Search

Purpose or Learning Objective To investigate whether a radiomic analysis performed on hepatocellular carcinoma can reveal the presence of microvascular invasion (MVI). Methods or Background The dataset includes seventy-one early-stage HCC nodules (Milan criteria, nodule≤3 cm, without macrovascular invasion and extrahepatic spread), where forty-two are MVI positive (MVI+) and twenty-nine are MVI negative (MVI-), at histopathological report obtained after surgery. Radiomic analysis is performed on contrast-enhanced CT imaging during the arterial phase. HCC nodules were manually segmented and eighty-four local first-order radiomic features (RFs) are computed from HCC Region of Interest (ROIs). To avoid overfitting, only one couple of RFs is selected for discriminating MVI+ and MVI- into three steps: (i) a subset of RFs is first selected through LASSO; (ii) linearly correlated couples are discarded; (iii) after computing the ROC curve, the most discriminating couple is selected as that one yielding the highest AUC. The discrimination between MVI+ and MVI- is assessed through specificity and sensitivity computed at the Youden Index (YI). Results or Findings The selected couple combines a measure of local heterogeneity to mean CT image values in HCC ROIs and allows achieving an AUC=0.86, with specificity=81% and sensitivity=83% at the YI=0.64. Conclusion The radiomic analysis allows unravelling different inner properties of HCC MVI+ nodules, which show a more heterogeneous tumour pattern with respect to MVI-. Limitations This radiomic analysis was performed exclusively on arterial-phase contrast enhanced images, although it is reasonable arguing that the next inclusion of venous phase images must only improve the outcomes.

Multisystem inflammatory syndrome of children (MIS-C) continues to be a highly concerning diagnosis in those recently infected with SARS-CoV-2. The diagnosis of MIS-C cases will likely become even more challenging as vaccine uptake and natural immunity in previously infected persons leads to lower circulating rates of SARS-CoV-2 infection and will make cases sporadic. Febrile children presenting with cardiac dysfunction, symptoms overlapping Kawasaki disease or significant gastrointestinal complaints warrant a thorough screen in emergency departments, urgent care centers, and outpatient pediatric or family medicine practices. An increased index of suspicion and discussion regarding higher level of care (transferring to pediatric tertiary care centers or to intensive care) continues to be recommended. Herein we outline a broad approach with a multidisciplinary team for those meeting the case definition and believe such an approach is crucial for successful outcomes.

Previous studies have shown that tryptophan and vitamin B6 used in conjunction with melatonin induce sleep more effectively than melatonin alone. This study aims at evaluating the efficacy of different dosages and timings of administration of a solution containing melatonin, tryptophan, and vitamin B6 for inducing sleep in children undergoing ABR testing.294 children scheduled for Auditory Brain Response (ABR) evaluation were administered a solution containing melatonin, tryptophan, and vitamin B6 to induce sleep before the exam. Two different administration timings (pre-treatment and single shot treatment) and three dosages (0.5 ml in pre-treatment, 1.5 ml in pre-treatment, and 3 ml in single shot) were tested. The following parameters were evaluated: time needed for the subject to fall asleep before ABR testing, subject sl'eep features during ABR testing (quality, stability, duration), recorded ABR quality (including presence of abnormalities in amplitude and latency), subject waking up modality, and time needed for the subject to wake up at the end of the ABR exam.Quality of ABR signals was similar across treatments, and subjects responded in a similar manner in terms of time needed to wake-up and wake-up modality. However, pretreatment with the 1.5 ml dose induced sleep faster than the two other dosages, and the length of the induced sleep was longer than that induced by pre-treatment with 0.5 ml. In general, the pre-treatment with 1.5 ml led to a shorter ABR exam, because reduces the time for inducing sleep, allows a long sleeping phase with a good quality, without variation in the wakening up times.Melamil Tripto

Objectives Previous studies have shown that tryptophan and vitamin B6 used in conjunction with melatonin induce sleep more effectively than melatonin alone. This study aims at evaluating the efficacy of different dosages and timings of administration of a solution containing melatonin, tryptophan, and vitamin B6 for inducing sleep in children undergoing ABR testing. Methods 294 children scheduled for Auditory Brain Response (ABR) evaluation were administered a solution containing melatonin, tryptophan, and vitamin B6 to induce sleep before the exam. Two different administration timings (pre-treatment and single shot treatment) and three dosages (0.5 ml in pre-treatment, 1.5 ml in pre-treatment, and 3 ml in single shot) were tested. The following parameters were evaluated: time needed for the subject to fall asleep before ABR testing, subject sl'eep features during ABR testing (quality, stability, duration), recorded ABR quality (including presence of abnormalities in amplitude and latency), subject waking up modality, and time needed for the subject to wake up at the end of the ABR exam. Results Quality of ABR signals was similar across treatments, and subjects responded in a similar manner in terms of time needed to wake-up and wake-up modality. However, pretreatment with the 1.5 ml dose induced sleep faster than the two other dosages, and the length of the induced sleep was longer than that induced by pre-treatment with 0.5 ml. In general, the pre-treatment with 1.5 ml led to a shorter ABR exam, because reduces the time for inducing sleep, allows a long sleeping phase with a good quality, without variation in the wakening up times. Conclusions Melamil Tripto® is an alternative to sedative drugs for inducing sleep in pediatric subjects undergoing ABR testing. A pre-medication with 1.5 ml of MT 1 week before ABR testing further improves the strength of the solution.

Objective: We evaluated the validity of an electrothermal bipolar tissue sealing system (LigaSure, Valleylab Inc., USA) in lung surgery. Methods: Our study was divided into two phases. Experimental: We performed sutures of pulmonary vessels and bronchi and lung wedge resections by LigaSure in 28 lungs of adult pigs; subsequently, we quantitated the sealing capacity of the system detecting the burst pressure for each anatomical structure. Clinical: LigaSure was used in 36 patients undergoing lung surgery. We performed 23 thoracotomic procedures in 16 patients (19 wedge resections, 2 segmentectomies, and 2 fissure separations), and 20 thoracoscopic procedures (13 wedge resections, 5 bullectomies, and 2 adherence dissections). Results: Experimental: Bronchi and vessels were divided into seven groups (diameter: 1-7 mm); 10 burst pressure measurements for each group were performed. A total of 84 wedge resections were performed; lung specimens were divided into seven groups (weight: 0.2-1.4 g). The percentage of bronchial sutures resistant to the pneumatic critical pressure (60 mmHg) was 100% in the 1-mm and 2-mm groups. No bronchi with 6-mm or 7-mm diameter reached the critical pressure. All pulmonary vessel sutures were resistant to the critical hydrostatic pressure (150 mmHg). The average burst pressure of wedge resection margins was higher than the critical pressure, and the percentage of suture margins resistant to the critical pressure decreased from 95% (0.2-g group) to 68% (1.4-g group). Histology confirmed the sealing of vessels, with a mean depth of thermal injury limited to 1.1 mm. Clinical: In all patients, hemostasis obtained by LigaSure was effective, with minimal perioperative bleeding. The mean operating time was 77.2 min (range: 60-97) for thoracotomies and 60.3 min (range: 46-80) for thoracoscopies. The mean drainage duration was 3.1 days (range: 1-8). Two patients had prolonged air leaks (>7 days). The mean postoperative stay was 7.3 days (range: 5-13) for thoracotomies and 4.6 days (range: 1-6) for thoracoscopies. Conclusions: Use of LigaSure in lung surgery appears feasible and easy. It provides satisfactory hemostasis and air-leak prevention; results are comparable to those of stapling devices, but this system seems to have a better benefit/cost ratio. Larger series are needed to confirm these data. © 2005 Elsevier B.V. All rights reserved.

Background In patients undergoing lung resection for non-small cell lung cancer (NSCLC), the primary TNM (tumor–regional lymph node–distant metastasis) staging system is the best prognostic factor. However, it is necessary to investigate other factors that could more accurately predict a patient's prognosis. In this study we evaluated the significance of positive intraoperative pre-resectional lavage in patients with NSCLC. Methods We enrolled 84 patients (79 men, 5 women) aged between 36 and 81 years (mean age, 64.8 years) undergoing a major lung resection for NSCLC, with no preoperative evidence of pleural effusions. Intraoperatively, the patients were given a pre-resectional pleural lavage with physiologic saline solution. The fluid was aspirated and sent to cytology. Results Pre-resectional pleural lavage was positive in 19 patients (22.6%). The lavage was positive in 7.3% in patients with early stage I disease (3/41) and 37.2% in patients with stage II/III disease. In the group of 16 patients with chest wall neoplastic involvement (T3), 9 had a positive lavage (56.2%; p = 0.05). No significant correlation was found between positive lavage and nodal status, visceral pleural involvement, or histologic findings. Patients with malignant cells in the pre-resectional lavage had a significantly shorter survival than patients with a negative lavage ( p = 0.025). Conclusions A positive cytology finding of intraoperative pre-resectional pleural lavage could be an important prognostic factor in patients undergoing major lung resection for NSCLC. Patients with a positive lavage should be upstaged. However, larger series are needed to define accurately the role of this technique in early stage lung cancer.

A social information processing perspective was used to investigate appraisal processes in family conflict situations. Fifty-five young adolescents (32 males and 23 females) and their mothers who were experiencing sufficient conflict to seek mediation assistance, were presented with hypothetical scenarios depicting common sources of conflict. Participants were randomly assigned to two time conditions. After reading each scenario, participants chose one of four interpretations (two hostile and two non-hostile). Time condition did not influence the number of hostile interpretations for mothers, but when instructed to respond quickly, adolescents were more likely to interpret their mother's behaviour as hostile. The findings highlight the need for investigation of specific stressors which influence appraisal processes in family conflict.

Mechanical ventilation in patients with bronchopleural fistula after lung resection is a major problem, as it causes increase of the air-leak, complicates the healing process and makes residual lung tissue ventilation difficult. We present two cases in which the use of a modified double lumen endobronchial tube improved ventilation and eliminated the fistula air-leak. We used a right-sided double lumen sher-i-bronch tube (Sheridan Catheter Corp., USA). This method, by blocking the airflow through the fistula, may facilitate the expansion of the residual lung parenchyma. In both the patients treated with this technique, we obtained a good expansion of the residual parenchyma. Despite the procedure, the first patient died of septic shock; in the second patient, we achieved improvement of the respiratory function, the weaning from the mechanical ventilation, and thereafter, the healing of the fistula. The use of a modified double lumen sher-i-bronch tube in mechanically ventilated patients with post-resection bronchopleural fistula allows the anaesthesiologist to suction separately the two lungs and to ventilate adequately the remaining lung tissue, thus obtaining the lung reexpansion and the consequent reduction of the residual pleural space, and facilitating the healing of the fistula.

Surgery has never played a precise and well consolidated role in the planned treatment of lung microcytoma (SCLC). The acknowledged therapeutic strategy associates local treatment (radiotherapy) with general treatment (chemotherapy). Exeresis is particularly indicated in limited or peripheral forms, followed by intensive polychemotherapy. Scintigraphy with octreotide may be used for the initial screening of patients with widespread disease. Another minor role played by surgery is in the treatment of neoplastic foci remaining after chemotherapy. In some cases the use of a radioguided method which, after intravenous injection of radiolabeled octreotide, allows the accumulation of somatostatin analog in neoplastic foci to be assayed intraoperatively using a manual probe, might help the surgeon to check the radical nature of the operation. In addition, octreotide can be used as a radiotherapeutic pharmacological agent or to enhance the efficacy of chemotherapy in microcytoma and other lung tumours with neuroendocrine differentiation.

The study evaluates the role of radio-guided surgery (RGS) with 111In-octreotide in the treatment of lung neoplasms. RGS with octreotide appears to be useful in surgery, above all during the intraoperative staging of the tumour; it can define with greater precision the extent of the resections extended towards the lung wall and ensure a radical approach in minimal lung resections.

In a 28-year-old man with Cushing's syndrome, studies investigating a hypophyseal and/or adrenal origin of the disease, including computed tomography and magnetic resonance imaging, were negative. In agreement with reports showing somatostatin receptors on the cell membrane of ectopically secreting ACTH tumours, scintigraphy was performed after intravenous injection of 111 MBq 111In-pentetreotide (OCT). The radiolabelled OCT scan showed a small focal area of intense uptake at the inferior lobe of the right lung. Subsequent radioguided surgery located and defined a small mass (1.8 x 1.4 x 1.6 cm). The probe pinpointed the mass to the right inferior chest lobe, with a tumour/normal tissue count ratio of 6:1 and tumour/hilar normal lymph node ratio of 12:1, thus permitting the complete excision of the tumour to exclude lymph node and/or parietal involvement. A lung carcinoid was diagnosed at histology. The patient is still alive and disease-free 24 months after surgery. 111In-OCT was found to be useful for localizing the ACTH-secreting tumour and also permitted rapid non-invasive differential diagnosis between an ACTH-secreting pituitary adenoma and malignancy causing ectopic ACTH syndrome. This study also showed the clinical usefulness of radioguided surgery in the treatment of bronchial carcinoid.

The contribution of radio surgery (RGS) using octreotide labeled with Indium-111 (In111) has been studied for surgical treatment of lung cancer. Thirteen patients were administered 111 Mbq of In111 octreotide intravenously. Scintigraphic images were preoperatively taken at 4, 24, and 48 hours after the tracer injection. Pulmonary resection and intraoperative evaluation by RGS technique were then performed to set the section limits. Histological staining of all the resected specimens and resection margins were assessed and their results were used as a confirmation of the RGS intraoperative findings. RGS is a simple method that can help the surgeon in the intraoperative assessment of bronchial, parenchymal, and parietal resection margins. Further research is needed to verify whether this method also may be useful in the intraoperative definition of the extent of mediastinal lymph node dissection.

The expanding role of pulmonary surgery could be expected to lead to an increase in postoperative morbidity and mortality unless surgical risk factors are identified by means of a careful preoperative assessment. A careful and intelligent preoperative evaluation can reduce the morbidity and mortality after lung resection by ensuring the appropriate selection of patients and a rational choice of operative procedure. To evaluate the cardiologic risk in patients undergoing lung resection, 18 of them underwent a diagnostic protocol based on non invasive analysis including ECG, stress test with basal and exercise blood gas analysis, M- and B-mode and Doppler echocardiography. This protocol was able to identify possible cardiologic risk in the perioperative period without applying invasive techniques and with a good cost-benefits ratio.

The technique, indications and contraindications for endoscopic retrograde cholangiopancreatography are discussed. Some of the most demonstrative cholangiographic and pancreatographic pictures are described and the reasons that have led to a marked reduction in complications immediately after the examination are analysed. Therapeutical aids for limiting any slight disturbances connected with the examination are also presented. Finally, some morphological data useful for differentiating between inflammatory and neoplastic lesions in the juxta- and intrapancreatic biliary excretory way and the pancreas itself are considered.

Following an assessment of the long-term results of a homogenous series of 109 patients with gastroduodenal ulcer treated surgically according to the Billroth I technique, a personal opinion on this type of gastric resection is given. It may be considered positive, in the light of the data collected, both clinically and functionally. The need is also stressed for further, broader analysis for the purpose of a precise evaluation of the operation.