Salvatore Masala

Body composition assessment by dual-energy X-ray absorptiometry (DXA)

Body composition (BC) assessment is indispensable to evaluate nutritional status and thus health, both at the population and individual level, and to assess the efficacy of primary and secondary preventive nutritional strategies. Changes in BC, including the regional distribution of body fat, largely occur during pubertal transition, with marked differences between genders. They may, however, also occur in the elderly, who experience significant changes in the ratio between body fat and muscle with aging. The development and implementation of more sophisticated techniques (e.g. BC assessment at the molecular and atomic levels) could provide a major contribution to determining BC at different levels. This review discusses the application of dual-energy X-ray absorptiometry (DXA) on BC determination, given that DXA has the potential to provide overall and regional assessment of BC in terms of fat, lean mass and bone. DXA is widely used in many clinical settings primarily diagnosis osteoporosis. This article describes the use of whole-body DXA in assessing BC in patients with chronic diseases (e.g. metabolic syndrome) as well as in different sport activities to evaluate the effects of exercise.RiassuntoLa valutazione della composizione corporea, da qui in avanti denominata con il termine anglosassone di body composition (BC), è un metodo essenziale per analizzare lo stato di salute in termini nutrizionali, sia a livello di popolazione sia a livello individuale, come pure per indagare l’efficacia delle strategie nutrizionali preventive primarie e secondarie. I cambiamenti della BC, inclusa la distribuzione distrettuale del grasso corporeo, avvengono in larga parte durante il periodo puberale e si diversificano in base al sesso. Questi tuttavia possono manifestarsi anche nel soggetto anziano, per il quale il trascorrere degli anni può causare significativi cambiamenti nel rapporto tra grasso corporeo e muscolo. Per misurare la composizione corporea esistono numerose tecniche; alcune semplici, ma con margini di errore ancora elevati, altre invece costose e sofisticate (come per esempio la valutazione a livello atomico e molecolare della BC) ma più affidabili nel rilevamento dei risultati a vari livelli. Questa revisione della letteratura riguarda l’applicazione della tecnica dual-Energy X-ray absorptiometry (DXA) per la determinazione della composizione corporea, in quanto tale metodica permette di misurare sia in maniera totale che segmentale, per singoli distretti, i vari componenti quali: massa grassa, massa magra e tessuto osseo. Attualmente la DXA è principalmente usata per fare diagnosi di osteoporosi e/o per controllare la risposta alla terapia farmacologia. In questo articolo verranno descritte le altre possibili indicazioni, tra cui lo studio della BC nei pazienti con sindromi metaboliche croniche e l’applicazione in condizioni fisiologiche, quali per esempio nello sportivo, per valutare l’effetto dell’esercizio fisico sulla massa corporea.

Percutaneous Cryoablation of Small Hepatocellular Carcinoma with US Guidance and CT Monitoring: Initial Experience

The purpose of this study was to retrospectively determine the safety and effectiveness of percutaneous cryoablation, monitored with computed tomography (CT) and ultrasonographic (US) guidance, for the treatment of hepatocellular carcinoma (HCC). Four patients with small HCCs underwent one percutaneous cryoablation treatment session monitored with CT and US guidance. All patients underwent pretreatment blood chemistry testing and imaging evaluation. We treated lesions with simultaneous insertion of multiple 17-G cryoprobes (two or three) and defined technical success when the extension of a visible iceball was beyond 5 mm from the tumor margin. Intralesional enhancement or tumoral size increase was defined as local progression compared with that on images obtained immediately after ablation. We evaluated complications and follow-up (at 1, 3, and 6 months). All patients survived without short- or long-term complications. Cryoablation was technically successful in all patients at the end of the procedure. During follow-up two patients developed disease recurrence. One patient developed local tumor progression on the margin of the lesion; the other, a new HCC. In the case of local tumor progression a new elevation of α-fetoprotein (αFP) levels occurred at first follow-up control. In the other case levels of αFP remained stable during the first 3 months after the procedure, then demonstrated a progressive increase in αFP levels beginning at the fourth month, without tumor evidence during CT control at 3 months. We conclude that percutaneous cryotherapy with US guidance and CT monitoring is a feasible, safe, and effective for treatment of HCC. If local ablative procedures of hepatic lesions are to be performed, percutaneous cryoablation, not laparotomic, should be discussed as an alternative therapeutic measure. Longer follow-up should provide proof of the effectiveness of this technique.

Percutaneous vertebroplasty in multiple myeloma vertebral involvement

Study Design and Objective The aim of this study was to assess the effectiveness and safety of percutaneous vertebroplasty, a new technique for the treatment of vertebral pain deriving from fracture or gross osteolytic lesion due to multiple myeloma spinal involvement. Summary of Background Data Spinal osteolytic lesions are frequently associated with hematologic malignancies due to primary localization of disease (multiple myeloma and rarely lymphoma) or secondary effect of intensive corticosteroid therapy. Methods We treated 64 patients (34 males, 30 females; mean age 71.4±9.6 y) with pain refractory to conventional medical therapy (analgesics, bed-rest, bracing with orthopedic devices for more than 3 wk) localized in spine, in the absence of neurologic signs. Results This treatment generated swift pain relief associated with an evident augmentation in vertebral resistance. Average preprocedural pain level for all patients was reported to be 8.04±1.4 whereas average pain level at 1 and 6 months follow-up period was 1.82±1.84 and 1.92±1.68, respectively. Although preprocedure and postprocedure demonstrated a statistically significant reduction in numeric pain scores (P<0.01), the pain level at 1 and 6 months was not considered statistically significant. No procedure-related complications were observed in either leakages of polymethylmethacrylate in the epidural or foraminal area or in complications of pulmonary embolism for venous plexus involvement. Conclusions Vertebroplasty is widely considered as an alternative, effective, simple, and safe technique in the treatment of neoplastic vertebral localizations consequent to hematologic malignancies. The same injection of polymethylmethacrylate can be executed before radiation therapy treatment, synergizing its delayed analgesic action to pain, after failure or in the case of local recurrences.

Percutaneous vertebroplasty: Multi-centric results from EVEREST experience in large cohort of patients

PURPOSE The purpose of this study was to prospectively evaluate results and complications of percutaneous vertebroplasty (PV) performed in 6 different Italian Centres belonging to the European VErtebroplasty RESearch Team (E.VE.RES.T) in a large series of patients. MATERIALS AND METHODS Follow-up was obtained in 4547 patients (3211 females and 1336 males; mean age 70.2 years) that underwent PV for a total of 13.437 treated vertebrae. Procedures were performed by using fluoroscopic guidance or combined CT-fluoroscopic guidance. All patients underwent PV in local anaesthesia except for second cervical vertebrae treated with a trans-oral approach that required general anaesthesia. RESULTS 4004 out of 4547 (88.0%) patients reported significant pain relief (difference>or=2 point in pain evaluated with an 11-point visual analogue scale; p<0.0001) within 48 h: an average of 7.7 ± 0.4 dropped to 1.8 ± 0.6 in the osteoporotic patients; 8.3 ± 0.4 to 2.4 ± 0.4 in metastases; 8.3 ± 0.4 to 1.7 ± 1.0 in myeloma; 6.2 ± 3.5 to 0.3 ± 0.2 in angioma and 7.4 ± 0.4 to 1.4 ± 0.9 in trauma. 430 osteoporotic patients (13%) were retreated for a subsequent fracture; in 302/430 patients (70.2%), the new fracture occurred in the contiguous vertebra. No major neurologic complications were reported and the most frequent minor complication was venous leakage (20.5%). CONCLUSIONS This large series of patients confirms that percutaneous vertebroplasty is an effective and safe procedure in the treatment of vertebral fractures. Best results are obtained in the treatment of myeloma and trauma.

Percutaneous ilio-caval thrombectomy with the Amplatz device: preliminary results.

Abstract. The Amplatz Thrombectomy Device (ATD) is a percutaneous, rotational thrombectomy catheter, capable of recirculating and homogenizing the thrombus in order to obtain mechanical clot dissolution. The authors present their experience with mechanical thrombectomy with the ATD in eight cases of ilio-caval thrombosis. Under temporary caval filter protection, the ATD was introduced through the right transjugular approach (in one patient this was used in combination with the right femoral approach) and activated for a time ranging from 90 to 180 s. Complete clearing of thrombotic material in the treated venous segments was achieved in six cases (75 %), partial success was obtained in one case (12.5 %) and failure occurred in one patient (12.5 %). One patient developed a recurrence of venous iliac thrombosis 1 week after the procedure and postphlebitic syndrome 6 months after the first episode of deep venous thrombosis, and one patient died from acute myocardial infarction, unrelated to thrombectomy session, after 3 days. A negative clinical and radiological follow-up at 3, 6, 12 and 24 months was obtained in the remaining six patients. If a fresh free-floating ilio-caval clot must be removed immediately, the ATD can be effective under temporary filter protection.

Nucleoplasty in the Treatment of Lumbar Diskogenic Back Pain: One Year Follow-Up

PurposeThe spine is an important source of pain and disability, affecting two thirds of adults at some time in their lives. Treatment in these patients is mainly conservative medical management, based on medication, physical therapy, behavioral management, and psychotherapy, surgery being limited to elective cases with neurologic deficits. This study was carried out to evaluate the efficacy of percutaneous nucleoplasty in patients affected by painful diskal protrusions and contained herniations.MethodsFrom February 2004 to October 2005, 72 patients (48 men, 24 women; mean age 48 years) affected by lumbar disk herniation were treated with nucleoplasty coblation. All patients were evaluated clinically and with radiography and MRI in order to confirm the presence of lumbalgic and/or sciatalgic pain, in the absence of major neurologic deficit and with lack of response after 6 weeks of conservative management.ResultsAverage preprocedural pain level for all patients was 8.2 (on a visual analog scale of 1 to 10), while the average pain level at 12 months follow-up was 4.1. At the 1 year evaluation, 79% of patients demonstrated a statistically significant improvement in numeric pain scores (p < 0.01): 17% (12 patients) were completely satisfied with complete resolution of symptoms, and 62% (43 patients) obtained a good result.ConclusionOur data indicate that nucleoplasty coblation is a promising treatment option for patients with symptomatic disk protrusion and herniation who present with lumbalgic and/or sciatalgic pain, have failed conservative therapies, and are not considered candidates for open surgery.

Vertebroplasty and Kyphoplasty in the Treatment of Malignant Vertebral Fractures.

Summary The purpose of this retrospective study was to assess the effectiveness and safety of Percutaneous Vertebroplasty and Kyphoplasty, in the treatment of pain deriving from neoplastic vertebral compression fractures (VCF). We treated 33 oncologic patients with these new techniques (2 pts with aggressive haemangiomas, 8 pts with myelomas and 23 pts with metastases) suffering from severe motion pain in the back, notwithstanding conservative treatment with medication and corset therapy, in the absence of neurological signs. In 3 selected patients we associated radiofrequency heat ablation with vertebroplasty in the treatment of metastases. The aim is to destroy tumor tissue and to thrombose the paravertebral and intravertebral venous plexus before stabilizing the vertebra.

Amenorrhea after weight recover in anorexia nervosa: Role of body composition and endocrine abnormalities

Hypothalamic amenorrhea in anorexia nervosa often precedes weight loss and may persist after re-feeding and restoration of a stable normal weight. Aim: To assess the rate of persistent amenorrhea in anorexia nervosa (AN) after re-feeding and the relations of this condition with body composition changes and other endocrine parameters. Methods: A cohort of 250 female outpatients was studied to assess persistent amenorrhea prevalence after stable weight recovery. Among these, we selected 20 AN female patients (age 16.5–35), 10 with amenorrhea (group 1) and 10 with normal menses (group 2). We collected data such as age, age at menarche, age at onset of AN, actual body mass index (BMI) and at onset of AN, duration of disease. Physical activity has been evaluated as minute per day. The following data were obtained: prolactin, growth hormone, estradiol, luteinizing hormone, follicle stimulating hormone, thyroid stimulating hormone, free triiodothyronine, free thyroxine, free urinary cortisol, serum calcium and phosphates, urinary calcium, phosphaturia and alkaline phosphatase. Body composition was assessed with a dual energy x-ray absorptiometry (DEXA). Results: Thirty-five patients (14%) over a cohort of 250 where still amenorrhoic after stable weight recovery. No significance was found in the evaluation of blood biochemical tests of the 2 groups. Free urinary cortisol was significantly higher in amenorrhoic patients (58.14±0.4 vs 15.91±9.5), p=0.02. The analysis of body composition has shown a per-centage of fat of 22.23±5.32% in group 1 and of 26.03%±9.1% in group 2, respectively, showing no significant differences. Amenorrhoic patients carried on doing a significantly heavier physical activity than eumenorrhoic patients. Conclusions: An adequate body composition and a well represented fat mass are certainly a necessary but not sufficient condition for the return of the menstrual cycle. Such menstrual cycle recovery would probably need other conditions at present being studied and evaluated to occur, such as secretory patterns of leptin and its correlations with adrenal function.

Physical activity energy expenditure measured using a portable telemetric device in comparison with a mass spectrometer

Background: Several studies have evaluated the accuracy of portable metabolic gas analysis systems, which measure physical activity energy expenditure. Since the Cosmed K2 telemetric system, two K4 devices (RQ and b2) have been developed. Objective: To compare measurements using the Cosmed K4 RQ with measurements by a traditional method (mass spectrometer) for a sample of healthy subjects performing physical exercise of various intensities. Methods: Nine healthy male footballers (mean (SD) age 18.3 (2.2) years) performed an incremental exercise running test from 8 km/h to exhaustion, with an increase of 2 km/h for each level of the test protocol. The expired air was collected simultaneously using the Cosmed K4 RQ and Airspec QP9000 mass spectrometer. Oxygen consumption (Vo2) and carbon dioxide production (Vco2) were measured at rest and at each exercise intensity. Results: No significant differences were found between Vo2 and Vco2 measured by the two instruments, at rest or during exercise. Conclusions: The application of the Cosmed K4 RQ system for Vo2 and Vco2 measurements at rest and during both submaximal and maximal exercise may be of interest to sport physiologists, nutritionists, and doctors.

Diagnostic and Therapeutic Joint Injections

Joint injection is a useful tool in the diagnosis of intra-articular pathology that may improve diagnostic performance of computed tomography (CT) and magnetic resonance (MR) imaging. Historically, conventional arthrography under fluoroscopy was the first method to be used to image indirectly the intra-articular soft tissues, but with the advent of CT, CT arthrography offered better soft tissue depiction. The development of conventional MR allowed even better visualization of soft tissues, and in the early 1990s, MR arthrography surpassed CT arthrography in popularity. Joint injections may also be performed for therapeutic reasons with different drugs, such as corticosteroids, anesthetics, or hyaluronic acid, which have been shown to provide pain relief in various circumstances. In this article, the technical principles for joint injection of the shoulder, knee, elbow, hip, ankle, and wrist, used for therapeutic or diagnostic reasons, are discussed. Indications, expected benefits, and risks are also analyzed.