Prevalence of Polysubstance Abuse and Dual Diagnosis in Patients Admitted to Alcohol Rehabilitation Units for Alcohol-Related Problems in Italy: Changes in 15 Years.

AIMS: Alcohol abuse has long been known as a disease with social and economic burden to society. Given the complex nature of alcohol treatment, it is worthwhile to examine the change over time of patients admitted to residential alcohol abuse rehabilitation units. METHODS: The data were collected from two Italian projects on alcoholics performed in the mid-1990s (ASSALT) and in 2009 (CORRAL), respectively. Categorical variables were considered in terms of absolute and relative frequencies. Comparisons of relative frequencies between groups were assessed by means of Fisher's exact test. Mixed logistic regression models were fitted to CORRAL data to identify the predictors of the probability of being a polysubstance abuser or having a dual diagnosis. The association estimates were reported as adjusted odds ratios and relative 95% confidence intervals. RESULTS: Compared to the mid-1990s, in 2009 patients were older (P= 0.0003), with a higher level of education (P= 0.0204), with fewer comorbidities (liver disease except cirrhosis, P < 0.0001; polyneuropathy, P= 0.0001), more frequently polysubstance abusers (P < 0.0001), affected by dual diagnosis (P < 0.0001). In 2009, the probability of being a polysubstance abuser was higher in younger and in patients with dual psychiatric diagnosis. Female gender and polysubstance abuse were positively associated to the probability of being affected by dual psychiatric diagnosis. CONCLUSIONS: The increment of patients admitted to residential programs for alcohol dependence with polysubstance abuse and/or dual psychiatric diagnoses suggests the need to pay more attention to both psychological/psychiatric interventions and internal medicine/physical rehabilitation. SHORT SUMMARY: The results of this study suggest that further research is needed to identify the best treatment strategy that is safe and effective for the new population of alcoholics.

[Alcohol-addiction inpatient: characteristics of patients and rehabilitation program]. / La residenzialità alcologica ospedaliera: caratteristiche dei pazienti e dei percorsi terapeutici/riabilitativi.

AIM: The treatment of alcohol addiction in Italy has had a progressive evolution of therapeutic structures for in-and outpatients. During the last 20 years there had been a crescent presence of short residential treatment facilities (1-6 months) characterized by a high level of medical and psychotherapeutic intervention. About two years ago 12 of them jointed together in an association called CORRAL (COordinamento of Residenzialità Riabilitive Alcologiche). The aim of this study was to describe the socio-demographic medical and other characteristics of the patients coming for this type of treatment and to describe the characteristics of the residential treatment itself including referring and aftercare. METHODS: Two thousand sixty-one hospitalized patients of the 12 rehabilitative alcohol units were examined by using a questionnaire and collecting various sociodemographic variables and clinical diagnosis of the patients. Even it was asked who had referred the patients, the characteristics of the residential treatment and of the planned aftercare. RESULTS: The present residential facilities are mainly distributed in the North of Italy. The typical patient is male, with a high school instruction and with a comorbidity regarding psychiatric and liver disorders. The majority of the patients were referred by the public ambulatory services for addictions (SerT/SerD). The characteristics of the residential treatment were medical, pharmacological and psychotherapeutic interventions with a high intensity and the presence of a general-purpose staff. CONCLUSIONS: This study outlined a model of residential rehabilitation of alcohol disorders characterized by short duration and a complex, intense therapeutic intervention mainly addressed to patients with a severe clinical condition and a low level of social problems. Further research should be useful to understand better which sort of patient characteristics obtain a better clinical result and for that even economically a major effectiveness from this type of residential treatment.

Is it worthwhile using a transcutaneous bilirubinometer in the nursery?

Jaundice is a potential threat to neonatal health and/or life. The advantages and limitations of transcutaneous determination of bilirubin concentration and current devices are briefly discussed in this paper.

Pleomorphic adenoma of parotid gland: delayed enhancement on computed tomography.

OBJECTIVES: To assess the efficacy of multiphasic CT with 8 min delayed acquisition in the differential diagnosis between pleomorphic adenomas and other parotid neoplasias. METHODS: Between January 2004 and April 2007, 62 patients with parotid enlargement were enrolled in this prospective study. The CT protocol applied included the following four acquisitions: without contrast medium and 30 s, 120 s and 8 min after intravenous injection of contrast medium. We considered the degree of the enhancement of the lesions (rated as "low", "moderate" and "strong") and the degree of enhancement homogeneity (rated as "not homogeneous", "mildly homogeneous" and "uniform"). These parameters were compared with Hounsfield values of the lesions computed in each phase. The diagnosis was confirmed in all patients after surgery. RESULTS: On histological examination, 36 tumours were classified as pleomorphic adenomas and 26 as non-pleomorphic adenomas. On the basis of a statistical comparison, the third phase proved to be the most effective in the differential diagnosis between pleomorphic adenoma and non-pleomorphic adenomas, both for the assessment of the degree of the enhancement (in this phase, strong enhancement showed a sensitivity of 61.11%, specificity of 100%, positive predictive value (PPV) of 100% and negative predictive value (NPV) of 53.33%) and, above all, for the homogeneity of the enhancement (in this phase, indeed, uniform enhancement showed sensitivity, specificity, PPV and NPV of 100%). CONCLUSIONS: Our results seem to indicate that multiphasic CT with 8 min delayed acquisition allows the differential diagnosis between pleomorphic adenomas and other parotid neoplasias.

MAGIC-5: an Italian mammographic database of digitised images for research.

The implementation of a database of digitised mammograms is discussed. The digitised images were collected beginning in 1999 by a community of physicists in collaboration with radiologists in several Italian hospitals as a first step in developing and implementing a computer-aided detection (CAD) system. All 3,369 mammograms were collected from 967 patients and classified according to lesion type and morphology, breast tissue and pathology type. A dedicated graphical user interface was developed to visualise and process mammograms to support the medical diagnosis directly on a high-resolution screen. The database has been the starting point for developing other medical imaging applications, such as a breast CAD, currently being upgraded and optimised for use in a distributed environment with grid services, in the framework of the Instituto Nazionale di Fisicia Nucleare (INFN)-funded Medical Applications on a Grid Infrastructure Connection (MAGIC)-5 project.

A study on two different CAD systems for mammography as an aid to radiological diagnosis in the search of microcalcification clusters.

OBJECTIVE: The aim of the present study was to evaluate the efficacy of two different computer aided detection (CAD) systems for mammography in improving radiological diagnosis in the search of microcalcification clusters. The CAD systems used are: the SecondLooktrade mark (CADx Medical Systems, Canada) commercial system and the CALMA (computer assisted library in MAmmography) research CAD system. Three radiologists were asked to read mammographic images with and without the support of the CAD systems. MATERIAL AND METHODS: Three radiologists with respectively 3, 5 and 7 years of practice in mammogram reading in an Italian public hospital analysed a dataset composed of 120 digitized mammograms of healthy subjects with no lesion (proven by a radiological follow up of at least 3 years) and 70 images of patients with malignant cluster of microcalcification (proven by histopathological examination) both with no CAD support as well as with the help of the SecondLooktrade mark system. After 3 months they were asked to observe the same digitized mammograms with the assistance of the CALMA system. The radiologists worked independently and were unaware of the final diagnosis. The values of the area A(z) under the ROC curve, diagnostic sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy were evaluated with and without the support of the CAD systems. The reading time and qualitative evaluations of each radiologist were also reported. RESULTS: With the support of the two CAD systems an improvement in A(z) area was obtained ranging from 0.01 to 0.04. Sensitivity increased from +8.6 to +15.7% and specificity decreased from 0.8 to 4.2%. CONCLUSION: In our study, not conditioned by the dataset, the CAD systems as second reader produced an increase in overall sensitivity of up to 15.7%, with a little decrease in specificity of up to 4.2%. Based on these results both CAD systems might be used in the current practise to improve the sensitivity values of conventional reading (radiologist alone). The results of this study show that no significant differences exist in term of A(z), sensitivity and specificity between CALMA and CADx.

Sentinel lymph node identification in breast cancer patients.

PURPOSE: To evaluate the predictive value of sentinel lymph node biopsy versus axillary node dissection on lymph node status in patients with T1-T2 breast cancer. MATERIAL AND METHODS: Twenty-nine patients with T1 and 12 with T2 breast carcinoma and clinically N0 axillary lymph nodes, underwent lymphoscintigraphy following the administration of 99mTc-human albumin nanocolloids. The tracer was injected subdermally, over the tumor mass, in the 34 patients with palpable lesions and peritumorally (n=3) or intratumorally (n=4), under stereotactic or ultrasound guidance, in the 7 patients with non-palpable lesions. Anterior and lateral planar images were acquired 15 min after the injection of the tracer and repeated every 30 min up to 3 hr until identification of sentinel lymph node. At the end of the scintigraphic study, sentinel node skin projection was marked using a dermographic pen. Eighteen hours after lymphoscintigraphy, sentinel lymph node was identified and removed during surgery by hand-held gamma probe, then, the remaining axillary lymph nodes were dissected. All surgical specimens underwent histologic examination. Sentinel lymph nodes free of metastasis at histology, underwent additional examination with immunohistochemistry using monoclonal antibodies against cytokeratin and EMA to search for micrometastases. RESULTS: Sentinel lymph node was identified in the 34 patients injected subdermally and in the 3 patients injected peritumorally, while it remained undetected in the 4 patients injected intratumorally except for one case in which it was isolated by radioguided surgery but not scintigraphically. Sentinel nodes resulted free of metastases both at histology and immunohistochemistry in 32 cases and metastatic in 6. In the 32 patients with non-metastatic sentinel lymph nodes the other axillary nodes were also free of metastases. Among the 6 metastatic sentinel lymph nodes, in 3 cases they were the only metastatic nodes of the axilla while in the other 3 cases metastases were spread to other axillary nodes. CONCLUSIONS: In agreement with previous studies, our results showed that sentinel lymph node radioguided biopsy is a simple and reliable method for predicting axillary lymph nodes status and for avoiding axillary dissection in early breast cancer patients with sentinel node free of metastases.

Transabdominal sonography of the normal gastroesophageal junction in children.

PURPOSE: Because sonography identifies abnormalities of the gastroesophageal junction, it is essential to understand the normal sonographic anatomy. The aim of this study was to determine the normal sonographic appearance of the gastroesophageal junction and its variations and to provide measurements of the abdominal esophagus in asymptomatic, healthy children. METHODS: In this prospective study, 124 healthy children (75 boys and 49 girls), aged 2 days-12 years, underwent abdominal sonography. With the patient in a supine position, the transducer was placed under the xiphoid and the ultrasound beam was directed cephalad through the window of the left lobe of the liver. The length of the abdominal esophagus was measured from the point at which it penetrated the diaphragm to the gastroesophageal junction. The thickness was measured on the anterior wall at the midpoint of the abdominal esophagus. RESULTS: The gastroesophageal junction was identified by sonography in all of the children. The mean length of the abdominal portion of the esophagus ranged from 18 mm in the newborns to 34 mm in children older than 6 years. The wall thickness ranged from 2.4 mm to 5.7 mm. CONCLUSIONS: Our results indicate that visualization of the gastroesophageal junction and measurement of the abdominal esophagus are readily achievable with real-time sonography in healthy children.

Scintimammography with 99mTc-MIBI versus dynamic MRI for non-invasive characterization of breast masses.

Although mammography remains the technique of choice for the early detection of breast cancer, several imaging techniques, including scintimammography and magnetic resonance imaging (MRI), have recently been proposed as adjuncts for this purpose and included in many diagnostic protocols. This study was undertaken to assess the clinical accuracy of scintimammography with technetium-99m methoxyisobutylisonitrile (MIBI) and contrast-enhanced MRI in the detection of primary breast carcinoma in patients with equivocal mammographic findings. Forty-nine patients with a suspicious breast mass detected either by physical examination or by mammography and ultrasound (US) were studied. All patients underwent scintimammography and dynamic contrast-enhanced MRI 1 week apart. The results of the two techniques were compared and correlated to the final diagnoses. Two independent readers reported the scans using a four-point confidence scale. The areas under the receiver operator characteristic (ROC) curves were obtained. Scintimammography showed an accuracy for tumour detection of 84%, with a sensitivity of 80% and a specificity of 88%. MRI showed an accuracy of 86%, with a sensitivity and specificity of 96% and 75%, respectively. Comparison of the two areas under the ROC curves showed no significant differences between MRI, 0.91+/-0.05 (mean+/-SD), and scintimammography, 0.88+/-0.05 (P=0.9). It is concluded that dynamic MRI and scintimammography possess comparable accuracy in the diagnosis of primary breast carcinoma in patients with equivocal mammographic or US findings.

Hernia of foramen of Morgagni in adult: case report of laparoscopic repair.

The videolaparoscopic repair of a diaphragmatic hernia of Morgagni by external knot tying technique is described. A 69-year-old woman with subocclusive symptoms by intrathoracic migration of abdominal viscera had an immediate and complete postoperative recovery. The hernial sac was not excised. A four-year follow-up shows no hernia recurrence. This case indicated that the laparoscopic approach can be considered a suitable and safe procedure for treatment of Morgagni's hernia.

Measurement of global brain atrophy in Alzheimer's disease with unsupervised segmentation of spin-echo MRI studies.

In 16 patients with probable Alzheimer's disease (AD; NINDS criteria, age range 56-78 years), gray matter (GM), white matter (WM), and cerebrospinal fluid (CSF) absolute and fractional volumes were measured with an unsupervised multiparametric post-processing segmentation method based on estimates of relaxation rates R1, R2 (R1 = 1/T1; R2 = 1/T2) and proton density [N(H)] from conventional spin-echo studies (Alfano et al. Magn. Reson. Med. 1997;37:84-93). Global brain atrophy, and GM and WM fractions significantly correlated with Mini-Mental Status Examination and Blessed Dementia Scale scores. Compared with normals, brain compartments in AD patients showed decreased GM (-6.84 +/- 1.58%) and WM fractions (-9.79 +/- 2.47%) and increased CSF fractions (+58.80 +/- 10.37%). Changes were more evident in early-onset AD patients. In AD, measurement of global brain atrophy obtained by a computerized procedure based on routine magnetic resonance studies could complement the information provided by neuropsychological tests for the assessment of disease severity.

[Heart tomography with 99mTc sestamibi and echocardiography with dobutamine in the identification of reversible left ventricular dysfunction in patients with acute myocardial infarction]. / Tomografia cardiaca con 99mTc sestamibi ed ecocardiografia con dobutamina nell'identificazione della disfunzione ventricolare sinistra reversibile nei pazienti con infarto acuto del miocardio.

INTRODUCTION: We investigated the role of technetium-99m (99mTc) sestamibi cardiac imaging and dobutamine echocardiography in detecting myocardial viability early after acute myocardial infarction. MATERIAL AND METHODS: Nineteen patients (mean age 52 +/- 10 years) underwent coronary angiography, low-dose dobutamine echocardiography and rest 99mTc sestamibi imaging within 10 days of myocardial infarction. All patients were revascularized. Resting echocardiogram was repeated 8 months later to evaluate segmental functional recovery. RESULTS: Sixty-one of 108 akinetic or dyskinetic segments at baseline showed functional recovery after revascularization. Sensitivity in predicting segmental functional recovery was 87% for sestamibi imaging and 66% for dobutamine echocardiography (p < 0.001), while specificity and accuracy were comparable. Sestamibi activity was the strongest predictor of segmental functional recovery (p < 0.001). CONCLUSIONS: Dobutamine echocardiography predicts functional recovery after myocardial infarction. However, sestamibi imaging is useful to identify patients with dysfunctional segments without contractile reserve which may benefit by revascularization.

[Computerized tomography-guided drainage of postoperative abdominal fluid collections]. / Drenaggio guidato con tomografia computerizzata delle raccolte addominali post-operatorie.

INTRODUCTION: We report our personal technique and the results of CT-guided percutaneous drainage of postoperative abdominal fluid collections. MATERIAL AND METHODS: January 1990 to March 1998, eighty-three patients were treated for postoperative abdominal fluid collections. Forty-eight patients had undergone bowel resection, 11 laparoscopic cholecystectomy, 3 cholecystectomy, 5 splenectomy, 3 cephalopancreasectomy, 6 hepaticojejunal anastomosis, 4 hepatic resection, 2 laparocele, 1 hysterectomy. The complications had developed few days to about one year postoperatively. The suspicion of abdominal fluid collection was supported by clinical and laboratory findings. All patients were submitted to a preliminary CT scan to locate the fluid collection, assess its morphology and relationships with surrounding structures, and plan the safest access route. After local anesthesia, a trial fine needle (Chiba 20-22 G) aspiration was performed and then the draining tube was inserted into the collection under CT guidance; the tube caliber depended on the fluid amount and viscosity. After drainage, the tube was removed if CT showed complete resolution of the fluid collection; otherwise it was left in place for subsequent washing of the cavity. Based on clinical, laboratory and CT findings, another CT-guided percutaneous drainage was judged necessary in 30 patients, 2-9 days after the first one. Drainage was considered successful when sepsis resolved and no further percutaneous/surgical drainages were needed. RESULTS: CT-guided percutaneous drainage was successful in 61 of 83 patients (73.5%); the fluid collection resolved after one drainage in 26/61 patients, in 2-9 days in 18/61, and after a second CT-guided drainage in 17/61. Drainage was not resolutive in 22 of 83 patients, because major postoperative complications required laparotomic surgery; these complications were fistulas (anastomotic in 12 cases; pancreatic in 5 and biliary in 3) and segmentary bowel necrosis in 2 cases. Intracavitary bleeding as a catheter-related complication occurred only in one patient with an anterior abdominal wall abscess. CONCLUSIONS: CT-guided percutaneous drainage offers many advantages over surgery: it is less invasive, can be repeated and requires no anesthesia; there are no surgery-related risks and lower morbidity and mortality rates. Moreover, subsequent hospitalization is shorter and costs are consequently reduced. We conclude that CT-guided percutaneous drainage is the method of choice in the treatment of postoperative abdominal fluid collections.

Neurological deficit following spinal anaesthesia: MRI and CT evidence of spinal cord gas embolism.

A 62-year-old diabetic woman developed permanent neurological deficits in the legs following spinal anaesthesia. MRI showed oedema in the spinal cord and a small intramedullary focus of signal void at the T10 level, with negative density at CT. Intramedullary gas bubbles have not been reported previously among the possible neurological complications of spinal anaesthesia; a combined ischaemic/embolic mechanism is hypothesised.

[Computerized tomography and magnetic resonance in the study of retroperitoneal sarcomas]. / Tomografia Computerizzata e Risonanza Magnetica nello studio dei sarcomi retroperitoneali.

PURPOSE: We investigated the yield of CT and MRI in the diagnosis and staging of 15 patients with retroperitoneal sarcomas; these lesions are often asymptomatic and need radical surgery to avoid local recurrences. MATERIAL AND METHODS: April 1993, to September 1997, fifteen patients with retroperitoneal sarcomas were examined and then operated on. CT and CT-guided FNAB were always performed, while MRI was performed in 8 patients only. Because of the high risk of sampling errors, the bioptic specimens were immediately evaluated by a pathologist: a second sampling was required in 10 cases and a third sampling in 6 cases. MRI was performed with a .5 T system (GE Vectra); T1- and T2-weighted transverse images of the abdomen were acquired in all patients and additional coronal and sagittal images were acquired for each abnormal region. All patients underwent surgery and the pathologic diagnosis was compared with CT and MR findings. RESULTS: CT always allowed accurate location of the lesions and identification of their components, especially fat deposits. The cytologic examination of FNAB samples allowed the diagnosis of sarcoma in 12 of 15 cases. CT results were compared with MR findings in 8 patients and the latter method had better spatial definition of the abdominal masses, particularly of vascular structures, which is important for surgical planning. DISCUSSION: The present-day imaging techniques are very important to plan the surgical treatment of retroperitoneal sarcomas. In particular, CT has the advantage of high spatial resolution and excellent tissue contrast from abundant retroperitoneal fat tissue; it also permits the cytologic sampling of viable tumor tissue. However the bulk of such lesions often prevents CT from determining the tumor origin, in which case MRI provides better spatial resolution and vascular detailing, which helps surgical planning. CONCLUSIONS: Both CT and MRI are major tools in the diagnosis and staging of retroperitoneal sarcomas because they can accurately define the borders of large tumors and their relationships with surrounding organs. MRI has the advantage of characterizing the blood supply to the mass, but CT is better to guide FNAB.