Muscle magnetic resonance characterization of STIM1 tubular aggregate myopathy using unsupervised learning.

PURPOSE: Congenital myopathies are a heterogeneous group of diseases affecting the skeletal muscles and characterized by high clinical, genetic, and histological variability. Magnetic Resonance (MR) is a valuable tool for the assessment of involved muscles (i.e., fatty replacement and oedema) and disease progression. Machine Learning is becoming increasingly applied for diagnostic purposes, but to our knowledge, Self-Organizing Maps (SOMs) have never been used for the identification of the patterns in these diseases. The aim of this study is to evaluate if SOMs may discriminate between muscles with fatty replacement (S), oedema (E) or neither (N). METHODS: MR studies of a family affected by tubular aggregates myopathy (TAM) with the histologically proven autosomal dominant mutation of the STIM1 gene, were examined: for each patient, in two MR assessments (i.e., t0 and t1, the latter after 5 years), fifty-three muscles were evaluated for muscular fatty replacement on the T1w images, and for oedema on the STIR images, for reference. Sixty radiomic features were collected from each muscle at t0 and t1 MR assessment using 3DSlicer software, in order to obtain data from images. A SOM was created to analyze all datasets using three clusters (i.e., 0, 1 and 2) and results were compared with radiological evaluation. RESULTS: Six patients with TAM STIM1-mutation were included. At t0 MR assessments, all patients showed widespread fatty replacement that intensifies at t1, while oedema mainly affected the muscles of the legs and appears stable at follow-up. All muscles with oedema showed fatty replacement, too. At t0 SOM grid clustering shows almost all N muscles in Cluster 0 and most of the E muscles in Cluster 1; at t1 almost all E muscles appear in Cluster 1. CONCLUSION: Our unsupervised learning model appears to be able to recognize muscles altered by the presence of edema and fatty replacement.

Distribuição de abundância de espécies da comunidade arbórea do topo de um morro na floresta estacional subtropical / Species abundance distribution in tree community of a hill top in subtropical seasonal forest

Modelos ecológicos de distribuição de espécies (DAEs) em uma comunidade arbórea foram investigados para constatar: (i) se as variáveis ambientais são divididas de maneira estocástica e de modo similar entre as espécies; (ii) se cada espécie exaure mais da metade do nicho ecológico existente; (iii) se a comunidade arbórea possui muitas espécies com níveis intermediários de abundância e poucas espécies raras e comuns; (iv) e se, na sucessão secundária, as espécies colonizadoras tardias têm as maiores necessidades de um nicho especializado, de tal modo que são mais raras que as espécies colonizadoras iniciais. Obteve-se os dados em oito unidades amostrais de dimensões de 20m x 50m, distribuídas sistematicamente, perfazendo 0,8ha de amostra; ajustaram-se cinco modelos de DAEs (broken-stick, niche-preemption, log-normal, Zipf e Zipf-Mandelbrot) para a amostra e para as unidades amostrais; os critérios de acurácia dos modelos foram: Akaike, Bayesiano e Deviance. O modelo ecológico de DAEs que descreveu o ranking/abundância das espécies para a comunidade arbórea foi o Zipf-Mandelbrot. Os modelos ecológicos de DAEs que caracterizaram as unidades amostrais foram: niche-preemption, Zipf e Zipf-Mandelbrot. O modelo Zipf-Mandelbrot postula a colonização das espécies sob as exigências de condições ambientais prévias para o estabelecimento, assim, detecta-se uma comunidade arbórea em estágio de maturidade. Os modelos ecológicos de DAEs obtidos para as unidades amostrais, separadamente, evidenciam a disparidade da distribuição de abundância de espécies no interior da comunidade arbórea, que se interpretou como o efeito da heterogeneidade das condições e dos recursos ambientais, além de perturbações naturais, que originam um mosaico vegetacional.

Ecological Models of Species abundance distribution (SADs) of a tree community were investigated to find: (i) if environmental variables are divided stochastically and similarly between species; (ii) if each species exhausts more than half of the existing ecological niche; (iii) if the tree community has many species with intermediate levels of abundance and a few rare and common species; (iv) and if, in secondary succession, the later colonizing species have greatest needs for a specialized niche, so, they are more rare than the initial colonizers species. The data were obtained in eight sampling units with dimensions of 20m x 50m, distributed in a systematic way, totaling 0.8 ha sample; grouped in five models of SADs (broken-stick, niche-preemption, lognormal, Zipf and Zipf-Mandelbrot) for the sample of the tree community and the eight sampling units; the criteria of accuracy of the models were: Akaike, Bayesian and Deviance. The ecological model described the SADs that rank/abundance of tree species for ecological community which was the Zipf-Mandelbrot. The ecological models of SADs that characterized the eight sampling units were niche-preemption, Zipf and Zipf-Mandelbrot. The Zipf-Mandelbrot model postulates the colonization of species under the requirements of environmental preconditions for the establishment of the species, and thus detects up an arboreal community stage of maturity. The ecological models of SADs obtained for the sampling units, separately, show the disparity in the distribution of species abundance within the tree community that was interpreted as the effect of heterogeneity of conditions and environmental resources, and natural disturbances, originating a mosaic vegetation.

Liver resection for noncolorectal and nonneuroendocrine metastases: results of a study on 56 patients at a single institution.

The usefulness of surgical treatment for hepatic metastases of noncolorectal nonneuroendocrine (NCRNNE) tumors is not yet clear due to the natural history of these tumors, their frequent systemic dissemination and their histological heterogeneity. The aim of this study was to evaluate the long-term outcome of patients who underwent liver resection for NCRNNE metastases. For this purpose we retrospectively analyzed 202 patients who underwent liver resection for metastasis between January 1989 and December 2006 at the Department of Surgery of the University Hospital of Udine. Fifty-six patients underwent liver resection because of NCRNNE metastases. The preoperative assessment was based on hepatic ultrasonography and CT scan; PET was used in a few patients. All patients had intraoperative liver ultrasonography to evaluate the lesions and to define the resection. Gender, age, primary tumor site (gastrointestinal or nongastrointestinal), synchronous or metachronous metastasis, unilobar or bilobar localization, number and diameter of the lesion(s), type of resection, margin status, positive lymph nodes in the hepatoduodenal ligament, and time between surgery and diagnosis of liver metastases were evaluated as possible prognostic factors for survival. Univariate analysis showed that the location of the primary tumor and the disease-free interval since the treatment of the primary tumor were positive predictive factors for longer survival. Multivariate analysis showed that the only independent significant factor was gastrointestinal versus nongastrointestinal origin. Demographic data, the synchronous or metachronous appearance of metastases, their unilobar or bilobar location, number and size, the type of resection, the resection margin status and the involvement of lymph nodes did not prove to be prognostic factors.

Laparoscopic reconstruction after esophageal resection for perforation: a new surgical approach.

The authors present 2 cases of esophageal perforation treated using a new 2-step approach, consisting of esophageal resection and delayed reconstruction of the digestive tract after laparoscopic preparation and transposition of the stomach. The method is characterized by the minimally invasive insertion of a gastric tube through the precardial esophageal stump for postoperative enteral nutrition, and by the use of a laparoscopic method in the reconstruction step for gastrolysis and transposition of the stomach. The benefits lie in the opportunity for enteral feeding preparatory to the reconstruction, with no need for any gastrostomy or jejunostomy, and with fewer complications and a better recovery after reconstruction surgery thanks to the use of a laparoscopic method instead of a laparotomy.

Treatment of perforation in the healthy esophagus: analysis of 12 cases.

BACKGROUND: Perforation of the esophagus still carries high morbidity and mortality rates, and there is no gold standard for the surgical treatment of choice. MATERIALS AND METHODS: We reviewed the records of patients treated for esophageal perforation in the last decade at the General Surgery Unit of the University of Udine. Patients suffering from perforation secondary to surgical procedures or neoplastic disease were ruled out. RESULTS: Eight males (66.7%) and four females (33.3%) met the inclusion criteria. The cause of perforation was iatrogenic in seven cases (58.3%) and spontaneous in five (41.7%). The perforation was in the cervical esophagus in five cases (41.7%) and at thoracic level in the other seven (58.3%). Two patients (16.7%) with cervical lesions were treated conservatively; two (16.7%) underwent primary closure and the insertion of a drainage tube; one patient with a distal cervical lesion underwent diversion esophagostomy; six patients had resection of the entire thoracic esophagus and terminal cervical esophagostomy; one had segmental resection of the distal thoracic esophagus and lateral diversion esophagostomy. In the five patients whose reconstruction was postponed, esophagogastroplasty surgery was performed with an anastomosis at cervical level in four cases and at thoracic level in one. The global mortality rate was 25%. Late diagnosis-more than 24 h after the perforation event-seems to be the only factor correlated with fatal outcome (p = 0.045). CONCLUSIONS: The choice of treatment for perforation in a healthy esophagus depends mainly on the site and size of the lesion. Cervical lesions may be amenable to conservative treatment or require primary surgical repair, while thoracic lesions with associated sepsis or major loss of substance demand an aggressive approach, with esophageal resection and delayed reconstruction seeming to be the safest option.

Liver resection for hepatocellular carcinoma: a multivariate analysis of factors associated with improved prognosis. The role of clinical, pathological and surgical related factors.

AIMS AND BACKGROUND: Hepatocellular carcinoma (Hcc) is the third most common cause of cancer death. The aim of this study is to examine the factors associated with improved prognosis in Hcc after liver resection. PATIENTS AND METHODS: From September 1989 to March 2005, 134 consecutive patients had liver resection for Hcc on cirrhosis at our department. We performed 54 major liver resections and 80 limited resections. All patients enrolled in the study were followed-up three times during the first year after resection and twice the next years. RESULTS: In-hospital mortality rate was 7.4%, about 50% of these cases were Child-Pugh B patients. Morbidity rate was 47.7%, caused by the rising of ascites, temporary liver impairment function, biliary fistula, hepatic abscess, hemoperitoneum and pleural effusion. Overall survival resulted to be influenced by etiology (P = 0.03), underlying liver disease, in particular Child A vs BC (P = 0.04), Endmondson-Steiner grading (P = 0.01), the absence of a capsule (P = 0.004), the presence of more than one lesion (P = 0.02), lesion's size over 5 cm (P = 0.04), Pringle maneuver length over than 20 minutes (P = 0.03), an amount of resected liver volume lesser than 50% of total liver volume (P = 0.03), and the relapse of Hcc (P= 0.01). CONCLUSIONS: The treatment of hepatocellular carcinoma should be both the most radical to obtain the best outcome and to reduce the recurrence's rate, and the most suitable according to the patient's condition, lesion's characteristics and underlying liver disease: because of the large number of factors affecting the outcome of Hcc, unfortunately, we are still far from an agreement upon a group of criteria useful to select the best candidates for liver resection.

Liver resection for HCC: analysis of causes and risk factors linked to postoperative complications.

BACKGROUND/AIMS: Hepatic resection is widely accepted as the best treatment for localized hepatocellular carcinoma (HCC), even in those patients affected by cirrhosis after a sharp selection. Notwithstanding technical advances and high experience of liver resection of specialized centers, the rate of complication after surgical resection could be high. Herein we analyzed causes and foreseeable risk factors on the grounds of data derived from a single center surgical population. METHODOLOGY: From September 1989 to March 2005, 134 consecutive patients had liver resection for HCC on cirrhosis at our department. We performed 54 major liver resections and 80 limited resections. RESULTS: In-hospital mortality rate was 7.4%, about 50% of these cases were Child-Pugh B patients. Morbidity rate was 47.7%, caused by the rising of ascites, hepatic insufficiency, biliary fistula, hepatic abscess, hemoperitoneum and pleural effusion. Intraoperative mortality resulted to be influenced by the amount of resected liver volume (p < 0.05), and the rising of complication (p = 0.006). Some technical aspects of surgical procedure are responsible of the rising of complication as: Pringle maneuver length (p = 0.02), the amount of resected liver volume (p = 0.03) and the request of blood transfusion (p = 0.03). CONCLUSIONS: Complications that arise during the postoperative period, although treatable, delay patient's recovery and resumption of liver function; the evaluation of causes and foreseeable risk factors linked to postoperative morbidity during the planning of surgical treatment should play the same role as other factors weighted in the selection of patients eligible for liver resection.

Analysis of survival after pancreatic resection for oncological pathologies.

Surgical treatment of pancreatic cancer is to date the only modality that offers a chance of long-term survival. Potentially curative surgery is an option for only about 15% of patients with pancreatic adenocarcinoma. The aim of this study was to determine the survival and to assess the association of clinical, pathological, and treatment features with survival of patients who underwent resection of pancreatic cancer at the Department of Surgery of Udine University Hospital. From November 1989 to December 2005, 137 consecutive patients, who underwent surgical procedures for pancreatic cancer, were followed in our department. We performed 76 pancreatico-duodenectomy, 26 distal pancreatectomies and 35 total pancreatectomies. The surgical reconstruction after pancreatico-duodenectomy was as follows: 11 closures of the main duct with manual nonabsorbable stitches, 24 closures of the main duct with a linear stapler, 17 occlusions of the main duct with neoprene glue and 24 duct-to-mucosa anastomoses. Mean survival time was 27.7 +/- 26.93 months (mean +/- SD) and mean disease-free survival time was 25.4 +/- 23.06 months (mean +/- SD). 1, 3, 5, 7 and 9-year survival rates were 63.9, 33.7, 21.17, 12.7 and 10.2%, respectively. Significant differences in survival were recorded by the Log-rank test for age > 70 (p = 0.001), surgical procedures (p = 0.00046) and presence of metastases (p = 0.0055) The treatment of pancreatic cancer is undertaken with two different aims. The first is radical surgery for patients with early-stage disease, mainly stage I and partly stage II. In all other cases, the aim of treatment is the palliation of the several distressing symptoms related to this cancer. The standard treatment option for resectable tumours is radical pancreatic resection according to the Whipple procedure or total pancreatectomy.

Liver resective surgery: a multivariate analysis of postoperative outcome and complication.

INTRODUCTION: Notwithstanding technical advances and high experience of liver resection of specialized centers, the rate of complications after surgical resection could be high. In this study, we analyzed causes and foreseeable risk factors linked to postoperative morbidity on the ground of data derived from a single center surgical population. MATERIALS AND METHODS: From September 1989 to March 2005, 134 consecutive patients had liver resection for Hcc and 153 consecutive patients with liver metastasis (derived from either colorectal cancer or noncolorectal cancer) at our department. We performed 22 major hepatectomy, 20 left hepatectomy, 14 trisegmentectomy, 77 bisegmentectomy and/or left lobectomy, 74 segmentectomy, and 80 wedge resection. RESULTS: In-hospital mortality rate was 4.5%, about 7% in Hcc cases and 2.6% in liver metastasis. Morbidity rate was 47.7%, caused by the rising of ascites (10%), temporary impairment liver function (19%), biliary fistula (6%), hepatic abscess (25%), hemoperitoneum (10%), and pleural effusion (30%) sometimes combined each other. Some variables, associated with the technical aspects of surgical procedure, are responsible of the rising of complication as: Pringle maneuver length of more than 20 minutes (p=0.001); the type of liver resection procedure [major hepatectomy (p=0.02), left hepatectomy (p=0.04), trisegmentectomy (p=0.04), bisegmentectomy and/or left lobectomy (p=0.04)]; and the request of an amount of blood transfusion of more than 600 cc (p=0.04). Also, both liver dysfunction, in particular Child A vs B and C (p=0.01), and histopathological grading (p=0.01) are associated with a high rate of postsurgical complication in Hcc cases. CONCLUSION: We make the following recommendations: every liver resection should be planned after intraoperative ultrasonography, anatomical surgical procedure should be preferred instead of wedge resection, and modern devices should be used, like Argon Beam and Ligasure dissector, to reduce the incidence of both intraoperative and postoperative bleeding and biliary leakage.

Resective surgery for liver tumor: a multivariate analysis of causes and risk factors linked to postoperative complications.

BACKGROUND: In spite of accurate selection of patients eligible for resection, and although advances in surgical techniques and perioperative management have greatly contributed to reducing the rate of perioperative deaths, stress must be placed on reducing the postoperative complication rates reported to be still as high as 50%. This study was designed to analyze the causes and foreseeable risk factors linked to postoperative morbidity on the grounds of data derived from a single-center surgical population. METHODS: From September 1989 to March 2005, 287 consecutive patients, affected either with HCC or liver metastasis, had liver resection at our department. Among the HCC series we recorded 98 patients (73.2%) in Child-Pugh class A, 32 (23.8%) in class B and 4 in class C (3%). In 104 colorectal metastases, 71% were due to colon cancer, 25% rectal, 3% sigmoid, and 1% anorectal. In 49 non-colorectal metastases, 22.4% were derived from breast cancer, 63.2% gastrointestinal tumors (excluding colon) and 14.4% other cancers. We performed 80 wedge resections, 77 bisegmentectomies and/or left lobectomies, 74 segmentectomies, 22 major hepatectomies, 20 left hepatectomies, and 14 trisegmentectomies. RESULTS: The in-hospital mortality rate in this series was 4.5%, and the morbidity rate was 47.7%, because of pleural effusion (30%), hepatic abscess (25%), hepatic insufficiency (19%), ascites (10%), hemoperitoneum (10%), or biliary fistula (6%). The variables associated with the technical aspects of the surgical procedure that were responsible for the complications were: a Pringle maneuver length more than 20 minutes (P=0.001); the type of liver resection procedure, including major hepatectomy (P=0.02), left hepatectomy (P=0.04), trisegmentectomy (P=0.04), bisegmentectomy and/or left lobectomy (P=0.04); and a blood transfusion of more than 600 ml (P=0.04). CONCLUSION: The evaluation of causes and foreseeable risk factors linked to postoperative morbidity during the planning of surgical treatment should play the same role as other factors weighed in the selection of patients eligible for liver resection.

[Follow-up of patients submitted to antireflux laparoscopic treatment. A study by a telephone questionnaire]. / Follow-up dei pazienti sottoposti a chirurgia laparoscopica antireflusso mediante questionario telefonico.

OBJECTIVE: As it is difficult to submit patients to instrumental follow-up after laparoscopic treatment of the gastroesophageal reflux disease (GERD), it is not easy to have a complete patients analysis after fundoplication. Telephone questionnaire can be a valid instrument to investigate clinical outcome and patients satisfaction to surgery. METHODS: This study discusses the results acquired through a telephone questionnaire which has been administered to patients undergoing laparoscopic fundoplication to study postoperative clinical evolution of GERD and satisfaction to surgery through a numerical rating scale from 1 to 10. RESULTS: Sixty three patients, who had a laparoscopic antireflux procedure at Department of General Surgery of the University of Udine (Italy), answered to telephone questionnaires. Fifty patients (74.9%) reported no symptoms. Patients satisfaction to surgery was 7.93 +/- 2.36. Fifty eight patients (92.1%) would have repeated the operation and 59 (93.6%) would have advised it to a friend suffering of GERD. A significant difference of patients satisfaction between preoperative typical and atypical symptoms has been found (8.43 +/- 2.04 vs. 6.95 +/- 2.71 p < 0.05). DISCUSSION AND CONCLUSION: Telephone questionnaire is comparable with face to face consultation, allowing to do a correct clinical follow-up, to exclude patients accusing pathological acid reflux after fundoplication; however preoperative symptoms are not so accurate as postoperative symptoms. Their presence giustifies a postoperative oesophageal pH metry.