Intensified Total Neoadjuvant Therapy in Patients With Locally Advanced Rectal Cancer: A Phase II Trial

AIMS

We assessed the efficacy and safety of total neoadjuvant therapy, including targeted agent plus FOLFOXIRI (5-fluorouracil, leucovorin, oxaliplatin and irinotecan) induction chemotherapy followed by intensified chemoradiotherapy (CRT) and surgical resection, in patients with locally advanced rectal cancer.

MATERIALS AND METHODS

This was a single-arm, single-centre phase II trial. Eligible patients had non-metastatic locally advanced rectal adenocarcinoma. Based on Ras-BRAF status, patients were treated with bevacizumab (mutated Ras-BRAF) or panitumumab/cetuximab (wild-type Ras-BRAF) plus FOLFOXIRI regimen followed by oxaliplatin-5-fluorouracil-based CRT and surgery. The primary end point was pathological complete response rate. Secondary end points were toxicity, compliance, tumour downstaging, complete resection, surgical complications, local and distant failures and overall survival. The sample size was planned to expect an absolute 20% improvement in pathological complete response rate over historical literature data with an α error of 0.05 and a power of 80%.

RESULTS

Between October 2015 and September 2019, 28 patients (median age 66 years) were enrolled. All patients had regional lymph node involvement at diagnosis. FOLFOXIRI plus bevacizumab was administered in 11 mutated Ras-BRAF patients, whereas the 17 wild-type Ras-BRAF patients received FOLFOXIRI plus panitumumab/cetuximab. Overall, total neoadjuvant therapy was well tolerated and 26 patients (92.9%) completed the programmed strategy. A complete response was achieved in nine cases (32.1%) and a nearly pathological complete response (ypT1 ypN0) in two patients (7.2%). There was no evidence of febrile neutropenia and no grade 4 adverse events were recorded. Radical resection was achieved in all cases.

CONCLUSION

FOLFOXIRI plus targeted agent-based induction chemotherapy and intensified CRT before surgery showed promising clinical activity and was well tolerated in locally advanced rectal cancer patients. This phase II trial provides a strong rationale for phase III studies.

Carbon Monoxide, Cigarettes and Family Doctors

Aims and Background

General practitioners could play a key role in preventive programs against tobacco-related diseases. However, they seldom take action in the office even with minimal advice counselling. Such behaviour might reflect the lack of academic teaching and the lack of practice with motivational and dependence questionnaires, considered basic tools to help smokers to quit successfully. The study was aimed to investigate the awareness of a sample of Italian family doctors as regards tobacco epidemiology and smoking cessation strategies.

Methods

A total of 428 family doctors were administered a questionnaire with a set of questions on their personal smoking habits and on personal initiatives in the office towards smokers. Another set of questions regarded their knowledge on tobacco issues, with special attention to carbon monoxide, which is widely perceived as a very dangerous poison and works as a motivational tool on smokers and adolescents. Carbon monoxide measurement was carried out on all participants to obtain objective data on smoking and to show the feasibility of the test.

Results

The percentage of self-reported current smokers among general practitioners was 24%, with a high prevalence of ex-smokers (46%), and 29% of never smokers. Family doctors were more keen to counsel adolescents than adults about tobacco, and they were very interested in continuing medical education on the issue. The doctors who took part in our study showed a surprising limited knowledge of all the issues associated with smoking cessation and prevention such as epidemiology, cigarette characteristics, success rate of smoking cessation programs, Fagerström's tolerance questionnaire, safety of nicotine replacement therapy and the knowledge of carbon monoxide as a product of cigarette smoke.

Conclusions

The scenario depicted by our survey underscores the necessity to improve the knowledge and performance of primary care physicians on tobacco-related issues in order to implement primary and secondary prevention in clinical practice.

A modified sentinel lymph node technique combined with endoluminal loco-regional resection for the treatment of rectal tumours: a 14-year experience

AIM

After endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgey (TEM) the N parameter may remain undefined. Nucleotide-guided mesorectal excision (NGME) improves the lymph node harvest. The aim of the present study is to evaluate the long-term oncological results after ELRR with NGME.

METHOD

A total of 57 patients were enrolled over the period January 2001 to June 2015. All patients underwent ELRR by TEM. Prior to surgery, 99 m-technetium-marked nanocolloid was injected into the peritumoural submucosa. After removal of the specimen, the residual defect was probed to detect any residual radioactivity and 'hot' mesorectal fat was excised. All patients were included in a 5-year follow-up programme.

RESULTS

Significant radioactivity in the residual cavity was found in 28 out of 57 patients (49%). The mean number of lymph nodes harvest in irradiated and nonirradiated patients was 1.66 and 2.76, respectively. After 68.2 months' follow-up overall survival was 91.2%, disease-related mortality 3.5% and disease-free survival 89.5%. Two patients developed pulmonary metastases: one ypT3N0 patient underwent lung lobectomy after chemotherapy and one pT2N0 patient was managed with lung radiotherapy. Both patients are currently alive and disease-free at 48 months' follow-up. Two patients developed local recurrence 1 year after ELRR, both treated with neoadjuvant chemo-radiotherapy and total mesorectal excision. Comparing the present series with previous patients who did not undergo NGME, an increased number of harvested lymph nodes were observed, with a statistically significant difference (P = 0.0085).

CONCLUSION

NGME during ELRR improves the lymph node harvest and staging accuracy. The long-term results showed satisfactory local (3.5%) and distant (7%) recurrence rates.

Sensitivity analysis of ventricular activation and electrocardiogram in tailored models of heart-failure patients

Cardiac resynchronization therapy is not effective in a variable proportion of heart failure patients. An accurate knowledge of each patient's electroanatomical features could be helpful to determine the most appropriate treatment. The goal of this study was to analyze and quantify the sensitivity of left ventricular (LV) activation and the electrocardiogram (ECG) to changes in 39 parameters used to tune realistic anatomical-electrophysiological models of the heart. Electrical activity in the ventricles was simulated using a reaction-diffusion equation. To simulate cellular electrophysiology, the Ten Tusscher-Panfilov 2006 model was used. Intracardiac electrograms and 12-lead ECGs were computed by solving the bidomain equation. Parameters showing the highest sensitivity values were similar in the six patients studied. QRS complex and LV activation times were modulated by the sodium current, the cell surface-to-volume ratio in the LV, and tissue conductivities. The T-wave was modulated by the calcium and rectifier-potassium currents, and the cell surface-to-volume ratio in both ventricles. We conclude that homogeneous changes in ionic currents entail similar effects in all ECG leads, whereas the effects of changes in tissue properties show larger inter-lead variability. The effects of parameter variations are highly consistent between patients and most of the model tuning could be performed with only ~10 parameters.

Anal function after endoluminal locoregional resection by transanal endoscopic microsurgery and radiotherapy for rectal cancer

AIM

In patients with rectal cancer, surgery and chemoradiotherapy may affect anal sphincter function. Few studies have evaluated anorectal function after neoadjuvant chemoradiotherapy (n-CRT) and/or transanal endoscopic microsurgery (TEM). The aim of this study was to evaluate the effects of n-CRT and TEM on anorectal function.

METHOD

Thirty-seven patients with rectal cancer underwent anorectal manometry and Wexner scoring for faecal incontinence at baseline, after n-CRT (cT2-T3N0 cancer) and at 4 and 12 months after surgery. Water-perfused manometry measured anal tone at rest and during squeezing, rectal sensitivity and compliance. Twenty-seven and 10 patients, respectively, underwent TEM without (Group A) or with n-CRT (Group B).

RESULTS

In Group A, anal resting pressure decreased from 68 ± 23 to 54 ± 26 mmHg at 4 months (P = 0.04) and improved 12 months after surgery (60 ± 30 mmHg). The Wexner score showed a significant increase in gas incontinence (59%), soiling (44%) and urgency (37%) rates at 4 months, followed by clinical improvement at 1 year (41%, 26% and 18%, respectively). In group B, anal resting pressure decreased from 65 ± 23 to 50 ± 18 mmHg at 4 months but remained stable at 12 months (44 ± 11 mmHg, P = 0.02 vs preoperative values - no significant difference compared with evaluation at 4 months). Gas incontinence, soiling and urgency were observed in 50%, 50%, 25% and in 38%, 12% and 12% of cases, respectively, 4 and 12 months after treatment.

CONCLUSION

TEM does not significantly affect anal function. Instead, n-CRT does affect anal function but without causing major anal incontinence.

Thirteen years' experience with laparoscopic transcystic common bile duct exploration for stones. Effectiveness and long-term results

BACKGROUND

The aim of the present study was to evaluate the effectiveness and long-term results of laparoscopic transcystic common bile duct exploration (TC-CBDE).

METHODS

Ductal stones were present in 344 of 3212 patients (10.7%) who underwent laparoscopic cholecystectomy (LC). The procedure was completed laparoscopically in 329 patients (95.6%), with TC-CBDE performed in 191 patients (58.1%) who are the object of this study, or with a transverse choledochotomy in 138 cases (41.9%).

RESULTS

Biliary drainage was employed in 71 of 191 cases (37.2%). Major complications occurred in 10 patients (5.1%), including retained stones in 6 (3.1%). Mortality was nil. No patients were lost to follow-up (median: 118.0 months; range: 17.6-168 months). No signs of bile stasis, no recurrent ductal stones and no biliary stricture were observed. At present 182 patients are alive with no biliary symptoms; 9 have died from unrelated causes.

CONCLUSIONS

Long-term follow-up after laparoscopic TC-CBDE proved its effectiveness and safety for single-stage management of gallstones and common bile duct stones.

Transanal endoscopic versus total mesorectal laparoscopic resections of T2-N0 low rectal cancers after neoadjuvant treatment: a prospective randomized trial with a 3-years minimum follow-up period

BACKGROUND

This study aimed to compare the results and the oncologic outcomes of transanal endoscopic microsurgery (TEM) with neoadjuvant radiochemotherapy and laparoscopic resection (LR), also with neoadjuvant radiochemotherapy, in the treatment of T(2)-N(0) low rectal cancer.

METHODS

The study enrolled 40 patients with T2-N(0) rectal cancer, randomizing 20 to TEM (arm A) and 20 to LR (arm B).

RESULTS

After neoadjuvant radiochemotherapy, tumor downstaging was observed for 13 patients (65%) in arm A (7 pT0 and 6 pT1) and in 11 patients (55%) in arm B (7 pT0 and 4 pT1). More than a 50% reduction of the tumor diameter was observed in four arm A cases and in six arm B cases. At a median follow-up period of 56 months (range, 44-67 months) in both arms, one local failure (5%) occurred after 6 months in arm A and one (5%) after 48 months in arm B. Distant metastases occurred in one arm A patient (5%) after 26 months of follow-up evaluation and in one arm B patient (5%) at 31 months. The probability of local or distant failure was 10% for TEM and 12% for laparoscopic resection, whereas the probability of survival was 95% for TEM and 83% for laparoscopic resection.

CONCLUSIONS

The findings show comparative results between the two study arms in terms of probability of failure and survival.

Practice of opportunistic prostate-specific antigen screening in Italy: data from the Health Search database

The effectiveness of prostate-specific antigen (PSA) testing for opportunistic screening of prostate cancer is not yet well established, although this practice seems to be widely accepted. To estimate the opportunistic use of PSA by general practitioners (GPs) in Italy, we conducted a survey by querying the Health Search (HS) database, which collects clinical records from a representative sample of the Italian population. Clinical computerized data from 320 GPs and 221,557 male patients were analysed. Among total requests for PSA, 3% were linked to prostate cancer, 18% to a urological disease or symptom and 79% were not linked to any urological condition (opportunistic screening). Opportunistic screening was used for 31.4% of subjects over 50 with a significant (P<0.0001) difference between geographical areas (36.4% north, 33.5% central regions, 22.9% south and isles). This distribution was very similar to prostate cancer prevalence as it resulted from the HS data. PSA testing practice showed an increase over the years (12.7% of men over 50 in 2000, 14.3% in 2001 and 15.9% in 2002). In conclusion, the practice of opportunistic screening of prostate cancer seems to be extensively adopted by Italian GPs and is becoming more and more popular, although to date it is not supported by strong scientific evidence.

[Evaluation of the bactericidal activity of a disinfectant containing sodium hypochlorite (Amiclor)]

We evaluated the stability and the bactericidal activity of a disinfectant containing sodium hypochlorite (Amiclor), which associates the buffer effect of the system sodium carbonate/sodium tetraborate to the stabilizing action of sodium chloride. The stability was determined evaluating the trend of the active chlorine title in various conservation conditions and comparing it with a product having only sodium chloride as stabilizing component. The bactericidal activity, instead, was evaluated by suspension and surface tests against Escherichia coli (ATCC 10536) and in relation to several variables, as product concentration, contact time, presence of interfering substances and water hardness. From the obtained data it is possible to affirm that Amiclor owns a greater stability as regards the traditional products stabilized only with sodium chloride. The activity tests have pointed out that the practical conditions affect the choice of the combination "product concentration/contact time" necessary to obtain an effective bactericidal activity. The activity of Amiclor is conditioned by the presence of proteins in the mixture or on the surface of reaction. This influence is not very clear in clean conditions while it considerably increases in dirty conditions. A decrease of bactericidal activity was observed when the product was diluted in hard water, mainly for contact times of 5 minutes or low product concentrations.

Long-term results of laparoscopic versus open resections for rectal cancer for 124 unselected patients

BACKGROUND

Controversy continues to surround laparoscopic rectal resection for malignancy. A longer follow-up period is required to evaluate the long-term efficacy of the procedure and its impact on survival. Furthermore, no data from ongoing randomized controlled trials are yet available. The aims of this study were to compare long-term outcomes for unselected patients undergoing either laparoscopic or open rectal resection for cancer.

METHODS

A series of 124 unselected consecutive patients with rectal cancer, who underwent surgery by the same surgical team, have been included in this study. Patients with T1N0 tumors underwent local excision, and emergency cases were excluded from the study. Written consent was submitted by each patient, and inclusion in either group (laparoscopic or open) was left to the patient's choice. The laparoscopic approach was chosen by 81 patients, and 43 patients chose open surgery. All the patients underwent preoperative radiotherapy (5,040 cGy), performed in selected cases with chemotherapy (for patients younger than 70 years). The following parameters were compared between the two groups: length of the surgical specimen, clearance of the margins of the specimen, number of lymph nodes identified, local recurrence rate, incidence of distant metastases, and survival probability analysis. The mean follow-up period for both groups was 43.8 months (range, l-9 years).

RESULTS

We performed 60 laparoscopic and 27 open anterior resections, as well as 21 laparoscopic and 16 open abdomino perineal resections, respectively. No mortality occurred in either group. The mean length of the resected specimens was 24.3 cm in the laparoscopic group and 23.8 cm in the open group ( p = 0.47). The mean tumor-free margin was 3.0 cm in the laparoscopic group and 2.8 cm in the open group ( p = 0.57), and the mean number of lymph nodes identified was 10.3 in the laparoscopic group and 9.8 in the open group ( p = 0.63). Of the 124 patients, 86 (52 laparoscopic and 34 open) were included in out study. We excluded patients who underwent a palliative resection (6 laparoscopic and 6 open patients) or conversion to open surgery ( n = 10) and patients who had undergone surgery in the past year ( n = 16). One laparoscopic patient was lost to follow-up evaluation, whereas three laparoscopic patients and one open patient died of causes not related to cancer. No wound recurrence was observed. The local recurrence rate after laparoscopic resection was 20.8%, as compared with 16.6% after open resection ( p = 0.687). Distant metastases occurred in 18.2% of the patients in the laparoscopic group, as compared with 21.2% in the open group ( p = 0.528). Cumulative survival probability was 0.709 after laparoscopic resection after LR and 0.606 after open resection ( p = 0.162), whereas for Dukes' stages A, B, and C in the laparoscopic group versus the open group, it was 0.875 vs 0.889 ( p = 0.392), 0.722 vs 0.584 ( p = 0.199), and 0.500 vs 0.417 ( p = 0.320), respectively. At this writing 20 laparoscopic patients (62.5%) and 20 open patients (60.6%) are disease free ( p = 0.623).

CONCLUSIONS

Oncologic surgical principles were respected. Long-term outcome after laparoscopic resection of rectal cancer was comparable with that after conventional resection. We should wait to draw conclusive scientific statements until the completion of ongoing international randomized controlled trials.

Laparoscopic versus open hemicolectomy

AIM

In the last decade, laparoscopic procedures are applied to the treatment of almost all colonic diseases, including both benign and malignant lesions. Focusing our attention to the laparoscopic operative technique, we compare the perioperative results and the oncological outcomes of laparoscopic hemicolectomy with those after open conventional hemicolectomy.

METHODS

This prospective non randomized study is based on a series of 469 consecutive patients (73.6% with malignant lesions) operated on by the same surgical team following the same type of surgical technique, for laparoscopic and open approach, to perform right (RH) and left (LH) hemicolectomy, respectively, excluding segmental resections, emergency operations as well as transverse colon, splenic flexure and recurrent carcinomas. The treatment modality was selected by the patients after reading the informed consent form. Conversion rate to open surgery (for the laparoscopic group) and causes were assessed. Statistical significance (p) for operative time, resumption of gastrointestinal functions, length of stay, complications, perioperative mortality, as well as length of specimen, number of lymph-nodes harvest, incidence of local recurrences and distant metastases, and survival probability analysis in malignant cases, was assessed between the 2 groups (laparoscopic and open).

RESULTS

From March 1992 to February 2003, 166 patients underwent RH and 303 LH. In the RH group, 108 patients underwent laparoscopic approach and 58 underwent open surgery (26 vs 13 for benign lesions and 82 vs 45 for adenocarcinomas, respectively). LH was performed by laparoscopy in 202 patients and by laparotomy in 101 (55 vs 30 for benign lesions and 147 vs 71 for adenocarcinomas, respectively). There were no conversions to open surgery in laparoscopic RH, while 10 patients (4.9%) in the laparoscopic LH group required conversion: 3 of 34 performed for diverticular disease and 7 of 147 performed for malignancy. Mean operative time for laparoscopic surgery was longer than for open surgery (182 vs 140 min for RH and 222 vs 190 min for LH, respectively), but with increasing experience this decreased significantly. Mean hospital stay in patients who underwent laparoscopic procedures was significantly shorter both in RH and LH groups (9.2 vs 13.2 days and 9.9 vs 13.2 days, respectively). Similar major complication rates were observed between the 2 laparoscopic and open groups (1.8% vs 1.7% for RH and 4.1% vs 4.9% for LH, respectively). Follow-up time ranged between 12 and 109 months (mean, 57.3 months) in RH groups and between 12 and 111 months (mean, 57.5 months) in LH groups. The follow-up dropout was of only 3 patients after RH (in the laparoscopic group) and 5 after LH (3 in the laparoscopic group and 2 in the open group). The local recurrence rate was lower after laparoscopic surgery in both arms (7% vs 8.8% for RH and 3.3% vs 7% for LH, respectively), but the differences were not statistically significant. Two port site recurrences were observed in the laparoscopic groups, 1 after a Dukes D palliative RH and 1 after a Dukes C LH converted to open surgery (1.7% and 0.9%, respectively). Metachronous metastases rates were similar between the laparoscopic and open groups (20.9% vs 17.6% for RH and 4.4% vs 5.3% for LH, respectively). Cumulative survival probability (CSP) at 72 months after laparoscopic RH was 0.791 as compared to 0.765 after open surgery (p=0.326) and 0.956 after laparoscopic LH as compared to 0.877 after open surgery (p=0.115). CSP for Dukes stage A, B and C in the laparoscopic RH group was 0.875, 0.846, and 0.727 as compared to 0.9 (p=0.815), 0.889 (p=0.87), and 0.6 (p=0.183) after open surgery, respectively. CSP for Dukes stage A, B and C in the laparoscopic LH group was 0.1, 0.966, and 0.885 as compared to 0.1 (p=0.936), 0.944 (p=0.466), and 0.7 (p=0.072) after open surgery, respectively.

CONCLUSION

These results suggest that laparoscopic hemicolectomy for both benign and malignant lesions can be performed safely. Oncological outcomes were comparable with those of open surgery.

The incidence, natural history and associated outcomes of influenza-like illness and clinical influenza in Italy

OBJECTIVES

This study investigated the epidemiology, natural history and resource use associated with influenza in the general population setting in Italy.

METHODS

For a 3-month winter epidemic period, 202 GPs reported daily the number of visits performed for influenza-like illness (ILI), clinical influenza and any other cause. In addition, the first 10 cases of clinical influenza requiring a doctor's visit in each month of the 3-month period and for a total of 30 cases per GP were recorded carefully and followed-up, for evaluation of clinical evolution, associated outcomes and resource use.

RESULTS

Almost 200 000 visits were performed by 202 GPs, ILI and clinical influenza accounting for 13.8 and 8.3% of all-cause visits, respectively. A total of 6057 cases of clinical influenza were also recorded and evaluated for associated outcomes and resource use. Twenty percent of the patients were at risk because they were elderly (>65 years) or presented with concomitant chronic conditions. Almost all the patients received at least one prescription for symptomatic drugs and 36% received a prescription for antibiotics. Thirty-five percent of patients had at least one complication from influenza, primarily upper and lower respiratory tract bacterial infections. At-risk patients had a significantly higher complication rate (odds ratio = 2.89) and required more instrumental exams and hospitalizations compared with the general population, accounting for most of the direct costs associated with clinical influenza. Patients with clinical influenza had an average of 5 days absence from work or school.

CONCLUSIONS

Influenza is associated with significant morbidity in the general and at-risk population, a high degree of resource use in the at-risk population and substantial reduction or loss of productivity in the active working Italian population.

Outcome predictors in anorectic patients after 6 months of multimodal treatment

BACKGROUND

Anorexia nervosa is a severe disorder that often responds poorly to treatment. At this time, little is known about pretreatment predictors of response.

METHODS

A sample of 42 restrictor type anorectics was tested at the assessment phase and after 180 days retested using the Temperament and Character Inventory and Eating Disorder Inventory 2 along with other clinical evaluation instruments. After 180 days of treatment with multimodal 'network' therapy, the patients were divided into two groups. The first group included patients who showed relevant clinical improvement; the second group included patients considered 'not yet responding'. Data collected from the not-yet-responding group were compared by the t test with the other group's data to evaluate prognostic indexes.

RESULTS

Diagnosis of personality disorder, which afflicted about 50% of patients, seemed not to be a relevant prognostic factor. However, a lower novelty seeking was characteristic of the nonresponder group. Higher levels of asceticism and maturity fears also characterized the nonresponder group.

CONCLUSION

Present data suggest some elements that could be useful to focus pharmacotherapy, psychotherapy and family counseling on the current psychopathology of each patient.

Outcomes following repair of quadriceps tendon ruptures

OBJECTIVES

The purpose of this study was to examine critically the outcomes of patients sustaining a quadriceps tendon rupture and to compare outcomes in patients with bilateral simultaneous ruptures versus a unilateral rupture.

DESIGN

Retrospective review.

SETTING

Patients were treated at a Level I trauma center.

PATIENTS/PARTICIPANTS

Fifty-one quadriceps tendon ruptures in thirty-nine patients were evaluated. A mean four-year follow-up (range 13 to 204 months) was available for forty-eight tendon ruptures.

INTERVENTIONS

All patients except one were treated with operative repair of the quadriceps tendon rupture(s).

MAIN OUTCOME MEASUREMENTS

Patients were assessed by physical examination, Lysholm and Tegner scores, a functional questionnaire, quadriceps isokinetic testing, and radiographs.

RESULTS

A statistically greater number of patients in the bilateral simultaneous rupture group had a systemic illness associated with tendon rupture (p = 0.014). This result did not adversely affect outcome as compared with patients with unilateral ruptures. Mean range of motion was 123 degrees in injured knees. Eighty-four percent of working patients returned to their previous occupations. More than half the patients, however, in general the most active, could no longer participate in their preinjury recreational activities. Fifty-three percent of unilateral rupture patients had persistent quadriceps strength deficits (>20 percent) in the injured extremity. Both quadriceps and hamstring isokinetic testing correlated significantly with Lysholm and Tegner scores.

CONCLUSIONS

Most patients with bilateral simultaneous and unilateral tendon repairs can expect a good range of motion and return to their previous occupation, but many have persistent weakness and difficulty returning to higher level sporting activities.

[Changes in renal function in subjects undergoing an aortocoronary bypass with extracorporeal circulation]

It is well known that extracorporeal circulation (ECC) may determine an impaired renal function. The aim of our study was to identify those patients who, on the basis of the presence of cardiovascular risk factors such as diabetes mellitus, hypertension and hyperlipidemia, show more evident signs of such dysfunction. The study was conducted on 333 male patients, aged > 49 years, with normal renal function, who underwent coronary artery by-pass surgery in extracorporeal circulation. The results show that, among the cardiovascular risk factors, hypertension has a major influence on renal function after performing extracorporeal circulation, particularly on glomerular filtration rate and, when associated to diabetes mellitus, renal dysfunction may persist until the 9th post-operative day.

Effects of L-carnitine administration on left ventricular remodeling after acute anterior myocardial infarction: the L-Carnitine Ecocardiografia Digitalizzata Infarto Miocardico (CEDIM) Trial

OBJECTIVES

This study was performed to evaluate the effects of L-carnitine administration on long-term left ventricular dilation in patients with acute anterior myocardial infarction.

BACKGROUND

Carnitine is a physiologic compound that performs an essential role in myocardial energy production at the mitochondrial level. Myocardial carnitine deprivation occurs during ischemia, acute myocardial infarction and cardiac failure. Experimental studies have suggested that exogenous carnitine administration during these events has a beneficial effect on function.

METHODS

The L-Carnitine Ecocardiografia Digitalizzata Infarto Miocardico (CEDIM) trial was a randomized, double-blind, placebo-controlled, multicenter trial in which 472 patients with a first acute myocardial infarction and high quality two-dimensional echocardiograms received either placebo (239 patients) or L-carnitine (233 patients) within 24 h of onset of chest pain. Placebo or L-carnitine was given at a dose of 9 g/day intravenously for the first 5 days and then 6 g/day orally for the next 12 months. Left ventricular volumes and ejection fraction were evaluated on admission, at discharge from hospital and at 3, 6 and 12 months after acute myocardial infarction.

RESULTS

A significant attenuation of left ventricular dilation in the first year after acute myocardial infarction was observed in patients treated with L-carnitine compared with those receiving placebo. The percent increase in both end-diastolic and end-systolic volumes from admission to 3-, 6- and 12-month evaluation was significantly reduced in the L-carnitine group. No significant differences were observed in left ventricular ejection fraction changes over time in the two groups. Although not designed to demonstrate differences in clinical end points, the combined incidence of death and congestive heart failure after discharge was 14 (6%) in the L-carnitine treatment group versus 23 (9.6%) in the placebo group (p = NS). Incidence of ischemic events during follow-up was similar in the two groups of patients.

CONCLUSIONS

L-Carnitine treatment initiated early after acute myocardial infarction and continued for 12 months can attenuate left ventricular dilation during the first year after an acute myocardial infarction, resulting in smaller left ventricular volumes at 3, 6 and 12 months after the emergent event.

[The Italian contribution to the application of high-technology methods to clinical trials]

Clinical trials are important research tools currently used in assessing new drugs and therapeutic strategies, which are unable to produce large effects evaluable in small series of patients. We describe methodological principles of clinical trials and significant advantages in their implementation produced by using a computer network for long-distance modem transmission of echocardiographic images and clinical data. This network has been recently developed in Italy and is operative at the University of Bari and the Associazione per la Ricerca in Cardiologia. Several clinical participating centers of the CEDIM Study and PHASE Study are connected in real time to a data center via modem by a special telephone network (RFD) of the Italian State Telephone Company (SIP). We describe the configuration, main features and applicative potential of such a powerful research tool in modem clinical trial methodology.

A digital network for long-distance echocardiographic image and data transmission in clinical trials: the CEDIM (Carnitina, Ecocardiografia Digitalizzata, Infarto Miocardico) study experience

A special computer network has been specifically designed and realized to connect 36 Italian cardiological institutions to a central core laboratory. This network, which has been created to run the CEDIM Multicenter Trial (effects of L-carnitine on left ventricular function in patients with myocardial infarction assessed by digital echocardiography), enables automatic verification, via computer, 24 hours a day, of patient eligibility criteria, randomization, transmission, and filing of real-time left ventricular echocardiographic examinations. All the investigators participating in the CEDIM trial underwent several training courses as well as dummy run procedures to achieve optimal performance of all the operational procedures required for the network to function smoothly and correctly. This paper describes the aims of this special network, its technical characteristics, and the investigator training and dummy run procedures.

Echo-Doppler evaluation of the effects of heart rate increments on left atrial pump function in normal human subjects

It is commonly believed that the atrial contribution to left ventricular filling increases during heart rate increments. However, the relative contribution of the pump function (atrial systole) and of the passive role (diastasis and reservoir) of the atrium to end-diastolic left ventricular filling is not well known. In order to investigate this problem, we performed a two-dimensional echo-Doppler study during right atrial pacing. Transmitral flow velocity curves were obtained by means of pulsed Doppler. Pacing was performed (1) at the lowest heart rate at which it was possible to obtain a stable capture of the atria, (2) at the heart rate at which the early and late Doppler filling waves almost completely overlapped. In both stages pacing was interrupted for a few seconds to obtain some post-pacing beats. Doppler tracing recorded at rest, during pacing and in the immediate post-pacing beats were analysed to obtain well-known parameters of atrial contribution; atrial peak flow velocity, early to atrial peak flow velocity ratio, and time-velocity integral of the atrial wave. Furthermore, in order to distinguish end-diastolic passive flow from the active contribution of atrial systole to filling, we superimposed the envelope of the last Doppler curve obtained during atrial pacing over the envelope of the first post-pacing curve. In this way the area of the atrial wave of the paced beat was divided by the mid-diastolic part of the post-pacing one into two areas, the integrals of which correspond to the active and passive atrial contribution respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Prediction of cardiac events after uncomplicated myocardial infarction by cross-sectional echocardiography during transesophageal atrial pacing

Atrial pacing can safely be utilized shortly after myocardial infarction. To evaluate the prognostic value of wall motion abnormalities induced by such pacing 83 consecutive patients with recent uncomplicated myocardial infarction underwent transthoracic cross-sectional echocardiography during transesophageal atrial pacing and upright bicycle exercise stress test. Patients were followed-up for 14 +/- 5 months. During the atrial pacing and the echocardiography, patients were defined at high risk if abnormalities of wall motion were detected in left ventricular regions remote from the infarcted area. Then, during the exercise stress test, high risk patients were those with ST segment depression greater than or equal to 1 mm. On the other hand, patients were considered to be at low risk if they had no abnormalities of wall motion during atrial pacing in remote regions or, in the case of the stress test, if they did not develop ST depression greater than or equal to 1 mm. Of the 83 patients, 21 had major cardiac events during the period of follow-up. Cardiac events occurred in 15/23 (65%) and 5/60 (8%, P less than 0.001) patients assigned to the groups adjudged to be at high and low risk, respectively, on the basis of echocardiographic results. Exercise testing was less reliable in identifying patients at risk of future cardiac events. Major events occurred in only 6 of the 19 patients with a positive stress test (32%, P less than 0.05 vs positive stress echocardiography) and in 14 of the 64 patients with a negative exercise stress test (22%, P = NS vs positive exercise stress test, P less than 0.05 vs negative atrial pacing echocardiography).

Errors in measurements of stroke volume for invasive and echo-Doppler evaluations of valvular regurgitant fractions. Clinical evaluation and computer simulation

The aim of this study was to compare cardiac catheterization (CATH) with 2D echo-Doppler (ED) in clinically evaluating the stroke volumes (SV) needed to calculate aortic and mitral regurgitant fractions (aortic and mitral SV for the ED method, thermodilution and angiographic SV for the CATH). As there is no 'gold standard' for this kind of measurement, only subjects without valvular regurgitation were considered. In these subjects, though the two SV measurements needed to calculate the regurgitant volume should have been identical, there was, in fact a difference due to the systematic and random errors of the methods. We calculated the mean value and the standard deviation of this difference in a series of patients without valvular regurgitation in order to obtain an estimate of both systematic and random errors. In 20 patients studied by ED a difference of 11.9 +/- 16.7 ml was found. In 36 patients studied by cardiac catheterization the difference was 19.6 +/- 20.1 ml. A significant systematic error was found for both ED and the invasive method; The transmitral SV tended to be larger than the aortic and the angiographic SV larger than that obtained by thermodilution. To try to determine the extent to which the random errors could be attributed to the reproducibility of the measurements, we carried out computer simulations. The SVs of 50 000 hypothetical patients were randomly generated and then attributed a random error calculated on the basis of the variability of the CATH (thermodilution 4%, angiography 10%) and the ED measurements (aortic annulus 6%, mitral annulus 18%, mitral time velocity integral 10%, aortic time velocity integral 8%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of coronary anatomy and coronary circulation by transesophageal echocardiography]

Nowadays the anatomy and coronary flow can be evaluated by means of various methods requiring cardiac catheterization. Transesophageal echocardiography is a new diagnostic method with great potential (excellent technical quality, stable positioning of the transducer, no lung interposition). Because of its potential we have used transesophageal echocardiography on a number of patients undergoing coronary angiography in order to investigate its reliability in estimating the anatomy and coronary flow. From the anatomical point of view 3 aspects were identified: absence of alterations affecting the vessel being explored (Criterion A); presence of non-stenotic calcific wall plaques (Criterion B); presence of stenotic calcific plaques (Criterion C). The percentage of visualization of the left main artery, the left anterior descending and the circumflex was 87%, 78% and 76% respectively. The criteria described showed varying reliability depending on the coronary portion being considered. Using the pulsed Doppler, during the transesophageal study, we obtained an adequate recording of the velocity profile of the left anterior descending in 28/37 patients. After dipyridamole infusion all velocity parameters (diastolic and systolic mean and maximum velocities) increased significantly in those patients with left anterior descending without stenosis, while remaining practically constant in those patients with significant stenosis of the left anterior descending artery. In particular the ratio between the maximum diastolic velocity recorded after dipyridamole and the velocity recorded immediately before infusion was significantly greater in those subjects with normal left anterior descending than in those with significant stenosis of the left anterior descending artery.

CONCLUSIONS

transesophageal echocardiography offers new prospects in studying anatomic alterations and flow patterns of the proximal part of the left coronary artery.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of acute intrathoracic pressure changes on left ventricular geometry and filling

Acute changes in intrathoracic pressure (ITP) affect left ventricular (LV) function. It has been suggested that this functional impairment could be the result of an alteration in LV filling caused by a reduction in LV compliance induced by the rearrangement of biventricular geometry that occurs under these conditions. Therefore, to evaluate the effects of an acute increase or decrease in ITP on LV geometry and filling, we used two-dimensional and Doppler echocardiography to study 25 normal volunteers both during the Müller maneuver (acute decrease in ITP induced by a forced inspiration against a closed airway) and during continuous positive airway pressure breathing. During both maneuvers LV geometry was altered as demonstrated by the significant increase in the normalized curvature radius of the interventricular septum and the unchanged curvature radius of the LV free wall. LV filling was altered during both maneuvers as demonstrated by significant decreases in early peak flow velocity, early-to-late peak flow velocity ratio, and early deceleration rate. Thus, during maneuvers that acutely decrease or increase ITP, alterations in LV geometry occur. These acute distortions of LV geometry may be one of the mechanisms responsible for alterations in LV filling.

Doppler echocardiographic evaluation of the effect of atrial pacing-induced ischemia on left ventricular filling in patients with coronary artery disease

Very little is known about the effects of acute myocardial ischemia on left ventricular filling. Previous studies of these effects have been of limited value because they were performed with 1) imaging techniques that, like cineventriculography or radionuclide ventriculography, do not allow beat to beat monitoring of left ventricular filling throughout the entire ischemic attack; and 2) exercise, which, even if effective in inducing myocardial ischemia in patients with coronary artery disease, also considerably shortens cycle length, thus leading to additional nonischemic filling alterations. To overcome these limitations, left ventricular filling was studied by means of Doppler echocardiographic evaluation of transmitral flow velocities before and immediately after rapid atrial pacing in 17 patients. Eight patients had coronary artery disease but did not develop ischemia (ST depression greater than or equal to 1.5 mm) during atrial pacing (Group 1) whereas nine had coronary artery disease and developed ischemia during atrial pacing (Group 2). No differences were observed from rest to postpacing in any of the filling variables considered in Group 1 patients. In contrast, a significant rearrangement of left ventricular filling occurred during ischemia in Group 2 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intramural diverticulosis of the gallbladder]

The authors report on 9 cases of acalculous adenomyomatosis of the gallbladder, selected to Arianoff's classification. The clinical, anatomopathological and radiological data are considered: there isn't difference concerning the clinical symptoms between adenomyomatosis and cholelithiasis; only radiological study may clarify the nature and character of these lesions. The authors conclude stressing the importance of surgical therapy because the medical therapy is only symptomatic and does not modify the natural evolution of the disease and its complications.

Prediction of the extent of coronary artery disease with the evaluation of left ventricular wall motion abnormalities during atrial pacing. A cross-sectional echocardiographic study

In patients with coronary artery disease, left ventricular performance during stress is affected by the degree of coronary stenosis. In order to verify whether there exists a relationship between the extent of wall motion abnormalities detectable during atrial pacing and the degree of coronary obstruction, 76 patients, without previous myocardial infarction, were studied. Each patient underwent cross-sectional echocardiography during transesophageal atrial pacing and exercise electrocardiography before coronary angiography. Of the 76 patients, 46 had significant coronary artery disease (stenosis greater than or equal to 75% of at least one major coronary vessel), while 30 had normal coronaries or a stenosis of less than 75%. Eighteen patients had single-, 14 had two- and 14 had three-vessel disease. For each patient a coronary score was obtained: the score used took into consideration the site, number and severity of the stenosis. This score was then correlated with the wall motion score, obtained from the analysis of 9 segments of the left ventricle. A weak correlation was obtained between wall motion score at rest and coronary score (r = -0.42), while the correlation between coronary score and the difference between wall motion score at rest and during transesophageal atrial pacing was slightly better (r = 0.53); this correlation further improved if wall motion score during pacing was considered (r = -0.63). If the patients with discordant diagnostic tests (echocardiography during transesophageal atrial pacing and exercise electrocardiography) were excluded, the correlation coefficient between coronary score and wall motion score during pacing increased even more (r = -0.77).

IN CONCLUSION

(1) analysis of wall motion of the left ventricle during atrial pacing is useful for the non-invasive evaluation of the severity of coronary disease; (2) cross-sectional echocardiography during atrial pacing, apart from being a useful diagnostic tool, is also a help in judging the degree of severity of coronary artery disease.

Atrial pacing in the detection and evaluation of coronary artery disease

Atrial pacing has been recently re-evaluated as a stress test for the detection of coronary artery disease. This sort of stress, especially if used in conjunction with cardiac imaging techniques can be considered a reliable alternative to physical exercise. In patients with recent myocardial infarction it can be usefully and safely utilized to obtain prognostic information. In fact, patients with recent myocardial infarction and a positive electrocardiogram (decreases ST greater than or equal to 1 mm) during atrial pacing more frequently than others present subsequent major cardiac events. Limitations of traditional pacing test (invasivity, poor sensitivity of electrocardiography) can be overcome with a new test we have recently proposed: two-dimensional echocardiography during atrial pacing. We have used this new stress test to detect patients with significant coronary artery disease, to identify patients with myocardial infarction and multivessel disease and to evaluate the effect of coronary artery bypass surgery.

Fournier's gangrene following a perianal abscess

Fournier's disease is an uncommon form of gas gangrene involving the scrotum and perineum. Described by Fournier as an idiopathic condition, it must be recognized as a synergistic gangrene secondary, in most cases, to a focus of perianal infection. Urinary tract infection and local trauma follow as possible causal factors. Five cases complicating a perianal abscess observed in a period of 11 years have been treated with urgent aggressive surgical debridement and intensive care support. Full-thickness skin grafts were required in three patients. Hospital mortality occurred in one case. Although combination antibiotic therapy and correct postoperative wound management are potentially successful, the mainstay of treatment is complete excision of all necrotic tissue. Colostomy and urinary diversion are not mandatory. Treatment with hyperbaric oxygen is controversial.

Comparison of postexercise and transesophageal atrial pacing two-dimensional echocardiography for detection of coronary artery disease

Two-dimensional (2-D) echocardiography during transesophageal atrial pacing (TAP) was recently proposed as an alternative to exercise 2-D echocardiography for the diagnosis of coronary artery disease (CAD). To compare these 2 methods, 78 consecutive patients with good-quality echocardiographic (echo) examinations at rest were studied. Two-dimensional echocardiography was performed immediately after supine bicycle exercise and at peak atrial pacing obtained with transesophageal atrial stimulation. Twenty patients were excluded: 16 because of poor quality of 2-D echo images after exercise and 4 because of inadequate TAP studies (atrial capture not achieved in 2 and intolerance in 2). Of the remaining 58 patients, 39 had significant CAD (at least 75% diameter stenosis of at least 1 major coronary artery) and 19 had no significant CAD. The 2 test responses were considered positive if a wall motion abnormality was detected during pacing or after exercise. Sensitivity and specificity were 82% and 95% after exercise and 90% and 84% during TAP. In patients with significant CAD but without wall motion abnormalities at rest, sensitivity was 75% during pacing and 56% after exercise. In patients with significant CAD, the wall motion score index decreased significantly with both types of stress; during pacing wall motion score index was significantly lower than after exercise. Thus, 2-D echo during TAP appears to be a feasible and reliable alternative to postexercise echo for the detection of CAD.