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Resumen Introducción: El síndrome de apnea obstructiva del sueño (SAOS) se asocia a aumento de morbimortalidad cardiovascular y metabólica, y a mala calidad de vida. Su diagnóstico y tratamiento eficaz mejora la salud individual y pública. Objetivo: evaluar concordancia entre análisis automático versus manual del dispositivo ApneaLink para diagnosticar y clasificar SAOS en pacientes con sospecha clínica. Material y Método: Evaluación retrospectiva de 301 poligrafías respiratorias del HOSCAR. Se mide correlación, acuerdo general y concordancia entre parámetros obtenidos manual y automáticamente usando coeficiente de Pearson, coeficiente de correlación intraclase y gráfico de Bland y Altman. Resultados: En 11,3% de casos el análisis automático interpreto erróneamente la señal de flujo. No hubo diferencias significativas entre índices de apnea-hipopnea automático (AHIa 18,9 ± 17,5) y manual (AHIm 20,8 ± 19,4) r + 0,97 (95% CI: 0,9571 a 0,9728; p < 0,0001) y tampoco entre la saturación mínima de oxígeno automática (82,1 ± 7,6) y manual (83,1 ± 6,8) r + 0,85 (95% CI: 0,8108 a 0,8766; p < 0,0001). No hubo buena correlación entre análisis automático y manual en clasificación de apneas centrales, r + 0,51 (95% CI: 0,4238 a 0,5942; p < 0,0001). Hubo subestimación de gravedad de SAOS por análisis automático: en 11% de casos. Conclusión: El diagnóstico entregado automáticamente por ApneaLink podría aceptarse sin confirmación manual adicional solamente en casos clasificados como severos. Para AHI menores se requeriría confirmación mediante análisis manual de experto.

Abstract Introduction: Obstructive sleep apnea syndrome (OSAS) is associated with increased cardiovascular and metabolic morbidity and mortality, and poor quality of life. Its effective diagnosis and treatment improve individual and public health. Aim: To evaluate concordance between automatic versus manual analysis of the ApneaLink device to diagnose and classify OSAS in patients with clinical suspicion. Material and Method: Retrospective evaluation of 301 respiratory polygraphs from HOSCAR. Correlation, general agreement and concordance between parameters obtained manually and automatically are measured using Pearson's coefficient, intraclass correlation coefficient, and Bland and Altman graph. Results: In 11.3% of cases, the automatic analysis misinterpreted the flow signal. There were no significant differences between automatic (AHIa 18.9 ± 17.5) and manual (AHIm 20.8 ± 19.4) apnea-hypopnea indices r + 0.97 (95% CI:0.9571 to 0.9728, p < 0.0001) and nor between automatic (82.1 ± 7.6) and manual (83.1 ± 6.8) minimum oxygen saturation r + 0.85 (95% CI: 0.8108 to 0.8766, p < 0.0001). There was no good correlation between automatic and manual analysis in the classification of central apneas, r + 0.51(95% CI:0.4238 to 0.5942, p < 0.0001). There was an underestimation of the severity of OSAS by automatic analysis in 11% of cases. Conclusion: The diagnosis delivered automatically by ApneaLink could be accepted without additional manual confirmation only in cases classified as severe. For minors AHI, confirmation through manual expert analysis would be required.

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OBJECTIVE: Coronary computed tomography angiography (CCTA) is becoming increasingly useful for the diagnosis of coronary artery disease (CAD). Coronary calcium score (CCS), epicardial fat volume (EFV), and number of coronary plaques (NoP) add important information for the risk stratification and prognosis prediction of these patients. However, evidence about their ability to predict obstructive CAD is limited. We sought to evaluate the ability of CCTA parameters in predicting obstructive CAD. PATIENTS AND METHODS: We conducted a cross-sectional, single-center study on patients at risk to develop CAD. CAD was defined as coronary stenosis > 50% after the other one (CCS, EFV and NoP were determined by CCTA). CCS was then ranked 5 severity groups: 0, 1-99, 100-399,400-999, and ≥1000. NoPs were classified in four categories: no plaques, 1-5, 6-10 and ≥10. Logistic regression analyses were performed, and statistical analysis was considered significant if p<0.05. RESULTS: Of all 540 patients (55.8±11.1 years) who met the enrolment criteria, 98 had obstructive CAD. CCS, EFV and NoP were significantly associated with the presence of obstructive CAD (p<0.0001). The area under the receiver operating characteristics (ROC) analysis revealed significant cut-off values (p<0.0001) of CCS (70.3), EFV (40.8), NoP (4) for predicting obstructive CAD. Their association proved to have an AUC of 0.969, and a specificity of 95%. A scoring system based on regression coefficients which proved to have statistical significance for obstructive CAD as further constructed. It included EFV, CCS and left ventricular ejection fraction. This scoring system significantly predicted obstructive CAD for a cut-off value of 62.46, with a NPV of 96.3%. CONCLUSIONS: The combined use of CCS, EFV and NoPs increases the predictive ability for obstructive CAD of each parameter used alone. These could be useful for developing a novel scoring system.

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Systemic sclerosis (SSc) is a systemic autoimmune disorder characterized by inflammation, fibroproliferative vasculopathy, and progressive fibrosis. Cardiac involvement is common in SSc and may affect the myocardium, pericardium, heart valves, conduction system, as well as coronary arteries. However, it remains asymptomatic for a long time, which leads to delayed diagnosis and poor prognosis. Accurate and early detection of cardiac abnormalities may warrant a better outcome in SSc. Recent advances in cardiac magnetic resonance imaging (CMR) improved the non-invasive evaluation of heart morphology and function. CMR can accurately identify both left and right ventricle dysfunction, which has a significant clinical and prognosis impact on SSc patients. In terms of myocardial structural alterations, CMR has remarkable diagnosis accuracy in identifying the presence and extent of myocardial fibrosis. When it comes to pulmonary arterial hypertension assessment, emerging data endorse the usefulness of CMR for the non-invasive quantification of it. Two-dimensional and time-resolved three-dimensional phase-contrast velocity-encoded CMR has become promising techniques for the assessment of pulmonary artery flow and stiffness measurements. Furthermore, CMR provides valuable prognostic information, both at the time of diagnosis and during follow-up in SSc patients with pulmonary arterial hypertension. The purpose of this review is to provide an overview of the latest findings in advanced cardiovascular imaging in patients with SSc.

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At present, in Europe, 18 million tonnes of MSWI Bottom Ash (BA) is annually stockpiled or used in low-grade applications (e.g. in road bases). Therefore, alternative applications, such as aggregate or as a cement component in concrete, are stimulated. Physical and chemical characteristics remaining after treatment, however, prevent its extensive application in building materials. Hence, knowledge is needed on the distinct properties of the material classes making up a heterogeneous BA, enabling the assessment of its characteristics and the resulting applicability. Furthermore, a user-friendly composition assessment procedure is necessary to evaluate the output of physical treatment processes. Crushing is a commonly applied treatment and its effect on the material classes comprising BA is still unknown. In this paper, the latter are identified and classified into slag, magnetic slag, glass, refractory, metals, and unburned material classes. The individual characteristics of each material class are identified and a suitable tracer for tracking these classes in heterogeneous samples is defined. Furthermore, a fast method to quantify the distribution of material classes based just on the oxide composition is developed and applied to approximate the changes in the configuration of BA through crushing. It is concluded that, although the jaw crushing of BA results in a more homogeneous distribution, beneficiation of material classes occurs and selective crushing is possible in order to improve the quality of the BA and therefore its subsequent application.

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Despite numerous studies concerning the application of by-products in the construction field, municipal solid waste incineration (MSWI) residues are not widely used as secondary building materials. In some European countries, washing treatment to the full bottom ash (BA) fraction (0-32 mm) is applied, isolating more contaminated particles, smaller than 0.063 mm. Therefore, a MWSI sludge is produced, having a high moisture content, and thus a limited presence of soluble species. In order to enhance its performance as building material, here, dry mechanical activation is applied on MSWI sludge. Thereafter, a reactivity comparison between reference BA and untreated and treated MSWI sludge is provided, evaluating their behaviour in the presence of cement and their pozzolanic activity. Moreover, the mechanical performances, as 25% substitution of Portland cement (PC) are assessed, based on the EN 450. Mechanical activation enhances MSWI sludge physically due to the improved particle morphology and packing. Chemically, the hydration degree of PC is enhanced by the MSWI sludge by ≈25%. The milling treatment proved to be beneficial to the residues performances in the presence of PC, providing 32% higher strength than untreated sample. Environmentally, the compliance with the unshaped material legislation is successfully verified, according to the Soil Quality Decree.

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In this lab study, a two-stage treatment was investigated to achieve the valorization of a municipal solid waste incineration (MSWI) bottom ash fraction below 4mm. This fraction of MSWI bottom ash (BA) is the most contaminated one, containing potentially toxic elements (Cu, Cr, Mo and Sb), chlorides and sulfates. The BA was treated for recycling by separating agglomerated fine particles (≤125µm) and soluble contaminants by using a sequence of sieving and washing. Initially, dry sieving was performed to obtain BA-S (≤125µm), BA-M (0.125-1mm) and BA-L (1-4mm) fractions from the original sample. The complete separation of fine particles cannot be achieved by conventional sieving, because they are bound in a cementitious matrix around larger BA grains. Subsequently, a washing treatment was performed to enhance the liberation of the agglomerated fine particles from the BA-M and BA-L fractions. These fine particles were found to be similar to the particles of BA-S fraction in term of chemical composition. Furthermore, the leaching behavior of Cr, Mo Sb, chlorides and sulfates was investigated using various washing parameters. The proposed treatment for the separation of agglomerated fine particles with dry sieving and washing (L/S 3, 60min) was successful in bringing the leaching of contaminants under the legal limit established by the Dutch environmental norms.

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The incineration of treated waste wood generates more contaminated fly ashes than when forestry or agricultural waste is used as fuel. The characteristics of these biomass fly ashes depend on the type of waste wood and incineration process parameters, and their reuse is restricted by their physical, chemical and environmental properties. In this study, four different fly ash types produced by two different incineration plants were analysed and compared to Dutch and European standards on building materials. A combined treatment was designed for lowering the leaching of contaminants and the effect of each treatment step was quantified. A pilot test was performed in order to scale up the treatment. It was found that chlorides (which are the main contaminant in all studied cases) are partly related to the amount of unburnt carbon and can be successfully removed. Other contaminants (such as sulphates and chromium) could be lowered to non-hazardous levels. Other properties (such as particle size, LOI, oxide and mineralogical compositions) are also quantified before and after treatment.

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The transperineal ultrasound (TPU) value of the angle of progression (AOP) during fetal head engagement, at station 0, is a critical cut-off for current obstetrical practice, especially when intrapartum instrumental interventions are required. Still, controversial measurements were reported in previous high resolution imagistic studies. Our TPU and direct "gold-standard" magnetic resonance (MRI) measurements confirm that station 0 corresponds to a 120° AOP, concordantly. Based on these findings, the fact that an AOP of 120° or greater was previously strongly associated with vaginal delivery may be due to the achievement of head engagement in labor.

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BACKGROUND: Early inflammatory arthritis (EIA) a condition defined by joint swelling, with or without morning stiffness, and/or swelling of metacarpophalangeal and/or metatarsophalangeal joints. Nail fold video-capillaroscopy (NVC) is important for the evaluation of microcirculation in vivo. There are limited data about the role of NVC in EIA. OBJECTIVES: To study the capillaroscopic pattern in patients with EIA. PATIENTS AND METHODS: 27 patients with EIA - 21 women, 6 men, mean age of 41.6±4.2 yrs, mean disease duration of 6.9±3.1 months. Anamnesis and clinical examination were perform to identify clinical signs associated with connective tissue diseases. All the patients were nonsmokers and had no personal medical history of diabetes or non-immune mediated occlusive vascular disease. Blood and urine samples were collected for bio-chemical and immunological evaluation. All the patients were interrogated by NVC. RESULTS: Raynaud's phenomenon was found in 9 patients, puffy fingers in 2 pts, telangiectasia in 2 pts, Sicca symptoms in 6 pts, malar rash in 2 pts, photosensitivity and psoriasis plaque in one patient. Combined information from clinical exam, NVC and immunological assessment allowed a specific diagnosis in 5 patients. CONCLUSIONS: Nail fold capillaroscopy assessment can provide further information and has diagnostic value in some cases of early arthritis. Nail fold capillaroscopy assessment contribution to the differential diagnosis in patients with early arthritis is sometimes significant, especially in poorly clinical and immunological defined cases.

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OBJECTIVES: To assess the acceptability of intrapartum ultrasound (IPUS) labor monitoring in unselected Romanian women attending a tertiary maternity unit and the patients' experience of the examination (i.e. the perceived difficulty regarding the evaluation protocol). METHODS: The research was a prospective longitudinal observational study on unselected low-risk women that delivered in our unit. IPUS monitoring of active labor was proposed for observational purposes in low-risk population. Transabdominal and transperineal scans were performed hourly in the first stage of labor and at every 15 minutes in the second stage. The second day after birth, consenting women were invited to take part in a questionnaire survey with features regarding the patient's impression about the ultrasound monitoring scans during labor, and the acceptability of having an IPUS protocol for labor monitoring in the future. RESULTS: From 200 parturient women questioned, 98% of them agreed to IPUS investigation protocol. The demographic characteristics did not influence the acceptance. However, due to the small number of women declining IPUS we were not able to compare the characteristics and perceptions of women who declined the scan with those who accepted it. Most of the women (93% of accepters and 75% of decliners) had little difficulty deciding whether or not to have the scan protocol. All laboring women who had the IPUS scan found it an acceptable experience; 21% of women without epidural anesthesia rated the perceived difficulty as "mild" or "discomforting". Women rated having the IPUS scan as being significantly less difficult than having a cervical smear, transvaginal scan or having a digital clinical evaluation. 67% of the studied patients expressed increased confidence while being able to follow along the medical personnel the progression of the labor on the ultrasound screen. 97% of the consenting women who had the IPUS scans and all the 4 decliners said they would definitely or probably agree such ultrasound monitoring in a future labor, if this technique is proven useful for the labor outcome. CONCLUSIONS: IPUS protocol for labor monitoring was overwhelmingly acceptable in our population of women, despite the fact that they were learning about the procedure for the first time. The demographic characteristics did not influence acceptance, but due to the high rate of acceptance, predictors of acceptance could not be analyzed. More than two thirds of the patients expressed increased confidence while being able to follow along the medical personnel the progression of the labor on the ultrasound screen and almost all the participants were willing to have the procedure again in future, further reinforcing their favorable attitude to the procedure.

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We describe a series of cases where modern ultrasound (US) techniques diagnosed major structural abnormalities of the fetus in the first trimester (FT), unapparent when using the basic protocol of US investigation. In some cases, major structural abnormalities can be revealed in the FT scan solely to specialized personnel. Perhaps early screening should be confined in specialized centers, because congenital abnormalities detailed diagnostic has a huge impact in counseling the couple and also in prenatal advice of future pregnancies.

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BACKGROUND: The liver is the most common site of hydatid disease. Complications like cyst rupture and infection may occur, sites of rupture including: bile ducts, gastrointestinal tract, bronchi, peritoneal and pleural cavity. Rupture into the subcutaneous tissue followed by external fistula is an extremely rare complication. CASE REPORT: A 71-year-old diabetic woman was referred for a progressive growing mass in the right hypochondrium, with a central fistula draining clear liquid with cystic elements and white membranes. No history of fever or jaundice was present. Abdominal ultrasound (followed by CT scan) revealed a liver hydatid cyst in the right lobe, in contact with the anterior abdominal wall, and a parietal fistula track. Cystic fluid exam showed protoscolices and serological ELISA test was positive for hydatid disease. At surgery, the lesion was approached through an incision starting from the fistula site. Partial cystectomy and external drainage of the residual cavity were performed. The fistula track was totally resected. After an uneventful recovery and six months of anti - parasitic treatment, the patient is symptoms- free (3 years after surgery). CONCLUSIONS: Spontaneous cyst-cutaneous fistula is an extremely rare complication of hydatid liver cyst, usually occurring silently, in elder people. Surgery is required to achieve complete evacuation of the cyst contents and resolution of the residual cavity. To the best of our knowledge, this is the seventh case published, and the first one in the Romanian literature.

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A differential refractive index (DRI) detector was tested as a pressure transducer for single capillary online viscometry in exclusion chromatography. The relationship between the detector response and pressure is linear, in agreement with the theoretically expected influence of pressure on refractive index and its dependence on temperature is negligible. Whole polymer and local intrinsic viscosities were determined and compared for narrow and, respectively, broad molecular weight distribution polymer samples. Considering that the detection system described can be improved, the results suggest that modern DRI detectors are susceptible to satisfy the requirements for a suitable pressure transducer in this application.

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BACKGROUND: Low cobalamin concentrations and mild hyperhomocysteinemia are common in the elderly but ethnic differences have not been defined. OBJECTIVE: Our objective was to determine the demographic characteristics of cobalamin deficiency in the elderly and its role in their hyperhomocysteinemia. DESIGN: We measured serum cobalamin, total homocysteine (Hcys), and methylmalonic acid (MMA) concentrations in 725 subjects >60 y old, and folate concentrations in 520 subjects. RESULTS: After exclusion of subjects taking cobalamin supplements or with renal insufficiency, high prevalences of low cobalamin (11.8%), high MMA (16.6%), and high Hcys (26.1%) concentrations were seen. Most cobalamin concentrations <140 pmol/L appeared to reflect deficiency because 78. 3% of them were accompanied by abnormal metabolites. Subjects with cobalamin concentrations of 140-258 pmol/L had significantly fewer metabolic abnormalities. A low cobalamin concentration and renal insufficiency were the strongest predictors of abnormal Hcys concentrations. Elderly men had higher Hcys concentrations than did women (P = 0.0001). Whites and Latin Americans had lower cobalamin concentrations than did blacks and Asian Americans (P < 0.005). Whites also had higher Hcys concentrations than all the other groups (P < 0.05). When included in the analysis, renal insufficiency in subjects was associated with 23.8% of all high Hcys and 25.5% of all high MMA concentrations; most with renal insufficiency were Asian American and black men. CONCLUSIONS: Mild cobalamin deficiency is most common in elderly white men and least common in black and Asian American women. Hyperhomocysteinemia, which is most strongly associated with low cobalamin concentrations, is also most common in elderly whites, whereas that associated with renal insufficiency is more common in blacks and Asian Americans. Ethnic differences in cobalamin deficiency and the Hcys patterns associated with it or with renal insufficiency warrant consideration in supplementation strategies. Extending suspicion of deficiency to persons with cobalamin concentrations of 140-258 pmol/L appears to provide more disadvantages than advantages.

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