The importance of subcapsular anesthesia in the anesthesiological management for thyroid radiofrequency ablation.

Radiofrequency ablation is a minimally invasive procedure alternative to surgery to treat benign thyroid nodules causing compressive symptoms. Tolerability of this procedure, aimed at treatment of benign conditions, is fundamental. In this study, we evaluated if local anesthesia should be enough to reduce both hospital costs and sedation-related risks for the patient, avoiding deep sedation and presence of the anesthesiologist. From July 2017 to August 2018, 14 consecutive patients (mean age 60.1 years) were treated and divided in two groups: Group A (7 patients) underwent systemic sedoanalgesia (intravenous remifentanil/fentanyl ± intravenous midazolam ± intravenous acetaminophen/nonsteroidal anti-inflammatory drugs) + subcutaneous anesthesia (lidocaine), with anesthesiologist. Group B (7 patients) underwent mild systemic sedoanalgesia (oral solution morphine sulfate + intravenous midazolam + intravenous acetaminophen) + both subcutaneous and subcapsular anesthesia (mepivacaine + bupivacaine), without anesthesiologist. Tolerability, sedation grade (Ramsay scale), total opioid dose, complications, and results at 12 months were analyzed and compared. Mean tolerability was 9.4 in group A and 8.9 in group B (p: 0.786). Mean sedation grade was 3.86 in group A and 2.71 in group B (p: 0.016). Mean total opioid dose was 70.9 mg in group A and 10 mg in group B (p:0.00015). No complications were observed. At 12 months, mean volume reduction was 56.1% in the group A and 60% in the group B. In thyroid radiofrequency ablation, subcapsular anesthesia can decrease both total opioid dose and level of patient's sedation without significant differences in tolerability, allowing to perform ablation without the anesthesiologist.

The value of precontrast thoraco-abdominopelvic CT in polytrauma patients.

PURPOSE: To evaluate the utility and radiation dose of thoraco-abdominopelvic precontrast CT in polytrauma patients. MATERIALS AND METHODS: We examined retrospectively 125 patients who underwent a thoraco-abdominopelvic CT for trauma. Two radiologists, independently, evaluated precontrast CT acquisition and two other radiologists examined the contrast-enhanced scans. A further two radiologists assessed both the acquisitions. Mean value of sensitivity (SE), specificity (SP), positive predictive value (PPV) and negative predictive value (NPV) were calculated by each group of radiologists. For 104 patients, CTDIvol, DLP data and individual mean size were collected to calculate effective dose. RESULTS: Mean values of SE, SP, PPV and NPV of findings of radiologists who assessed contrast-enhanced acquisitions were respectively: SE=85%, SP=98%, PPV=86%, NPV=88% versus: SE=43%, SP=95%, PPV=69%, NPV=88% of radiologists who examined non-contrast-enhanced scans. Mean values of radiologists who analyzed both acquisitions were: SE=80%, SP=97%, PPV=80%, NPV=88%. Neither the precontrast scans nor the precontrast and postcontrast scans together provided additional useful information compared to the single contrast-enhanced acquisition. Patients received a mean dose of 12 mSv for the precontrast CT. CONCLUSIONS: Precontrast CT acquisition did not provide significant information in trauma patients, exposing them to an unjustified radiation dose.

[Intra-abdominal adiposity in preterm infants: an explorative study]. / Adiposità intra-addominale in nati pretermine: studio esplorativo.

OBJECTIVE: The aim of the present study was to compare the total body fat mass and the intra-abdominal adipose tissue between preterm infants assessed at term corrected age and full-term newborns. METHODS: An observational explorative study was conducted. 25 preterm and 10 full term infants were evaluated at 0-1 month of corrected and postnatal age, respectively. The total body fat mass was assessed by means of an air displacement plethysmography system (Pea Pod COSMED, USA) and the intra-abdominal adipose tissue by means of magnetic resonance imaging (software program SliceOMatic, Version 4.3,Tomovision, Canada). RESULTS: Total body fat mass (g) of preterm and term infants was 633 (+/- 183) and 538 (+/- 203) respectively while intra-abdominal fat mass (g) was 14.2 (+/- 4.9) and 19.9 (+/- 11.4). CONCLUSIONS: Preterm infants, although exhibiting a total body fat mass higher than full term infants, do not show an increased intra-abdominal adipose tissue.

Intestinal interposition: the prevalence and clinical relevance of non-hepatodiaphragmatic conditions (non-Chilaiditi forms) documented by CT and review of the literature.

PURPOSE: This study was done to assess the prevalence and clinical impact of non-hepatodiaphragmatic interpositions in a sample of adult patients undergoing computed tomography (CT) for a variety of medical reasons. MATERIALS AND METHODS: From November 2008 to April 2009, two observers jointly examined the cases of intestinal interposition in 4,338 adults undergoing CT investigations. This study sought to identify not only hepatodiaphragmatic intestinal interpositions, defined as Chilaiditi, but also other forms of intestinal interposition, which we termed non-Chilaiditi. The latter were divided into five different classes on the basis of their anatomical relationships: splenorenal, retrogastric, hepatocaval, retrosplenic, and retrorenal. Moreover, a questionnaire investigating the clinical symptoms reported to be associated with Chilaiditi syndrome was given to patients exhibiting any form of intestinal interposition and to a control sample. Finally, clinical data related to the three groups were compared. RESULTS: Of the 4,338 patients examined, 130 (3%) were found to have intestinal interposition, for a total of 143 forms: 90 Chilaiditi and 53 non-Chilaiditi. Of the latter, 30 were splenorenal, 12 retrogastric, five hepatocaval, four retrosplenic and two retrorenal. Statistical analysis showed that the Chilaiditi group suffered most symptoms (24.4%), followed by the non-Chilaiditi group (18.9%) and control cases (10.8%). Our results were validated using the χ(2) test of significance. CONCLUSIONS: The number of non-Chilaiditi cases amounted to just over half the number of Chilaiditi cases, with the splenorenal form being by far the most frequent. Statistical analysis showed that patients with non-Chilaiditi forms of intestinal interposition had more symptoms than did controls.

ERCP and short-term stent-trial in patients with anastomotic biliary stricture following liver transplantation.

BACKGROUND: Anastomotic biliary stricture represents one of the possible factors leading to liver dysfunction after transplantation. PURPOSE: Our aims were to evaluate the role of endoscopic retrograde cholangio-pancreatography and a short-term stenting (stent-trial) in assessment of the clinical relevance of the biliary stricture. MATERIALS AND METHODS: Thirty transplanted patients for HCV (n=17) or non-HCV (n=13)-related cirrhosis (27M, median age 53 yr, range 24-67 yr) who developed persistently abnormal liver function tests and presented with an anastomotic biliary stricture suggested by non-invasive cholangiography, underwent endoscopic retrograde cholangio-pancreatography. If the stricture was confirmed, dilation was performed and a plastic stent was placed. Clinical and biochemical evaluation was done one and two months later. Resolution of symptoms and normalization or > 50% reduction of at least one liver function test were needed to consider the stricture as clinically relevant. Patients were followed up for a median of 19 months. RESULTS: Endoscopic retrograde cholangio-pancreatography was successful in 29 patients and confirmed the anastomotic biliary stricture in 19 (66%); 14 patients underwent endoscopic dilation and stenting and five patients underwent surgery. The stent-trial suggested the stricture to be clinically relevant in 7 of 14 patients, confirmed by prolonged stenting and follow-up. A trend towards a higher likelihood of a clinically relevant stricture was observed in HCV-negative compared to HCV-positive patients (5 of 7, 71% vs 2 of 7, 29% , respectively; p=0.1). CONCLUSIONS: Our data suggest that endoscopic retrograde cholangio-pancreatography is a valuable tool to evaluate the clinical relevance of an anastomotic stricture, when coupled with a short-term stent-trial.

Transarterial embolization with microspheres in the treatment of monofocal HCC.

BACKGROUND: Transarterial embolization using one permanent embolic agent alone enhances tumour ischaemia and spares patients with hepatocellular carcinoma form toxic chemotherapeutic drugs. PURPOSE: We assessed feasibility, tolerability and efficacy of transarterial embolization with microspheres in patients with a single node hepatocellular carcinoma. MATERIALS AND METHODS: Eighteen consecutive patients with compensated cirrhosis, hypervascularized single hepatocellular carcinoma, in whom liver transplantation was indicated (no.=3), or excluded from radical therapies (no.=15), received selective transarterial embolization with microspheres. Treatment was repeated every other month until complete devascularitazion was demonstrated by computed tomography, for a maximum of 3 cycles. RESULTS: Fifty transarterial embolization courses (mean: 2.8 courses, range 1-6) were administered, corresponding to a 100% applicability rates. Initial complete response was achieved in 16 (89%) patients and confirmed by histology in 2 transplanted patients. During 21-month follow-up (range 8-36), hepatocellular carcinoma recurred in 10 (62%) patients who achieved initial complete response, and de novo tumour nodes developed in 10 (56%). No patient required analgesics and none had liver function deteriorated following transarterial embolization. CONCLUSIONS: Transarterial embolization is a well-tolerated treatment for patients with early or intermediate hepatocellular carcinoma who are not suitable for radical treatment or await liver transplantation, but it allows to achieve a sustained complete response in a minority of patients.

Role of transjugular liver biopsy in the diagnostic and therapeutic management of patients with severe liver disease.

PURPOSE: This study sought to assess the diagnostic yield, the impact on treatment and the safety of transjugular liver biopsy. MATERIALS AND METHODS: We reviewed the medical records of 72 patients with severely impaired liver function who underwent transjugular biopsy at our department. Contraindications to percutaneous liver biopsy included thrombocytopenia, severe coagulopathy, marked ascites or a combination of the above. Patients were divided into four groups based on the clinically suspected cause of liver disease. Group 1 included 44 patients (58%) with acute abnormalities of liver function, whereas groups 2, 3 and 4 included patients with chronic abnormalities suspected to be due to infectious cirrhosis (12 patients, 16%), alcoholic cirrhosis (seven patients, 9%) and cirrhosis of unknown origin (13 patients, 17%), respectively. A Quick-Core (Cook, ProAct Ltd., State College, Pennsylvania, USA) needle allowing automated tissue sampling was used for all biopsies. RESULTS: Biopsy specimens were diagnostic in 69 out of 72 patients (91%). Biopsy findings influenced treatment in 34 out of 69 patients (49%). The most significant results were obtained in group 1, where the histological diagnosis differed from clinical suspicion in 25/39 patients. There was only one major complication and four minor complications. The major complication was an arteriovenous and arteriobiliary fistula with haemorrhage and anaemia, which was successfully embolised by the same team of interventional radiologists. CONCLUSIONS: Transjugular liver biopsy proved to be a safe procedure that provided important information for the clinical and therapeutic management of patients in whom treatment would have been either empirical or unfeasible.

Myoinositol content in the human brain is modified by transcranial direct current stimulation in a matter of minutes: a 1H-MRS study.

Brain content of myoinositol (mI) has been shown to be altered in several neuropsychiatric conditions. Likewise, various forms of electric currents have been applied to the human brain for therapeutic purposes in neuropsychiatric diseases. In this study we aimed to depict the effects of low-power transcranial direct current stimulation (tDCS) on brain mI by proton magnetic resonance spectroscopy ((1)H-MRS). We studied two groups of five healthy subjects by (1)H-MRS: the first group was studied before and after both anodal and sham (placebo) tDCS over the right frontal lobe, and the second group was studied at the same intervals without undergoing either sham or anodal tDCS. Anodal tDCS induced a significant increase of mI content at 30 min after stimulation offset (141.5 +/- 16.7%, P < 0.001) below the stimulating electrode but not in distant regions, such as the visual cortex, whereas sham tDCS failed to induce changes in mI. Neither N-acetyl-aspartate (NAA) nor the other metabolite contents changed after anodal or sham stimulation. (1)H-MRS represents a powerful tool to follow the regional effects of tDCS on brain mI and, possibly, on the related phosphoinositide system.

Autologous transplantation of muscle-derived CD133+ stem cells in Duchenne muscle patients.

Duchenne muscular dystrophy (DMD) is a lethal X-linked recessive muscle disease due to defect on the gene encoding dystrophin. The lack of a functional dystrophin in muscles results in the fragility of the muscle fiber membrane with progressive muscle weakness and premature death. There is no cure for DMD and current treatment options focus primarily on respiratory assistance, comfort care, and delaying the loss of ambulation. Recent works support the idea that stem cells can contribute to muscle repair as well as to replenishment of the satellite cell pool. Here we tested the safety of autologous transplantation of muscle-derived CD133+ cells in eight boys with Duchenne muscular dystrophy in a 7-month, double-blind phase I clinical trial. Stem cell safety was tested by measuring muscle strength and evaluating muscle structures with MRI and histological analysis. Timed cardiac and pulmonary function tests were secondary outcome measures. No local or systemic side effects were observed in all treated DMD patients. Treated patients had an increased ratio of capillary per muscle fibers with a switch from slow to fast myosin-positive myofibers.

Single-versus multidetector-row CT: comparison of sedation rates, conventional angiograms and motion artefacts in young children following liver transplantation.

PURPOSE: The aim of this study was to determine whether the use of multidetector computed tomography (MDCT) is associated with decreased sedation, frequency of motion artefacts and conventional angiograms compared with single-detector CT (SDCT). MATERIALS AND METHODS: CT examinations performed in young children between January 1993 and June 2005 were reviewed retrospectively. Prior to September 2000, SDCT was used; after that period, MDCT was used. The examinations obtained during these two periods were compared for the frequency of sedation, motion artefacts, and conventional angiograms. Statistical comparison between the two groups was determined by using the chi(2) test. RESULTS: A total of 126 infants and children younger than 6 years of age underwent 134 CT examinations. Eighty-eight were obtained with a SDCT (65%) (group 1) and 46 with a MDCT (35%) (group 2). Sedation was required in 31/88 (35%) CT examinations in group 1 and in 6/46 (13%) in group 2. Conventional angiography was performed in 20/88 (22%) cases in group 1 and in 6/46 (13%) in group 2. Motion artefacts were present in 8/88 (9%) CT examinations in group 1 and in 4/46 (8%) in group 2. There was significant statistical difference with regard to sedation and angiography rates between the two groups (p<0.001) whereas there was no significant difference with regard to motion artefacts (p>1). CONCLUSIONS: MDCT can reduce the need for sedation and conventional angiography in children after liver transplantation. There is no effect on patient motion artefacts.

[Imaging of small renal tumors]. / L'imaging dei piccoli tumori renali.

The advent of ultrasound and computed tomography resulted in a great increase in detection and diagnosis of small renal parenchymal tumors. These are mainly slow growing tumors, without metastatic disease and with possible multicentricity at the diagnosis. Moreover there is not agreement about the best treatment for the small (< 3 cm) renal cell carcinoma. In this paper the role of ultrasound, computed tomography and magnetic resonance for detection and characterization of the small renal masses is discussed. On occasion it is possible to obtain the tissue characterization of a solid renal mass by diagnostic imaging (for example angiomyolipomas); however, most frequently, solid renal masses have an aspecific appearance. The majority of problematic renal masses have cystic components. The diagnosis of simple cyst is based on few simple but rigid criteria: homogeneous water density, very thin wall, well defined and sharp interface with renal parenchyma, lack of contrast enhancement. When there are intracystic septae, thickened wall or increased density, the cyst is "complicated". In these cases the classification suggested by Bosniack can be helpful. Bosniack class-1-lesions are simple cysts; they do not require any further work-up. Bosniack class-2-lesions are minimally complicated but reliably benign cysts (thin wall, thin calcifications, thin septae). Some of these lesions require follow-up; and the majority of them do not. Class-3-lesions have thick septae, thick calcifications and thick and irregular walls, but not contrast enhancement. In most cases these lesions require surgical exploration for diagnosis and therapy. Bosniack class-4 lesions are clearly malignant; they are indicated by contrast enhancing regions within cysts. They always require surgery.

[Role of echography and phlebography in the assessment of patients with clinically suspected deep venous thrombosis of the legs]. / Ruolo dell'ecografia e della flebografia nella valutazione dei pazienti con sospetto clinico di trombosi venosa profonda degli arti inferiori.

The roles of US and venography in the evaluation of the patients with clinical suspicion of deep venous thrombosis are discussed relative to personal and literature data. The patients were divided into three groups: outpatients with previous history of venous thrombosis (group I), inpatients without previous history of venous thrombosis (group II) and patients with suspected recurrent venous thrombosis (group III). In group I, compression US yielded very good results: so much so that it can replace venography. In this group of patients, pulsed Doppler added no significant information, while color-Doppler appeared to be a valuable technique. As for the other two groups, venography was confirmed as the most useful technique, even though MR imaging is likely to play, in the future, an important role, since it allows better demonstration of the central thrombus, especially in diffuse occlusive thromboses.

Soft-tissue sarcomas: use of textural patterns in skeletal muscle as a diagnostic feature in postoperative MR imaging.

The authors assessed the value of tissue textural patterns as a diagnostic feature for differentiating nonspecific posttreatment tissue changes from musculoskeletal sarcoma recurrence on magnetic resonance (MR) images. The MR imaging studies of 40 patients who had previously undergone surgery and radiation therapy for soft-tissue sarcomas of the lower extremities were evaluated in a blind fashion. In 31 of the MR imaging studies, T2-weighted images demonstrated diffuse areas of high signal intensity in soft tissues at the operative region. Close examination of the corresponding regions on high-resolution transverse T1-weighted images demonstrated textural features typical of skeletal muscle in 23 patients and the absence of such features in eight. None of the 23 patients with the "texture sign" proved to have macroscopic tumor recurrence at clinical or surgical follow-up. Among the eight patients without recognizable textural features of muscle in the regions suspicious for tumor recurrence, two proved to have recurrent tumor at surgery. Recognition of a texture sign on high-resolution T1-weighted spin-echo images of regions suggestive of tumor recurrence helps improve the diagnostic specificity of follow-up MR examinations in patients who have undergone treatment for soft-tissue sarcomas.

[Diagnosis of deep venous thrombosis of the legs: accuracy of ultrasonography using vein compression]. / Diagnosi di trombosi venosa profonda degli arti inferiori: accuratezza dell'ecotomografia con compressione venosa.

We prospectively compared real-time US findings with venographic results in the legs of 171 consecutive outpatients with clinically suspected deep venous thrombosis (DVT). In each leg the common femoral and the popliteal veins were evaluated with venography and US. The two examinations were independently performed and reviewed. Vein compressibility (VC), intraluminal echogenicity and response to Valsalva maneuver were evaluated with US. Venography detected DVT in 54/171 legs. 10/54 legs had isolated distal DVT. With VC, US was 100% specific, 87% sensitive and 96% accurate. 6/7 false negative US studies were due to isolated distal DVT; therefore US sensitivity for proximal DVT was 98%. The other two US diagnostic criteria were much less accurate than VC. VC-US is an accurate, cheap and reproducible test for the detection of DVT in symptomatic outpatients.

[The side effects of phlebography of the lower extremities using iohexol. A prospective study]. / Effetti collaterali della flebografia degli arti inferiori con ioexolo. Studio prospettico.

In this prospective study 463 consecutive outpatients, who had undergone phlebography because of clinically suspected deep venous thrombosis (DVT) were examined with clinical follow-up and impedance plethysmography to evaluate the rate of contrast media complications. Seventy-nine patients had immediate and mild side effects, and one had moderate side effects (bronchospasm); no patient suffered from severe life-threatening conditions. There was only one case of DVT which occurred after an initially negative phlebography. In a subgroup of 40 patients, who underwent iodine-125-fibrinogen scanning after phlebography, the study was positive in 9 cases. None of them presented with any evidence of DVT at follow-up phlebography. Contrast phlebography with iohexol is a safe and comfortable procedure. Low-osmolality nonionic contrast media are well tolerated by the patient.

[High-resolution echography of the neck. Preoperative evaluation of lymph node metastases in patients with thyroid carcinoma]. / Ecografia ad alta risoluzione del collo. Valutazione preoperatoria delle metastasi linfonodali nei pazienti con carcinoma tiroideo.

Twenty-six patients with papillary and 4 with medullary thyroid carcinoma were examined by HRUS before surgery in order to evaluate its accuracy in detecting lymph node metastasis (N) of the neck from thyroid carcinoma. All patients underwent total thyroidectomy and nodal dissection. HRUS was accurate in 73% of cases in N staging, while clinical staging was accurate in 60% of cases only. In 50% of patients HRUS provided with interesting additional information, such as disclosing lymphadenopathy in 8 patients with no clinical evidence, proving nodal involvement in 5 cases, and showing extranodal extension in 5 cases. HRUS allowed the observation of anechoic necrotic areas and microcalcified nodes. On the other hand, according to our results, HRUS cannot either discriminate metastatic from benign nodal involvement, or identify mediastinal adenopathy. False negatives are possible due to micrometastatic areas in normal size nodes. Nevertheless, HRUS proved to be a valuable aid to complete clinical examination of the neck, and a good guide for the surgeon during nodal neck dissection.