The "double-fired" gastro-jejunostomy as a form of improved efficiency during Whipple procedure

BACKGROUND

Gastro-jejunostomy (GJ) after pylorus-resecting pancreatoduodenectomy (PD) is most commonly performed in a hand-sewn fashion. Intestinal stapled anastomosis are reported to be as effective as hand-sewn in terms of patency and risk of leakage in other indications. However, the use of a stapled gastro-jejunostomy hasn't been fully assessed in PD. The aim of the present technical report is to evaluate functional outcomes of stapled GJ during PD, its associated effect on operative time and related complications.

METHODS

The institutional database for pancreatic duct adenocarcinoma (PDAC) was retrospectically reviewed. Pylorus resecting open PD without vascular or multivisceral resections were considered for the analysis. The incidence of clinically significant delayed gastric emptying (DGE from the International Stufy Group of Pancreatic Surgery (ISGPS) grade B and C), other complications, operative time and overall hospitalization were evaluated.

RESULTS

Over a 10-years study period, 1182 PD for adenocarcinoma were performed and recorded in the database. 243 open Whipple procedures with no vascular and with no associated multivisceral resections were available and constituted the study population. Hand-sewn (HS) anastomosis was performed in 175 (72 %), stapled anastomosis (St) in 68 (28 %). No significant differences in baseline characteristics were observed between the two groups, with the exception of a higher rate of neoadjuvant chemotherapy in the HS group (74 % St vs. 86 % HS, p = 0.025). Intraoperatively, a significantly reduced median operative time in the St group was observed (248 min St vs. 370 mins HS, p < 0.001). Post-operatively, rates of clinically relevant delayed gastric emptying (7 % St vs. 14 % HS, p = 0.140), clinically relevant pancreatic fistula (10 % St, 15 % HS, p = 0.300), median length of stay (7 days for each group, p = 0.289), post-pancreatectomy hemorrhage (4.4 % St vs. 6.3 % HS, p = 0.415) and complication rate (22 % St vs. 34 % HS, p = 0.064) were similar between groups. However, readmission rates were significantly lower after St GJ (13.2 % St vs 29.7 % HS, p = 0.008).

CONCLUSION

Our results indicate that a stapled GJ anastomosis during a standard Whipple procedure is non-inferior to a hand-sewn GJ, with a comparable rate of DGE and no increase of gastrointestinal related long term complications. Further, a stapled GJ anastomosis might be associated with reduced operative times.

Priority setting in the German healthcare system: results from a discrete choice experiment

Worldwide, social healthcare systems must face the challenges of a growing scarcity of resources and of its inevitable distributional effects. Explicit criteria are needed to define the boundaries of public reimbursement decisions. As Germany stands at the beginning of such a discussion, more formalised priority setting procedures seem in order. Recent research identified multi-criteria decision analysis (MCDA) as a promising approach to inform and to guide decision-making in healthcare systems. In that regard, this paper aims to analyse the relative weight assigned to various criteria in setting priority interventions in Germany. A discrete choice experiment (DCE) was employed in 2015 to elicit equity and efficiency preferences of 263 decision makers, through six attributes. The experiment allowed us to rate different policy interventions based on their features in a composite league table (CLT). As number of potential beneficiaries, severity of disease, individual health benefits and cost-effectiveness are the most relevant criteria for German decision makers within the sample population, the results display an overall higher preference towards efficiency criteria. Specific high priority interventions are mental disorders and cardiovascular diseases.

Standardising policy and technology responses in the immediate aftermath of a pandemic: a comparative and conceptual framework

BACKGROUND

The initial policy response to the COVID-19 pandemic has differed widely across countries. Such variability in government interventions has made it difficult for policymakers and health research systems to compare what has happened and the effectiveness of interventions across nations. Timely information and analysis are crucial to addressing the lag between the pandemic and government responses to implement targeted interventions to alleviate the impact of the pandemic.

METHODS

To examine the effect government interventions and technological responses have on epidemiological and economic outcomes, this policy paper proposes a conceptual framework that provides a qualitative taxonomy of government policy directives implemented in the immediate aftermath of a pandemic announcement and before vaccines are implementable. This framework assigns a gradient indicating the intensity and extent of the policy measures and applies the gradient to four countries that share similar institutional features but different COVID-19 experiences: Italy, New Zealand, the United Kingdom and the United States of America.

RESULTS

Using the categorisation framework allows qualitative information to be presented, and more specifically the gradient can show the dynamic impact of policy interventions on specific outcomes. We have observed that the policy categorisation described here can be used by decision-makers to examine the impacts of major viral outbreaks such as SARS-CoV-2 on health and economic outcomes over time. The framework allows for a visualisation of the frequency and comparison of dominant policies and provides a conceptual tool to assess how dominant interventions (and innovations) affect different sets of health and non-health related outcomes during the response phase to the pandemic.

CONCLUSIONS

Policymakers and health researchers should converge toward an optimal set of policy interventions to minimize the costs of the pandemic (i.e., health and economic), and facilitate coordination across governance levels before effective vaccines are produced. The proposed framework provides a useful tool to direct health research system resources and build a policy benchmark for future viral outbreaks where vaccines are not readily available.

Supply-side solutions targeting demand-side characteristics: causal effects of a chronic disease management program on adherence and health outcomes

We estimate the effects of a chronic disease management program (CDMP) which adapts various supply-side interventions to specific demand-side conditions (disease-staging) for patients with chronic kidney disease (CKD). Using a unique dataset on the entire population of the Emilia-Romagna region of Italy with hospital-diagnosed CKD, we estimate the causal effects of the CDMP on adherence indicators and health outcomes. As CKD is a progressive disease with clearly-defined disease stages and a treatment regimen that can be titrated by disease severity, we calculate dynamic, severity-specific, indicators of adherence as well as several long-term health outcomes. Our empirical work produces statistically significant and sizeable causal effects on many adherence and health outcome indicators across all CKD patients. More interestingly, we show that the CDMP produces larger effects on patients with early-stage CKD, which is at odds with some of the literature on CDMP that advocates intensifying interventions for high-cost (or late-stage) patients. Our results suggest that it may be more efficient to target early-stage patients to slow the deterioration of their health capital. The results contribute to a small, recent literature in health economics that focuses on the marginal effectiveness of CDMPs after controlling either for supply- or demand-side sources of heterogeneity.

Comparing risk adjustment estimation methods under data availability constraints

The Italian National Healthcare Service relies on per capita allocation for healthcare funds, despite having a highly detailed and wide range of data to potentially build a complex risk-adjustment formula. However, heterogeneity in data availability limits the development of a national model. This paper implements and ealuates machine learning (ML) and standard risk-adjustment models on different data scenarios that a Region or Country may face, to optimize information with the most predictive model. We show that ML achieves a small but generally statistically insignificant improvement of adjusted R² and mean squared error with fine data granularity compared to linear regression, while in coarse granularity and poor range of variables scenario no differences were observed. The advantage of ML algorithms is greater in the coarse granularity and fair/rich range of variables set and limited with fine granularity scenarios. The inclusion of detailed morbidity- and pharmacy-based adjustors generally increases fit, although the trade-off of creating adverse economic incentives must be considered.

The SMART-ALPPS Protocol: Strategy to Minimize ALPPS Risks by Targeting Invasiveness

BACKGROUND

The range of procedures with documented feasibility by laparoscopic approach is widening in the setting of liver resections. Many technical limits have been overcome in the attempt to reduce the biological impact of major procedures [1-8]. Similarly, associated liver partition and portal vein ligation for staged hepatectomy (ALPPS)-which could be assumed as the paradigm of maxi-invasiveness-has recently been proposed in a minimally invasive fashion to reduce the impact of this procedure [9-12]. Technical insights to perform laparoscopic ALPPS are provided.

METHODS

Perioperative and intraoperative tips for laparoscopic ALPPS are provided within a SMART (Strategy to Minimize ALPPS Risks by Targeting invasiveness) protocol. Stage 1: After volumetric and functional assessment, partial liver transection is performed, keeping intact both the hilum and the caval plane (to prevent adhesions), therefore avoiding portal ligation. No inert material is left inside the abdominal cavity at the end of procedure to keep the liver surfaces apart. Radiologic portography with portal vein embolization is scheduled on postoperative day (POD) 1. Liver volume (pre-PVE: 29%; post-PVE: 52%) and liver function measured through a Technetium-99 hepatobiliary scintigraphy [13] (pre-PVE: 2.15%/min/sqm; post-PVE: 3.67%/min/sqm) of the future remnant liver are reassessed within 10 days to verify whether size and function are adequate. Stage 2: After 2 weeks from the first stage, laparoscopic right hepatectomy is performed following an anterior approach.

RESULTS

No conversion to open was required. Operative time was 100 and 300 minutes for stage 1 and 2, respectively. Intraoperative blood loss was 50 and 300 ml for the two procedures. Postoperative course was uneventful; patient was discharged on POD 6 of the second operation.

CONCLUSIONS

The implementation of a perioperative protocol to prevent the risk of liver failure by both assessing volume and function of FLR and targeting the invasiveness of the surgical procedure may allow to minimize and control risks of a maximally invasive procedure, such as ALPPS.

Disease management in diabetes care: When involving GPs improves patient compliance and health outcomes

Although the study of the association between interventions in primary care and health outcomes continues to produce mixed findings, programs designed to promote the greater compliance of General Practitioners and their diabetic patients with guidelines have been increasingly introduced worldwide, in an attempt to achieve better quality diabetes care through the enhanced standardisation of patient supervision. In this study, we use clinical data from the Diabetes Register of one large Local Health Authority (LHAs) in Italy's Emilia-Romagna Region for the period 2012-2015. Firstly, we investigate whether GPs' participation in the local Diabetes Management Program (DMP) leads to improved patient compliance with regional guidelines. Secondly, we test whether the monitoring activities prescribed for diabetics by the Regional diabetes guidelines have a positive impact on patients' health outcomes and increase appropriateness in health care utilization. Our results show that such a Program, which aims to increase GPs' involvement and cooperation in following the Regional guidelines, achieves its goal of improved patient compliance with the prescribed actions. In turn, through the implementation of the DMP and the greater involvement of physicians, Regional policies have succeeded in promoting better health outcomes and improved appropriateness of health care utilization.

Metronomic chemotherapy for advanced breast cancer patients in the real world practice: Final results of the VICTOR-6 study

Metronomic chemotherapy (mCHT) refers to the minimum biologically effective dose of a chemotherapy agent given as a continuous dosing regimen, with no prolonged drug-free breaks, that leads to antitumor activity. Aim of the present study is to describe the use of mCHT in a retrospective cohort of metastatic breast cancer (MBC) patients in order to collect data regarding the different types and regimens of drugs employed, their efficacy and safety. Between January 2011 and December 2016, data of 584 metastatic breast cancer patients treated with mCHT were collected. The use of VRL-based regimens increased during the time of observation (2011: 16.8% - 2016: 29.8%), as well as CTX-based ones (2011: 17.1% - 2016: 25.6%), whereas CAPE-based and MTX-based regimens remained stable. In the 1st-line setting, the highest ORR and DCR were observed for VRL-based regimens (single agent: 44% and 88%; combination: 36.7% and 82.4%, respectively). Assuming VRL-single agent as the referee treatment (median PFS: 7.2 months, 95% CI: 5.3-10.3), the longest median PFS were observed in VRL-combination regimens (9.5, 95%CI 88.8-11.3, HR = 0.72) and in CAPE-single agent (10.7, 95%CI 8.3-15.8, HR = 0.70). The VICTOR-6 study provides new data coming from the real-life setting, by adding new information regarding the use of mCHT as an option of treatment for MBC patients.

Theory of Relativity for Posterosuperior Segments of the Liver

BACKGROUND

The accessibility to posterosuperior segments of the liver has traditionally constituted a restrain to adopt the laparoscopic approach in this setting. To overcome this challenge, multiple approaches have been reported in literature. Total transabdominal approach has been previously described for this purpose, even though the rationale to standardly adopt it and a technical depiction of how to achieve an optimal mobilization has never been specifically addressed.

METHODS

Total transabdominal purely laparoscopic approach to posterosuperior segments of the liver is presented, with detailed emphasis to the rotational motions targeted in laparoscopy. A literature review is presented to summarize all other possible accesses to posterosuperior area of the liver. The institutional series for the laparoscopic approach to Sg 7, Sg 6+7, and Sg8 is retrospectively described.

RESULTS

Three rotational motions of the liver are specifically addressed in a video presentation and described for the laparoscopic total-transabdominal approach; the local institutional series using this approach is presented. Other miscellaneous approaches identified from literature encompassing variations in operative position, transabdominal, transthoracic, and combined approaches are described.

CONCLUSIONS

Complete mobilization of the ligaments of the liver leads to a rotation of the transection line in front of the operator's view, allowing to achieve a safe total trans-abdominal laparoscopic approach to the posterosuperior ligaments of the liver, without compromising the vascular inflow control, the possibility to convert to open approach, nor requiring potentially harmful decubitus.

Intra-Arterial Hepatic Carboplatin-Based Chemotherapy for Ocular Melanoma Metastatic to the Liver. Report of a Phase II Study

Aims and Background

ocular melanoma tends to metastasize to the liver, sparing for a long time the rest of the organism. Therefore, a regional treatment is especially indicated.

Methods

eight patients with ocular melanoma metastatic to the liver were treated with intraarterial hepatic carboplatin-based chemotherapy at the dose of 300 mg/m2 once every two weeks at an outpatient clinic. All the patients were submitted to laparotomy with surgical implantation of an arterial port device through the gastroduodenal artery.

Results

the overall response rate was 38% with a median survival time of 15 months. The regimen was well tolerated and the principle toxicity was myelosuppression; any instance of hepatic and/ or cholangitic damage was reported.

Conclusions

Carboplatin seems suitable for intraarterial hepatic chemotherapy and active in ocular melanoma metastic to the liver.

Hepatoma Today: Therapeutic Experiences of Multimodal Approach

Aims and Background

Hepatocellular carcinoma (HCC) ranks third of cancer deaths in China, it kills 100,000 patients every year. In Italy HCC is an increasing malignant tumor and kills about 7000 patients every year. Fortunately, due to a multimodal approach to the treatment of this fatal disease, HCC has been changed from « Incurable » to « partly curable ». The authors report and comment the methods and the strategies that have been used to increase the cure-rate of HCC.

Methods

The actual approaches, developed in the last thirty years mainly in China, included: screening of cirrhotic patients, early resection, new surgical criteria for cirrhotic liver, early detection of subclinical recurrence and re-resection, multimodality treatment for cytoreduction of huge HCC, sequential resection after cytoreduction of unresectable HCC, targeting therapy using radiolabelled antibodies and lipiodol, transarterial embolization, radiotherapy combined with Chinese herbs, other regional cancer therapy and biological response modifiers.

Results

Are that these methods have reached a marked increase series 5-year survival rate and number of 5-year survivors in more expert institutions.

Conclusions

We conclude that further biological and genetic studies on HCC are warranted and that it is mandatory to perform large clinical randomized trials comparing the more promising treatments.

Cyclophosphamide, Methotrexate, 5-Fluorouracil, Alternating with Adriamycin and Mitomycin C in Metastatic Breast Cancer: A Pilot Study

To explore the clinical applicability of the Goldie and Coldman hypothesis, we treated 28 patients with metastatic breast cancer with alternating non-cross-resistant chemotherapy. The patients received cyclophosphamide, 600 mg/m2, 5-fluorouracil, 600 mg/m2, methotrexate, 40 mg/m3, alternated every three weeks with adriamycin, 60 mg/m2, and mitomycin C, 10 mg/m2. Only one patient had previously received palliative chemotherapy. Six patients had received adjuvant CMF, and 17 patients had been pretreated with endocrine therapy (13 for advanced disease, 4 as adjuvant). Fourteen patients had bone involvement, and 10 had visceral metastases. A mean of 12 cycles was given to 24 evaluable patients. The objective response rate was 67%: 11 patients (46%) achieved complete and 5 (21%) partial remission. Response rate in soft tissues was 83.3%, in bone 50%, in liver 100%, and in lung 80%. The median duration of response was 14 months, with 7 patients still in remission. No life-threatening toxicity was observed. Our preliminary results support the validity of this approach and the efficacy of this combination chemotherapy. A large-scale randomized study is warranted.

Irinotecan Hepatic Arterial Infusion Chemotherapy for Hepatic Metastases from Colorectal Cancer: Results of a Phase I Clinical Study

Background

Hepatic arterial infusion chemotherapy is a promising approach in liver metastases from colorectal cancer, but chemical hepatitis, biliary sclerosis, arterial thrombosis and right upper quadrant pain are limiting factors. Irinotecan (CPT-11) is an active drug in colorectal cancer. We planned a short hepatic arterial infusion of CPT-11 to describe the toxicity, to determine the dose-limiting toxicity, and to define the doses of CPT-11 to be recommended for phase II studies.

Patients and Methods

Fourteen patients with a median liver substitution of 30% (10-60%) were enrolled. All patients received hepatic arterial infusion chemotherapy with CPT-11 on an outpatient basis every 3 weeks as a short, 30-min infusion.

Results

At 240 mg/m2, 2 of 4 patients experienced grade 4 diarrhea and neutropenia, and 3 of them also reported grade 4 abdominal pain of the right upper quadrant. The maximum tolerated dose was reached at 240 mg/m2. The recommended doses of CPT-11 for phase II studies is 200 mg/m2, given every 3 weeks.

Conclusions

CPT-11 presents a low hepatic toxic profile and could be considered a new active drug, suitable for hepatic arterial infusion in liver metastases from colorectal cancer.

Tips and Tricks for a Laparoscopic Approach to Paracaval Liver Segments

BACKGROUND

A dramatic spread of laparoscopic liver surgery has been experienced over the last years. The approach to paracaval liver segments 1 and 9 is still poorly described in literature, mainly due to its technical demands.

OBJECTIVE

The aim of this article was to introduce a safe and effective approach to paracaval liver segments through laparoscopy.

METHODS

A minimally invasive approach to resection of Segments 1 and 9 is presented, and an operative set-up is depicted. A step-by-step technique describing the inferior vena cava (IVC) with left and right hepatic venous junction exposure, segmental pedicle isolation, and parenchymal transection is shown through a video document.

RESULTS

Postoperative courses were uneventful, and patients were discharged on postoperative day 3.

DISCUSSION

The approach to paracaval liver segments requires accurate preoperative case selection, technical, surgical, and anesthesiological expertise in laparoscopic liver surgery, and adequate instrumentary.

CONCLUSION

Paracaval segments of the liver can be approached safely through laparoscopy by teams with extensive expertise in the field of laparoscopic liver surgery; however, suspected malignant infiltration of the IVC or unclear preoperative anatomy still contraindicate this approach.

How do hospital-specialty characteristics influence health system responsiveness? An empirical evaluation of in-patient care in the Italian region of Emilia-Romagna

Studies of health system responsiveness mostly focus on the demand side by investigating the association between sociodemographic characteristics of patients and their reported level of responsiveness. However, little is known about the influence of supply-side factors. This paper addresses that research gap by analysing the role of hospital-specialty characteristics in explaining variations in patients' evaluation of responsiveness from a sample of about 38,700 in-patients treated in public hospitals within the Italian Region of Emilia-Romagna. The analysis is carried out by adopting a 2-step procedure. First, we use patients' self-reported data to derive 5 measures of responsiveness at the hospital-specialty level. By estimating a generalised ordered probit model, we are able to correct for variations in individual reporting behaviour due to the health status of patients and their experience of being in pain. Second, we run cross-sectional regressions to investigate the association between patients' responsiveness and potential supply-side drivers, including waiting times, staff workload, the level of spending on non-clinical facilities, the level of spending on staff education and training, and the proportion of staff expenditure between nursing and administrative staff. Results suggest that responsiveness is to some extent influenced by the supply-side drivers considered.

Enteric methane emissions, intake, and performance of young Nellore bulls fed different sources of forage in concentrate-rich diets containing crude glycerine

Forty young Nellore bulls were used to determine the effects of different sources of forage in concentrate-rich diets containing crude glycerine on feed intake, performance, and enteric methane emissions. Ten animals (397 ± 34 kg and 20 ± 2 months of age) were slaughtered to estimate the initial carcass weights, and the remaining 30 animals (417 ± 24.7) were randomly assigned to three treatments with 10 replicates. The treatments consisted of three different sources of forage [NDF from forage (fNDF) was fixed 15% of dry matter]; corn silage, sugarcane, and sugarcane bagasse; in diets rich in concentrates with 10% dry matter crude glycerine. There were no differences in the intake of dry matter, organic matter, crude protein, neutral detergent fibre, gross energy, or metabolisable energy. No effects of the type of forage were observed on performance or enteric methane emissions. These results suggest that alternatives to corn silage that have high fibre content, such as sugarcane and sugarcane bagasse, do not significantly affect the intake, performance, or enteric methane emissions of young Nellore bulls.

Decision Making and Priority Setting: The Evolving Path Towards Universal Health Coverage

Health technology assessment (HTA) is widely viewed as an essential component in good universal health coverage (UHC) decision-making in any country. Various HTA tools and metrics have been developed and refined over the years, including systematic literature reviews (Cochrane), economic modelling, and cost-effectiveness ratios and acceptability curves. However, while the cost-effectiveness ratio is faithfully reported in most full economic evaluations, it is viewed by many as an insufficient basis for reimbursement decisions. Emotional debates about the reimbursement of cancer drugs, orphan drugs, and end-of-life treatments have revealed fundamental disagreements about what should and should not be considered in reimbursement decisions. Part of this disagreement seems related to the equity-efficiency tradeoff, which reflects fundamental differences in priorities. All in all, it is clear that countries aiming to improve UHC policies will have to go beyond the capacity building needed to utilize the available HTA toolbox. Multi-criteria decision analysis (MCDA) offers a more comprehensive tool for reimbursement decisions where different weights of different factors/attributes can give policymakers important insights to consider. Sooner or later, every country will have to develop their own way to carefully combine the results of those tools with their own priorities. In the end, all policymaking is based on a mix of facts and values.

Competitive Health Markets and Risk Equalisation in Australia: Lessons Learnt from Other Countries

The aims of this paper are to evaluate the risk equalisation (RE) arrangement in Australia's private health insurance against practices in other countries with similar arrangements and to propose ways of improving the system to advance economic efficiency and solidarity. Possible regulatory responses to insurance market failures are reviewed based on standard economic arguments. We describe various regulatory strategies used elsewhere to identify essential system features against which the Australian system is compared. Our results reveal that RE is preferred over alternative regulatory strategies such as premium rate restrictions, premium compensation and claims equalisation. Compared with some countries' practices, the calculated risk factors in Australia should be enhanced with further demographic, social and economic factors and indicators of long-term health issues. Other coveted features include prospective calculation and annual clearing of equalisation payments. Australia currently operates with a crude mechanism for RE in which the scheme incentivises insurers to select on risk rather than focusing on efficiency and equity-promoting actions. System changes should be introduced in a stepwise manner; thus, we propose an incremental reform.

Price Changes in Regulated Healthcare Markets: Do Public Hospitals Respond and How?

This paper examines the behaviour of public hospitals in response to the average payment incentives created by price changes for patients classified in different diagnosis-related groups (DRGs). Using panel data on public hospitals located within the Italian region of Emilia-Romagna, we test whether a 1-year increase in DRG prices induced public hospitals to increase their volume of activity and whether a potential response is associated with changes in waiting times and/or length of stay. We find that public hospitals reacted to the policy change by increasing the number of patients with surgical treatments. This effect was smaller in the 2 years after the policy change than in later years, and for providers with a lower excess capacity in the pre-policy period, whereas it did not vary significantly across hospitals according to their degree of financial and administrative autonomy. For patients with medical DRGs, instead, there appeared to be no effect on inpatient volumes. Our estimates also suggest that an increase in DRG prices had no impact on the proportion of patients waiting more than 6 months. Finally, we find no evidence of a significant effect on patients' average length of stay. Copyright © 2016 John Wiley & Sons, Ltd.

Different forms and frequencies of soybean oil supplementation do not alter rumen fermentation in grazing heifers

Over the productive cycle, the performance of cattle in grazing systems may be compromised, and feed supplementation is a strategy to establish nutritional balance and maximise the performance of grazing animals. The objective of this study was to evaluate the effect of different supplementation frequencies (i.e. daily supplementation (DS) versus Monday, Wednesday and Friday (MWF)) with different forms of soybean oil (i.e. soybean grain (SG), soybean oil (SO) and rumen-protected fat (RPF)) on the nutrient digestion and rumen fermentation of heifers grazing Brachiaria brizantha cv. Marandu pastures. Twelve crossbred heifers (1/4 Nellore × 1/4 Santa Gertrudis × 1/2 Braunvieh) with an initial bodyweight of 236.3 ± 27.6 kg were distributed in a completely randomised design with a factorial arrangement 3 × 2 (three diets and two supplementation frequencies). There was no interaction among the SO form or supplementation frequency on dry matter intake and dry matter digestibility (P > 0.05). The animals supplemented with SG exhibited lower nitrogen intake and absorption compared with animals that were fed SO (P < 0.05). The efficiency of microbial synthesis was not influenced by the diet or supplementation frequency (P > 0.05). Forms of SO affected the rumen pH; animals fed SO showed pH values similar to those of animals receiving SG but lower values than animals fed RPF (P < 0.05). Animals supplemented with DS exhibited higher levels of rumen ammonia nitrogen relative to those supplemented MWF. The reduction of supplementation frequency (from DS to MWF k) in our experimental conditions can be used to increase the efficiency of pasture utilisation without effects in fermentation activity of the rumen microbial population. Supplementation with SO is a strategy to increase propionic acid concentration and reduce A : P ratio, which is an indicator of improvement of the efficiency of the ruminal energy utilisation.

Impact of ground soybean and starch levels on the quality of meat from feedlot young Nellore bulls

Twenty-eight young Nellore bulls (395±32kg initial body weight) were assigned to a completely randomized design (2×2 factorial design with 7 animals per treatment) to evaluate effects on the quality of meat. Diet treatments consisted of high (about 25%) or low (about 16%) starch levels, with or without ground soybean addition. Shear force was decreased in the meat from animals fed a low-starch diet (P=0.0016). Meat from animals fed a high-starch diet had increased total concentrations of unsaturated (P=0.0029) and monounsaturated fatty acids (P=0.0253). Polyunsaturated fatty acid content increased in the meat from animals fed a diet containing soybean (P=0.0121). High starch diets (>25%) decreased the concentration of saturated fatty acids and increased the amount of unsaturated fatty acids in the meat from young Nellore bulls.

Chemoresistant Myeloma: Phase II Clinical Study with Low-Dose Thalidomide Plus High-Dose Dexamethasone

Thalidomide produces a response rate from 32 to 66% of pre-treated myeloma patients with doses ranging from 100 to 800 mg/daily. Common, dose-related side effects are sedation, constipation, polyneuropathy. Increased incidence of thromboembolic events were observed in myeloma patients receiving thalidomide as front-line therapy or in association with chemotherapy. Less common adverse reactions are central nervous system (CNS) dysfunction and cutaneous reactions. We describe the update of our experience with low dose thalidomide plus monthly high dose dexamethasone and zolendronate. Most patients were able to tolerate this regimen with few side effects. Erythrocyte sedimentation rate (ESR) lowering was early observed in patients who subsequently responded.

Thoracic Stop-Flow Perfusion in the Treatment of Refractory Non Small Cell Lung Cancer

This study was undertaken to determine the survival of patients with unresectable and refractory non small cell lung cancer (NSCLC) submitted to thoracic stop-flow perfusion (TSP). Forty-five patients with NSCLC confined to thoracic region entered the study. All 45 patients had been pretreated with some form of chemotherapy and had progression of disease. The cytostatic regimen was mitomycin 10 mg/m2, navelbine 25 mg/m2 and cisplatin 60 mg/m2. In 39/45 patients, immediately after TSP, hemofiltration was performed to reduce systemic side effects There were 16/45 responses to the first TSP (CR 0; PR 16): a response rate of 35.6%. Median time to progression was 4 months. Median survival was 7.5 months.1-year survival rate was 36.4%, 2-year survival rate was 14%, and 3-year survival rate was 5.7%.

Dealing with minor illnesses: The link between primary care characteristics and Walk-in Centres' attendances

The reformulation of existing boundaries between primary and secondary care, in order to shift selected services traditionally provided by Emergency Departments (EDs) to community-based alternatives, has determined a variety of organisational solutions. One innovative change has been the introduction of fast-track systems for minor injuries or illnesses, whereby community care providers are involved in order to divert patients away from EDs. These facilities offer an open-access service for patients not requiring hospital treatments, and may be staffed by nurses and/or primary care general practitioners operating within, or alongside, the ED. To date little research has been undertaken on such experiences. To fill this gap, we analyse a Walk-in Centre (WiC) in the Italian city of Parma, consisting of a minor injury unit located alongside the teaching hospital's ED. We examine the link between the utilisation rates of the WiC and primary care characteristics, focusing on the main organisational features of the practices and estimating panel count data models for 2007-2010. Our main findings indicate that the extension of practice opening hours significantly lowers the number of attendances, after controlling for General Practitioner's and practice's characteristics.

Effect of lipid sources with different fatty acid profiles on the intake, performance, and methane emissions of feedlot Nellore steers

The present study was conducted to evaluate the effect of lipids with different fatty acid profiles on the intake, performance, and enteric CH4 emission of Nellore steers. A total of 45 Nellore animals with an average initial BW of 419 ± 11 kg (at 15 ± 2 mo) were distributed in a completely randomized design consisting of 5 treatments and 9 replicates. The roughage feed was maize silage (600 g/kg on a DM basis) plus concentrate (400 g/kg on a DM basis). The dietary treatments were as follows: without additional fat (WF), palm oil (PO), linseed oil (LO), protected fat (PF; Lactoplus), and whole soybeans (WS). The lipid source significantly affected (P < 0.05) nutrient intake. The greatest intakes of DM, OM, and CP were observed in the animals that were fed the WF or PF diets, and the lowest intakes were observed in the animals that were fed the PO diet. Intake of NDF decreased (P < 0.05) with the addition of PO. Enteric methane emission (g/kg DMI) was reduced by an average of 30% when the animals were fed diets containing WS, LO, and PO (P < 0.05), and these diets caused a larger reduction in the energy loss in the form of methane compared to those without added fat and with added PF (3.3 vs. 4.7%). The different fatty acid profiles did not affect the backfat thickness or the loin eye area of the animals (P > 0.05). However, animals fed PO displayed lower daily weight gain (0.36 kg/d), feed efficiency (0.08 kg ADG/kg DM), HCW (245 kg), and hot yield percentage (52.6%) compared to animals that were fed the other diets. Therefore, PO compared to the other lipid sources used in this study reduces intake, performance, feed efficiency, and carcass yield. Therefore, PO is not suggested for feedlot-finished animals.

Abstract P3-14-16: A phase 2 trial of myocet®, cyclophosphamide +/- trastuzumab followed by weekly paclitaxel +/- trastuzumab as primary systemic therapy in operable and locally advanced breast cancer

BACKGROUND: Anthracycline- and taxane-based chemotherapies are highly effective in primary systemic treatment of breast cancer (BC). Myocet® (M) is a non-pegylated liposomal doxorubicin exhibiting reduced cardiotoxicity as compared to doxorubicin. Combination of M and cyclophosphamide (C) has demonstrated efficacy in first line treatment of metastatic BC, however few data are available in neoadjuvant setting, especially in combination with trastuzumab (T). The aims of the study were activity, in terms of pathological complete response (pCR; ie, no remaining invasive tumor in breast and lymphnodes) and safety of a sequential schedule of M and C +/- T followed by weekly paclitaxel (P) +/- T. METHODS: Estrogen receptor (ER), progesterone receptor (PgR), HER2 positivity (defined as 3+ overexpression by immunoistochemical testing or HER2 amplification by fluorescent in situ hybridisation) and Ki67 index were assessed in core needle biopsies at baseline and in residual tumour after chemotherapy. Patients with stage II/III BC received 4 cycles of MC (myocet 60 mg/m2, cyclophosphamide 600 mg/m2 on day 1 every 3 weeks), followed by 12 weekly doses of P (paclitaxel 80 mg/m2); all patients with HER2+ disease received T in combination with chemotherapy (trastuzumab loading dose of 8 mg/kg followed by 3 cycles of 6 mg/kg alongside MC; 2 mg/kg per week with the following 12 P administrations). RESULTS: 49 patients were enrolled, with 44 patients having completed chemotherapy and undergoing surgery to date. Median age was 56 years (range, 34 to 72). Tumour characteristics were as follows: stage IIA 10 patients, IIB 16, IIIA 13, IIIB 5, IIIC 1, and 4 patients with inflammatory BC; ER+/PgR+ 21 patients, ER+/PgR- 13, triple negative 8, HER2+ 16; Ki67&gt; 15% in 41 patients. Forty-four patients were evaluable for pathological response. pCR was obtained in 12 patients (27.3%). The rate of pCR in HER2+ and HER2- BC was 57.1% and 13.3%, respectively. Clinical response was obtained in 36 out of 41 clinically evaluable patients (87.8%): CR in 20 (48.8%) and PR in 16 (39%). Conservative surgery was performed in 16 patients (36.4%) and mastectomy in 28 (63.6%). The most frequently observed grade 3-4 AEs were: alopecia 47 patients (95.9%), grade 3 neutropenia 2 (4.1%), febrile neutropenia 2 (4,1%), grade 3 paresthesia 2 (4.1%), grade 3 vomiting 1 (2%), grade 3 cutaneous erythema 1 (2%). Only 1 patient experienced an asymptomatic decrease of ejection fraction lower than 50%. Five patients (10.2%) discontinued treatment with M+C because of: allergic reaction to M in 3 patients, grade 2 liver toxicity in 1 and grade 3 vomiting in 1. All of them completed the following treatment with P. Three patients (6.1%) discontinued P because of: allergic reaction in 1 patient, infectious pneumonia in 1 and grade 3 cutaneous erythema in 1. CONCLUSIONS: The use of M in this sequential anthracycline- and taxane-based regimen resulted tolerable even in combination with T and active despite of the high rate of patients with ER+ disease and with locally advanced cancer. Consistently with previous data, pCR was higher in patients with HER2+ BC.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-14-16.

Modulation of Vascular Endothelium by Imatinib: A Study on the EA.hy 926 Endothelial Cell Line

In this study the EA.hy 926 endothelial cell line--simulating endothelial cells--was treated with imatinib in order to define a possible anti-angiogenic role for imatinib. Dose and time response experiments were performed. Cell morphology was studied, while migration efficiency, intercellular permeability and VE-cadherin expression were assayed, both in the presence and in the absence of imatinib. Imatinib-induced EA.hy 926 cell apoptosis was also examined. Results showed that imatinib reduced the endothelial cell population, changed cell monolayer morphology and reduced cell-to-cell cohesiveness. Migration efficiency was significantly decreased while intercellular permeability was 2.76-fold increased in the presence of imatinib. Indirect immunofluorescence microscopy showed nearly complete down-regulation of VE cadherin in imatinib-treated cells. Furthermore, apoptotic activity was detected in imatinib-treated cells. Altogether our results support an antiangiogenic profile for imatinib that possibly contributes to its therapeutic potential.

Intra-Arterial Hepatic Chemoembolization in Liver Metastases from Neuroendocrine Tumors: A Phase II Study

Neuroendocrine tumors, particularly those of gastrointestinal tract origin, have a predisposition for metastasizing to the liver, causing parenchymal substitution and paraneoplastic syndrome. Lipiodol embolization combined with anticancer drugs is a recent tool in regional therapy. It has been proven that chemoembolization reduces tumor bulk and hormone levels, and that it palliates the symptoms of many patients with liver-dominant neuroendocrine metastases. Beginning in December 1988, ten patients with unresectable and chemotherapy-refractory liver metastatic neuroendocrine tumors were treated with chemoembolization based on a mixture of lipiodol, mitomycin, cisplatin, epirubicin, followed by gelfoam powder and contrast media. Toxicity encountered included: upper right quadrant pain requiring narcotics, elevation of lactate dehydrogenase, alkaline phosphatase, and transaminases. One patient had liver abscess and persistent fever for 2 weeks. We obtained two complete remissions lasting 12 and 34 months and 5 partial remissions. The median survival was 22 months. Four patients had urinary elevation of 5-hydroxyindolacetic acid (5-HIAA). They showed more than a 75% decrease in urinary secretion after treatment. In a patient with transplanted liver we noticed a partial response lasting 7 months. We conclude that chemoembolization will improve the clinical condition of a significant percentage of patients with liver metastases, that future therapy of carcinoid tumors will be based on specific tumor biology and that treatment will be customized for each individual patient combining the use of cytoreductive procedures including radiofrequency ablation, laser treatment and chemoembolization.

Ceravolo C, Miserocchi L, Mambrini A, Del Freo A, Zamagni D, Rabbi C, Marangolo M. Ceravolo

Gemcitabine is considered the gold standard treatment for unresectable pancreatic adenocarcinoma. Intra-arterial drug administration had shown some interesting results in small phase II studies. In this study, patients were randomly assigned to receive gemcitabine at a dose of 1,000 mg/m2 over 30 minutes intravenously weekly for 7 weeks, followed by 1 week of rest, then weekly for 3 weeks every 4 weeks or FLEC: 5-fluoruracil 1,000 mg/m2, leucovorin 100 mg/m2, epirubicin 60 mg/m2, carboplatin 300 mg/m2 infused bolus intra-arterially into celiac axis at a 3-week interval 3 times or 5-fluorouracil 400 mg/m2 plus folinic acid 20 mg/m2 for 5 days every 4 weeks for 6 cycles. The primary endpoint was overall survival, while time to treatment failure, response rate, clinical benefit response were secondary endpoints. Sixty-seven patients were randomly allocated gemcitabine and 71 were allocated FLEC intra-arterially. Patients treated with FLEC lived for significantly longer than patients on gemcitabine (p=0.036). Survival at 1 year increased from 21% in the gemcitabine group to 35% in the FLEC group. Median survival was 7.9 months in the FLEC group and 5.8 months in the gemcitabine group. Median time to treatment failure was longer with FLEC (5.3 vs 4.2 months for FLEC vs gemcitabine respectively; p=0.013). Clinical benefit was similar in both groups (17.9% for gemcitabine and 26.7% for FLEC; p=NS). CT-scan partial response was similar in both groups (5.9% for gemcitabine and 14% for FLEC; p=NS). Toxicity profiles were different. Compared with gemcitabine, the FLEC regimen given intra-arterially improved survival in patients with unresectable pancreatic adenocarcinoma.

First characterisation of natural radioactivity in building materials manufactured in Albania

This study focuses on the radiological characterisation of building materials manufactured in Albania by using a high-resolution gamma-ray spectrometer. The average activity concentrations of (40)K, (226)Ra and (232)Th were, respectively, 644.1±64.2, 33.4 ± 6.4 and 42.2 ± 7.6 Bq kg(-1) in the clay brick samples and 179.7 ± 48.9, 55.0 ± 5.8 and 17.0 ± 3.3 Bq kg(-1) in the cement samples. The calculated activity concentration index (ACI), varied from 0.48±0.02 to 0.63±0.04 in the clay brick samples and from 0.29±0.03 to 0.37±0.02 in the cement samples. Based on the ACI, all of the clay brick and cement samples were categorised as A1 materials. The authors can exclude (at 3σ level) any restriction of their use as bulk materials.