relatively high. The possibility of doing a mechanical anastomosis introducing the stapler through the pylorus is described. At the moment cases are too few to give a full evaluation of this new technique, but certainly it could be a valid alternative, safer and quicker, to manual anastomosis.

Prognostic factors for head and neck tumor recurrence

The introduction of new treatment methods has stimulated the identification of further prognostic factors capable of defining the clinical and biological characteristics of the tumor type in question and improving treatment programming. The aim of this study was to identify which characteristics of the host and tumor are of prognostic value in relation to the onset of locoregional tumor recurrence. A total of 396 patients were studied. The tumor site distribution can be summarized as follows: 267 laryngohypopharyngeal, 74 oropharyngeal, 55 oral cavity. Variables regarding patient, tumor and histology were evaluated for the purpose of analysis. Multivariate analysis of these prognostic factors was performed using PLR software by BMDP. Mean tumor recurrence time was 19 months. Seventeen of the 29 variables analysed did not influence the probability of tumor recurrence. Two variables reduced the risk of tumor recurrence: age > 61 years and abundant and prevalently lymphocytic intra-and peritumoral infiltrate. The study of tumor recurrence onset mechanisms is justified by its impact on the evolution of disease. The use of multivariate analysis in this study showed that some clinical and pathological characteristics of squamous cell carcinoma of the head and neck have a statistically significant impact on tumor recurrence.

[The evaluation of isoflurane's effect on the cochlear blood flow by laser doppler flowmetry]

Laser-Doppler flowetry is actually the method of choice in cochlear blood flow measurement. The Authors analyze, by means of laser doppler flowmetry, the effect of isoflurane, an anesthetic drug with an hypotensive effect, on cochlear blood flow on 10 patients submitted to miringoplasty. A slight increase of cochlear blood flow was recorded in each subject nevertheless a significative reduction of systemic pressure. Since normally hypotension determines a reduction of cochlear blood flow, the Authors state that isoflurane has a protective effect on this microcircular district.