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Background: Lung ultrasound (US) proved useful in patients with COVID-19, but limited data are available about its use in affected children. Aim: Lung ultrasound (US) is in the front door in the assessment of patients with coronavirus disease 19 (COVID-19), but limited data are available about its use in affected children. We aimed to describe lung US features and discuss its potential applications in COVID-19 children considering the usually mild disease course. Methods: We performed lung US to children with COVID-19 admitted between March 1st and April 27th, 2020. Clinical and radiological data were collected. One or more subsequent lung US were obtained from all subjects. Results: A series of 13 confirmed COVID-19 children were recruited. 8/13 patients showed signs of respiratory interstitial syndrome as for focal or coalescent B-lines or white lung, also in the absence of relevant clinical symptoms. Conclusions: As clinical characteristics of pediatric COVID-19 differ from adults, it is of interest to determine whether pediatric lung US shares the same imaging pattern of adults and whether COVID-19 pneumonia may differ from other virus pneumonia. Our small series highlighted that lung US documented signs of interstitial pneumonia in paucisymptomatic or asymptomatic pediatric patients. In conclusion, we pinpoint the usefulness of point of care lung US for the evaluation of infected children correlated with clinical information.

Protein-losing enteropathy (PLE) is a rare condition characterized by protein loss through the gastrointestinal tract, leading to hypo-proteinemia. Patients may be asymptomatic or present with variety of complications of hypoproteinemia (e.g., oedema, ascites, pleural, and cardial effusions). We describe a case report of a young girl suffering from behavioral disorder since childhood who presented with generalized oedema, hypoproteinaemia, and microcytic hypochromic anemia. In addition, the girl had an intervention for jejunal atresia and intestinal malrotation in her past medical history. Upper gastrointestinal endoscopy revealed a trichobezoar extending from stomach into the small bowel, thus classified as Rapunzel Syndrome (RS), causing mechanical obstruction of intestinal lumen and intestinal lymphatic drainage resulting in a protein-losing enteropathy (PLE). Trichobezoar was successfully removed by a surgical laparotomy resulting in resolution of symptoms and normalization of biochemical parameters. Possibly, previous surgery might have had an influence on intestinal dysmotility and trichobezoar formation. PLE is a very rare presenting symptom of RS, developing as result of intestinal obstruction caused by large trichobezoars. RS has to be considered in patients, especially adolescents, suffering from behavior disorder as trichotillomania and trichophagia. Surgical removal and nutritional supplementation are the gold treatment of large trichobezoar.

Background Primary meningococcal arthritis is a rare infectious disease that occurs in less than 3% of meningococcal infections and is characterized by arthritis without meningitis, fever, rash, or hemodynamic instability Barahona [Case Rep Orthop 4696014:2017 ]. There are no validated clinical criteria that can be used for the diagnosis. We present two pediatric cases of atypical presentation of meningococcal disease revealed by molecular tests. Case presentation The clinical presentation of the two children (6- and 9-years-old) was characterized by signs of arthritis. By Real Time Polymerase Chain Reaction (RT-PCR), we identified N. meningitidis serogroup Y in the joint fluid in both cases. After specific antimicrobial treatment, the clinical conditions of the two patients quickly improved during hospitalization. Conclusions. We believe that the incidence of meningococcal arthritis could be underestimated in those settings where the use of RT-PCR is limited. Clearer data on the incidence of meningococcal disease would help to design specific treatments and the best possible national vaccine strategies [Fiji Sci Rep 23:39784, 2016, J Infect 67:385-90, 2013].

IntroductionLimited data exist on epidemiology, clinical presentation and management of acute hyperkinetic movement disorders (AHMD) in paediatric emergency departments (pED).MethodsWe retrospectively analysed a case series of 256 children (aged 2 months to 17 years) presenting with AHMD to the pEDs of six Italian tertiary care hospitals over a 2-year period (January 2012 to December 2013).ResultsThe most common type of AHMD was tics (44.5%), followed by tremors (21.1%), chorea (13.7%), dystonia (10.2%), myoclonus (6.3%) and stereotypies (4.3%). Neuropsychiatric disorders (including tic disorders, psychogenic movement disorders and idiopathic stereotypies) were the most represented cause (51.2%). Inflammatory conditions (infectious and immune-mediated neurological disorders) accounted for 17.6% of the cases whereas non-inflammatory disorders (including drug-induced AHMDs, genetic/metabolic diseases, paroxysmal non-epileptic movements and idiopathic AHMDs) accounted for 31.2%. Neuropsychiatric disorders prevailed among preschoolers and schoolers (51.9% and 25.2%, respectively), non-inflammatory disorders were more frequent in infants and toddlers (63.8%), whereas inflammatory conditions were more often encountered among schoolers (73.3%). In 5 out of 36 Sydenham’s chorea (SC) cases, tics were the presentation symptom on admission to emergency department (ED), highlighting the difficulties in early diagnosis of SC. Inflammatory disorders were associated with a longer hospital stay and a greater need of neuroimaging test compared with other disorders.ConclusionsThis study provides the first large sample of paediatric patients presenting to the ED for AHMDs, helping to elucidate the epidemiology, aetiology and clinical presentation of these disorders.

The near-miraculous discovery of the X-ray by Wilhelm Roentgen in 1895 (University of Wurzburg-Bavaris n.d.) was coincidentally coupled with the most recent developments in rapid long-distance communication abilities. Those simultaneous discoveries made it quickly possible to propel forth a new discipline of research into the possible applications of this new radiation breakthrough. From the outset, radiation was thought to be not only an important diagnostic tool—evaluating fractures without the then standard-of-care painful manipulations—but also as a possible therapeutic option, especially for cancer. Following Emil Grubbe’s discovery that radiation exposure adversely affected cancerous growths (Grubbe 1903), the medical world became almost immediately excited that a new therapy option could become a surgical accessory, if not an alternative, for the treatment of cancers. There were big questions to answer: What to treat, who to treat, and how to treat? The intent of this book focuses on the latter question since at this point within the modern era of radiation therapy, there is little doubt in the therapeutic advantages of radiation, especially for the curative and conservation techniques (Chou et al. 2001).

Synovial sarcoma (SS) is the most common nonrhabdomyosarcomatous soft tissue sarcoma in childhood, but the head-neck site accounts for less than 5% of cases. The authors report a 10-year-old boy with SYT-SSX1 positive left parapharyngeal SS, resistant to front-line VAIA chemotherapy, who obtained a good partial response by salvage regimen (I(3)VE + CEV + I(3)VE) and local radiotherapy, so a complete surgical resection could be performed. The complete remission was subsequently consolidated by ablative high-dose chemotherapy, followed by autologous stem cell reinfusion. The child remains in complete remission at 36 months after completion of treatment.

Purpose Many studies confirmed the evidence of a dose-response relationship in prostate cancer. Escalation of dose using conventional techniques is however limited by rectal tolerance. IMRT and 3D-CRT have been designed to allow dose escalation while not exceeding rectal tolerance. We evaluated the acute and early late tolerance to surrounding organs upon dose escalation from 70 to 78 Gy in 3D-CRT setting, in order to introduce the IMRT process as a routine practice in prostate cancer treatment. Materials and Methods We compared clinical data from 35 patients with localized adenocarcinoma of the prostate, who received 70 Gy within a traditional reconstructed three-dimensional treatment planning, and data from 72 patients who received 78 Gy within a three-dimensional conformal setting. In order to respect rectal tolerance in the higher dose group, limits were set for rectum doses, and simulation procedures were standardized. We evaluated radiation morbidity (acute and late gastrointestinal and genitourinary toxicity) using the Radiation Therapy Oncology Group scoring criteria (RTOG scale). Results Increasing doses from 70 Gy to 78 Gy resulted in no significant difference for acute and late effects. Conclusion A procedural standardization aiming at minimizing day-by-day variation, as well as a more consistent dose distribution to critical organs may significantly reduce the risk of increased toxicity in dose-escalation setting.

Background and purpose Oropharyngeal mycosis (OPM) is a complication of radiotherapy (RT) treatments for head and neck (H&N) cancer, worsening mucositis and dysphagia, causing treatment interruptions and increasing overall treatment time. Prophylaxis with antifungals is expensive. Better patient selection through the analysis of prognostic factors should improve treatment efficacy and reduce costs. Materials and methods A multicentre, prospective, controlled longitudinal study, with ethics committee approval, examined H&N cancer patients who were candidates for curative treatments with radio-chemotherapy. Patients were divided in groups according to OPM appearance: before the starting of RT (cases), during RT (new cases) and never (no cases). Results Of 410 evaluable patients, 20 were existing cases, 201 new cases and 189 did not report OPM. In our study OPM appears in 42.4% of people >70years and in 58.2% of younger individuals ( p =0.0042), and in 68.6% of women versus 50.8% of men ( p =0.0069). Mucositis and dysphagia were higher and salivation reduced among people with OPM ( p p =0.0002) and longer (>12days) treatment interruptions ( p =0.0288). Conclusions Patients with OPM had higher toxicity and a greater number of long treatment interruptions. Analyses of prognostic factors can help clinicians understand OPM distribution and select patients with the highest probability of OPM for antifungal prophylaxis.

With the discovery of radium by Curie in 1898, researchers recognized that this unique radionuclide had specific biologic properties that were applicable to treating patients with cancer. In the beginning, the radium sources were placed within cavities as independent sources and, when needles were available, implanted into tissues. The first combination of brachytherapy technologies with external-beam radiation therapy was reported by Wright at the Memorial Sloan-Kettering Cancer Center in New York in 1914 in the treatment of a patient with cervical cancer. Next, there was a rapid implementation of brachytherapy in the treatment of cancer by intracavitary placement of radionuclides, interstitial implantation technologies, and systemic administrations. With the development of new radionuclides, including cesium-137, cobalt-60, iridium-192, iodine-125, palladium-103, ruthenium-109, strontium-90, iodine-131, and californium-225, which had varying types of radiation emissions appropriate when properly selected in treatment of cancer, there was a rapid development of innovative technologies to treat all malignancies, especially gynecologic cancer. The evolution of events brought forth new applicators and techniques that allowed for better distribution of the radiation dosage within the tumor being treated, safer use of radionuclides, and the development of computer programs allowing for varying source applications and dose distributions within the volume implanted.

The results obtained with interstitial brachytherapy in thirty-six low-grade cerebral gliomas (2 pilocytic astrocytomas, 23 astrocytomas and 11 oligodendrogliomas) are reported (mean follow-up: 75 months, range 37-159). All tumours were situated in locations which did not call for surgical removal as the treatment of choice. Their volume ranged from 4 to 82 cc (m = 32); the Karnofsky performance status (KPS) of the treated patients lay between 0.60 and 0.90. The sources utilized (Iridium-192 in 32 cases and Iodine-125 in 4) were implanted permanently in 22 patients and temporarily in 14, using the Talairach stereotactic apparatus. The mean peripheral dose was 89.7 Gy for the permanent implants and and 42.8 Gy with a rate of 32.05 cGy/h for the temporary implants. External beam irradiation was added for tumour volumes greater than 35 cc (19 cases) on a second target volume extending 2 cm beyond the tumoural borders treated with interstitial irradiation. The survival estimates for the entire group showed a probability of 82.9% at 60 months, of 56.8% at 96, 39.4% at 120 (m.s.t.: 112 months). The quality of life in the treated patients was satisfactory, KPS never falling below a mean score of 0.70. The extent of the target volume turned out to be the most significant factor influencing survival at the multivariate analysis. Severe neurological impairment due to radionecrosis occurred in 4 patients (11%), three of them requiring surgical decompression.(ABSTRACT TRUNCATED AT 250 WORDS)

Since 1975, seven groups of investigators have reported clinical results of interstitial brachytherapy (IBT) for pancreatic cancer. The reports are comprised of data from 254 patients, 21 of whom died in the postoperative period for an overall operative mortality rate of 8.7%. Operative mortality rate range from 0% to 32% in individual reports. Most patients have been treated with 125I, although 25 patients were treated with 198Au seeds. Most investigators report combining IBT with external beam radiation therapy (EBRT) +/- adjuvant chemotherapy. In general, IBT has been associated with considerable morbidity. Median patient survival time has not exceeded 15 months. This report describes an additional seven patients with locally unresectable pancreatic cancer, without distant metastases, treated primarily with 60 to 100 Gy matched peripheral dose (MPD) by 125I IBT. One patient died postoperatively of a pulmonary embolus. Four of the remaining six patients were also treated with modest doses (10.5 to 30 Gy) of EBRT late in the course of the disease for local tumor progression. One developed a pancreaticocutaneous fistula, and one developed exacerbation of pre-existing diabetes mellitus. The median patient survival time from the date of IBT was 7 months (range: 0 to 21 months). One patient is alive without clinical evidence of cancer 9 months after IBT.

The authors' experience of more than 5 years in the diagnostic and therapeutic use of radioiodinated MIBG in neural crest tumors is reported.123I/131I-MIBG scintigraphhy was performed in 158 patients: 75 suspected (24 proven) pheochromocytomas (pheos), 43 neuroblastomas (NB), 20 medullary thyroid carcinomas (MTC), 6 ganglioneuromas, 5 carcinoids and 1 insulinoma. Eight cases of tumors not originating from the neural crest were also investigated. The diagnostic sensitivity of the method was above 90% both in pheos and NB (primary tumors and bone metastases). The examination was less effective in localizing MTC (sensitivity=64.4% in primary or residual/recurrent tumors). The scintigraphie outcome was negative in ganglioneuromas, carcinoids and insulinoma. Specificity was very high (> 95%), and no false positive results were found in tumors not deriving from the neural crest.

A rapidly and constantly increasing aged population in the western countries poses a wide range of specific problems to oncologists. A different way to face medical issues should be sought for older patients with cancer, looking at the characteristics that are peculiar to the elderly from different points of view. Brachytherapy is an effective form of radiotherapy which, for its specific characteristics, may be a valid alternative to more complex modalities of treatment, thus allowing a better sparing of normal tissues and structures yet achieving a similar tumor control rate. This paper reviews the literature on the subject of cancer treatment in the elderly, focusing on radiotherapy and brachytherapy, to evaluate the current attitude toward this problem in the medical community and to see if it is possible to identify a patient population that will benefit from this technique.

To evaluate intraluminal brachytherapy (ILBT) in patients with extrahepatic bile duct or pancreatic cancers.Thirty-one patients (aged 33-87 years) with unresectable extrahepatic bile duct (n = 18) or pancreatic (n = 13) cancer received ILBT exclusively or as part of a definitive treatment regimen. ILBT was performed with transhepatic percutaneous drainage in four patients and with endoscopic retrograde cholangiopancreatography in 27. Fourteen patients with no metastases, an Eastern Cooperative Oncology Group performance score ofor = 2, and good hematologic parameters received combined modality treatment: 30-Gy ILBT and 45-Gy external-beam radiation therapy with continuous infusion of fluorouracil. Seventeen patients underwent 50-Gy ILBT alone for palliation.No direct treatment-related acute toxic reactions were seen. Three patients had cholangitis early in the study. Three patients had late gastrointestinal bleeding. Jaundice was palliated in all patients (n = 29); pain, in 11 of 13 patients. The survival rate in patients with extrahepatic bile duct cancer was 62% (five of eight) at 2 years for combined modality treatment. No patient with pancreatic cancer lived for longer than 2 years.ILBT is an effective palliative treatment of unresectable extrahepatic bile duct and pancreatic cancers. Results suggest a possible "curative" role in specific clinical settings when properly integrated with other treatments.

Prostate cancer is the most common as well as the most frequently irradiated malignancy involving the genitourinary tract. In 1995, the American Cancer Society anticipates that in the United States there will be 244 000 new cases diagnosed with 40 400 deaths due to the disease process American Cancer Society 1995). In addition, it is among the most successfully treated cancers of the genitourinary tract in terms of both definitive outcome and metastatic presentations.

The preliminary results obtained in 19 patients treated with interstitial irradiation for malignant gliomas are reported. Three different groups are included in the study: I Newly diagnosed tumours not suitable for surgery: 13 cases (10 anaplastic astrocytomas (AA) and 3 glioblastomas (GBM), mean volume 46.56 cc, source Ir 192) were implanted permanently (n = 11, mean peripheral dose 93.54 Gy) or temporarily (n = 2, 50 Gy = 0.5 Gy/hr). External beam irradiation was additionally applied in all cases. II Residual or recurrent tumours: 5 patients (2 AA and 3 GBM, mean volume 7.2 cc, source Ir 192) received temporary implants (150 Gy peripheral dose = 1.5 Gy/hr) after surgery and conventional radiotherapy. III Newly diagnosed surgically removable tumours: only one patient with AA (15 cc volume, source Ir 192) received temporary implantation with the same dose regimen used in Group II before surgery and external beam irradiation.

Splenectomy and splenic irradiation (SI) are the sole treatment modalities to control drug resistant splenomegaly in patients with myelofibrosis (MF). SI has been used in poor surgical candidates but optimal total dose and fractionation are unclear. We retrospectively reviewed 14 MF patients with symptomatic splenomegaly. Patients received a median of 10 fractions in two weeks. Fraction size ranged from 0.2–1.4 Gy, and total dose varied from 2–10.8 Gy per RT course. Overall results indicate that 81.8% of radiation courses achieved a significant spleen reduction. Splenic pain relief and gastrointestinal symptoms reduction were obtained in 94% and 91% of courses, respectively. Severe cytopenias occurred in 13% of radiation courses. Furthermore patients were divided in three groups according to the radiation dose they received: 6 patients in the low-dose group (LDG) received a normalized dose of 1.67 Gy; 4 patients in the intermediate-dose group (IDG) received a normalized dose 4.37 Gy; the remaining 4 patients in the high-dose group (HDG) received a normalized dose of 9.2 Gy. Subgroup analysis showed that if no differences in terms of treatment’s efficacy were seen among dose groups, hematologic toxicity rates distributed differently. Severe cytopenias occurred in 50% of courses in the HDG, and in the 14.3% and in 0% of the IDG and LDG, respectively. Spleen reduction and pain relief lasted for a median of 5.5 months in all groups. Due to the efficacy and tolerability of the low-dose irradiation 4 patients from the LDG and IDG were retreated and received on the whole 12 RT courses. Multiple retreatments did not show decremental trends in terms of rates of response to radiation nor in terms of duration of clinical response. Moreover, retreatment courses did not cause an increased rate of adverse effects and none of the retreated patients experienced severe hematologic toxicities. The average time of clinical benefit in retreated patients was much longer (21 months, range 44–10) than patients who were not retreated (5.75 months, range 3–6).

8245 Background: Darbepoetin is a new drug active in anemia from chemotherapy and 2-to 3- times longer serum half life then recombinant-human Epo (rHuEPO). Reticulocytes can constitute an useful parameter to check the medullar reserve and give an indication of the erythropoietic answer. Methods: 42 patients in chemotherapy were randomised in 3 groups: the first two reported severe asthenia and have been deal respective with (I) darbepoetin 2.25μg/kg once weekly or (II) rHuEPO 150 U/Kg three times weekly; the third group (III), used like control, did not report relevant asthenic symptoms. The study evaluated time zero, after 4 and 8 weeks hemoglobin, reticulocyte count,serum ferritin, transferrin and iron. Results: The group treated with darbepoetin reported an increase of Hb after 4 weeks of approximately 2 g/dl if the starting value were >10 g/dl (8pts), instead patients with values of Hb

Radioactive metaiodobenzylguanidine (131I-MIBG) is taken up specifically by neuroblastoma cells and appears to represent a new treatment modality in patients with advanced neuroblastoma. Taking into account the fact that all patients so far treated were heavily pretreated and resistant to chemotherapy, the results obtained appear encouraging. In order to explore further the potential role of this new drug in untreated patients, we treated with 131I-MIBG a child with stage III neuroblastoma at diagnosis. We observed the complete disappearance of a large abdominal tumor mass after a relatively low dosage of 131I-MIBG, with minimal hematologic toxicity. No further treatment was given and, at present, the patient is alive with no evidence of disease 18 months from diagnosis. This child represents, to our knowledge, the only case of neuroblastoma thus far treated at diagnosis and the excellent response obtained suggests the need for further investigations of this therapy in untreated patients.

Seven patients with neuroblastoma (six children and one adult) were treated with therapeutic doses of high specific activity /sup 131/I-metaiodobenzylguanidine (/sup 131/I-MIBG). Six patients were in stage IV and unresponsive to conventional treatment. One patient, in stage III, was treated at diagnosis, an approach never previously reported. Single doses of /sup 131/I-MIBG varying from 70 to 184 mCi split into two parts were administered by slow i.v. infusion (4 to 8 hours) at 2- to 4-day intervals. The following results were obtained in the six evaluable patients: two patients showed transient stabilization of the disease; three had an objective response, with shrinking of the primary tumor and/or regression of the metastatic lesions. Of these three patients, two suffered relapses at 2 and 7 months, respectively, from the first course of MIBG. The third patient, in whom the residual disease almost completely disappeared following MIBG therapy, is still alive in complete remission after autologous bone marrow transplantation with a follow-up of 14 months. The single patient treated at diagnosis showed a dramatic response to a relatively low dosage of MIBG, with histologically proved disappearance of the tumor mass. Our data indicate that MIBG may be useful in the treatment of neuroblastomamore » unresponsive to conventional chemotherapy. The complete response observed in the patient treated at diagnosis suggests that the full potentiality of MIBG therapy should be explored in untreated patients.« less

One hundred patients with pancreatic cancer were evaluated between March 1981 and December 1989. This study showed that 61 were not candidates for definitive surgery because of nonoperability (28 patients) or nonresectability (33 patients). An additional 25 patients had cancers that were unresectable because of metastases (13 patients) or local spread of disease (12 patients) discovered at laparotomy. Fourteen patients had resectable cancers. Ten were treated by total pancreatectomy, three by distal pancreatectomy and one by pancreatoduodenectomy (Whipple). There were two operative mortalities. The median patient survival time was 20.5 months. Two patients survived 5 years. Five patients are alive at 3, 14, 18, and 47 months. Palliative surgical procedures performed in 18 patients included 10 biliary bypasses, 9 gastrojejunostomies, and 6 T-tube placements. This was associated with an operative mortality rate of 11%. The median survival time was 5 months. Other palliative measures included endoscopic placement of biliary and pancreatic stents (47 patients, 2.7% mortality rate), endoluminal radiation therapy, interstitial radiation therapy and external beam radiation therapy. The median survival time of patients so treated was 4.5 months.

Aims and backgroundA meta-analysis of diagnostic test performance was conducted to compare the results of relevant studies reporting diagnostic accuracy values for mediastinal staging in patients with non-small cell lung cancer (NSCLC). This paper deals with the two most accurate imaging techniques currently in use: positron emission tomography (PET) with FDG and computed tomography (CT). A statistical pooling method was used to perform a quantitative meta-analysis aimed at demonstrating the potential advantage of one of these two methods.MethodsStudies in all languages published between 1998 and 2005 that examined the use of FDG-PET and CT for mediastinal staging in NSCLC patients, enrolled at least 18 participants, and provided enough data to allow calculation of sensitivity and specificity rates were considered eligible for the quantitative meta-analysis. Statistical methods to pool the overall estimates of sensitivity and specificity and to compare the discriminant power of PET and CT were discussed and used.ResultsOf the 13 studies included in the analysis, 12 reported greater accuracy of FDG-PET than CT in detecting mediastinal lymph node metastases. The sensitivity of FDG-PET ranged from 50% to 100%. The estimate of the overall sensitivity was 0.83% with 95% CI (0.749–0.913). Specificity ranged from 79% to 100%, with an overall estimated specificity of 0.87% with 95% CI (0.80–0.95). For CT, the sensitivity and specificity ranged from 50% to 97% and 58% to 94%, respectively; the overall estimate was 0.68% with 95% CI (0.582–0.788) and 0.76% with 95% CI (0.668–0.859). The summary receiver operating characteristic (SROC) approach was used to assess the superior diagnostic accuracy of one of the two methods. The areas under the two SROC curves were AUCPET= 0.909 vs AUCCT= 0.794.ConclusionsNumerical and visual results of the meta-analysis of recent relevant reports agreed that FDG-PET is more accurate than CT in identifying mediastinal lymph node metastases in non-small cell lung cancer.