Typical values of z-resolution for different Digital Breast Tomosynthesis systems evaluated in a multicenter study

PURPOSE

The aim of the present study, conducted by a working group of the Italian Association of Medical Physics (AIFM), was to define typical z-resolution values for different digital breast tomosynthesis (DBT) models to be used as a reference for quality control (QC). Currently, there are no typical values published in internationally agreed QC protocols.

METHODS

To characterize the z-resolution of the DBT models, the full width at half maximum (FWHM) of the artifact spread function (ASF), a technical parameter that quantifies the signal intensity of a detail along reconstructed planes, was analyzed. Five different commercial phantoms, CIRS Model 011, CIRS Model 015, Modular DBT phantom, Pixmam 3-D, and Tomophan, were evaluated on reconstructed DBT images and 82 DBT systems (6 vendors, 9 models) in use at 39 centers in Italy were involved.

RESULTS

The ASF was found to be dependent on the detail size, the DBT angular acquisition range, the reconstruction algorithm and applied image processing. In particular, a progressively greater signal spread was observed as the detail size increased and the acquisition angle decreased. However, a clear correlation between signal spread and angular range width was not observed due to the different signal reconstruction and image processing strategies implemented in the algorithms developed by the vendors studied.

CONCLUSIONS

The analysis led to the identification of typical z-resolution values for different DBT model-phantom configurations that could be used as a reference during a QC program.

Preoperative Radiotherapy of Soft Tissue Sarcoma with Simultaneous Integrated Boost: A Phase II Study

PURPOSE/OBJECTIVE(S)

Neoadjuvant radiotherapy to 50 Gy in 25 fractions is delivered in operable Soft Tissue Sarcoma (STS) patients to downstage the tumor and improve resectability, although at the expense of increased risk of wound dehiscence. Nonetheless, clear margin resection (R0) may not be achieved in tumors located in proximity of critical structures such as the neurovascular bundle (NVB), resulting in impaired local control. The aim of this study is to increase R0 rate through addition of an IMRT boost to the potential sites of suboptimal resection in STS patients receiving neoadjuvant RT. We report hereby the dosimetric results and safety results from the first 5 patients enrolled in this trial.

MATERIALS/METHODS

We designed a prospective monocentric interventional single-arm Phase II study enrolling locally advanced STS eligible for surgery. RT is administered in 25 daily fractions to include the MRI-based Gross Tumor Volume (GTV) and peritumoral tissue at risk of microscopic spread (CTV1) to a dose of 50 Gy (2Gy/fraction), with SIB (Simultaneous Integrated Boost) intensification to the tumor/dissection plane interface (CTV2) to a dose of 60 Gy (2.4 Gy/fraction). CTV2 delineation is approved by both a Radiation Oncologist and Surgeon. A margin of 0.5 cm is applied to both CTV to obtain PTV1 and PTV2. Concurrent anthracyclines-based chemotherapy (ChT) is allowed up to 3 cycles. Primary endpoint is R0 resection rate. Secondary endpoints include pathologic complete response rate, objective response rate, overall survival, local and distant progression-free survival, acute and chronic toxicity rate. To assess an increase in R0 rate from 81% to 97% assuming β = 80% e α = 0.05, 33 patients will be included. Dose constraints are summarized in Table1. At least 95% of the PTV1 and PTV2 should be covered by 95% the prescription dose up to a maximum allowed dose of 107%.

RESULTS

Five patients were included. Tumor was located in the limbs and in the trunk in respectively 4 and 1 patient. Mean age was 47 years (range: 19-67). Concurrent chemotherapy was performed in 2 patients. Mean GTV size was 228.6 cm3 (range: 59.8-314.5). Mean PTV coverage by the 95% of the dose prescription was 98% (95-100) and 97% (95-100) in PTV1 and PTV2, respectively. Mean PTV1 and PTV2 Dmax were 61.6 Gy (range: 59-63) and 64.1 Gy (range:63-66), in both cases below the 107% threshold. Mean Bone Dmax was 55 Gy (56.6-61.8 Gy). Dmax to the skin corridor exceeded 20 Gy in 1 patient (range 12.5-58.1). While the NVB was overlapping the PTV2 in all cases, Dmax was below 66 Gy. At the time of this report, no Grade ≥3 acute skin toxicity was observed. Two patients underwent surgery with a radiological partial response (RECIST) and pathological complete response. No major wound complication was reported.

CONCLUSION

Planning goals of the first 5 enrolled patients are achieved in most cases. Preliminary results show a benign safety profile and promising tumor response rate.

Clinical outcomes and predictors of success with Impella weaning in cardiogenic shock: a single-center experience

Introduction

Cardiogenic shock (CS) is a severe syndrome with poor prognosis. Short-term mechanical circulatory support with Impella devices has emerged as an increasingly therapeutic option, unloading the failing left ventricle (LV) and improving hemodynamic status of affected patients. Impella devices should be used for the shortest time necessary to allow LV recovery because of time-dependent device-related adverse events. The weaning from Impella, however, is mostly performed in the absence of established guidelines, mainly based on the experience of the individual centres.

Methods

The aim of this single center study was to retrospectively evaluate whether a multiparametrical assessment before and during Impella weaning could predict successful weaning. The primary study outcome was death occurring during Impella weaning and secondary endpoints included assessment of in-hospital outcomes.

Results

Of a total of 45 patients (median age, 60 [51-66] years, 73% male) treated with an Impella device, 37 patients underwent impella weaning/removal and 9 patients (20%) died after the weaning. Non-survivors patients after impella weaning more commonly had a previous history of known heart failure (p = 0.054) and an implanted ICD-CRT (p = 0.01), and were more frequently treated with continuous renal replacement therapy (p = 0.02). In univariable logistic regression analysis, lactates variation (%) during the first 12-24 h of weaning, lactate value after 24 h of weaning, left ventricular ejection fraction (LVEF) at the beginning of weaning, and inotropic score after 24 h from weaning beginning were associated with death. Stepwise multivariable logistic regression identified LVEF at the beginning of weaning and lactates variation (%) in the first 12-24 h from weaning beginning as the most accurate predictors of death after weaning. The ROC analysis indicated 80% accuracy (95% confidence interval = 64%-96%) using the two variables in combination to predict death after weaning from Impella.

Conclusions

This single-center experience on Impella weaning in CS showed that two easily accessible parameters as LVEF at the beginning of weaning and lactates variation (%) in the first 12-24 h from weaning begin were the most accurate predictors of death after weaning.

Fully Immersive Virtual Reality Using 360° Videos to Manage Well-Being in Older Adults: A Scoping Review

OBJECTIVE

The development of negative behavioral and psychosocial factors (depression, anxiety, apathy, etc) is associated with poor well-being, which can contribute to health issues in ageing, especially in the context of COVID-19. Despite its relative novelty, fully immersive virtual reality (VR) interventions through 360° immersive videos are becoming more accessible and flexible and constitute an emerging method to potentially enhance well-being. The aim of this scoping review is to assess the effectiveness of 360° interventions on well-being in older adults with or without cognitive impairment, as well as cybersickness and attitudes toward this technology.

DESIGN

Scoping review.

SETTING AND PARTICIPANTS

Older adults with or without cognitive impairment.

METHODS

The PRISMA-SR guideline was followed. Four databases were used, and we selected articles published until April 2022. We have analyzed the effect of 360° videos on the well-being of older adults with respect to the study design, the population, the contents, the duration of intervention, and the outcomes.

RESULTS

A total of 2262 articles were screened, of which 10 articles were finally included in this review. Most of them are pilot studies and used mixed methods including scales and interviews. The material and content of VR are diversified. Many behavioral and psychological outcomes were assessed, including anxiety, apathy, loneliness, depression, social engagement, quality of life, and emotions. The results were positive or mixed, according to the outcomes. We recorded few adverse events, and the interviews show contrasting results concerning the participants' feelings (ie, degree of immersion, familiarity with technology, and VR content).

CONCLUSIONS AND IMPLICATIONS

The use of VR 360° videos seems feasible in community-dwelling older adults or residential aged care facilities, as they are safe and provide enjoyment. It constitutes an emerging and promising therapeutic tool to manage psychosocial disorders. This review provides key considerations for the design and implementation of interventions using VR 360° video in clinical practice.

Temporal trend mortality and in-hospital mortality predictors in an ischemic cardiogenic shock population: a 10 years single-centre retrospective study

Background

Cardiogenic shock (CS) after acute myocardial infarction (AMI) is a life-threatening condition with an high rate of in-hospital mortality.

Purpose

This study aims to 1) describe predictors of in-hospital mortality; 2) evaluate ten years mortality temporal trend in our Cardiac Intensive Care Unit (CICU); 3) assess the feasibility of CARDSHOCK risk score in our population; 4) elaborate a simpler version of CARDSHOCK risk score.

Methods

All consecutive patients with CS after AMI admitted at our CICU from March 2012 to July 2021 were included in this single-centre retrospective study.

Results

We included 167 patients [males 67%; age 71 (61–80) years] with ischemic CS. Patients had severe LV dysfunction in 66%. Baseline serum lactate was 5.2 (3.1–8.8) mmol/L. All patients required inotropes: 71% required dopamine [mean dose 5.6 (2.4–11,3) mcg/kg/min], 65% required noradrenaline [mean dose 0.10 (0.05–0.18) mcg/kg/min], 32% required dobutamine [mean dose 4.5 (2.2–15.9) mcg/kg/min]; 17.4% received levosimendan alone [mean dose 0.1 mcg/kg/min]. Mechanical cardiac support (MCS) was pursued in 91.1% [65% IABP, 23% Impella CP, 4% VA-ECMO]. From March 2012 to July 2021 we observed a significative temporal trend mortality reduction (OR=0.90, 95% CI: 0.84–0.96, p=0.0015), in particular in-hospital mortality has reduced from 57% of first time-quartile to 29% of the fourth quartile (Figure 1). In addition we also noted a significant increase in Impella catheter use (p=0.0005) with a consequent reduction of IABP (p=0.01), a reduction in dopamine administration (p=0.0007) and a greater use of dobutamine and levosimendan (p=0.015 and p=0.0001). In our population of AMI-CS patients CARDSHOCK risk score was a reliable in-hospital mortality predictor tool (OR 1.11; 95% CI, 1.06–1.17; p=0.00011). After the multivariate analysis only ejection fraction (EF) at baseline (OR=0.99, 95% CI: 0.98–0.99, p=0.009), lactate level at presentation (OR=1.03, 95% CI: 1.01–1.06, p=0.015) and presence of three-vessels coronary artery disease (OR=0.73, 95% CI: 0.59–0.90, p=0.0038) resulted to be in-hospital mortality predictors. For this reason, a prediction model composed by those three variables was created which exhibited better predictive performance for in-hospital mortality than Cardshock risk score (AUC of 0.94 vs AUC of 0.72 respectively, p=0.015) (Figure 2).

Conclusions

In our retrospective single-centre study a significant reduction of mortality through the years is observed, probably due to more extensive use of micro axial pumps and better manipulation of inotropic drug therapies. The use of Cardshock risk score has been proven to be a feasible tool in prediction on in-hospital mortality also in our sample composed only of AMI-CS patients. In addition, a more simplified risk score made up of only three clinical variables demonstrates at least the same predictive performance. Future validation in a larger population could be advisable to validate the simplified score.

Funding Acknowledgement

Type of funding sources: None.

Does the cerebellar sequential theory explain spoken language impairments? A literature review

During the past decades, converging evidence from clinical, neuroimaging and neuroanatomical studies has demonstrated the key role of the cerebellum in the processing of non-motor aspects of language. Although more is known about the way in which the cerebellum participates in the mechanisms involved in written language, there is ambiguous information on its role in other aspects of language, such as in non-motor aspects of spoken language. Thus, to contribute additional insight into this important issue, in the present work, we review several original scientific papers focusing on the most frequent non-motor spoken language impairments evidenced in patients affected by cerebellar pathology, namely, verbal working memory, grammar processing and verbal fluency impairments. Starting from the collected data, we provide a common interpretation of the spoken language disorders in cerebellar patients, suggesting that sequential processing could be the main mechanism by which the cerebellum participates in these abilities. Indeed, according to the cerebellar sequential theory, spoken language impairments could be due to altered cerebellar function to supervise, synchronize and coordinate the activity of different functional modules, affecting the correct optimization of linguistic processing.

Inter-leg Distance Measurement as a Tool for Accurate Step Counting in Patients with Multiple Sclerosis

Step detection is commonly performed using wearable inertial devices. However, methods based on the extraction of signals features may deteriorate their accuracy when applied to very slow walkers with abnormal gait patterns. The aim of this study is to test and validate an innovative step counter method (DiSC) based on the direct measurement of inter-leg distance. Data were recorded using an innovative wearable system which integrates a magneto-inertial unit and multiple distance sensors (DSs) attached to the shank. The method allowed for the detection of both left and right steps using a single device and was validated on thirteen people affected by multiple sclerosis (0 <; EDSS <; 6.5) while performing a six-minute walking test. Two different measurement ranges for the distance sensor were tested (DS₂₀₀: 0-200 mm; DS₄₀₀: 0-400 mm). Accuracy was evaluated by comparing the estimates of the DiSC method against video recordings used as gold standard. Preliminary results showed a good accuracy in detecting steps with half the errors in detecting the step of the instrumented side compared to the non-instrumented (mean absolute percentage error 2.4% vs 4.8% for DS₂₀₀; mean absolute percentage error 2% vs 5.4% for DS₄₀₀). When averaging errors across patients, over and under estimation errors were compensated, and very high accuracy was achieved (E_%<; 1.2% for DS₂₀₀; E_%<; 0.7% for DS₄₀₀). DS₄₀₀ is the suggested configuration for patients walking with a large base of support.

WITHDRAWN: Assessment of the inter-laboratory repeatability of gait analysis measurements in patients with multiple sclerosis

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Synergy as a warning sign of transitions: The case of the two-dimensional Ising model

We consider the formalism of information decomposition of target effects from multisource interactions, i.e., the problem of defining redundant and synergistic components of the information that a set of source variables provides about a target, and apply it to the two-dimensional Ising model as a paradigm of a critically transitioning system. Intuitively, synergy is the information about the target variable that is uniquely obtained by taking the sources together, but not considering them alone; redundancy is the information which is shared by the sources. To disentangle the components of the information both at the static level and at the dynamical one, the decomposition is applied respectively to the mutual information and to the transfer entropy between a given spin, target, and a pair of neighboring spins (taken as the drivers). We show that a key signature of an impending phase transition (approached from the disordered size) is the fact that the synergy peaks in the disordered phase, both in the static and in the dynamic case: The synergy can thus be considered a precursor of the transition. The redundancy, instead, reaches its maximum at the critical temperature. The peak of the synergy of the transfer entropy is far more pronounced than those of the static mutual information. We show that these results are robust with respect to the details of the information decomposition approach, as we find the same results using two different methods; moreover, with respect to previous literature rooted in the notion of global transfer entropy, our results demonstrate that considering as few as three variables is sufficient to construct a precursor of the transition, and provide a paradigm for the investigation of a variety of systems prone to crisis, such as financial markets, social media, or epileptic seizures.

Ising model with conserved magnetization on the human connectome: Implications on the relation structure-function in wakefulness and anesthesia

Dynamical models implemented on the large scale architecture of the human brain may shed light on how a function arises from the underlying structure. This is the case notably for simple abstract models, such as the Ising model. We compare the spin correlations of the Ising model and the empirical functional brain correlations, both at the single link level and at the modular level, and show that their match increases at the modular level in anesthesia, in line with recent results and theories. Moreover, we show that at the peak of the specific heat (the critical state), the spin correlations are minimally shaped by the underlying structural network, explaining how the best match between the structure and function is obtained at the onset of criticality, as previously observed. These findings confirm that brain dynamics under anesthesia shows a departure from criticality and could open the way to novel perspectives when the conserved magnetization is interpreted in terms of a homeostatic principle imposed to neural activity.

Synergy, redundancy and unnormalized Granger causality

We analyze by means of Granger causality the effect of synergy and redundancy in the inference (from time series data) of the information flow between subsystems of a complex network. Whilst fully conditioned Granger causality is not affected by synergy, the pairwise analysis fails to put in evidence synergetic effects. We show that maximization of the total Granger causality to a given target, over all the possible partitions of the set of driving variables, puts in evidence redundant multiplets of variables influencing the target, provided that an unnormalized definition of Granger causality is adopted. Along the same lines we also introduce a pairwise index of synergy (w.r.t. to information flow to a third variable) which is zero when two independent sources additively influence a common target; thus, this definition differs from previous definitions of synergy.

[Epidemiological, social and public health aspects of tuberculosis in Ferrara in the 19th century]

Our first study of tuberculosis in Ferrara during the nineteenth century, whose results have been recently published, focused on disease treatment. Here we present the descriptive analysis of mortality, with the following results being attained: two behavioural patterns are detected with regard to the onset of disease, before and after 1850; TB is a specific disease that affects all parts of the body in all age groups: childhood, and active and passive populations; there are no significant differences with regard to gender; as regards the occupations performed by the deceased, those related to industry and agriculture and to various other activities and services are those with the highest mortality; tuberculosis has a seasonal pattern; summer and autumn are the periods of greatest prevalence (hot weather and humidity are factors that affect the respiratory system); among the forms of tuberculosis it can be observed that up to the year 1850 people died in Ferrara either of pulmonary tuberculosis or TB localised in other areas; from 1851 onward there appears to have been a dramatic change, with a decrease in unspecific diagnosis but the appearance of disease manifestations in its various clinical forms.

Redundant variables and Granger causality

We discuss the use of multivariate Granger causality in presence of redundant variables: the application of the standard analysis, in this case, leads to under estimation of causalities. Using the un-normalized version of the causality index, we quantitatively develop the notions of redundancy and synergy in the frame of causality and propose two approaches to group redundant variables: (i) for a given target, the remaining variables are grouped so as to maximize the total causality and (ii) the whole set of variables is partitioned to maximize the sum of the causalities between subsets. We show the application to a real neurological experiment, aiming to a deeper understanding of the physiological basis of abnormal neuronal oscillations in the migraine brain. The outcome by our approach reveals the change in the informational pattern due to repetitive transcranial magnetic stimulations.

[Surgical education: from teledidactics to virtual training]

The assessment of efficacy and quality of computer-assisted learning is today under evaluation. The Authors propose to use distant learning in the surgical knowledge teaching. In Italy, thanks to the Ministry of University and Scientific Research, a Master on distant learning in Medicine is now starting in 11 Italian Universities under the coordination of the second Faculty of Medicine of the University of Rome 'La Sapienza'. Thanks to the help of medicine and surgery teachers and informatics and telecommunication engineers, this Master is a first step to form and to license medical and surgical specialists experts in distant learning and videoconferencing telemedicine. Videoconferencing system can support Telementoring. Telementoring isn't an exclusive methodology but it is an additional methodology to tradictional didactic for clinicians and surgeons. It allows personal virtual trainings using computers and telecommunication systems.

Identification of network modules by optimization of ratio association

We introduce a novel method for identifying the modular structures of a network based on the maximization of an objective function: the ratio association. This cost function arises when the communities detection problem is described in the probabilistic autoencoder frame. An analogy with kernel k-means methods allows us to develop an efficient optimization algorithm, based on the deterministic annealing scheme. The performance of the proposed method is shown on real data sets and on simulated networks.

The association of GRB 060218 with a supernova and the evolution of the shock wave

Although the link between long gamma-ray bursts (GRBs) and supernovae has been established, hitherto there have been no observations of the beginning of a supernova explosion and its intimate link to a GRB. In particular, we do not know how the jet that defines a gamma-ray burst emerges from the star's surface, nor how a GRB progenitor explodes. Here we report observations of the relatively nearby GRB 060218 (ref. 5) and its connection to supernova SN 2006aj (ref. 6). In addition to the classical non-thermal emission, GRB 060218 shows a thermal component in its X-ray spectrum, which cools and shifts into the optical/ultraviolet band as time passes. We interpret these features as arising from the break-out of a shock wave driven by a mildly relativistic shell into the dense wind surrounding the progenitor. We have caught a supernova in the act of exploding, directly observing the shock break-out, which indicates that the GRB progenitor was a Wolf-Rayet star.

Gamma-ray bursts: huge explosion in the early Universe

Long gamma-ray bursts (GRBs) are bright flashes of high-energy photons that can last for tens of minutes; they are generally associated with galaxies that have a high rate of star formation and probably arise from the collapsing cores of massive stars, which produce highly relativistic jets (collapsar model). Here we describe gamma- and X-ray observations of the most distant GRB ever observed (GRB 050904): its redshift (z) of 6.29 means that this explosion happened 12.8 billion years ago, corresponding to a time when the Universe was just 890 million years old, close to the reionization era. This means that not only did stars form in this short period of time after the Big Bang, but also that enough time had elapsed for them to evolve and collapse into black holes.

A short γ-ray burst apparently associated with an elliptical galaxy at redshift z = 0.225

Gamma-ray bursts (GRBs) come in two classes: long (> 2 s), soft-spectrum bursts and short, hard events. Most progress has been made on understanding the long GRBs, which are typically observed at high redshift (z approximately 1) and found in subluminous star-forming host galaxies. They are likely to be produced in core-collapse explosions of massive stars. In contrast, no short GRB had been accurately (< 10'') and rapidly (minutes) located. Here we report the detection of the X-ray afterglow from--and the localization of--the short burst GRB 050509B. Its position on the sky is near a luminous, non-star-forming elliptical galaxy at a redshift of 0.225, which is the location one would expect if the origin of this GRB is through the merger of neutron-star or black-hole binaries. The X-ray afterglow was weak and faded below the detection limit within a few hours; no optical afterglow was detected to stringent limits, explaining the past difficulty in localizing short GRBs.

Bright X-ray Flares in Gamma-Ray Burst Afterglows

Gamma-ray burst (GRB) afterglows have provided important clues to the nature of these massive explosive events, providing direct information on the nearby environment and indirect information on the central engine that powers the burst. We report the discovery of two bright x-ray flares in GRB afterglows, including a giant flare comparable in total energy to the burst itself, each peaking minutes after the burst. These strong, rapid x-ray flares imply that the central engines of the bursts have long periods of activity, with strong internal shocks continuing for hundreds of seconds after the gamma-ray emission has ended.

An unexpectedly rapid decline in the X-ray afterglow emission of long γ-ray bursts

'Long' gamma-ray bursts (GRBs) are commonly accepted to originate in the explosion of particularly massive stars, which give rise to highly relativistic jets. Inhomogeneities in the expanding flow result in internal shock waves that are believed to produce the gamma-rays we see. As the jet travels further outward into the surrounding circumstellar medium, 'external' shocks create the afterglow emission seen in the X-ray, optical and radio bands. Here we report observations of the early phases of the X-ray emission of five GRBs. Their X-ray light curves are characterised by a surprisingly rapid fall-off for the first few hundred seconds, followed by a less rapid decline lasting several hours. This steep decline, together with detailed spectral properties of two particular bursts, shows that violent shock interactions take place in the early jet outflows.

Subcortical nodular heterotopia: a functional MRI and somatosensory evoked potentials study

Subcortical nodular heterotopia (SNH) associated with refractory epilepsy may be surgically treated, and a positive outcome can be expected following the complete excision of the malformed tissue. Recent functional neuroimaging studies have suggested the possible functional relevance of cerebral malformations, and may make it possible to improve presurgical planning, thus allowing extended resections and minimising post-operative deficits. We here report the case of a 19-year-old man with epilepsy and a giant SNH associated with diffused abnormal gyrations of the right temporal-parietal regions. Cortical functional organisation was investigated by means of functional magnetic resonance imaging (MRI) during sensory and motor tasks, and somatosensory evoked potentials. The results revealed enlarged and displaced motor and sensory cortical areas with heterotopic tissue functional activation. The relevance of these findings is discussed in the light of the possible surgical treatment of drug-refractory epilepsy associated with cerebral malformations: surgical treatment based on conventional MRI studies alone, without taking the functional nature of dysplastic tissues into account, may lead to considerable side effects.

Steady-state visual evoked potentials and phase synchronization in migraine patients

We investigate phase synchronization in EEG recordings from migraine patients. We use the analytic signal technique, based on the Hilbert transform, and find that migraine brains are characterized by enhanced alpha band phase synchronization in the presence of visual stimuli. Our findings show that migraine patients have an overactive regulatory mechanism that renders them more sensitive to external stimuli.

Neuromyelitis optica in a child with atypical onset and severe outcome

We report on a seven-year-old boy with inflammatory relapsing-remitting CNS disease, involving the optic nerves and spinal cord, with increasingly severe sequelae after each relapse. Clinical course, neuroimaging and laboratory findings were consistent with neuromyelitis optica. Biopsy of leptomeninges and underlying nervous tissue showed increased vascularization and thickened hyalinized vessel walls, reported as suggestive for neuromyelitis optica. Clinical features at onset were atypical, rendering the case highly unusual and the diagnosis tentative.

Phase shifts of synchronized oscillators and the systolic-diastolic blood pressure relation

We study the phase-synchronization properties of systolic and diastolic arterial pressure in healthy subjects. We find that delays in the oscillatory components of the time series depend on the frequency bands that are considered, in particular we find a change of sign in the phase shift going from the very low frequency band to the high frequency band. This behavior should reflect a collective behavior of a system of nonlinear interacting elementary oscillators. We prove that some models describing such systems, e.g., the Winfree and the Kuramoto models, offer a clue to this phenomenon. For these theoretical models there is a linear relationship between phase shifts and the difference of natural frequencies of oscillators and a change of sign in the phase shift naturally emerges.

[Detection, characterization and clinical significance of circulating cancer cells in patients surgically treated for breast cancer]

Recent technological advances have led to an increasing ability to detect isolated or groups of tumour cells in blood, lymph nodes or bone marrow in patients with different tumour types. However, the clinical evidence of these advances is unclear. The detection and the characterisation of circulating breast cancer cells and the eventually micrometastasis represent an important prognostic factor with therapeutic implications. The number of neoplastic cells being very small, these are not easily detected by using only cytomorphology, possibly associated to immunocytochemistry. In the last decade many studies have been directed in order to identify new assays. In the present review the Authors summarize advantages and disadvantages about two different technical approaches: molecular and immunomagnetic selection with cellular enrichment and immunocytochemistry.

[Is the Lauren classification an independent parameter for the prognostic evaluation of surgically treated gastric cancer patients? Analysis of a case series]

The Authors highlight the efficacy of the Lauren's classification in 28 surgically treated gastric cancer patients. Lauren's classification allows a prognostic evaluation corresponding to the effective gastric cancer natural history. Present histo-morphological classification criteria appear not to coincide with the clinical evolution; as a matter of fact over- or understaging is possible in gastric cancer patients. 64,28% of the Lauren's classification intestinal type patients survive after a four year follow up vs. 42,85% of the diffuse type patients. The Authors discuss about new biomolecular knowledge in gastric cancer oncogenesis.

[Telementoring in surgery]

Tele-mentoring is an interactive experimental method that allows young surgeons' education by distant learning tutoring of an expert surgeon. The problem about assessment of efficacy and quality of computer-assisted instruction is under evaluation today. Tele-mentoring is supported by videoconferencing system and it is not an exclusive methodology but an additional methodology to traditional didactic for clinicians and surgeons. It allows personal virtual trainings by computers and telecommunication systems. Videoconference allows tutoring for telemedicine, teletriage and telesurgery also.

An unusual association of malignant melanoma and small cell lung cancer: case report. An eleven-year-follow-up

The authors report the case of a patient affected by malignant melanoma and small cell lung cancer. After having underlined the rareness of this pathological association, reviewing the most recent literature, the description of the clinical case aims at opening a discussion on how the surgical treatment performed, associated to chemotherapy, brought to an unhoped-for success, also helped by an unexpected combination of events that were absolutely out of any protocol. Eleven years later, at the present follow-up, the patient shows a complete remission of both diseases.

Digital stereotactic biopsies for nonpalpable breast lesion

BACKGROUND

Percutaneous biopsy (BP) is a valid alternative to open surgical biopsy. The aim of our study was to evaluate the results and diagnostic value of vacuum-assisted core biopsy (VACB; Mammotome) and advanced breast biopsy instrumentation (ABBI).

METHODS

From June 1999 to December 2001, 360 BPs were performed: all patients had dubious mammography lesions not confirmed by ultrasonography. Indications were as follows 264 (73.3%) microcalcifications, 64 (17.8%) nodular opacities, and 32 (8.8%) parenchymal distortions.

RESULTS

All BPs were performed with a digital stereotactic table with a vacuum suction aspiration system for VACB and a cutting cannula for ABBI. All BPs were correctly performed. Seventy-one (19.7%) lesions were malignant, whereas 258 (71.6%) were benign: 31 (8.6%) of the lesions removed with VACB were atypical ductal hyperplasia.

CONCLUSIONS

BP is a valid method for the diagnosis of nonpalpable breast lesions. In our experience, VACB is the method of choice because it is easy to perform and has high adaptability.

Neonatal dopa-responsive extrapyramidal syndrome in twins with recessive GTPCH deficiency

The authors report two twin sisters, age 15 years, with recessive GTP cyclohydrolase deficiency, who presented with neonatal onset of rigidity, tremor, and dystonia but with no other symptoms suggestive of a diffuse CNS involvement. The plasma phenylalanine levels were normal. Treatment with L-dopa/carbidopa, started at age 1 year, was associated with sustained recovery from all neurologic signs. The patients were homozygous for a new recessive mutation in the GHI gene.

[Periareolar subcutaneous quadrantectomy: a new approach in breast cancer surgery]

Plastic and oncological breast surgery are becoming more and more closer as one surgical treatment. The term "oncoplastic surgery" refers to the use of plastic surgery techniques in breast cancer surgery, in order to avoid and to correct the adverse aesthetic findings. The care of cosmetic sequelae of breast cancer surgery has reached an important therapeutic role for psychological consequences of disease and because of the higher patients expectations of a good aesthetic result. Considering the concept of oncoplastic surgery, since 1999 the Authors began to use a periareloar approach in the breast conserving therapy (BCT), associated to axillary dissection performed through the same periareolar incision. This technique, original from the oncological point of view, is not different from the traditional quadrantectomy in the extension of the glandular resection, while the skin may be preserved in according to the conventional protocols of BCT. Oncological and aesthetic results have proved to be safe and satisfactory.

Use of mesh to repair the submuscolar pocket in breast reconstruction: a new possible technique

The reconstruction of the female breast after mastectomy has become a crucial part of primary breast cancer therapy. Setting of an implant is possible only in case of locally abounding soft tissue coverage and when no radiation has before performed. It is necessary a complete integrity of the submuscolar pocket and good blood supply of the skin to avoid failure of the procedure. In Author's experience, started since 1994, an immediate breast reconstruction after mastectomy is performed using gel-silicon implants directly when it was possible or setting first an expander. In six cases the condition of major pectoralis muscle after mastectomy was so foul that an immediate breast reconstruction with prosthesis was not realizable. However, the Authors tried a new technique using polypropylene mesh sutured on the major pectoralis muscle to cover the muscle partially destroyed. Preliminary data from the 6 pts seems to be encouraging.

[Use of abdominal wall retractor Laparo Tenser in gasless laparoscopic cholecystectomy]

High pressure CO2-peritoneum for laparoscopic surgery is not indicated in patients with impairment of cardiorespiratory and renal function and in high risk patients and in obesity. On the other site the uncontrolled abdominal insufflation and the blind insertion of the first trocar in patients with extended intraperitoneal adhesions, often cause bleeding and the intestinal loops dislocation, and can determine visceral lesions. In these patients gasless technique with an abdominal laparolifter can be employed. We report an experience of 36 patients undergoing laparoscopic cholecystectomy by a subcutaneous planar retractor. It was observed a good operative exposure in 83.3%; the surgery was safely performed in 88.8%. Two suprafascial hematoma related to the insertion of the needles of the Laparo Tenser occurred. A regular post-operative discharge was observed in 84.4%. These good results supports the extension of the laparoscopic approach for the cholecystectomy to complicated or to high risk patients.

[Randomized prospective study of early removal of drainage in breast cancer surgery]

Axillary seroma is absolutely the most frequent complication of breast cancer surgery. The Authors have accrued 100 consecutive breast cancer patients in a randomized study in order to compare seroma incidence by removing drains on 2nd postoperative day (1st arm) versus 3rd postoperative day (2nd arm); 48 patients were accrued in the first arm and 52 in the second. All patients received a standard axillary dissection. Two suction drains were placed. A compressive medication was applied after surgery. Patients started physiotherapy on the 1st postoperative day. The overall seroma prevalence was 21%. We have 8/48 (16%) seromas in the 1st group and 13/52 (25%) in the 2nd. No significant differences were registered between two arms. Clinical seroma was treated by needle aspiration and medication with a steroid. Conclusions coming out from this study are: 1) early drains removal doesn't increase seroma rate; 2) axillary clearance has to be performed removing en bloc the fatty tissue respecting surgical plains; 3) apply a compressive bandaging; 4) early arm physiotherapy; 5) medication with steroid may reduce the fluid formation.

Surgery in Italy

During the past 15 years, surgery in Italy has undergone significant developments in health care services at the teaching and organizational levels. In 1987, the new teaching regulations of medical and surgical schools came into force with the introduction of integrated courses that converge into educational and training areas with precise objectives. For more than a decade, postgraduate schools have had a common guideline throughout the European community--becoming real "residencies." Surgical activity is provided by university hospital facilities and hospitals with a business administration that is completely autonomous as far as organization, income, management, technique, and accounts are concerned. Research guidelines for future developments are mainly addressed toward optimization of organization and use of the most recent technology. The widespread application of day surgery and video-assisted surgery substantiates this evolution of surgery in Italy.

Progressive multifocal leukoencephalopathy in a child with hyperimmunoglobulin E recurrent infection syndrome and review of the literature

Progressive multifocal leukoencephalopathy (PML) is a fatal demyelinating disease due to infection with polyomavirus JC (JCV). PML occurs almost exclusively in immunocompromised patients, and although it has increased markedly in relation to AIDS, remains exceptional in children. We present the case of an immunocompromised child with hyperimmunoglobulin E recurrent infection syndrome (HIES) and pathologically-proven PML. HIES is a rare congenital immunodeficiency that to our knowledge has never before been reported in association with neurological complications. Following a recurrence of bronchopneumonia, the child's motor and cognitive functions deteriorated progressively in parallel with alterations on cerebral MRI. The neurological onset coincided with lymphocyte subset changes. PCR for JCV DNA did not detect the virus in CSF, and brain biopsy was required to secure the diagnosis. Antiviral treatment with cidofovir produced no benefit. Autopsy revealed the typical neuropathological findings of PML which were associated with inflammatory eosinophilic infiltrate (a marker of HIES). In accordance with the few pediatric PML cases reported and here reviewed, the child died five months after neurological onset.