Radiation Exposure during Fluoroscopy-Guided Ozone Chemonucleolysis for Lumbar Disc Herniation.

Introduction: Radiation exposure is a frequent drawback of spinal surgery, even if X-ray guidance plays a pivotal role in improving the accuracy and safety of spinal procedures. Consequently, radiation protection is essential to reduce potential negative biological effects. The aim of this study was to evaluate patients' radiation exposure, the radiation dose emission during fluoroscopy-guided ozone chemonucleolysis (OCN), and the potential role of patient characteristics. Methods: The radiation dose emission reports were retrospectively evaluated in patients who underwent single-level OCN for lumbar disc herniation. A generalized linear model (GLM) with a gamma distribution and log link function was used to assess the association between radiation emission and patients' characteristics such as age, sex, BMI, level of disc herniation, disc height, and site of disc herniation. Results: Two hundred and forty OCN cases were analyzed. A safe and low level of radiation exposure was registered during OCN. The median fluoroscopy time for OCN was 26.3 (19.4−35.9) seconds, the median radiation emission dose was 19.3 (13.2−27.3) mGy, and he median kerma area product (KAP) was 0.46 (0.33−0.68) mGy ⋅ m2. The resulting KAP values were highly dependent on patient variables. In particular, sex, obesity, and residual disc height < 50% significantly increased the measured KAP, while levels of disc herniations other than L5-S1 reduced the KAP values. Conclusions: The radiation exposure during OCN is low and quite similar to a simple discography. However, patient characteristics are significantly related to radiation exposure and should be carefully evaluated before planning OCN.

Características das prescrições de metilfenidato em ambulatório de neuropediatria / Characteristics of methylphenidate prescriptions in a pediatric neurology outpatient clinic

RESUMO O metilfenidato não é disponibilizado pelo Sistema Único de Saúde (SUS), pois não faz parte da Relação Nacional de Medicamentos Essenciais. Todavia, o metilfenidato 10 mg é disponibilizado pela rede pública em Maringá-PR de acordo com a Política da Assistência Farmacêutica do município. Objetivou-se analisar as características das prescrições médicas de metilfenidato para crianças em ambulatório de neuropediatria vinculado ao SUS no município. Estudo transversal observacional retrospectivo de caráter quantitativo, realizado por meio da coleta de dados dos prontuários cadastrados no Sistema Gestor da rede pública de saúde do município, pelo ambulatório de neuropediatria na Unidade Básica de Saúde, Zona 7, entre janeiro de 2017 e novembro de 2019. Analisaram-se os dados por frequência relativa e absoluta. Emitiram-se 339 prescrições pelo neuropediatra responsável do ambulatório para 107 pacientes de 6 a 11 anos. Notou-se distribuição geográfica desigual das crianças atendidas conforme bairro da cidade, o que denota influência socioeconômica na prescrição de medicamentos. Ressaltam-se picos de prescrições coincidindo com o período do ano letivo escolar. Concluiu-se que o acompanhamento especializado adequado é premissa para o tratamento, não dispensando a rede longitudinal de assistência. Ademais, evidencia-se o impacto das condições socioeconômicas, tanto na prescrição como na aquisição do medicamento.

ABSTRACT Methylphenidate is not available through the Unified Health System (SUS), as it is not part of the National List of Essential Medicines. However, methylphenidate 10 mg is available through the public system in Maringá-PR, according to the Pharmaceutical Assistance Policy of the municipality. Retrospective cross-sectional observational study of a quantitative character occurred through the collection of data from the medical records registered in the Management System of the public health network in Maringá-PR, Brazil, by the neuropediatric outpatient clinic in the Basic Health Unit, between January 2017 and November 2019. Data were analyzed by relative and absolute frequency. 339 prescriptions were issued by the responsible neuropediatrician for 107 patients aged 6 to 11 years. There was an uneven geographic distribution of the number of children attended according to the neighborhood of the city, which points to a socioeconomic influence on the medication prescription. It is worth noting peaks of prescriptions coinciding with the period of the school year, following to a national trend. It was concluded that adequate specialized monitoring is a premise for better treatment, not dispensing the longitudinal assistance network. The impact of socioeconomic conditions is significant in the prescription and purchase of the medication.

A single phantom, a single statistical method for low-contrast detectability assessment.

PURPOSE: The assessment of low-contrast-details is a part of the quality control (QC) program in digital radiology. It generally consists of evaluating the threshold contrast (Cth) detectability details for different-sized inserts, appropriately located in dedicated QC test tools. This work aims to propose a simplified method, based on a statistical model approach for threshold contrast estimation, suitable for different modalities in digital radiology. METHODS: A home-madelow-contrast phantom, made of a central aluminium insert with a step-wedge, was assembled and tested. The reliability and robustness of the method were investigated for Mammography, Digital Radiography, Fluoroscopy and Angiography. Imageswere analysed using our dedicated software developed on Matlab®. TheCth is expressed in the same unit (mmAl) for all studied modalities. RESULTS: This method allows the collection of Cthinformation from different modalities and equipment by different vendors, and it could be used to define typical values. Results are summarized in detail. For 0.5 diameter detail, Cthresults are in the range of: 0.018-0.023 mmAl for 2D mammography and 0.26-0.34 mmAl DR images. For angiographic images, for 2.5 mm diameter detail, the Cths median values are 0.55, 0.4, 0.06, 0.12 mmAl for low dose fluoroscopy, coronary fluorography, cerebral and abdominal DSA, respectively. CONCLUSIONS: The statistical method proposed in this study gives a simple approach for Low-Contrast-Details assessment, and the typical values proposed can be implemented in a QA program for digital radiology modalities.

EVALUATION OF THE RADIATION DOSE TO THE HANDS OF ORTHOPAEDIC SURGEONS DURING FLUOROSCOPY USING STORED IMAGES.

Data were collected from 642 orthopaedic interventions during which the images produced by X-rays were recorded. By examining these images, it is possible to determine the time that the orthopaedic surgeons' hands were exposed to the direct radiation beam. The procedures with greater exposure to the direct beam were those involving the hand (median 15 s) and the wrist (median 13 s). Two surgeons wore a ring to measure the absorbed dose at the fingers: one on the dominant hand and the other on the non-dominant hand. The two surgeons performed 34 and 48 operations, respectively, in 14 months. The total doses measured with the rings were 2.30 and 1.04 mSv, respectively. The images of the interventions were examined, determining how much each individual hand was exposed. The interventional reference point (IRPeff (left or right)) was calculated by comparing the doses at the IRP with the exposure times of the right or the left hand. Summing the IRPeff of the two surgeons in 14 months, it is obtained the maximum values of 2.87 mGy for the left hand of one and 6.74 mGy for the right hand of the other, which are of the order of 1/100 of the annual dose limit for the extremities.

Patient dose in angiographic interventional procedures: A multicentre study in Italy.

PURPOSE: The Council Directive 2013/59/EURATOM considers interventional radiology to be a special practice involving high doses of radiation and requiring strict monitoring to ensure the best quality assurance programs. This work reports the early experience of managing dose data from patients undergoing angiography in a multicentre study. MATERIALS AND METHODS: The study was based on a survey of about 15,200 sample procedures performed in 21 Italian hospitals centres involved on a voluntary basis. The survey concerned the collection of data related to different interventional radiology procedures: interventional cardiology, radiology, neuroradiology, vascular surgery, urology, endoscopy and pain therapy from a C-Arm and fixed units. The analysis included 11 types of procedures and for each procedure, air-kerma, kerma-area product and fluoroscopy time were collected. RESULTS: The duration and dose values of fluoroscopic exposure for each procedure is strongly dependent on individual clinical circumstances including the complexity of the procedure; the observed distribution of patient doses was very wide, even for a specified protocol. The median values of the parameters were compared with the diagnostic reference levels (DRL) proposed for some procedures in Italy (ISTISAN) or internationally. This work proposes local DRL values for three procedures. CONCLUSION: This first data collection serves to take stock of the situation on patient's dosimetry in several sectors and is the starting point for obtaining and updating DRL recalling that these levels are dependent on experience and technology available.

DETERMINATION OF LOCAL LEVELS OF RADIATION EXPOSURE IN ORTHOPEDIC INTERVENTIONS USING STRUCTURED DOSE REPORT DATA DRAWN FROM THE HOSPITAL PICTURE ARCHIVING AND COMMUNICATION SYSTEM.

The aim of this study was to determine the dosimetric parameters of radiation to which orthopedic in-patients are exposed, using data drawn from the hospital's picture archiving and communication system. Data for 310 patients, relating to seven different anatomical districts, were examined. Femoral operations were divided into three types. The 75th percentile dose at the interventional reference point (IRP) exceeded 2 mGy only for femoral interventions (4.6-6.2 mGy) with 75th percentile kerma-area product (KAP) values ranging from 84.8 to 109.1 µGy m2. The 75th percentile fluoroscopy time was longer than 1 min only for the humeral operations and the three types of femoral intervention. In general, the radiation exposure times and doses recorded in our institute were lower than those reported in the literature. The correlation between KAP and kerma at the IRP was very strong for all districts (R > 0.80). The correlation between KAP and fluoroscopy times was very strong for seven cases (R > 0.80), and strong for two (0.60 < R < 0.79).

A study of neck and shoulder morbidity following neck dissection: The benefits of cervical plexus preservation.

We conducted a study to evaluate the hypothesis that the preservation of cervical root branches of the cervical plexus is associated with greater shoulder mobility, less loss of face and neck sensation, and better quality of life (QoL) following functional neck dissection in which the spinal accessory nerve is spared. We also investigated the impact of postoperative physiotherapy on these three outcomes. Our study population was made up of 54 patients-47 men and 7 women, aged 34 to 78 years (mean: 53.4)-who had undergone functional neck dissection as a treatment for head and neck cancer over a 3-year period at our institution. Patients were divided into two groups: 23 patients whose cervical root branches were preserved during surgery (preservation group) and 31 whose branches were removed (removal group). Shoulder mobility was measured by the Arm Abduction Test (AAT), face and neck sensation was assessed by fingertip touch in eight areas of the head and neck, and QoL was determined by the University of Washington-Quality of Life questionnaire (UW-QoL4). The AAT revealed that the preservation group had significantly better shoulder mobility. The fingertip touch evaluation revealed significantly less loss of sensation in Saffold regions A and D. Analysis of the UW-QoL4 results revealed that the preservation group experienced significantly less pain, significantly fewer shoulder complaints, and significantly fewer limitations on activities and recreation, as well as significantly better health-related and overall QoL. The preservation group also had a significantly better composite score, global score, social function score, and mood and anxiety score on the UW-QoL4 assessment. Finally, we found that physiotherapy improved both QoL and shoulder mobility, although these improvements were not statistically significant. We conclude that preservation of the cervical root branches significantly improves outcomes in patients who undergo functional neck dissection.

Plexiform schwannoma of the posterior pharyngeal wall in a patient with neurofibromatosis 2.

We report a case of plexiform schwannoma of the posterior pharyngeal wall that occurred in a 37-year-old man who had been previously diagnosed with neurofibromatosis type 2 (NF2). Plexiform schwannoma has been rarely reported in association with NF2. Moreover, as far as we know, only 6 cases of posterior pharyngeal wall schwannoma have been previously reported in the literature, none of which was associated with NF2 and none of which was histopathologically differentiated in schwannoma or plexiform schwannoma. The patient was treated with laser excision of the tumor via a transoral route, and at 6 and 12 months of follow-up, he exhibited no signs of recurrence. To the best of our knowledge, our patient represents the first reported case of a posterior pharyngeal wall schwannoma that occurred in association with NF2 and the first case in which the schwannoma was removed via transoral laser excision. This case illustrates that plexiform schwannoma is a possible finding in NF2 and that transoral laser excision is a safe surgical procedure in such a case.

Il riconoscimento del progetto migratorio del minore e la valorizzazione della rete parentale nell'accoglienza dei minori stranieri non accompagnati. L'evoluzione della presa in carico nel comune di Cremona (2005 – 2011) / The recognition of the children migrant's project and the exploitation of the parental network in taking over the unaccompained minors migrants. The evolution of the care in the Municipality of Cremona (2005 - 2011)

Il fenomeno dei minori stranieri non accompagnati fu gestito a Cremona, fino all'anno 2007, unicamente tramite l'accoglienza in strutture residenziali. Tale pratica dovette però confrontarsi con la criticità (anche di tipo economico) rappresentata dalla massiccia crescita degli arrivi di minorenni stranieri dichiaranti essere "non accompagnati", verificatasi negli anni 2006 e 2007. La frequente presenza di reti parentali dei minori nelle provincie limitrofe, indusse a ritenere che il percorso migratorio dei MSNA giunti a Cremona fosse il risultato di una strategia messa a punto da adulti di riferimento, i quali indirizzavano il giovane verso quei territori dove le pratiche d'accoglienza apparivano più efficaci riguardo all'acquisizione del titolo di soggiorno. Ciò che emerge è la correlazione intercorrente tra modalità di accoglienza e strategia migratoria. A partire dall'anno 2008, il riconoscimento del carattere "famigliare" del progetto migratorio del minore, e della sua rete parentale come risorsa per una più efficace e sostenibile presa in carico, portò all'identificazione di una strategia di accoglienza incentrata sull'affidamento famigliare.(AU)

The phenomenon of unaccompanied minors migrants occurred in Cremona, until 2007, only through their reception in residential facilities. This practice had to confront the critical issues (also economic) represented by the massive growth of arrivals, which occurred in Cremona in the years 2006 and 2007, of underage foreign migrants declaring "unaccompanied".The frequent presence of children's parental networks in the neighbouring cities led to the path of migration of unaccompanied minors arriving in Cremona. This was the result of a strategy devised by representatives adults which addressed the young immigrants towards those areas where the practices of reception seemed more effective with regards to the acquisition of the permit residency. The correlation between host and migratory strategy became evident. In 2008, the "familiar character" of the migration - for the most part of the unaccompanied minors - was recognized by the Social Services of Cremona. This was regarded as a resource for a more effective taking-over. This led to the identification of a strategy based on the care in some host families.(AU)

Human papillomavirus tumor-infiltrating T-regulatory lymphocytes and P53 codon 72 polymorphisms correlate with clinical staging and prognosis of oropharyngeal cancer.

The association between human papillomavirus (HPV) DNA positivity, p53 codon 72 polymorphisms, and the type of leukocyte infiltration in head and neck squamous cell carcinomas (HNSCC) and their combined impact upon patient survival is poorly investigated. For this reason, leukocyte infiltration profile and p53 codon 72 polymorphisms were assessed in freshly removed HNSCC specimens (N=71 patients). HPV detection was performed by nested-PCR followed by DNA sequencing. Viral loads were determined by quantitative RT-PCR. The choice to investigate fresh instead of archive paraffin-embedded specimens was privileged to avoid possible artifacts due to sample processing. HPV DNA was detected in 14% of cases. Oropharyngeal carcinomas were the most frequently associated with the presence of HPV16 DNA (41%) and were associated with p53 Pro/Pro or Pro/Arg polymorphisms. In HPV16-positive oropharyngeal carcinomas increased infiltrations of CD3+ and FoxP3+ T-cells correlated with higher HPV16 copy numbers. The presence of HPV may trigger a stronger immune response and may be considered a reliable marker for clinical staging and a more favorable prognosis of oropharyngeal carcinoma.

Radiofrequency volume turbinate reduction versus partial turbinectomy: clinical and histological features.

BACKGROUND: Nasal obstruction is a common symptom related to turbinate hypertrophy in 20% of cases. When medical treatment failed different surgical options were available. Actually, nasal physiology impairment after surgical treatment is not fully clear. This study evaluates microscopic mucosal changes and physiological function, by means of mucociliary transport time (MCT), after radiofrequency volume turbinate reduction and partial inferior turbinectomy. METHODS: Forty-eight nonallergic patients were treated for chronic nasal obstruction. Twenty-six patients (group A) underwent radiofrequency turbinate reduction and 22 patients (group B) underwent partial turbinectomy associated with septoplasty. Mucosal specimens obtained before T(0) and 6 months (T(1)) after surgery were compared by means of optical microscope and transmission electron microscope. All patients were evaluated using MCT at T(0) and T(1). RESULTS: Optical analysis showed circumscribed squamous metaplasia and fibrosis in specimens obtained from group A. Same changes were more evident in group B. Ultrastructural analysis evidenced loss of ciliated epithelium in group B, whereas in group A a normal number of cilia was found. In all patients at T(1), MCT time was prolonged in comparison with the preoperative values. After surgery, group B showed significantly prolonged MCT in comparison with group A (p < 0.05). CONCLUSION: In our study both surgical techniques achieved good clinical outcomes with improved nasal function, although the ciliated epithelium appeared partially impaired. These findings resulted in a prolonged MCT in all patients, especially in those treated with partial turbinectomy. Compared to partial resection, intraturbinal turbinate reduction seems to be the method of choice to better preserve nasal physiology.

The platysma myocutaneous flap (PMF) for head and neck reconstruction: a retrospective and multicentric analysis of 91 T1-T2 patients.

The platysma myocutaneous flap (PMF) was first applied to intraoral reconstructions in 1978. PMF is not only an alternative to microvascular flaps but it also represents an excellent reconstructive choice especially in cases where free tissue transfer cannot be carried out. Failure and complications rate have been described as varying from 18 to 45% and this is why this flap should not be used in specific cases such as in the presence of cervical metastases and in cases of mandibulectomy and simultaneous reconstruction with alloplastic materials. The purpose of this study is to examine the experience and results obtained in three different and independent institutes where PMF has been adopted in 91 patients for head and neck cancer reconstructions. The authors report their departments' separate but simultaneous experiences with PMF for small and middle-size soft tissue defects in a 10-year period.

Radiofrequency inferior turbinate reduction: long-term olfactory and functional outcomes.

OBJECTIVE: The aim of this study was to assess the long-term effects of radiofrequency inferior turbinate reduction (RITR) on nasal function in patients affected by nasal obstruction secondary to turbinate hypertrophy, focusing attention on increased sense of smell and its persistence after a 2-year follow-up. STUDY DESIGN: Case series with planned data collection. SETTING: ENT division, university hospital. SUBJECTS AND METHODS: A total of 40 consecutive patients undergoing RITR for allergic or nonallergic chronic rhinitis with inferior turbinate hypertrophy were included. We planned a series of tests, including the "Sniffin' Sticks" test battery, anterior rhinomanometry, and the nasal Obstruction Symptom Evaluation (NOSE) scale, on the day of the procedure and at the 2-month and 2-year follow-up visits. RESULTS: Of the 40 patients, 35 completed all the objective and subjective examinations on the day of the procedure and at the 2-month and 2-year follow-up visits. The authors found a significant decrease in nasal resistances from a mean of 1.13 Pa/cm(3)s(-1) preoperatively to a mean of 0.29 Pa/cm(3)s(-1) 2 years postoperatively and improvement in odor threshold, discrimination, and identification scores 2 years postoperatively. The NOSE score diminished significantly 2 years after surgery from a mean of 23.14 to a mean of 4.14 (all P < .01 with the t test for repeated measures). CONCLUSION: This long-term evaluation showed that radiofrequency treatment for allergic or nonallergic inferior turbinate hypertrophy appeared to provide improvement in olfaction, decrease nasal resistances, and have subjective benefits, maintained 2 years after the procedure.

Orthostatic hypotension and psychiatric comorbidities in patients with dizziness.

PURPOSE: The present study was undertaken to investigate orthostatic hypotension and psychiatric comorbidity with anxiety and depression in dizzy patients. MATERIALS AND METHODS: Sixty-three patients with nonspecific dizziness and 27 volunteer subjects were evaluated with the head-up tilt test (HUTT) and the Standardized Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I. RESULTS: Orthostatic hypotension was induced by HUTT in 44% of patients and in 15% of volunteers (P = .0082); we found that the incidence of anxiety and depression was significantly higher (P < .05) in patients with nonspecific dizziness than in controls. Orthostatic hypotension was related to age but not to antihypertensive therapy and sex. Dizziness during the HUTT was reported by 49% of patients and 33% of volunteers (P = .2469). Among patients, dizziness was found to be related to sex (female) and anxiety. A correlation between dizziness and anxiety was also present in volunteers. Head-up tilt test induced vasovagal reactions in 2 volunteers. CONCLUSIONS: Orthostatic hypotension is present in a high percentage of patients with orthostatic dizziness, and anxiety and depression are an important factor in the onset of dizziness. A high percentage of abnormal responses in volunteer subjects seems to indicate that the HUTT is not indicated for routine use.

[The prevention of noise inducted hearing loss: the new challenge of active electronic hearing protection]. / La prevenzione individuale del trauma acustico cronico: la nuova frontiera degli otoprotettori attivi.

Based on today's common hearing aid design and technology, the team of researchers successfully designed a DPI which allows the worker to be "protected" against loudness and in the same time guarantee a good level of communication and perception of the surrounding environment. The design of this new device is very much similar to a standard BTE hearing aid which allows the use of an active DPI very comfortable, robust and easy to use. The research using the prototypes was divided into 3 phases: Phase 1: 24 volunteers coming from non-industry companies did undergo a specific trial protocol. Phase 2: 6 workers coming from a mining company did undergo the same protocol used in Phase 1. Phase 3: The Acoustics Laboratory from the "Energetica" Department of the Polytechnic of Turin (University/Institute) took objective measures for the DPI attenuation figures used in phase 1 and 2.

[NHIL epidemiology in Italy. 20 years from DLgs 277/91: review and expectations]. / L'epidemiologia del danno a rumore in Italia a 20 anni dal D.Lgs 277/91: stato attuale e previsioni.

Digs 277/91 and following related laws brought up a large number of NHILs, but also planned surveillance more and more effective in preventing hearing loss. In these two decades we also saw an inversion in percentages between working populations. The Authors analize these two factors, better and wider prevention and changing in work populations, related to resulting reduction of NHIL's cases. Besides, the Authors compare different insurance scales adopted to evaluate hearing damage in this period, bringing out similarities. INAIL's path achieved another last goal since 2007 in planning the new protocol about hearing aids, aiming to more effective compensation of the recognized hearing loss, looking more at "Biological value" of the person than at former "working capability".

[Socio-presbyacusis: definition and prevention]. / La sociopresbiacusia: cos'è e come si previene.

Socio-presbyacusis is a hot topic with an increasing incidence and high social costs. The main etiological factors are: genetics, smoking and drinking habits, diet, metabolic syndrome, chronic otitis and noise exposure (professional, environmental and recreative). Despite its multifactorial origin, the pathogenetic mechanism of cochlear damage is based on the increased production of Reactive Oxygen Species (ROS). The clinical characteristic feature of socio-presbyacusis is represented by slow cochlear degeneration causing a reduction of central hearing inputs. The result is a gradual social isolation of the deaf patient with a worsening of his Quality of Life. The main target of the management of socio-presbyacusis is the early diagnosis and prosthetic remediation in order to avoid patient's isolation. New preventive and remediative strategies are represented by antioxidant drugs.

Induction chemotherapy with carboplatin and taxol followed by radiotherapy and concurrent weekly carboplatin + taxol in locally advanced nasopharyngeal carcinoma.

PURPOSE: Aim of this study was the clinical evaluation of carboplatin-taxol combination in a neoadjuvant and concomitant setting with conventional radiotherapy in loco-regionally advanced nasopharyngeal carcinoma (A-NPC). METHODS: Thirty patients were treated with three cycles of carboplatin (AUC6) plus taxol (175 mg/m(2)) on day 1 every 3 weeks, followed by weekly carboplatin (AUC1) plus Taxol (60 mg/m2) and concomitant radiotherapy (70 Gy). RESULTS: We observed the objective complete response rates of 33% (after chemotherapy) and 87% (after chemo-radiotherapy). Treatment tolerability and toxicity were controllable. Three- and five-year progression-free survival were 80 and 75%, respectively, and 3- and 5-year overall survival were 85 and 80% (follow-up 49.5 months). Five-year loco-regional control was 90.3%, and five-year distant metastases-free survival was 85%. CONCLUSIONS: Neoadjuvant chemotherapy with such protocol represents a feasible, efficient treatment for patients with A-NPC, ensuring excellent loco-regional disease control and overall survival with low incidence of distant metastases.