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A multicentre prospective survey on the use of artificial nutrition (AN) and its complications has been carried out on 1657 hospitalised patients including 7.8% in surgical departments, 7.1% in medical departments and 59.9% in intensive care units. Gastrointestinal diseases and cancer were the most frequent pathologies among patients requiring AN. Parenteral nutrition (PN) alone was employed in 1103 (66.5%) patients. In 267 (16.1%) PN was associated with enteral nutrition (EN). 287 (17.3%) patients were fed by the enteral route alone. The average daily energy intake was 35 kcal/kg for central PN, 26 kcal/kg for peripheral PN and 33 kcal/kg for EN. The mean daily nitrogen intake was 0.19 g/kg for central PN, 0.17 g/kg for peripheral PN and 0.20 g/kg for EN. In 10% of patients PN was electrolyte free and in only 50% all the main electrolytes were added. Trace elements were added in 48% of formulations, mainly as multiple combination. Insulin was added in 61% of PN patients, while albumin was given with PN in 20% of patients. Adverse reactions were observed in 10.9% of PN patients and in 11.5% of EN patients. The most frequent complications occurring in parenterally fed patients were infections of the central venous catheter and metabolic alterations (severe electrolyte abnormalities, liver or renal dysfunction, hypo or persistent hyperglycemia). In enterally fed patients the frequent complications were abdominal distension, cramps and diarrhoea. Adverse reactions were responsible for discontinuation of AN in 2.2% of parenterally supported patients and in 5.7% of enterally fed patients.

Purpose: To investigate the feasibility of using the ratio of dose-area product at 20 cm and 10 cm water depths (DAPR20,10) as a beam quality specifier for radiotherapy photon beams with field diameter below 2 cm. Methods: Dose-area product was determined as the integral of absorbed dose to water (Dw) over a surface larger than the beam size. 6 MV and 10 MV photon beams with field diameters from 0.75 cm to 2 cm were considered. Monte Carlo (MC) simulations were performed to calculate energy-dependent dosimetric parameters and to study the DAPR20,10 properties. Aspects relevant to DAPR20,10 measurement were explored using large-area plane-parallel ionization chambers with different diameters. Results: DAPR20,10 was nearly independent of field size in line with the small differences among the corresponding mean beam energies. Both MC and experimental results showed a dependence of DAPR20,10 on the measurement setup and the surface over which Dw is integrated. For a given setup, DAPR20,10 values obtained using ionization chambers with different air-cavity diameters agreed with one another within 0.4%, after the application of MC correction factors accounting for effects due to the chamber size. DAPR20,10 differences among the small field sizes were within 1% and sensitivity to the beam energy resulted similar to that of established beam quality specifiers based on the point measurement of Dw. Conclusions: For a specific measurement setup and integration area, DAPR20,10 proved suitable to specify the beam quality of small photon beams for the selection of energy-dependent dosimetric parameters. © 2017 Associazione Italiana di Fisica Medica

Objective The biological heterogeneity of hepatocellular carcinoma (HCC) makes prognosis difficult. We translate the results of a genome-wide high-throughput analysis into a tool that accurately predicts at presentation tumour growth and survival of patients with HCC.Design Ultrasound surveillance identified HCC in 78 (training set) and 54 (validation set) consecutive patients with cirrhosis. Patients underwent two CT scans 6 weeks apart (no treatment in-between) to determine tumour volumes (V-0 and V-1) and calculate HCC doubling time. Baseline-paired HCC and surrounding tissue biopsies for microarray study (Agilent Whole Human Genome Oligo Microarrays) were also obtained. Predictors of survival were assessed by multivariate Cox model.Results Calculated tumour doubling times ranged from 30 to 621 days (mean, 107 +/- 91 days; median, 83 days) and were divided into quartiles: = 111 days (n= 19). Median survival according to doubling time was significantly lower for the first quartile versus the others (11 vs 41 months, 42, and 47 months, respectively) (p< 0.0001). A five-gene transcriptomic hepatic signature including angiopoietin-2 (ANGPT2), delta-like ligand 4 (DLL4), neuropilin (NRP)/tolloid (TLL)-like 2 (NETO2), endothelial cell-specific molecule-1 (ESM1), and nuclear receptor subfamily 4, group A, member 1 (NR4A1) was found to accurately identify rapidly growing HCCs of the first quartile (ROC AUC: 0.961; 95% CI 0.919 to 1.000; p< 0.0001) and to be an independent factor for mortality (HR: 3.987; 95% CI 1.941 to 8.193, p< 0.0001).Conclusions The hepatic five-gene signature was able to predict HCC growth in individual patient and the consequent risk of death. This implies a role of this molecular tool in the future therapeutic management of patients with HCC.

Background & Aims: Portosystemic encephalopathy (PSE) is a major complication of trans-jugular intrahepatic porto-systemic shunt (TIPS) placement. Most devices are self-expandable polytetrafluoroethylene-covered stent grafts (PTFE-SGs) that are dilated to their nominal diameter (8 or 10 mm). We investigated whether PTFE-SGs dilated to a smaller caliber (under-dilated TIPS) reduce PSE yet maintain clinical and hemodynamic efficacy. We also studied whether under-dilated TIPS self-expand to nominal diameter over time. Methods: We performed a prospective, non-randomized study of 42 unselected patients with cirrhosis who received under-dilated TIPS (7 and 6 mm) and 53 patients who received PTFE-SGs of 8 mm or more (controls) at referral centers in Italy. After completion of this study, dilation to 6 mm became the standard and 47 patients were included in a validation study. All patients were followed for 6 months; Doppler ultrasonography was performed 2 weeks and 3 months after TIPS placement and every 6 months thereafter. Stability of PTFE-SG diameter was evaluated by computed tomography analysis of 226 patients with cirrhosis whose stent grafts increased to 6, 7, 8, 9, or 10 mm. The primary outcomes were incidence of at least 1 episode of PSE grade 2 or higher during follow up, incidence of recurrent variceal hemorrhage or ascites, incidence of shunt dysfunction requiring TIPS recanalization, and reduction in porto-caval pressure gradient. Results: PSE developed in a significantly lower proportion of patients with under-dilated TIPS (27%) than controls (54%) during the first year after the procedure (P =.015), but the proportions of patients with recurrent variceal hemorrhage or ascites did not differ significantly between groups. No TIPS occlusions were observed. These results were confirmed in the validation cohort. In an analysis of self-expansion of stent grafts, during a mean follow-up period of 252 days after placement, none of the PTFE-SGs self-expanded to the nominal diameter in hemodynamically relevant sites (such as portal and hepatic vein vascular walls). Conclusions: In prospective, non-randomized study of patients with cirrhosis, we found under-dilation of PTFE-SGs during TIPS placement to be feasible, associated with lower rates of PSE, and effective.

Feline viral plaques are uncommon skin lesions clinically characterized by multiple, often pigmented, and slightly raised lesions. Numerous reports suggest thatpapillomaviruses(PVs) are involved in their development. Immunosuppressed and immunocompetent cats are both affected, the biological behavior is variable, and the regression is possible but rarely documented. Here we report a case of a FIV-positive cat with skin fragility syndrome and regressing multiple viral plaques in which the contemporary presence of two PV types (FcaPV2 and FcaPV3) was demonstrated by combining a quantitative molecular approach to histopathology. The cat, under glucocorticoid therapy for stomatitis and pruritus, developed skin fragility and numerous grouped slightly raised nonulcerated pigmented macules and plaques with histological features of epidermal thickness, mild dysplasia, and presence of koilocytes. Absolute quantification of the viral DNA copies (4555 copies/microliter of FcaPV2 and 8655 copies/microliter of FcaPV3) was obtained. Eighteen months after discontinuation of glucocorticoid therapy skin fragility and viral plaques had resolved. The role of the two viruses cannot be established and it remains undetermined how each of the viruses has contributed to the onset of VP; the spontaneous remission of skin lesions might have been induced by FIV status change over time due to glucocorticoid withdraw and by glucocorticoids withdraw itself.

A new diamond detector to perform absorbed-dose- to-water measurement in radiotherapy photon beams with small field sizes is being developed in the framework of the EURAMET/EC FP7 project “External Beam Cancer Therapy”. An objective of the project is to obtain detectors capable of ensuring traceability of absorbed dose measurements in radiotherapy photon beams with field size down to 1 cm x 1 cm. To this end the CVD diamond detectors up to now developed were found not adequate. The present project requires detectors with high spatial resolution, good stability and low energy dependence. Diamond detectors were chosen for their high spatial resolution and good tissue equivalence (Z = 6). The detector studied in this work is based on a single crystal CVD diamond with dimensions 3 mm x 3 mm x 0.5 mm on which 0.2 μm electrodes were thermally evaporated. Particular care was addressed to ensure the tissue-equivalence of the detector by using appropriate materials. A thorough analysis of the priming procedure, stability and signal reproducibility was carried out in a Co-60 gamma beam at dose rates in the range from 0.3 Gy min− 1 to 1.38 Gy min− 1. Moreover the detector response was studied by Monte Carlo calculations as a function both of the beam quality, from Co-60 to 10 MV photon beams, and field size, from 10 cm x 10 cm to 1 cm x 1 cm. The perturbation due to the non-water equivalence of electrodes was also determined by Monte Carlo simulations.

BACKGROUND & AIMS: We performed a randomized controlled trial to evaluate the safety and efficacy of enoxaparin, a low-molecular-weight heparin, in preventing portal vein thrombosis (PVT) in patients with advanced cirrhosis. METHODS: In a nonblinded, single-center study, 70 outpatients with cirrhosis (Child-Pugh classes B7-C10) with demonstrated patent portal veins and without hepatocellular carcinoma were assigned randomly to groups that were given enoxaparin (4000 IU/day, subcutaneously for 48 weeks; n = 34) or no treatment (controls, n = 36). Ultrasonography (every 3 months) and computed tomography (every 6 months) were performed to check the portal vein axis. The primary outcome was prevention of PVT. Radiologists and hepatologists that assessed outcomes were blinded to group assignments. Analysis was by intention to treat. RESULTS: At 48 weeks, none of the patients in the enoxaparin group had developed PVT, compared with 6 of 36 (16.6%) controls (P = .025). At 96 weeks, no patient developed PVT in the enoxaparin group, compared with 10 of 36 (27.7%) controls (P = .001). At the end of the follow-up period, 8.8% of patients in the enoxaparin group and 27.7% of controls developed PVT (P = .048). The actuarial probability of PVT was lower in the enoxaparin group (P = .006). Liver decompensation was less frequent among patients given enoxaparin (11.7%) than controls (59.4%) (P < .0001); overall values were 38.2% vs 83.0%, respectively (P < .0001). The actuarial probability of liver decompensation was lower in the enoxaparin group (P < .0001). Eight patients in the enoxaparin group and 13 controls died. The actuarial probability of survival was higher in the enoxaparin group (P = .020). No relevant side effects or hemorrhagic events were reported. CONCLUSIONS: In a small randomized controlled trial, a 12-month course of enoxaparin was safe and effective in preventing PVT in patients with cirrhosis and a Child-Pugh score of 7-10. Enoxaparin appeared to delay the occurrence of hepatic decompensation and to improve survival.