Quantitative analysis of myocardial blood flow in surgically revascularized and not revascularized myocardial segments. A pilot PET study.

PURPOSE: To prospectively compare changes in myocardial blood flow (MBF) and myocardial flow reserve (MFR) in multivessel coronary artery disease (MVCAD) patients undergoing incomplete revascularization (IR) versus complete revascularization (CR) by coronary artery bypass grafting (CABG). METHODS: Seven male patients (age 68 ± 9 years) with MVCAD underwent myocardial perfusion PET/CT with [13N]ammonia before and at least 4 months after CABG. Segmental resting and stress MBF as well as MFR were measured. Resting and during stress left ventricle ejection fraction (LVEF) were also calculated. RESULTS: Three patients (43%) underwent CR and four (57%) IR. Among 119 myocardial segments, 101 (85%) were revascularized, and 18 (15%) were not. After CABG, stress MBF (mL/min/gr) and MFR are significantly increased in all myocardial segments, with a greater increase in the revascularized segments (p = 0.013). In both groups, LVEF significantly decreased during stress at baseline PET (p = 0.04), but not after CABG. CONCLUSION: Stress MBF and MFR significantly improve after CABG in both revascularized and not directly revascularized myocardial segments. IR strategy may be considered in patients with high surgical risk for CR.

High-dose intravenous immunoglobulin therapy for scleromyxoedema: a prospective open-label clinical trial using an objective score of clinical evaluation system.

BACKGROUND: Scleromyxoedema is a primary fibro-mucinosis whose therapy is still challenging. OBJECTIVE: To evaluate the safety and efficacy of high-dose intravenous immunoglobulin (IVIg) for the management of scleromyxoedema prospectively using an objective score. METHODS: In a prospective open-label study, IVIg was administered to eight patients with scleromyxoedema in a dose of 2 g/kg per month. The patients were followed-up to a minimum of 6 months, and their disease activity and response to treatment were assessed using the Physician's Global Assessment of disease severity (PGA) and a modified objective skin scoring system for patients with scleroderma (modified Rodnan score system for scleromyxoedema or mRSSS). We used a stringent statistical nonparametric test, the Mann-Whitney U-test, to assess the changes in the mRSSS following therapy with IVIg. RESULTS: Eight patients were included (five males) with a mean age of 59 years. Mean duration of scleromyxoedema was 19 months (6-37 months). The mean duration of treatment was 36.5 months (range 7-74 months).The patients were followed-up for a minimum of 15 months to a maximum of 87 months (mean 44 months). The mean baseline mRSSS of our cohort was 82.38 (37-145, SD 40.763) at the start of treatment, and this significantly decreased to 14.88 (0-37, SD 12.988) (P = 0.012) at the last clinical evaluation with a decrease in mRSSS of 81.6%. No considerable side effects were noted. Paraproteinemia remained substantially unchanged. In six cases, maintenance infusions were required to preserve disease control, while in two patients, therapy was stopped after 7 and 11 months. Relapses, however, occurred, respectively, after 6 and 25 months. CONCLUSIONS: Our study is the first to demonstrate a statistically clinical objective improvement of clinical symptoms of scleromyxoedema with IVIg.

Tracking target position variability using intraprostatic fiducial markers and electronic portal imaging in prostate cancer radiotherapy.

PURPOSE: Modern radiotherapy has achieved substantial improvement in tumour control and toxicity rates by escalating the total dose to the target volume while sparing surrounding normal tissues. It has therefore become necessary to precisely track tumour position in order to minimise geometrical uncertainties due to setup errors and organ motion. We conducted this prospective evaluation of prostate cancer patients treated with image-guided conformal radiation therapy at our institution. We implanted three fiducial markers (gold seeds) within the prostatic gland in order to quantify daily target displacements and to generate specific margins around the clinical target volume (CTV) to create an appropriate planned target volume (PTV). MATERIALS AND METHODS: Between April and December 2009, ten patients affected with localised prostate cancer were transrectally implanted with three radio-opaque markers. Each patient underwent a computed tomography (CT) scan for planning purposes following proper bladder and rectum preparation. During treatment two orthogonal images were acquired daily and compared with previously generated digitally reconstructed radiographs. After manual localisation, comparison between the position of the gold seeds on the portal and reference images was carried out, and a set of extrapolated lateral-lateral (LL), anterior-posterior (AP) and cranial-caudal (CC) shift corrections was calculated and recorded. Couch corrections were applied with a threshold of 3 mm displacement. RESULTS: Systematic and random errors for each direction were calculated either as measured according to displacement of the gold seeds prior to any couch movement and after couch position correction according to the radio-opaque markers. For skin marks, mean systematic and random errors were 0.12+2.94 mm for LL, 1.04+3.37 mm for AP, -1.14+2.71 mm for CC, whereas for seed markers, mean and systematic errors were 0.6+1.5 mm for LL, 0.51+2.45 mm for AP and -0.25+2.51 mm for CC. A scatter plot generated on all measurements after couch repositioning according to gold-seed displacement suggested a confidence range of shift distributions within 5 mm for LL, 8 mm for CC, and 7 mm for AP. The total systematic and random components were then used to calculate proper PTV in patients receiving conventional treatment (7 mm for LL and 9 mm for both AP and CC). CONCLUSIONS: Prostate positional variability during a course of radiation treatment is strongly influenced by setup and organ motion. Organ tracking through fiducial markers and electronic portal imaging is able to reduce the spread of displacements, significantly contributing to improve the ballistic precision of radiation delivery.

Activity and shelter-related behavior in Rhodnius prolixus: The role of host odours.

Triatomine bugs are considered nocturnal insects that feed on the blood of vertebrates and remain hidden inside narrow shelters during daylight hours. Nevertheless, it is not clear whether these insects become active and leave their shelters on a daily basis, less frequently or, even fortnightly. Activity patterns were studied in Rhodnius prolixus Stål, 1859 (Hemiptera: Triatominae) associated with shelters to evaluate whether the decision to leave a shelter depends on bug starvation and the presence of host odours. Experiments were conducted with groups of 5th instar nymphs released in an experimental arena offering an artificial shelter consisting of a piece of corrugated cardboard positioned in its centre. Results indicate that host odours promoted a significant increase in shelter related activity, i.e. shelter-leaving or entering movements, and also in bug locomotion. This increase could only be observed with bugs starved for 30 or 60 days, but not for 21 days. Most R. prolixus nymphs that left shelters and engaged in locomotory activity were starved and in the presence of host odours. Even though R. prolixus is mostly considered a very active and "aggressive" triatomine, our results contradict this perspective and suggest that its main strategy regarding hosts is to wait and carefully evaluate feeding chances before becoming exposed. This behavioural strategy might have arisen through their evolution in palm trees in association with a diverse fauna that may impose predation risks.

Exploratory Analysis on Overall Survival after Either Surgery or Stereotactic Radiotherapy for Lung Oligometastases from Colorectal Cancer.

AIMS: Lung metastasectomy and, more recently, stereotactic body radiotherapy (SBRT), are frequently proposed to stage IV oligometastatic colorectal cancer (CRC) patients. In the absence of a randomised comparison between the two treatments, we aimed to retrospectively explore the effect on overall survival and progression-free survival (PFS) in a comparative cohort study. MATERIALS AND METHODS: We included patients who consecutively underwent surgery (n = 142) or SBRT (n = 28) as first local therapy at the time of lung progression, between 2005 and 2012. Both overall survival and PFS functions according to treatment were calculated using the Kaplan-Meier method and compared using the Log-rank test. The effect of treatment on overall survival and PFS was estimated by Cox models using different adjustment methods. RESULTS: Patients receiving SBRT were older and were treated more recently, whereas the two cohorts were similar for most baseline prognostic factors. Overall survival at 1 and 2 years was 0.89 and 0.77 for SBRT and 0.96 and 0.82 for surgery (P = 0.134), respectively. Multivariable analyses did not highlight a clear treatment effect on overall survival (adjusted hazard ratioSBRT versus surgery = 1.71; 95% confidence interval 0.82-3.54; P = 0.149) and even smaller differences using the inverse probability treatment weighting method (hazard ratioSBRT versus surgery = 1.28, 95% confidence interval 0.58-2.82; P = 0.547). The results of PFS were unreliable because different follow-up protocols were applied in the two cohorts. CONCLUSION: With limitations consisting in the retrospective observational design and different sample sizes, the results of this explorative analysis indicate that overall survival probability after SBRT is similar to surgery for the first 2 years from treatment. This finding supports the need for high-quality trials comparing different treatment modalities for lung oligometastases from CRC.

Timing of radiotherapy in breast cancer conserving treatment.

The optimal timing and sequencing of adjuvant radiotherapy and chemotherapy after breast-conserving surgery for early invasive breast cancer is controversial. Several studies demonstrated that postoperative radiation therapy significantly reduces the incidence of breast recurrences. For patients who do not need systemic treatment, the interval between surgery and the start of radiotherapy should not exceed eight weeks. For node-positive and high-risk patients receiving breast-conserving treatment, adjuvant chemotherapy should be administered prior to radiotherapy, but the delay of radiation should not exceed 20-24 weeks. Side effects and complications of radiotherapy can be expected to increase when chemotherapy is administered concurrently. In particular, antracycline-based chemotherapy regimens increase the damage to heart muscle and coronary arteries: to avoid the risk of ischemic cardiovascular disease, radiotherapy must be performed after the end of systemic treatment.

FEC (5-fluorouracil, epidoxorubicin and cyclophosphamide) versus EM (epidoxorubicin and mitomycin-C) with or without lonidamine as first-line treatment for advanced breast cancer. A multicentric randomised study. Final results.

From May 1991 to December 1996, 326 patients with advanced metastatic breast cancer were enrolled in a multicentre, randomised, phase III clinical trial with four arms. Patients were randomised to receive chemotherapy according to the FEC regimen (5-fluorouracil (5-FU) 500 mg/m2, epidoxorubicin (EPI) 75 mg/m2 and cyclophosphamide (CFA) 500 mg/m2, intravenously (i.v.). every 3 weeks) or the EM regimen (EPI 75 mg/m2, i.v. every 3 weeks; mitomycin C (MMC) 10 mg/m2, i.v. every 6 weeks) or the same regimens with the addition of lonidamine (LND) until disease progression (orally, thrice daily, 150+150+300 mg); a maximum of eight chemotherapy cycles were planned. The aim of the trial was 2-fold: to compare the EM regimen with the commonly used FEC regimen and to evaluate the possible role of the addition of LND. Patients were eligible if they had histologically proven breast carcinoma, metastatic or locoregional relapse with measurable and/or evaluable disease and were aged between 18 and 70 years: 318 patients were considered eligible. Patients with previous anthracycline-based adjuvant chemotherapy or those who relapsed within 6 months after any adjuvant chemotherapy regimen were excluded. Chemotherapy-related toxicity of grade > or = 3 was manageable and there was no significant difference between the arms in terms of haematological side-effects. The impact on heart function was mild. No increased toxicity was observed in the LND arms (apart from myalgias in 27-30% of the cases). A significant increase in the complete response rate was observed for the FEC/EM + LND group (20.4%) versus the FEC/EM group (10.8%). The median survival time and the median time to progression for the overall series were 608 days and 273 days, respectively; EM+/-LND achieved significantly improved survival and time to progression versus FEC+/-LND (P=0.01). This result was confirmed also when the analysis was restricted to patients previously treated with adjuvant CMF schedules. On the basis of these results, we conclude that EM may represent a valuable alternative to FEC for patients requiring a first-line regimen for advanced/ metastatic breast carcinoma, especially in patients previously treated with CMF in an adjuvant setting. Furthermore, we conclude that, in spite of a better complete response rate in the LND arms, as there was no clear advantage in time to progression or survival resulting from the addition of LND to the FEC or EM regimens, the routine use of LND is not warranted outside a clinical trial.

Influence of the blood meal source on the development of Triatoma infestans, Triatoma brasiliensis, Triatoma sordida, and Triatoma pseudomaculata (Heteroptera, Reduviidae).

The objective of this study was to determine the influence of the blood meal source on the life cycle and reproductive development of female Triatoma infestans (Klug, 1834), Triatoma brasiliensis Neiva, 1911, Triatoma sordida (Stal, 1859), and Triatoma pseudomaculata Corrga & Espfinola, 1964. In all triatomine species studied the life cycle was shorter for the groups fed on mice than for those fed on pigeons, the range of differences being between 1.5 times (T pseudomaculata and T. infestans) and 2.4 times (T brasiliensis). The mortality rate of nymphs during the life cycle tended to be greater in insects fed on pigeons than in those fed on mice, the differences for T. brasiliensis being statistically significant. Females of T sordida and T pseudomaculata had a greater fecundity than those of T. infestans and T. brasiliensis independently of the blood meal source. The differences of fecundity observed probably reflect differences in the availability of blood in the silvatic ecotopes of these species, meals being more frequent for T. infestans and T brasiliensis, which live at high densities in association with rodents in highly stable ecotopes. Because T. sordida and T. pseudomaculata live in more unstable ecotopes with fewer sources of blood they form small sparse colonies and invest more energy in reproduction than maintenance.

CT-MRI image fusion for delineation of volumes in three-dimensional conformal radiation therapy in the treatment of localized prostate cancer.

The objective of this study was to assess the utility of CT-MRI image fusion software and compare both prostate volume and localization with CT and MRI studies. We evaluated the differences in clinical volumes in patients undergoing three-dimensional conformal radiation therapy for localized prostate cancer. After several tests performed to ensure the quality of image fusion software, eight patients suffering from prostate adenocarcinoma were submitted to CT and MRI studies in the treatment position within an immobilization device before the start of radiotherapy. The clinical target volume (CTV) (prostate plus seminal vesicles) was delineated on CT and MRI studies and image fusion was obtained from the superimposition of anatomical fiducial markers. A comparison of dose-volume histograms relative to CTV, rectum, bladder and femoral heads was performed for both studies. Image fusion showed a mean overestimation of CTV of 34% with CT compared with MRI. Along the anterior-posterior and superior-inferior direction, CTV was a mean 5 mm larger with CT study compared with MRI. The dose-volume histograms resulting from CT and MRI comparison showed that it is possible to spare a mean 10% of rectal volume and approximately 5% of bladder and femoral heads, respectively. This study confirmed an overestimation of CTV with CT images compared with MRI. Because this finding only allows a minimal sparing of organs at risk, considering the organ motion during each radiotherapy session and the excellent outcomes of prostate cancer treatment with CT based target identification, we are still reluctant to reduce the CTV to that identified by MRI.

[Biological potential of Triatoma brasiliensis]. / Potencial biológico do Triatoma brasiliensis.

Biological and physiological parameters of Triatoma brasiliensis, Triatoma infestans, and Triatoma pseudomaculata were studied and compared. T. brasiliensis, reared on mice, showed a faster evolutionary cycle from first stage to adult and higher fecundity, when compared to the other species. T. infestans showed the fastest blood intake in both hosts tested, followed by T. brasiliensis and T. pseudomaculata. Clotting tests using salivary gland extracts of T. brasiliensis presented intermediary values of anti-clotting activity when compared to T. infestans and T. pseudomaculata.

[Microclimatic properties of the Triatoma brasiliensis habitat]. / Aspectos microclimáticos del hábitat de Triatoma brasiliensis.

Vector-borne transmission of Chagas disease in Northeast Brazil is basically by Triatoma brasiliensis. It is thus crucial to determine this species' microclimatic preferences as limiting factors for its distribution and ability to infest domestic environments. We analyze the microclimatic properties of the shelters in which these insects are found in wild, domestic, and peridomiciliary environments in the State of Ceará, at Brazil. We measure temperature and relative humidity (RH) every 15 minutes for 3 days. Thermal variation was greatly dampened inside both domiciliary refuges and the more protected internal places in wild stony sites. For RH, we observed a similar dampening pattern, but mean RH was lower in both domiciliary refuges and wild ones inside stony sites as compared to reference levels in the surrounding environment. The results are discussed with regard to this species' microclimatic preferences in the laboratory and its potential as determinants of its geographical distribution.

[Role of total parenteral nutrition in the treatment of ulcerous colitis]. / Il ruolo della nutrizione parenterale totale nel trattamento della colite ulcerosa.

Reference is made to the literature and personal experience in an assessment of the rôle of total parenteral nutrition in ulcerative colitis. An estimate is made of the position of this form of treatment with respect to conventional medical and surgical management, and its influence on the natural course of the disease. The results observed in 6 patients treated in this way are reported and the treatment protocol employed for the management of ulcerative colitis in a surgical department is described.

[Microcystic serous cystadenoma of the pancreas. Enucleation or regulated pancreatic resection?]. / Cistoadenoma sieroso microcistico del pancreas. Enucleazione o resezione pancreatica regolata?

Cystic benign tumors of the pancreas are rare lesions: they represent less than 10% of all pancreatic neoplasms. We studied two cases of microcystic adenoma, one of the less common varieties, that only in the last few years has been morphologically recognized as a distinct pathological entity. Our clinical experience--though limited--made us remark some interesting features: 1) preoperative diagnostic procedures (ultrasonography and CT) may present great interpretative difficulties: in one of the cases observed, radiographic imaging demonstrated an unresectable pancreatic tumor. On the contrary, in both cases surgical radicality has been achieved; 2) preoperative needle aspiration cytology (FNAB) does not always provide diagnostic material, as happened in both case observed; 3) the diagnosis of a benign tumor may result from surgical exploration and multiple biopsies with intraoperative frozen sections. Further and more complex histological investigations will definitively diagnose a microcystic adenoma; 4) in disagreement with some authors' results, we observed that microcystic adenoma may grow rapidly: one of our patients, after an incomplete tumor enucleation, developed a local relapse in a few months, needing a subtotal distal pancreatectomy, followed by complete recovery; 5) surgical radicality is mandatory. This result can be achieved through a simple, but complete, tumor enucleation or through a pancreatic resection; 6) our immunohistochemical and ultrastructural studies on microcystic adenoma exhibited no cells with endocrine activity, supporting the hypothesis that this tumor may originate from ductal or centroacinar cells.

[Surgical treatment of perforated duodenal ulcer. Review of 36 cases]. / Il trattamento chirurgico dell'ulcera duodenale perforata. Revisione di 36 casi.

Results obtained in the surgical management of 36 cases of perforated duodenal ulcer treated between January 1976 and November 1979 are presented. A choice was made between three methods (suturing, excision plus pyloroplasty and truncular vagotomy, and Péan-Billroth resection and reconstruction) in the light of the duration of the disease, the extent of the duodenal alterations, and the concomitance of serious disorders. No account was taken of age, the time elapsed between perforation and treatment, or the extent of peritoneal reaction.

[Clear cell renal carcinoma metastatic to the thyroid. A case report]. / Metastasi tiroidea di carcinoma renale a cellule chiare. Caso clinico.

A case of clear cell renal carcinoma metastatic to the thyroid 5 years after surgical removal of the primary tumor is presented. The differential diagnosis related to cyto-histologic findings, the uncommon occurrence and the unpredictable behaviour of clear cell renal carcinoma are discussed.

[Etiopathogenesis of benign prostatic hypertrophy]. / Eziopatogenesi dell'ipertrofia prostatica benigna.

The pathogenesis of benign prostatic hyperplasia (BPH) remains largely unresolved. The natural history of the disease involves two distinct phases, a pathological and a clinical one, whose pathogenesis is different. The pathologic phase is composed of two stages microscopic and macroscopic neither of which produces clinical dysuria. Nearly all men develop microscopic BPH if they live long enough but only in 50% of men microscopic BPH grows to produce a macroscopic enlargement of the gland and the evolvement happens in a period between 5 and 7 years. So different etiologies for the microscopic and macroscopic evolution of prostate can be argued. The clinical phase of BPH involves the progression of pathologic BPH to the clinical form in which the patients develop symptomatic dysuria. Again only about 50% of the men with macroscopic BPH progress to the clinical form: although macroscopic enlargement of the prostate is necessary for the development of clinical BPH it is not sufficient by itself for the progression to clinical phase and additional factors are required such as phlogosis, vascular infarct, enanchement of alpha adrenergic tone. These remarks on natural history suggest a multiple approach to BPH not addressed to treat the pathologic phase but the clinical one.(ABSTRACT TRUNCATED AT 250 WORDS)

Perineal biofeedback versus pelvic floor training in the treatment of urinary incontinence.

Perineal floor training and perineal biofeedback allow to reach a good improvement of clinical discomfort in the treatment of stress and urge urinary incontinence. The aim of this study is the real evaluation of the benefit due to a 6 week perineal biofeedback and pelvic floor training (PFT) versus PFT alone. 8 female patients have been treated with a 6 week trial with perineal biofeedback plus PFT trial and 22 with a 3 month PFT alone one. PFT alone, permits a good improvement but 10% less than if associated to perineal biofeedback.

Treatment of adult primary uncomplicated nocturnal enuresis by pelvic floor training and behaviour modification therapy.

A therapeutical trial based on pelvic floor training, reduced evening fluid intake and a 3 hour nocturnal awakening has been performed by 12 adult primary enuretics. The aim of this study is to verify if diurnal pelvic floor training is useful to gain a nocturnal micturition control.

Extracorporeal shock-wave lithotripsy with MPL9000 for the treatment of urinary stones in pediatric patients.

Extracorporeal shock-wave lithotripsy (ESWL) is now applied as the treatment of choice in most cases of urinary stones. Its acceptance in pediatry, however has been only gradual despite numerous positive studies. We report on fourteen young patients (mean age: 9.7 years) who were all treated by ESWL with the MPL9000 lithotriptor for renal stones. Each patient received an average of 1440 shocks with generator energy set at 14.4 Kv. Six of these patients required either analgosedation or anesthesia. No observable complications of treatment occurred. At one-month follow up, the kidneys of twelve patients were found to be stone-free, while two still presented fragments that could pass spontaneously. At three-month follow-up, thirteen patients were stone-free and a single patient retained some fragments. From this data we infer that ESWL with the MPL9000 lithotriptor may be used safety and efficiently to treat urolithiasis in younger patients.

[Treatment of urinary incontinence in the patient operated on for benign prostatic hyperplasia]. / Trattamento della incontinenza da urgenza nel paziente operato per IPB.

A potential complication of prostatic adenomectomy and TURP is urinary incontinence. The incidence of this problem ranges from 0.1 to 1%. we reviewed our experience with 15 patients who were incontinent between 10 to 24 months after prostatectomy. We treated these patients with bladder training. At first, patients were evaluated for the type and extent of incontinence. Perineal exercise were taught in detail, tested for their correct use via simultaneous and abdominal examination. Patients were evaluated weekly for compliance. No pharmaceutical agents were used. All the 15 patients improved in the number of incontinence episodes 5 patients achieved total continence, while only one showed a little change. We conclude that patients who are incontinent after prostatectomy can improve with a well-done behavioral training program.