Influence of Pathophysiological Patterns of Coronary Artery Disease on Immediate Percutaneous Coronary Intervention Outcomes.

BACKGROUND: Diffuse coronary artery disease (CAD) impacts the safety and efficacy of percutaneous coronary intervention (PCI). Pathophysiological CAD patterns can be quantified using fractional flow reserve (FFR) pullbacks incorporating the pullback pressure gradient (PPG) calculation. This study aimed to establish the capacity of PPG to predict optimal revascularisation and procedural outcomes. METHODS: This prospective, investigator-initiated, single-arm, multicentre study enrolled patients with at least one epicardial lesion with an FFR ≤ 0.80 scheduled for PCI. Manual FFR pullbacks were employed to calculate PPG. The primary outcome of optimal revascularisation was defined as a post-PCI FFR ≥ 0.88. RESULTS: 993 patients with 1044 vessels were included. The mean FFR was 0.68 ± 0.12, PPG 0.62 ± 0.17, and post-PCI FFR 0.87 ± 0.07. PPG was significantly correlated with the change in FFR after PCI (r=0.65, 95% CI 0.61-0.69, p<0.001) and demonstrated excellent predicted capacity for optimal revascularisation (AUC 0.82, 95% CI 0.79-0.84, p<0.001). Conversely, FFR alone did not predict revascularisation outcomes (AUC 0.54, 95% CI 0.50-0.57). PPG influenced treatment decisions in 14% of patients, redirecting them from PCI to alternative treatment modalities. Periprocedural myocardial infarction occurred more frequently in patients with low PPG (<0.62) compared to those with focal disease (OR 1.71, 95% CI: 1.00-2.97). CONCLUSIONS: Pathophysiological CAD patterns distinctly affect the safety and effectiveness of PCI. The PPG showed an excellent predictive capacity for optimal revascularisation and demonstrated added value compared to a FFR measurement.

Early treatment of type II SMA slows rate of progression of scoliosis.

BACKGROUND: Type II spinal muscular atrophy (SMA) often leads to scoliosis in up to 90% of cases. While pharmacological treatments have shown improvements in motor function, their impact on scoliosis progression remains unclear. This study aims to evaluate potential differences in scoliosis progression between treated and untreated SMA II patients. METHODS: Treatment effect on Cobb's angle annual changes and on reaching a 50° Cobb angle was analysed in treated and untreated type II SMA patients with a minimum 1.5-year follow-up. A sliding cut-off approach identified the optimal treatment subpopulation based on age, Cobb angle and Hammersmith Functional Motor Scale Expanded at the initial visit. Mann-Whitney U-test assessed statistical significance. RESULTS: There were no significant differences in baseline characteristics between the untreated (n=46) and treated (n=39) populations. The mean Cobb angle variation did not significantly differ between the two groups (p=0.4). Optimal cut-off values for a better outcome were found to be having a Cobb angle <26° or an age <4.5 years. When using optimal cut-off, the treated group showed a lower mean Cobb variation compared with the untreated group (5.61 (SD 4.72) degrees/year vs 10.05 (SD 6.38) degrees/year; p=0.01). Cox-regression analysis indicated a protective treatment effect in reaching a 50° Cobb angle, significant in patients <4.5 years old (p=0.016). CONCLUSION: This study highlights that pharmacological treatment, if initiated early, may slow down the progression of scoliosis in type II SMA patients. Larger studies are warranted to further investigate the effectiveness of individual pharmacological treatment on scoliosis progression in this patient population.

Rationale and design of the pullback pressure gradient (PPG) global registry.

INTRODUCTION: Diffuse disease has been identified as one of the main reasons leading to low post-PCI fractional flow reserve (FFR) and residual angina after PCI. Coronary pressure pullbacks allow for the evaluation of hemodynamic coronary artery disease (CAD) patterns. The pullback pressure gradient (PPG) is a novel metric that quantifies the distribution and magnitude of pressure losses along the coronary artery in a focal-to-diffuse continuum. AIM: The primary objective is to determine the predictive capacity of the PPG for post-PCI FFR. METHODS: This prospective, large-scale, controlled, investigator-initiated, multicenter study is enrolling patients with at least 1 lesion in a major epicardial vessel with a distal FFR ≤ 0.80 intended to be treated by PCI. The study will include 982 subjects. A standardized physiological assessment will be performed pre-PCI, including the online calculation of PPG from FFR pullbacks performed manually. PPG quantifies the CAD pattern by combining several parameters from the FFR pullback curve. Post-PCI physiology will be recorded using a standardized protocol with FFR pullbacks. We hypothesize that PPG will predict optimal PCI results (post-PCI FFR ≥ 0.88) with an area under the ROC curve (AUC) ≥ 0.80. Secondary objectives include patient-reported and clinical outcomes in patients with focal vs. diffuse CAD defined by the PPG. Clinical follow-up will be collected for up to 36 months, and an independent clinical event committee will adjudicate events. RESULTS: Recruitment is ongoing and is expected to be completed in the second half of 2023. CONCLUSION: This international, large-scale, prospective study with pre-specified powered hypotheses will determine the ability of the preprocedural PPG index to predict optimal revascularization assessed by post-PCI FFR. In addition, it will evaluate the impact of PPG on treatment decisions and the predictive performance of PPG for angina relief and clinical outcomes.

Quantitative flow ratio modulated by intracoronary optical coherence tomography for predicting physiological efficacy of percutaneous coronary intervention.

BACKGROUND: The combination of coronary imaging assessment and blood flow perturbation estimation has the potential to improve percutaneous coronary intervention (PCI) guidance. OBJECTIVES: We aimed to evaluate a novel method for fast computation of Murray law-based quantitative flow ratio (µQFR) from coregistered optical coherence tomography (OCT) and angiography (OCT-modulated µQFR, OCT-µQFR) in predicting physiological efficacy of PCI. METHODS: Patients treated by OCT-guided PCI in the OCT-arm of the Fractional Flow Reserve versus Optical Coherence Tomography to Guide RevasculariZAtion of Intermediate Coronary Stenoses trial (FORZA, NCT01824030) were included. Based on angiography and OCT before PCI, simulated residual OCT-µQFR was computed by assuming full stent expansion to the intended-to-treat segment. Plaque composition was automatically characterized using a validated artificial intelligence algorithm. Actual post-PCI OCT-µQFR pullback was computed based on coregistration of angiography and OCT acquired immediately after PCI. Suboptimal functional stenting result was defined as OCT-µQFR ≤ 0.90. RESULTS: Paired simulated residual OCT-µQFR and actual post-PCI OCT-µQFR were obtained in 76 vessels from 74 patients. Simulated residual OCT-µQFR showed good correlation (r = 0.80, p < 0.001), agreement (mean difference = -0.02 ± 0.02, p < 0.001), and diagnostic concordance (79%, 95% confidence interval: 70%-88%) with actual post-PCI OCT-µQFR. Actual post-PCI in-stent OCT-µQFR had a median value of 0.02 and was associated with left anterior descending artery lesion location (ß = 0.38, p < 0.001), higher baseline total plaque burden (ß = 0.25, p = 0.031), and fibrous plaque volume (ß = 0.24, p = 0.026). CONCLUSIONS: This study based on patients enrolled in a prospective OCT-guidance PCI trial shows that simulated residual OCT-µQFR had good correlation, agreement, and diagnostic concordance with actual post-PCI OCT-µQFR. In OCT-guided procedures, OCT-µQFR in-stent pressure drop was low and was significantly predicted by pre-PCI vessel/plaque characteristics.

Myocardial bridge evaluation towards personalized medicine: study design and preliminary results of the RIALTO registry.

Myocardial bridge (MB) is the most frequent inborn coronary artery variant in which a portion of the myocardium overlies an epicardial coronary artery segment. Although MB has long been considered a benign entity, a growing body of evidence has suggested its association with angina and adverse cardiac events. However, to date, no data on long-term prognosis are available, nor on therapies improving cardiovascular outcomes. We are currently conducting an ambispective, observational, multicentre, study in which we enrol patients with a clinical indication to undergo coronary angiography (CA) and evidence of MB, aiming to describe the incidence of symptoms and cardiovascular events at baseline and at long-term follow-up (FUP). The role of invasive full-physiology assessment in modifying the discharge therapy and eventually the perceived quality of life and the incidence of major cardiovascular events will be analysed. Basal clinical-instrumental data of eligible and consenting patients have been acquired after CA; FUP was performed 6, 12, and 24 months after the angiographic diagnosis of MB. The primary endpoint of the study is the incidence of major adverse cardiovascular events (MACE), defined as the composite of cardiac death, myocardial infarction, cardiac hospitalization, and target vessel revascularization; the secondary endpoints are the rate of patients with Seattle Angina Questionnaire (SAQ) summary score <70 and the incidence of MACE in patients undergoing invasive intracoronary assessment. Among patients undergone FUP visits, we recorded 31 MACE at 6 months (11.6%), 16 MACE at 12 months (6.5%), and 26 MACE at 24 months (13.5%). The rate of patients with SAQ <70 is 18.8% at 6 months, 20.6% at 12 months, and 21.8% at 24 months. To evaluate the prognostic role of invasive intracoronary assessment, we compared MB patients who underwent only angiographic evaluation (Angio group) to those who underwent acetylcholine (ACH) provocative test with indication to calcium-channel blockers (CCBs) at discharge (Angio + ACH + CCBs group) and those who underwent functional assessment with fractional flow reserve (FFR) with indication to beta-blockers (BBs) at discharge (Angio + FFR + BBs group). After 2 years of FUP, the rate of MACE was significantly reduced in both Angio + ACH + CCBs group (6 vs. 25%, P = 0.029) and Angio + FFR + BBs group (3 vs. 25%, P = 0.005) compared with Angio group. The preliminary results of our study showed that MB may be a cause of angina and adverse cardiac events in patients referred to CA for suspected coronary artery disease (CAD). Full-physiology assessment unmasking MB-related ischaemia mechanisms, allowed to guide the treatment, personalizing the clinical management, improving the quality of life, and cardiovascular outcomes in patients with MB.

An inter- and intra-rater agreement assessment of a novel classification of pyogenic spinal infections.

PURPOSE: Pola et al. described a clinical-radiological classification of pyogenic spinal infections (PSI) based on magnetic resonance imaging (MRI) features including vertebral destruction, soft tissue involvement, and epidural abscess, along with the neurological status. We performed an inter- and intra-observer agreement evaluation of this classification. METHODS: Complete MRI studies of 80 patients with PSI were selected and classified using the scheme described by Pola et al. by seven evaluators. After a four-week interval, all cases were presented to the same assessors in a random sequence for repeat assessment. We used the weighted kappa statistics (wκ) to establish the inter- and intra-observer agreement. RESULTS: The inter-observer agreement was substantial considering the main categories (wκ = 0.77; 0.71-0.82), but moderate considering the subtypes (wκ = 0.51; 0.45-0.58). The intra-observer agreement was substantial considering the main types (wκ = 0.65; 0.59-0.71), and moderate considering the subtypes (wκ = 0.58; 0.54-0.63). CONCLUSION: The agreement at the main type level indicates that this classification allows adequate communication and may be used in clinical practice; at the subtypes level, the agreement is only moderate.

Broadening the phenotypic spectrum of Beta3GalT6-associated phenotypes.

Biallelic mutations in B3GALT6, coding for a galactosyltransferase involved in the synthesis of glycosaminoglycans (GAGs), have been associated with various clinical conditions, causing spondyloepimetaphyseal dysplasia with joint laxity type 1 (SEMDJL1 or SEMDJL Beighton type), Al-Gazali syndrome (ALGAZ), and a severe progeroid form of Ehlers-Danlos syndrome (EDSSPD2). In the 2017 Ehlers-Danlos syndrome (EDS) classification, Beta3GalT6-related disorders were grouped in the spondylodysplastic EDSs together with spondylodysplastic EDSs due to B4GALT7 and SLC39A13 mutations. Herein, we describe a patient with a previously unreported homozygous pathogenic B3GALT6 variant resulting in a complex phenotype more severe than spondyloepimetaphyseal dysplasia with joint laxity type 1, and having dural ectasia and aortic dilation as additionally associated features, further broadening the phenotypic spectrum of the Beta3GalT6-related syndromes. We also document the utility of repeating sequencing in patients with uninformative exomes, particularly when performed by using "first generations" enrichment capture methods.

Systemic mastocytosis revisited with an emphasis on skeletal manifestations.

Systemic mastocytosis (SM) is a rare form of mastocytosis that can affect various organ systems. Bone involvement is the most common and prominent imaging feature in patients with SM regardless of the subtype. Furthermore, bone involvement is a prognostic factor as it may entail an aggressive course of the disease. Diagnosis is established by bone marrow biopsy complemented by imaging modalities such as radiography, CT, and magnetic resonance (MR) imaging. The radiographic and CT appearances are that of sclerotic, lytic, or mixed patterns with focal or diffuse distribution, involving primarily the axial skeleton and the ends of the long bones. Bone marrow infiltration is best recognized on MR imaging. Osteoporosis is common in SM; thus, a bone mineral density measurement at lumbar spine and proximal femur by dual-energy X-ray absorptiometry should be obtained. Imaging plays a huge part in the diagnostic process; when skeletal imaging findings are carefully interpreted and correlated with clinical features, they can lead to the suspicion of SM. The primary aims of this review article were to focus on the role of imaging in detection and characterization of skeletal patterns of SM and to discuss relevant clinical features that could facilitate prompt and correct diagnosis.

Radiological evaluation of fusion patterns after lateral lumbar interbody fusion: institutional case series.

INTRODUCTION: There is no consensus on how to evaluate segmental fusion after lateral lumbar interbody fusion (LLIF). Bone bridges (BB) between two contiguous vertebra are reported as pathognomonic criteria for anterior fusion. However, to the best of our knowledge, there are no radiological investigations on zygapophyseal joints (ZJ) status after LLIF. The aim of this radiological study was to investigate the different fusion patterns after LLIF. MATERIALS AND METHODS: This is a retrospective single-centre radiological study. Patients who underwent LLIF and posterior percutaneous screw fixation for degenerative spondylolisthesis, on a single lumbar level, were considered for eligibility. Complete radiological data and a minimum follow-up of 1 year were the inclusion criteria. Intervertebral BB were investigated for evaluating anterior fusion and ZJ ankylotic degeneration was evaluated according Pathria et al., as a matter of proof of posterior fusion and segmental immobilization. RESULTS: Seventy-four patients were finally included in the present study. Twelve months after surgery, intervertebral BB were recognized in 58 segments (78.3%), whereas ZJ Pathria grade was I in 8 (10.8%) patients, II in 15 (20.3%) and III in 51 (68.9%) that were considered posteriorly fused. The overlapping rate between anteriorly and posteriorly fused segments was 72.4% (42 segments), whereas 10 (13.5%) did not achieve any fusion, anterior or posterior, and 6 (8.1%) were posteriorly fused only. CONCLUSIONS: Our results seem to suggest that anterior fusion is not sufficient to achieve segmental immobilization. Further properly designed investigations are needed to investigate eventual clinical-radiological correlations.

Working with emotion predicts sudden gains during experiential therapy for depression.

Objective: This study involves the first attempt to identify sudden gains in a sample of clients undergoing experiential therapy for depression while also investigating client and therapist change processes related to sudden gains.Method: Pre- and post-session Beck Depression Inventory, short form (BDI-SF) questionnaires were used to identify sudden gains and differentiate between in-session and between-session symptom changes in thirty-six client-therapist dyads. Archival videotape data of a sub-sample were coded using the Experiencing Scale, Classification of Affective Meaning States, and the Coding System for Therapist Focus.Results: The study revealed that 63.9% of clients experienced a sudden gain and the bulk of the total mean symptom decrease (74.9%) was found to occur within the session preceding the sudden gain. During this critical session, clients were more likely to display deepened experiencing (p < .01, η2 = .34), clients were more likely to express "primary adaptive emotions" (p < .05, r = .38), and therapists were found to be more likely to focus on unmet client needs (p < .01, d = .75).Conclusion: The majority of the sudden gain change occurs within session in experiential therapy, and primary adaptive emotions as well as addressing unmet needs are possible processes of sudden gains.

Self-Contempt, the Working Alliance and Outcome in Treatments for Borderline Personality Disorder: An Exploratory Study.

Objective. We examined the role of expressed self-contempt in therapy for borderline personality disorder (BPD). Based on previous literature on BPD, we assumed an association between the self-contempt and the core symptoms of BPD. We also studied the progression of expressed self-contempt during the treatment and its effect on the alliance and the outcomes of treatment.Method. We rated the expressed self-contempt in 148 tape-recorded sessions with patients with BPD (N = 50), during a brief psychiatric treatment. We rated self-contempt at three time-points, using an observer-rate scale. Self-reported questionnaires were used to assess symptoms and the working alliance.Results. There are some associations between self-contempt and BPD symptoms. Expressed self-contempt did not change during the treatment. One measure of self-contempt was associated with a weaker alliance rated by the patients and with a stronger alliance rated by the therapists. The expression of high self-contempt was not predictive of outcomes when the initial level of problems was controlled for.Conclusions. The results highlight the importance to examine the complex effects of self-contempt in BPD undergoing treatment in a differentiated manner and suggest to clinicians and researchers to be attentive to this specific emotional state, and change therein, in psychotherapy.Keywords: Self-contempt; Borderline Personality Disorder; Brief Treatment; Therapeutic Alliance; EmotionTrial registration: ClinicalTrials.gov identifier: NCT01896024.

A less-invasive totally-endovascular (LITE) technique for trans-femoral transcatheter aortic valve replacement.

OBJECTIVES: To describe and report the results of an original technique for trans-femoral (TF) transcatheter-aortic-valve-replacement (TAVR). BACKGROUND: TF approach represents the commonest TAVR technique. The best technique for TF-TAVR is not recognized. METHODS: We developed a less-invasive totally-endovascular (LITE) technique for TF-TAVR. The key aspects are: precise TAVR access puncture using angiographic-guidewire-ultrasound guidance radial approach as the "secondary access" (to guide valve positioning, to check femoral-access hemostasis and to manage eventual access-site complications) non-invasive pacing (by retrograde left ventricle stimulation or by definitive pace-maker external programmer) The LITE technique has been systematically adopted at our Institution. Procedure details, complications and clinical events occurring during hospitalization were prospectively recorded. Major vascular complications and life-threatening or major bleedings were the primary study end-points. RESULTS: A total of 153 consecutive patients referred for TF-TAVR were approached using the LITE technique. Mean predicted surgical operative mortality was 4.9% and mean TAVR predicted mortality was 3.9%. In 132 (86.3%) patients, TAVR was completed without the need for additional femoral artery access or transvenous temporary pace-maker implantation. Major vascular complications occurred in 2 (1.3%), life-threatening or major bleedings occurred in 4 (2.6%) patients. All-cause death occurred in 3 patients (2.0%). CONCLUSIONS: TF-TAVR according to LITE technique is feasible and is associated with very low rates of vascular or bleeding complications.

How Personality Disorders Change in Psychotherapy: a Concise Review of Process.

PURPOSE OF REVIEW: The present review summarizes the current state of the art in psychotherapy processes during treatments for clients with personality disorders. We outline some methodological challenges in the discipline of process research, give a brief historical account on process research, and then focus on specific processes studied from an empirical perspective. RECENT FINDINGS: The current review acknowledges the centrality of the therapeutic relationship, in particular the therapeutic alliance, therapist empathy, and responsiveness in explaining outcome across treatment modalities for personality disorders. The review describes evidence from three overall and overlapping lines of inquiry that have garnered scientific interest in the past years. For emotional change (regulation, awareness, and transformation), socio-cognitive change (mentalizing, meta-cognition, and interpersonal patterns), and increase in insight and change in defense mechanisms, evidence is moderate to strong for these processes to contribute to healthy change in treatments for personality disorders, in particular borderline personality disorder. Avenues of future studies are outlined.

Bone and soft tissue infections in patients with diabetic foot.

Bone and soft tissue infection involving the foot is a serious complication of diabetes mellitus and represents a major public health and socioeconomic burden to National Health Services worldwide. Research in the past decade has improved diagnosis and treatment of these frequent and potentially devastating complications of diabetic foot which often remain difficult to be diagnosed and treated despite the availability of various clinical, serological, and imaging modalities. Furthermore, neuropathic osteoarthropathy can share many clinical and imaging features of osteomyelitis, and infection is often superimposed in patients with neuropathic disease. Thus, distinguishing between the two abnormalities is further complicated. Although the reference standard for diagnosis remains microbiologic analysis of bone specimens, in most clinical practice, soft tissue and bone infection involving the diabetic foot is diagnosed solely on the basis of a combination of clinical evaluation, serum inflammatory markers, and imaging modalities. Correlation between imaging findings and clinical features is very important as well as a common knowledge base for treatment team members rather than a compartmentalized view. Thus, the primary purpose of this review article was to provide radiologist and clinician with important clinical knowledge and relevant radiological semiotics, respectively, in order to facilitate a prompt diagnosis and personalised treatment of diabetic foot infections.

Predictive factors of discordance between the instantaneous wave-free ratio and fractional flow reserve.

OBJECTIVES: To identify clinical, angiographic and hemodynamic predictors of discordance between instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR). BACKGROUND: The iFR was found to be non-inferior to the gold-standard FFR for guiding coronary revascularization, although it is discordant with FFR in 20% of cases. A better understanding of the causes of discordance may enhance application of these indices. METHODS: Both FFR and iFR were measured in the prospective multicenter CONTRAST study. Clinical, angiographic and hemodynamic variables were compared between patients with concordant values of FFR and iFR (cutoff ≤0.80 and ≤0.89, respectively). RESULTS: Out of the 587 patients included, in 466 patients (79.4%) FFR and iFR agreed: both negative, n = 244 (41.6%), or positive, n = 222 (37.8%). Compared with FFR, iFR was negative discordant (FFR+/iFR-) in 69 (11.8%) patients and positive discordant (FFR-/iFR+) in 52 (8.9%) patients. On multivariate regression, stenosis location (left main or proximal left anterior descending) (OR: 3.30[1.68;6.47]), more severe stenosis (OR: 1.77[1.35;2.30]), younger age (OR: 0.93[0.90;0.97]), and slower heart rate (OR: 0.59[0.42;0.75]) were predictors of a negative discordant iFR. Absence of a beta-blocker (OR: 0.41[0.22;0.78]), older age (OR: 1.04[1.00;1.07]), and less severe stenosis (OR: 0.69[0.53;0.89]) were predictors of a positive discordant iFR. CONCLUSIONS: During iFR acquisition, stenosis location, stenosis degree, heart rate, age and use of beta blockers influence concordance with FFR and should be taken into account when interpreting iFR.

Long-Term Outcomes of Extent of Revascularization in Complex High Risk and Indicated Patients Undergoing Impella-Protected Percutaneous Coronary Intervention: Report from the Roma-Verona Registry.

OBJECTIVE: To investigate the effect of extent of revascularization in complex high-risk indicated patients (CHIP) undergoing Impella-protected percutaneous coronary intervention (PCI). BACKGROUND: Complete revascularization has been shown to be associated with improved outcomes. However, the impact of more complete revascularization during Impella-protected PCI in CHIP has not been reported. METHODS: A total of 86 CHIP undergoing elective PCI with Impella 2.5 or Impella CP between April 2007 and December 2016 from 2 high volume Italian centers were included. Baseline, procedural, and clinical outcomes data were collected retrospectively. Completeness of coronary revascularization was assessed using the British Cardiovascular Intervention Society myocardial jeopardy score (BCIS-JS) derived revascularization index (RI). The primary end-point was all-cause mortality. A multivariate regression model was used to identify independent predictors of mortality. RESULTS: All patients had multivessel disease and were considered unsuitable for surgery. At baseline, 44% had left main disease, 78% had LVEF ≤ 35%, and mean BCIS-JS score was 10±2. The mean BCIS-JS derived RI was 0.7±0.2 and procedural complications were uncommon. At 14-month follow-up, all-cause mortality was 10.5%. At follow-up, 67.4% of CHIP had LVEF ≥ 35% compared to 22.1% before Impella protected-PCI. Higher BCIS-JS RI was significantly associated with LVEF improvement (p=0.002). BCIS-JS RI of ≤ 0.8 (HR 0.11, 95% CI 0.01- 0.92, and p = 0.042) was an independent predictor of mortality. CONCLUSIONS: These results support the practice of percutaneous Impella use for protected PCI in CHIP. A more complete revascularization was associated with significant LVEF improvement and survival.

Instability and impending instability in patients with vertebral metastatic disease.

Metastatic disease commonly involves the spine with an increasing incidence due to a worldwide rise of cancer incidence and a longer survival of patients with osseous metastases. Metastases compromise the mechanical integrity of the vertebra and make it susceptible to fracture. Patients with pathological vertebral fracture often become symptomatic, with mechanical pain generally due to intervertebral instability, and may develop spinal cord compression and neurological deficits. Advances in imaging, radiotherapy, as well as in spinal surgery techniques, have allowed the evolution from conventional palliative external beam radiotherapy to modern stereotactic radiosurgery and from traditional open surgery to less-invasive, and sometimes prophylactic stabilization surgical treatments. It is therefore clear that fracture risk prediction, and maintenance or restoration of intervertebral stability, are important objectives in the management of these patients. Correlation between imaging findings and clinical manifestations is crucial, and a common knowledge base for treatment team members rather than a compartmentalized view is very important. This article reviews the literature on the imaging and clinical diagnosis of intervertebral instability and impending instability in the setting of spine metastatic disease, including the spinal instability neoplastic score, which is a reliable tool for diagnosing unstable or potentially unstable metastatic spinal lesions, and on the different elements considered for treatment.

Identification of the most significant magnetic resonance imaging (MRI) radiomic features in oncological patients with vertebral bone marrow metastatic disease: a feasibility study.

OBJECTIVES: Recently, radiomic analysis has gained attention as a valuable instrument for the management of oncological patients. The aim of the study is to isolate which features of magnetic resonance imaging (MRI)-based radiomic analysis have to be considered the most significant predictors of metastasis in oncological patients with spinal bone marrow metastatic disease. MATERIALS AND METHODS: Eight oncological patients (3 lung cancer; 1 prostatic cancer; 1 esophageal cancer; 1 nasopharyngeal cancer; 1 hepatocarcinoma; 1 breast cancer) with pre-radiotherapy MR imaging for a total of 58 dorsal vertebral bodies, 29 metastatic and 29 non-metastatic were included. Each vertebral body was contoured in T1 and T2 weighted images at a radiotherapy delineation console. The obtained data were transferred to an automated data extraction system for morphological, statistical and textural analysis. Eighty-nine features for each lesion in both T1 and T2 images were computed as the median of by-slice values. A Wilcoxon test was applied to the 89 features and the most statistically significant of them underwent to a stepwise feature selection, to find the best performing predictors of metastasis in a logistic regression model. An internal cross-validation via bootstrap was conducted for estimating the model performance in terms of the area under the curve (AUC) of the receiver operating characteristic. RESULTS: Of the 89 textural features tested, 16 were found to differ with statistical significance in the metastatic vs non-metastatic group. The best performing model was constituted by two predictors for T1 and T2 images, namely one morphological feature (center of mass shift) (p value < 0.01) for both datasets and one histogram feature minimum grey level (p value < 0.01) for T1 images and one textural feature (grey-level co-occurrence matrix joint variance (p value < 0.01) for T2 images. The internal cross-validation showed an AUC of 0.8141 (95% CI 0.6854-0.9427) in T1 images and 0.9116 (95% CI 0.8294-0.9937) in T2 images. CONCLUSIONS: The results suggest that MRI-based radiomic analysis on oncological patients with bone marrow metastatic disease is able to differentiate between metastatic and non-metastatic vertebral bodies. The most significant predictors of metastasis were found to be based on T2 sequence and were one morphological and one textural feature.

[Thymoma in a patient with klinefelter syndrome. Case report]. / Síndrome de Klinefelter diagnosticado en un adulto a raíz del estudio de infección respiratoria recurrente y masa mediastínica. Caso clínico.

Klinefelter syndrome (47, XXY in most cases) is a frequently underdiagnosed chromosomal anomaly associated with multiple comorbidities in adult life. Patients with Klinefelter syndrome have a higher risk of cancer. Specifically, these patients have a higher risk for mediastinal germ cell tumors. It is estimated that 8% of male patients with mediastinal tumors have Klinefelter. We report a 42-years-old male who suffered recurrent respiratory infections. During the study, a mediastinal mass was found, whose pathological study disclosed a type B thymoma. The patient had a history of infertility, high stature, gynecomastia, obesity with gynecoid distribution of body fat and testicular atrophy. A karyotype was requested (47, XXY), confirming the diagnosis of Klinefelter syndrome.