Unlocking Hope: Anti-VEGFR inhibitors and their potential in glioblastoma treatment

PURPOSE

This systematic review summarizes evidence of VEGFR gene mutations and VEGF/VEGFR protein expression in glioblastoma multiforme (GBM) patients, alongside the efficacy and safety of anti-VEGFR tyrosine kinase inhibitors (TKIs) for GBM treatment.

METHODS

A comprehensive literature review was conducted using PubMed up to August 2023. Boolean operators and MeSH term "glioma," along with specific VEGFR-related keywords, were utilized following thorough examination of existing literature.

RESULTS

VEGFR correlates with glioma grade and GBM progression, presenting a viable therapeutic target. Regorafenib and axitinib show promise among studied TKIs. Other multi-targeted TKIs (MTKI) and combination therapies exhibit potential, albeit limited by blood-brain barrier penetration and toxicity. Combining treatments like radiotherapy and enhancing BBB penetration may benefit patients. Further research is warranted in patient quality of life and biomarker-guided selection.

CONCLUSION

While certain therapies hold promise for GBM, future research should prioritize personalized medicine and innovative strategies for improved treatment outcomes.

Intensive Care Unit Admission After Spine Surgery: A Narrative Review

INTRODUCTION

Intensive care unit (ICU) admissions constitute a substantial financial challenge for health care systems and patients and are linked to various potentially life-altering complications. A wide range of patient-related, surgical, and medical factors are associated with an increased risk of ICU admission following spine surgery.

DISCUSSION

The most notable examples include lung, heart, and kidney disease, as well as estimated blood loss and length of surgery. Various scores that include the most significant patient- and procedure-related factors have been described to assess the risk associated with surgery for individual patients. To date, the fusion risk score and the American Society of Anesthesiologists score have been the most useful in predicting postoperative complications and admission to the ICU. However, other risk factors have also been implicated in ICU admission and length of stay. The current scores must further adapt by using the available evidence to fulfill their intended purpose. Moreover, a handful of measures have shown efficacy in decreasing ICU admission and length of stay, with their benefits still to be demonstrated by future research.

CONCLUSION

This review underscores the risk factors predictive of ICU admission following spine surgery and will help surgeons and clinicians in patient stratification. However, future studies are needed to validate the role of protective measures in preventing ICU admissions and the significance of certain risk factors.

Mental health during the COVID-19 pandemic and first lockdown in Lebanon: Risk factors and daily life difficulties in a multiple-crises setting

INTRODUCTION

Research from around the world shows important differences in the impact of the COVID-19 pandemic and lockdowns on mental health. This study examined the extent of mental health challenges (depressive and anxiety symptoms and daily life difficulties) and their associations with pandemic- and response-related factors during the first lockdown in Lebanon, which happened amid a severe economic crisis and socio-political turmoil.

METHODS

Data come from a cross-sectional internet-based survey (May-June 2020). Association of depressive (Patient Health Questionnaire (PHQ-9)) and anxiety symptoms (Generalized Anxiety Disorder (GAD-7)) with outbreak-related worries and knowledge, information sources, and confidence and satisfaction in response measures were estimated using logistic regression adjusted for sociodemographic and socioeconomic indicators.

RESULTS

Among 510 participants (mean age 36.1±11.3; 69.4% women), 32.3% had elevated depressive and 27.3% had elevated anxiety symptoms; younger age, unemployment, loss of employment, and lower income were related to more mental health symptoms. Most prevalent daily life challenges were feelings of uncertainty (74.5%) and financial (52.2%) and emotional (42.2%) difficulties; these and all other daily life difficulties (work-related, caregiving, and online learning) were significantly higher among participants with higher depressive and anxiety symptoms. Higher outbreak-related worries were associated with higher depressive (OR = 1.36, 95% CI = 1.20,1.53) and anxiety symptoms (OR = 1.47, 95% CI = 1.30,1.67). Higher pandemic-related knowledge, reliance on and trust in local health agencies and professionals' information, and satisfaction and confidence regarding governmental and health institutions' response were all related to lower mental health symptoms.

CONCLUSION

Results show that mental health burden in Lebanon during the first lockdown (when the COVID-19 outbreak was still minimal) is among the highest reported worldwide and highlight elevated emotional and financial tolls and widespread impact on daily life. In this high-burden and multiple-challenges context, results suggest an important role for the healthcare body, knowledge, and trust in the institutions managing the response.

Tyrosine kinase inhibitors in osteosarcoma: Adapting treatment strategiesa

Osteosarcoma (OS) is an aggressive primary bone malignancy that metastasizes rapidly. The standard of care has changed little over the previous four decades, and survival rates have plateaued. In this context, tyrosine kinase inhibitors (TKIs) emerge as potential treatments. A literature search was conducted to collect data related to receptor tyrosine kinase genetic alterations and expression in OS specimens. Gene amplification and protein expression of these receptors were linked to prognosis and tumor behavior. Relevant TKIs were evaluated as monotherapies and as parts of combination therapies. Certain TKIs, such as apatinib, regorafenib, and cabozantinib, present a potential therapeutic avenue for OS patients, especially when combined with chemotherapy. Producing long-lasting responses and enhancing quality of life remain key goals in OS treatment. To this effect, optimizing the use of TKIs by identifying biomarkers predictive of response and assessing promising TKIs in larger-scale trials to validate the efficacy and safety outcomes relative to these drugs reported in phase II clinical trials. To this effect, it is necessary to identify biomarkers predictive of response to TKIs in larger-scale trials and to validate the efficacy and safety of these drugs reported in phase II clinical trials.

Simultaneous amorphous silica and phosphorus recovery from rice husk poultry litter ash

The livestock sector is one of the most important sectors of the agricultural economy due to an increase in the demand for animal protein. This increase generates serious waste disposal concerns and has negative environmental consequences. Furthermore, the food production chain needs phosphorus (P), which is listed as a critical raw material due to its high demand and limited availability in Europe. Manure contains large amounts of P and other elements that may be recycled, in the frame of circular economy and "zero waste" principles, and reused as a by-product for fertilizer production and other applications. This paper focuses on the extraction and recovery of amorphous silica from rice husk poultry litter ash. Two different extraction procedures are proposed and compared, and the obtained silica is characterized. This work shows that amorphous silica can be recovered as an almost pure material rendering the residual ash free of P. It also addresses the possibility of more specific phosphorous extraction procedures via acid leaching.

Bottom ash derived from municipal solid waste and sewage sludge co-incineration: First results about characterization and reuse

This paper reports a complete characterization of the lowest fractions of bottom ash derived from co-combustion of municipal solid waste with sewage sludge (COBA), with the aim to suggest suitable reuse strategies of this by-product. X-Ray Microanalysis is coupled with mineralogical characterization, based on X-Ray Diffraction and Rietveld refinement, to extract information about COBA crystalline and amorphous phases. The composition of different particle size fractions shows that amount of amorphous increases with the increase of fractions sizes. In particular, the finest COBA size fraction (<300 μm) shows more leachable heavy metals (i.e. Pb, and Zn) compared to the investigated fraction with the highest sizes (1400 µm). On the basis of their composition, lowest particle size fractions show a better hydraulic behavior compared to bottom ash obtained from incineration of only municipal solid waste, suggesting possible attractive COBA applications, as for example, Portland cement substitution. In addition, COBA with size fractions in the range of 1000-1400 μm are proposed to be used to produce glass and ceramic. Finally, due to its high amount of reactive amorphous phase (about 73% for fraction size of 1400 μm) COBA is used, in combination with other by-products (coal fly ash and flue gas desulphurization residues), to stabilize municipal solid waste incinerator fly ash produced at the same incinerator plant, following the azure chemistry principle of use a waste to stabilize another waste.

Poultry litter ash characterisation and recovery

This paper reports a complete characterisation of poultry litter ash and its potential use as a heavy metal stabiliser. We propose a novel approach, in which the ashes deriving from municipal solid waste incineration (MSWI) are combined with poultry litter ash, rather than with coal combustion flue gas desulfurisation (FGD) residues. Heavy metals stabilisation was demonstrated by comparing the elemental concentrations in the leaching solutions of the starting raw and stabilised materials: leachable Pb and Zn showed a reduced solubility. The characterisation was conducted by total reflection X-ray fluorescence (TXRF), X-ray diffraction (XRD), micro-Raman spectroscopy and scanning electron microscopy combined with energy-dispersive X-ray spectrometry (SEM-EDX). The results showed that the poultry litter ash was Ca-, P-, K- and S-rich (>29 g/kg). It contained amorphous materials (i.e. fly ash economiser (FAECO) 73% and fly ash cyclone (FACYC) 61%) and soluble phases (e.g. arkanite and sylvite; up to 13% FAECO and 28% FACYC), as well as resilient crystalline (up to 2% of FAECO and FACYC) and amorphous phases (e.g. hydroxyapatite). After two months, the Pb and Zn concentrations in the leachate solutions were below the limit set by the European regulations for waste disposal (<0.2 mg/L and 1.5 mg/L, respectively). We propose a mechanism for the heavy metals stabilisation based on the carbonation process and high amounts of P, Ca and reactive amorphous phases. In conclusion, it is demonstrated that poultry litter ash can be an effective secondary source of heavy metals, allowing their immobilisation through P- and Ca-based reactive amorphous phases.

Antibiotic guidelines coupled with selective reporting of antibiograms

OBJECTIVES

We reported the impact of internal guidelines coupled with selective reporting of antibiotic susceptibility tests (srAST) on antibiotic adequacy in healthcare facilities.

METHODS

This prospective study involved clinicians from three clinics with medical and surgical activities employing a full-time infectious disease (ID) specialist. Internal guidelines were updated in 2016. The clinics were working with the same laboratory, which delivered the srAST introduced in March 2017. Two weeks per month over a 6-month period, all isolated bacterial specimens, empirical antibiotic therapies (EAT) and the documented ones were analyzed. An EAT listed in the guidelines and a documented therapy mentioned in the srAST defined their adequacy.

RESULTS

A total of 257 positive bacterial samples were analyzed in 199 patients, for which 106 infections were studied. Of these, 32% were urinary tract infections, 15% were primary bloodstream infections, 11% were bone infections, and 42% were other types of infection. The three main bacteria were Escherichia coli (27%), Staphylococcus aureus (24%), and Enterococcus faecalis (14%). The total number of antibiotic prescriptions was 168, with 75 (45%) EATs and 93 (55%) documented therapies. There were 35/75 (47%) adequate EATs and 86/93 (92%) adequate documented therapies. The ID specialist was not involved in 90/168 (53.5%) prescriptions, of which 43/90 (48%) were adequate, with 21/35 (60%) EATs and 22/86 (25%) documented therapies. There was a statistical correlation between compliance of the EATs with guidelines and of the documented therapy with srAST (p=0.02).

CONCLUSION

Combining internal guidelines and srAST led to a high rate of antibiotic adequacy.

Dataset on the use of metal hydroxides, instead of flue gas desulfurization residues, to stabilize fly ash by using bottom ash

Municipal solid waste incineration (MSWI) provides significant benefits on waste treatment technologies. Nevertheless some by-products such as fly ash (FA) and bottom ash (Ash) are produced in the incineration plant. Indeed, FA is considered a toxic waste due to the presence of leachable heavy metals (i.e Zn, Cd, Pb, Hg) and metalloid (like As). This data article aims to investigate the reactivity of Ca(OH)₂ and Mg(OH)₂ as possible substitute of flue gas desulfurization (FGD) residues by mixing with FA, BA and silica fume through a low cost technology. To assess the immobilization process of heavy metals and metalloid, three different samples' compositions were prepared for Ca(OH)₂ and Mg(OH)₂ series, respectively. Elemental chemical analysis of leaching solutions were carried out by Total reflection X-Ray Fluorescence spectroscopy (TXRF). Data revealed that mixing municipal solid waste ashes with Mg(OH)₂ decrease significantly Pb and Zn leachability after two months, and reduce their environmental impact in landfill.

Understanding the foot's functional anatomy in physiological and pathological conditions: the calcaneopedal unit concept

BACKGROUND

A thorough review of the available orthopaedic literature shows significant controversies, inconsistencies and sparse data regarding the terminology used to describe foot deformities. This lack of consensus on terminology creates confusion in professional discussions of foot anatomy, pathoanatomy and treatment of deformities. The controversies apply to joint movements as well as static relationships between the bones.

DESCRIPTION

The calcaneopedal unit (CPU) is a specific anatomical and physiological entity, represented by the entire foot excepted the talus. The calcaneus, midfoot and forefoot are solidly bound by three strong ligaments that create a unit that articulates with the talus. The movement of the CPU is complex, as it rotates under the talus, around the axis of Henke that coincides with the talo-calcaneal ligament of Farabeuf.This calcaneopedal unit is deformable. It is compared with a twisted plate, able to adapt to many physiological situations in standing position, in order to acheive a plantigrade position.Moreover, the calcaneopedal unit and the talo-tibiofibular complex are interdependent; rotation of the latter produces morphologic modifications inside the former and vice versa.

PURPOSE

This paper is a review article of this concept and of its physiopathological applications.

Comparison of multiple X-ray fluorescence techniques for elemental analysis of particulate matter collected on air filters

This work reports on qualitative and semi-quantitative elemental analysis of particulate matter (PM) collected on PTFE membrane filters, for a source apportionment study conducted in Brescia (Italy). Sampling was undertaken in a residential area where an increase in Mn emissions has been highlighted by previous studies. Filters are measured by means of X-ray Fluorescence (XRF) based techniques such as micro-XRF and grazing incidence XRF using synchrotron radiation, Mo or W excitation sources, after applying an automatized sample preparation method. A heterogeneous distribution in PM shape, size and composition was observed, with features typical of anthropogenic sources. XRF measurements performed at various incidence angle, on large areas and different experimental setup were reproducible. The results demonstrate a successful comparison of the various XRF instrumentation, and the decrease in Mn content with the distance away from the identified emission source. This work highlights the potentialities of the presented approach to provide a full quantitative analysis, and ascertain its suitability for providing a direct, fast, simple and sensitive elemental analysis of filters in source apportionment studies and screening purposes.

Validity and reliability of different techniques of neck-shaft angle measurement

AIM

To determine a valid and reliable neck-shaft angle (NSA) measurement method while rotating the pelvises in increments of 5° in order to simulate patient malpositioning.

MATERIALS AND METHODS

CT images of 17 patients were used to produce digitally reconstructed radiographs in frontal and lateral views and three-dimensional (3D)-reconstructions of the femurs, considered to be the reference standard. Malpositioning was simulated by axially rotating the frontal radiographs from 0° to 20°. Three operators measured in two-dimensions the NSA using four different methods, three times each, at each axial rotation (AR) position. Method 1 (femoral neck axis drawn by joining the centre of the femoral head (CFH) to the median of the femoral neck base; femoral diaphysis axis drawn by joining the median of two lines passing through the medial and lateral edges of the femoral axis below the lesser trochanter) and method 2 (femoral axis taken as the median of a triangle passing through base of femoral neck and medial and lateral head-neck junction; femoral diaphysis as previous) were described for the first time; method 3 was based on a previous study; method 4 was a free-hand technique. Reliability, validity, and global uncertainty were assessed.

RESULTS

Method 1 showed the best reliability and validity. The global uncertainty also showed minimal values for method 1, ranging from 7.4° to 14.3° across AR positions.

CONCLUSION

Method 1, based on locating the CFH, was the most reliable and valid method and should be considered as a standardised two-dimensional NSA measurement method for clinical application.

Lower-limb lengths and angles in children older than six years: Reliability and reference values by EOS® stereoradiography

BACKGROUND

Lower-limb alignment in children is classically assessed clinically or based on conventional radiography, which is associated with projection bias. Low-dose biplanar radiography was described recently as an alternative to conventional imaging. The primary objective of this study was to assess the reliability of length and angle values inferred from 3D reconstructions in children seen in everyday practice. The secondary objective was to obtain reference values for goniometry parameters in children.

HYPOTHESIS

3D reconstructions can be used to assess the lower limbs in children.

MATERIAL AND METHODS

The paediatric reliability study was done in 18 volunteers who were divided into three groups based on whether they were typically developing (TD) children, had skeletal development abnormalities, or had cerebral palsy. The reference data were obtained in 129 TD children. Each study participant underwent biplanar radiography with 3D reconstruction performed by experts and radiology technicians. Goniometry parameters were computed automatically. Reproducibility was assessed based on the intra-class coefficient (ICC) and the ISO 5725 standard (standard deviation of reproducibility, SDR).

RESULTS

For length parameters, the ICCs ranged from 0.94 to 1.00 and the SDR from 2.1 to 3.5mm. For angle parameters, the ICC and SDR ranges were 0.60-0.95 and 0.9°-4.6°, respectively. No significant differences were found across experts or radiology technicians. Age-specific reference data are reported.

DISCUSSION

These findings confirm the reliability of low-dose biplanar radiography for assessing lower-limb parameters in children seen in clinical practice. In addition, the study provides reference data for commonly measured parameters.

LEVEL OF EVIDENCE

IV.

A Case of Malignant Phyllodes Tumor with Muscular and Fatty Differentiations

A 50-year-old female underwent surgical removal of a mammary phyllodes tumor, whose peculiar histologic feature was the coexistence of areas of liposarcoma and leiomyosarcoma. The morphologic differential diagnosis is briefly discussed.

Influence of patient rotational malpositioning on pelvic parameters assessed on lateral radiographs

AIM

To estimate the effect of patients' axial rotation (AR) during pelvic radiograph acquisition, on the reliability and validity of sagittal pelvic parameters.

MATERIALS AND METHODS

Lateral digitally reconstructed radiographs (LDRRs) were obtained from the pelvic computed tomography (CT) scans of eight children and nine adults. Then, the AR of the pelvis was simulated and the corresponding LDRRs were reconstructed at 5°, 10°, 15°, and 20° of the AR. Pelvic parameters were measured digitally on each radiograph. Intra- and interobserver variability were evaluated at each AR position (three operators repeated the measurements three times each). The bias on each clinical parameter, in each AR position, was calculated relatively to the 0° position.

RESULTS

Interobserver variability increased similarly in children and adults with AR. It reached 4.4° for pelvic incidence and 4.7° for the sacral slope at 20° of AR. Biases on radiological parameters increased with AR and exceeded the acceptable threshold of errors when AR reached 10°. A linear regression was established (R²=0.834, p<0.0001) in order to estimate the AR of a patient on a lateral pelvic radiograph based on the measurement of the bifemoral distance normalized to the sagittal pelvic thickness.

CONCLUSIONS

AR of patients during radiograph acquisition can be estimated in clinical practice, which would allow physicians to discard any radiographs where the calculated AR exceeded 10°.

A podoscopic and descriptive study of foot deformities in patients with Down syndrome

INTRODUCTION

Subjects with Down syndrome (DS) are known to be affected by various foot deformities. Despite the fact that some of these deformities have been reported in the literature, a more comprehensive description would be of benefit. The aim of this study is to investigate the prevalence of known foot deformities in patients with DS and of other previously non-described foot anomalies in this population.

HYPOTHESIS

Subjects with DS have an increased prevalence of foot deformities compared to control subjects.

METHODS

Fifty-five subjects with DS (age: 14.6±7.4 years) had undergone podiatric clinical and podoscopic examinations to study their main foot deformities and their footprints, respectively. The results of these examinations were compared to those of an age-matched asymptomatic control group of fifty-three subjects (age: 13.4±11.2 years).

RESULTS

Significantly more prevalent foot deformities were found in the DS group: hallux valgus (36.4%), syndactyly between the 2nd and 3rd toes (9.1%), grade II pes planus (39.1%) and grade III pes planus (30%). Moreover, joint laxity (43.6%) was significantly more prevalent in the DS group. Furthermore, the presence of an increased space between the 1st and 2nd toes in patients with DS and its prevalence (73.6%) were described for the first time. A multivariate analysis revealed a significant relationship between the presence of joint laxity and flatfoot in only the control but not the DS group. Other foot deformities were found to be consistently more frequent in the DS population but not significantly higher than the control group.

DISCUSSION

Although subjects with DS had significantly greater joint laxity and BMI compared to the control group, neither of these factors was found to be related to the increased prevalence of flatfoot in DS patients.

LEVEL OF EVIDENCE

IV-retrospective study.

Vitreoretinal surgery for shotgun eye injuries: outcomes and complications

PURPOSE

To analyse the postoperative anatomic and functional outcomes in addition to complications after vitreoretinal surgery for patients with shotgun eye injuries related to hunting accidents.

MATERIALS

Retrospective review of the clinical records of all cases of shotgun eye injuries presented between January 2000 and January 2011 and with a minimum follow-up of 1 year. Collection of demographics, type of injury, choice of management, complications and final surgical success with final visual acuity is reported.

RESULTS

Twenty eyes of 19 patients (all male) with a mean age of 36.1 years (range 16-60 years) were included in the study. Mean postoperative follow-up was 47.5 months (range 15-118 months). Best corrected visual acuity (BCVA) at presentation ranged from perception of light to 20/200. Ten eyes had a penetrating injury and 10 others had a perforating injury. All the eyes underwent an initial vitrectomy and the intraocular pellet was removed in all the 10 penetrating injuries. Concurrent cataract surgery was performed in 12 cases, internal tamponade was used in 15 cases and a supplemental encircling scleral buckle was inserted in 12 cases. One additional vitreoretinal surgery was required in seven cases (35%) and two additional surgeries required in two other cases (10%). At last follow-up BCVA ranged from NPL to 20/20 and was 20/100 or better in 10 eyes (50%). All patients had a flat retina except for two cases (10%) that developed severe proliferative vitreoretinopathy.

CONCLUSION

These results suggest that vitreoretinal surgery can offer good visual rehabilitation in patients with shotgun eye injuries.

Aspiration biopsy cytology of pleuro-pulmonary metastasis from a recurrent meningioma

A transthoracic fine-needle aspiration biopsy, sampled under echographic guidance from a pleuro-pulmonary mass, proved to be a metastatic meningioma. The meningioma had been operated on from the left parietal lobe, twelve years previously. Cytologic specimens showed nests of round-to-spindle-shaped tumor cells with whorl formation; the cells were immunoreactive for vimentin and epithelial-membrane antigen. The cytological appearance of the tumor cells was diagnostic of meningioma. In the course of the clinical staging, a recurrent cerebral meningioma was found and was judged to be inoperable, because of extensive growth and brain infiltration.

Metachronous contralateral Leydig-cell tumour in an 8-year-old boy

Leydig-cell tumours of the testis are rare and usually benign in children. The possibility of metachronous bilateral tumours should be considered not only for testicular teratomas but also in the follow up of a Leydig-cell tumour. Testis-sparing surgery is feasible and safe in prepubertal boys after exclusion of a malignant tumour.

Macular microholes: pathogenesis and natural history

AIMS

To study the natural history and evaluate optical coherence tomography (OCT) and the retinal thickness analyser (RTA) in patients with macular microholes.

METHODS

The medical records of 22 patients with a well demarcated red intraretinal foveal or juxtafoveal defect were reviewed. Fluorescein angiography (FA), RTA, and OCT were performed. The main outcome measures were visual acuity (VA), and OCT and RTA characteristics of microholes. Long term follow up was available in 13 eyes of 12 patients.

RESULTS

The patients had a mean age of 50 years and a mean refractive error of -0.93 dioptres. The presenting symptom was a central scotoma in 14 eyes and metamorphopsia in eight eyes. All patients had a corrected VA ranging from 20/16 to 20/125, with 20 out of 24 eyes (83%) having a VA > or =20/40. Symptoms remained stable or improved in 16 out of 22 patients (72%). OCT 2 findings were normal but an abnormality of the outer retina and/or a defect of the retinal pigment epithelium (RPE) were demonstrated on OCT 3 in 15 of 18 eyes (83%). The RTA topographic map demonstrated a defect at the site of the microhole in two out of 12 eyes.

CONCLUSION

Although biomicroscopic examination suggested an inner foveal defect, the OCT 3 scans demonstrated a localised abnormality of the outer retina and/or RPE which could not be resolved using OCT 2. Macular microholes have a favourable long term prognosis with stable VA. Bilateral involvement is uncommon.

Surgery of thyroid cancer: twelve years' personal experience

Diagnosis and treatment of thyroid carcinoma require a multidisciplinary approach. The close and long-standing collaboration between the Otorhinolaryngology, Pathological Anatomy and Nuclear Medicine Departments of Legnano Hospital has led to a precise diagnostic and therapeutic protocol in thyroid patients. In the 1990-2002 period, 131 patients underwent total thyroidectomy after diagnosis of thyroid cancer at the Otorhinolaryngology--Head and Neck Surgery Department. Patients submitted to lobectomy for differentiated thyroid cancer were excluded from the present study. The patient population is composed of 96 females (73%) and 36 males (27%) aged between 22 and 85 years. Of the 131 patients, 115 (87%) presented papillary carcinoma, 13 (10%) follicular carcinoma, 2 (2%) medullary carcinoma and one (1%) undifferentiated carcinoma. Two patients (2%) suffered from a preoperative monolateral recurrent nerve palsy. Total thyroidectomy was performed in all 131 patients. Selective neck dissection was performed only in patients with positive lymph nodes for papillary (37/115, 32%) and follicular carcinoma histotype (2/13, 15%) and, in both patients with medullary carcinoma (100%). Of the 131 patients, 15 (11%) did not undergo routine follow-up and were, therefore, excluded from the study, the remainder completed a mean follow-up of 47 months. During follow-up, the incidence of the two most frequent complications of thyroid surgery were evaluated: recurrent nerve paralysis and permanent hypoparathyroidism (exceeding the postoperative 6 months). Results of treatment have been evaluated considering the incidence of local and/or distant recurrences and patient survival rate. As far as concerns papillary and follicular histotype, we have considered as healed (absence of signs suggesting loco regional and distant recurrence) only those patients presenting both negligible levels of plasma thyroglobulin and a negative total-body 131I scintigraphy. Briefly, in 3 cases (3%), all papillary carcinomas, local recurrence occurred; 9 (8%), all with papillary carcinoma, developed lateral neck recurrence; 6 (5%), 5 with papillary carcinoma and one with follicular carcinoma, developed distant metastases, of which 3 pulmonary, 2 bone and 1 hepatic. Serum thyroglobulin values were considered during the last control visit in 95/113 patients (84%). Of these, 86 (91%) with negligible thyroglobulin levels and negative 131I scintigraphy, were considered healed. All 113 patients with differentiated thyroid carcinoma were alive at the last control visit. Both patients with medullary carcinoma are alive with no sign of illness at the last follow-up control. The patient presenting undifferentiated carcinoma died 2 months after surgery. In conclusion, at the last follow-up control, 1 (1%) patient has died, 5 patients (4%) are alive with disease (2 of whom suffered from multiple recurrences) and the remaining 110 (95%) patients are alive without evidence of disease. As far as concerns complications of surgery, iatrogenic recurrent palsy and permanent hypoparathyroidism are present in 2 (2%) and 10 patients (8%), respectively.

Laser photocoagulation alters the pattern of staining for neurotrophin-4, GFAP, and CD68 in human retina

AIMS

To investigate the staining pattern of neurotrophin-3 (NT3), neurotrophin-4 (NT4), and brain derived neurotrophic factor (BDNF) as well as glial fibrillary acid protein (GFAP) and CD68 in lasered human retina.

METHODS

Retinal laser photocoagulation was performed on four patients (two males, two females) with choroidal malignant melanoma 1-6 days before enucleation. Three other enucleated eyes with malignant melanoma and three normal cadaveric donor eyes were used as controls. Immunohistochemistry was performed to investigate the pattern of staining of NT3, NT4, BDNF, GFAP, and CD68 in 7 mm sections of fixed specimens.

RESULTS

Expression of NT4 was detected in the inner and outer nuclear layers of all the retinal sections examined but no NT3 and BDNF staining was seen. NT4 staining was found to be less intense in lasered and melanoma controls compared to normal cadaveric donor retinas. There was an upregulation of GFAP expression in both lasered and control eyes with melanoma in comparison with normal controls. CD68 staining was only observed in retinal pigment epithelium and choroid of lasered eyes.

CONCLUSION

NT4 is expressed in inner and outer nuclear layers of normal human retina and its expression is downregulated following laser photocoagulation. This occurs in parallel with an increased expression of GFAP suggesting that reactive changes in Muller cells may be responsible for reduced NT4 staining. Expression of CD68 at the site of laser injury is consistent with a wound healing process as a response to local damage.

Progression on metastatic neuroendocrine carcinoma from a recurrent prolactinoma: a case report

A 54 year old man was referred to the department of neurosurgery for frontal headache and vomiting. The patient was known in the department because of previous multiple surgery for a locally invasive pituitary prolactinoma (eight years, three years, and one year previously). The neurological examination revealed a frontal mass, which adhered to the dura, suggesting a meningioma. One year later, a left temporal metastasis was removed. Three months later, the patient died, with spinal metastases, of massive lung embolism. Histology revealed a progression of adenohypophyseal prolactinoma on neuroendocrine carcinoma, with an increase in proliferating indexes and modification of hormone production. This study documents a 10 year history of a rare prolactin producing pituitary carcinoma, which metastasised via liquoral flow.

Combined phacoemulsification and transpupillary drainage of silicone oil: results and complications

AIM

To review retrospectively 74 consecutive cases of combined phacoemulsification and transpupillary drainage of silicone oil.

METHODS

Candidate patients for intraocular silicone oil removal and cataract extraction underwent combined phacoemulsification and transpupillary drainage of silicone oil through a planned posterior capsulorrhexis and without the use of a pars plana infusion line.

RESULTS

The retina remained attached in 59 (79.7%) patients postoperatively. In this success group, the postoperative visual acuity improved in 42 (71.2%) patients. There was no association between age, duration of silicone oil tamponade, preoperative diagnosis, macular status or number and nature of previous surgery, and the incidence of redetachment following silicone oil removal.

CONCLUSION

Combined phacoemulsification and transpupillary drainage of silicone oil is a safe and reliable technique that offers the main advantage of diminished surgical trauma.

Repeatability and reproducibility of upper eyelid measurements

AIM

The aim of this study was to assess the repeatability and reproducibility by physicians of upper lid measurements and to investigate the influence of clinical experience on the learning curve effect.

METHODS

Both eyes of 22 outpatients were assessed for three basic measures of ptosis: marginal reflex distance (MRD) for upper and lower lids, upper lid skin crease (SC), and levator function (LF). Patients with variable eyelid positions were excluded. The patients were measured twice by a consultant and once by each of a clinical fellow, a specialist registrar, and a senior house officer in random order. Each observer was masked to their colleagues' results and followed a standard measurement protocol. Data were analysed using Bland-Altman plots.

RESULTS

Consultant repeatability was high and consistent, the median difference between measures being 0 for each of the four parameters. Clinically acceptable reproducibility was shown in all measurements for even the least experienced physician and was particularly consistent for extreme observations. There was evidence of a learning curve effect.

CONCLUSIONS

These results suggest that interobserver and intraobserver variability in assessment of upper lid ptosis using a standard measurement protocol is low and clinically acceptable when the technique of assessment is standardised.

Fine-needle aspiration of testicular lesions: report of 17 cases

In this article we report on our diagnostic experience of fine-needle aspiration biopsies (FNAB) performed on 17 patients with testicular lesions in the period from 1994-1998. The cytological diagnosis was consistent with seminoma in 7 cases, sex cord-stromal tumors in 3 cases (2 Sertoli cell tumors, 1 Leydig cell tumor), embryonal carcinoma in 3 cases, and yolk-sac tumor in 1 case; the other 3 patients were suffering from flogistic pathology. The cytological diagnosis was confirmed in all cases after surgery. According to our experience, ultrasound FNAB of testicular lesions proved to be a very reliable technique in predicting malignancy with high sensitivity and specificity. None of the patients developed local recurrences or inguinal lymph-node metastasis due to FNAB. Therefore, tumor stage classification (TNM) was not modified in any patient.

Hepatic amyloidosis with light chain deposition disease. A rare association

Monoclonal immunoglobulin deposition diseases are due to pathological protein deposition in various tissues and organs. Protein deposits may be found in a single tissue or systemically and the organs most frequently involved are kidney, heart, peripheral nerves and the liver. Depending on the pattern of the deposits and the type of immunoglobulin, these diseases are distinguished as primary amyloidosis, light chain deposition disease. Differential diagnosis is made in tissue specimens: microscopically by the identification of positive Congo red staining of the deposits, by immunohistochemical demonstration of proteins reacting with light chain (lambda or kappa) antisera or by recognition of fibrillar structures on electron microscopy. We report an unusual case of light chain deposition disease associated with amyloidosis, where hepatomegaly was the presenting manifestation and liver failure the cause of death, without any kidney involvement.

[Application of PCR in the diagnosis of B-type non-Hodgkin's lymphomas in cytological specimens from fine-needle aspiration]

The application of PCR to detect monoclonality at the immunoglobulin heavy chain gene locus in FNA cytologic specimens was evaluated.

MATERIALS AND METHODS

Immunoglobulin heavy chain gene rearrangement analysis was performed by a nested PCR for the VDJ region on 27 lymph nodes FNA paraffin embedded by cell blocking technique specimens (1 suspicious of NOS lymphoma, 1 Hodgkin's disease, 6 B cell non Hodgkin's lymphomas, 10 reactive hyperplasias).

RESULTS

A monoclonal band was seen in 13 of 17 suspicious or positive malignant cases. The other 4 specimens gave a policlonal pattern. Specimens from reactive lymph nodes produced policlonal bands in 8 cases, no product in 1 case and 1 specimen gave a monoclonal band. When needed, the results of PCR examinations were compared with the subsequent histologic evaluation of the same lymph-node.

CONCLUSIONS

From our experience we can see that clonal analysis by PCR based IgH gene rearrangement analysis can be applied to FNA material and can be useful in diagnosis.

Occult sporadic medullary microcarcinoma with lymph node metastases

A sporadic form of medullary occult microcarcinoma was cytologically diagnosed, by fine-needle aspiration biopsy (FNAB), on metastatic cervical lymph nodes. The cytologic specimens were partially smeared and partially zinc-formalin-fixed, so that a microinclusion clot for immunohistochemical studies would be possible. The reactivity to calcitonin of neoplastic cells obtained from metastatic cervical lymph nodes supported the search for a thyroid tumor, which only a careful echographic study revealed. Under sonographic guidance, FNAB on a 0.5-cm hypoechoid nodule was performed. The smears were diagnostic of medullary carcinoma. A total thyroidectomy with node dissection was made. Diagn. Cytopathol. 1999;21:203-206.

Pure yolk sac tumors in genital and extragenital sites: study on three pedriatic cases, with cytological findings on two

Cytopathological findings on three pedriatic gonadic-extragonadic pure yolk sac tumor are reported: the highly variable histological patterns (reticular, solid, festooning or pseudopapillary, polyvesicular vitelline), reflecting differentiation towards extraembryonic yolk sac structures, are not appreciated in cytologic samples. Since the tumor's cytologic spectrum is very broad, the most diagnostic differential difficulty with yolk sac tumor is adenocarcinoma. The presence of intracellular and extracellular hyaline globules, that are periodic acid-Schiff stain (PAS) positive and diastase resistant and correspond to alpha-fetoprotein production, alpha-fetoprotein positivity of the neoplastic cells; showing nuclear pleomorphism and vacuolated "bubbly" cytoplasm are the most consistent cytologic hallmarks of this neoplasm, which diagnosis would be confirmed by histologic, immunocytochemical and clinical findings.

Secretory meningioma, a rare meningioma subtype with characteristic glandular differentation: an histological and immunohistochemical study of 9 cases

AIM

We studied the immunophenotype of 9 cases of secretory meningioma (SM), a rarely reported meningioma variant, characterized by small gland-like lumina filled with a PAS-positive, diastase-resistant substance.

METHODS

Three samples of arachnoid tissue and 9 SMs were studied with a panel of monoclonal antibodies (MoAbs) against cytokeratins (Ck) 7,8, 20, vimentin, EMA, CEA and the mucin epitopes sialyl-Tn, Tn, CA19.9, CA125, against the BerEP4 and CD15; 3 colonic adenocarcinomas metastatic to the brain and a case of meningioma with metastasis from a gastric signet-ring cell carcinoma were also studied with the same panel of MoAbs for comparison.

RESULTS

The 3 samples of arachnoid cap cells were positive only for EMA and vimentin in the supportive stroma. All 9 SMs resulted Ck7+, Ck8+, Ck20-, EMA+, CEA and mucin epitopes+, confirming at an immunohistochemical level the glandular differentiation. Notable exceptions were the negativity for BerEP4 and CD15 antigens. Conversely, the 3 metastatic colonic adenocarcinomas to the brain were Ck7-, Ck8+, Ck20+, CEA and mucin epitopes+, BerEP4 and CD15+; the gastric signet-ring cell carcinoma metastatic to a meningioma showed the same immunophenotype as the other metastatic adenocarcinomas with the exception of BerEP4 negativity.

CONCLUSION

The different pattern of cytokeratin expression (Ck7+/Ck20- for SMs, and Ck7-/ Ck20+ for adenocarcinomas) and the negativity for BerEP4 and CD15 epitopes of SMs, could be relevant for the distinction between SMs and metastatic adenocarcinomas.