Rethinking Tako-tsubo Cardiomyopathy: The Contribution of Myocardial Pathology and Molecular Imaging.

BACKGROUND: Despite substantial research, the mechanisms behind stress Tako-tsubo cardiomyopathy (TTC) remain rather elusive. OBJECTIVE: The purpose of this paper was to provide a detailed review of the mainstream factors underlying the pathophysiology of TTC, highlighting the novel contributions of molecular pathology and in-vivo molecular imaging. METHODS: A careful literature review selected all papers discussing TTC, specifically those providing novel insights from myocardial pathology and cardiac molecular imaging. RESULTS: Results concerning myocardial pathology, defect extension, sites and relationships between functional parameters underline the existence of a causal relationship between a determinant (e.g., the release of catecholamines induced by stress) and an outcome for TTC, which is not limited to a reversible contractile cardiomyopathy, but it includes reversible changes in myocardial perfusion and a long-lasting residual deficit in sympathetic function. Besides, they reinforce the hypothesis that sympathetic nerves may exert a complex control on cardiac contractile function, which is likely to be direct or indirect through metabolism and microvascular perfusion changes during anaerobic and aerobic conditions. CONCLUSION: TTC is characterized by acute transient left ventricular systolic dysfunction, which can be challenging to distinguish from myocardial infarction at presentation. Catecholamineinduced myocardial injury is the most established theory, but other factors, including myocardial metabolism and perfusion, should be considered of utmost importance. Each effort to clarify the numerous pathways and emerging abnormalities may provide novel approaches to treat the acute episode, avoid recurrences, and prevent major adverse cardiovascular events.

ACR TI-RADS Score combined with cytopathology classification improves the risk stratification of indeterminate thyroid nodules.

BACKGROUND: The aim of this retrospective study was the elaboration of a new diagnostic model that integrate cytological reports (2017 Bethesda System for Reporting Thyroid Cytopathology) with ultrasonographic features (based on ACR TI-RADS score) to achieve a more accurate definition of indeterminate thyroid nodule malignancy risk. METHODS: Ninety patients submitted to thyroidectomy were divided in three classes: low malignancy risk (AUS/FLUS with TI-RADS 2/TI-RADS 3 and FN/SFN with TI-RADS 2), intermediate malignancy risk (AUS/FLUS with TI-RADS 4/TI-RADS 5 and FN/SFN with TI-RADS 3/TI-RADS 4), and high malignancy risk (FN/SFN with TI-RADS 5). RESULTS: The surgical approach should be recommended in high-risk patients (81.82% of malignancies), carefully evaluated in intermediate risk (25.42%), whereas a conservative approach can be adopted in low-risk patients (0.00%). CONCLUSIONS: The integration of these two multiparametric systems in a Cyto-US score has proven to be a feasible and reliable aid to achieve a more accurate definition of malignancy risk.

The utility of intraoperative PTH dosage in primary hyperparathyroidism based on preoperative diagnosis and surgical choice.

BACKGROUND: The aim of this study was to evaluate the impact of the intraoperative PTH (ioPTH) monitoring in the success of parathyroidectomy based on the concordant or indeterminate preoperative imaging studies of localization and the performed surgical choices. METHODS: Fourthy-seven patients who received parathyroidectomy operations were divided in four groups: concordance of the imaging and ioPTH, concordance of the imaging and no ioPTH, indeterminate imaging and ioPTH and indeterminate imaging and no ioPTH. RESULTS: Overall, patients in whom ioPTH monitoring was not performed were healed in 89.47% of cases, while the percentage of recovery in patients receiving ioPTH was 85.71%. There were no differences in the changes in strategy or in the cure rates with the use of ioPTH. CONCLUSIONS: No significant differences were found, independently from the preoperative imaging agreement, in either the cure rate or in the change of intraoperative strategy using the ioPTH dosage.

Physical Educators' Perceptions and Experiences of Teaching Students With Mobility Disabilities.

Schools can support physical education (PE) among students with mobility disabilities (SMDs). However, previous research has indicated that people and resources in the school environment have served as facilitators and barriers to engaging SMDs in PE. Thus, the purpose of this pragmatic, qualitative study was to explore physical educators' perceptions and experiences of teaching SMDs to learn how to develop a PE environment supportive of SMDs. Eleven K-8 PE teachers who taught SMDs engaged in semistructured interviews. A thematic analysis revealed three themes describing facilitators and barriers of a supportive PE environment for SMDs: (a) teacher planning, (b) students in the PE environment, and (c) resources and support. These findings provide context to PE environments for SMDs and highlight a need for increased communication and collaboration with students with or without mobility disabilities, training or professional development for PE teachers to develop skills for adapted PE, and financial and personnel support.

Synthesis, Antiproliferative Activity, and DNA Binding Studies of Nucleoamino Acid-Containing Pt(II) Complexes.

We here report our studies on the reaction with the platinum(II) ion of a nucleoamino acid constituted by the l-2,3-diaminopropanoic acid linked to the thymine nucleobase through a methylenecarbonyl linker. The obtained new platinum complexes, characterized by spectroscopic and mass spectrometric techniques, were envisaged to exploit synergistic effects due to the presence of both the platinum center and the nucleoamino acid moiety. The latter can be potentially useful to protect the complexes from early deactivation, as well as to facilitate their cell internalization. The biological activity of the complexes in terms of antiproliferative effects was evaluated in vitro on different cancer cell lines and healthy cells, showing the best results on human cervical adenocarcinoma (HeLa) cells along with good selectivity for cancer over normal cells. In contrast, the metal-free nucleoamino acid did not show any cytotoxicity on both normal and cancer cell lines. Finally, the ability of the novel Pt(II) complexes to bind various DNA model systems was investigated by circular dichroism (CD) spectroscopy and polyacrylamide gel electrophoresis analyses proving that the newly obtained compounds can potentially target DNA, similarly to other well-known anticancer Pt complexes, with a peculiar G-quadruplex vs. duplex selectivity.

Radiofrequency Thermal Ablation of Benign Thyroid Nodules: The Correlation Between Ultrasound Nodule Characteristics and Results.

Background. The aim of this observational study was to investigate for which nodules a better response to radiofrequency thermoablation (RFA) for nonfunctioning benign thyroid nodules is likely. Methods. Aesthetic score, compressive score, and volume of 32 benign nodules from 32 patients were registered during follow-up at baseline, 1, 3, 6, and 12 months. Results. A volume reduction rate (VRR) of 72.56% at 12 months after the procedure (P = .009) was registered. A significant (P < .001) improvement in the compressive and aesthetic scores was observed. Nodules with a baseline volume <20 mL had VRRs at 3 and 6 months that were significantly greater than those with volume >20 mL (P = .037). Conclusions. RFA was shown to be a safe and effective procedure for the management of benign thyroid nodules and that there is a correlation between the initial size of the nodule and the response to treatment.

Intra-operative neurophysiological mapping and monitoring during brain tumour surgery in children: an update.

INTRODUCTION: Over the past decade, the reluctance to operate in eloquent brain areas has been reconsidered in the light of the advent of new peri-operative functional neuroimaging techniques and new evidence from neuro-oncology. To maximise tumour resection while minimising morbidity should be the goal of brain surgery in children as much as it is in adults, and preservation of brain functions is critical in the light of the increased survival and the expectations in terms of quality of life. DISCUSSION: Intra-operative neurophysiology is the gold standard to localise and preserve brain functions during surgery and is increasingly used in paediatric neurosurgery. Yet, the developing nervous system has peculiar characteristics in terms of anatomical and physiological maturation, and some technical aspects need to be tailored for its use in children, especially in infants. This paper will review the most recent advances in the field of intra-operative neurophysiology (ION) techniques during brain surgery, focussing on those aspects that are relevant to the paediatric neurosurgery practice.

"I'm thankful for being Native and my body is part of that": the body pride experiences of young Aboriginal women in Canada.

Body pride may be a predictor of health and well-being among Aboriginal youth. Body pride could potentially be addressed in health interventions, but it is critical to understand how body pride is conceptualized among Aboriginal youth. The purpose of this qualitative description study was to better understand the experiences of body pride among young Aboriginal women living in urban centers in Alberta, Canada. Eight young Aboriginal women (15-18 years old) participated in one-on-one interviews. A qualitative content analysis highlighted five themes that represent the participants' meanings of body pride. Participants described how body pride is: (a) accepting everything about your body, (b) who you are and how you show it, (c) connected to culture, (d) being healthy, and (e) being thankful to be Native. This research makes a contribution to the growing body pride literature by providing an initial glimpse into the complexities of young Aboriginal women's body pride experiences.

A systematic review and meta-analysis of total thyroidectomy versus bilateral subtotal thyroidectomy for Graves' disease.

BACKGROUND: Our aim was to perform a meta-analysis of high-quality published trials, randomized and observational, comparing total thyroidectomy (TT) and bilateral subtotal thyroidectomy (ST) for Graves' disease. METHODS: All studies published from 1970 to August 2012 were identified. All randomized controlled trials (RCTs) were included. Selection of high-quality, nonrandomized comparative studies (NRCTs) was based on a validated tool (Methodological Index for Nonrandomized Studies). Recurrent hyperthyroidism during follow-up, progression of ophthalmopathy, postoperative temporary and permanent hypoparathyroidism, and permanent recurrent laryngeal nerve (RLN) palsy were compared using odds ratios (ORs). RESULTS: Twenty-three studies were included (4 RCTs and 19 NRCTs) compromising 3,242 patients (1,665 TT, 1,577 ST). TT was associated with a decrease in recurrent hyperthyroidism (P < .00001; OR, 0.10; 95% confidence interval [CI], 0.06-0.18), but with an increase in both temporary (P < .00001; OR, 2.70; 95% CI, 2.04-3.56) and permanent hypoparathyroidism (P = .005; OR, 2.91; 95% CI, 1.59-5.32). Progression of ophthalmopathy (P = .76; OR, 0.90; 95% CI, 0.48-1.71) and permanent RLN palsy (P = .82; OR, 0.91; 95% CI, 0.41-2.02) were similar. CONCLUSION: TT offers a better chance of cure of hyperthyroidism than bilateral ST and can be accomplished safely with only a small increase in temporary and permanent hypoparathyroidism.

Intraoperative neurophysiological monitoring during surgery for Chiari malformations.

Reports on the use of intraoperative neurophysiological monitoring (INM) techniques during surgery for Chiari malformations are anecdotal. There are almost no data on significant intraoperative worsening in either somatosensory-evoked potentials (SEPs) or brainstem auditory-evoked potentials (BAEPs) during surgery that would have alerted the surgeon to modify the surgical strategy. Yet, a few reports suggest that INM may play a role in preventing spinal cord injury during positioning of the patient. Overall, the use of INM in this type of surgery can be considered only as an option. More speculatively, INM adds information to the ongoing discussion on the most appropriate surgical technique for posterior fossa decompression in Chiari malformations. This debate applies especially to children where a more conservative approach is advisable to reduce the complications. Studies on the conduction time of BAEPs provide some evidence that, from a merely neurophysiological perspective, most of the improvement occurs after bony decompression and removal of the dural band at the level of the atlanto-occipital membrane, not after duraplasty.

Feasibility of an accurate assessment of myocardial salvage by comparing functional and perfusion abnormalities in post-reperfusion gated SPECT.

BACKGROUND: Because of persistent stunning, post-treatment functional abnormalities could identify the initial risk area. The study aims to detect myocardial salvage using post-revascularization gated SPECT in acute myocardial infarction (AMI) treated by reperfusion therapy. METHODS: In 36 AMI patients, we performed a first gated SPECT injecting (99m)Tc-sestamibi before primary percutaneous coronary intervention (PCI), and a second 5 days later. The salvage index defined by the two perfusion images was compared with the value obtained by subtracting in the second gated SPECT the extent of perfusion defect from the extent of wall thickening abnormalities. RESULTS: The wall thickening salvage index correlated with the reference perfusion salvage index (Spearman's ρ = .92, P < .0001), with a 95% limit of agreement = ±.25. The agreement between the classifications in salvage index tertiles of the reference and of the wall thickening salvage index was good (kappa = .75). All patients with optimal PCI result and 18/24 of those with intermediate or poor outcome were correctly classified. CONCLUSIONS: Comparing function and perfusion in a single post-PCI (99m)Tc-sestamibi gated SPECT it is possible to estimate myocardial salvage. This could have useful implications in studies comparing different treatment strategies for AMI.

Prognostic value of combined perfusion and function by stress technetium-99m sestamibi gated SPECT myocardial perfusion imaging in patients with suspected or known coronary artery disease.

The incremental prognostic value of combined regional wall motion and perfusion over perfusion alone by gated single-photon emission computed tomographic myocardial perfusion scintigraphy has not been evaluated. Of the 402 consecutive patients who underwent stress single-photon emission computed tomographic myocardial perfusion scintigraphy for suspected myocardial ischemia, we identified 333 patients (217 men, mean age 63 +/- 10 years; exercise in 249 and dipyridamole adminstered to 84). Visual scoring of perfusion images and regional wall motion used 20 segments and a scale of 0 to 4. Resting and poststress left ventricular ejection fraction was automatically generated. On follow-up (median 13 months), 30 hard cardiac events (17 cardiac deaths, 13 nonfatal acute myocardial infarctions) and 66 total cardiac events (including hard events, 26 with unstable angina, and 10 who underwent late revascularization) occurred. After adjustment for prescan information, the best independent predictors of hard events were summed stress score for wall motion (Wald's chi-square 8.3, p <0.004) and several vascular territories with ischemia by perfusion/function (Wald's chi-square 6.2, p <0.01). The strongest predictors of all cardiac events were the number of ischemias (Wald's chi-square 32.1, p <0.0001) and the number of ischemic vascular territories by perfusion (Wald's chi-square 13.1, p <0.0001). Addition of function data to the combined model of perfusion data yielded an incremental value of 26% for predicting hard events but not for all events. In conclusion, the assessment of combined perfusion/function provides incremental prognostic information for further hard events with perfusion data alone; perfusion data best predict all cardiac events.

Can the reversible regional wall motion abnormalities on stress gated Tc-99m sestamibi SPECT predict a future cardiac event?

BACKGROUND: Myocardial stunning has recently been demonstrated by use of stress gated technetium 99m sestamibi single photon emission computed tomography (SPECT) myocardial perfusion scintigraphy. However, its prognostic value is less well determined. The aim of this study was to investigate the prognostic value of reversible regional wall motion abnormalities (RWMAs). METHODS AND RESULTS: We studied 303 consecutive subjects with known or suspected coronary artery disease who underwent 2-day stress-rest gated Tc-99m sestamibi SPECT and were followed up for 19 +/- 16 months. Clinical and test-derived variables were evaluated to predict cardiac death, nonfatal myocardial infarction (MI), unstable angina, and early or late coronary revascularization. Reversible RWMAs were identified in 102 patients. On Cox analysis, the presence, site, degree, and extent of reversible RWMAs did not identify an adverse outcome, except in patients without prior MI. After adjustment for prescan data, the strongest predictors of hard events and all cardiac events were poststress RWMAs and the amount of ischemia. The addition of poststress RWMAs to the combined model of prescan and perfusion data yielded incremental prognostic value. CONCLUSION: Poststress RWMAs and ischemia by perfusion were the most powerful predictive parameters of cardiac events. However, myocardial stunning should always be considered, particularly in patients without prior MI and in the referral of patients for early revascularization.