P141 CORRELATION BETWEEN TAKO–TSUBO SYNDROME AND OCCULT CANCER

Introduction

Tako–Tsubo Syndrome (“TTS”) is a cardiomyopathy characterized by an acute reversible left ventricular dysfunction, mainly triggered by emotional or physical stress. Several variants have been reported, including reverse TTS, characterized by hypokinesia of basal segments and hyperkinesis of the apical ones. TTS has a clinical presentation similar to acute coronary syndrome but without evidence of obstructive coronary artery disease. A surprising association between TTS and cancer arose out of recent studies.

Case Presentation

74–year–old patient got to the emergency room of our hospital for the appearance, apparently in the health, in the absence of physical or emotional stress of oppressive chest pain. On the ECG, there was evidence of ST–segment elevation in inferior leads, for which urgent coronary angiography was performed. It did not show significant stenotic lesions nor evidence of elevated troponin values. The Echocardiogram showed hypokinesia of the basal segments and hyperkinesis of the mid–apical ones, with EF 40%. In the following days, the patient performed MRI–heart with detection of LGE of the intramyocardial type (non–ischemic pattern) in correspondence with the inferior wall in the medioventricular area. During hospitalization on routine chest x–ray, hypodiaphanous image was found in the left apex for which an HR CT scan of the chest was performed which a lesion in the left apical lung area with spiculated margins of a heteroplastic nature, associated with multiple bilateral lesions suggestive of secondaryism. Therefore, the patient was taken over by the Oncology service.

Conclusions

Such case confirms the association between TTS and occult cancer. In the absence of obvious physical or emotional stress that may explain the onset of TTS, it is important to research for any silent neoplastic pathology. The literature shows that the prevalence of malignant diseases is high in patients with TTS. Recent studies have pinpointed the activation of the sympathetic nervous system promotes cardiac inflammation by upregulating ICAM–1 and the expression of p53. Furthermore, inflammation can lead to the activation of p38 MAP Kinase, thus contributing to myocardial stunning. The specific role of inflammation as a cofactor of adrenaline–induced stunning deserves further investigation in the specific context of malignant tumors, which are frequently associated with an enhanced inflammatory state.

Recoil Directionality Experiment

Directional sensitivity to nuclear recoils could provide a smoking gun for a possible discovery of dark matter in the form of WIMPs. A hint of directional dependence of the response of a dual-phase liquid argon Time Projection Chamber was found in the SCENE experiment. Given the potential importance of such a capability in the frame work of dark matter searches, a new dedicated experiment, ReD (Recoil Directionality), was designed in the framework of the DarkSide Collaboration, in order to scrutinize this hint. This contribution will describe the performance of the detectors achieved during the first test-beam, the current status of ReD and the perspectives for physics measurements during the forthcoming beam-time.

Clinical features in insulin-treated diabetes with comorbid diabulimia, disordered eating behaviors and eating disorders

Adherence to self-management and medication regimens is required to achieve blood glucose control in diabetic patients. Therefore, diabulimia, the deliberate insulin restriction/omission to lose weight, and other disordered eating behaviors (DEBs) or eating disorders (EDs), place these patients at risk of complications.

We aimed to establish the frequency of diabulimia, DEBs and EDs among patients with type 1 and 2 diabetes (T1DM and T2DM) and their association with other clinical features.

A total of 211 insulin-treated diabetic patients (13–55 years old) answered the Diabetes Eating Problem Survey-Revised (DEPS-R), a diabetes-specific screening tool for DEBs, and the Eating Disorders Inventory-3 (EDI-3). SCID-I modified according to DSM-5 criteria was used to diagnose EDs.

At the DEPS-R, 20.8% of the sample scored above the cutoff, more frequently females (P = 0.005), patients with T1DM (P = 0.045), with a diagnosis of ED (P < 0.001), positive to the EDI-3 (P ≤ 0.001), with physical comorbidities (P = 0.003), with HbA1c > 7% (P = 0.020). Combining data from the interview with the results at the DEPS-R, 60.2% of the sample presented diabulimia. Dividing the sample by gender, we found that diabulimic females more frequently used diet pills (P = 0.006), had significantly higher HbA1c (P = 0.019) and STAI-Y1 scores (P = 0.004). Other DEBs comprised dietary restraint (51.8% of the sample), binge eating (42.2%), vomiting (6.2%), diet pills (7.1%) or laxatives (1.9%) or diuretics use (4.3%). Overall, 21.8% of the sample, mostly females (P < 0.001) met criteria for at least one DSM-5 diagnosis of ED.

Diabetic patients, especially women, should be carefully monitored for the presence of diabulimia, BEDs and EDs.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Risk factors in reoperative thyroid surgery for recurrent goitre: our experience

AIM

Reoperative thyroid surgery is an uncommon operation associated with a higher complication rate; we reviewed our series of patients on whom reoperative thyroid surgery was performed.

METHOD

106 patients had a thyroid reoperation for recurrent multinodular goiter (93 patients), recurrent thyrotoxicosis (3) or suspected malignancy (10); bilateral completion thyroidectomy was performed in 68 cases, lobectomy in 36, removal of a mediastinal recurrence and of a pyramidal remnant in 1 patient respectively.

RESULTS

Temporary hypoparathyroidism occurred in 41 patients (38.67%), definitive in 7 (6.6%), transient recurrent laryngeal nerve palsy in 5 (4.71%), permanent nerve palsy in 1 (0.94%); in 3 cases (2.83%) surgical revision of haemostasis was necessary for postoperative haemorrhage. After monolateral surgery we had 13 cases of transient hypoparathyroidism (34.21%), 2 of definitive (5.26%) and 1 transient recurrent laryngeal nerve palsy (2.63%); after bilateral surgery we had 29 cases of transient hypoparathyroidism (42.64%), 5 of definitive (7.35%), 4 of transient recurrent laryngeal nerve palsy (5.88%), 1 of definitive (1.47%) and 3 of postoperative bleeding (4.41%).

CONCLUSIONS

Reoperative thyroid surgery is a technical challenge with a high incidence of complications. Scarring, edema and friability of the tissues together with distortion of the landmarks make reoperative surgery hazardous. A higher risk of complications is described when previous surgery has been performed on both sides. Total thyroidectomy should be considered the procedure of choice for benign multinodular goiter eliminating the potential of a reoperation. Whenever necessary, reoperative thyroidectomy may be performed safely with little morbidity in experienced hands.

Computational models to predict stenosis growth in carotid arteries: which is the role of boundary conditions?

This work addresses the problem of prescribing proper boundary conditions at the artificial boundaries that separate the vascular district from the remaining part of the circulatory system. A multiscale (MS) approach is used where the Navier-Stokes equations for the district of interest are coupled to a non-linear system of ordinary differential equations which describe the circulatory system. This technique is applied to three 3D models of a carotid bifurcation with increasing stenosis resembling three phases of a plaque growth. The results of the MS simulations are compared to those obtained by two stand-alone models. The MS shows a great flexibility in numerically predicting the haemodynamic changes due to the presence of a stenosis. Nonetheless, the results are not significantly different from a stand-alone approach where flows derived by the MS without stenosis are imposed. This is a consequence of the dominant role played by the outside districts with respect to the stenosis resistance.

Primary mesenteric liposarcoma. Report of a case

Primary mesenteric liposarcomas are very rare neoplasms. The authors report a case of mesenteric liposarcoma recently observed. The patient presented with a history of dyspeptic syndrome, meteorism and abdominal pain associated with a change in bowel habit and constipation. On physical examination there was a large, well-circumscribed, abdominal mass. Computed tomography revealed an abdominal, dishomogeneous, low-density mass. Surgical excision with a tumour-free margin was achieved. The histologic appearances were those of a well-differentiated liposarcoma (atypical lipomatous tumour). The patient is alive and disease-free 33 months after the surgery. Primary mesenteric liposarcoma is often resectable and requires aggressive surgical management; in consideration of the high risk of tumour recurrence, the treatment of choice is a wide surgical excision.

[Spigelian hernia. Diagnosis and surgical treatment]

Spigelian hernia (SH) is a rare partial abdominal wall defect; its manifestation is rare. Seven cases were observed--4 females and 3 males with mean age of 56.5 years (range 38-65)--in 857 patients operated for hernia (0.8%) between 1995 and 2003. Ultrasound examination avoid the diagnosis and marked the fascial defect, measuring diameter and sac contents. In all cases a surgical approach with an epicritic incision has be done and the fascia defect closed with properitoneal and subfascial polypropylene mesh (Prolene Hernia System, PHS). All patients underwent to follow-up demonstrating no recurrences or complications like mesh suppuration or dislocation.

[Color Doppler ultrasound in acute mesenteric ischemia: 2 case reports]

Acute mesenteric insufficiency is a surgical emergency with a difficult methodological approach. Its high mortality is mainly due to delay in the correct diagnosis. In turn this is due to the lack of specificity, especially in the early-middle phase of the clinical presentation, and of the laboratory data and abdominal radiographic findings. Echo-doppler ultrasound promises to be more accurate than conventional ultrasound in the diagnosis of visceral ischemia and may help to identify those patients who may require angiography. Two women presenting atrial fibrillation, abdominal pain, leukocytosis, hyperamylasemia were accepted in October 2000 ad March 2001. US colordoppler was performed 12 hours after admittance demonstrating a "stop" of enhancement of the superior mesenteric artery in one case and absence of enhancement in the other.

Reconstruction and web distribution of measurable arterial models

In this paper a novel framework for the segmentation, 3D reconstruction and web distribution of vessel structures specifically tailored to the assessment of abdominal aortic aneurysms for endovascular surgery planning is presented. Deformable models are used for segmentation, while VRML97 and ECMA scripting are used to obtain models that are not only viewable from any VRML97 enabled browser, but that also allow users to perform, directly from standard web browsers, guided measurements of geometrical parameters, relevant to surgical planning.

Internet patient records: new techniques

BACKGROUND

The ease by which the Internet is able to distribute information to geographically-distant users on a wide variety of computers makes it an obvious candidate for a technological solution for electronic patient record systems. Indeed, second-generation Internet technologies such as the ones described in this article--XML (eXtensible Markup Language), XSL (eXtensible Style Language), DOM (Document Object Model), CSS (Cascading Style Sheet), JavaScript, and JavaBeans--may significantly reduce the complexity of the development of distributed healthcare systems.

OBJECTIVE

The demonstration of an experimental Electronic Patient Record (EPR) system built from those technologies that can support viewing of medical imaging exams and graphically-rich clinical reporting tools, while conforming to the newly emerging XML standard for digital documents. In particular, we aim to promote rapid prototyping of new reports by clinical specialists.

METHODS

We have built a prototype EPR client, InfoDOM, that runs in both the popular web browsers. In this second version it receives each EPR as an XML record served via the secure SSL (Secure Socket Layer) protocol. JavaBean software components manipulate the XML to store it and then to transform it into a variety of useful clinical views. First a web page summary for the patient is produced. From that web page other JavaBeans can be launched. In particular, we have developed a medical imaging exam Viewer and a clinical Reporter bean parameterized appropriately for the particular patient and exam in question. Both present particular views of the XML data. The Viewer reads image sequences from a patient-specified network URL on a PACS (Picture Archiving and Communications System) server and presents them in a user-controllable animated sequence, while the Reporter provides a configurable anatomical map of the site of the pathology, from which individual "reportlets" can be launched. The specification of these reportlets is achieved using standard HTML forms and thus may conceivably be authored by clinical specialists. A generic JavaScript library has been written that allows the seamless incorporation of such contributions into the InfoDOM client. In conjunction with another JavaBean, that library renders graphically-enhanced reporting tools that read and write content to and from the XML data-structure, ready for resubmission to the EPR server.

RESULTS

We demonstrate the InfoDOM experimental EPR system that is currently being adapted for test-bed use in three hospitals in Cagliari, Italy. For this we are working with specialists in neurology, radiology, and epilepsy.

CONCLUSIONS

Early indications are that the rapid prototyping of reports afforded by our EPR system can assist communication between clinical specialists and our system developers. We are now experimenting with new technologies that may provide services to the kind of XML EPR client described here.

Measurable models of abdominal aortic aneurysm on the Web

In this paper we describe a method for 3D reconstruction and web distribution of vessel structures specifically designed to allow the remote measurement of parameters of surgical interest. Deformable models are used for segmentation, while VRML and ECMA scripting are used to obtain 3D models that are not only viewable from any VRML97 enabled browser, but that also allow users to interact with the model, navigate along the vessel lumen and perform guided measurements of distances and angles.

NGF, a useful tool in the treatment of chronic vasculitic ulcers in rheumatoid arthritis

Vasculitic necrosis and ulceration of the skin are frequent complications of connective tissue diseases and are very difficult to heal. We treated chronic vasculitic leg ulcers in rheumatoid arthritis and systemic sclerosis by topical application of nerve growth factor (NGF). In all patients with rheumatoid arthritis, NGF led to rapid healing, whereas less striking results were obtained in patients with systemic sclerosis. The efficacy of NGF could be due to its promoting activity on keratinocytes proliferation and vascular neoangiogenesis. We suggest that topical application of NGF could represent a powerful pharmacological tool for the treatment of vasculitic ulcers.

Catheter insertion simulation with co-registered direct volume rendering and haptic feedback

We have developed an experimental catheter insertion simulation system supporting head-tracked stereoscopic viewing of volumetric anatomic reconstructions registered with direct haptic 3D interaction. The system takes as input data acquired with standard medical imaging modalities and regards it as a visual and haptic environment whose parameters are interactively defined using look-up tables. The system's display, positioned like a surgical table, provide a realistic impression of looking down at the patient. Measuring head motion via a six degrees-of-freedom head tracker, good positions to observe the anatomy and identify the catheter insertion point are quickly established with simple head motion. By generating appropriate stereoscopic images and co-registering physical and virtual spaces beforehand, volumes appear at fixed physical positions and it is possible to control catheter insertion via direct interaction with a PHANToM haptic device. During the insertion procedure, the system provides perception of the effort of penetration and deviation inside the traversed tissues. Semi-transparent volumetric rendering augment the sensory feedback with the visual indication of the inserted catheter position inside the body.

ViVa: the virtual vascular project

The aim of the virtual vascular project (ViVa) is to develop tools for the modern hemodynamicist and cardiovascular surgeon to study and interpret the constantly increasing amount of information being produced by noninvasive imaging equipment. In particular, we are developing a system able to process and visualize three-dimensional (3-D) medical data, reconstruct the geometry of arteries of specific patients, and simulate blood flow in them. The initial applications of the system will be for clinical research and training purposes. In a later stage, we will explore the application of the system to surgical planning. ViVa is based on an integrated set of tools, each dedicated to a specific aspect of the data processing and simulation pipeline: image processing and segmentation; real-time 3-D volume visualization; 3-D geometry reconstruction; 3-D mesh generation; and blood flow simulation and visualization.