Assessing Family Functioning Before and After an Integrated Multidisciplinary Family Treatment for Adolescents With Restrictive Eating Disorders

Introduction

Previous studies applying the Lausanne Trilogue Play (LTPc), a semi-structured method for observing family dynamics, highlighted dysfunctional interaction patterns in the families of individuals affected by restrictive eating disorders (REDs). Family-centered approaches are considered the first-line treatment for severe cases of REDs in adolescence.

Objectives

To investigate family functioning in the families of adolescents with severe REDs assessed before and 6 months after a multidisciplinary family treatment program that combined psychodynamic psychotherapy, parental role intervention and triadic or family-centered intervention.

Methods

Sixty-seven families of adolescent patients diagnosed with REDs were assessed for eligibility between July 2017 and October 2020. Family functioning was assessed using the clinical version of LTPc. Nutritional counseling and neuropsychiatric monitoring were also provided.

Results

We observed a significant change in the family functioning score for the LTPc phase 2, in which the father interacts with his daughter while the mother acts as a silent observer. This suggests that the fathers, when playing an active role, could improve dyadic family functioning. The treatment was not found to change triadic functioning: a 6-month treatment may not be long enough to modify interactions at the triadic level.

Conclusions

A brief multidisciplinary treatment program may significantly improve family functioning in the families of patients diagnosed with severe REDs. Although appropriate clinical trials are needed to further test the efficacy of this treatment, our study reinforce the concept that treatment programs targeting the individual patient and both the parents should be a first-line approach in adolescents with severe REDs.

Disclosure

The authors declare that they do not have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstrac.

Peripheral inflammation exacerbates α-synuclein toxicity and neuropathology in Parkinson's models

AIMS

Parkinson's disease and related disorders are devastating neurodegenerative pathologies. Since α-synuclein was identified as a main component of Lewy bodies and neurites, efforts have been made to clarify the pathogenic mechanisms of α-synuclein's detrimental effects. α-synuclein oligomers are the most harmful species and may recruit and activate glial cells. Inflammation is emerging as a bridge between genetic susceptibility and environmental factors co-fostering Parkinson's disease. However, direct evidence linking inflammation to the harmful activities of α-synuclein oligomers or to the Parkinson's disease behavioural phenotype is lacking.

METHODS

To clarify whether neuroinflammation influences Parkinson's disease pathogenesis, we developed: (i) a 'double-hit' approach in C57BL/6 naive mice where peripherally administered lipopolysaccharides were followed by intracerebroventricular injection of an inactive oligomer dose; (ii) a transgenic 'double-hit' model where lipopolysaccharides were given to A53T α-synuclein transgenic Parkinson's disease mice.

RESULTS

Lipopolysaccharides induced a long-lasting neuroinflammatory response which facilitated the detrimental cognitive activities of oligomers. LPS-activated microglia and astrocytes responded differently to the oligomers with microglia activating further and acquiring a pro-inflammatory M1 phenotype, while astrocytes atrophied. In the transgenic 'double-hit' A53T mouse model, lipopolysaccharides aggravated cognitive deficits and increased microgliosis. Again, astrocytes responded differently to the double challenge. These findings indicate that peripherally induced neuroinflammation potentiates the α-synuclein oligomer's actions and aggravates cognitive deficits in A53T mice.

CONCLUSIONS

The fine management of both peripheral and central inflammation may offer a promising therapeutic approach to prevent or slow down some behavioural aspects in α-synucleinopathies.

Case report: the thoracoscopic surgery in peritoneal-pleural leakage. A valid therapeutic strategy

Pleuro-peritoneal leakage is an uncommon complication of peritoneal dialysis (PD). In this study, we report the case of a male patient (age 83), treated with PD (daytime single-exchange). In October 2019, hospitalization was necessary due to dyspnoea and a reduction of peritoneal ultrafiltration. A right pleural leakage resulted at chest x-ray. A regression of the pleural leakage was immediately observed after interrupting PD. It was then performed a pleuro-peritoneal CT scan at baseline, followed by a second scan performed 4 hours after the injection of 2 L of isotonic solution with 100ml of contrast medium, which evidenced a pleuro-peritoneal communication. It was then decided to perform a video-assisted thoracoscopic surgery (VATS), that showed no evidence of diaphragm communication. It was then executed a pleurodesis using sterile talcum. The patient was released on the 3rd day, with a conservative therapy and a low-protein diet. After 2 weeks a new pleuro-peritoneal CT scan with contrast medium was executed. This time the scan evidenced the absence of contrast medium in the thoracic cavity. The patient then resumed PD therapy, with 3 daily exchanges with isotonic solution (volume 1.5 L), showing no complications. Concerning the treatment of pleuro-peritoneal leakage, VATS allows both the patch-repairing of diaphragmatic flaws and the instillation of chemical agents. In our case, VATS allowed the chemical pleurodesis which in turn enabled, in just 2 weeks of conservative treatment, the resuming of PD. In conclusion, this methodology is a valid option in the treatment of pleuro-peritoneal leakage in PD patients.

Surgical Resections of Superinfected Pneumatoceles in a COVID-19 Patient

Emerging studies on radiologic findings in patients with coronavirus disease 2019 (COVID-19) report a high incidence of bilateral lung involvement, with ground-glass opacities imaging being the most common pattern on computed tomography. Cystic lesions, such as pneumatoceles, are rare, although they may occur in 10% of cases. Cyst formation may be explained by a focal pulmonary trauma caused by mechanical ventilation or infection-related damage to the alveolar walls leading to pneumatoceles. The superinfection of pneumatoceles is a potential life-threatening condition for which no standardized therapeutic algorithm has been accepted. We report a case of a COVID-19 patient successfully treated by lung resections for infected pneumatoceles.

Video-assisted thoracoscopic resection of lung nodules localized with a hydrogel plug

OBJECTIVES

Computed tomography (CT)-guided hydrogel plug deployment was recently proposed for lung nodule preoperative localization and simultaneous prevention of pneumothorax. We analysed our initial experience with CT-guided hydrogel plug localization of lung nodules in patients undergoing video-assisted thoracoscopic (VATS) resection.

METHODS

We retrospectively evaluated the medical notes from 27 consecutive patients (mean age 68 ± 11 SD years; men 74%) undergoing VATS lung wedge resection for biopsy or definitive treatment of 28 small pulmonary nodules (malignant 82%) at a single institution between October 2017 and July 2018. Difficult intraoperative nodule localization was anticipated with a lesion <10 mm, a depth from pleura:size ratio >1, ground-glass opacity or the judgement of the operating surgeon. All lesions were preoperatively marked by deployment of a CT-guided hydrogel plug. Study end points were frequency of postlocalization pneumothorax; feasibility of delayed surgery; rate of localization of intraoperative nodule and rate of successful VATS resection.

RESULTS

The mean sizes of the solid nodules (n = 24) and of the ground-glass opacities (n = 4) were, respectively, 10.4 ± 3.4 mm and 16.0 ± 6.2 mm. One (4%) hydrogel plug marking procedure caused a clinically relevant pneumothorax. Nodule resection was scheduled flexibly as required by patient management/operating room scheduling: same day (11 nodules) or delayed [median 6 days (range 1-60 days)]; (17 nodules). All nodules were localized intraoperatively: 25 (89%) by hydrogel plug; 3 (11%) by palpation and pleural puncture hole visible after plug displacement. All nodules were completely excised by VATS, without complications.

CONCLUSIONS

CT-guided hydrogel plug marking was valuable for VATS localization and resection of challenging lung nodules. The plug minimized clinically relevant pneumothoraxes and allowed flexible surgical schedules.

Beta1- and Beta2-Adrenoceptors Expression Patterns in Human Non-small Cell Lung Cancer: Relationship with Cancer Histology

Assessment of Beta-AR protein expression on tumour tissues might be a plausible strategy to select cancer patients who can benefit from Beta-blockers therapy. The aim of this study is to evaluate the differences between resected tissue specimens from primary lung cancer (adenocarcinoma (ADC) and squamous cell carcinoma (SCC)) in terms of expression pattern of Beta1- and Beta2-AR in both tumour and adjacent surrounding non-tumour tissue. This retrospective study was based on the analysis of 80 patients with histologically confirmed diagnosis of primary Non-Small Cell Lung Cancer (NSCLC) who received surgical treatment. The cases were carefully selected in order to obtain the most homogeneous sample in terms of histologic subtype (40 ADCs and 40 SCCs) and clinical stage (10 each). Beta1- and Beta2-AR expression was determined by immunohistochemistry and the staining evaluated by semi-quantitative scoring using the H-score method. In our NSCLC series, Beta1- and Beta2-AR are differentially expressed. Beta1-AR expression is present at low levels in both SCC and ADC. Likewise, when compared with the matched surrounding non-tumour tissues, Beta1-AR expression level was significantly lower in both histologic subtypes. Conversely, Beta2-AR is highly expressed in both histologic subtypes, but clearly highly expressed in ADC when compared with SCC and with their matched surrounding non-tumour tissue. Overall, this clinicopathological study highlights the differential expression of Beta1- and Beta2-AR in ADC and SCC. Repurposing non-selective Beta-blockers in oncologic setting might be a suitable therapeutic strategy for lung ADC. Graphical abstract.

Quantitative computed tomography detects interstitial lung diseases proven by biopsy

Background: The Quantitative chest CT (QCT) is emerging as a promising tool in the assessment of interstitial lung disease (ILD). However, the precise relationship between QCT parameters and the fibrosis detectable in lung tissue, remains to be established. Objectives: The aim of this study was to compare QCT and histopathological features in patients with ILD. Moreover we verified if the QCT assessment is similar in patients with or without a ILD diagnosis proven by a biopsy. Methods: Twenty patients affected by ILD who underwent a chest CT and, later, a lung biopsy, were enrolled. Patients were divided according to the histopathological findings (IPF vs sarcoidosis) in two groups (respectively bIPF and bSarc). Other 20 patients with a radiological diagnosis of IPF were included in a control group (rIPF). All CTs were post-processed with a free software (Horos) in order to obtain an ILD quantitative assessment. Results: There were no differences in terms of gender, smoking habit and spirometric values between patients' groups. rIPF subjects were older than the other: 70 vs 59 and 47 years (p<0.001). A different distribution of QCT parameters was observed between bIPF and bSarc (p<0.01) while it was comparable within bIPF and rIPF. Conclusions: QCT parameters were similar in subjects affected by the same type of ILD detected with biopsy and with CT alone. These findings make stronger the assumption that QCT can identify the presence of pulmonary fibrosis and, ultimately, that it can represent an useful and effective tool to assess ILD. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 16-20).

Comparison of outcomes for patients with lepidic pulmonary adenocarcinoma defined by 2 staging systems: A North American experience

OBJECTIVE

Application of the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society (IASLC/ATS/ERS) classification of lepidic adenocarcinomas in conjunction with American Joint Committee on Cancer (AJCC) staging has been challenging. We aimed to compare IASLC/ATS/ERS and AJCC classifications, to determine if they could be integrated as a single staging system.

METHODS

We reviewed patients from 2001-2013 who had AJCC stage I lepidic adenocarcinomas, and categorized them according to IASLC/ATS/ERS guidelines: adenocarcinoma in situ (AIS); minimally invasive adenocarcinoma (MIA); or invasive adenocarcinoma (IA). We integrated the 2 classification systems by separating AIS and MIA as being stage 0, and routinely classifying IA as stage I.

RESULTS

Median follow-up was 52 months in 138 patients. The IASLC/ATS/ERS classification demonstrated a higher disease-free survival (DFS) in AIS (100%) and MIA (96%) versus IA (80%) (P = .022), and higher overall survival (OS): 100% for AIS and MIA, versus 90% for IA (P = .049). The AJCC classification identified a DFS of 87% and an OS of 94% for stage I patients. Integration of the 2 systems demonstrated higher DFS in stage 0 (98%) versus I (80%) (P = .006), and higher OS: 100% for stage 0 versus 90% for stage I (P = .014).

CONCLUSIONS

The IASLC/ATS/ERS classification better discriminates AIS and MIA compared with current AJCC staging; however, integration suggests that these categories may be collectively classified in AJCC staging, based on similarly favorable outcomes and distinctive survival rates.

Resection rate of lung cancer in Teesside (UK) and Varese (Italy): a comparison after implementation of the National Cancer Plan

BACKGROUND

In a lung cancer survey in 2000 we showed significantly less favourable stage distribution and lower resection rate in Teesside (UK) than in the comparable industrialised area of Varese (Italy). Lung cancer services in Teesside were subsequently reorganised according to National Cancer Plan recommendations.

METHODS

For all new lung cancer cases diagnosed in Teesside (n=324) and Varese (n=260) during the 12 months October 2010 to September 2011 (hereafter 'the 2010 cohort'), demographic, clinico-pathological and disease management data were prospectively recorded using the same database and protocol as the 2000 survey. Findings were analysed focusing on resection rate.

RESULTS

In the 2010 cohort compared with 2000, both in Teesside and Varese emergency referral decreased (p<0.001), performance status improved (p<0.001), but cancer stage shift was not seen; resection rate improved in Teesside, from 7% to 11% (p=0.054), and was unchanged in Varese (24%). Moreover, in Teesside compared with Varese the stage distribution remained less favourable, stage I-II non-small cell lung cancer (NSCLC) proportion being respectively 12% and 19% (p=0.040), and resection rate in all lung cancers remained lower (11% and 24%; p<0.001). On multivariate analysis, resection predictors in Teesside were as follows: stage I-II NSCLC (OR 86.14; 95% CI 31.80 to 233.37), performance status 0-1 (OR 5.02; 95% CI 1.48 to 17.07), belonging to 2010 cohort (OR 2.85; 95% CI 1.06 to 7.64).

CONCLUSIONS

In Teesside the main independent predictor of resection was disease stage; in 2010-2011 compared with 2000, lung cancer service improved but stage shift did not occur, and resection rate increased but remained significantly lower than in Varese.

Efficacy and safety of surgical lung biopsy for interstitial disease. Experience of 161 consecutive patients from a single institution in Italy

BACKGROUND

The role of surgical biopsy for interstitial lung disease (ILD) is controversial, because of possible postoperative morbidity and mortality. We aimed to assess the efficacy and safety of surgical biopsy for ILD.

METHODS

We retrospectively analysed the diagnostic performance and the postoperative complications of 161 consecutive surgical lung biopsy procedures carried out in suspected ILD cases that were undefined after multidisciplinary clinico-radiological evaluation. In 151 cases (93.8%) the biopsy was performed by video-assisted thoracoscopic surgery (VATS), in 6.2% by limited thoracotomy.

RESULTS

A specific histological diagnosis was obtained in 154 (95.7%) of the surgically biopsied patients, while 4.3% remained histologically unclassified. The predominant histological patterns were sarcoidosis (29.8 %), usual interstitial pneumonia/idiopathic pulmonary fibrosis (UIP/IPF) (24.2%), cryptogenic organizing pneumonia (18.6%) and nonspecific interstitial pneumonia (8.1%). The postoperative course was uneventful in 142 cases. In 19 patients (11.8%) we observed postoperative complications, predominantly prolonged air leakage (5.0% of all cases). Thirty-day postoperative mortality was 3.1%, mostly due to acute exacerbation of respiratory insufficiency. Postoperative mortality independently correlated with preoperative need of oxygen therapy (OR, 5.21; 95% CI, 1.19-22.95) and with UIP/IPF histology (OR, 5.67; 95% CI, 1.27-25.25).

CONCLUSIONS

Lung biopsy was performed mostly by VATS, with limited morbidity, and was effective in yielding a specific histologic diagnosis in the vast majority of undefined ILD cases. To optimize the outcome of surgical biopsy for specific diagnosis of ILD, this procedure should be performed only exceptionally in patients with critical respiratory illness as postoperative mortality risk in these subjects is exceedingly high.

Is chest X-ray screening for lung cancer in smokers cost-effective? Evidence from a population-based study in Italy

Background

After implementation of the PREDICA annual chest X-ray (CXR) screening program in smokers in the general practice setting of Varese-Italy a significant reduction in lung cancer-specific mortality (18 %) was observed. The objective of this study covering July 1997 through December 2006 was to estimate the cost-effectiveness of this intervention.

Methods

We examined detailed information on lung cancer (LC) cases that occurred among smokers invited to be screened in the PREDICA study (Invitation-to-screening Group, n = 5815 subjects) to estimate costs and quality-adjusted life-years (QALYs) from LC diagnosis until death. The control group consisted of 156 screening-eligible smokers from the same area, uninvited and unscreened, who developed LC and were treated by usual care. We calculated the incremental net monetary benefit (INMB) by comparing LC management in screening participants (n = 1244 subjects) and in the Invitation-to-screening group versus control group.

Results

The average number of QALYs since LC diagnosis was 1.7, 1.49 and 1.07, respectively, in screening participants, the invitation-to-screening group, and the control group. The average total cost (screening + management) per LC case was higher in screening participants (€17,516) and the Invitation-to-screening Group (€16,167) than in the control group (€15,503). Assuming a maximum willingness to pay of €30,000/QALY, we found that the intervention was cost-effective with high probability: 79 % for screening participation (screening participants vs. control group) and 95 % for invitation-to-screening (invitation-to-screening group vs. control group).

Conclusions

Based on the PREDICA study, annual CXR screening of high-risk smokers in a general practice setting has high probability of being cost-effective with a maximum willingness to pay of €30,000/QALY.

Radiologic Evaluation of Small Lepidic Adenocarcinomas to Guide Decision Making in Surgical Resection

BACKGROUND

The International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society classification of pulmonary adenocarcinomas identifies indolent lesions associated with low recurrence, superior survival, and the potential for sublobar resection. The distinction, however, is determined on the pathologic evaluation, limiting preoperative surgical planning. We sought to determine whether preoperative computed tomography (CT) characteristics could guide decisions about the extent of the pulmonary resection.

METHODS

We reviewed the preoperative CT scans for 136 patients identified to have adenocarcinomas with lepidic features on the final pathologic evaluation. The solid component on CT was substituted for the invasive component, and patients were radiologically classified as adenocarcinoma in situ, 3 cm or less with no solid component; minimally invasive adenocarcinoma, 3 cm or less with a solid component of 5 mm or less; or invasive adenocarcinoma, exceeding 3 cm or solid component exceeding 5 mm, or both. Analysis of variance, t test, χ(2) test, and Kaplan-Meier methods were used for analysis.

RESULTS

The radiologic classification identified 35 adenocarcinomas in situ (26%) and 12 minimally invasive (9%) and 89 invasive adenocarcinoma (65%) lesions. At a 32-month median follow-up, patient outcomes associated with the radiologic classification were similar to the pathologic-based classification: the radiologic classification identified 14 of 16 patients with recurrent disease and all 6 who died of lung cancer. In addition, patients with radiologic adenocarcinoma in situ and minimally invasive adenocarcinoma who underwent sublobar resections had no recurrence and 100% disease-free and overall survival at 5 years.

CONCLUSIONS

The radiologic classification of patients with lepidic adenocarcinomas is associated with similar oncologic and survival outcomes compared with the pathologic classification and may guide decision making in the approach to surgical resection.

Surveillance of the Remaining Nodules after Resection of the Dominant Lung Adenocarcinoma is an Appropriate Follow-Up Strategy

INTRODUCTION

Adenocarcinomas, commonly present as a dominant lesion (DL) with additional nodules in the ipsilateral or contralateral lung. We sought to determine the fate and management of the secondary nodules and to assess the risk of these nodules using the Lung CT Screening Reporting and Data System (Lung-RADS) criteria and the National Comprehensive Cancer Network (NCCN) Guidelines to determine if surveillance is an appropriate strategy.

METHODS

We retrospectively evaluated patients with lepidic growth pattern adenocarcinoma and secondary nodules from 2000 to 2013. Risk assessment of the additional lesions was completed with a simplified model of Lung-RADS and NCCN-Guidelines.

RESULTS

Eighty-seven patients underwent resection of 87 DLs (Group 1) concurrently with 60 additional pulmonary nodules (Group 2), while 157 non-DLs were radiologically surveyed over a median follow-up time of 3.2 years (Group 3). Malignancy was found in 29/60 (48%) nodules in Group 2. Whereas, only 9/157 (6%) of the lesions in Group 3 enlarged, 4 of which (2.5% of total) were found to be malignant, and then treated, while the remaining nodules continued surveillance. After applying the Lung-RADS and NCCN simplified models, nodules in Group 2 were at higher risk for lung cancer than those in Group 3.

CONCLUSION

In patients with lepidic growth pattern adenocarcinoma associated with multiple secondary nodules, surveillance of the remaining nodules, after resection of the DL, is a reasonable strategy since these nodules exhibited a slow rate of growth and minimal malignancy. In contrast, nodules resected from the ipsilateral lung at the time of the DL, harbor malignancy in 48%. Risk assessment models may provide a useful and standardized tool for clinical assessment of pulmonary nodules.

Assessment of the aggregate risk score to predict mortality after surgical biopsy for interstitial lung disease†

OBJECTIVES

An aggregate risk score (range 0-6 points) for predicting mortality after surgical biopsy for interstitial lung disease (ILD) was recently developed from four independent variables: intensive care unit treatment (2 points), age >67 years (1.5 points), immunosuppression (1.5 points), open biopsy (1 point). In the development cohort, patients were grouped in four classes of aggregate score (A, B, C, D) showing incremental risk of death within 90 days from biopsy. We tested this mortality risk model in an independent cohort.

METHODS

The aggregate risk score and the corresponding class of 90-day mortality risk was retrospectively determined in 151 consecutive patients undergoing biopsy for uncertain ILD at the Center for Thoracic Surgery, University of Insubria (Varese, Italy) in 1997-2012. We evaluated, by Spearman's ρ test, the correlation between aggregate risk score and mortality rate in the development cohort and in our cohort. Fisher's exact test was used for comparison of overall mortality rate between the two cohorts.

RESULTS

The mortality rate correlation with risk score differed in our cohort (ρ = 0.127; P = 0.06) compared with the development cohort (ρ = 0.352; P < 0.0001). In our dataset mortality polarized: it was minimal in Classes A and B (2% and 0%, respectively), 33% in Classes C and D. This skewed mortality distribution was possibly contributed by significantly lower overall mortality rate in our cohort than in the development cohort (2.6% vs 10.6%; P = 0.0017). Despite the difference in mortality distribution, in our dataset, we confirmed that ILD patients with aggregate score >2 (Classes C and D) were at exceedingly high risk of postoperative mortality.

CONCLUSIONS

The aggregate score is a simple and useful risk score for ILD. Our dataset confirms that lung biopsy is reasonably safe in Class A and B patients while, in Class C and D patients, it is indicated only if histology would substantially change management and prognosis.

Management of hypertension in intrapericardial paraganglioma

Functioning paraganglioma is extra-adrenal catecholamine-secreting tumours that may cause secondary hypertension. Primary intrapericardial paragangliomas are very rare and are located adjacent to the great vessels or heart, typically near the left atrium. These tumours are an exceptionally uncommon finding during the investigation of refractory hypertension. However, in recent years, intrapericardial paragangliomas have been diagnosed incidentally with increased frequency, due to the extensive use of radiologic chest imaging. The mainstay of treatment of functioning intrapericardial paraganglioma is surgical removal, which usually achieves blood pressure normalization. Due to the locations of these tumours, the surgical approach is through a median sternotomy or posterolateral thoracotomy, and manipulation-induced catecholamine release may cause paroxysmal hypertension. Typically in these patients, blood pressure fluctuates dramatically intra- and post-operatively, increasing the risk of cardiovascular complications. We review here the current modalities of perioperative fluid and hypotensive drug administration in the setting of surgery for functioning intrapericardial paraganglioma and discuss the recently proposed paradigm shift that omits preoperative preparation.

Cost of a population-based programme of chest x-ray screening for lung cancer

BACKGROUND

After the implementation of a population-based programme of chest x-ray (CXR) screening on smokers in Varese, Italy, lung cancer (LC) mortality was significantly reduced. Analysis of the incremental costs due to this type of screening programme is needed to evaluate its economic impact on the healthcare system.

METHODS

In July 1997 a population-based cohort, consisting of all high-risk smokers (n=5,815) identified among 60,000 adult residents from the Varese province, was invited to a LC screening programme (an annual CXR for five years) in a general practice setting, and was observed through 2006. Invitees received National Health Service (NHS) usual care, with the addition of CXRs in screening participants. At the end of observation, among the 245 LCs diagnosed in the entire screening-invited cohort the observed LC deaths were 38 fewer than expected. To estimate the incremental direct cost due to screening in the invited cohort for the period July 1997-2006, we compared the direct cost of screening administration, CXR screens and LC management in the invited cohort and in the uninvited and unscreened controls in NHS usual care setting.

RESULTS

Over the 9.5 years, the total incremental direct healthcare costs (including screening organization/administration, CXR screens, additional procedures prompted by false-positive tests, overdiagnosed LCs) were estimated to range from euro 607,440 to euro 618,370 (in euros as of 2012), equating to between euro 15,985- euro 16,273 per patient out of the 38 LC deaths averted.

CONCLUSIONS

In a general practice setting, the incremental cost for a CXR screening programme targeted at all high-risk smokers in a population of 60,000 adults was estimated to be about euro 65,000 per annum, approx. euro 16,000 for each LC death averted.

The challenge of prognostic markers in pleural mesothelioma

Malignant pleural mesothelioma (MPM) is a very aggressive tumor, highly resistant to chemo- and radio-therapy. Treatment of MPM patients is often disappointing, regardless of the modality used. Inter-individual variability of response to multimodal treatment remains a challenge and generally the MPM prognosis continues to be poor. Knowledge of predicting factors of outcome is currently insufficient; therefore, it would be highly desirable to find specific prognostic markers for MPM. Translational research projects are to be implemented.

Cost of reproduction. Changes in metabolism and endosulfan lethality caused by reproductive behavior in Hyalella curvispina (Crustacea: Amphipoda)

Biocides are periodically applied in agricultural activities, reaching aquatic systems and acting upon the biota. Amphipods are widely used in toxicity tests because of their sensitivity to a wide range of pollutants. In this work, we report the differential lethality of a widely used pesticide, endosulfan, on the amphipod Hyalella curvispina at two life stages and in three different adult groups, males and females separated by sex and both sexes grouped together. In addition, oxygen consumption of adult groups was determined as a way to estimate the role of behavioral activities and exposure to endosulfan in metabolism shifts. There were no differences between the LC(50) of juveniles and the adults when they were separated by sex (p>0.05). Nevertheless, the LC(50) of adults without sexual differentiation was significantly lower than the LC(50) of juveniles and adults separated by sex (p<0.05). The oxygen consumption rate was higher when adults were grouped without sexual differentiation in the control group. The exposure to low concentrations of endosulfan causes an increase in oxygen consumption in all the treatments. The sexual behavior increased the metabolism and the sensitivity to endosulfan. In future evaluations, adults grouped without sexual differentiation, which were the most sensitive group, should be included in order to mimic the environmental conditions. Using only juveniles or adults separated by sex in toxicity tests may inaccurately estimate the lethality of biocides, especially in species with constant reproductive activities.

Bullous lung disease and neurofibromatosis type-1

Lung interstitial diseases and bullae are described as possible complications of neurofibromatosis type-1 (NF-1), a genetic disorder inherited as a autosomal-dominant trait. We report the case of a 16-year-old male non-smoker with NF-1, who presented with pneumothorax caused by ruptured lung bullae. The case of this young patient, successfully treated by video-assisted thoracoscopic resection of bullae, supports the concept that pulmonary alterations may be part of the NF-1 syndrome, rather than as an unrelated complication.

Fasting hyperglycaemia and in-hospital mortality in elderly population

BACKGROUND

Admission hyperglycaemia has shown to be a marker of poor clinical outcome. The prevalence of admission hyperglycaemia and its relationship with in-hospital mortality in elderly population has not been clearly defined. We assessed the prevalence and prognostic significance of admission fasting hyperglycaemia in aged patients.

METHODS

A total of 808 elderly patients were studied. Patients were classified into group I (serum glucose < 126 mg/dl), II (126-180 mg/dl) and III (> 180 mg/dl). Groups II and III were considered newly recognised fasting hyperglycaemia (NRFH) in non-diabetic patients.

RESULTS

NRFH was present in 18.6%. After excluding diabetic patients (n = 206, 25.5%), the distribution of patients (n = 602, 74.5%) was as follows: group I (n = 452, 55.9%), group II (n = 122, 15.1%) and group III (n = 28, 3.5%). In the whole cohort, median fasting glucose was lower in patients who survived [105 mg/dl (88-135)] than in those who died [127 mg/dl (93-159), p < 0.001]. This significant difference was maintained only when non-diabetic patients were considered [100 mg/dl (87-122) vs. 118 mg/dl (92-149), p < 0.001]. In-hospital mortality rate in groups I, II and III was 8.5%, 14.1% and 22.9%, respectively (p < 0.001). Mortality rate was 8.4%, 18.0% and 32.1% (p < 0.001) in groups I, II and III, respectively in non-diabetic population. Both low albumin and high glucose serum concentrations were the only independent risk factors for in-hospital all-cause mortality in non-diabetic patients.

CONCLUSIONS

In non-diabetic elderly patients admitted for acute disease, serum glucose concentration is an important, simple and independent predictor of hospital mortality.

[Extramedullary hematopoyesis: compensatory mechanism or clinic syndrome? Case report and review of literature]

Extramedullary hematopoiesis (EMH) is a compensatory mechanism occurring in patients with chronic anemia. Liver, spleen, and lymph nodes are frequently involved. However, EMH may also develop in several sites such as thymus, kidneys, retroperitoneum, paravertebral areas of the thorax, lungs, bowel and others. Rarely symptomatic, it often shows a variety of clinical features. This condition, frequently, may be fatal. A correct early diagnosis of EHM might avoid, if possible, a bad prognosis. The Authors report a case where bone marrow cells were identified in centrifuge cerebrospinal fluid of a patient suffering from non-Hodgkin lymphoma.

Visceral leishmaniasis in a patient treated for polyarteritis nodosa

We report a case of visceral leishmaniasis in a patient receiving steroids and cyclophosphamide for polyarteritis nodosa. The clinical presentation of leishmaniasis, with fever, pancitopenia and hypergammaglobulinemia may be confused with a reactivation of vasculitis or with other non-infectious conditions such as haematologic diseases. In endemic areas, the case of latent leishmaniasis must be considered and serology for Leishmania should be performed before starting immunosuppressive treatment.

[Continence problems after radical prostatectomy: medical treatment]

OBJECTIVE

We hypothesized that a benefit can be obtained from both urine storage and urethral resistance after retropubic radical prostatectomy through the induction of artificial erections.

MATERIAL AND METHODS

From January 1993 to December 2000 we have submitted 127 patients to radical retropubic prostatectomy. According to preoperative bladder behaviour, 59 patients (46.5%) presented voiding disorders, 10 (7.9%) filling disorders, 4 (3.1%) mixed disorders, whereas 54 (42.5%) were asymptomatic. The urethral catheter was removed between the 10th and the 12th postoperative day. Fourteen patients entered a programme of early sexual rehabilitation with intracavernous injection of prostaglandin E1 (ICI) within 7 days from catheter removal.

RESULTS

After catheter removal the recovery of urinary continence occurred within 2.2 +/- 2.3 days. At dismissal from the hospital, 8 patients (6.2%) were almost totally incontinent; 2 (1.5%) were still incontinent after a 6-month period; 73 (57.4%) were dismissed with clinical signs of detrusor instability hence treated with anticholinergic drugs such oxybutynin or tolterodine; 3 (2.3%) resulted obstructed after surgery because of stenosis of the anastomosis. Almost all the patients submitted to early sexual rehabilitation referred an improvement of their incontinence after the first injection. The patients who did not begin an early sexual rehabilitation generally recovered from incontinence in a longer time.

CONCLUSIONS

Our preliminary observations showed that artificial erection PGE1-induced is effective in improving or accelerating post radical prostatectomy incontinence recovery. The results apply also to patients with pre-operatory detrusor instability.

[Endoscopic surgery in day hospital using bladder and urethral anesthesia with EMDA]

PURPOSE

To assess the suitability of EMDA local anaesthesia for invasive procedures on lower urinary tract in one day surgery treatment.

PATIENTS AND METHODS

The deep penetration of lignocaine into the bladder wall was attained by catheters, electrodes and electric current generators using revised electrochemical principles. Since 1994 203 patients with transitional cell carcinoma of the bladder underwent TURBT and 70 patients with bladder neck or prostatic obstruction underwent TURP, TUIP, TULAP; 20 patients underwent miscellaneous procedures: in 34 patients the procedures were combined. The patients' age was within 20 and 90 years (mean age 67.3). The procedures were performed in a single small endoscopic theatre annexed to the Urology Ward. A standard rigid resectoscope was used as well as a standard electrocautery (360 kHz) or a mega frequency low temperature Vesalius generator (4 MHz). Most patients received a premedication and some of them a light sedation when necessary, but all of them were fully conscious and able to complete an assessment using a simple pain scale.

RESULTS

8 out of 273 patients (3%) considered pain intolerable and other 11 (4%) reported painful but tolerable sensation, and the remaining 254 patients referred absent or minimal discomfort. Most of the patients were able to walk back to their room and go home in the evening. Those who had no chance of going back home were admitted for the night as well as those who had no assistance at all at home or those who had high probability of haemorrhage. Side effects were minimal and not related to local anesthesia: the serum lignocaine levels measured in 4 patients were innocuous. All patients experienced some tingling and reddening at the skin site of the dispersive electrode fading in a few hours.

CONCLUSIONS

Local anaesthesia by using EMDA proved to be effective for most invasive endoscopic procedures in the lower urinary tract and suitable for patients undergoing day hospital surgery.

[Amyotrophic lateral sclerosis in a patient with Waldenstrom's macroglobulinemia]

Although a peripheral neuropathy is the best known neurological complication of Waldenstrom's Macroglobulinemia (WM), the association of Amyotrophic Lateral Sclerosis (ALS), or other Motor Neuron Diseases (MND) with monoclonal gammopathies is described. We report the case of a male patient (41 years old) with WM and ALS. Whether monoclonal gammopathies play a role in the pathogenesis of MND is unclear but is la possible that patients might have antibodies against motor neurons. In our reported case neurologic symptoms were the first and the most important manifestations of the underlying hemopathy and despite plasmapheresis and immunosuppressive treatment ALS syndrome progressed. The neurologic disease worsened despite the improvement of WM.

Low prevalence of islet autoantibodies in patients with gestational diabetes mellitus

OBJECTIVE

To determine the proportion of patients with gestational diabetes mellitus (GDM) who have serological characteristics typical of IDDM.

RESEARCH DESIGN AND METHODS

Islet cell antibodies (ICAs), insulin autoantibodies (IAAs), GAD65, and IA-2 antibodies were measured in 145 pregnant women with GDM, 33 with impaired glucose tolerance (IGT), and in 73 with normal glucose tolerance (NGT). ICAs were measured by indirect immunofluorescence; GAD65 and IA-2 antibodies, by a radio-ligand immunoassay incorporating 35S-labeled recombinant antigen; and IAAs, by a liquid-phase radiobinding assay.

RESULTS

The prevalences of islet autoantibodies were low and not significantly different between groups. ICAs were detected at levels ranging from 5 to 45 Juvenile Diabetes Foundation U in 14 (10%) women with GDM, 2 (6%) women with (GT, and in 4 (5%) women with NGT. IAAs were detected at levels between 3 and 4 SD above the mean in 4 (3%) women with GDM, 0 women with IGT, and in 1 (1%) woman with NGT. None had both ICAs and IAAs. Neither GAD65 nor IA-2 antibodies, which have been detected in the majority of pre-IDDM and IDDM patients, were found in NGT, IGT, or GDM patients.

CONCLUSIONS

Low-titer ICAs and IAAs are not infrequent in pregnant women, but multiple islet autoantibodies and antibodies to GAD65 or IA-2 were not found in GDM. These findings suggest that the serological characteristics of IDDM are rare in GDM.

Insulin antibodies do not preclude optimization of metabolic control in women with IDDM during pregnancy

OBJECTIVE

To evaluate whether the presence of insulin antibodies (IAs) may preclude the optimization of metabolic control during pregnancy and affect outcome in women with IDDM.

RESEARCH DESIGN AND METHODS

IAs were measured by radiobinding assay in 44 women with IDDM referred to the Diabetes and Pregnancy Outpatients' Clinic during 46 pregnancies. Age, duration of IDDM, metabolic control (HbA1c, mean pre- and postprandial capillary blood glucose, frequency of hypo- or hyperglycemia), insulin requirement at 1st and 3rd trimester of pregnancy, BM1, and weight gain were recorded. Neonatal variables such as gestational age, weight, length, and the presence at birth of either hypoglycemia, hypocalcemia, or jaundice requiring phototherapy were also considered.

RESULTS

IAs correlated positively with insulin requirement (P < 0.05) and negatively with HbA1c at term (P < 0.01). Patients with IA levels > or = 40% insulin binding (8 of 46) had a higher insulin requirement and lower preprandial capillary blood glucose at the beginning of pregnancy but not at term (P < 0.005), whereas they had lower HbA1c at term than did patients with low IA levels (P < 0.01). IA levels decreased slightly at term (P = 0.007). IA levels > or = 40% were not associated with a higher rate of hypo- or hyperglycemic episodes or with diabetic complications or thyreopathy. No correlation was found between 1A levels and any of the neonatal variables considered.

CONCLUSIONS

The presence of IAs does not preclude optimization of metabolic control during pregnancy and is compatible with a favourable outcome.

Glutathione conjugation with 1-chloro-2,4-dinitrobenzene (CDNB): interindividual variability in human liver, lung, kidney and intestine

The rate of glutathione conjugation with 1-chloro-2,4-dinitrobenzene (CDNB) was measured in specimens of human liver (n = 93), sigmoid colon (n = 56), renal cortex (n = 67) and lung (n = 68). In the liver there was a weak but significant (r = - 0.247 p = 0.017) negative correlation between the activity of glutathione transferase and the liver donor's age. Such a correlation was not found in the renal cortex, lung and colon. In the renal cortex and in lung the rate of glutathione conjugation with CDNB was a little but significantly (p < 0.05) higher in women than men, whereas no sex-dependent difference was observed in the liver and colon. The distribution of glutathione transferase activity was polymorphic in the mucosa of colon and renal cortex of men but not in that of women. Smoking seems not to affect the glutathione conjugation rate with CDNB in lung. The activity of glutathione transferase was 2-, 6-, and 7-fold greater in liver than in the renal cortex, lung and colon, respectively. There was a large interindividual variability of the hepatic glutathione transferase activity, and because this variability, 15% of the population studied catalyzed the glutathione conjugation with CDNB at a rate similar to those of the renal cortex and duodenum. The subjects with low expression of the hepatic glutathione transferase should be more exposed to the effects of toxic and carcinogenic compounds.

Interindividual variability of the human hepatic sulphotransferases

The variability among subjects of the hepatic activities of O-sulphotransferase towards dopamine, p-nitrophenol, testosterone and ethinyloestradiol and of N-sulphotransferase with 1,2,3,4-tetrahydroisoquinoline (TIQ) as substrate is described. The rates of testosterone and TIQ sulphation were higher in men than women whereas those of ethinyloestradiol, dopamine and p-nitrophenol were similar in both sexes. The sulphotransferase activities towards p-nitrophenol and dopamine were positively skewed whereas those towards ethinyloestradiol approached normality. The coefficients of variations for the sulphotransferase activities ranged between 34% and 62% indicating a considerable variability among subjects. The rates of dopamine-, TIQ- and p-nitrophenol-sulphation were measured in the mucosa of the human intestine, and the duodenum/liver ratios were 10, 0.9 and 0.1, respectively. Thus the contribution of the intestine in the sulphation of xenobiotics is substrate dependent.