Optimum imaging of chronic pancreatitis.

Chronic pancreatitis is an inflammatory process of the pancreas characterized by progressive parenchyma destruction, resulting in pain and exocrine and endocrine insufficiency. In the advanced stages the diagnosis by imaging is usually straightforward, while in the early phases of the disease there can be a paucity of findings at imaging, thus making an early diagnosis challenging. Different imaging modalities can have a role in the initial diagnosis and in the longitudinal follow-up of patients affected by chronic pancreatitis, also enabling to assess the complications of the disease. Radiography, Ultrasonography, CT and MRI can all provide morphological information, and MRI with the administration of secretin can also provide functional information. The use of an appropriate technique is fundamental for optimizing the examination to the clinical question.

Correlation between appearance of the retroportal fat plane at preoperative CT and pathology findings in resected adenocarcinoma of the pancreatic head.

AIM: To correlate the appearance of the retroportal fat plane at preoperative computed tomography (CT) and the pathology findings in resected adenocarcinoma of the pancreatic head (PDAC). MATERIAL AND METHODS: Forty-eight patients with resected PDAC of the pancreatic head were included (24 men, 24 women, mean age 63 years, median BMI 24.1). All patients underwent CT <30 days before surgery. The state of the retroperitoneal resection margin and the presence of lymphatic or perineural invasion were obtained from pathology reports. CT images were reviewed independently by two radiologists for assessment of the retroportal fat plane and graded in two categories (clear/effaced). Inter-reader discrepancies were solved in consensus. Interobserver agreement was calculated and Fisher's test was used to assess the correlation between CT and pathology findings. Visceral fat areas were measured and correlated with CT findings. RESULTS: A clear retroportal fat plane was significantly associated with a negative retroperitoneal margin at pathology with 100% specificity and PPV (p=0.0001). No association was observed between the appearance of the fat plane at CT and the presence of lymphatic or perineural invasion (p=ns). Interobserver agreement for retroportal fat plane evaluation was good (0.741). False-positive cases had a significantly lower visceral fat area than the correctly classified patients (p=0.0480). CONCLUSIONS: A clear retroportal fat plane is significantly associated with negative retroperitoneal resection margins at pathology. The lack of visceral adipose tissue can lead to overestimation of retroportal fat plane involvement at preoperative CT.

Virtual autopsy using multislice computed tomography in forensic medical diagnosis of drowning.

PURPOSE: This study evaluated the usefulness of multidetector computed tomography (MDCT) in the postmortem diagnosis of death by drowning in fresh water by measuring the difference of blood density within the cardiac chambers. MATERIALS AND METHODS: Twenty-two corpses including six cases of fresh-water drowning (group A) and 16 deaths by other causes (group B), among which were also different forms of mechanical asphyxia other than drowning, underwent MDCT and conventional autopsy. Blood density within the right and left heart chambers, the aorta and the pulmonary trunk was measured and values compared between groups and within each group between heart chambers. RESULTS: Blood density in all cardiac chambers was lower in group A than in group B. The difference was statistically significant within the left atrium and ventricle and was significantly lower in the left than in the right heart chambers in group A only. CONCLUSIONS: MDCT, together with conventional autopsy, may contribute to the diagnosis of drowning, by measuring blood density in the heart chambers.

Bull's-eye pattern of pancreatic-duct stones on multidetector computed tomography and gene-mutation-associated pancreatitis (GMAP).

PURPOSE: This study prospectively assessed whether the presence of a bull's-eye pattern of pancreatic-duct stones on multidetector computed tomography (MDCT) correlated with gene-mutation-associated pancreatitis (GMAP) and whether other signs suggestive of GMAP can be detected with MDCT. MATERIALS AND METHODS: Forty-seven patients with chronic calcific pancreatitis underwent genetic testing for CFTR, SPINK1 and PRSS1 mutations and an MDCT scan of the abdomen. Qualitative analysis assessed the presence or absence of pancreatic-duct stones with bull's-eye appearance. Quantitative analysis included the number and maximum diameter of stones and the diameter of the main pancreatic duct. RESULTS: Fifteen of 47 patients (32%) were positive for gene mutations (GMAP patients). The bull's-eye pattern was found in 10/15 patients (67%) with GMAP and in 4/32 (12%) patients with chronic pancreatitis not associated with GMAP (NGMAP; p<0.0001). The mean diameter of duct stones was 15 mm in patients with GMAP and 10 mm in patients with NGMAP (p<0.04). CONCLUSIONS: The presence of duct stones with a bull's-eye pattern correlates with GMAP. Duct stones with diameter ≥15 mm are another sign suggestive of GMAP.

Radioiodine ablation: when and how.

Differentiated thyroid cancer (DTC) is the most common endocrine malignancy with the highest mortality although with appropriate treatment has a good long-term prognosis and cure rate. Over the last 30 years there is a worldwide trend showing an increasing incidence of thyroid cancer. In DTC patients, total thyroidectomy has been for many decades routinely followed by the administration of radioiodine (131I) activity to destroy remnant thyroid tissue. Several reasons are in favour to routine ablation of postoperative thyroid remnants. The combination of both surgery and radioiodine has proven as a safe and effective treatment, resulting in improved life expectation and reduced recurrence rate for DTC patients. Recently, however, 131I ablation is not uniformly recommended for cancers smaller than 10 mm, and its use is debated for papillary tumours with diameter between 10 and 20 mm. Indeed, the decision about subsequent 131I thyroid remnant ablation is recommended as "individualized and selective". Even if new evidence has emerged that provides additional support for performing 131I treatment, the possible presence of radioiodine-associated side effects should be not overlooked. Moreover, a lot of discussion has taken place as to whether, and to what extent, 131I may cause secondary malignancies. Blood-based dosimetry is important to avoid surplus bone marrow toxicity while treating DTC patients. In this regard, the availability of a genetically engineered version of recombinant human TSH (rhTSH) provides an alternative tool to enhance serum TSH levels without inducing hypothyroidism. The administration of rhTSH to thyroid cancer patients still on LT4 therapy promotes radioiodine uptake and thyroglobulin production by thyroid cells to an extent comparable with hypothyroidism, preserving patients' quality of life, increasing the renal clearance of 131I and decreasing both the whole body and the blood dose. In this review the authors will discuss the pros and cons of postoperative radioiodine-induced thyroid remnant ablation.

Metabolic syndrome in patients with intermittent claudication referred to vascular rehabilitation.

AIM: The prevalence of the metabolic syndrome, a clustering of cardiovascular risk factors whose underlying pathophysiology is related to insulin resistance, was estimated in patients with intermittent claudication referred to a short-course intensive rehabilitation program focused on physical training. Improvements in walking distance at the end of the program were also compared among patients with and without the syndrome. METHODS: The metabolic syndrome was documented among 34 (39%) out of 87 enrolled patients, without significant differences between those with and without the syndrome concerning sex (males 91% vs 92% respectively, P=0.816), age (64+/-8 vs 65+/-7 years, P=0.54), coronary heart disease (44% vs 32%, P=0.365), localization of peripheral arterial disease, and impairment of walking capacity as evaluated by constant treadmill test (initial claudication distance (ICD) 156+/-93 vs 176+/-126 m, P=0.428; absolute claudication distance (ACD) 429+/-324 vs 409+/-269 m, P=0.756). RESULTS: At the end of the program, both ICD and ACD significantly improved without any of significant differences between the two groups (ICD +152% vs +174% respectively, P=0.518; ACD +112% vs +177%, P=0.053). CONCLUSIONS: Metabolic syndrome is frequent among patients with intermittent claudication and is not associated with poor response to physical training. Our data highlight the need for considering vascular rehabilitation in these patients in order to both improve walking capacity and minimize cardiovascular morbidity and mortality.

Economic evaluation of a short-course intensive rehabilitation program in patients with intermittent claudication.

AIM: The aim of this study was to provide cost-description and cost-effectiveness of a short-course intensive in-hospital rehabilitation program in patients with intermittent claudication. METHODS: Costs per case treated were calculated according to a local standard protocol including diagnostic evaluation of peripheral arterial disease and other related cardiovascular conditions, physical training, and secondary prevention. Three additional less structured scenarios were also evaluated. RESULTS: All 107 enrolled patients (males 91%, mean age 65+/-8 years) completed the program (4-week duration; twice a day walking exercise) and showed significant increases in walking performance, as evaluated by constant treadmill-test. At admission, the mean values of initial claudication distance (ICD) and absolute claudication distance (ACD) were 150+/-111 and 432+/-327 m, respectively. At the end of the program, 12 (11%) patients completed the treadmill test without pain, while 31 (29%) completed the test without stopping due to maximal pain. Among the remaining 64 (60%) patients, the ICD and ACD increased by 137% and 112%, respectively. The cost per case treated ranged from Euro 1733.2 (standard protocol) to Euro 918.9 (physical training only). By adding the cost of hospitalization and indirect costs, the same costs ranged from Euro 4626.2 to Euro 3811.9. The average cost to walk one additional meter without pain as a result of the rehabilitation program was Euro 57.5, while the cost to walk one additional meter before stopping was Euro 27. As showed by sensitivity analysis, the maintenance of the expected level of treatment success was crucial for program's cost-effectiveness. CONCLUSION: From the societal viewpoint, short-course intensive rehabilitation may be cost-effective in patients with stable intermittent claudication and could be considered in decision models evaluating different therapeutic options.

Short and long-term evaluation of two structured self management programmes on asthma.

In recent years education programmes for adults have been developed focusing on improving patient self-management. The aim of this study was to evaluate the efficacy of two different educational programmes on asthma at one year (short-term efficacy) and three years (long-term efficacy). Changes in pulmonary function (FEV1), knowledge of disease and skill concerning inhalation technique were evaluated to determine the efficacy of the educational programme. Forty patients were randomly assigned to the two different educational programmes. Twenty subjects (mean age 49 +/- 11 yrs; FEV1 79% +/- 15 of predicted) were assigned, to a basic educational programme, while the others (mean age 44 +/- 11 yrs; FEV1 79% +/- 14 of predicted) were assigned to an "asthma school" programme. In both "basic" and "asthma school" groups there was a significant increase from baseline to one year (p < 0.05) and three years (p < 0.05) in FEV1, number of correct answers to the knowledge questionnaire, and number of correct steps during the inhalation procedure. No significant differences were found between the two groups at baseline, one year and three years for all three variables studied. This study confirms that both educational programmes determine in asthmatics an improvement in lung function, knowledge of disease and skill for inhalation technique at one year and three years following commencement of the programme. A "basic" educational programme is as effective as an "asthma school" one.

Surveillance of anti-tuberculosis drug resistance: results of the 1998/1999 proficiency testing in Italy. SMIRA (Italian Multicentre Study on Antituberculosis Drug Resistance) Study Group.

OBJECTIVE: To determine the accuracy of drug-susceptibility testing (DST) for isoniazid, rifampicin, ethambutol and streptomycin in a provisional network of 22 regional laboratories in Italy. METHODS: Methods, definitions and reference Mycobacterium tuberculosis strains were derived from the WHO/IUATLD Global Project on Anti-tuberculosis Drug Resistance Surveillance. The laboratories were selected based on technical skills required by the project, the number of DST performed annually and geographic localisation. The results (sensitive/resistant strain) were compared with the gold standard (global project results). Sensitivity (ability to detect true resistance), specificity (ability to detect true susceptibility), positive predictive values for resistance and susceptibility, efficiency and reproducibility were calculated in two rounds. RESULTS: Eighteen of 22 laboratories completed the first round of proficiency testing for the four drugs. Sensitivity was 76.6%, specificity 97.2%, predictive value of a resistant test 89.8% and of a susceptible test 86.8%, efficiency 87.8% and reproducibility 92.8%. A second round was performed by all those laboratories that did not achieve > or = 90% agreement with the results of the Global Project. Overall, after the second round, all the parameters except specificity improved, exceeding 90%. CONCLUSIONS: A network of 15 regional laboratories that fulfil the quality criteria for determining the susceptibility of M. tuberculosis to the four primary antituberculosis drugs was established in Italy.

Microbiological confirmation of tuberculosis cases at diagnosis and at the end of treatment in Italy.

Microbiological findings at diagnosis and at the end of treatment are relevant for evaluating tuberculosis (TB) treatment programmes. The objectives of this study were to describe the microbiological findings at diagnosis and at the end of treatment in pulmonary and extrapulmonary TB patients treated under programme conditions in Italy. The study was a prospective monitoring activity based on the collection of standard recording and reporting forms from a representative sample of Italian TB Units. The forms with individual data were reviewed and analysed on a quarterly basis, 9 months after enrolment. The complete bacteriological profile of patients was analysed at diagnosis and at the completion of treatment. Individual data on 992 patients were analysed. At diagnosis 320 (32.2%) of cases were pulmonary sputum smear positive, 361 (36.4%) pulmonary smear negative or not done and 311 (33.4%) extrapulmonary; 424 (42.7%) of all TB cases were culture confirmed at diagnosis (368, 50.2%, of pulmonary cases); 575 (84.4%) of pulmonary cases had a culture done at diagnosis and 156 (22.9%) at the end of treatment (p < 0.001); 572 (84%) had a sputum smear done at diagnosis and 164 (24.1%) at the end of treatment (p < 0.001). Although the rate of bacteriologically confirmed cases is similar to that of other European countries, the bacteriological confirmation at diagnosis and, particularly, at the end of treatment, is sub-optimal. The importance of further disseminating national guidelines among physicians managing TB is emphasized, in order to achieve a higher proportion of TB cases bacteriologically confirmed at diagnosis and monitored at the end of treatment.

Savings obtained using an oxygen economizer device: a cost-minimization analysis.

As liquid oxygen represents a relevant burden on healthcare systems, different methods have been developed to reduce oxygen consumption, including economizers. The aims of the study were: 1) to evaluate the efficacy of an economizer device (Companion 5 Oxygen Saver) in a significant sample of patients, and 2) to perform cost-minimization analysis of the possible savings to be obtained using the device. The study was designed as an open, prospective clinical trial in which equivalence in haemoglobin saturation with and without the economizer device was demonstrated, preliminary to cost-minimization analysis in patients affected by restrictive and obstructive lung disease. Patients were to use their usual O2 flow, provided it was able to guarantee a saturation of > or = 90% and an arterial oxygen tension (Pa,O2) of > or = 8.0 kPa (60 mmHg) during rest, sleep and exercise with and without the economizer (mean value and different saturation ranges compared by means of parametric or nonparametric tests where appropriate). The average unit cost was calculated with and without the economizer, based on the average unit O2 consumption, and cost-minimization analysis was performed. In 29 patients enrolled, the mean (+/- SD) O2 flow in L.min-1 was 1.5 +/- 0.6 during sleep, 1.4 +/- 0.6 during rest and 2.3 +/- 1.1 during exercise. The mean oxygen saturation during sleep was 91.2 +/- 19.5% without and 97.2 +/- 3.9% with the economizer device (p = 0.09), the mean saturation during rest was 88.8 +/- 22.7% without and 92.1 +/- 14.9% with the economizer device (p = 0.42), and the mean saturation during exercise was 84.7 +/- 19.3% without and 91.8 +/- 15.9% with the economizer device (p = 0.04). The total daily O2 consumption was significantly lower using the economizer device (2,384 +/- 950.3 versus 93.0 +/- 482.9 L, p < 0.001). The potential savings, estimated per patient per year, were 530,114 +/- 184,233 L, corresponding to US$2,492 +/- 866. During the first year the total unit savings would be US$1,892. The savings, consistently relevant alongside the whole range of variation explored by sensitivity analysis both during the first and the following years, justify considering the adoption of similar economizers on a larger scale, although further studies should be performed to evaluate whether or not liquid oxygen really represents the most cost-effective method of treating hypoxaemic patients.

The Italian AIPO study on tuberculosis treatment results, report 1996. National AIPO "Tuberculosis" Study Group. Associazione Italiana Pneumologi Ospedalieri.

In Italy, no national data on tuberculosis (TB) treatment results were available. In 1995, the AIPO (Italian Association of Hospital Pneumologists) TB Study Group, in collaboration with the Istituto Superiore di Sanità (technical branch of the Ministry of Health), started a prospective monitoring activity based on World Health Organization (WHO) and International Union against Tuberculosis and Lung Disease (IUATLD) recommendations. Data were collected from a nationwide network of 41 TB units, managing a significant proportion of all the TB cases notified in Italy each year. The aim of this study was to analyse the case findings and treatment results for the year 1996. Eight hundred and thirty eight TB cases were reported (56% males; 26% immigrants), 708 (84%) being new cases. Of these cases, 565 (67%) were pulmonary, 235 (28%) extrapulmonary and 38 (5%) both pulmonary and extrapulmonary. The main risk factors for TB were a history of recent contact and diabetes among native Italians and recent contact and human immunodeficiency virus-seropositive status among immigrants. The majority of immigrants were from Africa and Asia, and had been in Italy > 24 months before diagnosis of TB. Thirty-six per cent of patients had a positive direct sputum smear examination for alcohol acid-fast bacilli; 37% were resistant to any drug (monoresistance to isoniazid 4.4%; multidrug resistance 10.4%). In 96% of cases, the duration of treatment was < 12 months. The overall success rate (cured plus treatment completed) was 84.1%. A significantly higher percentage of deaths was found in native Italians (being age-related), whereas immigrants had a higher default rate.

Cost-comparison of different management policies for tuberculosis patients in Italy. AIPO TB Study Group.

Although in developing countries the treatment of tuberculosis (TB) cases is among the most cost-effective health interventions, few studies have evaluated the cost-effectiveness of TB control in low-prevalence countries. The aim of the present study was to carry out an economic analysis in Italy that takes into account both the perspective of the resource-allocating authority (i.e. the Ministry of Health) and the broader social perspective, including a cost description based on current outcomes applied to a representative sample of TB patients nationwide (admission and directly observed treatment (DOT) during the initial intensive phase of treatment); a cost-comparison analysis of two alternative programmes: current policy based on available data (scenario 1) and an hypothetical policy oriented more towards outpatient care (scenario 2) (both scenarios included the option of including or not including DOT outside hospital admission, and incentives) were compared in terms of cost per case treated successfully. Indirect costs (such as loss of productivity) were included in considerations of the broader social perspective. The study was designed as a prospective monitoring activity based on the supervised collection of forms from a representative sample of Italian TB units. Individual data were collected and analysed to obtain a complete economic profile of the patients enrolled and to evaluate the effectiveness of the intervention. A separate analysis was done for each scenario to determine the end-point at different levels of cure rate (50-90%). The mean length of treatment was 6.6 months (i.e. patients hospitalized during the intensive phase; length of stay was significantly higher in smear-positive patients and in human immunodeficiency virus (HIV) seropositive patients). Roughly six direct smear and culture examinations were performed during hospital admission and three during ambulatory treatment. The cost of a single bed day was US$186.90, whereas that of a single outpatient visit ranged, according to the different options, from US$2.50 to US$11. Scenario 2 was consistently less costly than scenario 1. The cost per case cured for smear-positive cases was US$16,703 in scenario 1 and US$5946 in scenario 2. The difference in cost between the cheapest option (no DOT) and the more expensive option (DOT, additional staff, incentives) ranged from US$1407 (scenario 1, smear-negative and extrapulmonary cases) to US$1814 (scenario 2, smear-positive cases). The additional cost to society including indirect costs ranged from US$1800 to US$4200. The possible savings at the national level were in the order of US$50 million per year. In conclusion, cost-comparison analysis showed that a relatively minor change in policy can result in significant savings and that the adoption of DOT will represent a relatively modest economic burden, although the real gain in effectiveness resulting from DOT in Italy requires further evaluation.

Prospective multicentre study on the evaluation of antituberculosis treatment results in Italy: comparison of the culture- versus the smear-based methods. National AIPO Tuberculosis Study Group.

Cohort analysis of treatment outcomes is the most informative technique to evaluate the tuberculosis (TB) control programme. The aim of the study was to assess treatment outcomes comparing the smear- versus the culture-based methods, using data on TB patients treated under programme conditions in Italy. This was a prospective monitoring study based on the standardized collection of forms from a representative sample of Italian TB Units. The forms, with individual data, were reviewed and analysed on a quarterly basis according to the principles of cohort analysis, using both the smear- and culture-based methods. The complete bacteriological profile of patients was analysed at diagnosis and at completion of treatment. Nine hundred and ninety-two TB cases were notified. Among 681 pulmonary cases, 368 cases were culture-confirmed at diagnosis (333 new and 35 retreatment cases, 293 being sputum smear positive, 79.6%). At the end of treatment, out of the 333 new culture-confirmed cases, 136 (40.8%) were defined "cured" using the culture-based method and 108 (32.4%) using the smear-based method (p<0.05, chi2 test). The culture-based method is the recommended tool to evaluate pulmonary tuberculosis treatment results. Culture allows a more precise definition of a "cured" patient in both sputum smear positive and negative tuberculosis cases.