Comparison of computed tomographic angiography with digital subtraction angiography in the diagnosis of cerebral aneurysms: a meta-analysis

OBJECTIVE: To compare a novel diagnostic radiological technique, computed tomographic angiography (CTA), with the standard method, namely digital subtraction angiography (DSA), in the diagnosis of cerebral aneurysms. METHODS: A comprehensive search of the world literature on CTA was performed. Articles that reported on prospective comparisons of CTA and DSA in the evaluation of patients suspected of harboring cerebral aneurysms were selected for data extraction. Suitable statistical methods were applied to the extracted data for meta-analysis. RESULTS: Twenty-one references met the criteria for use in the meta-analysis. Unweighted calculations based on data for 1251 patients resulted in a sensitivity of 0.933 (93.3%; range, 75.4-100%) and a specificity of 0.878 (87.8%; range, 0-100%). When the studies were weighted for the number of patients in each study, the sensitivity decreased slightly, to 0.927 (92.7%), and the specificity decreased more substantially, to 0.772 (77.2%). CONCLUSION: On the basis of this meta-analysis, DSA remains the standard method. However, many who use CTA have reported it to be as good as or better than DSA in the diagnosis and treatment of cerebral aneurysms, as well as being of less risk and discomfort to their patients and easier and less expensive to perform.     

'Spindle cell oncocytoma' of the adenohypophysis: a tumor of folliculostellate cells?

We describe five primary tumors of the adenohypophysis featuring mitochondrion-rich spindle cells. The patient ages ranged from 53 to 71 years (mean 61.6 years); two were female. All presented with panhypopituitarism. Two also had visual field defect. On neuroimaging all tumors showed suprasellar extension and were indistinguishable from pituitary adenoma. None showed imaging or operative evidence of dural involvement. All were gross totally removed: four by transsphenoidal surgery and one by frontal craniotomy. Follow-up ranged from 2 to 68 months (mean 35.4 months). No recurrences were noted. The clinical workup was noncontributory in all but two patients: one (case no. 4) with an oncocytic thyroid adenoma and another (case no. 5) with squamous carcinoma of both the uterine cervix and of vocal cord. Histologically, the five tumors were composed mainly of fascicles of spindle cells with eosinophilic, granular cytoplasm. Mitoses were rare and necrosis was absent. Neoplastic cells were immunoreactive for vimentin, epithelial membrane antigen, S-100 protein, and galectin-3. Stains for pituitary hormones, synaptophysin, chromogranin, glial fibrillary acidic protein, cytokeratin CAM5.2, smooth muscle actin, CD34, and CD68 were negative. No thyroglobulin immunoreactivity was noted in the tumor of case no. 4. Ultrastructurally, the neoplastic cells contained numerous mitochondria with lamellar cristae. The neoplastic cells were linked by intermediate junctions and desmosomes. No secretory granules were noted. The histologic, immunohistochemical, and fine structural features of these tumors were unlike those of pituitary adenoma or any other primary sellar tumor. A derivation from adenohypophyseal folliculostellate cells is suggested.     

Acute Appendicitis: Still a Surgical Disease? Results from a Propensity Score-Based Outcome Analysis of Conservative Versus Surgical Management from a Prospective Database

Objective

The aim of the present study was to compare the outcomes of conservative versus surgical treatment for acute appendicitis.

Background

Although acute appendicitis is a common disease, great debate exists regarding the appropriate management of patients. Conservative treatment has shown positive results in several RCTs, eliciting questions about indications to surgery, therapeutic appropriateness and ethical conduct.

Methods

Data were prospectively collected; a Propensity Score-based matching method was implemented in order to reduce bias arising from characteristics of the patients; a proportion of patients (69 in total) were excluded to obtain two comparable groups of study (1a). Main outcomes of the study were: failure rate, in-hospital length of stay (at first admission and cumulative), post-discharge absence from work. Within the medical group, failure was defined as the necessity for appendectomy after conservative treatment, while it was identified with complications and negative appendectomy within the surgical group (Failure 1). In parallel, an additional definition of failure was proposed (Failure 2) and excluded negative appendectomy from the reasons for failure within the surgical group (5b).

Results

The failure rate for the conservative treatment resulted to be inferior, as compared to the surgical treatment (16.5 vs. 28.4%, OR 0.523 p = 0.019), considering negative appendectomy as a reason for failure. When excluding negative appendectomy from the definition of failure, medical and surgical treatment appeared to perform equally (failure rate: 16.5 vs. 18.3%, OR 1.014 p = 0.965). Patients managed conservatively showed to have a shorter length of stay at first admission than the patients who underwent appendectomy (3.11 vs. 4.11 days, β = ?0.628 days, p < 0.0001). A lower number of lost work days after discharge resulted from a conservative approach (6 vs. 14.64 days, β = ?8.7 days, p < 0.0001).

Conclusions

Considering each outcome as part of a wide-angle analysis, the conservative management of acute appendicitis resulted to be safe and effective in the selected group of patients. In terms of failure rate, the medical treatment resulted to perform as effectively as surgical treatment, if negative appendectomy was excluded from failure, or better, when negative appendectomy was included in the definition of failure. A diminished length of stay during the first admission and a reduced number of lost work days were evident with a conservative approach. The comparison between medical and surgical treatment for acute appendicitis requires a change in perspective, from a spare ‘effectiveness analysis’ to a more thorough ‘appropriateness analysis’: in the present study, the conservative treatment showed to address the clinical requirements in terms of therapeutic appropriateness. Although acute appendicitis is considered a ‘surgical disease’, increasing evidence supports the effectiveness and safety of a conservative approach for selected groups of patients.

     

Transvaginal uterosacral ligament hysteropexy: a video tutorial

Introduction and hypothesis

Uterine-sparing procedures could be attractive in patients concerned about fertility preservation and corporeal image changes. Transvaginal uterosacral ligaments (USLs) hysteropexy can provide a mesh-free technique for uterine suspension. This video is intended to serve as a tutorial for surgical steps.

Methods

A 38-year-old woman with symptomatic stage III POP desired preserving fertility. After proper counseling, the patient was admitted for vaginal hysteropexy through bilateral high USL suspension according to the featured technique.

Results

Prolapse repair was successfully achieved without complications. We had already published a series of 20 cases that confirmed that transvaginal USLs hysteropexy is a promising technique for correcting genital prolapse with uterus preservation.

Conclusion

Transvaginal USLs hysteropexy provides a feasible technique for apical support without the use of prosthetic material. This procedure could be attractive to women who desire a uterine-sparing surgical option.

     

Numerical Stability Analysis for a Stationary and Translating Droplet at Extremely Low Viscosity Values Using the Lattice Boltzmann Method Color-Gradient Multi-Component Model with Central Moments Formulation

Multicomponent models based on the Lattice Boltzmann Method (LBM) have clear advantages with respect to other approaches, such as good parallel performances and scalability and the automatic resolution of breakup and coalescence events. Multicomponent flow simulations are useful for a wide range of applications, yet many multicomponent models for LBM are limited in their numerical stability and therefore do not allow exploration of physically relevant low viscosity regimes. Here we perform a quantitative study and validations, varying parameters such as viscosity, droplet radius, domain size and acceleration for stationary and translating droplet simulations for the color-gradient method with central moments (CG-CM) formulation, as this method promises increased numerical stability with respect to the non-CM formulation. We focus on numerical stability and on the effect of decreasing grid-spacing, i.e. increasing resolution, in the extremely low viscosity regime for stationary droplet simulations. The effects of small- and large-scale anisotropy, due to grid-spacing and domain-size, respectively, are investigated for a stationary droplet. The effects on numerical stability of applying a uniform acceleration in one direction on the domain, i.e. on both the droplet and the ambient, is explored into the low viscosity regime, to probe the numerical stability of the method under dynamical conditions.     

Lymphadenopathies in patients with renal cell carcinoma: clinical and pathological predictors of pathologically confirmed lymph node invasion

Introduction

In renal cell carcinoma (RCC), lymph node status at preoperative imaging is affected by a non-negligible false-positive rate. We aimed to investigate which factors are related to a concordance between clinical suspicion and pathological confirmation of lymph node invasion (LNI).

Methods

At a single tertiary care institution, 2954 RCC patients underwent either partial or radical nephrectomy. For the aim of the study, only clinically positive lymph node cases were included (cN1). Statistical analyses assessed the concordance between preoperative and pathological nodal status.

Results

Preoperative axial CT scans revealed 424 (14.4 %) patients showing at least one enlarged lymph node suspected for LNI (cN1). All lymphadenopathies were removed at surgery, and LNI was pathologically confirmed (pN1) in 122 patients (28.8 %). When focusing the analyses on clinical characteristics (variables known before surgery), metastases at diagnosis [OR 3.0 (95 %1.9–4.8), p < 0.001] and tumor size [OR 1.1 (95 % 1.1–1.2), p < 0.001] were the two most informative predictors of concordance between clinical and pathological nodal status. Concordance was also more likely in patients with papillary type II tumors (55.6 %) relative to papillary type I (38.1 %), clear cell (27.7 %) and chromophobe (8.3 %) tumors. At multivariable analyses, none of the considered blood markers resulted to be independently associated with LNI.

Conclusions

Roughly 70 % of patients showing a suspected lymph node preoperatively do not show LNI at the final pathological report. Among patients with clinically positive nodes, clinical tumor size and metastases at diagnosis represent the most informative and independent predictors of confirmed LNI at final pathology.

     

CT-guided high-dose-rate brachytherapy of unresectable hepatocellular carcinoma

Strahlentherapie und Onkologie - The purpose of the present study was to evaluate the clinical outcome of CT-guided high-dose-rate brachytherapy (CT-HDRBT) in patients with unresectable...     

Improving the preservation of the urethral sphincter and neurovascular bundles during open radical retropubic prostatectomy

OBJECTIVES: To describe a technique for open nerve-sparing radical retropubic prostatectomy. METHODS: The technique basically implies incising the levator and prostatic fasciae high anteriorly (1 and 11 o'clock positions) over the prostate, developing the plane between the prostatic capsule and prostatic fascia, and displacing the neurovascular network localized between the two fasciae laterally. This allows for a minimal-touch dissection of the external urethral sphincter and a very efficient dissection of the neurovascular bundles at the level of membranous urethra and prostatic apex. RESULTS: Forty-two patients underwent a bilateral nerve-sparing operation and were followed- up for 6 months. Six patients (14.3%) had positive margins: 4 patients had pT2 disease (in all, the positive margin was monofocal) and 2 patients had pT3 disease (both had multifocal positive margins). Continence (defined as being dry or having one pad remain dry for 24 hours) was achieved in 44% of patients at catheter removal, and in 60%, 72%, and 90% of patients at the 1-, 3-, and 6-month follow-up visits. Potency (defined as an erectile function domain score > or =26) was obtained in 15%, 40%, and 52% of patients at the 1-, 3-, and 6-month follow-up visits. All patients used a PDE5-inhibitor during the investigation period. CONCLUSIONS: These preliminary results suggest that the high incision of the levator and prostatic fasciae may facilitate efficient preservation of the external urethral sphincter and the neurovascular bundles innervating the corpora cavernosa and the sphincter.     

Hipogonadismo prolongado tras la suspensión de tratamiento hormonal en pacientes con cáncer de próstata

ObjectivesTo study the levels of LH, testosterone and PSA after suspending prolonged treatment with LH-RH analogs.Materials and MethodHormonal evolution was studied in 29 patients from whom treatment had been withdrawn. The patients had previously been receiving treatment with LH-RH analog for more than one year, and with LH< 2 mUI/mL and testosterone <2.8 ng/mL. LH, testosterone and PSA were determined monthly, together with clinical assessment. The treatment was re-initiated and the period of monitoring ended before the presence of clinical progression and/or PSA ? 10 ng/mL. The cohort was described and survival was calculated using Kaplan-Meier and Cox regression.ResultsThe mean period of time without treatment for the series was 35 months (CI 95%, 15.7-54.2 months). Prolonged hypogonadism (> 24 months) was presented by 17% of the patients. The recovery of the LH-T-PSA axis, when it occurred, followed the expected sequence. The variables that influenced the period of recovery of the PSA were the PSA pretreatment and the association of an antiandrogen.ConclusionsAfter withdrawing the prolonged treatment with LH-RH analogs, most of the patients recovered the levels of LH-T-PSA, although a subgroup remained hypogonadic for more than 24 months.