Iterative reconstruction in CT : using mathematical model observers to determine low dose images' trustworthiness

La tomodensitométrie (TDM) est une technique d'imagerie pour laquelle l'intérêt n'a cessé de croitre depuis son apparition au début des années 70. De nos jours, l'utilisation de cette technique est devenue incontournable, grâce entre autres à sa capacité à produire des images diagnostiques de haute qualité. Toutefois, et en dépit d'un bénéfice indiscutable sur la prise en charge des patients, l'augmentation importante du nombre d'examens TDM pratiqués soulève des questions sur l'effet potentiellement dangereux des rayonnements ionisants sur la population. Parmi ces effets néfastes, l'induction de cancers liés à l'exposition aux rayonnements ionisants reste l'un des risques majeurs. Afin que le rapport bénéfice-risques reste favorable au patient il est donc nécessaire de s'assurer que la dose délivrée permette de formuler le bon diagnostic tout en évitant d'avoir recours à des images dont la qualité est inutilement élevée. Ce processus d'optimisation, qui est une préoccupation importante pour les patients adultes, doit même devenir une priorité lorsque l'on examine des enfants ou des adolescents, en particulier lors d'études de suivi requérant plusieurs examens tout au long de leur vie. Enfants et jeunes adultes sont en effet beaucoup plus sensibles aux radiations du fait de leur métabolisme plus rapide que celui des adultes. De plus, les probabilités des évènements auxquels ils s'exposent sont également plus grandes du fait de leur plus longue espérance de vie. L'introduction des algorithmes de reconstruction itératifs, conçus pour réduire l'exposition des patients, est certainement l'une des plus grandes avancées en TDM, mais elle s'accompagne de certaines difficultés en ce qui concerne l'évaluation de la qualité des images produites. Le but de ce travail est de mettre en place une stratégie pour investiguer le potentiel des algorithmes itératifs vis-à-vis de la réduction de dose sans pour autant compromettre la qualité du diagnostic. La difficulté de cette tâche réside principalement dans le fait de disposer d'une méthode visant à évaluer la qualité d'image de façon pertinente d'un point de vue clinique. La première étape a consisté à caractériser la qualité d'image lors d'examen musculo-squelettique. Ce travail a été réalisé en étroite collaboration avec des radiologues pour s'assurer un choix pertinent de critères de qualité d'image. Une attention particulière a été portée au bruit et à la résolution des images reconstruites à l'aide d'algorithmes itératifs. L'analyse de ces paramètres a permis aux radiologues d'adapter leurs protocoles grâce à une possible estimation de la perte de qualité d'image liée à la réduction de dose. Notre travail nous a également permis d'investiguer la diminution de la détectabilité à bas contraste associée à une diminution de la dose ; difficulté majeure lorsque l'on pratique un examen dans la région abdominale. Sachant que des alternatives à la façon standard de caractériser la qualité d'image (métriques de l'espace Fourier) devaient être utilisées, nous nous sommes appuyés sur l'utilisation de modèles d'observateurs mathématiques. Nos paramètres expérimentaux ont ensuite permis de déterminer le type de modèle à utiliser. Les modèles idéaux ont été utilisés pour caractériser la qualité d'image lorsque des paramètres purement physiques concernant la détectabilité du signal devaient être estimés alors que les modèles anthropomorphes ont été utilisés dans des contextes cliniques où les résultats devaient être comparés à ceux d'observateurs humain, tirant profit des propriétés de ce type de modèles. Cette étude a confirmé que l'utilisation de modèles d'observateurs permettait d'évaluer la qualité d'image en utilisant une approche basée sur la tâche à effectuer, permettant ainsi d'établir un lien entre les physiciens médicaux et les radiologues. Nous avons également montré que les reconstructions itératives ont le potentiel de réduire la dose sans altérer la qualité du diagnostic. Parmi les différentes reconstructions itératives, celles de type « model-based » sont celles qui offrent le plus grand potentiel d'optimisation, puisque les images produites grâce à cette modalité conduisent à un diagnostic exact même lors d'acquisitions à très basse dose. Ce travail a également permis de clarifier le rôle du physicien médical en TDM: Les métriques standards restent utiles pour évaluer la conformité d'un appareil aux requis légaux, mais l'utilisation de modèles d'observateurs est inévitable pour optimiser les protocoles d'imagerie. -- Computed tomography (CT) is an imaging technique in which interest has been quickly growing since it began to be used in the 1970s. Today, it has become an extensively used modality because of its ability to produce accurate diagnostic images. However, even if a direct benefit to patient healthcare is attributed to CT, the dramatic increase in the number of CT examinations performed has raised concerns about the potential negative effects of ionising radiation on the population. Among those negative effects, one of the major risks remaining is the development of cancers associated with exposure to diagnostic X-ray procedures. In order to ensure that the benefits-risk ratio still remains in favour of the patient, it is necessary to make sure that the delivered dose leads to the proper diagnosis without producing unnecessarily high-quality images. This optimisation scheme is already an important concern for adult patients, but it must become an even greater priority when examinations are performed on children or young adults, in particular with follow-up studies which require several CT procedures over the patient's life. Indeed, children and young adults are more sensitive to radiation due to their faster metabolism. In addition, harmful consequences have a higher probability to occur because of a younger patient's longer life expectancy. The recent introduction of iterative reconstruction algorithms, which were designed to substantially reduce dose, is certainly a major achievement in CT evolution, but it has also created difficulties in the quality assessment of the images produced using those algorithms. The goal of the present work was to propose a strategy to investigate the potential of iterative reconstructions to reduce dose without compromising the ability to answer the diagnostic questions. The major difficulty entails disposing a clinically relevant way to estimate image quality. To ensure the choice of pertinent image quality criteria this work was continuously performed in close collaboration with radiologists. The work began by tackling the way to characterise image quality when dealing with musculo-skeletal examinations. We focused, in particular, on image noise and spatial resolution behaviours when iterative image reconstruction was used. The analyses of the physical parameters allowed radiologists to adapt their image acquisition and reconstruction protocols while knowing what loss of image quality to expect. This work also dealt with the loss of low-contrast detectability associated with dose reduction, something which is a major concern when dealing with patient dose reduction in abdominal investigations. Knowing that alternative ways had to be used to assess image quality rather than classical Fourier-space metrics, we focused on the use of mathematical model observers. Our experimental parameters determined the type of model to use. Ideal model observers were applied to characterise image quality when purely objective results about the signal detectability were researched, whereas anthropomorphic model observers were used in a more clinical context, when the results had to be compared with the eye of a radiologist thus taking advantage of their incorporation of human visual system elements. This work confirmed that the use of model observers makes it possible to assess image quality using a task-based approach, which, in turn, establishes a bridge between medical physicists and radiologists. It also demonstrated that statistical iterative reconstructions have the potential to reduce the delivered dose without impairing the quality of the diagnosis. Among the different types of iterative reconstructions, model-based ones offer the greatest potential, since images produced using this modality can still lead to an accurate diagnosis even when acquired at very low dose. This work has clarified the role of medical physicists when dealing with CT imaging. The use of the standard metrics used in the field of CT imaging remains quite important when dealing with the assessment of unit compliance to legal requirements, but the use of a model observer is the way to go when dealing with the optimisation of the imaging protocols.

Congenital inferior vena cava anomalies: a review of findings at multidetector computed tomography and magnetic resonance imaging

Inferior vena cava anomalies are rare, occurring in up to 8.7% of the population, as left renal vein anomalies are considered. The inferior vena cava develops from the sixth to the eighth gestational weeks, originating from three paired embryonic veins, namely the subcardinal, supracardinal and postcardinal veins. This complex ontogenesis of the inferior vena cava, with multiple anastomoses between the pairs of embryonic veins, leads to a number of anatomic variations in the venous return from the abdomen and lower limbs. Some of such variations have significant clinical and surgical implications related to other cardiovascular anomalies and in some cases associated with venous thrombosis of lower limbs, particularly in young adults. The authors reviewed images of ten patients with inferior vena cava anomalies, three of them with deep venous thrombosis. The authors highlight the major findings of inferior vena cava anomalies at multidetector computed tomography and magnetic resonance imaging, correlating them the embryonic development and demonstrating the main alternative pathways for venous drainage. The knowledge on the inferior vena cava anomalies is critical in the assessment of abdominal images to avoid misdiagnosis and to indicate the possibility of associated anomalies, besides clinical and surgical implications.

European cancer mortality predictions for the year 2016 with focus on leukemias.

BACKGROUND: Current cancer mortality statistics are important for public health decision making and resource allocation. Age standardized rates and numbers of deaths are predicted for 2016 in the European Union. PATIENTS AND METHODS: Population and death certification data for stomach, colorectum, pancreas, lung, breast, uterus, prostate, leukemia and total cancers were obtained from the World Health Organisation database and Eurostat. Figures were derived for the EU, France, Germany, Italy, Poland, Spain and the UK. Projected numbers of deaths by age group were obtained for 2016 by linear regression on estimated numbers of deaths over the most recent time period identified by a joinpoint regression model. RESULTS: Projected total cancer mortality trends for 2016 in the EU are favourable in both sexes with rates of 133.5/100,000 men and 85.2/100,000 women (8% and 3% falls since 2011, due to population ageing) corresponding to 753,600 and 605,900 deaths in men and women for a total number of 1,359,500 projected cancer deaths (+3% compared to 2011). In men lung, colorectal and prostate cancer fell 11%, 5% and 8% since 2011. Breast and colorectal cancer trends in women are favourable (8% and 7% falls, respectively), but lung and Pancreatic cancer rates rose 5% and 4% since 2011 reaching rates of 14.4 and 5.6/100,000 women. Leukemia shows favourable projected mortality for both sexes and all age groups with stronger falls in the younger age groups, rates are 4.0/100,000 men and 2.5/100,000 women, with respectively falls of 14% and 12%. CONCLUSION: The 2016 predictions for EU cancer mortality confirm the favourable trends in rates particularly for men. Lung cancer is likely to remain the leading site for female cancer rates. Continuing falls in mortality, larger in children and young adults, are predicted in leukemia, essentially due to advancements in management and therapy, and their subsequent adoption across Europe.

Bien-être et croyance en un monde juste en ex-Yougoslavie: traces laissées par les guerres et la précarité socio-économique

RÉSUMÉ En combinant la perspective du parcours de vie à la théorie du stress et selon une approche psychosociale, cette thèse montre comment les expériences individuelles et collectives de victimisation ont marqué les parcours de vie, les croyances et le bien-être d'une cohorte de jeunes adultes ayant traversé les guerres en ex-Yougoslavie. Le premier article applique des analyses de courbes de croissance à classes latentes et dégage différentes trajectoires d'exclusion entre 1990 et 2006. L'analyse de ces trajectoires met en évidence les intersections entre vies individuelles, contexte et temps socio-historique et démontre que les expériences de guerre et les périodes d'exclusion socio-économique laissent des traces sur le bien-être à long terme. Les deuxième et troisième articles montrent que la croyance en un monde juste est ébranlée suite à des expériences de précarité socio-économique et de victimisation dues à la guerre au niveau individuel et contextuel. Un effet curvilinéaire et des interactions entre les niveaux indiquent que ces relations varient en fonction de l'intensité de la victimisation au niveau contextuel. Des effets de récence sont aussi relevés. Le quatrième article démontre que l'impact négatif de la victimisation sur le bien-être est en partie expliqué par un effritement de la croyance en un monde juste. De plus, si les individus qui croient davantage en un monde juste sont plus satisfaits de leur vie, la force de ce lien varie en fonction du niveau de victimisation dans certains contextes. Cette thèse présente un modèle multiniveaux dynamique dans lequel la croyance en un monde juste n'exerce plus le rôle de ressource personnelle stable mais s'érode face à la victimisation, entraînant ainsi un bien-être moindre. Ce travail souligne l'importance d'articuler les niveaux individuels et contextuels et de considérer la dimension temporelle pour expliquer les liens entre victimisation, croyance en un monde juste et bien-être. ABSTRACT By combining a life course perspective to stress theory and according to a psychosocial approach, this thesis shows how individual and collective victimisation experiences marked the life course, beliefs and well-being of a cohort of young adults who lived through the wars in former Yugoslavia. In the first article, latent class growth analyses were applied to identify different exclusion trajectories between 1990 and 2006. The analysis of these trajectories highlighted the intersections between individual lives, socio-historical context and time and demonstrated that experiences of war and socio-economic exclusion leave traces on well-being in the long term. The second and third articles showed that the belief in a just world was shattered due to socio-economic precariousness and war victimisation at individual and contextual levels. A curvilinear effect and cross-level interactions indicated that these relations varied according to the intensity of victimisation at the contextual level. Time effects were also noted. The fourth article showed that the negative impact of victimisation on well-being was partly explained by an erosion of the belief in a just world. Furthermore, if high believers were more satisfied with their lives, the strength of this relation varied depending on the level of victimisation in particular contexts. This thesis presents a multilevel dynamic model in which the belief in a just world no longer exercises the role of a stable personal resource but erodes in the face of victimisation, leading to a lower well-being. This work stresses the importance of articulating individual and contextual levels as well as considering the temporal dimension to explain the links between victimisation, belief in a just world and well-being.

Computed tomography-guided percutaneous trephine removal of the nidus in osteoid osteoma patients: experience of a single center in Brazil

AbstractObjective:To report the results of computed tomography (CT)-guided percutaneous resection of the nidus in 18 cases of osteoid osteoma.Materials and Methods:The medical records of 18 cases of osteoid osteoma in children, adolescents and young adults, who underwent CT-guided removal of the nidus between November, 2004 and March, 2009 were reviewed retrospectively for demographic data, lesion site, clinical outcome and complications after procedure.Results:Clinical follow-up was available for all cases at a median of 29 months (range 6–60 months). No persistence of pre-procedural pain was noted on 17 patients. Only one patient experienced recurrence of symptoms 12 months after percutaneous resection, and was successfully retreated by the same technique, resulting in a secondary success rate of 18/18 (100%).Conclusion:CT-guided removal or destruction of the nidus is a safe and effective alternative to surgical resection of the osteoid osteoma nidus.

On-line life history calendar and sensitive topics : A pilot study

The use of the life history calendar (LHC) or the event history calendar as tools for collecting retrospective data has received increasing attention in many fields of social science and medicine. However, little research has examined the use of this method with web-based surveys. In this study, we adapted this method to an on-line setting to collect information about young adults' life histories, sexual behaviors, and substance use. We hypothesized that the LHC method would help respondents to date sensitive and non-sensitive events more precisely than when using a conventional questionnaire. We conducted an experimental design study comparing university students' responses to an on-line LHC and a conventional on-line question list. A test-retest design in which the respondents completed the survey again two weeks later was also applied to test the precision and reliability of the participants' dating of events. The results showed that whereas the numbers of sensitive and non-sensitive events were generally similar for the two on-line questionnaires, the responses obtained with the LHC were more consistent across the two administrations. Analyses of the respondents' on-line behavior while completing the LHC confirmed that respondents used the LHC's graphic interface to correct and reedit previous answers, thus decreasing data errors. (C) 2015 Elsevier Ltd. All rights reserved.

Análisis del proceso de adquisición del código audiovisual y de la intervención de los agentes que forman a los ciudadanos en el conocimiento de los medios

The research group Gre‐TICE (Grupo de investigación en tecnologías de la Información y la Comunicación en Educación) has the acquisition of the multimedia language and their use as a form of expression as one of their lines of research. During the academic year 2002‐ 2003, following previous work in the use of ICT in Education, commenced upon the project: “The acquisition of visual and sound codes and the processes related to the visual media”. The intention of this project is to study how formal or non‐formal education context can help young adults and children to acquire visual and sound codes to become ‘critical consumers’ with the media and to use the tools in a creative way. To achieve this objective, the project team has developed a partner group which includes professional from different European regions; including teachers and managers from across the age spectrum, government institutions and cultural organisations. Whilst the project will call upon qualitative analysis of the previous projects / research, it will seek to develop ‘Good Practice’ guides and other resources/ materials to be disseminated to project partners (and others) to build innovative actions throughout the European region

The Regulation of Skeletal and Cardiac Muscle Blood Flow in Humans. Studies by positron emission tomography with special reference to exercise, adenosine and nitric oxide

Virtually every cell and organ in the human body is dependent on a proper oxygen supply. This is taken care of by the cardiovascular system that supplies tissues with oxygen precisely according to their metabolic needs. Physical exercise is one of the most demanding challenges the human circulatory system can face. During exercise skeletal muscle blood flow can easily increase some 20-fold and its proper distribution to and within muscles is of importance for optimal oxygen delivery. The local regulation of skeletal muscle blood flow during exercise remains little understood, but adenosine and nitric oxide may take part in this process. In addition to acute exercise, long-term vigorous physical conditioning also induces changes in the cardiovasculature, which leads to improved maximal physical performance. The changes are largely central, such as structural and functional changes in the heart. The function and reserve of the heart’s own vasculature can be studied by adenosine infusion, which according to animal studies evokes vasodilation via it’s a_2A receptors. This has, however, never been addressed in humans in vivo and also studies in endurance athletes have shown inconsistent results regarding the effects of sport training on myocardial blood flow. This study was performed on healthy young adults and endurance athletes and local skeletal and cardiac muscle blod flow was measured by positron emission tomography. In the heart, myocardial blood flow reserve and adenosine A_2A receptor density, and in skeletal muscle, oxygen extraction and consumption was also measured. The role of adenosine in the control of skeletal muscle blood flow during exercise, and its vasodilator effects, were addressed by infusing competitive inhibitors and adenosine into the femoral artery. The formation of skeletal muscle nitric oxide was also inhibited by a drug, with and without prostanoid blockade. As a result and conclusion, it can be said that skeletal muscle blood flow heterogeneity decreases with increasing exercise intensity most likely due to increased vascular unit recruitment, but exercise hyperemia is a very complex phenomenon that cannot be mimicked by pharmacological infusions, and no single regulator factor (e.g. adenosine or nitric oxide) accounts for a significant part of exercise-induced muscle hyperemia. However, in the present study it was observed for the first time in humans that nitric oxide is not only important regulator of the basal level of muscle blood flow, but also oxygen consumption, and together with prostanoids affects muscle blood flow and oxygen consumption during exercise. Finally, even vigorous endurance training does not seem to lead to supranormal myocardial blood flow reserve, and also other receptors than A_2A mediate the vasodilator effects of adenosine. In respect to cardiac work, atheletes heart seems to be luxuriously perfused at rest, which may result from reduced oxygen extraction or impaired efficiency due to pronouncedly enhanced myocardial mass developed to excel in strenuous exercise.

Den talande bokens poetik : en studie med fokus på olika unga vuxnas reception av tre fiktiva texter inlästa på band

The purpose of the research project The poetics of the talking book is to contribute to the knowledge about patterns of understanding in young adults’ reception of fiction, which they listened to through audio books. The problem explored was: How do different groups of listeners receive fictive text presented as a talking book with variations regarding use of voice, engagement and sound effects? The problem formulation rendered four specific research questions: 1. What patterns can be identified in the listeners’ answers regarding story structure and cognitive content in a comparative perspective comprising different reading styles in the taped versions of the text? 2. What patterns of understanding in interpretative reading can be identified in different listeners? 3. Which thoughts do the listeners have about what the talking book should sound like? 4. What affordances for young adults with the functional disability of mild mental retardation can be made visible through guided literature conversations? The theoretical frame of reference was formed by text–reader-oriented literary theory, psychological schema theory, and research regarding voice quality and communication. The project was carried out in two steps. The first phase was to produce the audio books with two variations of reading practice of three short stories with an existential theme in each text. The second step comprised interviewing of 32 young adults (a special group with a reading handicap in form of mild mental retardation, and a reference group with no handicap). The interviews formed as literary conversation were carried out three times during one year. The phenomenological-hermeneutic approach focused on the life worlds of the participants as meaning seeking beings. The analysis was carried out using method triangulation, mainly using phenomenological meaning concentration. The double hermeneutics in use when interpreting the interpretations of the participants revealed a capacity for aesthetic reading of fiction in the special group as well as in the reference group. The aesthetic qualities were found sufficient in all variations of reading by the professional readers of the audio book they listened to. The young adults also could describe how they wanted the audio book to sound: just as if you were reading yourself. A model describing the analytical steps and concepts in use was a result that can serve as an outline of a poetics for the talking book. Unexpected research results were how important the guided literary conversation turned out to be in order to realise the affordances given by the texts regarding exploration of existential themes in the young adults’ life worlds. Thus the result of the research project can be positioned as a piece of emancipatory research stressing the importance of including this group of young adults in the society’s conversation about culture and meaning.

Abnormal eating behaviors among medical students at a university in southern Santa Catarina, Brazil

OBJECTIVES: Disturbances in eating behavior significantly affect young adults. This study aimed to estimate the prevalence of abnormal eating behaviors, according to the Eating Attitudes Test - 26 (EAT-26) in medical students at a university in southern Santa Catarina State, Brazil. METHODS: Self-reported questionnaire, based on the EAT-26 scale, was administered to medical students. Additional questions about age, gender, study period of the course, weight and height were asked. A total of 391 medical students were assessed, amounting to 93.3 percent of the 419 students enrolled. RESULTS: Ten percent of the surveyed subjects had positive EAT-26 scores. This outcome measure was positive associated with females (PR 6.5), body mass index (BMI) ≤ 25 kg/m² (PR 4.5), age ≤ 20 years (PR 1.3) and being student from 1st to 5th semester of the course (PR 1.7). A higher proportion of women gave positive responses to behaviors related to control of food intake or weight loss than men. CONCLUSION: The significant prevalence of behaviors related to eating disorders, predominantly among women, suggests the implementation of preventive measures targeting this population.

Pharmacokinetics of Oxycodone and Paracetamol in the Elderly. Clinical Pharmacokinetic Study on Orthopaedic Surgical Patients and Healthy Volunteers

The proportion of elderly people over 65 years of age in Finland is expected to grow to over 25% by the 2025. It has been estimated that elderly people today consume nearly 40% of all drugs. Age brings about number of physiological changes that may affect the disposition, metabolism and excretion of drugs. The function of heart, lungs, liver and kidneys decreases even in healthy people, as they get older. The proportion of total body water decreases and the relative fat percentage increases. Also several other factors such as concurrent diseases, concomitant medication and nutritional factors have an effect on drug therapy in elderly. Age increases the risk of adverse drug reactions, which most often are dose-dependent. Despite all this there are not enough studies involving the elderly people and the elderly are most often excluded from clinical trials. Oxycodone is a strong opioid analgesic, which is used to treat moderate or severe pain. Paracetamol is a widely used nonopioid analgesic, which has become popular in the treatment of pain in many patient groups. In this series of studies the pharmacokinetics of oral and intravenous oxicodone as well as intravenous paracetamol in the elderly and young adult patients were investigated. Also a study investigating the interaction of oral antibiotic clarityhromycin, a known cytochrome P450 (CYP) 3A4 inhibitor, with oxycodone pharmacokinetics and pharmacodynamics in elderly and young healthy volunteers was carried out. The pharmacokinetics of oxycodone showed a clear age depency. Patients over 70 years had 50-80% higher mean exposure to oral oxycodone and a twofold greater plasma concentration than young adults 12 h after ingestion of the drug. Elderly patients had 40-80% greater exposure to intravenous oxycodone and patients over 80 years had over twofold greater plasma concentrations 8 h post dose than the young adults. The elderly patients had also greater exposure to intra venous paracetamol compared to young adults. Clarithromycin increased the exposure to oral oxycodone in both young and elderly volunteers. The elderly had marked interindividual variation in the pharmacokinetics and pharmacodynamics when clarithromycin was given concomitantly with oxycodone. Because the pharmacokinetics of oxycodone and intravenous paracetamol depend on the age of the subject, it is important to titrate the analgesic dose individually in the elderly.

Cirurgia de tikhoff-linberg para tratamento de condrossarcoma localmente avançado da região escápulo-umeral

Chondrosarcoma is a rare malignant neoplasia that most of the time affects young adults. Its location is preferentially the pelvic and scapular girdle and surgery is its treatment of choice. There are no role for chemo or radiation therapy, because of their low index of response. We describe a case of a 45 year-old male patient with an extensive low grade right umerus chondrosarcoma. In spite of the local extension, there was no invasion of the shoulder neurovascular structures. Treatment proposed was the Tikhoff-Linberg procedure, and the operation was performed with success, with no complications. Free margins were obtained. The patient is now on two years follow-up with no evidence of recurrent disease and is able to drive, fish and carry packs. He can not abduct his arm, but he could not do that even before surgery, due to severe pain. We believe this is an excellent conservative approach to such tumors, that otherwise would require a forequarter amputation, and strongly recommend the technique.

Sarcoma sinovial primário do esôfago

Synovial sarcomas are uncommon malignant mesenchymal tumors occurring mainly near the joints of the extremities of young adults. Synovial sarcomas are exceedingly rare neoplasms of the digestive tract. We report the first diagnosed case of esophageal synovial sarcoma, highlighting its diagnostic features surgical management and follow-up.

Risk factors for mortality in blunt abdominal trauma with surgical approach

ABSTRACTObjective:identify risk factors for mortality in patients who underwent laparotomy after blunt abdominal trauma.Methods:retrospective study, case-control, which were reviewed medical records of blunt trauma victims patients undergoing laparotomy, from March 2013 to January 2015, and compared the result of the deaths group with the group healed.Results:of 86 patients, 63% were healed, 36% died, and one patient was excluded from the study. Both groups had similar epidemiology and trauma mechanism, predominantly young adults males, automobilistic accident. Most cases that evolved to death had hemodynamic instability as laparotomy indication - 61% against 38% in the other group (p=0.02). The presence of solid organ injury was larger in the group of deaths - 80% versus 48% (p=0.001) and 61% of them had other associated abdominal injury compared to 25% in the other group (p=0.01). Of the patients who died 96% had other serious injuries associated (p=0.0003). Patients requiring damage control surgery had a higher mortality rate (p=0.0099). Only one of 18 patients with isolated hollow organ lesion evolved to death (p=0.0001). The mean injury score of TRISS of cured (91.70%) was significantly higher than that of deaths (46.3%) (p=0.002).Conclusion:the risk factors for mortality were hemodynamic instability as an indication for laparotomy, presence of solid organ injury, multiple intra-abdominal injuries, need for damage control surgery, serious injury association and low index of trauma score.

Fetal alcohol spectrum disorders in Finnish children and adolescents : diagnosis, cognition, behavior, adaptation and brain metabolic alterations

Alcohol consumption during pregnancy can potentially affect the developing fetus in devastating ways, leading to a range of physical, neurological, and behavioral alterations most accurately termed Fetal Alcohol Spectrum Disorders (FASD). Despite the fact that it is a preventable disorder, prenatal alcohol exposure today constitutes a leading cause of intellectual disability in the Western world. In Western countries where prevalence studies have been performed the rates of FASD exceed, for example, autism spectrum disorders, Down’s syndrome and cerebral palsy. In addition to the direct effects of alcohol, children and adolescents with FASD are often exposed to a double burden in life, as their neurological sequelae are accompanied by adverse living surroundings exposing them to further environmental risk. However, children with FASD today remain remarkably underdiagnosed by the health care system. This thesis forms part of a larger multinational research project, The Collaborative Initiative on Fetal Alcohol Spectrum Disorders (the CIFASD), initiated by the National Institute of Alcohol Abuse and Alcoholism (NIAAA) in the U.S.A. The general aim of the present thesis was to examine a cohort of children and adolescents growing up with fetal alcohol-related damage in Finland. The thesis consists of five studies with a broad focus on diagnosis, cognition, behavior, adaptation and brain metabolic alterations in children and adolescents with FASD. The participants consisted of four different groups: one group with histories of prenatal exposure to alcohol, the FASD group; one IQ matched contrast group mostly consisting of children with specific learning disorder (SLD); and two typically-developing control groups (CON1 and CON2). Participants were identified through medical records, random sampling from the Finnish national population registry and email alerts to students. Importantly, the participants in the present studies comprise a group of very carefully clinically characterized children with FASD as the studies were performed in close collaboration with leading experts in the field (Prof. Edward Riley and Prof. Sarah Mattson, Center for Behavioral Teratology, San Diego State University, U.S.A; Prof. Eugene Hoyme, Sanford School of Medicine, University of South Dakota, U.S.A.). In the present thesis, the revised Institute of Medicine diagnostic criteria for FASD were tested on a Finnish population and found to be a reliable tool for differentiating among the subgroups of FASD. A weighted dysmorphology scoring system proved to be a valuable additional adjunct in quantification of growth deficits and dysmorphic features in children with FASD (Study 1). The purpose of Study 2 was to clarify the relationship between alcohol-related dysmorphic features and general cognitive capacity. Results showed a significant correlation between dysmorphic features and cognitive capacity, suggesting that children with more severe growth deficiency and dysmorphic features have more cognitive limitations. This association was, however, only moderate, indicating that physical markers and cognitive capacity not always go hand in hand in individuals with FASD. Behavioral problems in the FASD group proved substantial compared to the typically developing control group. In Study 3 risk and protective factors associated with behavioral problems in the FASD group were explored further focusing on diagnostic and environmental factors. Two groups with elevated risks for behavioral problems emerged: length of time spent in residential care and a low dysmorphology score proved to be the most pervasive risk factor for behavioral problems. The results underscore the clinical importance of appropriate services and care for less visibly alcohol affected children and highlight the need to attend to children with FASD being raised in institutions. With their background of early biological and psychological impairment compounded with less opportunity for a close and continuous caregiver relationship, such children seem to run an especially great risk of adverse life outcomes. Study 4 focused on adaptive abilities such as communication, daily living skills and social skills, in other words skills that are important for gradually enabling an independent life, maintain social relationships and allow the individual to become integrated into society. The results showed that adaptive abilities of children and adolescents growing up with FASD were significantly compromised compared to both typically-developing peers and IQ-matched children with SLD. Clearly different adaptive profiles were revealed where the FASD group performed worse than the SLD group, who in turn performed worse than the CON1 group. Importantly, the SLD group outperformed the FASD group on adaptive behavior in spite of comparable cognitive levels. This is the first study to compare adaptive abilities in a group of children and adolescents with FASD relative to both a contrast group of IQ-matched children with SLD and to a group of typically-developing peers. Finally, in Study 5, through magnetic resonance spectroscopic imaging (MRS) evidence of longstanding neurochemical alterations were observed in adolescents and young adults with FASD related to alcohol exposure in utero 14-20 years earlier. Neurochemical alterations were seen in several brain areas: in frontal and parietal cortices, corpus callosum, thalamus and frontal white matter areas as well as in the cerebellar dentate nucleus. The findings are compatible with neuropsychological findings in FASD. Glial cells seemed to be more affected than neurons. In conclusion, more societal efforts and resources should be focused on recognizing and diagnosing FASD, and supporting subgroups with elevated risk of poor outcome. Without adequate intervention children and adolescents with FASD run a great risk of marginalization and social maladjustment, costly not only to society but also to the lives of the many young people with FASD.