BILATERAL CAROTID BODY PARAGANGLIOMAS - LITERATURE REVIEW AND COMMENTS IN A PATIENT WITH NO SIGNS OF MEN SYNDROME

Paragangliomas are rare neuroendocrine slow-growing tumors, often asymptomatic, that originate from embryonic neural crest cell. In the head and neck area, the most common location is the carotid body, followed, with decreasing frequency, in jugular, tympanic and vagal sites. Bilateral carotid body tumors are extremely rare.

Aim

To present the most important features of carotid body paragangliomas, illustrating the clinical characteristics, associated with a thorough analysis of the diagnostic imaging elements, but also the current therapeutic strategies, with respective anatomical, surgical considerations and potential complications that can occur. Surgical resection is the main line of treatment. The complex anatomy of the cervical region and the close relationships of carotid body paragangliomas with carotid vessels and cranial nerves, as well as its intense vascularization makes the surgical intervention a real challenge even for an experienced surgeon.

Discussion

Starts from a bilateral carotid paraganglioma in a 35-year-old male, with painless lateral neck swelling, accidentally discovered by his barber about two years ago. Diagnosis was suspected on the basis of history, clinical and radiological findings. "Wait and scan" strategy plus endocrinologic assessment for MEN syndromes were considered the optimal therapeutic approach in this case.

Self-reported disease severity in women with systemic lupus erythematosus

Systemic lupus erythematosus (SLE), pathology with net feminine predominance, is one of the most complex autoimmune diseases and has major impact on patients' life. The aim is to identify patient and disease-related factors associated with self-perceived disease severity in female SLE patients. This cross-sectional study enrolled 73 women fulfilling the 2012 Systemic Lupus International Collaborating Clinic (SLICC) criteria. SLE disease activity was assessed by the Systemic Lupus Activity Measure (SLAM) score and overall damage by the SLICC/American College of Rheumatology (ACR) index. Patients' general characteristics, associated conditions as well as SLE specific clinical involvements and therapeutic principles were also noted. Fatigue was assessed by FACIT-fatigue scale. Self-perceived disease severity was assessed using numerical rating scales (1-10 NRSs), to evaluate the disease severity at inclusion (1-10 NRS now) and worst severity anytime during disease history (1-10 NRS worst ever). In regard to worst ever lupus severity, 54.8% of patients responded with 9 or 10, while none with 1 or 2 even if only 22.9% of the patients responded with 7 or more for disease severity at inclusion (1-10 NRS now). Women with higher 1-10 NRS now answers had also higher 1-10 NRS worst ever, SLAM, SLICC, and FACIT-fatigue scores. They associated more frequently anxiety/depression diagnosis, antiphospholipid syndrome, joint involvement as well as treatments with corticosteroids. Self-reported disease severity worst ever, anxiety/depression diagnosis, fatigue, and the daily dose of corticosteroids were independently associated with patients' perception on lupus severity at inclusion: OR (95% CI), 2.13 (1.15-3.94) p = 0.017, 6.67 (1.11-39.97) p = 0.038, 1.10 (1.02-1.19) p = 0.018, and 1.11 (1.02-1.21) p = 0.020, respectively. The vast majority of patients identified severe and very severe events during their disease history, results that raise awareness of burden concerning lupus occurrence in women's life. Self-perceived lupus severity is multifactorial, influenced also by factors less considered in the SLE management like fatigue and the depression/anxiety disorders, but also by the previous patient's experience.

Image quality in extended ARC filtered digital tomosynthesis

Purpose: To study image quality in filtered digital tomosynthesis (FDTS) tomograms as a function of their reconstruction arc, using isocentrically acquired, fluoroscopic projection data.

Material and Methods: Both digital tomosynthesis (DTS) and cone beam CT (CBCT) reconstruction algorithms are based on backprojection and use cone beam projection data as input. Under limited angle conditions, CBCT is reduced to FDTS, where only a subset of projection data are used for reconstruction. The effect of the reconstruction arc on the spatial resolution, slice thickness, contrast sensitivity, shape distortion and artifacts, was also experimentally studied. The investigation was performed using both simulated and actual fluoroscopic images.

Results and Conclusion: Image quality in terms of spatial resolution, slice thickness, shape distortion and artifacts, improved with increasing reconstruction arc and was optimized at 180°, while contrast continued to improve as the arc was increased to 360°. However, DTS was determined to be the technique of choice when reconstruction arcs of less than 40° were used. Consequently, FDTS may be successfully implemented in applications involving extended arc reconstructions, in the range between 40° delimiting the DTS domain and 360° corresponding to CBCT.

Application of artificial neural networks to a study of nursing burnout

Nursing is generally considered to be a profession with high levels of emotional and physical stress that tend to increase. These high stress levels lead to a high risk of burnout. The objective was to assess whether artificial neural network (ANN) paradigms offer greater predictive accuracy than statistical methodologies, which are commonly used in the field of burnout. A radial basis function (RBF) network and hierarchical stepwise regression was used to assess burnout. The comparison of the two methodologies was carried out by analysing a sample of 462 nurses and student nurses. The subjects were from three hospitals in Madrid (Spain), who completed the 'Nursing Burnout Scale' survey. A RBF network was better suited for the analysis of burnout than hierarchical stepwise regression. The outcomes indicate furthermore that the relationship with the burnout process of the predictive variables age, job status, workload, experience with pain and death, conflictive interaction, role ambiguity and hardy personality is not entirely linear. The usage of ANNs in the field of burnout has been justified due to their superior ability to capture non-linear relationships, which is relevant for theory development. STATEMENT OF RELEVANCE: Due to the superior ability to capture non-linear relationships, ANNs are better suited to explain and predict burnout and its subdimensions than common statistical methods. From this perspective, more specific programmes to prevent burnout and its consequences in the workplace can be designed.

IL-17 in cutaneous lupus erythematosus

BACKGROUND

Lupus erythematosus (LE) is a heterogeneous disease with broad clinical spectrum from cutaneous to visceral and systemic inflammation. IL-17 isoforms (IL-17A and IL-17F) are proinflammatory cytokines with unclear implications in lupus erythematosus pathogenesis. In this study we focused upon IL-17 in normal and modified lupus skin with a correlative study between local and serological expression.

MATERIAL AND METHODS

89 subjects were recruited and divided in 5 groups-10 patients with psoriasis (disease control group), 13 healthy controls, 26 with discoid chronic lupus (DLE), 23 with systemic lupus erythematosus (SLE) and 17 with subacute lupus erythematosus (SCLE). Blood samples and skin punched-biopsy specimens were performed. Serum IL-17A, IL-17F, and IL-23 concentrations were determined by ELISA. Skin IL-17A and CD4 expression were evaluated by immunohistochemistry.

RESULTS

Immunohistochemical expression of IL-17A was higher in DLE, SCLE and SLE patients than in negative control subjects (all p<0.05). Serum IL-17A concentrations were higher in DLE and SLE patients than in negative controls (p<0.05). Serum IL-17A levels were similar in SCLE and negative controls (p>0.05). Serum IL-17F concentrations were higher in DLE, SCLE and SLE patients than in healthy controls (all p<0.05). In DLE, SCLE, SLE patients and healthy controls we observed comparable levels of IL-23 (p>0.05). Serum anti Ro antibodies correlate with IL-17A+ lymphocytes from SCLE lesion and SLE normal skin (all p<0.05).

CONCLUSION

IL-17 isoforms (IL-17A and IL-17F) are implicated in SLE but also in DLE and SCLE immunopathogenesis.

Micro-CT with respiratory and cardiac gating

Cardiopulmonary imaging in rodents using micro-computed tomography (CT) is a challenging task due to both cardiac and pulmonary motion and the limited fluence rate available from micro-focus x-ray tubes of most commercial systems. Successful imaging in the mouse requires recognition of both the spatial and temporal scales and their impact on the required fluence rate. Smaller voxels require an increase in the total number of photons (integrated fluence) used in the reconstructed image for constant signal-to-noise ratio. The faster heart rates require shorter exposures to minimize cardiac motion blur imposing even higher demands on the fluence rate. We describe a system with fixed tube/detector and with a rotating specimen. A large focal spot x-ray tube capable of producing high fluence rates with short exposure times was used. The geometry is optimized to match focal spot blur with detector pitch and the resolution limits imposed by the reproducibility of gating. Thus, it is possible to achieve isotropic spatial resolution of 100 microm with a fluence rate at the detector 250 times that of a conventional cone beam micro-CT system with rotating detector and microfocal x-ray tube. Motion is minimized for any single projection with 10 ms exposures that are synchronized to both cardiac and breathing motion. System performance was validated in vivo by studies of the cardiopulmonary structures in C57BL/6 mice, demonstrating the value of motion integration with a bright x-ray source.

Logarithmic amplifier for computed tomography tasks using fluoroscopic projections

The image intensifier (II)-based imaging systems, as radiotherapy simulators or C-arm X-ray units, have also been used for image acquisition in computed tomography. When analogue-to-digital conversion is performed on the output signal of the television camera, the accuracy for low-amplitude video signals, corresponding to X-ray pathways crossing high attenuation structures, is limited. To deal with this lack of accuracy, we investigated the benefits of using a logarithmic amplifier (LOGAMP) inserted between the television camera output and the analogue-to-digital converter (ADC) in the image acquisition chain. Such a device was intended to provide better use of the available ADCs of a given resolution and actually to reduce the quantization noise. Simulated data were used in this study, and cases with and without logarithmic amplifier were compared. Based on the simulation results, we formulate requirements for several signal and acquisition system parameters where the use of such a circuit is recommended.

[Association of atypical pulmonary TB, polyserositis, severe leukopenia and panniculitis. Case report]

Many reports have associated tuberculosis with haematological abnormalities. These reports suggest that severe pulmonary tuberculosis, if associated with reduced tissue cellular reaction, may cause blood discrasias. Anemia was present in 32 percent of patients. Leucopenia with neutropenia and lymphopenia was observed in 15 percent in patients with very severe clinical tuberculosis. Active tuberculosis was associated with significant reductions in absolute numbers of total T, T4 and B lymphocytes, but there were no significant differences in total T8 counts. T4 lymphopenia causes reversal of T4/T8 ratio. Also, many histopathologic diagnosis of panniculitis have been reported in tuberculosis patients--the incidence of panniculitis caused by tuberculosis was 8.2%. We present a case of secondary pulmonary tuberculosis with atypically Rx changes, associated with polyserositis and severe leucopenia, which debuted with a panniculitis.

[Chemical obliterans bronchiolitis after azotic acid exposure]

The authors present the case of a 48 years old man having an exposure to irritant gases (azotic and lactic acids) in a closed space, inhaling them for 5 minutes. Shortly after the accident the patient displayed the signs of corneal and conjunctival burn; several days afterwards respiratory symptoms appeared: shortness of breath, dyspnea to minor efforts, then nocturnal dyspnea and orthopnea. Chest X-ray, CT scan, complex lung function tests and bronchoalveolar lavaje, together with the history of recent exposure to irritant gases led to the diagnosis of hypersensitivity obliterant bronchiolitis. Oral corticoids in dose of 60 mg/day determined a substantial clinical, radiological and functional improvement. The authors make some comments on the need of early diagnosis and efficient treatment.

Three-dimensional localisation based on projectional and tomographic image correlation: an application for digital tomosynthesis

Accurate three-dimensional tumor localisation in Radiotherapy, is critical to the treatment outcome, particularly when high dose gradients are present. A number of techniques have been proposed for the localisation of anatomical structures or markers. The present study proposes an approach to a concurrent maximisation of localisation accuracy and efficiency by correlation of tomographic and projectional images. The method introduces an element of direct verification and interactive optimisation of the process. Tomographic images are used for the identification of a point of interest. Its position is computed within the treatment co-ordinate system and verification of this position is achieved by obtaining the beam's eye view of the identified point on two projection radiographs. The key element of the approach is that all images used should be part of one single image data set. The implementation of this localisation method, as part of the functionality of a Digital Tomosynthesis prototype, has provided an integrated facility for localisation, of optimised accuracy and precision, while easy and efficient to use. The considerations are general and apply in principle to any imaging system that can augment tomographic images with projections.

A wavelet-based method for removal of out-of-plane structures in digital tomosynthesis

Reconstructed images in digital tomosynthesis (DTS) are affected by artifacts due to blur from planes other than the fulcrum plane. A wavelet-based method has been developed for the discrimination and subsequent removal of unrelated structures from the reconstructed plane. The approach exploits both the specific pattern of noise in DTS and the spatial locality of the wavelet transformation. The technique was implemented on a DTS clinical protoype system. Experimental evaluation on angiographic types of images demonstrated excellent noise differentiation and elimination. The method is therefore particularly useful for certain medical imaging applications such as vascular DTS imaging.