A case of hemorrhagic shock due to massive upper gastrointestinal bleeding: from the differential diagnosis to the correct management

Upper Gastro-Intestinal Bleeding (UGIB) spans from minor bleeding to life-threatening events. Identification of early signs of shock, proper management of hemodynamically unstable patients, and correct risk stratification are essential for an appropriate diagnostic workup and therapy. This case reports a young man admitted to the emergency department with haematemesis. His medical history was unremarkable, without any risk factors for gastrointestinal bleeding. A few hours after admission, further episodes of haematemesis occurred, and the patient's condition rapidly deteriorated to irreversible shock. A contrast-enhanced computed tomography (CECT) revealed morphological features of chronic liver disease and oesophagal varices. The patient underwent upper gastrointestinal endoscopy, confirming oesophagal varices with massive bleeding. Although promptly applied, endoscopic hemostasis was ineffective, and the patient died twenty-four hours after admission. Based on this case, we reviewed the diagnostic and therapeutic approaches for patients with massive UGIB and provided a practical approach to this life-threatening emergency

Application of Parametric X-ray Radiation to Diagnostic Radiology: A Theoretical Study

none5Parametric X-ray Radiation (PXR) is well known as intense, tunable and quasi-monochromatic x-ray source. From the very first work of Ter-Mikaelian, who proposed the interaction phenomenon for Parametric X-rays, many theoretical and experimental studies have investigated the characteristics of such a novel x-ray source. Within the framework of classical electrodynamics, we have thoroughly studied the physical implications of electrons moving through a medium at relativistic speed and then developed an analytical model of x-ray diffraction based on the PXR phenomenon. The model has been used to obtain information on the characteristics of PXR diffracted beam in terms of x-ray intensity, energy spectrum and angular distribution. Preliminary results on the diagnostic potential of PXR have shown that, at a distance from the crystal which produces a size of the x-ray field useful for an imaging application, the photon yield of PXR is higher than that produced by a conventional x-ray tube, provided that a similar electron current is available. Based on the analytical model of PXR generated by a relativistic electron beam in crystals, in this contribution we discuss the possible application to x-ray breast imaging. Since the Parametric X-ray Radiation depends on the characteristics of electron beam, crystal target, and geometric configuration, an optimization study has been carried out to evaluate the performance of this novel x-ray source. Several crystals have been taken into account both in Bragg and Laue geometry and their relative yield has been compared. We also investigated the irradiation field by considering real experimental conditions that broaden theoretical PXR photon distribution. To this aim the effects of multiple scattering and divergence of electron beam have been included in the analytical model and the characteristics of the x-ray field are presented in terms of beam uniformity and energy gradient. Finally, the effects of electron interaction within the crystal target on the spatial resolution properties of PXR source are also discussed.noneG. Di Domenico; P. Cardarelli; M. Gambaccini; M. Marziani; A. TaibiDI DOMENICO, Giovanni; Cardarelli, Paolo; Gambaccini, Mauro; Marziani, Michele; Taibi, Angel

Training minimally invasive surgery\u2019s basic skills: is expensive always better?

Introduction Not all hospitals have a MIS training facility because often training is not a main corporate objective and could require lots of money. We tried to build a laparoscopic simulator that was effective and that would allow to carry out an adequate laparoscopic training similar to that obtained with the models normally used in MIS training programs. To construct a box trainer that would achieve the equivalent results than those usually used. A validation study was carried out by evaluating the content validity and construct validity of our simulator in addition a comparison study of our homemade trainer vs Karl Storz box trainer was performed. Material and methods The HM laparoscopic trainer was assembled using a wood frame. Two LED lights were positioned on the inside roof of the trainer and a webcam was positioned through a special support as operative optic. The webcam was then connected to a PC and the latter was used as a monitor for the operator. Participants were 20 students and a group of 6 surgeons. Students were prospectively randomized to perform 4 of the 5 tasks of the fundamental laparoscopic surgery (FLS) program on both the HM trainer and the KS trainer (pegboard transfer, pattern cut, placement of ligating loop and intracorporeal knot suture). Simple paired t test was performed to compare times between the trainers. Then students performed two more sets of exercises on the HM. The group of surgeons performed three sets of the same exercises performed by the students on the HM. The time taken by surgeons and students to complete the exercises was compared using t test. At the end, all the participants carried out a questionnaire to evaluate their experience with the HM box trainer. For the questionnaire it was chosen to use a Linkert 1\u20135 scale (1 = strongly disagree; 2 = disagree; 3 = undecided; 4 = agree; 5 = strongly agree). Results HM vs KS BT: Comparing time to complete the 4 tasks performed by students on both the BT, for the first task the p value was 0.30, for the second task 0.48, for the third task 0.80, for the fourth task 0.93, and for the total time 0.86. The comparison between the mean time of the first set of tasks of the participants who started with the HM BT and one of the participants who started on the KS p value was 1 p = 0.09; task 2 p = 0.32; task 3 p = 0.62; task 4 p = 0.32; total time p = 0.81. The comparison between the meantime of the second set of tasks of the participants who switched to the HM BT with the one of those who switched to the KS BT showed a p value of: p = 0.20 tasks 1 p = 0.53 task 2; p = 0.39 task 3; p = 0.30 task 4; p = 0.56 total time. Construct validity: The mean experts and students time of every single task and the total one showed a p value of: p < 0.01 for task 1; p < 0.01 task 2; p < 0.01 task 3; p < 0.01 task 4; p < 0.01 total time. Content validity: Both experts and students indicated the HM BT as a useful training tool and appreciated its easy use. Both groups would use it at home if it were available. Conclusion Valid MIS trainer can be easily built at home with few low-cost materials. Our study shows how training programs can be structured even with few resources in a creative and innovative way

Laue lens to focus an X-ray beam for radiation therapy

A Laue lens is an optical component composed of a set of crystals that produce a convergent beam exploiting X-ray diffraction in transmission geometry. Employment of a system formed by a properly designed Laue lens coupled with an X-ray unit to selectively irradiate tumours is proposed. A convergent beam leads to a depth dose profile with a pronounced peak at the focal depth, which may result in a high precision of the dose delivery. Using a custom-made Monte Carlo code and the GAMOS code, we carried out a design study to determine the geometry and the optimal features of the crystals composing the lens. As an application, a Laue lens capable of focusing a 80keV beam 50cm downstream of the lens has been designed. The lens is composed of an ensemble of Si crystals with curved diffracting planes. The lens produces a focal spot of 2mm enclosing 7.64 × 106 photons for an electron charge of 1mC impinging on the surface of the X-ray tube anode. The combination of these important figures of merit makes the proposed system suitable for irradiating both sub-cm and larger tumour masses efficiently. A dose of 2Gy can be delivered to a small tumour in a few seconds, sparing at the same time the surrounding tissues

Dual-energy imaging in full-field digital mammography: a phantom study

A dual-energy technique which employs the basis decomposition method is being investigated for application to digital mammography. A three-component phantom, made up of plexiglas, polyethylene, and water, was doubly exposed with the full-field digital mammography system manufactured by General Electric. The 'low' and 'high' energy images were recorded with a Mo/Mo anode-filter combination and a Rh/Rh combination, respectively. The total dose was kept within the acceptable levels of conventional mammography. The first hybrid images obtained with the dual-energy algorithm are presented in comparison with a conventional radiograph of the phantom. Image-quality characteristics at contrast cancellation angles between plexiglas and water are discussed. Preliminary results show that a combination of a standard Mo-anode 28 kV radiograph with a Rh-anode 49 kV radiograph provides the best compromise between image-quality and dose in the hybrid image

Energy distribution measurement of narrow-band ultrashort x-ray beams via K-edge filters subtraction

The characterization of novel x-ray sources includes the measurement of the photon flux and the energy distribution of the produced beam. The aim of BEATS2 experiment at the SPARC-LAB facility of the INFN National Laboratories of Frascati (Rome, Italy) is to investigate possible medical applications of an x-ray source based on Thomson relativistic back-scattering. This source is expected to produce a pulsed quasi-monochromatic x-ray beam with an instantaneous flux of 1020 ph=s in pulses 10 ps long and with an average energy of about 20 keV. A direct measurement of energy distribution of this beam is very difficult with traditional detectors because of the extremely high photon flux. In this paper, we present a method for the evaluation of the energy distribution of quasi-monochromatic x-ray beams based on beam filtration with K-edge absorbing foils in the energy range of interest (16–22 keV). The technique was tested measuring the energy distribution of an x-ray beam having a spectrum similar to the expected one (SPARC-LAB Thomson source) by using a tungsten anode x-ray tube properly filtered and powered. The energy distribution obtained has been compared with the one measured with a HPGe detector showing very good agreement

A Characterization System for the Monitoring of ELI-NP Gamma Beam

The ELI-NP (Extreme Light Infrastructure-Nuclear Physics) facility, currently under construction near Bucharest (Romania), is the pillar of the project ELI dedicated to the generation of high-brilliance gamma beams and high-power laser pulses that will be used for frontier research in nuclear physics. To develop an experimental program at the frontiers of the present-day knowledge, two pieces of equipment will be deployed at ELI-NP: a high power laser system consisting of two 10 PW lasers and a high brilliance gamma beam system. The ELI-NP Gamma beam system will deliver an intense gamma beam with unprecedented specifications in terms of photon flux, brilliance and energy bandwidth in an energy range from 0.2 to 20 MeV. Such a gamma beam requires special devices and techniques to measure and monitor the beam parameters during the commissioning and the operational phase. To accomplish this task, the Gamma Beam Characterization System, equipped with four elements, was developed: a Compton spectrometer (CSPEC), to measure and monitor the photon energy spectrum; a nuclear resonant scattering system (NRSS), for absolute beam energy calibration and inter-calibration of the other detectors; a beam profile imager (GPI) to be used for alignment and diagnostics purposes; and finally a sampling calorimeter (GCAL), for a fast combined measurement of the beam average energy and intensity. The combination of the measurements performed by GCAL and CSPEC allows fully characterizing the gamma beam energy distribution and intensity with a precision at the level of few per mill, enough to demonstrate the fulfillment of the required parameters. This article presents an overview of the gamma beam characterization system with focus on these two detectors, which were designed, assembled and are currently under test at INFN-Firenze. The layout and the working principle of the four devices is described, as well as some of the main results of detector test

Liquorice Toxicity: A Comprehensive Narrative Review

Background: Renowned since ancient times for its medical properties, liquorice is nowadays mainly used for flavoring candies or soft drinks. Continuous intake of large amounts of liquorice is a widely known cause of pseudo-hyperaldosteronism leading to hypertension and hypokalemia. These manifestations are usually mild, although in some cases may generate life-threatening complications, i.e., arrhythmias, muscle paralysis, rhabdomyolysis, and coma. In addition, liquorice has an important estrogenic-like activity. Methods: We summarized the current knowledge about liquorice and reviewed 104 case reports in both the English and Italian languages from inception to June 2023 concerning complications due to an excess of liquorice intake. Results: In contrast to most published data, female sex and old age do not appear to be risk factors. However, hypertension and electrolyte imbalance (mainly hypokalemia) are prevalent features. The detection of glycyrrhetinic acid in blood is very uncommon, and the diagnosis is essentially based on an accurate history taking. Conclusions: Although there is not a significant mortality rate, liquorice toxicity often requires hospitalization and therefore represents a significant health concern. Major pharmaceutical drug regulatory authorities should solicit public awareness about the potentially dangerous effects caused by excessive use of liquorice

X-RAY-IMAGING TEST OF A MU-STRIP SILICON DETECTOR WITH A TRANSPUTER DAQ

The authors have developed a TDC+Transputer-based acquisition system to study the X-ray imaging capabilities of a silicon μ-strip detector with 100 and 200 μm read-out pitch. This system allows real-time image acquisition and display. The authors present images obtained with an X-ray mammography tube using sub-millimeter high contrast test objects on a 16*16 channels prototyp