G. La Tona

Videofluorography swallow study of patients with systemic sclerosis.

PurposeThis study was undertaken to evaluate the role of the videofluorographic (VFG) swallow study in patients with systemic sclerosis.Materials and methodsOver a 23-month period, 45 women (mean age 58 years, range 27–76 years) with a known diagnosis of systemic sclerosis and a history of dysphagia underwent a dynamic and morphological study of the oral, pharyngeal and oesophageal phases of swallowing with videofluorography. All examinations were performed with a remote-controlled digital C-arm device with 16-in image intensifier, 0.6- to 1.2-mm focal spot range and maximum tube voltage of 150 kVp in fluorography and 120 kVp in fluoroscopy. Cineradiographic sequences were acquired for the swallow study with 12 images per second and matrix 512×512 after the ingestion of boluses of high-density (250% weight/volume) barium. The evaluation of oesophageal peristalsis was documented with digital cineradiographic sequences with six images per second in the upright and supine positions during the swallowing of barium (60% weight/volume), and the water siphon test was performed with the patient in the supine position to evaluate the presence of gastro-oesophageal reflux disease (GORD). All patients subsequently underwent laryngoscopy, endoscopy and pH monitoring, and the data thus obtained were processed and compared.ResultsThe VFG swallow study identified alterations of epiglottal tilting associated with intraswallowing laryngeal penetration in 26 patients (57.8%), pooling of contrast agent in the valleculae and pyriform sinuses in 23 (51.1%) and radiographic signs of nonspecific hypertrophy of the lingual and/or palatine tonsils in 18 (40%). The study of the oesophageal phase revealed the presence of altered peristalsis in all patients, and in particular, 36 patients (80%) showed signs of atony. Altered oesophageal clearing mechanisms were evident in all 45 patients, sliding hiatus hernia in 43 (93%) and GORD in 44 (97%).ConclusionsOur study demonstrated that in patients with systemic sclerosis, there is no primary alteration of the oral or pharyngeal phase of swallowing. In addition, alterations of epiglottal tilting associated with laryngeal penetration of contrast agent were found to be secondary to chronic GORD. Indeed, in 40% of patients, radiographic signs were found that indicated nonspecific hypertrophy of the lingual tonsil and/or palatine tonsils and nonspecific signs of chronic pharyngeal inflammation, and GORD was identified in 93% of patients, which in 40% of cases extended to the proximal third of the oesophagus. The data obtained were confirmed in 85% of cases with pH monitoring and in all cases with laryngoscopy.RiassuntoObiettivoValutare il ruolo dello studio videofluorografico (VFG) nella valutazione della deglutizione in pazienti affetti da sclerodermia sistemica.Materiali e metodiIn un periodo di 23 mesi 45 pazienti di sesso femminile (età media 58 anni; range 27–76 anni), con diagnosi certa di sclerodermia, che riferivano anamnesticamente disfagia sono stati sottoposti a studio dinamico e morfologico del tratto oro-faringeo della deglutizione e del tratto faringo-esofageo-cardiale mediante videofluorografia. Tutti gli esami sono stati eseguiti con apparecchio telecomandato con arco a C digitale dotato di intensificatore di brillanza da 16 pollici, macchia focale da 0,6 a 1,2 mm e massima differenza di potenziale di 150 pkV in grafia e 120 pkV in scopia. Per lo studio della deglutizione sono state acquisite sequenze cineradiografiche digitali con 12 immagini/secondo con matrice 512×512 previa ingestione di boli progressivi di MdC baritato ad alta densità (250% P/V). La valutazione della peristalsi esofagea è stata documentata con sequenze cineradiografiche digitali con 6 immagini/secondo, in ortostasi e clinostasi durante deglutizione di boli di bario (60% P/V) ed, infine, è stato effettuto, in clinostasi, il test del sifone d’acqua (WST) per la valutazione del reflusso gastroesofageo (GERD). Tutti i pazienti sono stati sottoposti successivamente a valutazione laringoscopica, endoscopica e pH-metrica, i dati così ottenuti sono stati rielaborati e confrontati.RisultatiLo studio della funzione deglutitoria, effettuato mediante VFG, ha evidenziato alterazioni del tilting epiglottico associato a fenomeni di penetrazione subepiglottica intradeglutitoria in 26 pazienti (57,8%), ristagno del MdC in corrispondenza delle vallecule glosso-epiglottiche e dei seni piriformi in 23 (51,1%) e segni radiografici di ipertrofia aspecifica della tonsilla linguale e/o delle tonsille palatine in 18 (40%). Lo studio del viscere esofageo ha evidenziato la presenza di alterazioni della peristalsi nella totalità della popolazione ed in particolare 36 pazienti (80%) manifestavano evidenti segni di atonia. In tutti i 45 pazienti si apprezzavano alterazioni dei meccanismi di clearing esofageo, in 42 (93%) ernia jatale da scivolamento ed in 44 (97%) reflusso gastro-esofageo.ConclusioniIl nostro studio ha evidenziato come, in pazienti affetti da sclerodermia sistemica non vi è un’alterazione primitiva della fase orale o faringea della deglutizione. Inoltre le alterazioni del ribaltamento dell’epiglottide (tilting) associate a fenomeni di penetrazione subepiglottica del MdC, si sono dimostrate secondarie ad insulto cronico da GERD. Infatti nel 40% dei pazienti, sono stati evidenziati segni radiografici riferibili ad un’ipertrofia aspecifica della tonsilla linguale e/o delle tonsille palatine segni aspecifici di flogosi cronica faringea ed è stato, inoltre, identificato GERD, nel 93% dei pazienti che, nel 40% dei casi, si estendeva sino al III prossimale del viscere. I dati ottenuti sono stati confermati nell’85% anche da valutazione pH-metrica e nella totalità dei casi da valutazione laringoscopica.

Plantar fascia evaluation with a dedicated magnetic resonance scanner in weight-bearing position: our experience in patients with plantar fasciitis and in healthy volunteers

PurposeThis study assessed the usefulness of upright weight-bearing examination of the ankle/hind foot performed with a dedicated magnetic resonance (MR) imaging scanner in the evaluation of the plantar fascia in healthy volunteers and in patients with clinical evidence of plantar fasciitis.Materials and methodsBetween January and March 2009, 20 patients with clinical evidence of plantar fasciitis (group A) and a similar number of healthy volunteers (group B) underwent MR imaging of the ankle/hind foot in the upright weight-bearing and conventional supine position. A 0.25-Tesla MR scanner (G-Scan, Esaote SpA, Genoa, Italy) was used with a dedicated receiving coil for the ankle/hind foot. Three radiologists, blinded to patients’ history and clinical findings, assessed in consensus morphological and dimensional changes and signal intensity alterations on images acquired in both positions, in different sequences and in different planes.ResultsIn group A, MR imaging confirmed the diagnosis in 15/20 cases; in 4/15 cases, a partial tear of the plantar fascia was identified in the upright weight-bearing position alone. In the remaining 5/20 cases in group A and in all cases in group B, the plantar fascia showed no abnormal signal intensity. Because of the increased stretching of the plantar fascia, in all cases in group A and B, thickness in the proximal third was significantly reduced (p<0.0001) under upright weight-bearing compared with the supine position.ConclusionsImaging the ankle/hind foot in the upright weight-bearing position with a dedicated MR scanner and a dedicated coil might enable the identification of partial tears of the plantar fascia, which could be overlooked in the supine position.RiassuntoObiettivoScopo del nostro lavoro è stato dimostrare l’utilità dell’esame sotto carico del retropiede/caviglia eseguito con apparecchiatura di risonanza magnetica (RM) dedicata finalizzato alla valutazione della fascia plantare in volontari sani ed in pazienti con evidenza clinica di fascite plantare.Materiali e metodiNel periodo compreso tra gennaio e marzo 2009, 20 pazienti con diagnosi clinica di fascite plantare (gruppo A) ed altrettanti volontari sani (gruppo B), sono stati sottoposti ad esame RM del retropiede/caviglia sia in ortostatismo che in clinostatismo. Per le indagini è stata utilizzata una apparecchiatura RM dedicata da 0,25 Tesla (G-Scan, Esaote SpA, Genova, Italia) con bobina di ricezione dedicata per retropiede/caviglia. Tre radiologi in consenso e in cieco sull’anamnesi e l’obiettività clinica dei soggetti hanno valutato le alterazioni morfo-dimensionali e dell’intensità di segnale nelle immagini acquisite nelle due posizioni, nelle diverse sequenze e nei differenti piani di scansione.RisultatiNel gruppo A, la RM ha confermato la diagnosi in 15/20 casi; in 4/15 casi è stata evidenziata una rottura parziale della fascia plantare visualizzata solo nella posizione ortostatica. Nei restanti 5/20 casi del gruppo A ed in quelli del gruppo B la fascia plantare non presentava alterazioni dell’intensità di segnale. A causa della maggiore tensione della fascia plantare in tutti i casi, gruppo A e B, lo spessore del tratto peri-inserzionale sotto carico si riduceva significativamente (p<0,0001) rispetto al clinostatismo.ConclusioniL’imaging del retropiede/caviglia nella posizione ortostatica con RM dedicata e bobina dedicata potrebbe consentire di dimostrare le rotture parziali della fascia plantare che possono rimanere misconosciute in clinostatismo.

A novel EMS for residential microgrids reconciling end-user and utility needs

Among those currently proposed in the technical literature, most Energy Management Systems (EMSs) that are based on the formulation and solution of an optimization problem, can be classified in two categories: some of them solve the problem using Dynamic Programming (DP), which is quite computationally expensive in terms of memory occupation; others, in order to solve the problem using Linear Programming (LP) that has a lower computational cost, introduce a simplification, i.e., they consider positive and negative power flows at bidirectional devices separately, instead of considering the net exchanged power. Furthermore, each currently available EMS is only able to achieve one goal at a time, providing advantages either for the end-user or for the grid manager/administrator. Starting from the above considerations, a novel EMS for residential microgrids is proposed in this paper. It exploits the forecasting of PV generation and load demand profiles by means of suitably chosen and trained neural networks. Furthermore, it is based on solving two different optimization problems during two stages of the algorithm, aiming at reconciling end-user and utility needs. Thanks to a suitable mathematical formulation, it manages to solve the optimization problems using Mixed Integer Linear Programming (MILP), instead of DP. A series of simulations is performed to validate the proposed EMS, whose results are presented and discussed.

Intratumoral Haemorrhage Causing an Unusual Clinical Presentation of a Vestibular Schwannoma.

We present a case of an elderly woman with no history of audiological disease with sudden onset of visual and hearing deficits associated with systemic clinical signs. On examination she had impairment of right CNs from V to X. CT and MR imaging demonstrated a cystic vestibular schwannoma with a rare intralesional fluid-fluid level correlated to a recent bleed. We include high quality MR images to show the acute impairment of the cranial nerves next to the tumour after acute bleeding. Our case report includes a voxel-based morphometry (VMB) analysis of the tumour that, as far as we know, has never been done before for such a tumour. VBM analysis was performed to calculate the hypothesized volume changes after the acute bleed which likely resulted in a sudden increase in the overall size of the tumour resulting in atypical clinical signs and symptoms due to the establishment of a mechanical conflict with the adjacent cranial nerves.

Energy Management Systems for effective gap reduction between actual and predicted power in smart homes and buildings

In order to optimize energy efficiency and to achieve cost savings in smart buildings and grid-connected smart homes that include renewable generators and electrical storage systems, Energy Management Systems (EMSs) are today the most up to date solution. Besides achieving these two goals, a suitable design of the EMS can provide a quite deterministic management of power flows, reducing the gap between actual and predicted power due to forecasting errors. On the basis of a previously proposed EMS that allows reducing both the end-users electricity bill and the generation/demand uncertainty impact, this paper proposes a detailed analysis of several factors affecting the EMSs performance. Variations of algorithm strategy parameters, market constraints and size of hardware components have been investigated and the results have been evaluated in terms of reduction of power gap and cash flow. Simulation results obtained in a six-day period for a grid connected smart home with a 3 kWp photovoltaic generator and a battery storage system are presented and some guidelines for proper EMS design have been proposed.

Rheumatoid Arthritis: Evaluation of Temporomandibular Joint Abnormalities with MR Imaging

It is well known that the temporomandibular joint (TMJ), as well as other joints, may be affected in patients with rheumatoid arthritis (RA). Conventional radiographic methods can be used in the assessment of bone damage but its usefulness is limited as the soft tissue involvement cannot be demonstrated. Many reports have shown the potential of magnetic resonance imaging in the evaluation of different TMJ components, all of which are often compromised in rheumatic disease; moreover MR imaging is superior for depicting advanced stages of rheumatic disease with various degrees of disc destruction. The purpose of this study was to evaluate the role of MR imaging in the assessment of RA. MR imaging of the TMJ was performed on 14 patients (11 women and 3 men, aged 36–79 years, mean 57.5) with diagnosed RA in stages 2 and 3 according to Steinbroker criteria. Both TMJs were evaluated in ten patients. A total of 24 TMJs were studied in this group of patients. Informed consent was obtained in each case. The goal of MR is not only to facilitate a diagnosis of rheumatoid arthritis, which may be done using laboratory and clinical parameters, but to assess the extent of the early soft-tissue and bone manifestations of the inflammatory process and to identify the stage of the disease.