Tумесцентната техника како регионална анестезија

Тумесцентната техника е техника на инфилтрација во супкутаното ткиво на голем волумен пуфериранфизиолошки раствор во кој е потопена мала концентрација лидокаин заедно со адреналин. Овој раствор лесно и безболно се инфилтрира и доведува до анестезија на поткожното ткиво од одредени телесни регии како абдоменотили натколеното,обезбедува помало крвавење за време на интервенциите изведувани на кожата и поткожното ткиво. Тумесцентната локална анестезија (ТЛА) е многу лесна и сигурна процедура, која широко се употребува во многу хируршки гранки. Целта на трудот беше да се направи проценка на вредноста на тумесцентната локална анестезија кај липосукција. Материјал и методи: Беа евалуирани 16 пациентки со средна возраст од 32 години(24-46), кај кои  беше извршена липосукција на една до три регии, односно на вкупно 27 регии. Во тек на интервенцијата се употреби тумесцентната техника; инфилтрација на раствор од 0,075% лидокаин со 1: 1.000.000 адреналин и 25 мл 8,4% бикарбонати во 1000 мл физиолошки раствор, средно инфилтриран раствор од 2506 мл (1600-5000), средна доза на лидокаин 25,9 мг/кг (18,9-50,6 мг/кг), вкупно средно инфилтриран лидокаин од 2010 мг (1360-4000мг). Резултати: ТЛА беше успешно реализирана; 68,8% (11) од пациентките беа среќни и задоволни, 12,5% (2) од пациентките имаа главоболка и вртоглавица, кај 12,5% (2) од пациентките беше сопрена интервенцијата поради силни болки, кај едната на една регија, кај другата на втората регија и кај 6,3% (1) од пациентките имаше лесни знаци за интоксикација со лидокаин. Немаше компликации кои бараа третман или хоспитализација, а немаше и смртен исход. Заклучок: Самостојно употребена тумесцентна локална анестезија во доза од 18-50мг/кг лидокаин кај правилно избрани пациенти е сигурна техника за регионална анестезија за процедури на поткожното масно ткиво.Tumescent technique is a technique of infiltration a large volume of buffered low concentration of lidocaine and adrenaline in normosaline in the subcutaneous tissue. This solution that is easily and painlessly infiltrated, anesthetizes a large area of subcutaneous tissue in particular body areas like: abdomen, thigh or arms; it provides less bleeding during procedures performed on the skin and subcutaneous tissue.  The tumescent local anesthesia (TLA) is a very simple and save procedure, widely used in many surgical branches. The aim of the paper was to assess the value of the tumescent local anesthesia during liposuction. Material and methods: Sixteen patients with a mean age of 32 years (24-46) underwent liposuction of one to three body areas, using tumescent technique, wide-awake. Тotal of 27 procedures were performed, with infiltration of solution of 0.075% lidocaine with 1:1,000,000 adrenaline and 25 ml of 8.4% sodium bicarbonate in 1000 ml normosaline, mean infiltrated solution of 2506 ml (1600-5000), mean dosage of lidocaine 25.9 mg/kg (18.88-50.6 mg/kg), total amount of lidocaine 2010 mg (1360-4000 mg). Results: TLA was successfully realized; 68.8% (11) of patients were happy and satisfied, 12.5% (2) of patients had headache and dizziness, in 12.5% (2) of patients the procedure was stopped because of a severe pain, one in the first region and one in the second region, and in 6.3% (1) of patients mild signs of lidocaine toxicity were observed. There were no complications that needed treatment or hospitalization; also, there were no lethal cases. Conclusion: Sole tumescent local anesthesia at a dosage 18-50 mg/kg lidocaine in prudent chosen patients seems to be safe regional anesthesia technique for the procedure of subcutaneous fat tissue

Вредноста на магнетната резонанца во мултимодалниот третман на локално напреднат ректален карцином

MRI is a basic tool in patient selection for preoperative neoadjuvant treatment of rectal carcinoma, with assessment of stage reduction. The aim of the paper was to evaluate chemoradiotherapy effects in advanced stage rectal carcinoma by comparison of MRI findings before and after chemoradiotherapy. Material and methods: Prospectively, MRI findings of 15 patients with rectal carcinoma confirmed at colonoscopy, were evaluated. In all patients preoperative neoadjuvant treatment was done and MRI restaging was performed after 6 to 8 weeks. MRI standard protocol was done on 1.5T machine, sagital T2WI, axial T1WI, T2WI and DWI. On MRI was assessed tumor and nodal stage, presence of extra-mural vascular invasion (EMVI), tumor localization within the rectum (low, medium, high rectum, recto-sigmoid junction). Computer tomography was performed in all patients for distant metastases assessment. Results: Out of 15 patients, 12 (66.7%) were male, and 3 (33.3 %) were female, with a mean age of 65 years (range 50 to 80years). Six cases had middle rectum localization, 6 cases in low rectum, and 3 patients had recto-sigmoid localization. At initial MRI, 7 cases (46.6%) had MR signs for T3 stage, and 8 cases (53.3%) had T4 stage. Comparison of MRI results before and after chemoradiotherapy showed stage decreasing in 5(33.3%), from T4 to T3 stage. In 11 patients (73.7%), EMVI after therapy became negative with a statistically significant difference before and after chemoradiotherapy. All patients before therapy had different numbers of metastatic lymph nodes in mesorectum, with number reduction in all cases after therapy and two patients were without metastatic lymph nodes. Conclusion: MRI has a significant value in pre- and post-neoadjuvant therapy assessment of resection margins involved by tumor, positive extramural vascular invasion, and metastatic lymph node around resection margins. This is important for operative planning in order to avoid extensive resection with surgery techniques that preserve the anal sphincter.Магнетната резонанца е основен дијагностички  метод  за селекција на пациенти со докажан ректален карцином кои имаат потреба од  предоперативна хеморадиотерапија со цел намалување на стадиумот на болеста. Целта на овој труд беше да се направи евалуација на ефектите од хеморадиотерапијата во напреднат стадиум на ректален карцином, со споредба на МР прегледот пред и по третманот. Материјал и методи: Проспективно, беа евалуирани  МР наоди  на 15 пациенти со ректален карцином потврден на колоноскопија. Кај сите пациенти беше направен предоперативен неадјувантен третман и беше направи контролен МР преглед по 6 до 8 недели. МР прегледот беше направен на 1.5T магнет, во пулс секвенци: сагитален T2WI, аксијален T1WI, T2WI и DWI. На МР беше утврден Т стадиумот, нодалниот стадиум, присуство на екстрамурална васкуларна инвазија (ЕМВИ), локализација на тумор во ректумот (низок, среден, висок ректум, ректосигмоиден спој). Компјутерска томографија беше направена кај сите пациенти за утврдување на далечни метастази. Резултати: Од 15 пациенти, 12 беа мажи  (66,7%), а 3 (33,3%) беа жени, на возраст од 50 до 80 години. Локализација на ректален карцином: кај 6 пациенти во низок ректум, кај 6 пациенти во среден ректум и кај 3 пациенти на ректосигмоиден спој. На првичниот МР преглед, 7 (46,6%) пациенти беа во Т3 стадиум, 8 (53,3%)  во  Т4 стадиум. Споредбата на резултатите од МР прегледот пред и по хеморадиотерапијата покажа намалување на стадиумот во 5 (33,3%) од Т4 во Т3 фаза. Кај 11 пациенти (73,7%), ЕМВИ по терапијата стана негативна со статистички значајна разлика пред и по хеморадиотерапијата. Сите пациенти пред терапијата имаа различен број на метастатски лимфни јазли во мезоректум, со намалување на бројот во сите случаи по терапијата, а двајца пациенти беа без метастатски лимфни јазли. Заклучок: МР има значајна вредност во проценката на ефектите од хеморадиотерапијата. Ова е важно за оперативно планирање со цел да се избегне широка ресекција со хируршки техники кои го зачувуваат аналниот сфинктер

Low-Grade Malignancy Glomus Tumor in a Setting of Multiple Glomus Tumors – Case Report

BACKGROUND: Glomus tumors are rare neoplasms accounting for less than 2% of all soft tissue tumors but multiple lesions may be seen in up to 10% of the patients. Solitary glomus tumor (GT) most frequently appears as small nodule in specific locations such as subungual region or deep dermis. However, rarely these entities have been observed in extracutaneous locations such as the gastrointestinal, cardiovascular, respiratory tracts, and other visceral organs. A small fraction of the GTs may present as tumors of uncertain malignant potential or as malignant glomus tumors. CASE PRESENTATION: We report a patient with multiple glomus tumors on the time of diagnosis, which was histologically diagnosed as an atypical glomus tumor following resection of a tumor thrombus in the left renal vein, inferior vena cava trombus with intracardial extension, and mitral valve specimen. The intramuscular lesion from the thigh was diagnosed as a glomus tumor of uncertain malignant potential. Further examinations revealed multiple lesions trough her body: kidneys, breast, heart and subcutaneous tissue. The diagnosis of glomus tumor of uncertain malignant potential versus glomus tumor with low malignant potential could be quite challenging, and the clinical course may be as a determining factor for final diagnosis. CONCLUSION: To our knowledge, this is the only known case of glomus tumor with multiple organ involvement and aggressive biological behavior at presentation

Structural analysis of x-ray irradiated carbon nanostructures

One of the new and promising applications of carbon nanostructures (CNs) are various dosimetry devices. Namely, these devices based on carbon nanostructures can provide the possibility for device miniaturization, lower costs, and high scale manufacturing. So, very important factors for the device processing need a quantitative study of the effects of relatively lower doses of X-ray irradiation on the carbon nanostructures. In this study, we present the effects of relatively low doses of x-ray irradiation on the physical and chemical properties of three carbon-based nanostructures (multiwall carbon nanotubes - MWCNTs, graphene - G, hybrid - G/MWCNTs). We have used a range of characterization techniques including scanning electron microscopy, Raman and FTIR spectroscopy, thermal and particle size analysis. Specifically, it was found that irradiation exposure results in a reduction in the sp2 nature of all three carbon-based nanostructures

Impact of Dual-Energy Computed Tomography (DECT) Postprocessing Protocols on Detection of Monosodium Urate (MSU) Deposits in Foot Tendons of Cadavers

Objective: To evaluate two different dual-energy computed tomography (DECT) post-processing protocols for the detection of MSU deposits in foot tendons of cadavers with verification by polarizing light microscopy as the gold standard. Material and Methods: A total of 40 embalmed cadavers (15 male; 25 female; median age, 82 years; mean, 80 years; range, 52–99; SD ± 10.9) underwent DECT to assess MSU deposits in foot tendons. Two postprocessing DECT protocols with different Hounsfield unit (HU) thresholds, 150/500 (=established) versus 120/500 (=modified). HU were applied to dual source acquisition with 80 kV for tube A and 140 kV for tube B. Six fresh cadavers (4 male; 2 female; median age, 78; mean, 78.5; range 61–95) were examined by DECT. Tendon dissection of 2/6 fresh cadavers with positive DECT 120 and negative DECT 150 studies were used to verify MSU deposits by polarizing light microscopy. Results: The tibialis anterior tendon was found positive in 57.5%/100% (DECT 150/120), the peroneus tendon in 35%/100%, the achilles tendon in 25%/90%, the flexor halluces longus tendon in 10%/100%, and the tibialis posterior tendon in 12.5%/97.5%. DECT 120 resulted in increased tendon MSU deposit detection, when DECT 150 was negative, with an overall agreement between DECT 150 and DECT 120 of 80% (p = 0.013). Polarizing light microscope confirmed MSU deposits detected only by DECT 120 in the tibialis anterior, the achilles, the flexor halluces longus, and the peroneal tendons. Conclusion: The DECT 120 protocol showed a higher sensitivity when compared to DECT 150

Soft tissue tumor imaging in adults: European Society of Musculoskeletal Radiology-Guidelines 2023—overview, and primary local imaging: how and where?

Objectives: Early, accurate diagnosis is crucial for the prognosis of patients with soft tissue sarcomas. To this end, standardization of imaging algorithms, technical requirements, and reporting is therefore a prerequisite. Since the first European Society of Musculoskeletal Radiology (ESSR) consensus in 2015, technical achievements, further insights into specific entities, and the revised WHO-classification (2020) and AJCC staging system (2017) made an update necessary. The guidelines are intended to support radiologists in their decision-making and contribute to interdisciplinary tumor board discussions. Materials and methods: A validated Delphi method based on peer-reviewed literature was used to derive consensus among a panel of 46 specialized musculoskeletal radiologists from 12 European countries. Statements were scored online by level of agreement (0 to 10) during two iterative rounds. Either “group consensus,” “group agreement,” or “lack of agreement” was achieved. Results: Eight sections were defined that finally contained 145 statements with comments. Overall, group consensus was reached in 95.9%, and group agreement in 4.1%. This communication contains the first part consisting of the imaging algorithm for suspected soft tissue tumors, methods for local imaging, and the role of tumor centers. Conclusion: Ultrasound represents the initial triage imaging modality for accessible and small tumors. MRI is the modality of choice for the characterization and local staging of most soft tissue tumors. CT is indicated in special situations. In suspicious or likely malignant tumors, a specialist tumor center should be contacted for referral or teleradiologic second opinion. This should be done before performing a biopsy, without exception. Clinical relevance: The updated ESSR soft tissue tumor imaging guidelines aim to provide best practice expert consensus for standardized imaging, to support radiologists in their decision-making, and to improve examination comparability both in individual patients and in future studies on individualized strategies. Key Points: • Ultrasound remains the best initial triage imaging modality for accessible and small suspected soft tissue tumors. • MRI is the modality of choice for the characterization and local staging of soft tissue tumors in most cases; CT is indicated in special situations. Suspicious or likely malignant tumors should undergo biopsy. • In patients with large, indeterminate or suspicious tumors, a tumor reference center should be contacted for referral or teleradiologic second opinion; this must be done before a biopsy

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VII, nerves of the lower limb.

Funder: Università degli Studi di MilanoOBJECTIVES: To perform a Delphi-based consensus on published evidence on image-guided interventional procedures for peripheral nerves of the lower limb (excluding Morton's neuroma) and provide clinical indications. METHODS: We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around peripheral nerves in the lower limb (excluding Morton's neuroma) to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper. RESULTS: Nine statements on image-guided interventional procedures for peripheral nerves of the lower limb have been drafted. All of them received strong consensus. Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. CONCLUSION: Despite the promising results reported by published papers on image-guided interventional procedures for peripheral nerves of the lower limb, there is still a lack of evidence on the efficacy of most procedures. KEY POINTS: • Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. • US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. • US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. The volume of local anesthetic affects the size of the blocked sensory area

Soft tissue tumor imaging in adults: European Society of Musculoskeletal Radiology-Guidelines 2023-overview, and primary local imaging: how and where?

OBJECTIVES: Early, accurate diagnosis is crucial for the prognosis of patients with soft tissue sarcomas. To this end, standardization of imaging algorithms, technical requirements, and reporting is therefore a prerequisite. Since the first European Society of Musculoskeletal Radiology (ESSR) consensus in 2015, technical achievements, further insights into specific entities, and the revised WHO-classification (2020) and AJCC staging system (2017) made an update necessary. The guidelines are intended to support radiologists in their decision-making and contribute to interdisciplinary tumor board discussions. MATERIALS AND METHODS: A validated Delphi method based on peer-reviewed literature was used to derive consensus among a panel of 46 specialized musculoskeletal radiologists from 12 European countries. Statements were scored online by level of agreement (0 to 10) during two iterative rounds. Either "group consensus," "group agreement," or "lack of agreement" was achieved. RESULTS: Eight sections were defined that finally contained 145 statements with comments. Overall, group consensus was reached in 95.9%, and group agreement in 4.1%. This communication contains the first part consisting of the imaging algorithm for suspected soft tissue tumors, methods for local imaging, and the role of tumor centers. CONCLUSION: Ultrasound represents the initial triage imaging modality for accessible and small tumors. MRI is the modality of choice for the characterization and local staging of most soft tissue tumors. CT is indicated in special situations. In suspicious or likely malignant tumors, a specialist tumor center should be contacted for referral or teleradiologic second opinion. This should be done before performing a biopsy, without exception. CLINICAL RELEVANCE: The updated ESSR soft tissue tumor imaging guidelines aim to provide best practice expert consensus for standardized imaging, to support radiologists in their decision-making, and to improve examination comparability both in individual patients and in future studies on individualized strategies. KEY POINTS: • Ultrasound remains the best initial triage imaging modality for accessible and small suspected soft tissue tumors. • MRI is the modality of choice for the characterization and local staging of soft tissue tumors in most cases; CT is indicated in special situations. Suspicious or likely malignant tumors should undergo biopsy. • In patients with large, indeterminate or suspicious tumors, a tumor reference center should be contacted for referral or teleradiologic second opinion; this must be done before a biopsy

Ewing's sarcoma and primary osseous lymphoma : spectrum of imaging appearances

Ewing's sarcoma (ES) is a rare, highly malignant anaplastic stem cell tumor. Histologically, the tumor consists of uniform densely packed small monomorphic cells with round nuclei. The typical appearance at hematoxylin and eosin (H&E) staining is small blue round cells without any matrix formation. On conventional radiography, ES typically presents as a permeative lesion in the diaphysis of a long bone in a child. A large soft tissue component is another characteristic feature, best depicted by magnetic resonance imaging. Primary osseous lymphomas are most commonly highly malignant B-cell lymphomas. At H&E histologic staining, the tumor stroma consists of diffuse round-cell infiltrates that resembles the appearance of ES. Although there is no typical imaging appearance of an osseous lymphoma, it should be considered in an adult presenting with a Lodwick grade II or III lesion in the metaphysis or diaphysis of a large long bone, the pelvis, or the vertebral column. Histologic confirmation is mandatory