Glucose-6-phosphate dehydrogenase deficiency in Italian blood donors: prevalence and molecular defect characterization.

BACKGROUND: In the countries with high G6PD deficiency prevalence, blood donors are not routinely screened for this genetic defect. G6PD deficiency is often asymptomatic, blood donors may be carriers of the deficiency without being aware of it. The aim of the study was to evaluate the prevalence of G6PD deficiency among the Italian blood donors. DESIGN AND METHODS: From October 2009 to April 2011, 3004 blood donors from a large hospital transfusion centre were screened for G6PD deficiency using differential pH-metry and the characterization of G6PD mutations was performed on G6PD-deficient subjects. The haematological features of G6PD-deficient and normal donors were also compared. RESULTS: Thirty-three subjects (25 men and 8 women) with low G6PD activity were identified, corresponding to 1·1% of the examined blood donor population. The frequencies of class II severe alleles (Mediterranean, Valladolid, Chatham and Cassano) and class III mild alleles (Seattle, A- and Neapolis) were 48% and 43%, respectively. The haematological parameters of G6PD- donors were within normal range; however, the comparison between normal and G6PD- class II donors showed significant differences. CONCLUSION: In Italy, the presence of blood donors with G6PD deficiency is not a rare event and the class II severe variants are frequent. The identification of G6PD-deficient donors and the characterization of the molecular variants would prevent the use of G6PD-deficient RBC units when the haemolytic complications could be relevant especially for high risk patients as premature infants and neonates and patients with sickle cell disease submitted to multiple transfusions.

Technical note: patient-specific quality assurance methods for TomoDirect(TM) whole breast treatment delivery.

PURPOSE: To investigate the feasibility of implementing a novel approach for patient-specific QA of TomoDirect(TM) whole breast treatment. METHODS: The most currently used TomoTherapy DQA method, consisting in the verification of the 2D dose distribution in a coronal or sagittal plane of the Cheese Phantom by means of gafchromic films, was compared with an alternative approach based on the use of two commercially available diode arrays, MapCHECK2(TM) and ArcCHECK(TM). The TomoDirect(TM) plans of twenty patients with a primary unilateral breast cancer were applied to a CT scan of the Cheese Phantom and a MVCT dataset of the diode arrays. Then measurements of 2D dose distribution were performed and compared with the calculated ones using the gamma analysis method with different sets of DTA and DD criteria (3%-3 mm, 3%-2 mm). The sensitivity of the diode arrays to detect delivery and setup errors was also investigated. RESULTS: The measured dose distributions showed excellent agreement with the TPS calculations for each detector, with averaged fractions of passed Γ values greater than 95%. The percentage of points satisfying the constraint Γ < 1 was significantly higher for MapCHECK2(TM) than for ArcCHECK(TM) and gafchromic films using both the 3%-3 mm and 3%-2 mm gamma criteria. Both the diode arrays show a good sensitivity to delivery and setup errors using a 3%-2 mm gamma criteria. CONCLUSIONS: MapCHECK2™ and ArcCHECK(TM) may fulfill the demands of an adequate system for TomoDirect(TM) patient-specific QA.

Dose reduction in multislice CT by means of bismuth shields: results of in vivo measurements and computed evaluation.

PURPOSE: We investigated the amount of patient dose reduction in the thyroid, lens of the eye and the breast when using bismuth protections in multislice computed tomography (CT) exams as well as their influence on the quality of diagnostic images. MATERIALS AND METHODS: The radiation dose was measured by using thermoluminescence dosimeters. The study was conducted on the two CT scanners installed in our radiology department (64 and eight slices). The shield effects on the CT image were evaluated by measuring the signal-to-noise ratio in a phantom and in vivo, and by verifying the presence of artefacts on patients' images. The obtained organ-dose reduction factors were used to evaluate the effects of shielding on the effective dose. RESULTS: The shielding attenuation ranged from 30% to 60% depending on the CT scan protocols and organs. The difference between shielded and unshielded signal-to-noise ratio was statistically significant but within the standard requirements for quality assurance. Results were in agreement with the radiologists' perception of image quality. The use of the shields allowed up to 38% reduction of effective dose. CONCLUSIONS: Use of bismuth shields significantly decreases both organ and effective radiation dose, with a consequent reduction in health risk for the patient, quantified in 1.4 fewer cases of radiation-induced tumours every 5 years in our centre (12,100 exams/year), in agreement with the risk factors proposed by Publication 60 of the International Commission on Radiological Protection (ICRP). The relative inexpensiveness of these protections, their easy application and their substantial lack of influence on image quality suggest their massive introduction into routine clinical practice.

Patient's Peak Skin Dose evaluation using Gafchromic films in interventional cardiology procedures and its correlation with other dose indicators.

OBJECTIVE: Number and complexity of interventional cardiology procedures have increased during last years and can result in patient skin dose high enough to cause deterministic skin effects. The aim of the work is to investigate the correlation between Peak Skin Dose (PSD) and the dosimetric indicators directly registered by the radiological equipment and provide the physicians a tool to identify patients at risk of deterministic effects and include them into a follow-up program. METHODS: PSD was measured in vivo using radiochromic Gafchromic XR-RV3 films, properly calibrated. DAP, Cumulative Dose at the interventional reference point (CD) and exposure time of each procedure were retrieved from the Radiation Dose Structured Reports created by an Allura Clarity Xper FD20 angiographic system. Linear correlation between PSD and both DAP and CD was investigated. RESULTS: 42 interventional cardiology procedures (16 CA and 26 PTCA) were involved in the study. The dosimetric indicators values for PTCA are generally higher than those for CA, due to the different levels of procedure complexity. Mean PSD values were (103 ±â€¯64) and (526 ±â€¯436) mGy for CA and PTCA procedures. For CA, we found strong correlation both between PSD and DAP (r = 0.753) and PSD and CD (r = 0.782). For PTCA, good correlation both for DAP (r = 0.648) and CD (r = 0.649) was found. CONCLUSIONS: DAP and CD show strong correlation with PSD measured with Gafchromic films during interventional procedures. The proposed method allows the physician to estimate patient's PSD from the dosimetric indicators that the radiological equipment display and record at the end of the procedure.

Red marrow and blood dosimetry in (131)I treatment of metastatic thyroid carcinoma: pre-treatment versus in-therapy results.

Treatment with radioiodine is a standard procedure for patients with well-differentiated thyroid cancer, but the main approach to the therapy is still empiric, consisting of the administration of fixed activities. A predictive individualized dosimetric study may represent an important tool for physicians to determine the best activity to prescribe. The aim of this work is to compare red marrow and blood absorbed dose values obtained in the pre-treatment (PT) dosimetry phase with those obtained in the in-treatment (IT) dosimetry phase in order to estimate the predictive power of PT trial doses and to determine if they can be used as a decision-making tool to safely administer higher (131)I activity to potentially increase the efficacy of treatment. The PT and IT dosimetry for 50 patients has been evaluated using three different dosimetric approaches. In all three approaches blood and red marrow doses, are calculated as the sum of two components, the dose from (131)I activity in the blood and the dose from (131)I activity located in the remainder of the body (i.e. the blood and whole-body contributions to the total dose). PT and IT dose values to blood and red marrow appear to be well correlated irrespective of the dosimetric approach used. Linear regression analyses of PT and IT total doses, for blood and red marrow, and the whole-body contribution to these doses, showed consistent best fit slope and correlation coefficient values of approximately 0.9 and 0.6, respectively: analyses of the blood dose contribution to the total doses also yielded similar values for the best fit slope but with correlation coefficient values of approximately 0.4 reflecting the greater variance in these dose estimates. These findings suggest that pre-treatment red marrow dose assessments may represent an important tool to personalize metastatic thyroid cancer treatment, removing the constraints of a fixed activity approach and permitting potentially more effective higher (131)I activities to be safely used in-treatment.

[Preliminary observations on the behavior of immunoglobulins in diabetics treated by different methods]. / Prime osservazioni sul comportamento delle immunoglobuline in diabetici sottoposti a differenti terapie

IgG, IgM and IgA values were determined in 45 diabetic patients of various ages and both sexes (30 treated with oral hypoglycaemising drugs and 15 with insulin). A marked departure from normal serum IgA values in subjects receiving oral hypoglycaemising preparations for at least 4 yr was the only alteration worthy of note.

[Double-blind polycentric study of the action of S-adenosylmethionine in hepatic cirrhosis]. / Studio policentrico in doppio cieco sull'azione della solfoadenosilmetionina nella cirrosi epatica

Two comparable groups of patients with hepatic cirrhosis of different genesis in a compensation phase have been treated for 30 days with S-adenosylmethionine and vitamine B-12 (28 cases) or with vitamine B-12 alone (25 cases). The drugs were given by slow intravenous route at the daily dose of 150 mg of SAMe and 2000 gamma of vit. B-12 or of 2000 gamma of vit. B-12 alone, in two adminstrations. An evaluation of the results was carried out mostly on the laboratory data testing the liver function. Only the group of patients who had received SAMe showed significant modifications of all the parameters considered. This is confirming SAMe ability to restore hepatocyte activity bringing also to normal the protein synthesis.

[Evaluation of the cost of maintenance therapy (6 months) with 150 mg ranitidine vs 20 mg omeprazole vs 20 mg omeprazole every other day in duodenal ulcer]. / Valutazione dei costi della terapia di mantenimento (sei mesi) con ranitidina 150 mg vs omeprazolo 20 mg vs omeprazolo 20 mg a giorni alterni nell'ulcera duodenale.

Prevention of ulcer relapse and of its complications is a problem which remains to be solved. Our study involved 250 patients, with healed duodenal ulcer. We evaluated efficacy and costs of three different maintenance therapies: ranitidine 150 mg/day, omeprazole 20 mg/day every other day and omeprazole 20 mg/day. Six months later, we found the incidence of relapse to be 24.4% (32/131) in the once-a-day ranitidine group, 19.7% (13/66) in the day every-other-day omeprazole group, and 3.8% (2/53) in the once-a-day omeprazole group. Further, we evaluated costs relative to relapsing patients, and total costs for each treatment group. From these data, we conclude that personalized maintenance therapy with omeprazole is the most cost-effective: a dosage of 20 mg/day is extremely effective in maintaining remission, and is therefore most indicated in patients at risk; omeprazole 20 mg/day every-other-day affords better compliance, lower costs and fewer relapses with respect to standard H2-antagonist dosages.

[Computerized methods in the diagnosis and prognosis of surgically treated bilio-pancreatic diseases]. / Metodi computerizzati per la diagnosi e la prognosi delle malattie bilio-pancreatiche di interesse chirurgico.

Multivaried and trend analyses were applied to a set of 27 periodic haematochemical checks on 37 patients given surgery for biliopancreatic pathology. Preoperative and postoperative data were separately analysed. The software employed was specially designed for the purpose. The discriminating function was used in the preoperative period to establish the best moment for diagnosis, which turns out to be 5 days after admission to hospital. Variance and regression analyses were used for short term prognosis by calculating survival chances. In one case the prognosis turned out to be distinctly inaccurate.

[Glucose-6-phosphate dehydrogenase deficiency and hereditary hemolytic anemia]. / Deficit di glucosio-6-fosfato deidrogenasi ed anemia emolitica ereditaria.

G6PD deficiency is the most common enzymopathy in the world. The highest frequency values are found in tropical Africa, in the Middle East, in some areas of the Mediterranean, in tropical and sub-tropical Asia and in Oceania. This genetic defect shows sex linked inheritance and a marked heterogeneity. At least 400 abnormal variants with different biochemical characteristics and about 100 diverse mutations have been identified. In most cases the phenotypic expression is a marked decrease in erythrocyte G6PD activity. The most common clinical consequences are neonatal jaundice and sporadic haemolytic crises caused by a number of drugs, by infections or by ingestion of fava beans. A few cases of chronic non-spherocytic haemolytic anaemia associated with rare molecular variants have been reported. Early diagnosis, education and epidemiologic surveillance have been proved to be cornerstones in the prevention of the haemolytic disease. Therefore they should be taken into account in the national health programmes, especially in the countries with high prevalence rates.

Exposures from nuclear medicine diagnostic procedures: the dose impact on the Aosta Valley population.

The present work evaluates the per-procedure, annual collective and per-capita effective doses to the Aosta Valley region population from nuclear medicine (NM) examinations performed from 2005 to 2011 at the regional NM department. Based on its demographical and socioeconomics characteristics, this area can be considered as representative of the level I countries, as defined by the United Nations Scientific Committee on the Effects of Atomic Radiation. The NM per-procedures effective doses were within the range of 0.018-35 mSv. A steady frequency per 10 000 inhabitants has been observed, together with a decrease for thyroid and whole-body bone scintigraphy. Myocardial and bone scintigraphy studies were the major contributors to the total collective effective dose. The mean annual collective and per-capita effective doses to the population were 15 man Sv y(-1) and 120 µSv y(-1), respectively. The NM contribution to the total per-capita effective dose accounts for 5.9 % of that due to the medical ionising radiation examinations overall.

Effective dose delivered by conventional radiology to Aosta Valley population between 2002 and 2009.

OBJECTIVE: Medical diagnostic procedures can be considered the main man-made source of ionising radiation exposure for the population. Conventional radiography still represents the largest contribution to examination frequency. The present work evaluates procedure frequency and effective dose from the majority of conventional radiology examinations performed at the Radiological Department of Aosta Hospital from 2002 to 2009. METHOD: Effective dose to the patient was evaluated by means of the software PCXMC. Data provided by the radiological information system allowed us to obtain collective effective and per caput dose. RESULTS: The biggest contributors to per caput effective dose from conventional radiology are vertebral column, abdomen, chest, pelvis and (limited to females) breast. Vertebral column, pelvis and breast procedures show a significant dose increment in the period of the study. The mean effective dose per inhabitant from conventional radiology increased from 0.131 mSv in 2002 to 0.156 mSv in 2009. Combining these figures with those from our study of effective dose from CT (0.55 mSv in 2002 to 1.03 mSv in 2009), the total mean effective dose per inhabitant increased from 0.68 mSv to 1.19 mSv. The contribution of CT increased from 81% to 87% of the total. In contrast, conventional radiology accounts for 85% of the total number of procedures, but only 13% of the effective dose. CONCLUSION: The study has demonstrated that conventional radiography still represents the biggest contributor to examination frequency in Aosta Valley in 2009. However, the frequency of the main procedures did not change significantly between 2002 and 2009.

Late rectal bleeding after 3D-CRT for prostate cancer: development of a neural-network-based predictive model.

The aim of this study was to develop a model exploiting artificial neural networks (ANNs) to correlate dosimetric and clinical variables with late rectal bleeding in prostate cancer patients undergoing radical radiotherapy and to compare the ANN results with those of a standard logistic regression (LR) analysis. 718 men included in the AIROPROS 0102 trial were analyzed. This multicenter protocol was characterized by the prospective evaluation of rectal toxicity, with a minimum follow-up of 36 months. Radiotherapy doses were between 70 and 80 Gy. Information was recorded for comorbidity, previous abdominal surgery, use of drugs and hormonal therapy. For each patient, a rectal dose-volume histogram (DVH) of the whole treatment was recorded and the equivalent uniform dose (EUD) evaluated as an effective descriptor of the whole DVH. Late rectal bleeding of grade ≥ 2 was considered to define positive events in this study (52 of 718 patients). The overall population was split into training and verification sets, both of which were involved in model instruction, and a test set, used to evaluate the predictive power of the model with independent data. Fourfold cross-validation was also used to provide realistic results for the full dataset. The LR was performed on the same data. Five variables were selected to predict late rectal bleeding: EUD, abdominal surgery, presence of hemorrhoids, use of anticoagulants and androgen deprivation. Following a receiver operating characteristic analysis of the independent test set, the areas under the curves (AUCs) were 0.704 and 0.655 for ANN and LR, respectively. When evaluated with cross-validation, the AUC was 0.714 for ANN and 0.636 for LR, which differed at a significance level of p = 0.03. When a practical discrimination threshold was selected, ANN could classify data with sensitivity and specificity both equal to 68.0%, whereas these values were 61.5% for LR. These data provide reasonable evidence that results obtained with ANNs are superior to those achieved with LR when predicting late radiotherapy-related rectal bleeding. The future introduction of patient-related personal characteristics, such as gene expression profiles, might improve the predictive power of statistical classifiers. More refined morphological aspects of the dose distribution, such as dose surface mapping, might also enhance the overall performance of ANN-based predictive models.

Population exposure to ionising radiation from CT examinations in Aosta Valley between 2001 and 2008.

Recent and continuous advances in CT, such as the development of multislice CT, have promoted a rapid increase in its clinical application. Today, CT accounts for approximately 10% of the total number of medical radiographic procedures worldwide. However, the growing performance of the new CT generations have increased not only the diagnostic opportunities, but also the radiation dose to the patient. The relative contribution to the collective radiation dose is now estimated to be approximately 50%. Several papers have been published concerning the intensive use of CT and its contribution to the collective dose. However, most of the literature concerns the years 1997-2003 and the dosimetric evaluations are generally limited to the main standard protocols (chest, head and abdomen), deriving the effective dose by the simple application of the diagnostic reference levels. Only specific dosimetric analyses of single and innovative procedures have been published recently. Moreover, few data comes from Italian radiology departments. This paper aims to bridge these gaps. Firstly, it characterises in terms of measured CT dose index (CTDI) two last-generation scanners of the Radiological Department of Aosta Hospital. Secondly, it evaluates the effective dose from most of the CT examinations performed from 2001 to 2008 to compare protocols and technologies in line with the suggestions of the 2007 Recommendations of the International Commission on Radiological Protection, Publication 103. Finally, it estimates the collective dose to the population.

[A quality control test of the image obtained with electronic portal imaging devices]. / Verifica della qualità dell'immagine ottenuta mediante sistemi di imaging portale elettronico.

INTRODUCTION: A quality control of the digital image obtained from two electronic portal imaging devices is discussed. The devices are used to verify the radiotherapic treatment setup by comparing online images of the irradiated volume with those of the simulation devices. MATERIAL AND METHODS: Both iView and Target View devices, respectively installed on a dual energy SLi Precise Elekta and Saturne 42 Ge linear accelerators, consist of highly efficient phosphor screen and high quality videocamera, controlled by a workstation, able to generate digital portal images from few cGy doses. A phantom and software package are used to assess the spatial resolution and signal to noise ratio, and to compare tha data obtained. Spatial resolution and signal to noise ratio of both systems were studied as a function of energy, gantry angle and image acquisition parameters. RESULTS: The mean spatial resolutions obtained from the first 30 measurements were 0,265+/-0,012 and 0,220+/-0,010 lp/mm respectively for 6 and 18 MV of Saturne 42 (Target View) and 0,241+/-0,006 and 0,239+/-0,005 lp/mm for 4 and 6 MV of SLi (iView). Spatial resolution decreases as a function of energy, meanwhile there are no significant statistical differences as regards of the acquisition parameters; signal to noise ratio, instead, increases with integration time. Different values of the spatial resolution as a function of gantry angle are due to changes in the screen-camera distance and flexing of the detector housing. The quality control test is performed every 15 days by the technicians of our Radiotherapy Department. We set the reject level of spatial resolution and signal to noise ratio to be three standard deviations below the mean value obtained during the initial EPID characterization: if the measures fall below these values preventative maintenance is scheduled. CONCLUSIONS: The efficacy of the use electronic portal imaging devices for visualizing and quantifying the relative positions of anatomical structures within the radiation field depends on the image quality. It is therefore essential to devise quality control tests for the devices themselves, to guarantee an optimal level of system performance in a fast and efficient manner.

[Physical-dosimetric characterization of a multi-leaf collimator system for clinical implementation in conformational radiotherapy]. / Caratterizzazione fisico-dosimetrica di un sistema di collimazione multilamellare per l'impiego clinico nella radioterapia conformazionale.

INTRODUCTION: In the present paper we discuss the main dosimetric characteristics of the multileaf collimator (MLC) installed on the Elekta SLi Precise accelerators. To evaluate the effectiveness of the MLC in conformal radiotherapy, beam transmission through leaves and/or diaphragms, leakage between the leaves, central axis depth dose, surface dose, effective penumbra, scalopping effect and field size factors were measured. MATERIALS AND METHODS: The MLC installed on the dual energy (4 and 6 MV) linear accelerator Elekta SLi Precise consists of 40 opposed pairs of 75 mm thick tungsten leaves, set in two raws mounted in place of the upper collimator. Each leaf has a nominal projected width of 10 mm. The maximum field size attainable is 40 x 40 cm2 at 100 cm SAD. Beam transmission through leaves and/or diaphragms and field size factors were measured in RW3 phantom with a ionization chamber, leakage between the leaves and effective penumbra were instead evaluated with radiographic films (X-Omat-V) and a laser scanning photodensitometer. Percentage depth doses were measured in an automatic water phantom. RESULTS: For both energies, approximately 1% of the incident radiation on the multileaf collimator is transmitted through the backup collimator, while the transmission through the different combinations of leaves and collimators is between 0.03 and 0.14%. These values show a good agreement with literature data and are in general lower than the peak values specified by the manufacturer. The peak value of the leakage between the leaves was about 2% for both energies, without significative variation with gantry or collimator angle or distance from the axis. MLC shaped fields show a skin dose less (about 3%) than the one of cerrobend block shaped fields, because of the electronic contamination due to the plexiglass tray of the cerrobend blocks; in both cases, the depth doses are similar, as are flatness and symmetry of irradiation fields. The effective penumbra increases with field dimension, depth and leaves positioning, with a mean value of about 9 mm for both energies. The different beam configurations do not significantly affect the values of the field size factors. CONCLUSIONS: The dosimetric characteristics and the case of use of the Elekta multileaf collimator make its application to conformal radiotherapy convenient and reliable, able to improve the accuracy and the effectiveness of radiation therapy and to develop new kinds of treatments. However, because of the complexity of the MLC, its implementation in radiotherapic practice requires careful dosimetric characterization to evaluate those parameters (transmission, penumbra and output factors) that play a fundamental role in the accuracy of the treatment.

[THe cost of radiotherapy. Piedmontese experience]. / Il costo della radioterapia. L'esperienza piemontese.

INTRODUCTION: An integrated task force of radiotherapists and administrators of the Piedmont region studied the estimated cost of radiotherapy (RT) to compare it with the figures in the 502/92 law modifying the financing of medical structures. This law changed the financing method from productive factors compensation to actually provided performances compensation. MATERIAL AND METHODS: The RT departments of the Turin and Novara university hospitals, those of Ivrea and Asti and that of the Pinna Pintor Clinic (Turin) participated in the study, with 4889 examinations in the period of interest. The study consisted of 6 steps: 1) defining a nomenclator; 2) making a list of standard resources; 3) calculating the actual resource consumption; 4) relating 2) to 3); 5) calculating cost and times; 6) defining quality standards. A technical and/or a central group(s) carried out all the steps. The nomenclator indicates 13 main activities (e.g., irradiation, telecobalt therapy, brachytherapy, hyperthermia), each of them featuring some subactivities (e.g., telecobalt therapy: flash, a fixed beam, two opposing beams). The following productive factor were considered: a) personnel; b) material; c) investments; d) the service cost; e) general costs. The personnel cost (the main cost) was calculated as: A) routine activity; B) activity for other units; C) congress activity; D) research. The times for individual performances were estimated according to professional roles (e.g., medical doctor, physicist, technician, nurse, administrative) for each subactivity. RESULTS: The estimated RT costs were as follows (please note that all figures are expressed in US $, at a rate of 1$ = ItL 1700). Irradiation: 15 (cost/session +/- 3%); telecobalt therapy: 30-55; Linac (energy < > 10 Mev): 38-60; special techniques: 931-2,314; HDR brachytherapy: 878-1,515; hyperthermia: 285; simulation: 50-92; dosimetry: 52-286; examination, treatment planning, follow-up, etc.: 24-59; immobilization devices, photographs, etc.: 3-66. The quality criteria are related to the personnel; high energy equipment; treatment planning; 3D dosimetry. CONCLUSIONS: Our study led the Italian Ministry of Health to revise the estimated cost of RT examinations in July, 1996. We will further enquire into the new figures.

[The importance of using computed tomographic scanning in breast irradiation after conservative treatment]. / L'importanza dell'utilizzazione delle scansioni con Tomografia Computerizzata nell'irradiazione della mammella dopo trattamento conservativo.

Conservative surgery followed by radiotherapy is the current treatment of choice for primary breast cancer: indeed, this protocol ensures local control, relatively good cosmetic results and NED survival values similar to those of more invasive surgery. Radiotherapy requires the optimization of the irradiation technique to minimize the dose to the organs at risk. To this purpose, 30 patients submitted to quadrantectomy for breast carcinoma and then to radiotherapy on the residual breast were examined, January through December, 1994, at the Radiotherapy Service of the Ivrea Hospital, to investigate if CT can help optimize treatment planning, sparing as much of the pulmonary tissue underlying the residual breast as possible. Our series of patients was then compared with a literature series whose treatment had been planned only on the mapping of body outline. Some interesting considerations follow from our results: 1) With CT, larger fields can be used than those used with the body outline, so that the planned target volume can be more closely approached; 2) Larger fields can be used because the critical organ included in the irradiation field is more correctly and precisely defined; 3) The comparison with the literature shows that in the past the fields were larger, because the target volume and the critical organ were more difficult to define. The use of larger fields means a higher dose to the lung and thus maybe a higher risk of radiation pneumonia.

[Cardiac troponin I and T in unstable angina: incidence, correlation, kinetics of release and prognostic value]. / Troponina i cardiaca e troponina T cardiaca nell'angina instabile: incidenza, correlazione, cinetica di rilasciamento e valore prognostico.

BACKGROUND: The aim of this study was to ascertain the incidence of altered serum cardiac Troponin-T (cTnT) and cardiac Troponin I (cTnI) in patients with unstable angina, the concordance between findings for the two proteins, their release kinetics and their utility in predicting coronary events. METHODS: We studied 32 consecutive patients (pts) admitted to the Coronary Unit with a diagnosis of unstable angina; following Braunwald classification criteria, 5 pts were in class I, 4 class II, 23 class III. A blood sample was taken on admission to hospital and subsequently every 8 hours for two days, a total of 7 samples being obtained per pt. Cardiac-TnT values ranging from 0-0.17 mugr/L (Boehringer Mannheim) were considered normal, as were cTnI values ranging from 0 to 0.7 mugr/L (Stratus-Dade). RESULTS: Among 218 samples, altered cTnT values (0.18-0.68 mugr/L) were found in 19 (3 pts), and 13 of these samples were positive for cTnI (0.8-5.5 mugr/L), while the remaining 6 showed borderline values for cTnI (0.5-0.7 mugr/L). No cTnT negative samples were found to be positive for cTnI. The release kinetics of cTnT and cTnI were comparable in all three cases, with a "plateau" pattern, unlike the kinetics in the course of acute myocardial infarction (AMI). The mean follow-up was 13 months on average (range 1-19). In two pts with altered cTnT and cTnI values, symptoms were controlled with medical therapy, while the remaining patient failed to respond to medical therapy and therefore underwent PTCA. Fifteen months later, they are alive and have not had myocardial infarction. Of the 29 pts with normal cTnT and cTnI values, three developed AMI, which in two cases was fatal. Seven pts were submitted PTCA, seven to aorto-coronary bypass surgery, two were subsequently rehospitalized for a recurrent angina symptoms. In 13 pts complete control of symptoms was achieved with medical therapy. CONCLUSIONS: Our findings demonstrate that the incidence of altered cTnT and cTnI values in pts with unstable angina is low; there is close agreement between findings for the two proteins; in cases of angina, the cTnT and cTnI release kinetics are different from those in AMI. The finding of altered cTnT and cTnI values in the serum of our pts with unstable angina does not appear to be of prognostic value for future coronary events.

Strategy for the retreatment of failed Helicobacter pylori eradication therapy: a case series.

BACKGROUND: Helicobacter pylori eradication therapy can be unsuccessful in 5 to 20% of patients. AIM: To investigate the validity of a strategy using triple therapies for the retreatment of patients with eradication failure, avoiding retreatment with antibiotics prone to induce resistance after use in the first treatment. PATIENTS AND METHODS: From a consecutive sampling of 108 patients still Helicobacter pylori-positive after a first course of antibiotic-based treatment, 74 (68.5%) agreed to a second course of triple therapy. Group 1 (N = 17): treatment failures on an imidazole (1)-based therapy were retreated with clarithromycin (C)-based regimen; Group 2 (N = 28): failures on a C-based therapy with an I-based regimen; Group 3 (N = 7): failures on an IC-based therapy using an I-based regimen and Group 4 (N = 22): failures on a non-I/non-C based therapy with either an I-based, C-based or IC-based regimen. The presence of Helicobacter pylori was assessed by histology and the CLO-test at study entry and two months after stopping therapy. RESULTS: Nine patients were withdrawn from the study (12.2%) due to a lack of end point endoscopy. Helicobacter pylori was cured after the second course of therapy in all but seven patients [10.7% failure by Per Protocol analysis, 21.6% by Intention-To-Treat analysis]. No statistically significant differences were found between the four groups (Group 1: 92.9% PP, 76.5% ITT; Group 2: 90.9% PP, 71.4% ITT; Group 3: PP and ITT 85.7%; Group 4: PP and ITT 86.4%). Minor adverse events were experienced in nine, none of whom required withdrawal from the drug therapy. CONCLUSIONS: A second course of triple therapy with alternate antibiotics effectively eradicated Helicobacter pylori, with only very few treatment failures. This suggests that the therapeutic strategy employed may be recommended.