Anemia may influence the outcome of patients undergoing neo-adjuvant treatment of rectal cancer

BACKGROUND

We hypothesized that anemia could represent one of the major factors influencing the outcome of patients undergoing neo-adjuvant treatment of rectal cancer.

PATIENTS AND METHODS

This analysis included all the consecutive patients who underwent neo-adjuvant treatment (chemotherapy and/or radiotherapy) before surgery for rectal cancer in three oncology/radiotherapy departments from June 1996 to December 2003.

RESULTS

Three hundred and seventeen patients were eligible for our analysis. Median age at diagnosis was 64 years (range 26-88 years); male/female ratio was 184/133. Two hundred and eighty-five patients (89.9%) were diagnosed with adenocarcinoma, while 32/317 (10.1%) with mucinous adenocarcinoma. Neo-adjuvant treatments carried out were as follows: radiotherapy alone in 75/317 patients (23.7%), radiotherapy plus chemotherapy in 242/317 patients (76.3%). At univariate and multivariate analysis, only the hemoglobin (Hb) level (group 1: < or=12 g/dl versus group 2: >12 g/dl) resulted in a significant factor for disease-free survival. The role of the Hb level seemed to be confirmed further by the clinical downstaging obtained in approximately 55% of patients in group 2, in comparison with 35% of the patients achieving a significant downstaging in group 1.

CONCLUSION

Our results indicated that anemia could represent an important parameter able to influence the outcome in patients receiving neo-adjuvant treatment of rectal cancer.

Usefulness of an early neurofunctional assessment in predicting neurodevelopmental outcome in very low birthweight infants

OBJECTIVE

To evaluate whether early neurofunctional assessment may be useful in predicting neurodevelopmental outcome in children of very low birth weight (VLBW).

DESIGN

Observational longitudinal study.

SETTINGS

Northern Italy.

PATIENTS

A total of 250 VLBW children (129 boys, 121 girls) born consecutively 1996-1999.

MAIN OUTCOME MEASURES

Neurodevelopment at 36 months of chronological age, classified in accordance with the classification of Tardieu and the International classification of functioning.

RESULTS

Of the infants exhibiting normal neurodevelopment (n = 183) or major dysfunction (n = 17) at 3 months of corrected age, 72% and 94% respectively did not change their score during the study. Minor dysfunctions at 3 months of corrected age were transient in 17 (34%) children. After adjustment for neonatal variables, neurodevelopment at 3 months of corrected age remained predictive of dysfunction at 36 months (odds ratio = 4.33, 95% confidence interval 2.05 to 9.12). If the results for the normal and minor dysfunction groups were pooled, the predictive qualities of the 3 month neurofunctional assessment were: sensitivity 0.5, specificity 0.99, positive predictive value 0.94, negative predictive value 0.93.

CONCLUSION

Early neurofunctional evaluation may be useful in predicting later neurodevelopmental outcome in VLBW children.

Cytomegalovirus infection after autologous stem cell transplantation: incidence and outcome in a group of patients undergoing a surveillance program

This study was performed to evaluate the incidence, risk factors, and outcome of cytomegalovirus (CMV) infection in autologous stem cell transplantation (ASCT), with the aim of performing preemptive therapy in patients with antigenemia. Starting from 2001, 171 consecutive ASCTs were performed in 136 patients; 102 of these patients were seropositive for CMV at the onset of hematological disease. In all these patients, a CMV pp65 antigenemia assay was determined weekly, starting from the day when the absolute neutrophil count went above 500/microL, and until day 60 after ASCT; subsequently, antigenemia was determined only when a CMV infection was suspected. Among the 136 transplanted patients, 40 (29.4%) presented a positive antigenemia; all of them were seropositive for CMV before ASCT; and no cases of primary infection were seen. The incidence of CMV infection in the seropositive population was 40/102 (39.3%); 6 patients (5 with multiple myeloma and 1 with non-Hodgkin's lymphoma) who received 2 ASCTs developed CMV infections after both transplantations, so that positive antigenemia developed after 46/171 (26.9%) transplantations. First positive antigenemia presented a median of 32 days (range 7-57) after stem cell reinfusion. The median antigenemia level at the first appearance was 2/200,000 (range 1-1000). No significant prognostic factors could be shown. Enteritis was present in 5 patients; 2 of them also had fever, and 1 of them also had thrombocytopenia. In 5 patients fever without any other clinical signs or symptoms was present; 30 patients were asymptomatic. Fourteen patients were treated with anti-CMV drugs. CMV reactivation was successfully treated in all patients, and no patient died from CMV disease.

Different outcomes of pulmonary rehabilitation in patients with COPD with or without exacerbations

BACKGROUND

Pulmonary rehabilitation is recognised as an effective treatment in reducing disability and improving the quality of life in patients with COPD. We evaluated the effects of a course of pulmonary rehabilitation in improving the physical performance and lung function in patients with or without COPD exacerbations.

METHODS

74 patients with COPD were enrolled, 37 (24 males and 13 females, mean age 74.6 years) without exacerbations (group A), and 37 (23 males, 14 females, mean age 73.9 years) with exacerbations (group B). The latter must have had the latest exacerbation at least one month before the inclusion. All patients underwent to a rehabilitation programme of 8 visits in 4 weeks in a day-hospital setting, with exercise training, respiratory muscle training and education on COPD. The changes in physical performance and lung function in respect to baseline were measured by a 6-minute walking test, using phethysmography, and by an analogic manometer measuring maximal inspiratory and expiratory pressures (MIP, MEP).

RESULTS

Patients of group A showed a mean increase in timed walk distance of 58.38 +/- 57.46 m, compared to a mean increase of 31.38 +/- 44.78 m in group B patients (p = 0.028). As to lung function, a mean increase of 178.92 +/- 132.28 ml in FEV1 in group A versus 67.84 +/- 102.04 ml in group B (p < 0.0001) and a mean increase of 22.36 +/- 25.06 cm H2O in MEP in group A versus 7.70 +/- 12.28 cm H2O in group B (p = 0.002) was found.

CONCLUSIONS

These findings indicate that patients with COPD with exacerbations achieve a less favourable outcome of pulmonary rehabilitation, with a significantly lower improvement of physical performance, respiratory muscle strength and lung function in respect to subjects without exacerbations.

Thrombophilia and fetal germinal matrix-intraventricular hemorrhage: does it matter?

Germinal matrix-intraventricular hemorrhage (GMH-IVH) in the fetus is very rare and the role of thrombophilia in its pathogenesis is unclear. We report on the prenatal diagnosis by magnetic resonance imaging of GMH-IVH in a 24-week fetus. The newborn presented posthemorrhagic ventriculomegaly and was found to be heterozygous for two thrombophilic patterns, factor V Leiden and methylenetetrahydrofolate reductase mutation. The combination of this hypercoagulable state and prenatal GMH-IVH is discussed together with the opportunity of testing these infants for thrombophilia.

[Sodium gold thiosulfate therapy: an open, viewed, multicenter trial in rheumatoid arthritis patients followed for two years]

OBJECTIVE

To evaluate if parenteral gold-therapy with Sodium gold thiosulfate is effective and safe for the treatment of rheumatoid arthritis we began an open, multicenter trial.

METHODS

126 rheumatoid arthritis patients were treated with Sodium gold thiosulfate for two years. Efficacy, quality of life, progression of joint damage, inflammatory parameters and side effects were evaluated.

RESULTS

Gold salts reduced joint inflammation and improved subjective and objective symptoms, quality of life and activity of illness within 6 months. Side effects appeared in 13,8% of all cases and regressed, promptly, when gold therapy stopped. The poor efficacy caused the interruption and the change from the gold therapy to others disease-modifying anti-rheumatic drugs (DMRDs) in 17,8 % of the patients.

CONCLUSIONS

The follow-up showed Sodium gold thiosulfate was effective in Rheumatoid Arthritis and the survival in therapy was of 77,8% to one year and of 68,4% to two years.

The assessment of quality of life as a measure of gold salts treatment efficacy in rheumatoid arthritis

BACKGROUND

In the evaluation of functional status of patients with rheumatoid arthritis (RA) the health related quality of life is currently considered important because of its approach to various components of life, such as social, psychological, and physical aspects. We used the Stanford Health Assessment Questionnaire (HAQ) to assess the improvement of functional status in patients with RA treated with gold salts.

METHODS

In a prospective investigation 91 patients with RA in anatomical stage I, II, or III, 66 females and 25 males, with a mean age of 53.17 years, were evaluated during medical treatment in a 1-year follow-up. The treatment consisted in sodium aureothiosulphate, plus corticosteroids and NSAID. The assessments were done during ambulatory visits, at baseline and after 6 and 12 months of treatment, by HAQ as well as by other parameters such as Ritchie Index, visual analog scale (VAS), and morning stiffness. A group of 19 RA patients included by the same criteria and treated only by corticosteroids and NSAID was used as control for the first 6 months of the study.

RESULTS

HAQ scores and other parameters were significantly lower (p=0.0001) at the 6th and 12th month measurements when compared with baseline. In the control group only a significant difference in the VAS score was detected.

CONCLUSIONS

All the parameters measured in our study were useful in detecting clinical improvement in RA patients treated with sodium aureothiosulphate plus corticosteroids and NSAIDs, but the HAQ provides a more global assessment of the patient's status.

[Cerebral oxygenation and near-infrared rays spectrophotometry]

Near infrared spectroscopy (NIRS) is a new technique which allows non invasive bedside monitoring of cerebral oxygenation and hemodynamics by measuring relative changes in cerebral oxy- and deoxyhaemoglobin and cytochrome aa3. We have applied this technique to evaluate the possible effects on cerebral oxygenation and hemodynamics of clinical procedures usually performed on preterm infants:--endotracheal suctioning, and we have demonstrated that the magnitude and the duration of the negative effects of open system are significantly reduced using closed endotracheal suctioning system;--withdrawal and infusion through umbilical vein and artery cause significant changes in cerebral hemodynamics: these effects are significantly reduced after administration of ibuprofen;--treatment of patent ductus arteriosus with ibuprofen does not significantly reduce cerebral perfusion and oxygen availability compared to indomethacin and ibuprofen administration also does not affect cerebral vasoreactivity to arterial carbon dioxide tension;--administration of different types and doses of natural surfactant causes different changes in cerebral hemodynamics and these effects seem to be dose-related. Therefore NIRS is an useful device to investigate cerebral oxygenation state of preterm infants and new possibilities could derive from the introduction of a new NIRS method which allows to measure the tissue oxygenation index.

Impact of thrombotic thrombocytopenic purpura on leukemic children undergoing bone marrow transplantation

Thrombotic thrombocytopenic purpura (TTP) has emerged as one of the main transplant-related complications over the last 15 years. The current study defines the incidence and the risk factors for the occurrence of TTP in 131 consecutive leukemic children who were transplanted between January 1994 and December 1997 at four Italian pediatric centers. Patients with ALL (101), AML (21), MDS (9), underwent an HLA-identical sibling BMT (82) or an HLA-identical unrelated BMT (49), receiving a conditioning regimen consisting of high-dose chemotherapy in 24 patients and of F-TBI combined with high-dose chemotherapy in 107 patients. The diagnosis of TTP was retrospectively evaluated on the basis of parallel criteria. TTP treatment varied according to the protocol of each treatment center. Twenty-eight of 131 patients (21.4%) developed TTP at a median of 46 days (range 21-80) after BMT. Multivariate analysis demonstrated that the risk of TTP was higher in patients who underwent unrelated BMT (P value = 0.02). Acute GVHD, stage of disease at BMT, conditioning with TBI, gender, age, did not appear to be associated with the occurrence of TTP. As to the outcome, TTP resolved in 19 patients while in nine it was the principal cause of death (32.1%). In patients with TTP, LDH peak value was the only statistically significant factor (P = 0.001) related to severe TTP. In conclusion, our experience demonstrates that leukemic children undergoing BMT, especially from an unrelated donor, should be carefully assessed for TTP which appears to be a severe and relatively common transplant-related complication when strict diagnostic criteria are applied.

Cerebral vasoreactivity to arterial carbon dioxide tension in preterm infants: the effect of ibuprofen

Cerebral vasoreactivity to CO(2), calculated by linear regression of total cerebral hemoglobin, measured by near infrared spectroscopy, and corresponding PaCO(2), in infants <32 weeks' gestation, was found to be unaffected by the administration of ibuprofen, which was given on the first postnatal day as prophylaxis against patent ductus arteriosus.

Determination of cut-off positivity values in nasal challenge testing of patients with allergic rhinitis

Nasal challenge testing with allergen extracts is currently used to diagnose nasal allergy and, to a greater extent, in studies of pathophysiology of allergic rhinitis. The resulting nasal obstruction, measured as nasal airway resistance (NAR), is determined by rhinomanometry (RMM). The aim of this study was to define a cut-off NAR value for a positive response in a nasal allergen challenge test. Forty-two, grass-allergic adult patients and 40 nonallergic adults were challenged out of the grass pollen season under standard conditions with timothy grass extract administered intranasally in doses increasing from 10 to 1500 IU/mL. Inspiratory NAR was determined by computerized anterior active RMM. The cut-off value for a positive test was determined from receiver operating characteristic curves plotted from these data with the LABROC1 computer program. In addition, the subjects' nasal cycle was recorded during the four hours preceding the allergen challenge. The patients' mean NAR value at baseline (0.33 Pa/cc/sec) and when challenged with normal saline solution did not differ from those of the control subjects. The patients, but not the control subjects, experienced typical nasal allergic symptoms when challenged with the grass extract. The control subjects had no symptoms and their NAR did not change significantly when they were challenged with the same extract. All 42 allergic patients had measurable increases in NAR at the 800 IU/mL allergen dose; 19/42 patients had complete obstruction (i.e., NAR unmeasurable) when challenged with the 1500 IU/mL dose. The maximum diagnostic value (= sensitivity + specificity at the discriminator position on the receiver operating characteristic curves) was 1.96 with the 800 IU/mL dose. At that dose, the NAR cut-off value was 0.91 Pa/cc/sec, which was 2.7 times greater than their mean value at baseline. NAR varied less than 1-fold between the maximum and minimum points of the normal nasal cycle in both groups of subjects. An increase of NAR of nearly three-fold during nasal allergen challenge compared to the baseline value determined by computerized anterior active RMM discriminates best patients with allergic rhinitis from nonallergic adults.

Closed versus open endotracheal suctioning in preterm infants: effects on cerebral oxygenation and blood volume

The aim of our study was to compare, using near-infrared spectroscopy (NIRS), the effects on cerebral intracellular oxygenation and cerebral blood volume (CBV) of closed endotracheal suctioning (CS), which permits continuous ventilation of the patient, with open endotracheal suctioning (OS), which requires disconnection from the ventilator. Eleven preterm infants were studied. Each patient underwent one CS, followed, after 60 min, by one OS, or vice versa, three times during the same day. Modifications in CBV and oxidized cytochrome oxidase (CytO2) were continuously detected by NIRS; arterial oxygen saturation (SaO2) heart rate (HR), transcutaneous carbon dioxide tension and mean arterial blood pressure were simultaneously recorded. Significant reductions in HR and SaO2 were observed following OS; the magnitude and duration of these negative effects of suctioning were significantly reduced with CS. In addition, the decrease in CBV was more pronounced than following CS. No changes in CytO2 concentration were seen.

Comparative evaluation of the effects of indomethacin and ibuprofen on cerebral perfusion and oxygenation in preterm infants with patent ductus arteriosus

OBJECTIVE

To compare the effects on cerebral perfusion and oxygenation of intravenous ibuprofen and indomethacin as treatment for patent ductus arteriosus in preterm infants.

STUDY DESIGN

Sixteen infants receiving mechanical ventilation (< 31 weeks gestation) with patent ductus arteriosus received either 0.2 mg/kg indomethacin (n = 8) or 10 mg/kg ibuprofen (n = 8) infused over 1 minute. Near-infrared spectroscopy was used to measure changes in cerebral blood volume and in oxidized cytochrome oxidase concentration. Cerebral blood flow velocity in the pericallosal artery was measured using Doppler ultrasonography.

RESULTS

Indomethacin caused a significant reduction of CBV (maximal changes in cerebral blood volume: -320 +/- 171 microL/100 gm) and, in four of eight patients, a fall in oxidized cytochrome oxidase concentration (maximal change in oxidized cytochrome oxidase concentration in the eight patients: -0.68 +/- 0.98 mumol/L, NS). Cerebral blood flow velocity fell significantly. Ibuprofen caused no significant reduction of cerebral blood volume, oxidized cytochrome oxidase concentration, or cerebral blood flow velocity, whereas a significant increase of cerebral blood volume (+207 +/- 200 microL/100 gm) was observed after 60 minutes. Ductus closure was seen in six of eight infants after the first dose of indomethacin and in five of eight infants after the first dose of ibuprofen. The therapeutic cycle involved administration of a second and third dose, provided no side effects occurred. Treatment was effective in all infants.

CONCLUSION

Compared with indomethacin, treatment with ibuprofen does not significantly reduce cerebral perfusion and oxygen availability; the observed increase in cerebral blood volume requires further investigation.

Influence of age, gender, hormonal status and smoking habits on colonic transit time

The factors that influence colonic transit time in healthy humans are not yet clearly defined. The aim of this study was therefore to determine (a) if there are differences in colonic transit time between men and women and (b) if age, female hormonal status or smoking habits are associated with alterations in these parameters. Colonic transit time was measured in 164 asymptomatic subjects (80 males, 84 females) by a radio-opaque marker technique with one single plain abdominal X-ray. Colonic transit time was significantly shorter in men than in women (30 +/- 2 vs. 42 +/- 3 h, P < 0.05). Colonic transit time in non-smoking males was significantly shorter compared with smoking males (26 +/- 2 vs. 40 +/- 5 h, P < 0.05). In females only height and menstrual cycle influenced colonic transit times. We conclude that gender and smoking habits should be considered when studying colonic transit time in health and disease.

Cut off values of bone mineral density defining postmenopausal women with bone fractures

OBJECTIVES

To define cut off values of bone mineral density (BMD), measured at different forearm sites by single photon absorptiometry, that discriminated postmenopausal women who have had fractures from those who have not, in order to provide an index of fracture risk for screening purposes.

METHODS

BMD values were measured at distal third radius (DTR) and ultradistal radius (UDR) sites in two groups of postmenopausal women. Group 1 (n = 398) had not suffered fractures, and group 2 (n = 354) had appendicular fractures. Results were evaluated using receiver operating characteristic (ROC) curves.

RESULTS

BMD values were significantly greater (p < 0.001) at both sites in group 1. Weight was lower in group 2 than in group 1 (p < 0.001). The BMD cut off value was 0.596 g/cm2 at DTR (sensitivity 63%, specificity 72%), and 0.310 g/cm2 at UDR (sensitivity 80%, specificity 80%). Values of area under ROC curves estimated for UDR were greater than for those DTR (p < 0.001).

CONCLUSION

For screening purposes the BMD cut off value of 0.310 g/cm2 at the UDR may be useful in identifying women at high risk of fracture in an unselected postmenopausal population. BMD measured at UDR appeared to have a better predictive value than that at DTR.

Comparison of rhinomanometry, symptom score, and inflammatory cell counts in assessing the nasal late-phase reaction to allergen challenge

Inspiratory nasal resistance, symptom score, and influx of inflammatory cells into the nose were evaluated before and after a nasal challenge in 15 patients with grass pollen rhinitis and in six nonallergic control subjects, to study the nasal late-phase reaction and its relationship with nasal cytology. All patients had an immediate positive reaction to specific nasal challenge. In seven allergic subjects we observed a later inspiratory nasal resistance increase, but only two had a significant late symptom score. Inflammatory cells increased by 8 hours in all the patients; the higher the cell influx, the higher the symptom score. Close correlations were found between the inspiratory nasal resistance increase, nasal obstruction at hours 8 and 24, and all cell counts. In control challenges there were no significant increases of symptom score or inspiratory nasal resistance either during the challenge or in the next 24 hours. A weakly significant increase was found only for neutrophil counts at 8 hours. These results indicate that an inflammatory reaction constantly occurs after a specific nasal challenge; its extent is closely related to inspiratory nasal resistance and to the intensity of nasal obstruction. Moreover, our data outline the pivotal role played by eosinophils and basophils in the genesis of an allergic late-phase reaction in the nose.