[Rupture of the right ventricular wall closed with Daflon patching and biological glue]

In this paper we present a rare case of Dacron patch closure of tear in right ventricular myocardial at outflow level, caused by stroke of hypoplastic right coronary artery occlusion, in patient with non-obstructive hypertrophic cardiomyopathy caused by hypertension and aortic stenosis, surgically treated by implantation of mechanical prostheses, and pericarditis postcardiotomy. Our purpose is to trace evidence from postmortem identification of pathogenic mechanisms occurring in causing fatal event. The severe myocardial hypertrophy observed is supposedly based on valvular or hypertensive, is compatible with a significant reduction of the diastolic function and with the genesis of acute pulmonary edema as a trigger: the latter case may result in death for the reduction of contractile reserve of the right ventricle, induced by the presence of the patch surgically implanted.

[Appropriateness prescribing and doctor's professional responsibility]

The public health spending has now reached very significant levels, in this sense, the responsibility of the medical doctor assumes a significant importance in medical law. The aim of this paper is to analyze the profile of responsibilities of the medical doctor in the light of recent case law. The appropriateness of prescribing and risk assessment are, according to the authors, the real test on which to test the skill, prudence and diligence which are called prescribers. Guidelines can be a valuable tool for the professional help, knowing, however, limits application of the recommendations where to be reconciling with the prevailing protection of personal rights of the user.

[Regenerative medicine: orthopaedical applications and medico legal questions]

Over the last decades, the increase in the global population's mean age has implied a corresponding increase in degenerative disease affecting various anatomical areas and tissues, including bones and cartilages, thus provoking a rising number of disabilities and a wider usage of drugs, mostly anti-inflammatory and cortisone. New developments in technologic and biomedical fields gave birth to new subjects, such as tissue engineering, cell therapy, gene therapy that, by and large, create a knowledge network falling under the concept of Regenerative Medicine. This science is essentially based on the usage of stem cells that can replicate and renovate themselves originating, if adequately stimulated, a number of cell types. Inter alia, in orthopaedic field a particular type of adult stem cells is used, the mesenchymal stem cells (MSCs). If combined with synthetic material produced in laboratories, the usage of these cells has provided inspiration for new study interests; today, it can be applied in various degenerative and post-traumatic pathologies, with great therapeutic benefits for the patient. Actually, many studies write about an improvement in patients' life quality. In this sense appear significant reflections on legal medicine, both in accidents and insurance, of this innovative therapeutic alternative and is hopefully an equally valid process of improvement of regulatory and case law.

[Medical legal issues associated with the evaluation of herniated discs in seafarers to merchant ships]

"Seafarer" means person employed with any job on board a ship offshore, whether publicly or privately, excluding ships of war. Day by day a seafarer is forced to confront a reality in constant motion and live in environments that require awkward movements, and restricting the normal mobility of the person. In order to verify the frequency of herniated discs in this particular category of workers, given the recent introduction of INAIL tabulated diseases, a study was conducted on a sample of seafarers. Data analysis showed that 48.3% of the seafarers of the sample has herniated lumbar disc, and 34.5% of these duties in the deck, and 65.5% of the machine. The study of sample, varied as to age and task being performed, supports the assertion that the individual risk factors, especially age and obesity, are not strongly implicated in the genesis of disk herniation suffered by seafarers while the work factors (vibrations) play a more significant role in the onset of this disease. This consideration is part of a context, that of legal medical evaluation and in particular the causal relationship, which currently seems rather lacking in terms of literature and scientific production.

The emerging role of sunitinib in the treatment of advanced epithelial thyroid cancer: our experience and review of literature

Tyrosine kinase receptors have been shown to play an important role in epithelial thyroid tumor growth and angiogenesis. Thyroid cancers commonly present oncogene mutations involved in MAPK kinase pathway like BRAF and RET; they are also frequently dependent on VEGF stimuli. Preliminary clinical experiences suggest a promising role of sunitinib (a tyrosine kinase inhibitor) for the treatment of advanced thyroid cancers. This review deals with the available data on the effect of sunitinib in the treatment of metastatic, radioiodine refractory thyroid cancers. We also report our experience with the off-label use of sunitinib in such patients.

Feasibility of transradial approach in a hub and spoke cath lab network

AIM

Radial artery approach for coronary angiography presents advantages in terms of reduction of costs and complications. Opening a diagnostic-only cath lab is controversial in an era of interventional approach. The authors present the data of Carpi diagnostic-only cath lab (Spoke), satellite of the main cath lab situated in Modena (Hub) 20 Kms apart.

METHODS

Between January 2004 and December 2007, 1496 coronary angiograms were performed. The indication was ischemic heart disease in 1197 cases (80%), dilated cardiomiopathy in other 165 cases (11%) and valvular heart disease in the remaining 134 patients (9%). The procedure was performed percutaneously via radial artery in 95% (N=1421) of the cases, via brachial artery in 1% (N=15) and via femoral artery in the remaining 4% (N=60) of patients.

RESULTS

Among the 1197 patients undergoing coronary angiography for ischemic heart disease, an indication to medical therapy was given in 443 (37%), a surgical indication in 216 (18%) patients and an indication to percutaneous coronary intervention (PCI) in 538 (45%) cases. PCI was performed in the Hub centre the same day and via the same arterial approach of the diagnostic angiography, maintaining the sheath in situ during transport. In 6 patients only it was necessary to shift to a femoral approach.

CONCLUSIONS

This model presents many advantages: 1) a cath lab in a peripheral hospital allows a early carrying out of the hemodynamic examination with reduction of hospital stay; 2) transport to the Hub centre cath lab is undertaken only in patients who really need PCI; 3) the PCI is feasible the same day of the diagnostic examination; 4) this model relieves the hub centre congestion, ensuring motivation and professional competence for personnel of peripheral hospital.

A phase II (PhII) trial of sorafenib (S) in combination with 5-fluorouracil (5FU) continuous infusion (c.i.) in patients (pts) with advanced hepatocellular carcinoma (HCC): Preliminary data

4592

Background: S, an oral multi-kinase inhibitor that targets Raf-kinase and receptor tyrosine kinases, improved overall survival (OS) and time to progression (TTP) versus placebo in a randomized phase III study in HCC (SHARP study). The safety of S in association with infusional and bolus 5FU regimens was established in a previous PhI study, with no clinically relevant pharmacokinetic interaction between S and 5FU. The present trial was designed to evaluate the safety and efficacy of S with infusional 5FU in HCC pts. Methods: Patients with advanced HCC (not eligible to surgical or locoregional therapies), age≥18 years, Child-Pugh Class A or B, ECOG PS 0–1, without prior systemic treatment for HCC and adequate bone marrow, liver and renal function, were eligible for the study. The primary endpoint is the Disease Control Rate (DCR). Secondary endpoints included response rate, TTP, OS and safety. According to a two-step Simon's model 46 pts were to be accrued. Pts were treated with oral S 400 mg bid continuously and c.i. 5FU 200 mg/sqm/day day 1–14 every 3 weeks. Tumour response was assessed according to RECIST criteria every 9 weeks. Results: Between October 2006 and October 2008 38 pts were enrolled: M-F: 32–6, median age (range): 68(47–83) years, ECOG-PS 0–1: 28–10, Child-Pugh A-B: 35–3, extrahepatic spread: 14 pts, macroscopic vascular invasion: 6 pts. Grade 3/4 (%) toxicities (NCI CTC v 3.0 criteria) included diarrhoea 5/0, stomatitis 21/3, hand foot syndrome 21/0, skin rash 11/0, hypertension 11/0; hyperbilirubinemia 5/3, AST 11/0, ALT 8/0, cardiac toxicity (one cardiac failure, one atrial fibrillation) 5/0 and bleeding (melena) in 3/0. One partial response was observed. Stable disease was obtained in 45% of pts with a median duration of 9.6 months (range 5–18+). Median TTP was 7.6 months (CI 95%=5.3–9.9) and median OS 12.2 months (CI 95%=4.45–19.8). Conclusions: Preliminary results of this PhII study show encouraging disease control rate, TTP and OS in pts with advanced HCC. The S+5FU association is feasible, well tolerated and AEs were predictable and manageable.

[Table: see text]

A randomized, open label, prospective study comparing the association between sorafenib (So) and interleukin-2 (IL-2) versus So alone in advanced untreated renal cell cancer (RCC): Rosorc Trial

5099

Background: So is an orally active multikinase inhibitor with a well documented activity in advanced RCC. IL-2 is a pleiotropic cytokine with antitumoral activity depending on dose and schedule. The aim of the study is to evaluate the activity and the safety of So and IL-2 association compared to So alone. Methods: In this multicenter, randomized, open label, phase II study, 128 previously untreated metastatic RCC patients (pts) were randomized to receive 400 mg of So, orally given twice daily continuously, in combination with IL-2, 4.5 MIU administered subcutaneously, five times a week for six consecutive weeks any eight weeks (arm A), or So alone (arm B) at the same dose. Therapy continued until progression of disease or unacceptable toxicity. The primary end point was progression free survival (PFS) and the secondary endpoints were response rate, safety and overall survival. Eligible pts had histological diagnosis of RCC, ECOG 0–2, no brain metastases, measurable disease and any Motzer's score. Pts were stratified according to different histotypes and Motzer's score. Results: All pts were enrolled from October 2006 to February 2008. Response rates (all partial responses, PR) were 23 % and 10 % in arm A and B respectively. Overall disease control rates (PR + stable disease SD) were 81 % versus 74 %. Tumour shrinkage was reported in 52 % and 34 % of arm A and B therapies respectively. Median PFS was 38 weeks (range 6–104+) for So + IL-2 and 30 weeks (range 6–102+) for So alone. PFS at 1 year was 31% in the combination therapy versus 22% in arm B. The most common adverse events (AEs) were asthenia, hand foot syndrome, hypertension, fever, diarrhoea and mucositis. AE were usually low or moderate in severity and always reversible and manageable. Grade 3–4 AE were reported in 33% and 22% in arm A and B, respectively. Conclusions: The safety and efficacy data suggest that the association So + IL-2 is safe and feasible and, compared to So alone, improves tumour shrinkage, disease control rate and PFS.

[Table: see text]

A multicenter phase II study of the combination of oxaliplatin, irinotecan and capecitabine in the first-line treatment of metastatic colorectal cancer

The triple drug combination consisting of irinotecan, oxaliplatin and 5-fluorouracil (FOLFOXIRI) has demonstrated higher activity and efficacy compared to the doublet FOLFIRI. 5-Fluorouracil could be substituted in FOLFOXIRI regimen by capecitabine, an oral fluoropyrimidine with similar efficacy. Recently, a dose-finding trial has demonstrated the feasibility of the combination of irinotecan, oxaliplatin and capecitabine (XELOXIRI) and established their recommended doses. The aim of this study was to evaluate the activity of XELOXIRI. A total of 36 patients with unresectable metastatic colorectal cancer received irinotecan 165 mg m⁻² and oxaliplatin 85 mg m⁻² on day 1 plus capecitabine 2000 mg m⁻² per day orally in two doses from day 1 to day 7, every 2 weeks. Grade 3–4 toxicities were infrequent, expect for neutropenia and diarrhoea, which were each observed in 30% of patients. Two complete and twenty-two partial responses were obtained, corresponding to an overall response rate of 67% (95% CI 51.4–82%). After a median follow-up of 17.7 months, the median progression-free and overall survival were 10.1 and 17.9 months, respectively.

The substitution of 5-fluorouracil with capecitabine, in combination with irinotecan and oxaliplatin, is feasible and does not impair the activity of the regimen. However, the XELOXIRI combination is associated with a high incidence of diarrhoea and, therefore, should be considered as a not preferable alternative to FOLFOXIRI.

SPREAD Italian Guidelines for stroke. Indications for carotid endarterectomy and stenting

This multidisciplinary guideline provides an overview of the current evidence on the benefits obtained by endoarterectomy and stenting for the surgical treatment of patients with symptomatic and asymptomatic carotid stenosis. A hundred forty-six authors, 37 Italian scientific societies and two Italian patients' associations participated in drafting the Stroke Prevention and Educational Awareness Diffusion (SPREAD) document, which has become the national guideline for the prevention and treatment of stroke in Italy. For the surgical therapy section of this document, the main trials on carotid endoarterectomy and stenting were critically reviewed following The Scottish Intercollegiate Guideline Network Oxford Centre for Evidence-Based Medicine methodology in order to formulate recommendations and syntheses for these procedures. The final document was peer reviewed and approved by all the participants. Recommendations and syntheses are presented for the referral of patients to either carotid endoarterectomy or stenting on the basis of whether carotid stenosis is symptomatic or asymptomatic, on the presence of various risk factors such as degree of arterial narrowing, and on concomitant pathology (cardiopathy and acute stroke).

VITATOPS, the VITAmins TO prevent stroke trial: rationale and design of a randomised trial of B-vitamin therapy in patients with recent transient ischaemic attack or stroke (NCT00097669) (ISRCTN74743444)

BACKGROUND

Epidemiological studies suggest that raised plasma concentrations of total homocysteine (tHcy) may be a common, causal and treatable risk factor for atherothromboembolic ischaemic stroke, dementia and depression. Although tHcy can be lowered effectively with small doses of folic acid, vitamin B(12) and vitamin B(6), it is not known whether lowering tHcy, by means of B vitamin therapy, can prevent stroke and other major atherothromboembolic vascular events.

AIM

To determine whether the addition of B-vitamin supplements (folic acid 2 mg, B(6) 25 mg, B(12) 500 microg) to best medical and surgical management will reduce the combined incidence of stroke, myocardial infarction (MI) and vascular death in patients with recent stroke or transient ischaemic attack (TIA) of the brain or eye.

DESIGN

A prospective, international, multicentre, randomised, double blind, placebo-controlled clinical trial.

SETTING

One hundred and four medical centres in 20 countries on five continents.

SUBJECTS

Eight thousand (6600 recruited as of 5 January, 2006) patients with recent (<7 months) stroke (ischaemic or haemorrhagic) or TIA (brain or eye).

RANDOMISATION

Randomisation and data collection are performed by means of a central telephone service or secure internet site.

INTERVENTION

One tablet daily of either placebo or B vitamins (folic acid 2 mg, B(6) 25 mg, B(12) 500 mug).

PRIMARY OUTCOME

The composite of stroke, MI or death from any vascular cause, whichever occurs first. Outcome and serious adverse events are adjudicated blinded to treatment allocation.

SECONDARY OUTCOMES

TIA, unstable angina, revascularisation procedures, dementia, depression. STATISTICAL POWER: With 8000 patients followed up for a median of 2 years and an annual incidence of the primary outcome of 8% among patients assigned placebo, the study will have at least 80% power to detect a relative reduction of 15% in the incidence of the primary outcome among patients assigned B vitamins (to 6.8%/year), applying a two-tailed level of significance of 5%.

CONCLUSION

VITATOPS aims to recruit and follow-up 8000 patients between 1998 and 2008, and provide a reliable estimate of the safety and effectiveness of folic acid, vitamin B(12), and vitamin B(6) supplementation in reducing recurrent serious vascular events among a wide range of patients with TIA and stroke throughout the world.