CHARACTERIZATION OF A SMALL FOV PORTABLE GC: MediPROBE.

In this work, we evaluated the performance of the prototype SFOV MediPROBE developed at the University of Naples Federico II through the protocol proposed by (Bhatia B.S., Bugby S.L., Lees J.E., Perkins A.C. A scheme for assessing the performance characteristics of a small field of-view gamma cameras. Physica. Medica., 31 (1), pp. 98-103. (2015) doi: 10.1016/j.ejmp.2014.08.004). We extensively investigated a new device configuration where the pinhole collimator was placed outside the housing of the probe, in order to increase the system spatial resolution, and the pixel size was doubled, in order to reduce the charge sharing effect. The experimental measurements show that the spatial resolution is enhanced by only about 10%, but the sensitivity decreases strongly. Therefore, the trade-off between these two features does not seem to be advantageous. In addition, our experiments suggest that the charge sharing effect is not completely canceled. Despite these results, the features of this device appear suitable for intraoperative surgical survey. We aim to use this device in the clinical practice for the intraoperative imaging of lymph nodes, breast, thyroid and parathyroid tumors.

Serum Free Light Chains Removal by HFR Hemodiafiltration in Patients with Multiple Myeloma and Acute Kidney Injury: a Case Series.

BACKGROUND/AIMS: Multiple myeloma (MM) represents 10% of all haematologic malignancies. Renal involvement occurs in 50% of MM patients; of them, 12-20% have acute kidney injury (AKI), with 10% needing dialysis at presentation. While hemodialysis (HD) has no effect upon circulating and tissue levels of monoclonal proteins, novel apheretic techniques aim at removing the paraproteins responsible for glomerular/tubular deposition disease. High cut-off HD (HCO-HD) combined with chemotherapy affords a sustained reduction of serum free light chains (FLC) levels. One alternative technology is haemodiafiltration with ultrafiltrate regeneration by adsorption on resin (HFR-SUPRA), employing a "super high-flux" membrane (polyphenylene S-HF, with a nominal cut-off of 42 kD). Aim of our pilot study was to analyze the effectiveness of HFR-SUPRA in reducing the burden of FLC, while minimizing albumin loss and hastening recovery of renal function in 6 subjects with MM complicated by AKI. METHODS: Six HD-dependent patients with MM were treated with 5 consecutive sessions of HFR-SUPRA on a Bellco® monitor, while simultaneously initiating chemotherapy. Levels of albumin and FLC were assessed, calculating the rates of reduction. Renal outcome, HD withdrawal and clinical follow-up or death were recorded. RESULTS: All patients showed a significant reduction of FLC, whereas serum albumin concentration remained unchanged. In three, HD was withdrawn, switching to a chemotherapy alone regimen. The other patients remained HD-dependent and died shortly thereafter for cardiovascular complications. CONCLUSION: Our study suggests that HFR-SUPRA provides a rapid and effective reduction in serum FLC in patients with MM and AKI, while minimizing the loss of albumin. When started early in combination with chemotherapy, blood purification by HFR-SUPRA was followed by the recovery of renal function in half of the patients treated.

Metformin associated lactic acidosis (MALA): clinical profiling and management.

Metformin (MF) accumulation during acute kidney injury is associated with high anion gap lactic acidosis type B (MF-associated lactic acidosis, MALA), a serious medical condition leading to high mortality. Despite dose adjustment for renal failure, diabetic patients with chronic kidney disease (CKD) stage III-IV are at risk for rapid decline in renal function by whatever reason, so that MF toxicity might arise if the drug is not timely withdrawn. Sixteen consecutive patients were admitted to our Hospital's Emergency Department with clinical findings consistent with MALA. Fifteen had prior history of CKD, 60 % of them with GFR between 30 and 60 ml/min. Of these, 5 required mechanical ventilation and cardiovascular support; 3 promptly recovered renal function after rehydration, whereas 10 (62 %) required continuous veno-venous renal replacement treatment. SOFA and SAPS II scores were significantly related to the degree of lactic acidosis. In addition, lactate levels were relevant to therapeutic choices, since they were higher in dialyzed patients than in those on conservative treatment (11.92 mmol/l vs 5.7 mmol/l, p = 0.03). The overall death rate has been 31 %, with poorer prognosis for worse acidemia, as serum pH was significantly lower in non-survivors (pH 6.96 vs 7.16, p > 0.04). Our own data and a review of the literature suggest that aged, hemodynamically frail patients, with several comorbidities and CKD, are at greater risk of MALA, despite MF dosage adjustment. Moreover, renal replacement therapy rather than simple acidosis correction by administration of alkali seems the treatment of choice, based on eventual renal recovery and overall outcome.

Hemodialysis in patients requiring 131I treatment for thyroid carcinoma.

PURPOSE: Thyroid malignancies can be treated by surgery followed by ablation of the remnant tissue with 131I. As iodide removal from the body occurs by renal extraction, in patients suffering from end-stage renal disease it is necessary to properly evaluate both timing and method of the extracorporeal treatment.
 METHODS: We present two patients on regular hemodialysis, admitted in isolation to the Nuclear Medicine Department and treated with 131I for thyroid carcinoma diagnosed during the check-up for transplantation. Both patients underwent two hemodialysis sessions with a portable machine for CRRT (continuous renal replacement therapy), 24 and 48 hours after the administration of 50 mCi of 131I. The nursing staff were monitored with a dosimeter. Radioactivity of the patients, dialysate and urines were measured during hemodialysis. 
 RESULTS: The greater reduction was obtained with the first dialysis, but in both patients a further, though shorter, hemodialysis at 48 hours was necessary for reaching a patient's radioactivity compatible with discharge. Radioactivity measured in the dialysate demonstrated the almost total removal of radioiodine by dialysis alone. In both patients, follow-up exams revealed a complete ablation of thyroid tissue, without signs of local recurrence. The dose of radioactivity of the dialysis staff was below allowable limits. 
 CONCLUSIONS: We conclude that a successful reduction of radioactivity, without dispersing its therapeutic efficacy, can be obtained with daily hemodialysis with a CRRT machine in patients in isolation treated with 131I. A therapeutic model is proposed.

Preventive hemostasis for hemodialysis vascular access surgical reinterventions.

Surgical reinterventions for treatment of complications or ligation of haemodialysis vascular access (VA), when performed in or below the mid/lower part of the upper arm, could benefit from the use of preventive haemostasis with an inflatable tourniquet. This technique offers several advantages, such as the reduced risk of bleeding and the increased accuracy of dissection allowing for a minimally invasive approach. The use of preventive haemostasis is safe, economical and time-saving. All the secondary procedures on VA that could benefit from its use are reviewed.

Assessment of long-term vasoplegia induced by brachial plexus block: a favorable effect for hemodialysis angioaccess surgery?

PURPOSE: Loco-regional anesthesia, along with the neurosensitive inhibition causes arterial and venous vasodilatation, that could be of interest for vascular access surgery. We evaluated the long term vasoplegia persistence after brachial plexic block. METHODS: Five patients submitted to brachial plexus block for an orthopedic procedure have been observed. Both radial arteries, that of the blocked arm and the opposite as a control, were analyzed by ultrasound examination, at time 0 and 360 minutes after anesthesia induction. All patients were treated with the same anesthesiologic protocol: axillary approach, use of an electroneurostimulator, injection 10 ml of ropivacain 7.5% + 10 ml of mepivacain 2%. The parameters evaluated from the arterial ultrasound flowmetry were: peak systolic velocity (PSV), end diastolic velocity (EDV) and resistance index (RI). RESULTS: No modification of the arterial flow were observed in the control arm at 0 and 360'after block induction. The blocked arm instead showed a significant decrease of the resistive index, stable at 360 minutes. CONCLUSIONS: The vasoplegia accompaning plexic block lasted 6 hours after anesthesia induction. Whereas this longstanding haemodynamic effect is beneficial for early patency of vascular access for hemodialysis, needs to be ascertained by further investigations.

[Hypertensive crisis in kidney patients]. / Le crisi ipertensive nel paziente nefropatico.

The classification and management of hypertensive crisis have been recently reviewed in the context of both European and American guidelines. The key points for proper blood pressure control in severe arterial hypertension are: 1 - Distinction between urgent intervention and emergencies 2 - Choice of the best drug(s) 3 - Choice of the correct route of administration. In patients with renal disease, beside the common causes of hypertension/ hypertensive crises, kidney-specific causes should be taken into account such as renal parenchymal hypertension, renovascular hypertension, sclerodermic crises, and preeclampsia.

Radiation therapy in primary orbital lymphoma: a single institution retrospective analysis.

BACKGROUND: Primary orbital lymphoma is a rare disease that accounts for 10% of all orbital tumors. Radiotherapy on the orbital cavity is the treatment of choice for this unusual presentation of localized non-Hodgkin's lymphoma (NHL). The aim of this study is to retrospectively evaluate the effectiveness and the toxicity of radiation treatment in patients with primary orbital lymphoma. METHODS: Forty-seven consecutive patients having primary orbital lymphoma treated in our department between May 1983 and September 2006 were investigated in a retrospective study. Either 60Co gamma rays or 6 MV X rays were used to deliver daily fractions of 1.8 or 2.0 Gy, 5 times/week, with total doses ranging from 34.2 to 50 Gy. Forty-three patients had stage IE, three had stage II and one stage IV disease. Thirty-eight patients had marginal zone B-cell lymphoma, 5 diffuse large B cell lymphoma, 3 mantle cell lymphoma and 1 Burkitt lymphoma. Local control (LC), disease free survival (DFS), overall survival (OS) and late side effects were evaluated in all patients. RESULTS: With a median follow up of 45 months, LC was obtained in 100% of patients. The estimated 5- and 7-year DFS rates were 75.8% and 55.3%, and the 5- and 7-year OS rates were 88.7% and 79.9% respectively. Acute toxicity was minimal. Late toxicity such as cataract, keratitis, retinopathy and xerophthalmia occurred respectively in 12 (25.5%), 5 (10.6%), 1 (2.1%), and 9 (19.1%) patients. CONCLUSION: Radiotherapy is an effective and at the same time well tolerated treatment for primary orbital lymphoma.

Reduction of early postoperative morbidity in cardiac surgery patients treated with continuous veno-venous hemofiltration during cardiopulmonary bypass.

Cardiac surgery with cardiopulmonary bypass is associated with a systemic inflammatory response syndrome. The major clinical features of this include a reduction of pulmonary compliance and increased extracellular fluids, with increased pulmonary shunt fraction similar to acute respiratory distress syndrome, thus resulting in prolonged mechanical ventilation time (VAM) and intensive care unit length of stay (ICU STAY). We evaluated the feasibility of an intraoperatory cardiopulmonary bypass (CPB) circuit connected with a monitor for continuous veno-venous hemofiltration (CVVH) to ameliorate pulmonary function after open heart surgery reducing VAM and ICU STAY. Forty patients undergoing elective coronary artery bypass grafting were randomized at the time of surgery into a control group (20 patients who received standard cardiopulmonary bypass) and a study group (20 patients who received CVVH during cardiopulmonary bypass). The analysis of postoperative variables showed a significative reduction of VAM in treated group (CVVH group mean 3.55 h +/- 0.85, control group 5.8 h +/- 0.94, P < 0.001) and ICU STAY (CVVH group mean 29.5 h +/- 6.7, control group 40.5 h +/- 6.67, P < 0.001). In our experience, the use of intraoperatory CVVH during cardiopulmonary bypass is associated with lower early postoperative morbidity.

Focal segmental glomerulosclerosis as a complication of graft-versus-host disease.

BACKGROUND: A 54-year-old man with multiple myeloma underwent peripheral blood stem cell transplantation (PBSCT) with cells donated by his human leukocyte antigen (HLA)-identical sister. Eight months after PBSCT, the patient experienced chronic graft-versus-host disease with skin involvement (generalized erythema), mucosal ulceration, sicca syndrome, and elevated liver enzymes. Two years after PBSCT, the patient developed nephrotic syndrome with massive proteinuria, which required hospitalization. INVESTIGATIONS: Physical examination, blood and urine analyses, liver function tests, 24 h urinary albumin excretion and renal biopsy. DIAGNOSIS: Focal segmental glomerulosclerosis as a complication of graft-versus-host disease. MANAGEMENT: Prednisone, ciclosporin and an angiotensin-converting-enzyme inhibitor.

Preoperative radiation treatment for rectal cancer: comparison of target coverage and small bowel NTCP in conventional vs. 3D-conformal planning.

A prospective study was undertaken to evaluate the improvement in rectal cancer radiation treatment achieved with the implementation of target delineation for conformal radiotherapy, replacing conventional technique using standard radiological anatomy for target volume definition. In 10 patients receiving preoperative pelvic irradiation for rectal cancer, a 3-field technique was designed by a 3-dimensional (3D) planning system. Two plans were simulated for each patient, one with the fields designed in the conventional way based on radiological anatomy, and the other with the fields designed on the basis of a computed tomography (CT) delineated planning target volume (PTV). A total dose of 45 Gy in 25-daily fractions of 1.8 Gy in 5 weeks was planned. Dose-volume histograms (DVHs) of PTV, small bowel, anal sphincter, and urinary bladder were analyzed to compare plans. The minimum, maximum, and mean dose in the PTV and in critical organs were also evaluated. The inhomogeneity coefficient (IC) and the target coverage (TC) were calculated. The normal tissue complication probability (NTCP) for each organ at risk (OAR) was determined. NTCP for small bowel and urinary bladder was not statistically different, while the PTV coverage was significantly lower with conventional treatment relative to conformal treatment (median IC=7.2, median TC=0.91 vs. median IC=0.14 and median TC=1, p<0.005). The 3D conformal treatment plan in preoperative radiotherapy for rectal cancer improves target coverage without significantly affecting small bowel and urinary bladder NTCP.

Lymph nodes in the irradiated field influence the yield of radiation-induced chromosomal aberrations in lymphocytes from breast cancer patients.

PURPOSE: To measure chromosomal aberrations in blood lymphocytes from breast cancer patients treated with radiotherapy after quadrantectomy or tumorectomy. METHODS AND MATERIALS: Twenty-two breast cancer patients treated with breast-conserving surgery and radiation were evaluated. Adjuvant chemotherapy was also given to 9 patients. Blood samples were obtained before radiotherapy, after about one-half of the fractions, and at the end of the treatment of the whole breast (50 Gy). Chromosome aberrations in peripheral blood lymphocytes were measured using chemical-induced premature chromosome condensation combined with fluorescence in situ hybridization. RESULTS: Radiation treatment produced a significant increase in the yield of chromosomal aberrations. A large interindividual variability was observed. The variability was not related to field size, previous chemotherapy, or treatment morbidity. Chromosome aberrations in lymphocytes at the end of the treatment were significantly higher in the group of patients with no lymph nodes surgically removed before the treatment than in the group of patients with more than 10 lymph nodes removed. CONCLUSION: The number of lymph nodes within the radiation field is an important factor affecting the yield of radiation-induced chromosomal aberrations in breast cancer patients.

Early treatment of benign prostatic hyperplasia: implications for reducing the risk of permanent bladder damage.

A significant change has occurred in the management of symptomatic benign prostatic hyperplasia (BPH) since effective pharmacological treatment became available and led to a significant decrease in the number of surgical procedures in many Western countries. The hypothesis of a causative role of benign prostatic enlargement and bladder outflow obstruction (BOO) in lower urinary tract symptoms (LUTS) was based on the association between prostate growth and symptoms of prostatism in elderly men and on the dramatic reduction of LUTS upon relief of obstruction. Careful investigation into the epidemiology of LUTS and BPH failed to confirm such an association and opened new perspectives in the pathophysiology of lower urinary tract dysfunction and symptoms. The observation that LUTS were equally distributed in male and female cohorts, when matched for age, moved attention away from the prostate and towards the urinary bladder and its aging-related disorders. When BPH surgery was developed, the management of the disease was aimed at preventing death from chronic renal failure, but the picture has changed and modern medical treatment is now aimed at improving the patient's quality of life. The increasing size of elderly populations in the Western world and the consequent financial constraints of national healthcare systems have raised the question of when pharmacological treatment of symptomatic BPH should be initiated. Retrospective and prospective analysis of various BPH populations and clinical studies has clearly defined the capacity of pharmacological treatment to reduce the incidence of complications of BPH, such as acute urinary retention and the need for surgery, but the cost/benefit ratio is unclear. Notwithstanding the limitations inherent in the experimental models, there is evidence from various animal models, investigating the pathophysiology of the urinary bladder in the presence of outflow obstruction, to indicate that a cause and effect relationship between BOO and bladder decompensation has been established and to support the hypothesis that permanent bladder damage may occur when the obstruction is not relieved early enough. Preliminary experimental evidence also suggests that alpha(1)-adrenoceptor antagonists may have a role in reducing the damaging effects of BOO on the urinary bladder. At present, there is no evidence to support the need for early pharmacological treatment of symptomatic BPH with no BOO beyond the obvious target of improving the patient's quality of life. The evidence for early treatment of BOO and the need to preserve bladder function is clear. Further experimental and clinical research is required to identify markers of early bladder damage and decompensation which can be used to select patients for early pharmacological treatment of BPH.

Primary non-Hodgkin's lymphoma of the lacrimal sac: a case report.

Primary non-Hodgkin's lymphoma of the lacrimal sac is an extremely rare presentation of orbital localization of lymphoma. We present a 45-year-old male patient with primary NHL of the lacrimal sac, stage IE, who was treated with surgery and radiotherapy. Fourteen months after the end of radiotherapy the patient is free of disease and does not show any treatment-related toxicity.