Adrenal metastasis as first presentation of hepatocellular carcinoma

BACKGROUND: Metastases from hepatocellular carcinoma (HCC) can be found in the lung and adrenal gland. We report case of a patient who presented with adrenal metastasis as the first clinical manifestation of HCC. CASE PRESENTATION: A patient was referred for surgical treatment for a tumor in retro-peritoneal space. The computerized tomography (CT) scan revealed a mass originating from the left adrenal gland. The patient underwent left adrenalectomy and the exploration of abdominal cavity did not reveal any other palpable lesions. Histologically, the resected lesion was a poorly differentiated metastatic tumor from HCC. Seven months later patient was readmitted complaining of cachexia, icterus, and significant weight loss. CT scan revealed hyperdense lesions of the liver CONCLUSION: HCC may have atypical presentations like in present case. Fine needle aspiration/tru-cut(® )biopsy might be useful in the investigation of an accidentally discovered adrenal mass regardless of the size and can lead to the detection of a primary tumor

Our local experience with the surgical treatment of ampullary cancer

BACKGROUND: The aim of this study is to report the outcome after surgical treatment of 32 patients with ampullary cancers from 1990 to 1999. METHODS: Twenty-one of them underwent pancreaticoduodenectomy and 9 local excision of the ampullary lesion. The remaining 2 patients underwent palliative surgery. RESULTS: When the final histological diagnosis was compared with the preoperative histological finding on biopsy, accurate diagnosis was preoperatively established in 24 patients. The hospital morbidity was 18.8% as 9 complications occurred in 6 patients. Following local excision of the ampullary cancer, the survival rate at 3 and 5 years was 77.7% and 33.3% respectively. Among the patients that underwent Whipple's procedure, the 3-year survival rate was 76.2% and the 5-year survival rate 62%. CONCLUSION: In this series, local resection was a safe option in patients with significant co-morbidity or small ampullary tumors less than 2 cm in size, and was associated with satisfactory long-term survival rates

Integrated Reverse Engineering Strategy for Large-Scale Mechanical Systems: Application to a Steam Turbine Rotor

An integrated reverse engineering methodology is proposed for a large-scale fully operational steam turbine rotor, considering issues that include developing the CAD and FE model of the structure, as well as the applicability of model updating techniques based on experimental modal analysis procedures. First, using an integrated reverse engineering strategy, the digital shape of the three sections of a steam turbine rotor was designed and the final parametric CAD model was developed. The finite element model of the turbine was developed using tetrahedral solid elements resulting in fifty-five million DOFs. Imposing impulsive loading in a free-free state, measured acceleration time histories were used to obtain the dynamic responses and identify the modal characteristics of each section of the complete steam turbine. Experimentally identified modal modes and modal frequencies compared to the FE model predicted ones constitute the actual measure of fit. CMA-ES optimization algorithm is then implemented in order to finely tune material parameters, such as modulus of elasticity and density, in order to best match experimental and numerical data. Comparing numerical and experimental results verified the reliability and accuracy of the applied methodology. The identified finite element model is representative of the initial structural condition of the turbine and is used to develop a simplified finite element model, which then used for the turbine rotordynamic analysis. Accumulated knowledge of the dynamic behavior of the specific steam turbine system, could be implemented in order to evaluate stability or instability states, fatigue growth in the turbine blades, changes in the damping of the bearing system and perform necessary scheduled optimal and cost-effective maintenance strategies. Additionally, upon a series of scheduled experimental data collection, a permanent output-only vibration SHM system could be installed and even a proper dynamic balancing could be investigated and designed

Local excision as a treatment for tumors of ampulla of Vater

BACKGROUND: Although local excision (ampullectomy) was first described by Halsted in 1899, its adequacy as an alternative surgical treatment for the ampullary tumors is still a matter of debate. The aim of this study was to evaluate the results of ampullectomy as a curative treatment for benign and malignant tumors arising from the ampulla, in a 14-year single-institution experience. METHODS: From 1990 to 2004, a total of 20 patients of adenocarcinoma (12) or adenoma (8) of the ampulla of Vater underwent local excision. Clinical data were collected and morbidity, mortality, as well as long-term survival were evaluated. The usefulness of several pre or intraoperative diagnostic methods was also recorded. Median follow-up was 85 (range 6–180) months. RESULTS: The combination of endoscopic preoperative biopsies and intraoperative frozen section examination adequately diagnosed ampullary tumors in all cases. The postoperative morbidity and mortality were 0%, whereas the 3 and 5-year survival rates for the patients with adenocarcinoma was 75 % and 33.3 % respectively. All the patients with adenoma are still alive without any sign of recurrence. CONCLUSION: In our series, local excision was a safe option, associated with satisfactory long-term survival rates in patients with benign lesions and in those with small(<2 cm), pT1, well differentiated ampullary tumours without nodal involvement

Non-blood medical care in gynecologic oncology: a review and update of blood conservation management schemes

This review attempts to outline the alternative measures and interventions used in bloodless surgery in the field of gynecologic oncology and demonstrate their effectiveness. Nowadays, as increasingly more patients are expressing their fears concerning the potential risks accompanying allogenic transfusion of blood products, putting the theory of bloodless surgery into practice seems to gaining greater acceptance. An increasing number of institutions appear to be successfully adopting approaches that minimize blood usage for all patients treated for gynecologic malignancies. Preoperative, intraoperative and postoperative measures are required, such as optimization of red blood cell mass, adequate preoperative plan and invasive hemostatic procedures, assisting anesthetic techniques, individualization of anemia tolerance, autologous blood donation, normovolemic hemodilution, intraoperative cell salvage and pharmacologic agents for controlling blood loss. An individualised management plan of experienced personnel adopting a multidisciplinary team approach should be available to establish non-blood management strategies, and not only on demand of the patient, in the field of gynecologic oncology with the use of drugs, devices and surgical-medical techniques

Vibration-Based Damage Detection Using Finite Element Modeling and the Metaheuristic Particle Swarm Optimization Algorithm

The continuous development of new materials and larger and/or more complex structures drives the need for the development of more robust, accurate, and sensitive Structural Health Monitoring (SHM) techniques. In the present work, a novel vibration-based damage-detection method that contributes into the SHM field is presented using Metaheuristic algorithms coupled with optimal Finite Element Models that can effectively localize damage. The proposed damage-detection framework can be applied in any kind of detailed structural FE model, while requiring only the output information of the dynamic response of the structure. It can effectively localize damage in a structure by highlighting not only the affected part of the structure but also the specific damaged area inside the part. First, the optimal FE model of the healthy structure is developed using appropriate FE model updating techniques and experimental vibration measurements, simulating the undamaged condition. Next, the main goal of the proposed method is to create a damaged FE model that approximates the dynamic response of the damaged structure. To achieve this, a parametric area is inserted into the FE model, changing stiffness and mass to simulate the effect of the physical damage. This area is controlled by the metaheuristic optimization algorithm, which is embedded in the proposed damage-detection framework. On this specific implementation of the framework, the Particle Swarm Optimization (PSO) algorithm is selected which has been used for a wide variety of optimization problems in the past. On the PSO&rsquo;s search space, two parameters control the stiffness and mass of the damaged area while additional location parameters control the exact position of the damaged area through the FE model. For effective damage localization, the Transmittance Functions from acceleration measurements are used which have been shown to be sensitive to structural damage while requiring output-only information. Finally, with proper selection of the objective function, the error that arises from modeling a physical damage with a linear damaged FE model can be minimized, thus creating a more accurate prediction for the damaged location. The effectiveness of the proposed SHM method is demonstrated via two illustrative examples: a simulated small-scale model of a laboratory-tested vehicle-like structure and a real experimental CFRP composite beam structure. In order to check the robustness of the proposed method, two small damage scenarios are examined for each validation model and combined with random excitations

Definition of the levels of interferon-γ interleukin-2 and tumor necrosis factor-α as prognostic indicators in patients with unstable angina

The aim of this study was the evaluation of the kinetics of the three cytokines: tumor necrosis factor-α (TNF-α), interferon-gamma (IFN-γ) and interleukin-2 (IL-2) by measuring their values on days 1st, 3rd, 7th of the hospitalization of patients suffering from unstable angina, as well as by counting their values on the 30th day, during their first follow-up. At the same time, we tried to correlate possible complications of our patients, like recurrence of angina, with the cytokine values at the above days of blood sampling. We also tried to find the probable prognostic value of these three cytokines for the future well being of these patients up to 18 months after their first, under study, episode of unstable angina pectoris. We enrolled in our study 90 consecutive patients (60 men and 30 women) of ages ranging from 37 to 75 years, that entered the coronary unit due to severe unstable angina (Braunwald class IIIb). All the patients of the study had negative, at repeated measurements, all the enzymes that show myocardial damage including troponin-T. Patients with renal or liver deficiency, or patients with a history of chronic inflammatory disease or cancer, or those with acute myocardial infarction or by-pass surgery in the 6 months prior of the study were excluded from the study, as well as those that had ECG with alterations that did not permit the evaluation of the ST segment deviation. At the same time we drew blood for the measurement of the above-mentioned cytokines from 32 healthy volunteers age and sex matched with the patients of our study. During their stay in the hospital (1st to 7th day of the study) 42 remained uncomplicated, while 48 had recurrence of the angina (without rise of the CPK) or suffered an arrhythmia calling for medical treatment. After their discharge from the hospital and till the 30th day of their observation, only 26 out of 90 showed complications, while from the 30th day till the 18th month of observation only 18 had a complicated clinical course.Ο σκοπός της παρούσας μελέτης ήταν η εκτίμηση της κινητικής των τριών κυτταροκινών: του παράγοντα νεκρώσεως του όγκου-α (TNF-α), της ιντερφερόνης-γ (IFN-γ) και της ιντερλευκίνης-2 (IL-2), μέσα από μετρήσεις των τιμών αυτών την 1η, 3η, 7η ημέρα νοσηλείας καθώς και την 30η ημέρα μετά την ένταξη τους στη μελέτη, ασθενών με ασταθή στηθάγχη. Ταυτόχρονα, έγινε προσπάθεια να συσχετισθούν πιθανές επιπλοκές στην πορεία των ασθενών, όπως η υποτροπή της στηθάγχης, με τις τιμές των κυτταροκινών στα ανωτέρω χρονικά διαστήματα., ενώ παράλληλα ερευνήθηκε η προγνωστική αξία των τριών αυτών κυτοκινών για την πορεία των ασθενών της μελέτης έως και 18 μήνες περίπου μετά το αρχικό επεισόδιο της ασταθούς στηθάγχης. Μελετήθηκαν συνολικά διαδοχικούς 90 ασθενείς (60 άνδρες και 30 γυναίκες) με εύρος ηλικίας από 37 έως 75 έτη που εισήχθησαν στην στεφανιαία μονάδα συνεπεία σοβαρής ασταθούς στηθάγχης (κλάση ΙΙΙb κατά Braunwald). Όλοι οι ασθενείς της μελέτης είχαν σε επανειλημμένες μετρήσεις αρνητικά όλα τα ένζυμα μυοκαρδιακής βλάβης συμπεριλαμβανομένης και της τροπονίνης-Τ. Αποκλείστηκαν επίσης από τη μελέτη ασθενείς με νεφρική ή ηπατική ανεπάρκεια, ιστορικό νεοπλασίας ή χρόνιας φλεγμονώδους νόσου, ασθενείς που υπέστησαν έμφραγμα του μυοκαρδίου ή υποβλήθηκαν σε αορτοστεφανιαία παράκαμψη τους προηγούμενους 6 μήνες προ της εισαγωγής τους καθώς και όσοι παρουσίαζαν ΗΚΓ με διαταραχές που δεν επέτρεπαν την ερμηνεία των μεταβολών του διαστήματος ST. Παράλληλα ελήφθησαν δείγματα ορού για τον προσδιορισμό των τριών κυτταροκινών από 32 υγιής μάρτυρες σε αντιστοιχία, όσον αφορά το φύλο και την ηλικία, με τους ασθενείς της μελέτης. Το διάστημα παραμονής τους στο νοσοκομείο (1η έως 7η ημέρα της μελέτης) 42 παρέμειναν ασυμπτωματικοί, ενώ 48 εμφάνισαν υποτροπή της στηθάγχης (χωρίς συνοδό αύξηση της CPK) ή αρρυθμία χρήζουσα φαρμακευτική αντιμετώπιση. Από την έξοδο τους από το νοσοκομείο έως και την 30η ημέρα παρακολούθησης 26 μόνο σε σύνολο 90 ασθενών υπήρξανε συμπτωματικοί, ενώ από την 30η ημέρα έως και τον 18ο μήνα της παρακολούθησης μόνο 18 είχαν επιπλεγμένη κλινική πορεία

Cervical pessary for the prevention of spontaneous preterm birth in women with a short mid trimester cervix

Introduction: Aim of this study was to evaluate the safety and efficacy of the combined treatment of cervical pessary and endovaginal progesterone for the prevention of spontaneous preterm birth (SPB) in women with a short cervical length between 20 to 24 weeks of gestation.Materials and Methods: Prospective study of women with a singleton pregnancy and a sonographically detected mid-trimester cervical length ≤25mm. The primary outcome measure was spontaneous delivery before 34 weeks (238 days) of gestation. . Secondary outcome measures were SPB before 37 completed weeks (259 days) of gestation, pregnancy prolongation, birth weight, apgar score, major adverse neonatal outcomes (intraventricular hemorrhage, infant respiratory distress syndrome, septicaemia, or necrotizing entercolitis), admission to the neonatal intensive care unit, use of continuous positive airway pressure, mechanical ventilation and fetal or neonatal death. Once the patients were identified were combined to form two groups. The first group (high-risk group) consisted of women that were found to have in their previous obstetrical and/or gynecological history at least one risk factor for SPB. The second group (low-risk group) consisted of women who were not found to have risk factors for SPB.Results: The study sample consisted of 90 women with a mean cervical length of 14.2 mm (SD=6.5 mm). 34.4% of the women had at least one risk factor for SPB. 7.8% of the women delivered preterm before 34 weeks of gestation, and 25.6% before 37 weeks. Neonatal death occurred in 2.2% of the cases. Women with lower body mass index (BMI) values, history of preterm delivery and the number of 2nd trimester miscarriages were independently associated with delivery before 34 weeks. Concerning association of primary and secondary study outcomes with the two study groups (table 5) it was found that rates of preterm delivery <34 weeks were similar between low and high-risk pregnancies after the combined treatment with both cervical pessary and vaginal progesterone. However, it was found a significantly greater rate of preterm delivery (<37 weeks) in women with high-risk pregnancies (p=0.005).Conclusion: Combination of vaginal progesterone and cervical pessary for the prevention of SPB in women with a short cervix is safe and well tolerated. This therapy was associated with a pregnancy prolongation, reduced prematurity rate and a low rate of perinatal complications. Moreover combined treatment may result in prolongation of the pregnancy regardless of the obstetrical and gynecological maternal history. Therefore combined treatment is a feasible and safe option in both low and high-risk women that may result in delaying birth and reducing prematurity.ΕισαγωγήΟ πρόωρος τοκετός (ΠΤ) εξακολουθεί να επηρεάζει έως και το 12,5% όλων των κυήσεων. Το μήκος του τραχήλου της μήτρας φαίνεται να είναι αντιστρόφως ανάλογο με τον κίνδυνο για αυτόματο ΠΤ. Στη σύγχρονη βιβλιογραφία έχουν προταθεί διαφορετικές στρατηγικές διαχείρισης για την πρόληψη του αυτόματου ΠΤ μετά από τη διάγνωση ενός «κοντού» τραχήλου. Οι περισσότερες θεραπείες έχουν ως στόχο την παροχή μηχανικής υποστήριξης, είτε με την τοποθέτηση ενός ράμματος είτε με τη χρήση ενός τραχηλικού πεσσού σιλικόνης. Επιπλέον, η φαρμακευτική θεραπεία με κολπικά χορηγούμενη προγεστερόνη μπορεί να αποτρέψει αποτελεσματικά τον αυτόματο ΠΤ σε αυτές τις περιπτώσεις.Σκοπός της μελέτηςΣκοπός της παρούσας μελέτης ήταν να εξετασθεί η αποτελεσματικότητα, αλλά και η ασφάλεια της συνδυασμένης παρέμβασης με τραχηλικό πεσσό σιλικόνης και ενδοκολπική προγεστερόνη σε γυναίκες με μονήρη κύηση και υπερηχογραφικά διαγεγνωσμένο κοντό τράχηλο στο 2ο τρίμηνο της κύησης, όπως και να αξιολογηθούν οι πιθανοί παράγοντες κινδύνου για αποτυχία της συνδυασμένης θεραπευτικής προσέγγισης.Μέθοδοι και ΥλικόΠρόκειται για προοπτική μελέτη γυναικών με μονήρη κύηση και μήκος τραχήλου ≤25mm στο Β τρίμηνο της κύησης, διαγεγνωσμένο με διακολπικό υπερηχογράφημα. Σύμφωνα με το πρωτόκολλο της μελέτης όλες οι ασθενείς μετά την τοποθέτηση του πεσσού κλήθηκαν να εισάγουν ενδοκολπικά μία κάψουλα προγεστερόνης 200mg κάθε βράδυ από τη διάγνωση έως τις 37 εβδομάδες. Το κύριο αποτέλεσμα έκβασης της μελέτης ήταν η συχνότητα του αυτόματου ΠΤ πριν από την ολοκλήρωση των 34 εβδομάδων (238 ημερών) της κύησης. Τα δευτερεύοντα αποτελέσματα έκβασης ήταν η συχνότητα του αυτόματου ΠΤ πριν από τη συμπλήρωση της 37ης εβδομάδας (259 ημέρες) κύησης, ο χρόνος παράτασης της κύησης από την τοποθέτηση του πεσσού έως τον τοκετό, το βάρος γέννησης του νεογνού, το «Αpgar score» κατά τον τοκετό, οι μείζονες νεογνικές επιπλοκές (ενδοκοιλιακή αιμορραγία, σύνδρομο αναπνευστικής δυσχέριας στο βρέφος, σηψαιμία ή νεκρωτική εντελοκολίτιδα), η εισαγωγή του νεογνού στη μονάδα εντατικής θεραπείας νεογνών (ΜΕΝ), η χρήση αερισμού με θετική πίεση (CPAP), ο μηχανικός αερισμός και ο θάνατος του εμβρύου ή νεογνoύ.ΑποτελέσματαΤο 7,8% (7/90) των γυναικών γέννησε πρόωρα <34 εβδομάδες, ενώ το 25,6% (23/90) των γυναικών γέννησε πριν τις <37 εβδομάδες. Το ποσοστό εισαγωγής των νεογνών στη μονάδα εντατικής θεραπείας νεογνών ήταν 10% (9/90), ενώ ο αερισμός με θετική πίεση (CPAP) χρησιμοποιήθηκε στο 4,4% των νεογνών. Η ανάγκη για χρήση μηχανικού αερισμού παρουσιάστηκε στο 3,3% των περιπτώσεων. Υπήρχαν επίσης και δύο περιπτώσεις θανάτων νεογνών εξαιτίας του συνδρόμου αναπνευστικής δυσχέριας των νεογνών, ένος στις 23+3 εβδομάδες και ενός στις 25+1 εβδομάδες κύησης. Όταν εφαρμόστηκε ανάλυση πολλαπλής λογιστικής παλινδρόμησης για τον ΠΤ πριν από τις 34 εβδομάδες κύησης, διαπιστώθηκε ότι ένας αυξημένος ΔΜΣ σχετίζεται με χαμηλότερο κίνδυνο για αυτόματο ΠΤ πριν από τις 34 εβδομάδες, ενώ μια αποβολή στο 2ο τρίμηνο αυξάνει τις πιθανότητες για αυτόματο ΠΤ <34 εβδομάδες σχεδόν 7 φορές. Επιπλέον, οι γυναίκες με τουλάχιστον έναν προηγούμενο ΠΤ είχαν 3.72 φορές μεγαλύτερο κίνδυνο για αυτόματο ΠΤ <34 εβδομάδες. Ο αριθμός των αποβολών του 2ου τριμήνου βρέθηκε επίσης να έχει στατιστικά σημαντική συσχέτιση με πρόωρο τοκετό <37 εβδομάδων.ΣυμπεράσματαΗ παρούσα μελέτη έδειξε ότι η συνδυασμένη θεραπεία με τη χρήση τραχηλικού πεσσού και ενδοκολπικής προγεστερόνης είναι μια ασφαλής και εφικτή επιλογή, η οποία μπορεί να έχει ευεργετική επίδραση στην παράταση της κύησης σε γυναίκες με ελαττωμένο μήκος τραχήλου στο 2ο τρίμηνο της κύησης και συνεπώς μπορεί να αποτελέσει αποτελεσματική μέθοδο για την πρόληψη του αυτόματου ΠΤ

Model-Based Damage Localization Using the Particle Swarm Optimization Algorithm and Dynamic Time Wrapping for Pattern Recreation

Vibration-based damage detection methods are a subcategory of Structural Health Monitoring (SHM) methods that rely on the fact that structural damage will affect the dynamic characteristic of a structure. The presented methodology uses Finite Element Models coupled with a metaheuristic optimization algorithm in order to locate the damage in a structure. The search domains of the optimization algorithm are the variables that control a parametric area, which is inserted into the FE model. During the optimization procedure, this area changes location, stiffness, and mass to simulate the effect of the physical damage. The final output is a damaged FE model which can approximate the dynamic response of the damaged structure and indicate the damaged area. For the current implementation of this Damage Detection Framework, the Particle Swarm Optimization algorithm is used. As an effective metric of the comparison between the FE model and the experimental structure, Transmittance Functions (TF) are used that require output only acceleration signals. As with most model-based methods, a common concern is the modeling error and how this can be surpassed. For this reason, the Dynamic Time Wrapping (DTW) algorithm is applied. When damage occurs in a structure it creates some differences between the Transmittance Functions (TF) of the healthy and the damaged state. With the use of DTW, the damaged pattern is recreated around the TF of the FE model, while creating the same differences and, thus, minimizing the modeling error. The effectiveness of the proposed methodology is tested on a small truss structure that consists of Carbon-Fiber Reinforced Polymer (CFRP) filament wound beams and aluminum connectors, where four cases are examined with the damage to be located on the composite material