Comparison between different referral strategies for acute ischemic stroke patients in a hub-spoke emergency stroke network: a real-world experience in south-east Lazio

AIM

To describe different referral strategies for acute ischemic stroke (AIS) patients in a Hub-Spoke emergency stroke network with their incidence, time metrics and related outcomes.

METHODS

Referral paradigms were defined as follows: primary transfer to the comprehensive stroke center (CSC) from a remote region, called mothership (MS); secondary transfer to the CSC from a primary stroke center where intravenous thrombolysis was available, called drip and ship (DS); secondary transfer to the CSC from a community hospital where no reperfusion therapy was available, called ship and drip (SD); primary transfer to the CSC from its catchment area, called direct CSC (dCSC).

RESULTS

Among 517 anterior circulation AIS patients treated with mechanical thrombectomy between 2015 and 2020, 16.6% of them were SD, in addition to the well-known referral paradigms of MS (21.8%) and DS (18.1%). This rate grew to 30% when only patients whose place of onset was outside the CSC catchment area were considered. In the SD group, onset to CSC and onset to groin were significantly longer (178±80 min vs. 102±60 min, p<0.001, and 277±77 min vs. 211±61 min, p<0.001, respectively), and the risk of any intracranial hemorrhage (ICH) was significantly higher (OR: 2.514; 95%CI: 1.18-5.35, p=0.017) compared to MS.

CONCLUSION

In this hub-spoke stroke network, a high proportion of SD paradigm was found, which was associated with longer times to treatment and higher rates of any ICH. A closer cooperation between hospital stroke physicians, national health system staff, and paramedics is warranted to identify the most appropriate referral strategy for each patient.

Plasma dosage of ghrelin, IGF-1, GLP- 1 and leptin related to gastric emptying and esophageal pH-impedance in children with obesity

PURPOSE

The main aim of the study was to assess the relationship between leptin, ghrelin, insulin-like growth factor 1 (IGF-1), and glucagon-like peptide 1 (GLP-1) blood levels and gastric motility in children with obesity compared to healthy children. Secondary aims were to assess the possible association between these hormones and obesity, reflux impedance parameters, reflux symptoms, other GI disorders, and quality-of-life scores within the same groups.

METHODS

Children with obesity plus GERD symptoms and 2 control groups of children with obesity without GERD and healthy lean children aged 4-17 years underwent an auxological evaluation, an assessment of gastro-intestinal symptoms and quality of life, hormonal dosages, and an evaluation of gastric emptying time (GET) through 13C-octanoic acid breath test.

RESULTS

No significant association was found between hormones and gastric motility. Leptin and ghrelin levels were significantly associated with obesity parameters. No significant differences were found between GET and hormones of the patients with obesity, either with or without GERD.

CONCLUSION

Although we found an association between auxological parameters and both leptin and ghrelin levels, this association did not imply an effect on the upper GI motility. Therefore, our hypothesis that alterations of these hormones in children with obesity could affect gastric emptying, triggering GERD, was not supported by our data.

Understanding the factors associated with reduction in the number of lymph nodes in rectal cancer patients treated by neoadjuvant treatment

INTRODUCTION

Rectal cancer patients frequently present with locally advanced disease for which the standard of care includes neoadjuvant chemoradiotherapy followed by total mesorectal excision. Positive lymph nodes are one of the most powerful risk factors for recurrence and survival in colorectal cancer. In the absence of specific rectal guidelines, the literature recommends to the pathologist to optimize the number of rectal lymph nodes (LN) retrieved. We made a literature review in order to identify factors that could potentially affect the number of LN retrieved in specimens of patients with rectal cancer treated by chemoradiotherapy (CRT) followed by total mesorectal excision (TME).

RESULTS

Age did not have a significant effect on LN yield. The effect of sex on LN number is not consistent in the literature. Most of the papers did not find a relationship between lower LN obtained and gender. Laparoscopy for primary rectal cancer is associated with a greater number of LN as well as short-term benefits. Tumors in the upper rectum are associated with a higher number of LN than those in the mid and lower rectum. The type of surgery had no effect on lymph node yield either. Tumors with complete or almost complete pathologic regression were exactly the ones with lower number of lymph nodes detected. Approximately one-third of patients with neoadjuvant treatment had less than 12 LN yield.

CONCLUSION

The tumor regression grade is the most important factor for the decrease in the number of lymph nodes.

[The management of post-surgical pain in the patient treated for hallux valgus with percutaneous and minimally invasive technique]

OBJECTIVE

In today's literature there are no defined guidelines for the treatment of postoperative pain in corrective surgery of hallux valgus. In this study we evaluated the use of a new treatment protocol designed to minimize the postoperative pain related to the surgical treatment of hallux valgus.

MATERIALS AND METHODS

The study involved 20 female patients (20 feet) treated for moderate to severe hallux valgus between September 2011 and December of 2012 with a percutaneous technique (10 feet) and minimally invasive surgery (Endolog System) (10 feet). All patients received postoperative as analgesic therapy 1 cp etoricoxib 120 mg/ day for 5 days + oxycodone hydrochloride/naloxone 5mg 1cp × 2/day for 15 days. The evaluation forms of pain VAS/VRS have been used for the evaluation of pre and postoperative pain at 15 and 30 days.

RESULTS

In both groups we found a significant reduction of pain in the days following surgery. At 30 days the VAS score was similar in between the two groups. Few and mild side effects were reported (1 case).

CONCLUSIONS

The co-administration of an anti-cox2 and an opioid in the first postoperative hours is useful to reduce soft tissue swelling and to control pain without causing significant side effects. The therapeutic protocol adopted, along with an adequate anesthesiological approach, has proved to be very effective for pain management in peri-and post-operative treatment of hallux valgus.

Increased severity of dyspeptic symptoms related to mental stress is associated with sympathetic hyperactivity and enhanced endocrine response in patients with postprandial distress syndrome

BACKGROUND

Mental stress (MS) may alter gastric sensory-motor function. The aim of the study was to assess postprandial autonomic nervous system activity and stress hormones in response to acute mental stress in dyspeptic patients.

METHODS

A total of 25 patients with postprandial distress syndrome (PDS; 11 mol L(-1), age 35.9 ± 9.3 years) and 12 healthy controls (5 mol L(-1), age 25.8 ± 4.6 years) underwent electrogastrography and (13) C-octanoate gastric emptying study using a 480 kcal solid meal. Heart rate variability (LF/HF ratio) and corticotrophin-releasing factor, adrenocorticotropic hormone (ACTH), and cortisol serum levels were also evaluated. Dyspeptic symptoms were scored by analogue visual scale and expressed as symptoms total score (TS). The protocol was repeated twice in each subject, with and without a mental stress test before the meal.

KEY RESULTS

Mental stress significantly increased postprandial symptoms severity in patients (TS: stress 111 ± 18 vs basal 50 ± 10; P < 0.05). Low-/high-frequency component ratio was significantly higher in patients after MS at 120 min (stress 5.46 ± 0.41 vs basal 3.41 ± 0.64; P < 0.01) and 180 min (stress 5.29 ± 0.2 vs basal 3.58 ± 0.19; P < 0.05). During stress session, in patients we found a significantly higher ACTH level than baseline at 30, 60, 90, 150, 210, 240, and 270 min and a significantly higher cortisol level at 30, 60, 90, 120, 210, and 270 min. Gastric emptying rate and electrical activity were not influenced by MS.

CONCLUSIONS & INFERENCES

In PDS patients, administration of MS before meal increases symptoms severity by inducing sympathetic hyperactivity and increased stress hormones levels. As the gastric emptying looks not altered, we conclude that these neurohormonal responses mainly affect sensitive function.

Recanalization with stent-retriever devices in patients with wake-up stroke

BACKGROUND AND PURPOSE

Stent-retriever devices play an increasing role in the interventional treatment of acute stroke patients, because fast recanalization can be achieved. The purpose of this study was to evaluate the feasibility of stent-retriever recanalization in patients with wake-up stroke in the anterior circulation.

MATERIALS AND METHODS

We retrospectively analyzed clinical and angiographic data of 19 consecutive patients with wake-up stroke who were treated with stent-retriever devices between 2009 and October 2011. Recanalization was assessed by using the Thrombolysis in Cerebral Infarction score. Clinical outcome was evaluated at discharge and after 90 days by using the modified Rankin Scale.

RESULTS

Median NIHSS score at admission was 17 (IQR, 15-20). Before the procedure, the TICI score was 0 in 18 patients and 1 in 1 patient. Recanalization with stent-retriever devices was successful (TICI ≥ 2) in 94.7%. Mean time to flow restoration was 36.7 minutes and to complete recanalization 83.7 minutes. Symptomatic intracranial hemorrhage occurred in 4 patients (21.1%). Eight patients had an NIHSS improvement of ≥4 points between admission and discharge. After 90 days, 2 (10.5%) of our patients presented with mRS 0-2; seven (36.8%) died.

CONCLUSIONS

Despite successful and rapid recanalization with stent-retriever devices, good clinical outcome in patients with wake-up stroke is achieved in a minority of patients. Clinical outcome remains poor. Bleeding rates were higher compared with recanalization procedures within 6 hours after stroke onset.

Gut--liver axis: the impact of gut microbiota on non alcoholic fatty liver disease

AIM

To examine the impact of gut microbiota on non alcoholic fatty liver disease (NAFLD) pathogenesis.

DATA SYNTHESIS

Emerging evidence suggests a strong interaction between gut microbiota and liver. Receiving approximately 70% of its blood supply from the intestine, the liver represents the first line of defence against gut-derived antigens. Intestinal bacteria play a key role in the maintenance of gut-liver axis health. Disturbances in the homeostasis between bacteria- and host-derived signals at the epithelial level lead to a break in intestinal barrier function and may foster "bacterial translocation", defined as the migration of bacteria or bacterial products from the intestinal lumen to mesenteric lymph nodes or other extraintestinal organs and sites. While the full repertoire of gut-derived microbial products that reach the liver in health and disease has yet to be explored, the levels of bacterial lipopolysaccharide, a component of the outer membrane of Gram-negative bacteria, are increased in the portal and/or systemic circulation in several types of chronic liver diseases. Derangement of the gut flora, particularly small intestinal bacterial overgrowth, occurs in a large percentage (20-75%) of patients with chronic liver disease. In addition, evidence implicating the gut-liver axis in the pathogenesis of metabolic liver disorders has accumulated over the past ten years.

CONCLUSIONS

Complex metabolic diseases are the product of multiple perturbations under the influence of triggering factors such as gut microbiota and diet, thus, modulation of the gut microbiota may represent a new way to treat or prevent NAFLD.

Gut--liver axis: the impact of gut microbiota on non alcoholic fatty liver disease

AIM

To examine the impact of gut microbiota on non alcoholic fatty liver disease (NAFLD) pathogenesis.

DATA SYNTHESIS

Emerging evidence suggests a strong interaction between gut microbiota and liver. Receiving approximately 70% of its blood supply from the intestine, the liver represents the first line of defence against gut-derived antigens. Intestinal bacteria play a key role in the maintenance of gut-liver axis health. Disturbances in the homeostasis between bacteria- and host-derived signals at the epithelial level lead to a break in intestinal barrier function and may foster "bacterial translocation", defined as the migration of bacteria or bacterial products from the intestinal lumen to mesenteric lymph nodes or other extraintestinal organs and sites. While the full repertoire of gut-derived microbial products that reach the liver in health and disease has yet to be explored, the levels of bacterial lipopolysaccharide, a component of the outer membrane of Gram-negative bacteria, are increased in the portal and/or systemic circulation in several types of chronic liver diseases. Derangement of the gut flora, particularly small intestinal bacterial overgrowth, occurs in a large percentage (20-75%) of patients with chronic liver disease. In addition, evidence implicating the gut-liver axis in the pathogenesis of metabolic liver disorders has accumulated over the past ten years.

CONCLUSIONS

Complex metabolic diseases are the product of multiple perturbations under the influence of triggering factors such as gut microbiota and diet, thus, modulation of the gut microbiota may represent a new way to treat or prevent NAFLD.

Frequency-comb-referenced singly-resonant OPO for sub-Doppler spectroscopy

We present a widely-tunable, singly-resonant optical parametric oscillator, emitting more than 1 W between 2.7 and 4.2 μm, which is phase locked to a self-referenced frequency comb. Both pump and signal frequencies are directly phase-locked to the frequency comb of a NIR-emitting fs mode-locked fibre laser, linked, in turn, to the caesium primary standard. We estimate for the idler frequency a fractional Allan deviation of ∼ 3 × 10⁻¹²τ⁻½ between 1 and 200 s. To test the spectroscopic performance of the OPO, we carried out saturation spectroscopy of several transitions belonging to the ν1 rovibrational band of CH₃I, resolving their electronic quadrupole hyperfine structure, estimating a linewidth better than 200 kHz FWHM for the idler, and determining the absolute frequency of the hyperfine components with a 50-kHz-uncertainty.

Effectiveness of Ischia thermal water nasal aerosol in children with seasonal allergic rhinitis: a randomized and controlled study

Allergic rhinitis is characterized by local inflammation. Nasal lavage may be a useful treatment, however, there are few studies on this topic. This study aims to evaluate the effects of Ischia thermal water nasal irrigation on allergic rhinitis symptoms and airway inflammation during the period of natural exposure to Parietaria pollen in children with allergic rhinitis and intermittent asthma. Forty allergic children were randomly divided into two groups: the first group (Group 1) practiced crenotherapy with thermal water aerosol for 15 days per month, for three consecutive months, the control group (Group 2) was treated with 0.9&#x0025; NaCl (isotonic) solution. In addition, all children were treated with cetirizine (0.5 gtt./kg/day once daily). Nasal symptom assessment, including Total Symptom Score (TSS), spirometry, and exhaled nitric oxide (FeNO) were considered before the treatment (T0), at the end of the treatment (T1) and again 2 weeks after the end of the treatment (T2). The study was registered in the Clinical Trials.gov (NCT01326247). Thermal water significantly reduced both TSS and FeNO levels and there was a significant relationship between reduction of nasal symptoms and FeNO values at the end of treatment with thermal water. In conclusion, this study shows that nasal crenotherapy with the hypermineral chloride-sodium water of Ischia was effective in children with seasonal allergic rhinitis based on the sensitivity to Parietaria. These results demonstrate that this natural treatment may be effective in a common and debilitating disease such as the allergic rhinitis.

A prospective observational study of the clinical efficacy and safety of intra-articular sodium hyaluronate in synovial joints with osteoarthritis

BACKGROUND

Clinical trials have demonstrated the safety and efficacy of hyaluronic acid-based products for the treatment of synovial joints affected by osteoarthritis (OA), but data from observational studies of normal medical practice are sparse.

AIM

This study investigated the safety and efficacy of intra-articular (IA) sodium hyaluronate (MW 1500-2000 KDa; Hyalubrix®) in the treatment of synovial joint OA.

DESIGN

This is prospective, and observational study.

SETTING

This study was carried out at 47 specialist centers for physiatrists, orthopedics and rheumatology in Italy; the enrolled population, 1266 outpatient, was predominantly female (66%, 840/1266), with a mean age of 66 years, and a mean weight of 74 kg.

POPULATION

The Participants with OA received IA injections of the study treatment (2 mL) once per week for 3 weeks. The knee was the joint most commonly affected by OA (right knee 802/1266 [63%]; left knee 598/1266 [47%]), and the longest median duration of disease occurred in the carpal joint (right carpal joint 40 months; left carpal joint 60 months).

METHODS

The primary endpoints were tolerability and details of usage of the IA sodium hyaluronate syringe device. Efficacy parameters included assessment of self-reported pain via the Visual Analogue Scale (VAS), and evaluation of motor function via the Health Assessment Questionnaire (HAQ). Quality of life (QoL) was assessed using the Euro QoL questionnaire (Clinical Trial Registration Number: ISRCTN 42690497).

RESULTS

Data from 1266 participants were collected. The adverse event (AE) rate was 0.8% (95% CI, 0.4 to 1.5). Thirteen AEs were reported, 12 of which were mild or moderate in severity. Only one participant discontinued study treatment following an AE. No serious adverse events occurred. Coadministration of local anesthetic was required by up to 10% of patients. Statistically significant improvements in VAS, HAQ and EuroQoL were recorded in multiple joints (P<0.0001 for each).

CONCLUSION

The study treatment was safe and well tolerated.

CLINICAL REHABILITATION IMPACT

. The study treatment reduced pain, improved mobility, and increased QoL in participants with OA.

Interaction between density and Cu toxicity for Enchytraeus crypticus and Eisenia fetida reflecting field scenarios

Effect assessment is usually based on responses obtained from standard tests, in which organisms are well fed and in an optimal population density. For a more thorough assessment of ecotoxicological risk, information is needed for chemical effects in systems that closer reflect the potential exposure in the field systems. Responses measured in standard density experiments do not fully reflect the field scenario, where populations' size fluctuate with environmental conditions, leading to very low organism number in certain season/conditions and high number in others. In the present study, the possible interaction between density and Cu-pollution was investigated in regard to population growth, using Enchytraeus crypticus, and for individual juvenile growth, using Eisenia fetida. The standardized ISO and OECD guidelines for enchytraeids and earthworms were adapted to test four densities and four Cu concentrations. The final population number was used to assess the effects and possible interaction between densities and Cu toxicity for population responses and the increase in individual organism wet weight was used as growth response. The study showed that although initial density itself had tremendous impact on population and individual growth, organisms under different densities had the same sensitivity to Cu.

Risk factors in gastric cancer

STATE OF THE ART

Gastric cancer (GC) is still a major health problem worldwide due to its frequency, poor prognosis and limited treatment options. At present prevention is likely to be the most effective means of reducing the incidence and mortality from this disease. The most important etiological factors implicated in gastric carcinogenesis are diet and Helicobacter pylori (H. pylori) infection. High intake of salted, pickled or smoked foods, as well as dried fish and meat and refined carbohydrates significantly increased the risk of developing GC while fibers, fresh vegetables and fruit were found to be inversely associated with GC risk. Epidemiological investigations (retrospective, case-control and prospective) and several meta-analyses have demonstrated that concurrent or previous H. pylori infection is associated with an increased risk of GC in respect to uninfected people. H. pylori colonizes gastric mucosa where it induces a complex inflammatory and immune reaction that on time leads to a severe mucosal damage i.e., atrophy, intestinal metaplasia (IM) and dysplasia. The risk of GC is closely related to the grade and extension of gastric atrophy, IM and dysplasia.

PERSPECTIVES AND CONCLUSIONS

Today a plausible program for GC prevention means: (1) a correct dietary habit since childhood increasing vegetables and fruit intake, (2) a decrease of H. pylori spread improving family and community sanitation and hygiene, (3) a search and treat H. pylori strategy in offspring of GC, (4) a search and treat H. pylori strategy in patients with chronic atrophic gastritis and intestinal metaplasia (IM), (5) a careful endoscopic and histologic follow-up if precancerous lesions persist irrespective of H. pylori eradication.

Microalbuminuria in Cerebrovascular Disease: A Modifiable Risk Factor?

Stroke is potentially preventable through risk factor modification. Over the past decade, there has been considerable interest on microalbuminuria as a risk factor for chronic diseases. The concept of microalbuminuria was originally introduced, about 25 years ago, to clinical practice as a useful marker of nephropathy. Since then various studies reported an association of microalbuminuria with the increased risk of cardiovascular events and all cause of mortality in subjects with or without diabetes. The presence of microalbuminuria was related to left ventricular dysfunction, stroke, and myocardial infarction. Microalbuminuria may be a predictor of stroke but further studies are required. However data on prognostic significance and therapeutic consequence, particularly in haemorrhagic stroke are lacking. This review focuses on the importance of microalbuminuria for cerebrovascular disease, stressing the clinical and therapeutic implications using antihypertensive therapy to control the urinary albumin excretion.