Disección aórtica aguda tipo A,una enfermedad catastrófica asociada al embarazo

Objective

To describe two fatal cases of type A acute aortic dissection associated with pregnancy.

Methods

We reviewed the medical records and autopsies of patients, and then identified some mechanisms linking this entity to pregnancy.

Results

Both deaths occurred in women aged less than 35 years at the end of gestation. One patient had aortic coarctation and bicuspid aortic valve, while the other had no risk factors.

Conclusion

Hemodynamic changes in the third trimester of pregnancy may be involved in the onset of this entity. Rapid diagnosis is essential to prevent its high associated mortality.     

Anatomical and clinical predictors of acute bowel toxicity in whole pelvis irradiation for prostate cancer with Tomotherapy

Purpose

Assessing predictors of acute bowel toxicity after whole-pelvis irradiation (WPRT) Image-guided Tomotherapy with simultaneous integrated boost on prostate/prostate bed.

Methods and materials

In the period March 2005-April 2009, 178 patients were treated with radical or adjuvant/salvage intent with WPRT Tomotherapy. Median dose to the pelvic nodes was 51.8 Gy/28 fractions while concomitantly delivering 65.5-74.2 Gy to prostate/prostatic bed. The impact of many anatomical and clinical parameters on ?Grade 2 acute bowel toxicity was investigated by logistic analyses.

Results

Only 15/178 patients (8.4%) experienced Grade 2 toxicity (none Grade 3). Main predictors at univariate analysis were nodal CTV (CTVN ? 380 cc; OR: 3.7, p = 0.017), treatment duration (<40 days; OR: 6.2, p = 0.006) and Grade 2 acute rectal toxicity (OR: 6.5, p = 0.015). A multivariate analysis including only pre-treatment variables revealed an independent role of CTVN and age; if including treatment-related factors the best predictors were age, treatment duration and Grade 2 rectal toxicity. This last was correlated with the overlap between PTVN and loops (OVPN ? 51 cc; OR: 14.4, p = 0.0003) that is representative of the volume of loops receiving the prescribed dose (51.8 Gy, 1.85 Gy/fr).

Conclusions

Acute bowel toxicity after WPRT Tomotherapy is mild, relatively rare and associated to larger CTVN and older age. While efforts to further reduce it do not appear to be relevant, the pre-treatment assessment of “high-risk” patients may help physicians in better managing symptoms. A prospective validation would be very important in confirming these results and in better refining dose-volume bowel effects including symptoms milder that the ones here investigated and retrospectively assessed.     

Digital breast tomosynthesis versus digital mammography: a clinical performance study

Objective

To compare the clinical performance of digital breast tomosynthesis (DBT) with that of full-field digital mammography (FFDM) in a diagnostic population.

Methods

The study enrolled 200 consenting women who had at least one breast lesion discovered by mammography and/or ultrasound classified as doubtful or suspicious or probably malignant. They underwent tomosynthesis in one view [mediolateral oblique (MLO)] of both breasts at a dose comparable to that of standard screen-film mammography in two views [craniocaudal (CC) and MLO]. Images were rated by six breast radiologists using the BIRADS score. Ratings were compared with the truth established according to the standard of care and a multiple-reader multiple-case (MRMC) receiver-operating characteristic (ROC) analysis was performed. Clinical performance of DBT compared with that of FFDM was evaluated in terms of the difference between areas under ROC curves (AUCs) for BIRADS scores.

Results

Overall clinical performance with DBT and FFDM for malignant versus all other cases was not significantly different (AUCs 0.851 vs 0.836, p?=?0.645). The lower limit of the 95% CI or the difference between DBT and FFDM AUCs was ?4.9%.

Conclusion

Clinical performance of tomosynthesis in one view at the same total dose as standard screen-film mammography is not inferior to digital mammography in two views.     

Prevalence of Type 1 Diabetes Autoantibodies (GADA, IA2, and IAA) in Overweight and Obese Children

OBJECTIVE

Little is known about the prevalence of β-cell autoantibodies in children with excess body weight. The prevalence of type 1 diabetes autoantibodies and its relation with hyperglycemia was analyzed in 686 overweight/obese children and adolescents.

RESEARCH DESIGN AND METHODS

All children underwent an oral glucose tolerance test, and anti-GAD, anti-IA2, and anti-IAA autoantibodies were measured. Autoantibody prevalence was evaluated in 107 normal-weight children for comparison.

RESULTS

A single autoantibody was present in 2.18% of overweight/obese subjects and 1.86% normal-weight subjects (P = NS). Postload glycemia was significantly higher in antibody-positive children (133 ± 69.9 vs. 105.4 ± 17.7 mg/dl, P < 0.0001) compared with autoantibody-negative subjects. No difference in autoantibody distribution was seen when our cohort was stratified by age, sex, SDS-BMI, pubertal stage, and homeostasis model assessment–insulin resistance (HOMA-IR).

CONCLUSIONS

The 2.18% prevalence of type 1 diabetes autoantibodies is similar to that reported in nonobese children. This study provided evidence that excess body weight and insulin resistance do not influence autoantibody frequency.Over the last 60 years, a striking increase in the incidence of childhood type 1 diabetes has been observed consistently in almost all populations. EURODIAB (1) reported an overall increase of 3.2% per annum in Europe between 1989 and 1998. There have also been considerable changes in childhood nutrition, which have resulted in changes in growth. Increased weight, height, and BMI in children have all been associated with a higher risk of type 1 diabetes (2). The so-called “accelerator hypothesis” argues that obesity causing overworked β-cells underlies both type 1 and type 2 diabetes and that these “types” are only distinguished by how the body responds to this growth-induced β-cell stress. This hypothesis therefore attributes the rise in type 1 diabetes to an increase in child obesity (3). A variation of the hypothesis suggests that, once initiated, islet autoimmunity progresses more rapidly in the context of “overload” of the β-cells due to increased insulin resistance (4).Sardinia has one of the highest incidences of type 1 diabetes worldwide, second only to Finland (5). Moreover, Sardinian children and adolescents are experiencing the same increase in obesity as other European populations (6). To date, little is known on the prevalence of autoantibodies against β-cells in children with excess body weight.The aim of our study was to analyze the prevalence of type 1 diabetes autoantibodies in a cohort of Sardinian overweight/obese children and adolescents and to evaluate their distribution in relation to the presence of glucose abnormalities.     

Imatinib resistance in CML

Imatinib is, at present, the first-choice treatment for patients with chronic myeloid leukaemia in chronic phase. Despite the impressive rate of complete haematological response and complete cytogenetical remissions, some cases show primary resistance or relapse after an initial response (secondary or acquired resistance). The most common mechanisms responsible for this resistance are BCR/ABL kinase domain mutations, BCR/ABL amplification and over-expression and clonal evolution with activation of additional oncogenic pathways. Here, we describe the molecular basis of imatinib resistance, the significance of molecular monitoring and the current efforts to overcome imatinib resistance, ranging from the development of new drugs to the stimulation of an immune response against the disease.     

Treating migraine with contraceptives

At least 18% of women suffers from migraine. Clinically, there are two main forms of migraine: migraine with aura (MA) and migraine without aura (MO) and more than 50% of MO is strongly correlated to the menstrual cycle. The high prevalence of migraine in females, its correlation with the menstrual cycle and with the use of combined hormonal contraceptives (CHCs) suggest that the estrogen drop is implicated in the pathogenesis of the attacks. Although CHCs may trigger or worsen migraine, their correct use may even prevent or reduce some forms of migraine, like estrogen withdrawal headache. Evidence suggested that stable estrogen levels have a positive effect, minimising or eliminating the estrogenic drop. Several contraceptive strategies may act in this way: extended-cycle CHCs, CHCs with shortened hormone-free interval (HFI), progestogen-only contraceptives, CHCs containing new generation estrogens and estrogen supplementation during the HFI.     

Interface Fluid Syndrome (IFS) following Toxic Anterior Segment Syndrome (TASS): not related to high intraocular pressure but to endothelial failure

We describe the case of a 52-year-old female with past history of LASIK, 21?years earlier, without Fuchs’ endothelial dystrophy, who underwent phacoemulsification and intraocular lens (IOL) implantation. During the early postoperative period severe corneal edema, anterior chamber cellularity and iris inflammation presented, accompanied by a clear space along the LASIK interface. Those findings were interpreted as part of a Toxic Anterior Segment Syndrome (TASS) and secondary interface fluid syndrome (IFS). When interface fluid was present, intraocular pressure (IOP) measured in the center of the cornea yielded very low values. In addition, applanation tonometry performed in the corneal periphery, as well as Schiotz tonometry and digital tonometry also indicated that the IOP was not high. Fluid in the interface persisted until a DMEK was carried out 11?months after the phacoemulsification surgery. Five days postoperatively the IFS resolved, confirmed by OCT imaging. The origin of IFS in this case was corneal edema secondary to endothelial cell dysfunction and it was not related to high IOP. This is the first reported case of IFS following TASS, the third case published of DMEK procedure used to solve endothelial failure-related IFS, and the case with the longest time of presentation after LASIK.