Giancarlo Facchini

Follow-up of bone mineral density and body composition in adolescents with restrictive anorexia nervosa: role of dual-energy X-ray absorptiometry.

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.

Treatment of osteoid osteoma of the elbow by radiofrequency thermal ablation

BACKGROUND This article presents the experience at the Rizzoli Orthopaedic Institute in the treatment of intracapsular osteoid osteoma (OO) of the elbow by computed tomography-guided percutaneous radiofrequency thermal ablation (RFA). MATERIALS AND METHODS Our team performed more than 800 RFA procedures to treat OO up to 2010. In 27 cases, the lesion site was the articular area of the elbow (humerus in 13 cases, ulna in 13, and radius in 1). These patients were reviewed and assessed for eradication rate, incidence of complications, and functional results measured by the Mayo Elbow Performance Score. The outcome was evaluated after a mean follow-up period of 67.4 ± 35.3 months (range, 24-128 months). RESULTS The mean duration of symptoms at the time of diagnosis was 31.0 ± 19.8 months (range, 5-72 months). All patients complained about pain, and in 24 of 27 cases (88.8%), the joint function was significantly impaired by the presence of OO (pretreatment score, 54.8). After RFA, the Mayo Elbow Performance Score improved by a mean of 37.7 ± 14.8 points, with 25 of 27 patients (92.5%) scoring 90 to 100 points at final follow-up. OO recurred in only 1 patient (3.7%), 5 months after the procedure. However, this was successfully retreated by RFA. No adverse effects were observed, and all patients were free of disease at the final follow-up. DISCUSSION The RFA procedure can be technically challenging in difficult sites such as the elbow joint. The low invasiveness of RFA compared with traditional surgery allows excellent functional recovery. RFA of elbow OO is effective and safe, and it should be considered the first-choice treatment for this disease.

A comprehensive review of pulsed radiofrequency in the treatment of pain associated with different spinal conditions

OBJECTIVE The objective of this review was to evaluate the efficacy of pulsed radiofrequency (PRF) treatment of pain associated with different spinal conditions. The mechanisms of action and biological effects are shortly discussed to provide the scientific basis for this radiofrequency modality. METHODS We systematically searched for clinical studies on spinal clinical conditions using PRF. We searched the MEDLINE (PubMed) database. We classified the information in one table focusing on randomized controlled trials (RCTs) and other types of studies. Date of last electronic search was October 2016. RESULTS We found four RCTs that evaluated the efficacy of PRF on cervical radicular pain and five observational studies. Two trials and three observational studies were conducted in patients with facet pain. For disc-related pathology, we found one RCT with PRF applied intradiscally and three RCTs for dorsal root ganglia PRF modulation lumbosacral radicular pain. For sacroiliac joint pain, spondylolisthesis, malignancies and other minor spinal pathology, limited studies were conducted. CONCLUSION From the available evidence, the use of PRF to the dorsal root ganglion in cervical radicular pain is compelling. With regard to its lumbosacral counterpart, the use of PRF cannot be similarly advocated in view of the absence of standardization of PRF parameters, enrolment criteria and different methods in reporting results; but, the evidence is interesting. The use of PRF in lumbar facet pain was found to be less effective than conventional RF techniques. For the other different spinal conditions, we need further studies to assess the effectiveness of PRF. Advances in knowledge: The use of PRF in lumbar facet pain was found to be less effective than conventional RF techniques. For the other different spinal conditions, we need further studies to assess the effectiveness of PRF.

Translational research in diagnosis and management of soft tissue tumours

Finding a soft tissue mass in the superficial regions is a common event in daily clinical practice. Correct management of the diagnostic process is crucial to avoid blunders. Diagnosis is posed by pathology, although both imaging and a better understanding of the cellular and molecular mechanisms play an important a role in the characterization, staging and follow-up of soft tissue masses. Cellular and molecular mechanisms can explain either the development of chemo-resistance and the underlying pre- and post-surgery metastasis formation. These are mandatory to improve prognosis and unveil novel parameters predicting therapeutic response. Imaging mainly involves ultrasound and MR and is fundamental not only in diagnosis but also in the first step of therapy: the biopsy. Novel imaging techniques like Ultrasound Elastosonography, Dynamic Contrast-Enhanced MR imaging (DCE), Diffusion Weighted MR imaging (DWI) and MR Spectroscopy (MRS) are discussed. This paper aims at reviewing and discussing pathological methods and imaging in the diagnosis of soft tissue masses underscoring that the most appropriate treatment depends on advanced molecular and radiological studies.

Diffuse lung disease associated with neurofibromatosis type-1 can also affect children

A 4-year-old child affected by neurofibromatosis type-1 (NF1) was submitted to computed tomography (CT) of the spine for the assessment of severe scoliosis. The CT scan confirmed scoliosis and revealed multiple rows of small sub-pleural air-filled lesions at the pulmonary upper lobes (Fig. 1). These pulmonary blebs present very thin walls (< 1 mm) and small diameters (2–7 mm). These findings suggested the diagnosis of diffuse lung disease associated with NF-1 (NF-DLD). Other lung regions were normal, no basilar fibrosis was detected. NF-1 is an autosomal-dominant disease with a prevalence of one in 3000 [1]. Most common clinical manifestations include “cafè au lait” skin macules, cutaneous and central nervous system tumours. NF-DLD is described as possible manifestation of NF-1 in adult patients. The disease is generally characterized by basilar fibrosis and/or upper lobes air-filled lesions such as bullae, blebs (as in the case) or cysts [2]. Symptomatic patients usually present with dyspnoea on exertion; pulmonary function tests show either an obstructive or a restrictive defect [2]. Sub-pleural air-filled lesions represent a risk of pneumothorax which could be the first clinical manifestation of the disease [3]. This is, to our knowledge, the only pediatric patient with documented NF-DLD. This case together with a youngadult patient reported in the literature (16 years old) [3], both with upper lobes air-filled sub-pleural lesions and no basilar fibrosis, suggests that these lesions may arise before fibrotic basilar involvement, even in childhood/adolescence.

Intra-Articular Hip Procedures

The approach for intra-articular injection/aspiration procedures in the coxofemoral joint is reviewed. Indications are briefly listed. Anatomy, techniques and materials, drugs and appropriate aftercare management as well as potential procedure-related symptoms and consequent treatment are included.

CT and 3D CT of the Elbow

Computed tomography (CT) provides important information in the evaluation of the musculoskeletal system. It represents the completion of a diagnostic path started with conventional radiography (XR). When the XR images do not allow a clear diagnosis, CT plays a fundamental role, especially with the supplement use of multi-planar and three-dimensional processing images that allow a better assessment of the regional anatomy. These techniques are used especially for districts difficult to explore with XR or those with complex anatomy such as the elbow.

The utility of contrast-enhanced hypodense sign for the diagnosis of pulmonary invasive mould disease in patients with haematological malignancies

OBJECTIVE The hypodense sign (HyS) on CT imaging is highly suggestive of pulmonary invasive mould disease (IMD) in patients with haematological malignancies, but its diagnostic utility has not been systematically evaluated on contrast-enhanced CT. The objective of this study was to compare the diagnostic performance of the HyS to other common CT findings in a cohort of haematology patients with proven, probable or possible IMD based on European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria. METHODS We analysed the diagnostic performance of the HyS to other common CT signs among 127 neutropenic patients with haematological malignancies submitted to both non-contrast-enhanced and contrast-enhanced CT scans of the lungs, including CT pulmonary angiography. RESULTS The HyS was detected in 15.7% of patients imaged without contrast, and 44.1% after contrast administration. A contrast-aided HyS was detected in 86.6, 78.0 and 15.5% of patients with European Organization for Research and Treatment of Cancer/Mycoses Study Group proven, probable and possible IMD, respectively. When analysed per clinical diagnosis (proven, probable and highly possible IMD-i.e. no alternative diagnosis to mould disease reached), the contrast-enhanced HyS was as sensitive as the halo sign but significantly more specific [halo sign 0.56, 95% CI (0.39-0.71) vs HyS 0.98, 95% CI (0.87-1.00)]. Only the vessel occlusion sign was more sensitive [0.97, 95% CI (0.91-0.99)] and specific [0.97, 95% CI (0.86-0.99)] than the HyS for IMD diagnosis. CONCLUSION The high specificity of the HyS strongly supports the diagnosis of pulmonary IMD in neutropenic patients, and is highly suggestive breakthrough fungal disease in patients on mould-active antifungal prophylaxis. Advances in knowledge: This is the first systematic analysis of the hypodense sign on contrast-enhanced CT; the sign can support the diagnosis of IMD when other CT signs are uncertain.

Metachronous osteoblastoma of the spine and osteoid osteoma of the femur

Osteoblastoma (OBL) and osteoid osteoma (OO) are usually solitary tumours, only rarely being multicentric. Herein, we report an unusual case in which a typical OBL of the spine was followed by an OO of the femur after a disease-free interval of 5 years. We believe that our unique case represents the first report of a metachronous OBL and an OO, and this presentation may confirm the close correlation between these two rare entities.

MRgFUS of osteoid osteoma started at the Rizzoli

BackgroundOsteoid osteoma is a bone-producing lesion frequentlylocalized in long bones. The most common presentingsymptom is pain with nocturnal exacerbation, respon-sive to nonsteroidal anti-i nflammatory drugs [1]. Mini-mally invasive treatment options have become thestandard of care for osteoid osteoma and at presentradiofrequency ablation is the treatment of choice [2].Only one preliminary study has been performed usingmagnetic resonance guided focused ultrasound(MRgFUS) to treat osteoid osteoma showing MRgFUSto be effective for pain relief through thermal cell deathand periosteal denervation induced by cortical heatingrelative to acoustic energy absorption [3]. The purposeof this research was to evaluate the efficacy of MRgFUSin treating osteoid osteoma and to highlight potentialbenefits and limitations provided by this technology.Materials and methodsSeven patients affected by osteoid osteoma were consecu-tively recruited for MRgFUS (ExAblate 2100, InSightec,Israel on 1.5 T Signa Twin Speed MR system, GE, USA).The diagnosis of osteoid ost eoma was based on typicalclinical and imaging findings (CT and MRI) . Pain andfunction were scored before and after MRgFUS (VAS –0-10 scale), and any intra- and post-procedure complica-tion or adverse effect was recorded. Initial follow-upincluded clinical assessment at discharge, and everymonth.ResultsIn one patient the lesion c ould not be approached dueto the high body mass index (33 Kg/m