Management of symptomatic uncomplicated diverticular colon disease: A systematic review of diagnosis and treatment. / Enfermedad diverticular de colon no complicada sintomática: revisión sistemática del diagnóstico y tratamiento.

Symptomatic uncomplicated diverticular colon disease (SUDCD) is a highly prevalent disease in our setting, which significantly affects the quality of life of patients. Recent changes in understanding the natural history of this disease and technological and pharmacological advances have increased the available options for both diagnosis and treatment. However, consensus regarding the use of these options is scarce and sometimes lacks scientific evidence. The objective of this systematic review is to clarify the existing scientific evidence and analyse the use of the different diagnostic and therapeutic options for SUDCD, comparing their advantages and disadvantages, to finally suggest a diagnostic-therapeutic algorithm for this pathology and, at the same time, propose new research questions.

Risk factors for open conversion of lateral transperitoneal laparoscopic adrenalectomy: retrospective cohort study of the Spanish Adrenal Surgery Group (SASG).

BACKGROUND: Laparoscopic adrenalectomy has become the standard of care for treating adrenal tumors. Conversion from laparoscopic adrenalectomy to an open approach during surgery may be necessary in some cases. This study aimed to identify the risk factors for open conversion of laparoscopic adrenalectomy. METHODS: Retrospective analysis of all consecutive patients undergoing lateral transperitoneal laparoscopic adrenalectomy in six endocrine surgery units of the Spanish Adrenal Surgery Group (SASG) between January 2005 and December 2017. Demographic, clinical, surgical, and histopathologic characteristics were recorded. Risk factors for conversion were assessed by logistic regression analysis. RESULTS: Of a total of 865 patients included in the study, 58 (6.7%) required conversion to open surgery. In the univariate analysis, factors associated with conversion from laparoscopic to open adrenalectomy were body mass index (BMI) ≥ 30 kg/m2 (P = 0.002), previous abdominal surgery (P = 0.015), tumor size > 5 cm (P = 0.001), and surgery for pheochromocytoma (P = 0.034). In the multivariate analysis, independent risk factors were BMI ≥ 30 kg/m2 [odds ratio (OR) 4.26, 95% confidence interval (CI) 2.81-8.75; P = 0.001], tumor size > 5 cm (OR 10.15, 95% CI 4.24-28.31; P < 0.001), and surgery for pheochromocytoma (OR 2.96, 95% CI 1.89-11.55; P = 0.015). CONCLUSIONS: Obesity, tumor size, and pheochromocytoma as the type of adrenal tumor were predictive factors for intraoperative conversion from laparoscopic to open adrenalectomy. Preoperative assessment of these characteristics should be valuable to clinicians in discussing conversion risk in patients and for surgical planning.

Pilot study of living donor liver transplantation for patients with hepatocellular carcinoma exceeding Milan Criteria (Barcelona Clinic Liver Cancer extended criteria).

A subset of patients with hepatocellular carcinoma (HCC) beyond Milan criteria might obtain acceptable survival outcomes after liver transplantation. Living donor liver transplantation (LDLT) has emerged as a feasible alternative to overcome the paucity of donors. In 2001, we started a protocol for LDLT in Child A-B patients with HCC fulfilling a set of criteria-the Barcelona Clinic Liver Cancer (BCLC) expanded criteria-that expanded the conventional indications of transplantation: 1 tumor ≤ 7 cm, 5 tumors ≤ 3 cm, and 3 tumors ≤ 5 cm without macrovascular invasion or downstaging to Milan after locoregional therapies. We present a prospective cohort of 22 patients with BCLC extended indications based on size/number (n = 17) or downstaging (n = 5) treated with LDLT between 2001 and 2014. Characteristics of the patients were as follows: median age, 57 years old; males/female, n = 20/2; Child-Pugh A/B, n = 16/6; and alpha fetoprotein < 100 ng/mL, n = 21. Twelve patients received neoadjuvant locoregional therapies. At the time of transplantation, 12 patients had HCC staging beyond Milan criteria and 10 within. Pathological reports showed that 50% exceeded BCLC expanded criteria. Perioperative mortality was 0%. After a median follow-up of 81 months, the 1-, 3-, 5-, and 10-year survival was 95.5%, 86.4%, 80.2%, and 66.8%, respectively. Overall, 7 patients recurred (range, 9-108 months), and the 5-year and 10-year actuarial recurrence rates were 23.8% and 44.4%, respectively. In conclusion, a proper selection of candidates for extended indications of LDLT for HCC patients provide survival outcomes comparable to those obtained within the Milan criteria, but these results need confirmation. Liver Transplantation 24 369-379 2018 AASLD.

Endoscopic-assisted laparoscopic resection for gastric subepithelial tumors.

BACKGROUND: Laparoscopic resection is considered the treatment of choice for gastric subepithelial tumors. Occasionally, it is necessary to perform an intraoperative gastroscopy to localize the lesion. There are no data in the literature addressing the factors that can predict when a combined laparoscopic-endoscopic approach will be needed. METHODS: A retrospective cohort study using a prospectively collected database was conducted. From January 2005 to December 2013, all the patients undergoing a laparoscopic gastric resection for subepithelial tumors irresectable by endoscopy were reviewed. Potential predictive factors for the need of an intraoperative endoscopy were analyzed. RESULTS: Thirty-eight consecutive patients (22 men and 16 women) with a mean age of 67 (41-86) years underwent laparoscopic gastric resection for subepithelial tumors. Fourteen (36.8%) patients required intraoperative endoscopic assessment. The only significant factors related to the need of endoscopic assessment during surgery were tumor growth pattern (P = 0.002) and size (P = 0.001). CONCLUSIONS: An accurate description of tumor growth pattern and size by EUS is recommended in the preoperative assessment of gastric subepithelial tumors. Small tumors (≤18 mm) with an intraluminal growth may need a combined endoscopic-assisted laparoscopic management.

Retinoic acid reduces solvent-induced neuropathy and promotes neural regeneration in mice.

In humans, exposure to organic solvents (OS) is frequent in work activities or as a recreational inhalant, inducing severe neuropathy (secondary to demyelization of peripheral nerves). We have previously shown that all-trans retinoic acid (ATRA) increases local content of neural growth factor (NGF), improving peripheral neuropathy of diverse origins. In this study, we evaluated the effect of ATRA on OS-induced peripheral neuropathy in experimental mice. Two simultaneous experiments were performed. The first one aimed to evaluate ATRA for the prevention of damage induced by OS, the second to test ATRA as an OS-induced neuropathy treatment. Nociceptive threshold latency and NGF concentration in serum and in peripheral nerves were determined. Morphological changes and evidence of sciatic nerve regeneration were evaluated. Mice exposed to OS developed neuropathy and axonal degeneration. ATRA diminished the effects of OS inhalation on sensorial changes and nerve morphology. Treatment with ATRA reversed sensorial and nerve morphological changes of OS-induced neuropathy, and this was associated with increased contents of NGF. Similar to previous experiences on diabetic and toxic neuropathy, ATRA reduced and partially reversed the peripheral neuropathy caused by OS exposure. These favorable effects apparently are due to local production of NGF induced by neural regeneration in response to the administration of retinoic acid.

Autoimmune pancreatitis: a surgical dilemma.

Autoimmune pancreatitis (AIP) is defined as a particular form of pancreatitis that often manifests as obstructive jaundice associated with a pancreatic mass or an obstructive bile duct lesion, and that has an excellent response to corticosteroid treatment. The prevalence of AIP worldwide is unknown, and it is considered as a rare entity. The clinical and radiological presentation of AIP can mimic bilio-pancreatic cancer, presenting difficulties for diagnosis and obliging the surgeon to balance decision-making between the potential risk presented by the misdiagnosis of a deadly disease against the desire to avoid unnecessary major surgery for a disease that responds effectively to corticosteroid treatment. In this review we detail the current and critical points for the diagnosis, classification and treatment for AIP, with a special emphasis on surgical series and the methods to differentiate between this pathology and bilio-pancreatic cancer.

Continuous innovation in precision radio-guided surgery.

Since its origins, nuclear medicine has faced technological changes that led to modifying operating modes and adapting protocols. In the field of radioguided surgery, the incorporation of preoperative scintigraphic imaging and intraoperative detection with the gamma probe provided a definitive boost to sentinel lymph node biopsy to become a standard procedure for melanoma and breast cancer. The various technological innovations and consequent adaptation of protocols come together in the coexistence of the disruptive and the gradual. As obvious examples we have the introduction of SPECT/CT in the preoperative field and Drop-in probes in the intraoperative field. Other innovative aspects with possible application in radio-guided surgery are based on the application of artificial intelligence, navigation and telecare.

Unilateral axilo-breast approach (UABA) with gas insufflation versus open conventional hemithyroidectomy: A prospective comparative study.

BACKGROUND: The objective of this study was to compare with the conventional open approach, the surgical and aesthetic results of endoscopic thyroidectomy via unilateral axillo-breast approach (UABA) with gas insufflation in patients with a unilateral thyroid nodule. METHODS: Between August 2017 and August 2020, a prospective comparative cohort study was carried out in patients proposed for hemithyroidectomy. The patients were assigned to one type of approach (Open or Endoscopic) in a successive manner. Surgical results and aesthetic satisfaction at hospital discharge and during the 12-month follow-up were evaluated and compared between both groups. RESULTS: A total of 200 patients were included in the study: 100 for the Open approach and 100 for the Endoscopic. The baseline patient characteristics were similar between both groups. Total operative time was longer in the Endoscopic approach, due to the time required for subcutaneous dissection (the hemithyroidectomy time was similar in both groups). There was no significant difference in the frequency of major complications. The length of hospital stay was longer (for 1 day) in the Endoscopic group. The aesthetic satisfaction of the patients was significantly higher in the Endoscopic than in the Open group (p < 0.001), at hospital discharge and at 12-month follow-up. CONCLUSION: UABA with gas insufflation for hemithyroidectomy represents a safe and effective therapeutic option for the treatment of unilateral benign thyroid pathologies.

Minilaparoscopy-assisted natural orifice total colectomy: technical report of a minilaparoscopy-assisted transrectal resection.

BACKGROUND: Experimental experience and the technological evolution of minimally invasive surgical devices have allowed initial reports describing the clinical applicability of natural orifice translumenal endoscopic surgery (NOTES). Colorectal resections are an interesting target for the NOTES platform. Theoretically, the transrectal approach could overcome the proposed limitations of transvaginal access, increasing NOTES clinical applicability. Hybrid procedures such as minilaparoscopy-assisted natural orifice surgery (MA-NOS) are the safe progression to pure NOTES. This report describes the first clinical case of a transrectal MA-NOS total colectomy. METHODS: The patient was a 36-year-old man with severe ulcerative colitis (UC) who experienced failure of immunosuppressive therapy. The standard steps of laparoscopic total colectomy were respected, with basic triangulation maintained throughout the case. A transrectal endoscopic device was used for optic assistance, colon dissection, ileum section, and specimen retrieval. Transrectal MA-NOS total colectomy was assisted by three laparoscopic ports: a 12-mm port used as the terminal ileostomy site, a 2-mm needle epigastric port, and a 5-mm umbilical port used as a drain site at the final intervention. No intraoperative complications occurred. RESULTS: The total operative time was 240 min. Oral intake was initiated on postoperative day 2. Because of UC rectal activity, a course with azathioprine was completed, and the patient was discharged receiving 1 g of rectal mesalazine for maintenance. The final pathology demonstrated pancolonic inflammatory bowel disease in the form of UC with severe activity. CONCLUSIONS: Transrectal MA-NOS total colectomy was feasible and safe in the reported case. Improvement in NOTES instrumentation and selective clinical applications are mandatory before clinical trials.

Thyroidectomy via unilateral axillo-breast approach (UABA) with gas insufflation: prospective multicentre European study.

BACKGROUND: Extracervical approaches for thyroidectomy are seldom explored in the western population. The objective of this study was to evaluate the outcomes of hemithyroidectomy via endoscopic unilateral axillo-breast approach (UABA) with gas insufflation. METHOD: Consecutive patients undergoing UABA hemithyroidectomy for symptomatic benign or cytologically indeterminate nodules (Bethesda III lesions) of less than 5 cm from July 2015 to December 2020 at three European institutions were included. Patients were excluded if presenting with a BMI more than 25 kg/m2, had previous neck surgery and/or radiation, had bilateral thyroid lesions, retrosternal goitre, Hashimoto thyroiditis or Graves' disease. Follow-up was carried out at 2 weeks, 3 months and 1 year. Outcomes of interest were surgical (including operating time, mean duration of hospital stay and complications) and self-assessed cosmetic outcomes. RESULTS: Out of 984 patients treated with hemithyroidectomy during the study interval, 253 were selected, including 214 women and 39 men. Patients' mean age was of 46.6 years with a mean BMI of 22.57. Mean operating time was 72.9 minutes. A transient recurrent laryngeal nerve injury was reported in 3.6 per cent of the patients, but none was persistent. Transient pectoral/cervical hypoesthesia was noted in 24.1 per cent of patients, with no permanent hypoesthesia. Skin burns and subcutaneous hematoma developed in 2.4 per cent and 2 per cent of patients but resolved within the third month after surgery. There was no tracheal/oesophageal perforation, conversion to open surgery or reoperation. The final pathology revealed 241 benign nodules, nine underlying papillary thyroid carcinomas, and three cases of follicular carcinoma. Hospital discharge was achieved on the first in 68.8 per cent of the patients and on the second postoperative day in 31.2 per cent of the cases. All patients were satisfied with the cosmetic aspect. CONCLUSION: In selected patients, UABA with gas insufflation for hemithyroidectomy could be performed for the treatment of unilateral thyroid pathologies.

Comparison of [18F]fluorocholine PET/CT with [99mTc]sestamibi and ultrasonography to detect parathyroid lesions in primary hyperparathyroidism: a prospective study.

Background: Primary hyperparathyroidism is a common endocrine disorder produced by the increase of parathyroid hormone (PTH) due to a benign adenoma of a single parathyroid gland, or as multiple gland hyperplasia, or as a rare malignant tumor. Preoperative imaging scans are frequently necessary for the minimally invasive parathyroidectomies to identify the location of enlarged parathyroid glands and to design the procedure. Methods: The diagnostic reliability of [18F]fluorocholine positron emission tomography/computed tomography (FCH PET/CT), [99mTc]sestamibi [multiplexed ion beam imaging (MIBI)] and cervical ultrasonography was analyzed in 37 patients diagnosed with primary hyperparathyroidism undergoing minimally invasive parathyroidectomy. The three preoperative imaging techniques were correlated with intraoperative and histopathological findings as well as changes in biochemical parameters (serum PTH and calcium levels). Statistical analysis was carried out with SPSS version 24.0. Results: In 30 of 37 patients (81.1%), FCH PET/CT correctly localized the pathological gland. In 3 cases of ectopic adenomas, the accuracy of the techniques was 100% (3/3) for FCH PET/CT, 66.7% (2/3) for MIBI, and 33.3% (1/3) for neck ultrasonography. Neither neck ultrasonography nor MIBI were able to locate pathological parathyroid glands in those patients with multiglandular disease, while FCH PET/CT correctly located one patient (1/3, 33.3%) with two adenomas and 3 patients (3/6, 50.0%) with hyperplasia. The three imaging techniques, FCH PET/CT, MIBI and neck ultrasound yielded a sensitivity of 92.1%, 57.9% and 32.4%, a positive predictive value of 94.6%, 84.6% and 78.6%, and a diagnostic accuracy of 96.4%, 85.7% and 79.0%, respectively. Conclusions: In this group of patients diagnosed with primary hyperparathyroidism, FCH PET/CT was superior to MIBI and neck ultrasound in detecting adenomas, particularly in the presence of ectopic glands or multiglandular disease.

Triple-negative breast cancer in Hispanic patients: high prevalence, poor prognosis, and association with menopausal status, body mass index, and parity.

BACKGROUND: Triple-negative breast cancer (TNBC) is defined as breast cancer that is negative for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2. TNBC represents 15% of all invasive breast cancers, but some studies have suggested that its prevalence differs between races. To the authors' knowledge, no previous studies have determined the prevalence of TNBC and its risk factors among Hispanic women. METHODS: The authors identified 2074 Hispanic women with breast cancer who attended the National Cancer Institute in Mexico City from 1998 to 2008. All histopathologic and immunohistochemical diagnoses were rereviewed by a breast cancer pathologist. The prevalence of TNBC, its association with clinicopathologic characteristics, and its prognostic impact were determined. RESULTS: The median patient age at diagnosis (±standard deviation) was 50 ± 12 years. The overall prevalence of TNBC was 23.1%. Younger age (P < .001), premenopausal status (P = .002), increased parity (P = .029), hormonal contraceptive use (P = .04) high histologic grade (P < .001), and advanced disease (P < .001) were associated independently with TNBC. Postmenopausal patients who had a body mass index (BMI) <25 kg/m(2) (P = .027) or <30 kg/m(2) (P < .001) were more likely to have TNBC. In multivariate analysis, patients with TNBC had a higher risk of locoregional recurrence (LRR), lower disease-free survival (DFS) (hazard ratio, 1.62; 95% confidence interval, 1.13-2.32; P = .009), and a lower cancer-specific survival (CSS) rate (hazard ratio, 1.66; 95% confidence interval, 1.20-2.30; P = .002) than patients with non-TNBC. CONCLUSIONS: The median age at diagnosis of Hispanic women with breast cancer was 11 years younger than the average age reported in the United States. The prevalence of TNBC in this study population was higher than that reported in white women with breast cancer. TNBC was associated with a higher risk of LRR and with lower DFS and CSS than those in patients with non-TNBC.

Angiogenesis and expression of estrogen and progesterone receptors as predictive factors for recurrence of meningioma.

Meningiomas are benign tumors, with low rate of recurrence after surgery. The most important factor predicting recurrence is the extent of surgical resection; other factors have been studied with conflicting results. Angiogenesis, an important substratum for growth and spread of neoplasic cells, and the expression of estrogen and progesterone receptors (ER, PR), could play a role in the recurrence of meningioma. We evaluated 42 patients with meningioma diagnosis (confirmed by histopathology) treated exclusively by surgery between January 1995 and December 1999, and compared the recurring and non-recurring groups after a ten-year follow-up period. Recurrence was associated with several factors including vascular density (VD), cell proliferation index (CPI), ER, PR, and cyclin E (CE) tissue expression, as evaluated by immunohistochemistry. Complete surgical resection was achieved in 41% of patients. Recurrence of meningioma was found in 17 patients (40%). Median + or - standard deviation (SD) of recurrence time was 32 + or - 5 months. When recurrence versus no recurrence was compared, mean + or - SD of VD and CPI were 9 + or - 3.6 and 607.6 + or - 233 (40x/10 fields) respectively. Tissue expression was positive for ER, PR, and CE in 28, 62 and 91% of patients, respectively. The sole significant recurrence-associated factors were extent of resection (P = 0.003) and VD (P = 0.004). ER, PR, and CE-tissue expression were not statistically significant. The most important factor associated with meningioma relapse was vascular density, independently of hormonal status and extent of surgical resection. Patients with a high risk of recurrence could benefit from additional treatment.

Brain metastasis development and poor survival associated with carcinoembryonic antigen (CEA) level in advanced non-small cell lung cancer: a prospective analysis.

BACKGROUND: Central nervous system is a common site of metastasis in NSCLC and confers worse prognosis and quality of life. The aim of this prospective study was to evaluate the prognostic significance of clinical-pathological factors (CPF), serum CEA levels, and EGFR and HER2 tissue-expression in brain metastasis (BM) and overall survival (OS) in patients with advanced NSCLC. METHODS: In a prospective manner, we studied 293 patients with NSCLC in IIIB-IV clinical stage. They received standard chemotherapy. CEA was measured prior to treatment; EGFR and HER2 were evaluated by immunohistochemistry. BM development was confirmed by MRI in symptomatic patients. RESULTS: BM developed in 27, and 32% of patients at 1 and 2 years of diagnosis with adenocarcinoma (RR 5.2; 95% CI, 1.002-29; p = 0.05) and CEA > or = 40 ng/mL (RR 11.4; 95% CI, 1.7-74; p < 0.01) as independent associated factors. EGFR and HER2 were not statistically significant. Masculine gender (RR 1.4; 95% CI, 1.002-1.9; p = 0.048), poor performance status (RR 1.8; 95% CI, 1.5-2.3; p = 0.002), advanced clinical stage (RR 1.44; 95% CI, 1.02-2; p = 0.04), CEA > or = 40 ng/mL (RR 1.5; 95% CI, 1.09-2.2; p = 0.014) and EGFR expression (RR 1.6; 95% CI, 1.4-1.9; p = 0.012) were independent associated factors to worse OS. CONCLUSION: High CEA serum level is a risk factor for BM development and is associated with poor prognosis in patients with advanced NSCLC. Surface expression of CEA in tumor cells could be the physiopathological mechanism for invasion to CNS.

Minimally-invasive endocrine neck surgery. / Cirugía endocrina cervical mínimamente invasiva.

Minimally invasive approaches for endocrine surgery of the neck are the result of efforts by several surgeons to extrapolate to neck surgery the proven benefits of minimally invasive techniques from other regions of the body, including less pain, morbidity and hospital stay. However, the main argument that led to the introduction of these techniques was the improvement of esthetic results. Endoscopic and robotic remote-access endocrine neck approaches through small incisions have been developed over the last 25 years and are constantly being refined. The objective of this review is to determine the current state of the literature through a systematic evaluation of the different techniques available in minimally invasive endocrine surgery of the neck, either with or without remote access, by describing their main characteristics and evaluating their advantages, disadvantages and controversies, while discussing their role and future in neck surgery.

Intussuscepted Metachronous small bowel tumor after treatment for colorectal adenocarcinoma.

INTRODUCTION: Small Bowel adenocarcinoma (SBA) is a rare malignant neoplasm without specific signs or symptoms. It's been associated with late stage disease presentations. Midterm outcomes have suggested that after successful removal of colorectal carcinoma, there is higher risk for developing a further primary (metachronous) colorectal tumor. However when it comes to small bowel, metachronous carcinomas are unusual. CASE PRESENTATION: A 46-year-old female who underwent an emergency Hartmann's procedure two years previously and treatment of adjuvant chemotherapy for adenocarcinoma of the sigmoid colon at stage IIB with loco-regional recurrence. The patient presented with bowel obstruction secondary to a small bowel intussusception, confirmed by computed tomography. An emergent exploratory laparotomy was performed and confirmed of an ileal tumor as the cause of small bowel intussusception and clinical bowel obstruction. Histopathology confirmed a primary small bowel mucinous adenocarcinoma with node metastasis (T3N1M0, stage IIIB). DISCUSSION AND CONCLUSION: Patients who develop a small or large bowel adenocarcinoma have high risk of presenting a second tumor at both sites. Since data available to guide therapeutic decisions for patients presenting with small bowel metachronic tumors are scarce, the role of adjuvant therapy in patients who undergo curative resection remains unclear. The aim of this manuscript is present a case report of a patient admitted for a rare obstructive small bowel intussusception therefore underwent surgery for metachronic small bowel carcinoma from colorectal primary witch previously treated by surgery and adjuvant chemiotherapy. Studies about strategies for detection at an earlier stage, optimal treatment and prognosis are mandatory for this disease.

Surgical outcomes of total thyroidectomy using the LigaSure™ Small Jaw versus LigaSure Precise™: A retrospective study of 2000 consecutive patients.

BACKGROUND: We compared surgical outcomes of LigaSure™ Small Jaw, which is a multifunctional thermal device that incorporates a tissue divider versus LigaSure Precise™ in thyroid surgery. METHODS: A retrospective, single-center study was carried out in an acute-care teaching hospital in Barcelona, Spain. Between January 2008 and June 2015, consecutive patients scheduled for total thyroidectomy were included in the study. Surgical outcomes were operative time, length of skin incision, use of a suction drain, intraoperative bleeding, postoperative complications and length of hospital stay. RESULTS: A total of 2000 patients were included (LigaSure™ Small Jaw, n = 1000; LigaSure Precise™, n = 1000). Demographics and indication for surgery were similar in both groups. A significant and independent shorter operative time (median 40 vs. 65 min, P = 0.002), smaller length of the skin incision (mean [SD] 4 [2] vs. 7 [3] cm, P = 0.031), lower percentages of patients with suction drain (15% vs. 66%, P = 0.012) and intraoperative bleeding (4% vs. 9%, P = 0.045) and reduced length of stay (median 1 vs. 3 days, P = 0.039) were found in the LigaSure™ Small Jaw than in the LigaSure Precise™. Postoperative complications including haematoma, hypoparathyroidism and recurrent laryngeal nerve injury were similar. CONCLUSIONS: The LigaSure™ Small Jaw in thyroid surgery results in significant less blood loss and operative time as well as shorter hospital stay compared to LigaSure Precise™. These findings could have direct application in daily practice.