Very long-term outcomes of transcatheter secundum atrial septal defect closure using intracardiac echocardiography without balloon sizing.

AIM: To assess the long-term outcomes of device-based closure of atrial septal defects (ASDs) with no sizing balloon. MATERIAL AND METHODS: Two hundred and eighty-one consecutive patients (mean age 34±13 years, 178 women) underwent intracardiac echocardiography (ICE)-aided transcatheter closure of secundum ASDs over a 15-year period (September 2002 to March 2017). Sizing of the ASDs was calculated under ICE guidance (UltraICE, EP Technologies, Boston Scientific Corporation, San Jose, CA, USA) using the concept of "supportive rim" for ASDs without the aid of a sizing balloon. Follow-up was conducted by transoesophageal and transthoracic echocardiography. RESULTS: The procedure was carried out successfully in all patients with 0% related mortality and 5.7% procedural complications. The Amplatzer ASD Occluder was implanted in 251 patients (89.3%, mean size 26.4±10.2 mm) whereas the Gore Cardioform was used in 30 patients (10.6%). Over 10.3±3 years of follow-up (range 1-15) 100% of patients were alive. The complete occlusion rate was 97.8%. No aortic or atrial free wall erosions, device thrombosis, or device frame fractures were detected during the follow-up period. CONCLUSION: The present study suggested that ICE-guided closure of ASDs with current devices without sizing balloons is safe and effective with very low procedural and late complications even in the very long-term follow-up.

Evaluation of adequacy of levo-thyroxine dosage in patients with differentiated thyroid carcinoma: correlation between morning and afternoon TSH determination.

PURPOSE: The aim of this study was to judge the reliability of evaluating thyroid-stimulating hormone (TSH) and free thyroxine (f-T4) in the morning and afternoon in differentiated thyroid carcinoma (DTC) patients. METHODS: We evaluated 153 DTC patients, aged 61 ± 13 years, in active follow-up in our center after primary treatments and under stabilized levo-thyroxine (L-T4) posology. In each patient, morning and afternoon examinations were performed 1-3 months apart. Blood samples were collected at 08:00-09:00 h and 15:00-16:00 h. TSH and f-T4 were evaluated in both samples. Thyroglobulin (Tg), Tg-antibodies and neck ultrasonography were also evaluated. RESULTS: According to clinical and laboratory examinations, 92% of patients were disease-free, 6% had biochemical disease, and 2% structural disease. L-T4 dosages (1.64 ± 0.38 µg/kg b.w.) proved the same on both occasions, despite slight changes in body weight or L-T4 posology in 15% of patients. Free-T4 values were significantly higher in the afternoon (21.5 ± 0.3 pmol/L) than in the morning (18.8 ± 0.4 pmol/L; P < 0.0001), whereas TSH values were statistically unchanged (morning 0.85 ± 0.25 mIU/L; afternoon 0.72 ± 0.20 mIU/L). There was a significant correlation (P < 0.0001) between the two TSH determinations in the same patients. CONCLUSIONS: In DTC patients, follow-up examination consists of clinical and laboratory evaluations. The majority of patients have good disease control. Our study suggests that the adequacy of L-T4 therapy can be monitored equally well either in the morning or in the afternoon. Afternoon examinations can alleviate crowding in hospital ambulatories in the morning.

Sertoli-Leydig cell tumors: hormonal profile after dynamic test with GnRH analogue: triptorelin represents a useful tool to evaluate tumoral hyperandrogenism.

We report the case of a 15-year-old woman with signs of hyperandrogenism affected by a Sertoli-Leydig cell tumor (SLCT). In our patient, blood analysis showed a high testosterone (T) level (T: 8.53 nmol/L; nv < 1.87 nmol/L) while the GnRH-analogue test demonstrated an exaggerated secretion of 17-hydroxyprogesterone (OHP), T, and androstenedione (A) by the ovary after stimulation. We compared the GnRH-analogue test of our patient with that obtained in a group of normal and healthy women (no. 8 subjects, 16-26 years old), men (no. 4 subjects, 18-28 years old), and in a group of PCOS patients with age and body weight compared. We found in our patient a value of OHP, 17-beta estradiol (E2) and T, from 2 to 18 times higher than healthy women. When we compared our patient with healthy men, we differently observed a comparable response of T. The response of our patient was also comparable with that observed in the PCOS group for E2. During the post-surgical follow up, the GnRH-analogue test of our patient showed a response of OHP, T, and E2 comparable with that of the PCOS group. The GnRH-analogue test is a useful tool to characterize steroidogenesis in SLCT.

Is HE4 a useful endometrioma marker?

PURPOSE OF INVESTIGATION: By the comparison between most used tumor marker trend (cancer antigen 125: CA 125 and human epididymal secretory protein E4: HE4) before and after laparoscopic surgery, the aim of the present study was to assess HE4 usefulness in ovarian benign cyst and endometrioma diagnosis. MATERIALS AND METHODS: Thirty-eight patients were enrolled in this prospective study: 25 women underwent unilateral endometriosis ovarian cyst excision, 13 underwent benign ovarian cyst incision, and 26 were healthy controls. CA 125 and HE4 serum levels were estimated before surgery (in the early proliferative phase of the cycle) and one month after surgery. RESULTS: A statistically significant decrease of CA 125 serum level was found after an endometrioma surgical excision but no decreases in HE4 serum level. CONCLUSION: In patients with endometrioma, no alteration was found in HE4 serum levels before and after surgery, while CA125 serum levels decreased after surgery. HE4 may better distinguish a malign cyst from benign one, but it is not useful in the diagnosis of low risk endometrioma.

Pregnancy outcome after laparoscopic myomectomy.

PURPOSE OF INVESTIGATION: Main purpose of this study was to analyze the reproductive and obstetrical outcome as delivery mode and incidence of major complications (uterine bleeding and uterine rupture) after laparoscopic myomectomy. MATERIALS AND METHODS: The authors conducted an observational study in patients who underwent laparoscopic myomectomy. Inclusion criteria were: surgery performed for single and or multiple myomas sized between five and 15 cm and pregnancy desire. Exclusion criteria were: surgery for pedunculated myomas and male or tubal infertility. Collected data on pregnancy desire, success in obtaining pregnancy surgical interval time before pregnancy, performing assisted reproductive medicine, gestational weeks, mode of delivery, indicating a possible cesarean section, and complications. On collected data the authors calculated pregnancy and abortion rates. RESULTS: Among patients aged between 19 and 42 years who answered a telephonic questionnaire, the authors selected 185 patients with pregnancy willing. A total number of 426 myomas were removed; 115 (62.2%) patients reported 151 pregnancies, nine in a total of 17 patients achieved it with reproductive assistance, 38 pregnancy ended in abortion, and two had an ectopic implantation. The authors finally reported 111 successful pregnancy, with seven preterm deliveries (6.3%). Mode of delivery had been cesarean section in 69 cases (63.4%) and vaginal delivery in 42 cases (36.6%), with a respective mean interval time between surgery and delivery of 24.6 +/- 20.0 months and 19.2 +/- 13.3 months. CONCLUSION: Laparoscopic myomectomy proved to be an effective procedure feasible for women who wish to become pregnant with a subsequent good reproductive outcomes, both in terms of pregnancy and abortion rates that were comparable with the literature. If laparoscopic suturing of the fovea myometralis is adequate, there are no contraindications for vaginal delivery, regardless of the patient's age, the number, size, and location of the myomas removed.

Thermal balloon ablation versus transcervical endometrial resection: evaluation of postoperative pelvic pain in women treated for dysfunctional uterine bleeding.

PURPOSE OF THE STUDY: To evaluate postoperative pain after mini-invasive surgical treatment for dysfunctional uterine bleeding (DUB) with transcervical endometrial resection or thermal ablation balloon. MATERIALS AND METHODS: A longitudinal observational study, analyzing 47 women affected by DUB who underwent endometrial ablation was conducted. The authors collected evaluation of pelvic pain at one and four hours after intervention and the individual necessity of analgesics. After 30 days, all patients underwent a gynecological visit to evaluate postoperative outcome. RESULTS: Pelvic pain was higher one and four hours after procedure in thermal balloon ablation group, and patients in the same group required more analgesic rescue dose. There were no complications such as uterine perforation, heavy blood loss or thermal injuries with both the procedures. CONCLUSION: Thermal balloon ablation appears a more painful procedure than endometrial resection, both in the immediate postsurgical time and 30 days after surgery. Ad hoc anaesthesiologic and analgesic protocol should be adopted to ensure quick recovery and good acceptance of the procedure.

Laparoscopic hysterectomy: really so risky to a vaginal cuff dehiscence?

PURPOSE OF INVESTIGATION: The authors report their experience with vaginal vault suturing procedure in patients that underwent total laparoscopic hysterectomy (TLH) for benign diseases. Vaginal vault colpotomy and closure were only laparoscopically carried out. MATERIALS AND METHODS: Longitudinal retrospective study was conducted in 550 patients, affected by gynaecological benign pathologies, that underwent TLH were enrolled. Information about age, body mass index, parity, corticosteroid therapy, previous pelvic surgery, smoking, diabetes, menopausal status, and procedure characteristics (operating time, blood loss, uterus weight, postoperative recovery time, and adverse outcomes) were collected. Postoperative complications and adverse outcomes were recorded. RESULTS: Only one case (0.2%,) of vaginal cuff dehiscence (VCD) occurred four weeks after surgery, which was quickly laparoscopically repaired with interrupted intracorporeal knots. The trigger event was sexual intercourse in a patient affected by systemic lupus erythematosus (SLE). No cases of VCD presented in patients with other considered comorbidities. CONCLUSION: A careful technique could further decrease the incidence of postoperative vaginal cuff dehiscence, regardless of laparoscopic or vaginal suture approach.

Monopolar versus bipolar device: safety, feasibility, limits and perioperative complications in performing hysteroscopic myomectomy.

PURPOSE OF INVESTIGATION: The authors' aim is to compare surgical outcome of hysteroscopic G1 and G2 submucous myomectomy using bipolar resectoscope to those performed by monopolar device. MATERIALS AND METHODS: a multicenter-observational-case-control study was conducted on premenopausal women affected by menorrhagia, pelvic pain or infertility because of submucous uterine myoma. The authors considered eligible: single G1 or G2 submucous uterine myoma, at least 0.5 cm ultrasound 'myometrial-free-margin' and two months GnRH pre-surgical treatment (myoma > three cm). Goup A patients were treated b y bipolar resectoscope and Group B by monopolar resectoscope. Primary endpoint was to compare the groups in term of complete or incomplete myomas resection ("second-step-procedure" rate). Secondary endpoint was to compare two treatments in term of surgical time and intraoperative complications rate. RESULTS: Group A (60 patients) and Group B (216 patients) were homogeneous for general features and myomas location but they differed for G2 type prevalence (73.3% vs 50.5%), mean myomas diameter (33.17 +/- 11.93 vs 29.45 +/- 9.63), and surgical time (29.43 +/- 12.6 vs 23.2 +/- 8.2 minutes). In Group A patients both G1 and G2 myomas were completely removed in single step without intraoperative/postoperative complications; in Group B surgical outcomes of G1 myomas were similar to those of Group A, while G2 myomas required procedure termination in 12% of cases because of light electrolyte disturbance (22 cases) and severe iponatremia in four cases. All intraoperative complications occurred when procedure time exceeded 30 minutes and when myomas diameter was greater than 37.5 millimeters. CONCLUSION: in the era ofmini-invasive surgery, hysteroscopic approach by bipolar device should be considered as a useful, safe, and large scale feasible procedure for submucosal myoma treatment, particularly when G2.

Laparoscopic surgical staging of endometrial cancer: does obesity influence feasibility and perioperative outcome?

AIM: Laparoscopic treatment of early-stage endometrial cancer is the gold standard to reduce perioperative morbidity. Obesity is a well-known risk factor for endometrial cancer and anesthesiological and surgical complications. The authors' aim was to examine the effect of body mass index (BMI) on perioperative parameters and complications in laparoscopically-treated patients with endometrial cancer. MATERIALS AND METHODS: A consecutive series of patients affected by endometrial cancer and their demographic and clinicopathological data were collected. Patients were divided in 41 non-obese (BMI or= 30) groups. All patients had been preoperatively evaluated with hysteroscopic procedures and toraco-abdominal computed tomography (CT) and had been submitted to laparoscopic radical hysterectomy according to Querleu-Morrow, pelvic lymphadenectomy, peritoneal washing, and bilateral adnexectomy. RESULTS: There was no statistically significant difference in blood loss, number of lymph nodes removed, and hospital stay between the groups, but there was a trend towards a lengthening of surgical time in the obese women. There were no major intraoperative and postoperative complications. DISCUSSION: This study demonstrates that laparoscopic approach is feasible and safe in obese women evaluating the anesthesiological risk.

Atypical endometrial lesions: hysteroscopic resection as an alternative to hysterectomy.

BACKGROUND: Endometrial hyperplasia is a precursor to endometrial carcinoma: the risk of progression to invasive endometrial cancer is increased in postmenopausal women and much more in cases of atypical endometrial hyperplasia (25%-30%). In addition, in 12.7% to 42.6% of cases according to various studies, endometrial cancer coexists in patients with diagnosis of atypical endometrial hyperplasia. The aim of this study was to evaluate the correlation between radical hysteroscopic resection of atypical endometrial lesions and the histopathological examination of the uterus. MATERIALS AND METHODS: The authors collected 25 patients referring to the Department of Woman and Child Health, in the University of Padua (Italy) from January 2008 to June 2012, undergoing hysteroscopic resection for atypical polyps and focal atypical endometrial hyperplasia, and following hysterectomy within 30 days. Average age, menopausal status, hormone replacement therapy, body mass index (BMI), presence of hypertension and diabetes, and taking tamoxifen were reported. RESULTS: After hysteroscopic resection in all patients atypical polyps and focal endometrial hyperplasia were confirmed. The hystopathologic evaluation of the uterus reported: in only two (8%) cases, the persistence of atypical endometrial lesion, whereas in 23 (92%) cases the endometrial tissue was negative for atypia or malignancy. CONCLUSIONS: Radical endometrial resection by hysteroscopy may serve as an alternative to hysterectomy in selected patients with atypical focal endometrial lesions, not only in fertile women, but also in patients who refuse hysterectomy or present high anesthesiologic and surgical risks, regardless of the risk of recurrence, and with the necessity of undergoing hysteroscopic close follow-up.

An empirical calibration method for an a-Si portal imaging device: applications in pretreatment verification of IMRT.

PURPOSE: A new calibration method for an amorphous silicon (a-Si) electronic portal imaging device (EPID) used for dose measurements in pretreatment verification (field-related) of intensity-modulated radiation therapy (IMRT) with sliding-window technique. The method is independent of data contained in the multileaf collimator (MLC) leaf-motion files and of any calculations made by the treatment planning system (TPS). MATERIALS AND METHODS: Sensitivity of the EPID is dependent on radiation energy. For fluence-modulated fields, different dose/reading calibration factors are associated with each pixel of the image acquired by calculating equivalent areas representing the exact ratio between primary and scatter components. The dose measured in the detector plane was compared with that calculated with TPS by using gamma-analysis. Each calibration factor was compared with that calculated by considering the individual contributions of primary and secondary radiation obtained using the convolution method with analytical kernel for homogeneous media. RESULTS: In 837/854 (98%) of the clinical fields analysed, the proportion of irradiated area in which the gamma-index was <1.0 exceeded 95%. The overall average gamma-index was 0.39. There was good agreement between the dose/reading calibration factors obtained with the empirical algorithm and with the convolution method. CONCLUSIONS: The proposed calibration method is suitable for routine clinical pretreatment verification in IMRT.

A krill oil supplemented diet reduces the activities of the mitochondrial tricarboxylate carrier and of the cytosolic lipogenic enzymes in rats.

The mitochondrial tricarboxylate carrier supplies cytosol with the carbon units necessary for hepatic lipogenesis. The activities of cytosolic acetyl-CoA carboxylase and fatty acid synthetase are therefore strictly connected to the function of mitochondrial tricarboxylate carrier. Dietary polyunsaturated fatty acids (PUFA) are potent modulators of hepatic lipogenesis. In rats fed with a diet enriched with 2.5% krill oil (KO), a novel source of dietary n-3 PUFA, a time-dependent decrease in the activities of the mitochondrial tricarboxylate carrier and of the lipogenic enzymes was found. The KO induced inhibition of hepatic lipogenesis was more pronounced than that found in fish oil (FO)-fed rats, at least at short feeding times. The decrease in the activity of the mitochondrial tricarboxylate carrier caused by KO was due to a reduced expression of the protein. Furthermore, in the KO-fed animals a greater reduction in the levels of hepatic triglycerides and cholesterol was found in comparison to FO-fed rats.

Photocatalytic reduction of Cr(VI) in a fully illuminated fluidized bed reactor.

The potential of a fluidized bed reactor for the UV-A photocatalytic reduction of Cr(VI), a priority water pollutant, by utilizing a TiO(2)/quartz sand composite, was explored. The effects of oxalic acid (OA) as a sacrificial agent in the heterogeneous system was also investigated and compared with the homogeneous photoreduction by the same dicarboxylic acid under both oxygenated or anoxic conditions of the reacting media. The performance of the 'preconditioned' photocatalyst, either by pretreating it with the OA solution (at dark or under UV-A illumination) or by letting the catalyst stand wet with the OA solution, during designated time intervals (1-5 weeks) prior to its reuse, was assessed. Then, up to 95% reduction of Cr(VI) to Cr(III) was achieved in less than 100 min.

[Acquired hemophilia A treated with rituximab. Report of one case]. / Hemofilia adquirida tratada con anti CD20, un anticuerpo anti linfocito B.

We report a 54-year-old male presenting with a history or recurrent nose bleeds and ecchymoses. The coagulation study showed a prolonged partial thromboplastin time, a factor VIII of 8% and a high inhibitor titer (193 Bethesda units). A diagnosis of acquired hemophilia A was reached. The patient was initially treated with cyclophosphamide for seven months without response. Therefore rituximab in doses of 375 mglm²/week for four weeks was started. After starting treatment, the patient had a hematoma in the psoas muscle with a concomitant factor VIII of less than 5%, that was treated with local measures. Thereafter, a progressive reduction in inhibitor titers was observed, until its disappearance at five months of treatment. Factor VIII levels normalized and the patient has not experienced abnormal bleeding episodes. The patient remains in remission after 67 months of follow up. Rituximab, a chimeric monoclonal antibody against the protein CD 20 is an effective treatment in acquired hemophilia A.

Comparative study of jaws with multislice computed tomography and cone-beam computed tomography.

PURPOSE: The aim of this study was to compare the dosimetric and diagnostic performance of multislice computed tomography (MSCT) and cone-beam computed tomography (CBCT) in the study of the dental arches. MATERIALS AND METHODS: Effective dose and dose to the main organs of the head and neck were evaluated by means of thermoluminescent dosimeters (TLDs) placed in an Alderson Rando anthropomorphic phantom and using a standard CBCT protocol and an optimised MSCT protocol. Five patients with occlusal plane ranging from 54 cm to 59 cm who needed close follow-up (range 1-3 months) underwent both examinations. Image quality obtained with CBCT and MSCT was evaluated. RESULTS: Effective dose and dose to the main organs of the head and neck were higher for MSCT than for CBCT. Image quality of CBCT was judged to be equivalent to that of MSCT for visualising teeth and bone but inferior for visualising soft tissues. Beam-hardening artefacts due to dental-care material and implants were weaker at CBCT than at MSCT. CONCLUSIONS: When panoramic radiography is not sufficient in the study of the teeth and jaw bones, CBCT can provide identical information to MSCT, with a considerable dose reduction. MSCT is, however, indicated when evaluation of soft tissue is required.

Optimisation of microwave assisted extraction (MAE) for polycyclic aromatic hydrocarbon (PAH) determination in smoked meat.

A rapid extraction method involving microwave assisted extraction (MAE), followed by sample clean-up on a silica cartridge, reversed-phase high performance liquid chromatography (RP-HPLC) and spectrofluorimetric detection, was optimised for polycyclic aromatic hydrocarbon (PAH) determination in smoked meat. Compared to solvent extraction assisted by sonication, MAE, carried out with n-hexane on 2g of lyophilised sample at 115°C for 15min, allowed to obtain better extraction efficiencies. Limits of quantification (LOQ, s/n=10) lower than 0.2µg/kg wet weight were found for all PAHs, except for Fl (0.3µg/kg), P (0.6µg/kg) and IP (0.4µg/kg). The optimised procedure, that presented good analytical performances (with recoveries ranging from 77% to 103%, and precision within 10% for most of the PAHs), was applied to determine PAH content in different smoked meat products from the Italian market.

The use of photostimulable phosphor systems for periodic quality assurance in radiotherapy.

The fusion of radiological and optical images can be achieved through charging a photostimulable phosphor plate (PSP) with an exposure to a field of X- or gamma-rays, followed by exposure to an optical image which discharges the plate in relation to the amount of incident light. According to this PSP characteristic, we developed a simple method for periodic quality assurance (QA) of light/radiation field coincidence, distance indicator, field size indicators, crosshair centering, coincidence of radiation and mechanical isocenter for linear accelerators. The geometrical accuracy of radiological units can be subjected to the same QA method. Further, the source position accuracy for an HDR remote afterloader can be checked by taking an autoradiography of the radioactive source and simultaneously an optical image of a reference geometrical system.

Genetic and phytochemical difference between some Indian and Italian plants of Withania somnifera (L.) Dunal.

The geographical distribution of Withania somnifera (L.) Dunal is quite wide. However, in Italy, this species is very rare and grows spontaneously only in Sicily and in Sardinia. The PCR-RAPD technique has been utilized in this work to determine the genetic relationship among Sicilian, Sardinian and Indian samples and the HPLC analysis of whitaferin A was used as a marker to evaluate the phytochemical differences. The genetic difference between Indian and Sicilian plants of W. somnifera turned out to be smaller than that between Indian and Sardinian plants of this species. The phytochemical analysis as well showed that the Sardinian specimen strongly differed from the Indian and Sicilian ones in its contents of withaferin A. Our results seem to confirm the hypothesis that the Italian populations of this species may not be indigenous but naturalised. Due to the high withaferin A content of the Sardinian samples, these plants could be used as a source for pharmaceutical purposes.

[Transcatheter embolization for endoscopically unmanageable acute nonvariceal upper gastrointestinal hemorrhage]. / Traitement par embolisation endovasculaire d'hémorragies gastro-intestinales hautes non variqueuses et aiguës après échec du traitement endoscopique.

OBJECTIVES: Evaluate the efficacy of endovascular embolization for patients with endoscopically unmanageable acute nonvariceal upper gastrointestinal hemorrhage as well as the factors that may influence mortality. MATERIALS AND METHODS. Retrospective study over a 4-year period including a historical cohort of 37 consecutive patients (22 men), with a mean age of 69.2 years (range, 22-93 years). In most cases (54%), the hemorrhage stemmed from a gastrointestinal ulcer. Technical, primary clinical, and secondary clinical success rates, as well as complication rates, were calculated. Several clinical and angiographic parameters were compared to the early mortality rate using Kruskal-Wallis or Fisher tests. RESULTS: Technical, primary clinical, secondary clinical success rates, and complication rates were, respectively, 89.2%, 83.8%, 88.9%, and 10.8%. The early mortality rate was 32.4%. The APACHE II and IGS II scores were strongly correlated with mortality (p=0.001 and p=0.003, respectively). CONCLUSION: Endovascular embolization in patients with endoscopically unmanageable acute nonvariceal upper gastrointestinal hemorrhage is effective. However, the mortality rate remains high because of the changes in the clinical condition of these patients.

Cost-effectiveness strategies in OSAS management: a short review.

Obstructive sleep apnoea (OSAS) is an underdiagnosed chronic disease with a high prevalence in adults. It is becoming a significant social problem, since it is associated with a worsening in quality of life and increase in mortality. The cost-effectiveness ratio of diagnostic and therapeutic management of OSAS is a strategic issue to counteract the expected increasing demand of objective testing. OSAS patients with any clinical evidence of comorbidities must be studied using simplified and less expensive systems such as Home Sleep Testing (HST). On the other hand, Sleep Laboratory Polysomnography (PSG) is the gold standard to manage OSAS patients with comorbidities. It should be pointed out that the use of HST can lead to incorrect diagnosis in poorly selected OSAS subjects. This short review discusses various topics for the proper diagnosis and treatment of OSAS in view of epidemiological factors and results in terms of costs and social benefit of the disease. Whatever the strategy chosen and/or the organisational model adopted for managing OSAS, it cannot and should not take into account only cost-effectiveness. Long-term prospective studies evaluating cost-effectiveness ratios and outcomes of OSAS treatment of hospital management models versus home care models are needed.