Acute intestinal ischemia in patients with COVID-19: single-centre experience and literature review.

OBJECTIVE: Acute Intestinal ischemia (AII) may involve the small and/or large bowel after any process affecting intestinal blood flow. COVID-19-related gastrointestinal manifestations, including AII, have been attributed to pharmacologic effects, metabolic disorders in ICU patients and other opportunistic colonic pathogens. AII in COVID-19 patients may be due also to "viral enteropathy" and  SARS-CoV-2-induced small vessel thrombosis. A critical appraisal of personal experience regarding COVID-19 and AII was carried out comparing this with a systematic literature review of published series. PATIENTS AND METHODS:   A retrospective observational clinical cohort study and a systematic literature review including only COVID-19 positive patients with acute arterial or venous intestinal ischemia were performed. The primary endpoint of the study was the mortality rate. Secondary endpoints were occurrence of major complications and length of hospital stay. RESULTS: Patient mean age was 62.9±14.9, with a prevalence of male gender (23 male, 72% vs. 9 female, 28%). The mean Charlson Comorbidity Index was 3.1±2.7. Surgery was performed in 24/32 patients (75.0%), with a mean delay time from admission to surgery of 6.0 ±5.6 days. Small bowel ischemia was confirmed to be the most common finding at surgical exploration (22/24, 91.7%). Acute abdomen at admission to the ED (Group 1) was observed in 10 (31.2%) cases, while 16 (50%) patients developed an acute abdomen condition during hospitalization (Group 2) for SARS-CoV-2 infection. CONCLUSIONS: Our literature review showed how intestinal ischemia in patients with SARS-CoV-2 has been reported all over the world. The majority of the patients have a high CCI with multiple comorbidities, above all hypertension and cardiovascular disease. GI symptoms were not always present at the admission. A high level of suspicion for intestinal ischemia should be maintained in COVID-19 patients presenting with GI symptoms or with incremental abdominal pain. Nevertheless, a prompt thromboelastogram and laboratory test may confirm the need of improving and fastening the use of anticoagulants and trigger an extended indication for early abdominal CECT in patients with suggestive symptoms or biochemical markers of intestinal ischemia.

Baseline metabolic disturbances and the twenty-five years risk of incident cancer in a Mediterranean population.

BACKGROUND AND AIMS: Obesity is predictive of metabolic syndrome (metS), type 2 diabetes, cardiovascular (CV) disease and cancer. The aim of the study is to assess the risk of incident cancer connected to obesity and metS in a Mediterranean population characterized by a high prevalence of obesity. METHODS AND RESULTS: As many as 1133 subjects were enrolled in two phases and followed for 25 years (859 subjects) or 11 years (274 subjects) and incident cancer was registered in the follow-up period. Anthropometric measures and biochemical parameters were filed at baseline and evaluated as predictors of incident cancer by measuring hazards ratios (HR) using multivariate Cox parametric hazards models. Best predictive threshold for metabolic parameters and metS criteria were recalculated by ROC analysis. Fasting Blood Glucose >5.19 mmol/L [HR = 1.58 (1.0-2.4)] and the TG/HDL ratio (log10) (Males > 0.225, Females > 0.272) [HR = 2.44 (1.3-4.4)] resulted independent predictors of survival free of cancer with a clear additive effect together with age classes [45-65 years, HR = 2.47 (1.3-4.4), 65-75 years HR = 3.80 (2.0-7.1)] and male gender [HR = 2.07 (2.3-3.1)]. CONCLUSIONS: Metabolic disturbances are predictive of cancer in a 25 years follow-up of a Mediterranean population following a traditional Mediterranean diet. The high prevalence of obesity and metS and the observed underlying condition of insulin resistance expose this population to an increased risk of cardiovascular disease and cancer despite the healthy nutritional habits.

Determinants in predicting duration of treatment in an out-patient rehabilitation orthopedic-traumatologic service.

BACKGROUND: Duration of rehabilitation is an important rehabilitation clinical outcome both from a clinical and administrative point of view. Very few studies have looked at predictors oftreatment duration in out-patient rehabilitation setting especially in patients with orthopedic-traumatologic conditions. AIM: We undertook a prospective study to assess treatment duration and identify variables predicting this outcome measure (primary outcome) and efficiency in range of motion and activities of daily living (secondary outcome). DESIGN: Prospective and observational study. SETTING: Out-patient Service for Rehabilitation. POPULATION: Two hundred and ten patients admitted to Out-patient Service for Rehabilitation of orthopedic disorders were enrolled: 94 patients had limb fracture (35 wrist fracture, 28 ankle fracture, 27 shoulder fracture), and 120 and undergone elective orthopedic surgery (27 cruciate reconstruction, 93 rotator cuff repair). METHODS: Univariate Regression analysis was applied to analyze relationships among variables and length of rehabilitation while backward stepwise regression analysis was used to predict treatment duration. The independent variables were age, gender, work, type of physical therapy, comorbidity, pain, onset to admission interval, initial disability, initial range of motion percentage (ROM), and diagnosis group. RESULTS: Mean treatment duration was 29.7±15 days. Treatment duration following rotator cuff repair was significantly longer than that of cruciate reconstruction (P=0.005), wrist fracture (P<0.001), and ankle fracture (P=0.002). Treatment duration was related to working status, admission disability, onset to admission interval, diagnosis group, admission pain, and admission range of motion. In multivariate regression analysis, admission range of motion and onset to admission interval were the only independent predictors of treatment duration and efficiency in range of motion, while admission range of motion and admission Health Assessment Questionnaire were predictors of efficiency in Health Assessment Questionnaire score. CONCLUSION: The study highlights that rehabilitative treatment duration has strong relationship with admission range of motion and onset admission interval. CLINICAL REHABILITATION IMPACT. These findings should be useful for physicians for planning therapeutic measures in patients with orthopedic-traumatologic conditions and for managing the usual activities of an Out-patient Rehabilitative Service.

High dose rate prostate brachytherapy: the California Endocurietherapy (CET) method.

BACKGROUND AND PURPOSE: To describe the rationale, protocol and procedure for the treatment of prostate cancer using high dose rate brachytherapy (HDR-BT) and a non-fixed template technique. MATERIALS AND METHODS: Between July 1991 and December 1998, 491 patients with carcinoma of the prostate were treated using HDR-BT and a non-fixed template technique. AJC stages T(1C)-T(3B), patients with prior transurethral resections of the prostate (TURP) and gland volumes >60 cm(3), were included. Flexible cystoscopy, fluoroscopy and transrectal ultrasound (TRUS) were used and 17 flexiguides were inserted through the perineum. Dosimetry was carried out using localization films. Treatment volume was defined at 4-6 mm outside the peripheral catheters. BT consisted of two implants, separated by 1 week, with two fractions given per implant for a total of four HDR fractions. Dose prescription to the treatment volume was 6 Gy (HDR) per fraction, with an additional dose of 0.5 to 0.75 Gy given where required. RESULTS: Patients with glands >60 cm(3), narrow pubic arches and TURP defects were treated satisfactorily. Symptoms of urinary irritation occurred with variable intensity and abated rapidly 2 weeks after the procedures. There was no high-grade chronic rectal morbidity and most patients reported no rectal symptoms or treatment-related chronic urinary incontinence. CONCLUSIONS: The non-fixed template technique allowed flexibility in flexiguide placement to encompass large glands (>60 cm(3)), extracapsular extension and seminal vesicle involvement without the need for additional flexiguides. Also, small pubic arches and TURP defects posed little problem in positioning the flexiguides. This versatility resulted in complete treatment volume coverage of the prostate.

High dose rate brachytherapy in the treatment of prostate cancer.

Because the HDR brachytherapy treatments are delivered within minutes and on an outpatient basis, HDR brachytherapy is very well tolerated by patients and offers complete radiation safety. Published studies2, 11, 12, 13, 16, 17, 18, 22, 24, 25 have shown high local clinical and biochemical control rates. Chronic complications have been acceptably low. Very low rates of urinary incontinence and high sexual potency rates have been reported. Gastrointestinal morbidity has been minimal. The development of Ir-192 HDR afterloading brachytherapy and refinements in the dosimetry have ushered in a new era in prostate brachytherapy. The control of the radiation dose and the ability to shape the radiation treatment envelope using a stepping source have allowed a giant step forward in radiation oncology technology. It is now possible to deliver tumoricidal doses of radiation conformally to the prostate while minimizing the dose to the bladder, urethra, and rectum. At present, HDR afterloaded brachytherapy is the optimal whole-organ and tumor-specific conformal radiation therapy for prostate cancer.

The use and advantages of a multichannel vaginal cylinder in high-dose-rate brachytherapy.

PURPOSE: This paper describes California Endocurietherapy's (CET) high-dose-rate (HDR) multichannel cylinder, the rationale for its design, procedure for its insertion, and the dosimetry involved in its use. A study was done that compared the doses achieved using the CET multichannel cylinder to the same cylinder if it only had a central channel. METHODS AND MATERIALS: The CET multichannel vaginal cylinder was inexpensively constructed, using parts from various suppliers. After insertion in the patient, the cylinder is affixed to a base plate to prevent displacement. Two sets of orthogonal films (without and with rectal barium) are taken in preparation for digitization of the catheters, bladder, rectal, and pelvic sidewall points. Using HDR brachytherapy planning software, the dose distribution is adjusted to achieve the prescribed dose (5 Gy HDR) 5 mm lateral to the cylinder surface, 5 mm lateral at the proximal parametrial tissue, and 4 mm superior to the vaginal apex. Doses to the bladder and rectum are limited to approximately 85% and 75%, respectively, of the prescribed dose. The plan is optimized on geometric parameters. For dose comparison to treatment using a central channel cylinder, the lateral channels are de-activated, leaving only the central channel activated. Dose points are placed 5 mm laterally and superiorly from the cylinder surface, and the plan is optimized to deliver a uniform dose to the defined dose points. The doses and treatment volumes are statistically compared. RESULTS: The CET multichannel cylinder allows much better dose control than the central channel cylinder. The multichannel cylinder achieves lower bladder and rectal doses by 14% and 15%, respectively, when compared to the central channel cylinder. By increasing the dwell times of certain dwell positions, the prescription dose is achieved in the vaginal apex and proximal parametrial tissues and along the length of the cylinder. CONCLUSION: The multichannel cylinder enables more flexibility in isodose shaping and dose control to various points and structures when compared to the conventional central channel cylinder.

[The phenomenon of abuse of aged Puerto Ricans]. / El fenómeno de la violencia contra los(as) ancianos(as) Puertorriqueños(as).

The present study is the first one to our knowledge that tries to give a panoramic view and explore the problem of Elderly Abuse in Puerto Rico. A retrospective statistical analysis of frequencies of cases by sex gender, age strata and region has been obtained showing an increasing tendency of cases. We conclude that the phenomena of abuse in the Puerto Rican Elderly population is one that requires rapid interventions with emphasis in the prevention component.

Normalization: what does it really mean?

Attempts have been made to standardize normalization techniques, but it remains a confusing issue. As of late there are five different possible normalization tools consisting of normalizing: 1. to the isocenter, 2. to a specific point other than the isocenter, 3. to a minimum target absorbed dose whose are of maximum target absorbed dose is a 2 cm2 area, 4. to an isodose value, 5. to the dmax of the beams. The International Commission on Radiation Units and Measurements has updated its report number 29 to further recommend normalization standards to include planning to a specification point that: 1. is easy to define in an unambiguous way, 2. is chosen in a region where the dose is rather homogeneous and representative of the dose distribution throughout the target volume, 3. defined where the dose can be accurately determined, 4. normalizes to the isocenter of the plan where the maximum absorbed dose is a 1.5 cm2 area, 5. limits the dose variation to 10%. With increasing complexity involving three-dimensional planning, mixed-beam therapy, and heterogeneity compensation, a full understanding of dose determination is necessary to accurately implement treatment plans.