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Background and Aims: Cirrhosis is the main risk factor of hepatocellular carcinoma (HCC), but only a minority of cirrhotic patients are referred to the hepatologist by primary care physicians (PCP) and receive regular ultrasound surveillance. The aim of this study was to determine whether a training program targeted to PCP could enhance the effectiveness of surveillance in a real-life setting., Patients and Methods: A total of 120 PCP in an Italian area with a high incidence of HCC were trained to identify cirrhotic patients, to refer them to the Hepatology Centers of the area, and to start regular ultrasound surveillance. Clinical characteristics, outcome of treatments, and survival of 190 consecutive HCC patients in the same centers after training were compared with 244 HCC referred from the same area before training, and to 232 HCC referred by untrained PCP from other areas., Results: Trained PCP referred significantly more HCC patients detected under surveillance and at an early stage (Barcelona Clinic Liver Cancer-A), suitable for radical treatments. In the intervention area, the 3 and 5-year survival of HCC patients increased after training from 35 to 48% and from 20 to 40%, respectively (P<0.05). In contrast, survival was unchanged in the other areas. At multivariate analysis, independent predictors adversely affecting survival were Child-Pugh B-C, α-fetoprotein more than 10 ng/dl, nonviral etiology, intermediate/advanced Barcelona Clinic Liver Cancer stage, and referral by an untrained PCP., Conclusion: Specific training of PCP aimed at the identification and referral of cirrhotic patients efficiently improves HCC survival.

There is growing evidence that factors encoded by cytoplasmic replicating viruses functionally interact with components of the nucleocytoplasmic transport apparatus. They do so either to access the cell nucleus, thus affecting genes expression, or to interfere with nuclear transport functionality, hindering host immune response. Recent studies revealed that the hepatitis C virus (HCV) makes no exception, interacting with the host cell nuclear transport machinery at two different levels. On the one hand, small amounts of both core and NS5A localize within the host cell nucleus during productive infection, modulating gene expression and signaling functions to promote persistent infection. On the other hand, HCV infection causes a profound redistribution of certain nucleoproteins to the close proximity of endoplasmic reticulum membrane-derived viral replication factories, where viral RNA amplification occurs. These nucleoporins are believed to form nuclear pore complex-like structures, as suggested by their ability to recruit nuclear localization sequence-bearing proteins. Thus, both processes are linked to virus-induced persistence and pathogenesis, representing possible targets for the development of novel anti-HCV therapeutics.

Background: The senile lung undergoes physiologic changes that are well known but have not been investigated with ultrasound (US). Thus, the aim of our study was to compare the US appearances of the lungs in a group of healthy, nonsmoker elderly subjects with those in a group of young subjects., Methods: One hundred elderly subjects older than 65 years of age (mean age ± SD, 79 ± 7 years) and 50 younger subjects less than 56 years of age (mean age ± SD, 33 ± 12) underwent US examination of the lungs. We analyzed the anterior, midlateral, and posterobasal surface of each lung to evaluate the presence or absence of A-lines and B-lines. Fisher's exact test and Pearson's χ 2 test were used to compare the findings in the two groups., Results: A-lines were absent in 94/100 (94%) elderly subjects versus 2/50 (4%) young subjects (p < 0.0001). B-lines were found in 37/100 (37%) elderly subjects: ≤3 lines per field of view in 27/37 (73%); >3 lines in 2/37 (5%); both ≤3 lines and >3 lines (depending on the region scanned) in 8/37 (22%). In contrast, only in 5/50 (10%) young subjects were B-lines visible (≤3 lines per field of view in all cases [p < 0.001])., Conclusions: The majority of the elderly subjects did not have A-lines, and B-lines were observed in a high percentage. The reduction of impedance between lung parenchyma and soft tissues of the chest wall and the increased thickness of interlobular septa might explain these results. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 43:230-234, 2015., (© 2014 Wiley Periodicals, Inc.)

Background & Aims: The role of hepatic resection for hepatocellular carcinoma (HCC) in different Barcelona Clinic Liver Cancer (BCLC) stages is controversial. We aimed at measuring the survival benefit of resection vs. non-surgical-therapies in each BCLC stage., Methods: Using the ITA.LI.CA database, we identified 2090 BCLC A, B, and C HCC patients observed between 2000 and 2012: 550 underwent resection, 1046 loco-regional therapy (LRT), and 494 best supportive care (BSC). A multivariate log-logistic model was chosen to predict median survival (MS) after resection vs. MS after LRT or BSC. The results were expressed as net survival benefit of resection: (MS resection-MS LRT)/MS BSC., Results: After stratifying for BCLC stage, the median net survival benefit of resection over LRT was: BCLC 0=62% (40%, 82%), A=45% (13%, 65%), B=46% (9%, 76%), C=-16% (-55%, 33%). Model for end-stage liver disease (MELD) score>9, Child B class, and performance status (PST)=2 were the main risk factors for liver resection. 1181 Child A patients (57%) with MELD⩽9 and PST<2 had always a large positive net survival benefit of resection over LRT, independently of BCLC stage: BCLC 0=64% (44%, 85%), A=59% (45%, 74%), B=71% (52%, 90%), C=56% (36%, 78%). Among the 909 (43%) patients with at least one risk factor (MELD>9 or PST=2 or Child B class), resection did not prove any survival benefit over LRT., Conclusions: Resection could result in survival benefit over LRT for HCC patients regardless of their BCLC stage, provided that liver dysfunction (Child B or MELD>9) and PST>1 are absent., (Copyright © 2014 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Background: Age-associated changes in the pulmonary system could be detected with imaging techniques. Widespread use of lung ultrasonography (US) requires characterization of a normal pattern., Objectives: To compare US and computed tomography (CT) findings in healthy subjects undergoing both techniques (with CT as the gold standard)., Methods: We prospectively selected 59 subjects undergoing chest CT and US on the same day, without a history of smoking, respiratory symptoms, or known pulmonary pathologies. There were 44 patients in group 1 (age ≥60 years - elderly) and 15 patients in group 2 (age ≤50 years - young). Lung US was performed with a convex and a linear probe, and 10 chest areas per patient were analyzed. Convex and linear probe agreement was evaluated by means of the Cohen κ statistic; Fisher's exact test was used to compare categorical variables between groups., Results: Isolated B-lines were frequent in both group 1 (54.5%) and group 2 (40.0%); the number of chest areas positive for B-lines increased with age (16.1% in group 1 vs. 5.3% in group 2, p = 0.0028). In group 2, we found that 37.5% of subjects with B-lines had at least 1 chest area with multiple B-lines, but only 2 subjects had 2 or more. Moreover, in group 1 the chest CT documented a reticular pattern (2.3%), areas of increased density (9.1%), ground glass (6.8%), cysts (2.3%), bronchiectasis (22.7%), and bronchial thickening (6.8%); in group 2, only cysts (6.7%) and bronchiectasis (6.7%) were found., Conclusions: The senile lung is characterized by mild changes on CT and US. Chest areas positive for B-lines increase with age, and focal multiple B-lines can be found. However, diffuse patterns, especially in symptomatic subjects, suggest a different diagnosis.

Anti-VEGF therapy perturbs tumor metabolism, severely impairing oxygen, glucose, and ATP levels. In this study, we investigated the effects of anti-VEGF therapy in multiple experimental tumor models that differ in their glycolytic phenotypes to gain insights into optimal modulation of the metabolic features of this therapy. Prolonged treatments induced vascular regression and necrosis in tumor xenograft models, with highly glycolytic tumors becoming treatment resistant more rapidly than poorly glycolytic tumors. By PET imaging, prolonged treatments yielded an increase in both hypoxic and proliferative regions of tumors. A selection for highly glycolytic cells was noted and this metabolic shift was stable and associated with increased tumor aggressiveness and resistance to VEGF blockade in serially transplanted mice. Our results support the hypothesis that the highly glycolytic phenotype of tumor cells studied in xenograft models, either primary or secondary, is a cell-autonomous trait conferring resistance to VEGF blockade. The finding that metabolic traits of tumors can be selected by antiangiogenic therapy suggests insights into the evolutionary dynamics of tumor metabolism., (©2014 American Association for Cancer Research.)

Background: HCC patients are heterogeneous in terms of both tumor and liver factors. Alpha-fetoprotein (AFP) is an important prognostic tumor marker for those patients with elevated AFP levels., Aims: To examine the differences in HCC patients with high or low AFP levels in blood and evaluate the prognostic parameters in low AFP patients., Methods: A cohort of 2,440 HCC patients from 11 Italian medical centers was studied. AFP-positive patients were compared to AFP-negative ones, and the blood and tumor parameters of AFP-negative patients were examined., Results: Low blood AFP levels were found in 58% of the total cohort, in 64% of patients with small HCCs, and in 51% of patients with large HCCs. In patients with large tumors, platelet and gamma glutamyl transpeptidase (GGTP) levels, tumor multifocality and portal vein thrombosis (PVT) incidence were all greater than in patients with small tumors, regardless of AFP status. Patients with higher AFP levels had worse survival rates than those with low AFP in each tumor size group. In patients with small tumors, the elevated AFP was associated with significantly increased PVT and worse survival. In patients with large tumors, the elevated AFP was associated with significantly higher GGTP, ALKP, and bilirubin levels, as well as with increased PVT and multifocality, and worse survival. Low-AFP patients with high GGTP levels had worse survival than patients with low GGTP levels., Conclusion: Patients with low AFP were the majority in this cohort, and patients with elevated GGTP had worse prognosis than those with low GGTP. GGTP may be a useful tumor and prognosis marker in low-AFP patients. AFP-negative patients are important to identify due to their enhanced survival.

Imaging plays a key role in the diagnosis and follow-up of acute respiratory distress syndrome (ARDS). Chest radiography, bedside lung ultrasonography and computed tomography scans can provide useful information for the management of patients and detection of prognostic factors. However, imaging findings are not specific and several possible differential diagnoses should be taken into account. Herein we will review the role of radiological techniques in ARDS, highlight the plain radiological and computed tomography findings according to the pathological stage of the disease (exudative, inflammatory and fibroproliferative), and summarise the main points for the differential diagnosis with cardiogenic oedema, which is still challenging in the acute stage., (©ERS 2014.)

Background & Aims: Ultrasound surveillance does not detect early stage hepatocellular carcinomas (HCCs) in some patients with cirrhosis, although the reasons for this have not been well studied. We assessed the rate at which ultrasound fails to detect early stage HCCs and factors that affect its performance., Methods: We collected information on 1170 consecutive patients included in the Italian Liver Cancer (ITA.LI.CA) database who had Child-Pugh A or B cirrhosis and were diagnosed with HCC during semiannual or annual ultrasound surveillance, from January 1987 through December 2008. Etiologies included hepatitis C virus infection (59.3%), alcohol abuse (11.3%), hepatitis B virus infection (9%), a combination of factors (15.6%), and other factors (4.7%). Surveillance was considered to be a failure when patients were diagnosed with HCC at a stage beyond the Milan criteria (1 nodule ≤5 cm or ≤3 nodules each ≤3 cm)., Results: HCC was found beyond Milan criteria in 34.3% of surveilled patients (32.2% during semi-annual surveillance and 41.3% during annual surveillance; P < .01). Nearly half of surveillance failures were associated with at least one indicator of aggressive HCC (levels of AFP >1000 ng/mL, infiltrating tumors, or vascular invasion and metastases). Semiannual surveillance, female sex, Child-Pugh class A, and α-fetoprotein levels of 200 ng/mL or less were associated independently with successful ultrasound screening for HCC., Conclusions: Based on our analysis of surveillance for HCC in patients with cirrhosis, the efficacy of ultrasound-based screening is acceptable. Ultrasound was least effective in identifying aggressive HCC, and at surveillance intervals of more than 6 months., (Copyright © 2014 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objective: The authors sought to evaluate the diagnostic accuracy of high-resolution computed tomography (HRCT) in the detection of pulmonary veno-occlusive disease (PVOD) in patients with pre-capillary pulmonary arterial hypertension (PAH) of unknown aetiology, and to identify the role of CT in diagnosis and therapy., Materials and Methods: The CT scans of 96 patients were retrospectively reviewed and assessed for specific HRCT findings: ground-glass opacities, septal lines and mediastinal lymph nodal enlargement (short diameter ≥1 cm). According to the HRCT findings, patients were divided into PVOD-suspicious and not PVOD-suspicious. Subsequently, a clinical-instrumental evaluation was performed, and the response to therapy and histopathological reports were evaluated., Results: Radiological evaluation based on HRCT findings revealed 29 patients as PVOD-suspicious and 67 as not PVOD-suspicious. The final diagnosis was PVOD in 22 patients and idiopathic PAH in 74 patients. The CT scan showed 95.5 % sensitivity, 89% specificity, 72.5% positive predictive value, and 98.5% negative predictive value, with a diagnostic accuracy of 90.5% in identifying patients with PVOD., Conclusions: Chest CT can be considered a screening test in the assessment of patients with PAH of unknown aetiology, and the radiologist can help the clinician to identify patients with CT findings that make PVOD highly probable.

Background & Aims: Lead-time is the time by which diagnosis is anticipated by screening/surveillance with respect to the symptomatic detection of a disease. Any screening program, including surveillance for hepatocellular carcinoma (HCC), is subject to lead-time bias. Data regarding lead-time for HCC are lacking. Aims of the present study were to calculate lead-time and to assess its impact on the benefit obtainable from the surveillance of cirrhotic patients., Methods: One-thousand three-hundred and eighty Child-Pugh class A/B patients from the ITA.LI.CA database, in whom HCC was detected during semiannual surveillance (n = 850), annual surveillance (n = 234) or when patients came when symptomatic (n = 296), were selected. Lead-time was estimated by means of appropriate formulas and Monte Carlo simulation, including 1000 patients for each arm., Results: The 5-year overall survival after HCC diagnosis was 32.7% in semiannually surveilled patients, 25.2% in annually surveilled patients, and 12.2% in symptomatic patients (p<0.001). In a 10-year follow-up perspective, the median lead-time calculated for all surveilled patients was 6.5 months (7.2 for semiannual and 4.1 for annual surveillance). Lead-time bias accounted for most of the surveillance benefit until the third year of follow-up after HCC diagnosis. However, even after lead-time adjustment, semiannual surveillance maintained a survival benefit over symptomatic diagnosis (number of patients needed to screen = 13), as did annual surveillance (18 patients)., Conclusions: Lead-time bias is the main determinant of the short-term benefit provided by surveillance for HCC, but this benefit becomes factual in a long-term perspective, confirming the clinical utility of an anticipated diagnosis of HCC., (Copyright © 2014 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Background: α-Fetoprotein (AFP) is a biomarker commonly used in the management of patients with hepatocellular carcinoma (HCC), although the possible determinants of its serum levels in these patients have not been adequately explored. For this study, the authors evaluated the relevance of demographic, clinical, and oncologic factors to the presence of elevated AFP levels in large cohort of patients with HCC., Methods: In 4123 patients with HCC who were managed by the Italian Liver Cancer Group, AFP levels were assessed along with their association with demographic, biochemical, clinical, and oncologic characteristics. Patients were subdivided according to the presence of elevated AFP (ie, >10 ng/mL)., Results: AFP levels were elevated in 62.4% of patients with HCC. Multivariate logistic regression analysis indicated that being a woman (odds ratio [OR], 1.497; 95% confidence interval [95%CI], 1.250-1.793; P < .0001), the presence of cirrhosis (OR, 1.538; 95% CI, 1.050-2.254; P = .027), liver disease with viral etiology (OR, 1.900; 95% CI, 1.589-2.272; P < .0001), an elevated alanine aminotransferase level (OR, 1.878; 95% CI, 1.602-2.202; P < .0001), a low albumin level (OR, 1.301; 95% CI, 1.110-1.525; P = .012), an HCC tumor size >2 cm (OR, 1.346; 95% CI, 1.135-2.596; P = .001), multinodular HCC (OR, 1.641; 95% CI, 1.403-1.920; P < .0001), and the presence of vascular invasion (OR, 1.774; 95% CI, 1.361-2.311; P < .0001) were associated independently with elevated levels of AFP. Both the median AFP level and the proportion of patients who had elevated levels increased with decreasing degrees of HCC differentiation (P < .0001)., Conclusions: Sex and features of chronic liver disease were identified as nontumor characteristics that influence serum AFP levels in patients with HCC. These findings should be taken into account as limitations in interpreting the oncologic meaning of this biomarker in clinical practice., (© 2014 American Cancer Society.)

Aim: To evaluate laparoscopic re-sleeve gastrectomy as a treatment of weight regain after Sleeve., Methods: Laparoscopic sleeve gastrectomy is a common bariatric procedure. Weight regain after long-term follow-up is reported. Patients were considered for laparoscopic re-sleeve gastrectomy when we observed progressive weight regain and persistence of comorbidities associated with evidence of dilated gastric fundus and/or antrum on upper gastro-intestinal series. Follow-up visits were scheduled at 1, 3, 6 and 12 mo after surgery and every 6 mo thereafter. Measures of change from baseline at different times were analyzed with the paired samples t test., Results: We observed progressive weight regain after sleeve in 11 of the 201 patients (5.4%) who had a mean follow-up of 21.1 ± 9.7 mo (range 6-57 mo). Three patients started to regain weight after 6 mo following Sleeve, 5 patients after 12 mo, 3 patients after 18 m. Re-sleeve gastrectomy was always performed by laparoscopy. The mean time of intervention was 55.8 ± 29.1 min. In all cases, neither intra-operative nor post-operative complications occurred. After 1 year follow-up we observed a significant (P < 0.05) mean body mass index reduction (-6.6 ± 2.7 kg/m(2)) and mean % excess weight loss (%EWL) increase (+31.0% ± 15.8%). An important reduction of antihypertensive drugs and hypoglycemic agents was observed after re-sleeve in those patients affected by hypertension and diabetes. Joint problems and sleep apnea syndrome improved in all 11 patients., Conclusion: Laparoscopic re-sleeve gastrectomy is a feasible and effective intervention to correct weight regain after sleeve.

Previous work has shown that two general processes contribute to hepatocellular cancer (HCC) prognosis: liver damage, monitored by indices such as blood bilirubin, prothrombin time (PT), and aspartate aminostransferase (AST); and tumor biology, monitored by indices such as tumor size, tumor number, presence of portal vein thrombosis (PVT) and blood alpha-fetoprotein (AFP) levels. These processes may affect one another, with prognostically significant interactions between multiple tumor and host parameters. These interactions form a context that provide personalization of the prognostic meaning of these factors for every patient. Thus, a given level of bilirubin or tumor diameter might have a different significance in different personal contexts. We previously applied network phenotyping strategy (NPS) to characterize interactions between liver function indices of Asian HCC patients and recognized two clinical phenotypes, S and L, differing in tumor size and tumor nodule numbers. Our aim was to validate the applicability of the NPS-based HCC S/L classification on an independent European HCC cohort, for which survival information was additionally available. Four sets of peripheral blood parameters, including AFP-platelets, derived from routine blood parameter levels and tumor indices from the ITA.LI.CA database, were analyzed using NPS, a graph-theory-based approach that compares personal patterns of complete relationships between clinical data values to reference patterns with significant association to disease outcomes. Without reference to the actual tumor sizes, patients were classified by NPS into two subgroups with S and L phenotypes. These two phenotypes were recognized using solely the HCC screening test results, consisting of eight common blood parameters, paired by their significant correlations, including an AFP-platelets relationship. These trends were combined with patient age, gender, and self-reported alcoholism into NPS personal patient profiles. We subsequently validated (using actual scan data) that patients in L phenotype group had 1.5× larger mean tumor masses relative to S, P = 6 × 10(-16). Importantly, with the new data, liver test pattern-identified S-phenotype patients had typically 1.7× longer survival compared to L-phenotype patients. NPS integrated the liver, tumor, and basic demographic factors. Cirrhosis-associated thrombocytopenia was typical for smaller S tumors. In L tumor phenotype, typical platelet levels increased with the tumor mass. Hepatic inflammation and tumor factors contributed to more aggressive L tumors, with parenchymal destruction and shorter survival. NPS provides integrative interpretation for HCC behavior, identifying two tumor and survival phenotypes by clinical parameter patterns. The NPS classifier is provided as an Excel tool. The NPS system shows the importance of considering each tumor marker and parameter in the total context of all the other parameters of an individual patient., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Cirrhosis-related abnormal liver function is associated with predisposition to hepatocellular carcinoma (HCC). It features in several HCC classification systems and is an HCC prognostic factor. The aim of the present study was to examine the phenotypic tumor differences in HCC patients with normal or abnormal plasma bilirubin levels. A 2,416-patient HCC cohort was studied and dichotomized into normal and abnormal plasma bilirubin groups. Their HCC characteristics were compared for tumor aggressiveness features, namely, blood alpha-fetoprotein (AFP) levels, tumor size, presence of portal vein thrombosis (PVT) and tumor multifocality. In the total cohort, elevated bilirubin levels were associated with higher AFP levels, increased PVT and multifocality, and lower survival, despite similar tumor sizes. When different tumor size terciles were compared, similar results were found, even among patients with small tumors. A multiple logistic regression model for PVT or tumor multifocality showed increased odds ratios for elevated levels of gamma glutamyl transpeptidase (GGTP), bilirubin, and AFP and for larger tumor sizes. We conclude that HCC patients with abnormal bilirubin levels had worse prognosis than patients with normal bilirubin. They also had an increased incidence of PVT and tumor multifocality, and higher AFP levels, in patients with both small and larger tumors. The results show an association between bilirubin levels and indices of HCC aggressiveness., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: Saber-sheath trachea is a specific radiographic parameter for chronic obstructive pulmonary disease (COPD), which consists of marked coronal narrowing associated with sagittal widening (tracheal index <2/3-0.67). The aim of this study was to investigate the correlation between saber-sheath trachea and clinical-radiological findings in a group of patients with COPD of varying severity., Materials and Methods: We evaluated the chest radiographs of 71 patients with COPD distributed as follows: GOLD class I, 8/71 (11.3 %); class II, 34/71 (47.9 %); class III, 16/71(22.5 %); class IV, 13/71 (18.3 %). In 52/71 (73.2 %) patients we also evaluated chest computed tomography (CT) scans. We analyzed the prevalence of saber-sheath trachea and its correlation with the Tiffenau index, GOLD stage and radiological signs of COPD. Moreover, we evaluated the sensitivity, specificity and accuracy of chest radiography as compared to CT taken as the gold standard, and the correlation between the radiographic and CT tracheal index., Results: Saber-sheath trachea was found in 18/71 (25.4 %) patients, with a greater prevalence in patients with lower Tiffenau Index (p = 0.02), GOLD stages III-IV and visual severity score 3 (severe) on chest CT. Saber-sheath trachea was not found to be related to other radiological signs of COPD. The sensitivity, specificity and accuracy values of radiography were 72.2, 97.0 and 88.5 %, with perfect concordance between the radiographic and CT tracheal index (p < 0.00001)., Conclusion: Saber-sheath trachea is linked to the functional severity of airway obstruction, but not to other radiological signs of COPD. Thus, evaluation of the trachea at chest radiography is strongly recommended.

Background/objectives: Restrictive Anorexia nervosa (ANR) is an eating disorder (ED) characterized by a low bone mineral content (BMC) and by an alteration in body composition (reduction and abnormal distribution of fat mass-FM and lean mass-LM). The aim of our study was to address whether bone and body composition changes could be influenced by hormonal status and sport in female adolescents with restrictive anorexia nervosa-ANR., Subjects/methods: Prospective study on 79 adolescents with ANR submitted to Dual Energy X-Ray Absorptiometry-DXA at baseline-T0 and after 12 months-T12. Among the 46/79-58.2% patients that completed the study, we evaluated total and regional FM and LM%, as well as lumbar bone mineral density (BMD) and Z-score, linking them to clinical variables: menarche/amenorrhea/hormonal therapy and physical activity., Results: At T0: body mass index (BMI)=16.4±1.4 kg/m2 with low levels of FM% (21.7±5.7) low BMC in 12/46-26.0% (mean Z-score: -1.21±1.27, with higher values related to physical activity-P=0.001). At T12: a significant increase in BMI-P=0.001, with LM reduction and FM increase (more evident in the trunk-P<0.001); regarding bone, no significant changes were observed, though a tendency in terms of improvement associated with resumption of menses., Conclusions: After 1 year, weight recovery was not associated with a reestablishment of bone values; by contrast, it was associated with an increase and a distortion in FM distribution, more evident in trunk region (potential and adjunctive risk factor for the relapse of the psychiatric condition). The complexity of these clinical findings suggested DXA, a low-dose and low-cost technique, in long-term monitoring of ANR patients.

Purpose: The aims of this study were to evaluate the high-resolution computed tomography (HRCT) features of subsolid pulmonary nodules (SSN) detected in cancer patients to differentiate between benign and malignant lesions, to assess their evolution during the follow-up, and to determine which neoplastic diseases are most frequently associated with the growth in size and/or density of SSN., Materials and Methods: Ninety-seven patients with a total of 146 subsolid nodules [140 pure ground-glass opacities (pGGOs) and six mixed ground-glass opacities (mGGOs)] were retrospectively recruited. Two chest radiologists independently reviewed the HRCT features of the nodules (location, shape, size, density) and the patients' clinical characteristics (sex, age, smoking and cancer history). Mean duration of follow-up was more than 2 years., Results: During follow-up, 58% of SSN remained stable, 10% disappeared. An increase in size and/or density was seen in 32% of SSN, and in particular in partly solid (mGGOs), large (≥10 mm) and irregular nodules. The majority of small-size (<5 mm) rounded SSN remained stable. SSN growth was more frequent in patients with advanced age and a history of smoking, and occurred even after a long period of stability (39% of pGGOs "changed" over 3 years). The neoplastic diseases most frequently associated with SSN growth were cancers of lung (34%), breast (15%), colon (15%) and bladder (10%)., Conclusions: The observation of a sample of cancer patients has shown that SSN may frequently grow in size and/or density in these patients, especially if associated powith cancers of lung, breast, colon and bladder. As the majority of SSN showed a very slow development time, a follow-up period longer than 3 years is warranted even in cancer patients.

Background: The role of clinically significant portal hypertension on the prognosis of cirrhotic patients undergoing hepatic resection for hepatocellular carcinoma (HCC) is debated., Aims: In this study, our aim was to assess the role of clinically significant portal hypertension after hepatic resection for HCC in patients with cirrhosis., Methods: We assessed the prognostic role of the presence of clinically significant portal hypertension (oesophageal/gastric varices/portal hypertensive gastropathy or a platelet count <100 × 10(9) /L associated with splenomegaly) in 152 patients with compensated cirrhosis who underwent hepatic resection for HCC at the Italian Liver Cancer centres. Survival rates were assessed in the whole series, in the subgroup of Child-Pugh score 5 patients with uninodular HCC ≤ 5 cm, and in Child-Pugh score 5 patients with uninodular HCC ≤ 2 cm and normal bilirubin., Results: Median survival was similar in patients with and without clinically significant portal hypertension (79 vs 77 months, P = 0.686). Child-Pugh score 5 was the only variable significantly associated with survival by Cox multiple regression (P = 0.007). In Child-Pugh score 5 patients with single HCC ≤ 5 cm or in those with single HCC ≤ 2 cm and normal bilirubin, there was no survival difference between patients with and without clinically significant portal hypertension (median survival: 94 vs 78 months, P = 0.121 and >100 vs 86 months, P = 0.742)., Conclusions: Presence of clinically significant portal hypertension has no influence on survival of patients with well-compensated cirrhosis undergoing hepatic resection for HCC., (© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background & Aims: Hepatitis C virus (HCV) is the leading aetiological factor of HCC in the western world where, overall, its incidence is increasing, despite data suggesting an initial drop in some areas. The aim of this study was to evaluate epidemiology, clinical features and survival of HCV-related HCC (HCV-HCC) in a wide time range in Italy., Methods: Multicentre retrospective study including 3695 patients prospectively recruited by the ITA.LI.CA group. Patients were classified into three subgroups according to aetiology (Group A[GA], pure HCV; Group B[GB], HCV + cofactors; and Group C[GC], non-HCV) and in 5 time cohorts (5 years each), according to the year of diagnosis. Age, gender, Child-Pugh score, modality of diagnosis, stage, presence of thrombosis/metastases, type of treatment and survival were analysed., Results: A total of 1801 GA patients, 445 GB and 1333 GC were recruited. The number of GA patients peaked in the 1996-2000, gradually dropping thereafter (P < 0.0001), as observed for GB (P < 0.0001). Age at diagnosis increased (P < 0.0001), while percentage of patients diagnosed during surveillance and stage improved only in GA (P = 0.02 and P = 0.003 respectively). The survival significantly increased over time particularly in GA (median 37 months) and was longer in GA than in GB and GC (P < 0.0001)., Conclusions: The prevalence of HCC-HCV is decreasing in Italy since 2001. HCV-HCC patients are older, more frequently diagnosed under surveillance and in an earlier stage. HCC survival improved in the last 15 years and is significantly higher in patients with HCV-HCC. We therefore expect a further drop in both incidence and mortality for HCV-HCC in the years to come., (© 2013 John Wiley & Sons A/S.)

Introduction: Endoscopic hernia repair methods have become increasingly popular over the past 15 years. Nonetheless, there is no consensus regarding an optimal fixation method. Transabdominal sutures and titanium tacks or staples are the most traditional ones., Case Report: We present a case of mechanic small bowel obstruction due to mesh migration occurring one year and a half after incisional hernia repair with polytetrafluoroethylene mesh fixed by spiral tacks., Discussion: Titanium spiral tacks are dangerous because of their sharp components, which can damage organs such as the small intestine, by causing microperforations. The type of prosthesis used has also contributed to the intraluminal migration, since polytetrafluoroethylene mesh is very flexible and poorly integrates in the abdominal wall., Conclusion: A prosthesis of a different material combined with a different fixation system such as absorbable tacks, biological glue, or mechanical tacks without sharp components, would have obviated mesh migration.

Ten years after the first papers on this subject, this editorial represents a brief review on lung cancer screening with low-dose spiral CT. The aim is to present the main theoretical and practical problems related to lung cancer screening, the historical background and results of observational studies and the main ongoing randomised controlled trials. In particular, the National Lung Screening Trial (NLST), which was interrupted early, is discussed. The opinion of the authors is that too many questions are still awaiting an answer.

Purpose: Although honeycombing is one of the key features for the diagnosis of idiopathic pulmonary fibrosis (IPF), its origin and evolution are still poorly understood. The aim of our study was to analyse the natural history of honeycombing in patients treated with single-lung transplantation., Materials and Methods: We considered seven patients who underwent single-lung transplantation; two of them (28.6%) were excluded from our analysis because they died in the posttransplantation period, whereas the remaining five (71.4%) were evaluated with computed tomography (CT) over 67.6±38.56 months. Each CT scan was assessed for disease extension and cyst size (visual score and size of target cysts); CT scans acquired after 2006 were also assessed for native lung volume., Results: All patients showed disease progression (with a concurrent reduction in lung volume in two, 40%) and a progression of honeycombing, with increased number and size of cysts in four (80%). We observed dimensional changes in all target cysts (enlargement or reduction); three patients (60%) also had radiological evidence of complications, such as spontaneous rupture with pneumothorax and development of mycetomas within the cysts., Conclusions: Honeycombing is a dynamic process in which the overall trend is represented by a dimensional increase in cystic pattern; however, single cysts may have a different evolution (enlargement, reduction or complications). This behaviour could be explained by the variety of the pathogenetic processes underlying honeycombing, with cysts that may present abnormal communication with the airway, including the development of a check-valve mechanism.

Objectives: Incidental diagnosis of vertebral fractures (VFs) may represent a key point in the assessment of bone health status. Our purpose was to retrospectively evaluate localisation sequences (MR-loc) of breast MRI as a potential tool to detect osteoporotic VFs., Methods: MR-loc sagittal images of 856 breast MRIs were reviewed by three expert musculoskeletal radiologists with a semiquantitative approach to detecting VFs. Anamnesis and data of patients were investigated. Official breast MRI and previous imaging reports were checked to understand if VFs or other relevant bone findings were known in patients' clinical history., Results: A total of 780/856 female patients (91.1 %) undergoing MRI for oncological reasons and 76/856 (8.9 %) with non-oncological aims were recruited into the study (54.7 ± 12.2 years old, 21-89 years); 57/856 MR-loc images (6.7 %) were considered inadequate for diagnostic purposes and were excluded from the analysis. MR-loc detected VFs in 71/799 patients (8.9 %). VFs were neither reported nor previously known in the clinical history of 63/71 patients (88.7 %; P < 0.001). No mention of VFs was found in any breast MR reports. In four patients MR-loc identified vertebral metastases., Conclusions: A systematic evaluation of MR-loc may offer additional clinical information to prevent unrecognised VFs. MR-loc may screen for VFs in other imaging settings., Key Points: Vertebral fractures are usually a hallmark of osteoporosis. Localisation sequences before breast MR examinations can identify vertebral fractures. MR localisers should be inspected for vertebral fractures in other clinical settings.

The objective of this study was to evaluate the diagnostic performance of the new dual-energy X-ray absorptiometry equipment vs digital radiography (DR) in the detection and scoring of abdominal aortic calcifications (AACs). Seventy-five patients with indication for morphometric evaluation of the spine underwent vertebral fracture assessment (VFA) and spinal DR (gold standard). The radiographic and VFA images were analyzed to detect AAC using a previously validated 24-point scale (AAC-24) and a simplified 8-point scale (AAC-8). The evaluation was conducted by 2 expert radiologists and repeated by the more experienced of the 2 after 7d to verify the results. Patients with a score of 5 or more in AAC-24 and 3 or more in AAC-8 were considered at risk for cardiovascular diseases (CVDs). The aorta was not completely visible in 11 VFA and 1 DR images. DR detected AAC in 42 of the 63 patients (66.7%), whereas 15 patients (23.8%) were considered at risk for CVD. The VFA showed sensitivity, specificity, and accuracy in the detection of AAC with values of 78.6%, 85.7%, and 81.0%, respectively, with both AAC-24 and AAC-8; in the identification of patients at risk for CVD, VFA demonstrated sensitivity, specificity, and accuracy, respectively, with values of 86.7%, 100%, and 96.8% using AAC-24 and 86.7%, 93.8%, and 92.1% using AAC-8. In the detection of AAC, intraobserver agreement was superimposable using both the techniques (κ=1.00), whereas in the identification of patients at risk for CVD, kappa values were 0.96 and 0.95 using AAC-24 and 1.00 and 0.96 using AAC-8 for DR and VFA, respectively. Interobserver agreement in the evaluation of the presence/absence of AAC showed a kappa value of 0.76 for DR and 0.71 for VFA, whereas kappa values of 0.91 and 0.87 for DR and 0.85 and 0.83 for VFA were achieved for CVD risk using AAC-24 and AAC-8, respectively. AAC can be easily and accurately diagnosed by VFA with satisfactory accuracy, reproducibility, and repeatability. VFA may be used in the assessment and monitoring of AAC., (Copyright © 2012 The International Society for Clinical Densitometry. Published by Elsevier Inc. All rights reserved.)

Purpose: Our aim was to evaluate the evolution of 20 patients with H1N1 pneumonia, focusing our attention on patients with severe clinical and radiological findings who developed post-acute respiratory distress syndrome (post-ARDS) pulmonary fibrosis., Materials and Methods: Twenty adult patients (nine women and 11 men; mean age 43.5 ± 16.4 years) with a diagnosis of H1N1 infection confirmed by pharyngeal swab came to our attention from September to November 2009 and were followed up until September 2010. All patients were hospitalised in consideration of the severity of clinical findings, and all underwent chest X-ray. Twelve of them underwent at least one computed tomography (CT) scan of the chest., Results: In 75% of cases (15/20), there was complete resolution of the clinical and radiological findings. Twenty-five percent of patients (5/20) developed acute respiratory distress syndrome (ARDS), which progressed to predominantly peripheral pulmonary fibrosis in 10% (2/20; one died and one had late-onset pulmonary fibrosis, documented on day 68). Moreover, in one patient with a CT diagnosis of pulmonary fibrosis, we observed progressive regression of radiological findings over 4 months of follow-up., Conclusions: In patients with H1N1 pneumonia, post-ARDS pulmonary fibrosis is not a rare complication. Therefore, a CT scan should be performed in all patients with severe clinical findings. Our study demonstrated that in these patients, fibrosis could present a different spatial distribution and a different temporal trend, with delayed late onset; moreover, in one case, the signs of interstitial lung disease partially regressed over time. Therefore, CT should be considered not only in the diagnostic stage, but also during the follow-up.

Purpose: The authors present the experience of a single institution with selective arterial embolisation for primary and metastatic bone tumours., Materials and Methods: A total of 365 patients were treated with 454 embolisation procedures from December 2002 to April 2010. Embolisation was the primary treatment for benign bone tumours, adjuvant treatment to surgery for benign and malignant bone tumours and palliative treatment for bone sarcomas and metastases. Indications for repeat embolisation included pain or imaging evidence of progressive disease: 105 patients had repeat embolisation at the same location at an interval of 1-3 months; 260 patients had one embolisation, 78 had two and 29 had three or more. In all patients, N-2-butyl cyanoacrylate (NBCA) in 33% lipiodol was the embolic agent used., Results: A total of 419 of the 454 embolisations (93%) were technically successful. In 35 cases, embolisation was not feasible because of poor lesion vascularisation (21 patients with bone metastases and two with aneurysmal bone cysts), origin of the Adamkiewicz artery in the embolisation field (four patients with bone metastases and one with aneurysmal bone cyst), atheromatosis and arteriosclerosis (five patients with bone metastases) and anatomical and technical problems such as small-calibre vessels, many branches and acute vessel angles (two patients with bone metastases). A clinical response was achieved in 406 of the 419 procedures (97%), and no response in 13 procedures in patients with pelvis and sacrum tumours. Complications included postembolisation syndrome in 81 patients (22%), transient paraesthesias in 41 (11%), skin breakdown and subcutaneous necrosis at the shoulder and pelvis in five (1.4%) and paresis of the sciatic nerve in one (0.3%)., Conclusions: We recommend embolisation as primary or palliative treatment or an adjunct to surgery for tumours of variable histology. Strict adherence to the principles of transcatheter embolisation is important. Arteries feeding the tumour and collaterals must be evaluated carefully and catheterised superselectively to protect the normal tissues. NBCA is considered the most appropriate embolic agent for small-vessel occlusion without major complications.

Videoassisted surgery has recently led to a new era, aimed mainly at minimising surgical trauma and improving the cosmetic result. Natural Transluminal Endoscopic Surgery (NOTES) and Single Incision Laparoscopic Surgery (SILS) are emerging as effective techniques whose advantages and possible applications have been widely explored in the most recent literature. Twenty-two consecutive patients, mean age 51.5 years (range: 24-86 years), were subjected to a laparoscopic cholecystectomy through a single, trans-umbilical, incision (SILS). We utilised standard laparoscopic instruments, placing one 10 mm trocar for the camera and two 5 mm trocars for the operative instruments. Mean operative time was 69 min (range: 40 - 120 min). There were no major complications during surgery, and the postoperative recovery was uneventful. All patients referred complete satisfaction with the surgical and cosmetic result obtained 1 and 3 weeks postoperatively.

Background: Although stapled mucosectomy has several advantages over hemorrhoidectomy for hemorrhoidal prolapse, complications such as hemorrhage, pain, and life-threatening pelvic sepsis may occur, often due to poorly executed purse-string suture. We describe a simple new anoscope that makes it easy to correctly perform and position the purse-string suture that is an integral part of stapled mucosectomy., Methods: The apex of the middle part of the new anoscope consists of digitiform projections separated by spaces. After insertion of the instrument into the anus, the inner part is removed, allowing strips of rectal mucosa to protrude through the spaces between the digitiform projections. The purse-string suture is made through these protrusions. The suture catches the mucosa and submucosa but not the deeper muscle layer, which does not protrude through the spaces., Conclusion: Preliminary histologic studies in the pig suggest that the design of the anoscope prevents inclusion of the muscular layer in the pursestring.

Post-traumatic chylothorax needs surgical approach when conservative treatment is not successful to reduce chyle leakage. Thoracic duct ligation requires thoracoscopic or thoracotomic access. The authors report on a surgical thoracotomic approach to a severe and unremitting thoracic duct lesion after IX and X ribs and vertebral fractures.

Staging laparotomy for Hodgkin's disease was carried out on 110 women in fertile age at the General Surgery Department of Padua Medical School from 1972 to 1977. An oophoropexy was done during the operation. According to the stage the patients underwent radiation therapy that was associated in some cases to chemotherapy. Complete evaluation was possible only in 66 patients. Eighteen out of the 66 had mantle field and para-aortic lymph node chain radiotherapy. One case of amenorrhoea (5.5%) and five pregnancies (27.8%), were found among them. Nineteen had the same type of radiotherapy with MOPP. 3 cases of amenorrhoea (15.8%) and 3 pregnancies (15.8%) were found. Five had total nodal irradiation (TNI) according to Kaplan and all of them had amenorrhoea (100%). Twenty four had TNI associated to MOPP with 24 cases of amenorrhoea (100%). Our results slightly differ from those of other Authors. They showed: 1) that the oophoropexy is not effective using standard surgical technique (probably because of the size of the central shielding) as it causes amenorrhoea in 100% of the cases; 2) the incidence of permanent amenorrhoea from chemotherapy with MOPP is the same as reported by other Authors; 3) the absence of teratogenic effects by chemotherapy in newborns of these patients.