Molecular alterations in pancreatic tumors

Genetic alterations in pancreatic tumors can usually be classified in: (1) Mutational activation of oncogenes; (2) Inactivation of tumor suppressor genes; and (3) Inactivation of genome maintenance genes controlling the repair of DNA damage. Endoscopic ultrasound-guided fine-needle aspiration has improved pre-operative diagnosis, but the management of patients with a pancreatic lesion is still challenging. Molecular testing could help mainly in solving these “inconclusive” specimens. The introduction of multi-gene analysis approaches, such as next-generation sequencing, has provided a lot of useful information on the molecular characterization of pancreatic tumors. Different types of pancreatic tumors (e.g., pancreatic ductal adenocarcinomas, intraductal papillary mucinous neoplasms, solid pseudopapillary tumors) are characterized by specific molecular alterations. The aim of this review is to summarize the main molecular alterations found in pancreatic tumors.

Opioid free pain management in ambulatory hemorrhoidectomy reduces pain

Objective

Outpatient hemorrhoid surgery is a topic of growing importance with a need of modifications to pain management to enable early discharge. Opioid free anesthesia and analgesia (OFAA) has the goal to reduce postoperative pain as well as to improve discharge circumstances. The impact of OFAA on patients receiving ambulatory hemorrhoidectomy is investigated.

Methods

A retrospective cohort study on ambulatory hemorrhoidectomy between 2018 and 2020 was performed and patients that did and did not receive OFAA were compared. In the OFAA group patients received spinal anesthesia with Takipril and hyperbaric technique. Additionally Metamizole 500mg i.v. and Paracetamol 1g i.v. was used. In the non-OFAA group opioids were administered intravenously (fentanyl or remifentanyl) and sublingual (buprenorphin). Primary endpoint was pain measured according to a numeric rating scale (NRS) one hour postoperatively. Secondary endpoints were pain 24 hours postoperative, duration of hospital stay, urinary retention, postoperative nausea and vomiting (PONV), overall morbidity, and re-admission. Wilcoxon Rank-Sum test was performed to search for differences between the outcomes.

Results

117 patients were included in the analysis. 41 percent of the patients were female. The mean age was 54±14 years. 40 patients did not receive opioids perioperatively (OFAA group) and 77 did (non-OFAA group). The non-OFAA group received a mean dose of 23.3±17.9 mg morphine equivalent. Median NRS score one hour postoperatively was 0 (interquartile range 0-1) for OFAA and 2 (0-4) for non-OFAA (p = 0.01). The median NRS score 24 hours postoperatively was 1 (0-2) for OFAA and 1 (0-3) for non-OFAA (p = 0.40). There were 3 patients (7.5%) with urinary retention in OFAA and 5 patients (6.5%) in non-OFAA(p = 0.84).No patient had PONV in OFAA and 5 (6.5%) in non-OFAA (p = 0.10). The overall morbidity was 5 (12.5%) in OFAA and 16 (20.8%) in non-OFAA (p = 0.27). There were two readmissions (5%) in OFAA and 6 (7.8%) in non-OFAA (p = 0.58).

Conclusion

There is a significant difference in pain one hour postoperatively between OFAA and non-OFAA with a clear benefit of not administering opioids. Opioids may trigger pelvic floor spasms and disimprove postoperative pain. In the context of outpatient surgery, we recommend an opioid free operation to reduce postoperative pain and improve discharge prerequisites.

4252Additional value of stress testing for evaluation of ventricular arrhythmias in athletes undergoing preparticipation screening

Introduction

The optimal protocol of athletes pre-participation screening is a matter of debate. The aim of this study is to test the additional value of exercise testing (ET) for evaluation of ventricular arrhythmias (VA) in athletes with otherwise normal findings.

Methods

The study included 10,975 competitive athletes who underwent preparticipation screening including ECG and stress testing. Athletes with ≥3 isolated premature ventricular beats or ≥1 repetitive VA underwent second-line investigations (echocardiography and 24-hour ambulatory ECG monitoring with a training session) and, in case of frequent, complex or exercise-induced VA or echocardiographic abnormalities, also cardiac magnetic resonance (CMR).

Results

451 (4,1%) athletes were excluded for abnormalities at history, physical examination and baseline ECG. Among the remaining 10524 athletes, 524 (5%)showed VA at ET, 87 of whom underwent CMR.Echocardiography identified major cardiac abnormalities in 5 athletes and regional ventricular systolic dysfunction in 7, which were confirmed by CMR in 6. Other 12 patients with normal echocardiography had a positive CMR. In particular, in 16 subjects the CMR showed left ventricular late gadolinium enhancement suggesting myocardial fibrosis with a non-ischemic distribution. At multivariate analysis, VA observed at high work load at ET, the presence of complex VA at ET and the presence of a morphology other than infundibular or fascicular predicted an underlying pathological myocardial substrate while the presence of frequent (>500/24-hour) premature ventricular beats did not.

Predictors of underlying pathological myocardial substrate Substrate Univariate Multivariable YES (n=23) NO (n=501) OR (95% IC) P OR (95% IC) P Age 17 [13–43] 15 [14–17] 1.03 [0.98 -1.06] 0.18 – Male gender 15 (65%) 184 (37%) 3.2 [1.3–7.7] <0.001 1.6 [0.7–4.8] 0.28 >500 PVBs/24-hour 7 (30%) 98 (20%) 1.8 [0.7–4.5] 0.21 – VA at high work-load 10 (44%) 78 (16%) 4.2 [1.8–9.8] <0.001 1.6 [1.1–4.7] 0.02 Couplets/NSVT at ET 14 (61%) 117 (23%) 6.2 [2.5–15] <0.001 8.5 [2.5–29] 0.01 PVBs other than infundibular/fascicular 17 (74%) 118 (24%) 6.1 [2.4–16] <0.001 3.9 [1.4–11] 0.008

Conclusions

VA at ET may represent the only sign of a pathological myocardial abnormalities, such as the “isolated nonischemic left ventricular scar”, that could be the substrate for life-threatening ventricular arrhythmias. Addition of ET to baseline ECG may increase the sensitivity of PPE of competitive athletes.

ALPs effective field theory and collider signatures

We study the leading effective interactions between the Standard Model fields and a generic singlet CP-odd (pseudo-) Goldstone boson. Two possible frameworks for electroweak symmetry breaking are considered: linear and non-linear. For the latter case, the basis of leading effective operators is determined and compared with that for the linear expansion. Associated phenomenological signals at colliders are explored for both scenarios, deriving new bounds and analyzing future prospects, including LHC and High Luminosity LHC sensitivities. Mono-Z, mono-W, W-photon plus missing energy and on-shell top final states are most promising signals expected in both frameworks. In addition, non-standard Higgs decays and mono-Higgs signatures are especially prominent and expected to be dominant in non-linear realisations.

Coronary blood flow and myocardial O2 consumption in hypertrophied cardiac muscle in dogs

In dogs with experimental cardiac hypertrophy in resting conditions, coronary blood flow and myocardial O2 consumption increased proportionately to the cardiac mass; coronary flow and O2 consumption per gram of myocardium, therefore, ranged within normal values. The coronary reserve, neasured as the percentage increase in the coronary blood flow from rest till peak flow during reactive hyperaemia, was noticeably reduced, because it was partially utilized, even at rest, and consequently the possibility of an increase in flow after exercise or stress was diminished.

[Applications of digital radiology to pediatric uroradiology]

The authors report their 4 years' experience with a computerized digital radiographic system based on photostimulable phosphor plates which was used mostly in pediatric radiology. Major protection advantages were observed for uroradiology where high kV (90-95 kV) and very low exposure times (0.02-0.010s) were used. With this radiographic technique reduced exposure parallels increased graininess due to quantum mottle: the two variables must therefore be balanced not to decrease diagnostic accuracy. During our 4 years' experience, 368 examinations were performed on pediatric patients: 252 micturition cystourethographs, 81 urograms and 35 retrograde pyelographs. None of these examinations needed to be repeated due to over/under-exposure and image quality was always high, in spite of a light "noise". Digital radiography in pediatric urology allows radiation dose to be reduced and high quality images to be acquired and is therefore likely to take over conventional radiologic techniques.

Computed radiography in neonatal intensive care

The Authors report their experience in the employment of a computerized digital radiographic system in Neonatal Intensive Care. The analog screen-film system is replaced by photosensitive imaging plates, scanned after X-ray exposure by a laser that releases the digital image, which can then be manipulated on computer work-stations. In a period of twelve months about 200 chest-abdomen X-ray examinations in Neonatal Intensive Care have been performed using this method with good technical and diagnostic results. The use of digital radiography in the neonatal area is of high interest: this system produces good quality images, there is a reduction in radiation dose and 'retakes', the system allows selective enhancement of different structures and their magnification.

Diagnostic potential of double contrast arthrography of the knee with the digital technique

Experience with digital radiography applied to double contrast arthrography of the knee performed with a photostimulable phosphor plate is reported. The image processing technique used to improve the digital image is described, and some theoretical considerations are discussed. A preliminary comparison is also made between arthrographic images obtained with conventional screen-film systems and the digital system, especially in respect of the image quality and visualization of the soft tissue structures least well demonstrated with conventional arthrography.

Development of dopaminergic drugs for the chronic treatment of congestive heart failure

1. The search of orally active dopaminergic drugs for the chronic treatment of congestive heart failure has followed two different approaches. 2. On the one hand, a selective DA-1 receptor agonist, such as fenoldopam, has been investigated as an agent developed for the stimulation of vascular and tubular DA-1 receptors in the kidney. On the other hand, orally active prodrugs were synthetized with the aim of mimicking the full pattern of dopaminergic and adrenergic actions of intravenous dopamine. 3. Ibopamine, the diisobutyric ester of N-methyldopamine, has shown effects comparable to those of dopamine in various animal models and in clinical investigations. Furthermore, patients suffering from mild or severe congestive heart failure were shown to benefit from ibopamine treatment in a number of therapeutic trials. 4. Limited experience is currently available on other prodrugs, such as docarpamine and Sim 2055, i.e. the 4-0-phosphate ester of N-methyldopamine. The latter is an analogue of ibopamine designed for a preferential delivery of N-methyldopamine in the kidney. 5. Based upon some additional studies with levodopa, the results suggest that a combination of DA-1 and DA-2 agonistic activity is a desirable feature of a new drug, since it appears suitable to provide vasodilation while counteracting the neurohumoral abnormality of congestive heart failure.

[Digital radiography in neonatal intensive care]

The authors report their experience with the routinary use of a computerized digital radiography system in Intensive Neonatal Care department. The conventional screen-film system is replaced by photostimulable imaging plates, which are scanned during processing by a laser providing the digital image. The latter is subsequently processable on high-resolution monitors. Over a 6-month period 86 examinations were performed with this method in Intensive Neonatal Care; good technical results were obtained. The use of digital radiography in intensive neonatal care is extremely promising for it allows high-quality images to be obtained, and radiation dose and number of acquisitions to be reduced. Finally, work stations allow both selective visualization of different body structures and their magnification.

[Traditional and digital urography compared. The authors' own experience]

A computed radiographic system for generating and archiving digital radiographic images was employed in ivp. The system produces 2 digital images per exposure: the first one simulates a conventional radiograph, while the second enhances some spatial frequencies and emphasizes the structure borders. The conventional radiographs and the digital images of 50 patients submitted to ivp were reviewed by four experienced radiologists to evaluate their comparative quality, and the results were statistically analyzed. Digital images proved to be better than conventional radiographs for some of the selected parameters, especially in the evaluation of renal edges and sometimes for calyceal opacification. As for the other parameters, no statistically significant difference was observed between conventional radiographs and digital images.

[Double-contrast arthrography in meniscal pathology. Remarks on 1000 cases]

The authors performed a statistical study on a series of 1000 patients examined with double-contrast fluoroscopically-guided knee arthrography. Arthrographic diagnoses were compared with the arthrotomic (500 patients), arthroscopic (350 patients) or clinical diagnoses of 150 patients with a follow-up of 6 months. In this series of patients with a history of "recurrent meniscal injury", arthrographic diagnoses were confirmed in a high percentage of cases, with 96.9% accuracy, 96.7% sensitivity for tears, and 98.6% specificity. On the basis of these results the authors suggest double-contrast arthrography as an examination of considerable value in the diagnosis of meniscal lesions, while in their opinion arthroscopy should be limited to questionable cases, to complex lesions with involvement of multiple articular structure and to the alterations clearly treatable by arthroscopy.

Acute haemodynamic effects of ibopamine and dopamine on isovolumic relaxation

The effects of intraduodenal ibopamine (a new orally active inotropic agent claimed to have haemodynamic effects similar to dopamine) on isovolumic relaxation were monitored for 90 min in eight closed-chest anaesthetized dogs. Dopamine and epinine (ibopamine active metabolite) were also infused at graded doses. After 15 min, ibopamine (12 mg/kg) shortened the time constant of isovolumic relaxation, and increased stroke volume and mean aortic pressure. Peak positive dP/dt increased significantly only 10 min later. Heart rate did not change. Dopamine (10 micrograms/kg per min) similarly reduced the time constant, and increased stroke volume, mean aortic pressure, peak positive dP/dt and heart rate. Epinine (10 micrograms/kg per min) caused similar changes in peak positive dP/dt, stroke volume, mean aortic pressure, and accelerated time constant without raising the heart rate. Ibopamine and epinine therefore significantly improved the isovolumic relaxation phase, like dopamine, without however affecting the heart rate.

Conservative management of urinary abnormalities detected in utero

During a 5-year period, we observed 48 fetuses with urinary malformations diagnosed by antenatal sonography. Postnatal investigations confirmed the presence of a urinary tract anomaly in 44 of the 48 fetuses selected by prenatal ultrasound (91%). Accurate antenatal diagnosis was made in 35 of the 48 cases (73%). In 9 fetuses renal disease was detected, but its specific nature was not in accordance with the prenatal diagnosis. In our series the most common anomaly was hydronephrosis secondary to ureteropelvic junction obstruction. This condition was observed in 31 of the 44 patients (70.4%); 7 of the newborns who showed an obstructive pattern were submitted to early surgical repair, while the remaining 24 cases and 1 renal unit of the group undergoing early surgical repair were relegated to expectant observation, with periodic clinical and laboratory controls. A spontaneous recovery was observed in 12 cases; the dilatation remained unchanged in 10 cases, while 3 patients showed a progressive worsening of the condition which led to a surgical correction. Our findings agree with those in recent reports in providing little support for early, indiscriminate surgical repair. Moreover, our experience confirms the possibility of a spontaneous recovery in newborns with hydronephrosis and draws attention to the benefit of a conservative management in properly selected patients.

Pharmacological characterization of epinine 3-O-sulphate and 4-O-sulphate

Ibopamine, the diisobutyric ester of N-methyldopamine, is able to increase cardiac output and induce vasodilatation on oral administration. While the pharmacodynamic activity of ibopamine is rather long-lasting, N-methyldopamine, i.e. ibopamine's primary metabolite, can be detected in plasma only for a short time after the administration. We have investigated the pharmacological activity of N-methyldopamine 3-O-sulphate and 4-O-sulphate, since the plasma levels of these conjugated metabolites are higher and last longer than those of N-methyldopamine. These compounds appeared to be devoid of any pharmacodynamic activity both in vivo on the main hemodynamic parameters in dog and on diuresis in rat, and in vitro on cat papillary muscle and rabbit ear artery. Consequently, the duration of ibopamine hemodynamic effects cannot be related to these circulating metabolites, thus other hypotheses should be taken into consideration.

Effects of ibopamine on acute cardiac failure following experimental coronary occlusion in dogs

The activity of ibopamine (SB-7505), the 3,4-diisobutyryl ester of N-methyldopamine, on myocardial contractility and systemic and renal hemodynamics was investigated in the anesthetized dog with experimental infarction, instrumented with catheters and electromagnetic flowmeters. Ibopamine, given by the intraduodenal route at a dose of 24 mg/kg, was effective in improving the hemodynamic parameters depressed by myocardial infarction, in particular myocardial contractility and renal hemodynamics. In eliciting such activity which resembles that developed by dopamine in similar experimental conditions, ibopamine seems to meet the requirements of an orally active pharmacological agent useful in the therapy of acute heart failure.

Effects of ibopamine on systemic, pulmonary and regional hemodynamics. Experimental investigations in anesthetized dogs

The effects of a new orally effective dopamine-like derivative, ibopamine (SB-7505), the 3,4-diisobutyryl ester of N-methyldopamine, on the cardiovascular system were investigated in anesthetized dogs. Ibopamine increased dose-dependently stroke volume index, cardiac index, left ventricular pressure, its first derivative: dP/dt, peak velocity left ventricular ejection and renal blood flow. After beta-blockade the positive inotropic effect of ibopamine is inhibited. Total peripheral resistance and renal vascular resistance decreased after ibopamine. Urine output was increased dose-dependently, reaching 115% after ibopamine 8 mg/kg intraduodenally. Coronary and femoral flows and resistance did not change after administration of 4 and 8 mg/kg. Only very high doses (24 mg/kg) caused an increase in flow and resistance. Mesenteric flow decreased transiently and then returned to the previous level or increased considerably over the basal figures when a high dose was used. No significant changes or fall in heart rate were observed with doses up to 16 mg/kg and no significant changes in pulmonary resistance were noted. The data obtained from the present investigation show, however, that oral ibopamine is capable of producing most of the effects induced by intravenously given dopamine in anesthetized dogs. Ibopamine's cardiac and renal effects may open new prospects for the long-term treatment of chronic heart failure in human subjects.

[Effects of dopamine, noradrenaline and isoproterenol on pulmonary circulation in anesthetized dogs]

Experiments were performed on 19 anaesthetized open-chest dog instrumented with polyethylene catheters inserted: into the aorta, in pulmonary artery and in left atrium and with an electromagnetic flow-transducer placed around the ascending aorta in order to record : systemic arterial and pulmonary pressures, mean left auricular pressure and phasic aortic flow. Heart rate, stroke volume, total systemic and pulmonary resistance, cardiac work were moreover calculated. Each dog was given intravenously by slow infusione : Dopamine (micrograms 5--10--20/kg/min/ 5 min), Isoproterenol (microgram 0.125--0.25--0.5/kg/min/5 min) and Norepinephrine (microgram 0.25--0.5--1 /kg/min/5 min). Results obtained on systemic hemodynamics agree with those reported by many other investigators. On pulmonary circulation : Isoproterenol, at the tested doses, elicited vasodilator effects, Norepinephrine increased total pulmonary resistance but not pulmonary vascular resistance, while Dopamine did not modify or slightly reduced vascular pulmonary tone.

Hemodynamic and metabolic changes induced by temporary clamping of the thoracic aorta

Numerous authors reported a significant deterioration of heart function induced by aortic cross-clamping. Nevertheless, the aorta has been clamped during various surgical procedures without any complication. We studied the hemodynamic and metabolic variations induced by 20 min thoracic aorta cross-clamping in 6 open-chest dogs. During clamping the most striking modifications were an increase in coronary blood flow of over 65%, an increase in cardiac work of over 77% and an increase in total peripheral resistances of over 68% compared to base values. No significant variations were found in the heart rate and cardiac index. Metabolic parameters, such as O2 consumption and lactate consumption increased significantly during the clamping period. The increase in lactate consumption and the progressive and continuous improvement in oxygenation indexes (lactate/pyruvate, redox potential, excess of lactate) proved the absence of any myocardial anoxia during this period. Within 15--30 min after declamping all hemodynamic and metabolic parameters reverted to values close to basal values. These data strongly suggest that the mammalian heart can tolerate this procedure satisfactorily for a limited period of time. In clinical settings, one should consider the base conditions of the cardiovascular system before transposing these conclusions.

Haemodynamics at rest and under effort in chronic arteriovenous fistulae (AVFs)

Latero-lateral femoro-femoral arteriovenous fistulae (AVFs) were surgically created in mongrel dogs. After 7-9 months during which the dogs were trained on a treadmill, devices suitable for recording arterial pressure and aortic and coronary flow were chronically implanted. Haemodynamic parameters of the dogs were controlled either at rest or after effort, keeping AVFs open or manually closed. The results, when statistically processed, showed that haemodynamic changes induced by occlusion of AVFs at rest and under effort are similar from a qualitative point of view, but considerably more marked after muscular exercise. Under effort the shunt index calculated rose to a higher extent than cardiac output. The decrease in heart rate after AVFs occlusion was significantly correlated with flow in the fistulae. However, the Nicoladoni-Branham phenomenon ought to be used for indirect evaluation of the shunt flow.

Absorption, fate and excretion of glaziovine-14C in the dog

The pharmacokinetic parameters of glaziovine, a proaporphine alkaloid with neuropharmacological properties, were investigated in dogs. At alkaline pH, glaziovine-14C showed a very high partition coefficient value from a buffered water solution and both benzene and chloroform. When administered i.v. to both conscious and anaesthetized dogs, levels of glaziovine-14C were higher in the heart, liver, kidneys and brain, and lower in skeletal muscle, skin and plasma. The high amount of radioactivity found in the small intestine as well as that found in bile obtained from a biliary fistula demonstrates that glaziovine is excreted both via the bile and via urine in not dissimilar amounts at least in dogs. When administered orally, peak plasma levels were encountered in 1 hr. Cumulative urinary excretion of glaziovine over a 24 hr period was 49% after the i.v. route and 39% after the oral route. By comparing the percentage of urinary excretion or the area under the plasma level time curve (AUC) obtained in the first 24 hr after i.v. and oral administration, percentages of bioavailability were obtained ranging from 80 to 98%. Glaziovine thus seems to possess a very high enteral absorption.