Safety and efficacy of ruxolitinib in splanchnic vein thrombosis associated with myeloproliferative neoplasms.

Splanchnic vein thrombosis (SVT) is one of the vascular complications of myeloproliferative neoplasms (MPN). We designed a phase 2 clinical trial to evaluate safety and efficacy of ruxolitinib in reducing splenomegaly and improving disease-related symptoms in patients with MPN-associated SVT. Patients diagnosed with myelofibrosis (12 cases), polycythemia vera (5 cases) and essential thrombocythemia (4 cases) received ruxolitinib for 24 weeks in the core study period. Spleen volume was assessed by magnetic resonance imaging (MRI) and splanchnic vein circulation by echo-Doppler analysis. Nineteen patients carried JAK2V617F, one had MPLW515L, and one CALRL367fs*46 mutation. Eighteen patients had spleno-portal-mesenteric thrombosis, two had Budd-Chiari syndrome, and one had both sites involved; 16 patients had esophageal varices. Ruxolitinib was well tolerated with hematological toxicities consistent with those of patients without SVT and no hemorrhagic adverse events were recorded. After 24 weeks of treatment, spleen volume reduction ≥35% by MRI was achieved by 6/21 (29%) patients, and a ≥50% spleen length reduction by palpation at any time up to week 24 was obtained by 13/21 (62%) patients. At week 72, 8 of the 13 (62%) patients maintained the spleen response by palpation. No significant effect of treatment on esophageal varices or in splanchnic circulation was observed. MPN-related symptoms, evaluated by MPN-symptom assessment form (SAF) TSS questionnaire, improved significantly during the first 4 weeks and remained stable up to week 24. In conclusion, this trial shows that ruxolitinib is safe in patients with MPN-associated SVT, and effective in reducing spleen size and disease-related symptoms.

Focal Liver Lesions Classification and Characterization: What Value Do DWI and ADC Have?

OBJECTIVE: The aim of this work was to analyze the value of diffusion-weighted imaging (DWI) in the classification/characterization of focal liver lesions (FLLs). METHODS: Retrospective study, approved by ethical board, of 100 proven FLLs (20 hemangiomas, 20 focal nodular hyperplasia, 20 dysplastic nodules, 20 hepatocellular carcinomas, and 20 metastases) was performed by 1.5-T MR. For each lesion, 2 readers, blinded of medical history, have evaluated 6 sets of images: set A (T1/T2-weighted images), set B (set A + DWI), set C (set B + apparent diffusion coefficient [ADC] map), set D (set A + dynamic and hepatobiliary phases), set E (set D + DWI), set F (set E + ADC map). RESULTS: In unenhanced images, the evaluation of the ADC improves the accuracy in classification/characterization (+9%/14%, respectively), whereas in enhanced images the accuracy was increased by DWI (+7%/12%, respectively) and ADC (+13%/19%, respectively). Diffusion-weighted imaging does not improve classification/characterization of hemangiomas, may be useful in focal nodular hyperplasia/dysplastic nodules vs metastases/hepatocellular carcinoma differentiation, and increases the classification/characterization of metastases in both unenhanced and enhanced images. CONCLUSIONS: Diffusion-weighted imaging may improve classification/characterization of FLLs at unenhanced/enhanced examinations.

Metal and motion artifacts by cone beam computed tomography (CBCT) in dental and maxillofacial study.

OBJECTIVES: This study aimed at evaluating incidence/degree of metal/motion artifacts and CT-dose-index in oral/maxillofacial examinations using Cone-Beam-CT. METHODS: Interferences caused by metal and motion artifacts were evaluated in 500 patients aged from 6 to 81 years, in dental arches, maxillofacial and splanchocranium Cone-Beam-CT exams. The interferences was divided into four progressive degrees (G0-G3) related to the possibility to answer the clinical query. The parameters considered were field-of-view, scan time, patient's age, and anatomical area. Furthermore volumetric CT-dose-index was measured. RESULTS: In the presence of metal artifacts the clinical query was always answered (G3 = 0). No artifacts (G0) were found in all cases when metal was beyond 5 cm from interest site and in 18.4% when metal was inside this distance. Beam hardening and photon starvation due to implants, restoration and orthodontic therapies achieved 56.2% G1 and 25.4% G2. Motion artifacts were more frequent in under ten (31.5%) and over sixty (82.2%), and in mandible analysis (inferior arch 59.5%, both arches 47.3%). Moreover, their incidence and intensity were influenced by scan time (49.1% at 36 s) but not by field-of-view. Mean volumetric CT-dose-index of all patients was mGy 9.11 (mGy 3.62, 5.78, 8.89, and 13.07 at 18, 24, 26, and 36 s, respectively). CONCLUSIONS: In our series Cone-Beam-CT diagnostic evaluation was never inhibited by metal artifacts and only in 1.9% of the cases by motion artifacts, always with a very low CT-dose-index.

Repetition of Examination Due to Motion Artifacts in Horizontal Cone Beam CT: Comparison among Three Different Kinds of Head Support.

AIMS AND OBJECTIVES: The aim of this study was to evaluate the repetition rate of examination due to motion artifacts in horizontal cone beam computed tomography, using three different kinds of head support, with reference to the patient's age. Further purpose was to evaluate how comfortable head supports were. MATERIALS AND METHODS: Seven hundred and fifty patients underwent a maxillofacial/dental arches volumetric imaging scan. They were divided into three groups depending on the head support used: foam headrest, foam headrest with head strap, and head restraint helmet. Each group was subdivided into three age groups: ≤18-year-old, 19-65-year-old, and ≥66-year-old patients. A severity index of motion artifacts, divided into four tiers from absence to remarkable artifacts, was adopted. Finally, each patient gave their judgment about the head support comfort by a questionnaire including ten yes/no questions. A three-score scale (insufficient, sufficient, and good) was used to judge the comfort. Collected data were analyzed using the SPSS® version 23.0 statistical analysis software. RESULTS: Forty-one patients (5.4%) repeated the examination. In 16 (2.1%), 15 (2.0%), and 10 (1.3%) of them, foam headrest, foam headrest with head strap, and head restraint helmet were used, respectively. Examination was repeated in 5.3%, 3.8%, and 10.6% in ≤18-year-old, 19-65-year-old, and ≥66-year-old patients, respectively. Patients almost always judged good the comfort for each kind of support. The lowest percentage of satisfaction was observed for the headrest with head strap and was judged good in 78% of the cases. CONCLUSIONS: The repetition rate of examination showed similar values among the foam headrest, foam headrest with head strap, and head restraint helmet in under 66-year-old patients. In over 65-year-old patients, the head restraint helmet obviously decreased the repetition rate of examination. All three head supports were good comfort, especially the foam headrest.

The role of diffusion-weighted imaging in the detection of hepatic metastases from colorectal cancer: A comparison with unenhanced and Gd-EOB-DTPA enhanced MRI.

OBJECTIVES: To compare the role of DWI vs. gadoxetic-acid-disodium enhanced MRI in the detection of colorectal hepatic metastases. METHODS: Fifty-four patients with 115 hepatic metastases were included in this retrospective study, approved by the Ethical Board. All patients underwent intraoperative-ultrasound and surgical resection within two weeks after MRI. Images were grouped in 4 sets, which were analyzed by two radiologists in different sessions: unenhanced T1-T2w (set A), set A plus DWI (set B), set A plus gadoxetic-acid-disodium (set C), set A plus DWI plus gadoxetic-acid-disodium (set D). For each set, metastases presence/size/site was reported. Interobserver agreement and statistical significance were assessed by Cohen's kappa and Mc-Nemar's test, respectively. RESULTS: Readers' agreement was always very good (k>0.80). Mean sensitivity values were 84.3/92.1/95.6/97.3% for set A/B/C/D, respectively. Mean specificity, positive predicted, negative predicted, and accuracy values strongly and progressively increased in the various set too: from 62.5% (set A) to 85.0% as for specificity, from 92.8% to 97.3% as for positive predicted value, from 41.0% to 85.1% as for negative predicted value, and from 81.1% to 95.5% as for accuracy. For each reader from set A to D, the number of false negatives progressively decreases. CONCLUSIONS: For both readers, DWI improved all statistical parameters in the unenhanced examinations, as for nodules either smaller or greater than 1cm, while in the EOB-enhanced examinations DWI prevalently increased specificity/negative predictive value.

Reviewing the use of antipsychotic drugs in people with intellectual disability.

INTRODUCTION: Antipsychotics are the most widely prescribed drugs in people with intellectual disability even if schizophrenia and other psychotic disorders do not affect more than 3% of such population. Many authors outline the lack of studies on the efficacy of antipsychotics on schizophrenia or other psychotic disorders in people with intellectual disability. MATERIALS AND METHODS: The aim of the present study is to review all evidences resulting from international trials selected by Medline, and compare efficacy and side effects of different antipsychotics in people with both intellectual disability and psychotic disorders and/or behavioural disorders. RESULTS: 195 studies were identified; 117 concern traditional antipychotics while 78 new generation ones. If we consider the type of studies, it results that only the 12.8% of all production is represented by meta-analyses, systematic reviews, and randomised and not controlled trials. CONCLUSIONS: Randomised controlled trials and systematic reviews would be the golden standard for therapeutical studies; unfortunately they are really few in this field. It is anyway significative that all the studies reported focus on the use of antipsychotics in people with intellectual disability presenting behavioural problems. To increase the validity of these studies it is recommendable to proceed only with well-designed studies, possibly double-blind versus placebo or other medications. There is need to define precise inclusion criteria, precise symptomatological or behavioural targets and adaptative ability assessment, using valid and reliable diagnostic instruments.