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Open access

Adriano Contillo, Anna Veronese, Luca Brombal, Sandro Donato, Luigi Rigon, Angelo Taibi, Giuliana Tromba, Renata Longo and Fulvia Arfelli

Abstract

Background

The SYRMA-3D collaboration is setting up the first clinical trial of phase-contrast breast CT with synchrotron radiation at the Elettra synchrotron facility in Trieste, Italy. In this communication, a quality control protocol for breast CT is proposed, and a first test of image quality measurements is performed by means of a custom-made radiographic phantom.

Materials and methods

A set of projections is acquired and used to perform a CT reconstruction of two selected portions of the phantom. Such portions contain a uniform layer of water and a set of radiographic inserts, respectively. Together, they allow to perform several image quality measurements, namely CT number linearity, reconstruction accuracy, uniformity, noise, and low contrast resolution. All measurements are repeated at different beam energies in the range of interest, and at two different dose values.

Results

Measurements show a good linearity in the soft tissue range, paired to a high accuracy of the CT number reconstruction. Uniformity and noise measurements show that reconstruction inhomogeneities are bound to a few percent of the average pixel values. However, low contrast detectability is limited to the higher portion of the explored energy range.

Conclusions

The results of the measurements are satisfactory in terms of their quality, feasibility and reproducibility. With minimal modifications, the phantom is promising to allow a set of image quality measurements to be used in the upcoming clinical trial.

Open access

Tanja Marinko and Karmen Stanic

Abstract

Background

Postmastectomy radiotherapy (PMRT) improves survival by eliminating potential occult lesions in the chest wall and lymphatic drainage area. Meta-analysis has shown that PMRT reduces mortality and local recurrence of patients with node positive breast cancer, but there is no specific data about the effectiveness of PMRT in a subgroup of patients with a high number of positive axillary lymph nodes (PALN). The aim of the study was to analyse the impact of the number of PALN on local and distant metastasis occurrence, overall survival (OS) and distant metastases free survival (DMFS) in patients treated with PMRT.

Patients and methods

We reviewed medical records of 129 consecutive breast cancer patients with PALN, treated at Institute of Oncology Ljubljana with PMRT between January 2003 and December 2004. We grouped patients according to the number of PALN as follows: Group 1 (less than 15 PALN) and Group 2 with more than 15 PALN. All patients received adjuvant systemic therapy according to the clinical guidelines. We analysed number of locoregional (LR) recurrences, distant metastasis, overall survival (OS), progression free survival (PFS) and DMFS.

Results

After the median follow-up time of 11.5 years, the Kaplan-Meier survival analysis of PALN showed significantly shorter OS (p = 0.006), shorter PFS (p = 0.002) and shorter DMFS (p < 0.001) in the group of > 15 PALN. Only one LR was found in the group of patients with more than 15 PALN. In multivariate analysis more than 15 PALN and treatment with anthracycline chemotherapy statistically significantly influenced OS and DMFS. For PFS presence of more than 15 PALN were the only independent factor of shorter survival.

Conclusions

Patients with more than 15 PALN have shorter DMFS, PFS and OS as compared to patients with less than 15 PALN, though they receive the same LR treatment. More studies with higher number of patients included are needed to further evaluate our findings.

Open access

Khai Doan Nang, Michael Reardon, Alan Lumsden and Zsolt Garami

Abstract

Introduction: Transcatheter aortic valve replacement (TAVR) has become an optimal substitute treatment for subjects with severe aortic stenosis who cannot undergo open chest surgery or who have a high surgical risk. Transcranial Doppler (TCD) provides monitoring of microembolic signals and cerebral blood flow during TAVR and detects ongoing fluctuations of intracerebral hemodynamics during each phase of the procedure.

Case report: We present the case of a patient who underwent TAVR, during which bilateral monitoring of the middle cerebral artery blood flow was performed with TCD.

Conclusions: The effectiveness of transcranial Doppler to identify cerebral embolisms and variations in the cerebral hemodynamics is imperative in fending off complications during transcatheter aortic valve replacement.

Open access

Anca Găitan, Cristian Stătescu, Radu Sascau, Mircea Balasanian and Cătălina Arsenescu Georgescu

Abstract

Background: In just a few years, cardiac resynchronization therapy (CRT) has emerged as a key player in the treatment of advanced heart failure (HF). However, approximately 30% of patients with CRT device implantation do not achieve a favorable response. The purpose of the present study was to identify clinical, electrocardiographic, and echocardiographic predictors of a positive response to biventricular pacing in patients with advanced decompensated HF.

Methods: This prospective, observational study involved 42 consecutive patients admitted in emergency settings in our clinic with HF in New York Heart Association (NYHA) functional class III/IV, with QRS duration ≥120 ms and left ventricle ejection fraction (LVEF) ≤35%, who underwent cardiac resynchronization therapy (CRT-P or CRT-D) between January 2010 and July 2014. Statistical analysis was performed using IBM SPSS statistical software.

Results: The clinical response (improvement in NYHA class) was recorded in 6 patients (14.3%), while echocardiographic response (change in ejection fraction and/or in endsystolic or end-diastolic volumes) was recorded in 10 patients (23.8%). The most frequently observed type of response to CRT was the double (clinical plus echocardiographic) response, recorded in 23 out of 42 patients (54.8%). ROC analysis identified the absence of chronic renal disease and the duration from onset of symptoms to CRT implantation as good predictors for clinical improvement after CRT (AUC = 0.625, 95% CI: 0.400–0.850 for absence of renal failure and AUC = 0.516, 95% CI: 0.369–0.853 for symptoms duration). However, gender, age, duration from symptom onset, and comorbidities were not good predictors for the echocardiographic response (AUC <0.600).

Conclusions: CRT represents an important therapeutic option for selected patents with advanced decompensated HF and prolonged QRS interval; however, only some of the commonly used criteria can predict a favorable outcome in patients undergoing CRT.

Open access

Theodora Benedek, Ioana Rodean, Mihaela Ratiu, Nora Rat, Lia Yero Eremie, Carmen Biriș, Luminița Lazăr, Mariana Păcurar and Imre Benedek

Abstract

Recent studies have shown that systemic inflammation caused by periodontal disease (PD) can determine important changes in the coronary arteries, favoring atherosclerosis progression and the development of acute coronary syndromes (ACS). The aim of the ATHERODENT study (Protocol Record Number CM0117-ATD) is to assess the interrelation between PD, inflammation, and the progression of coronary atherosclerosis in patients with ACS.

Material and methods: This case-control observational study will enroll 100 patients (group 1 – ACS and associated PD, and group 2 – ACS and no PD), in whom the following data will be collected: (1) demographic and clinical data; (2) cardiovascular risk factors; (3) full characterization of PD markers; (4) systemic inflammatory biomarkers; (5) imaging biomarkers derived from transthoracic echocardiography, computed tomography, coronary angiography, optical coherence tomography, and intravascular ultrasound; and (6) assessment of the presence of specific oral bacteria in samples of coronary plaques collected by coronary atherectomy, which will be performed during percutaneous revascularization interventions, when indicated in selected cases, in the atherectomy sub-study. The follow-up will be performed at 1, 3, 6, 12, 15, 18, and 24 months. The primary endpoint of the study will be represented by the rate of major adverse cardiovascular events (MACE) in PD vs. non-PD patients and in correlation with: (1) the level of systemic inflammation triggered by PD and/or by ACS at baseline; (2) the vulnerability degree of atheromatous plaques in the coronary tree (culprit and non-culprit lesions); and (3) the presence and burden of oral bacteria in atheromatous plaques. Secondary endpoints will be represented by: (1) the rate of progression of vulnerability degree of non-culprit coronary plaques; (2) the rate of progression of atheromatous burden and calcium scoring of the coronary tree; and (3) the rate of occurrence of left ventricular remodeling and post-infarction heart failure. The ATHERODENT study has been registered in clinicaltrials.gov (ClinicalTrials.gov Identifier: NCT03395041).

Open access

Victoria Rus, Diana Opincariu, Roxana Hodas, Tiberiu Nyulas, Marian Hintea and Theodora Benedek

Abstract

Background: The impact of nutritional status on the early outcome of subjects with acute myocardial infarction (AMI) is still not completely elucidated. This study aimed to assess the correlation between nutritional status, as expressed by the CONUT and PIN scores, and (1) clinical and laboratory characteristics, (2) complication rates, and (3) length of hospitalization, in patients with AMI.

Materials and methods: We included 56 consecutive patients with AMI who underwent primary percutaneous intervention and stenting. Evaluation of the nutritional status was comprised in the calculation of the CONUT and PNI scores. The study population was divided into 2 groups according to the calculated CONUT score, as follows: group 1 – CONUT score <3 points (normal to mildly impaired nutritional status) and group 2 – CONUT score ≥3 points (moderate to severe malnutrition). The primary end-point of the study was the rate of in-hospital complications (left ventricular free wall rupture, hemodynamic instability requiring inotropic medication, high-degree atrioventricular block, the need for temporary cardiostimulation, supraventricular and ventricular arrhythmias and in-hospital cardiac arrest). The secondary end-points included the duration of hospitalization and the length of stay in the intensive cardiac care unit.

Results: In total, 56 patients (44.64% with STEMI, 55.35% with NSTEMI) with a mean age of 61.96 ± 13.42 years, 58.92% males were included in the study. Group distribution was: group 1 – 76.78% (n = 43), group 2 – 23.21% (n = 23). There were no differences between the two groups regarding age, gender, cardiovascular risk factors, or comorbidities. PNI index in group 1 was 54.4 ± 10.4 and in group 2 41.1 ± 2.8, p <0.0001. Serum albumin was significantly lower in group 1 – 4.1 ± 0.3 vs. group 2 – 3.6 ± 0.3 (p <0.0001), similarly to total cholesterol levels (group 1 – 194.9 ± 41.5 vs. group 2 – 161.2 ± 58.2, p = 0.02). The complete blood cell count showed that group 2 presented lower levels of hematocrit (p = 0.003), hemoglobin (p = 0.002), and lymphocytes (p <0.0001) compared to group 1, but a significantly higher platelet count (p = 0.001), mean platelet volume (p = 0.03), neutrophil/lymphocyte (p <0.0001) and platelet/lymphocyte (p <0.0001) ratios, indicating enhanced blood thrombogenicity and inflammation. Regarding in-hospital complications, group 2 presented a higher rate of hemodynamic instability (group 1 – 11.6% vs. group 2 – 38.4%, p = 0.02). The overall hospitalization period was 7.7 ± 1.4 days in group 1 vs. 10.2 ± 4.8 days in group 2, p = 0.06; while the duration of stay in the intensive cardiac care unit was 2.6 ± 0.5 days in group 1 vs. 4.0 ± 2.5 days in group 2, p = 0.02.

Conclusions: This study proved that nutritional deficit in acute myocardial patients who undergo revascularization is associated with an increased rate of in-hospital complications and with a longer observation time in a tertiary intensive cardiac care unit.

Open access

Anca Negovan, András Mester and Dan Dumitrașcu

Abstract

Cardiovascular and digestive diseases frequently share the same risk factors such as obesity, unhealthy diet, or several social behaviors, and the increasing prevalence of patients with overlapped cardiovascular and digestive symptoms is a challenging problem in the daily practice. Patients with gastro-esophageal reflux disease can exhibit various forms of chest pain that can be very similar to angina. Furthermore, antithrombotic therapies used for preventive or curative purposes in patients with cardiovascular diseases are frequently associated with gastrointestinal side effects including bleeding. At the same time, in patients with coronary stents presenting to the emergency department with chest pain, angina triggered by stent thrombosis or restenosis should be differentiated from angina-like symptoms caused by a gastrointestinal disease. The aim of this review was to present the complex inter-relation between gastroesophageal diseases and angina in patients on dual antiplatelet therapy following an acute coronary syndrome, with a particular emphasis on the role of anemia resulting from occult or manifest gastrointestinal bleeding, as a precipitating factor for triggering or aggravating angina.

Open access

Anca Chiriac, Piotr Brzezinski, Mircea Betiu and Liliana Foia

Abstract

Angiotensin-converting enzyme inhibitors (ACEI) are widely used drugs nowadays in treating patients diagnosed with cardiovascular disorders. We present two consecutive cases of acquired angioedema caused by the administration of enalapril and lisinopril in patients with indication for ACE-inhibitors therapy. Rigorous follow-up of side effects of ACEI is required, due to these possible life-threatening adverse reactions.

Open access

Uros Smrdel, Marija Skoblar Vidmar and Ales Smrdel

Abstract

Background

Glioblastoma has in last 20 years seen the steady increase of incidence, which is most prominent in the group of older patients. These older than 70 years have significantly poorer prognosis than other patients and are considered a distinct group of glioblastoma patients. Modified prognostic factors are being used in these patients and this information is lately supplemented with the genetic and epigenetic information on tumour. The therapy is now often tailored accordingly. The aim of our study was to analyse the current treatment of the glioblastoma patients over 70 years of age to determine the impact of clinical prognostic factors.

Patients and methods

Among patients treated at the Institute of Oncology Ljubljana between 1997 and 2015, we found that 207 were older than 70 years. We analysed their survival, clinical prognostic factors (age, performance status) treatment modalities (extent of surgery, radiation dose, chemotherapy).

Results

Median survival of patients older than 70 years was 5.3 months which was statistically significant inferior to the survival of younger patients (p < 0.001). The clinical prognostic factors that influenced survival the most were performance status (p < 0.001), extent of surgical resection (p < 0.001), addition of temozolomide (p < 0.001) and addition of radiotherapy (p = 0.006). Patients receiving concomitant radiochemotherapy with temozolomide followed by adjuvant temozolomide, had same median survival as patients receiving adjuvant temozolomide after completion of radiotherapy.

Conclusions

The increase of the number of older patients with glioblastoma corresponds to the increase in the life expectancy but in Slovenia also to the increased availability of diagnostic procedures. Clinical prognostic markers are helpful in decision on the aggressiveness of treatment. Radiotherapy and temozolomide have the biggest impact on survival, but the radiotherapy dose seems to be of secondary importance. In selected patients, chemotherapy alone might be sufficient to achieve an optimal effect. Patients that were fitter, had more aggressive surgery, and received temozolomide fared the best. The scheduling of the temozolomide seems to have limited impact on survival as in our study, there was no difference weather patients received temozolomide concomitant with radiotherapy or after the radiotherapy. Thus far, our findings corroborate the usefulness of recursive partitioning analysis (RPA) classes in clinical decisions.