Favipiravir in patients hospitalised with COVID-19 (PIONEER trial): a multicentre, open-label, phase 3, randomised controlled trial of early intervention versus standard care

BACKGROUND

COVID-19 has overwhelmed health services globally. Oral antiviral therapies are licensed worldwide, but indications and efficacy rates vary. We aimed to evaluate the safety and efficacy of oral favipiravir in patients hospitalised with COVID-19.

METHODS

We conducted a multicentre, open-label, randomised controlled trial of oral favipiravir in adult patients who were newly admitted to hospital with proven or suspected COVID-19 across five sites in the UK (n=2), Brazil (n=2) and Mexico (n=1). Using a permuted block design, eligible and consenting participants were randomly assigned (1:1) to receive oral favipiravir (1800 mg twice daily for 1 day; 800 mg twice daily for 9 days) plus standard care, or standard care alone. All caregivers and patients were aware of allocation and those analysing data were aware of the treatment groups. The prespecified primary outcome was the time from randomisation to recovery, censored at 28 days, which was assessed using an intention-to-treat approach. Post-hoc analyses were used to assess the efficacy of favipiravir in patients aged younger than 60 years, and in patients aged 60 years and older. The trial was registered with clinicaltrials.gov, NCT04373733.

FINDINGS

Between May 5, 2020 and May 26, 2021, we assessed 503 patients for eligibility, of whom 499 were randomly assigned to favipiravir and standard care (n=251) or standard care alone (n=248). There was no significant difference between those who received favipiravir and standard care, relative to those who received standard care alone in time to recovery in the overall study population (hazard ratio [HR] 1·06 [95% CI 0·89-1·27]; n=499; p=0·52). Post-hoc analyses showed a faster rate of recovery in patients younger than 60 years who received favipiravir and standard care versus those who had standard care alone (HR 1·35 [1·06-1·72]; n=247; p=0·01). 36 serious adverse events were observed in 27 (11%) of 251 patients administered favipiravir and standard care, and 33 events were observed in 27 (11%) of 248 patients receiving standard care alone, with infectious, respiratory, and cardiovascular events being the most numerous. There was no significant between-group difference in serious adverse events per patient (p=0·87).

INTERPRETATION

Favipiravir does not improve clinical outcomes in all patients admitted to hospital with COVID-19, however, patients younger than 60 years might have a beneficial clinical response. The indiscriminate use of favipiravir globally should be cautioned, and further high-quality studies of antiviral agents, and their potential treatment combinations, are warranted in COVID-19.

FUNDING

LifeArc and CW+.

Pharmacokinetics of Efavirenz 400 mg Once Daily Coadministered With Isoniazid and Rifampicin in Human Immunodeficiency Virus-Infected Individuals

Background

The World Health Organization recommends efavirenz 400 mg (EFV400) as first-line antiretroviral therapy, with a disclaimer that no data with anti-tuberculosis (TB) treatment exist. Many people living with human immunodeficiency virus (PLWH) require TB treatment with isoniazid (INH) and rifampicin (RIF), which affect cytochrome P450 and antiretroviral exposure.

Methods

PLWH receiving tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC)/EFV 600 mg with a viral load (VL) <50 copies/mL switched to TDF/FTC/EFV400. Genetic polymorphisms and pharmacokinetic (PK) parameters of EFV400 without (PK1) and with INH/RIF following 4 (PK2) and 12 (PK3) weeks of coadministration were evaluated.

Results

Twenty-six PLWH were enrolled; 22 completed PK2. All maintained VL <50 copies/mL throughout the study. Geometric mean ratio (GMR) PK2/PK1 of EFV400 maximum plasma concentration (Cmax), area under the curve (AUC), and concentration at 24 hours postdose (C24h) were 0.91 (90% confidence interval [CI], .83-.99), 0.91 (90% CI, .79-1.05), and 0.85 (90% CI, .72-.99), respectively. GMRs (90% CI) of PK3/PK2 and PK3/PK1 Cmax, AUC, and C24h were 0.95 (.86-1.05) and 0.92 (.83-1.01), 0.88 (.75-1.03) and 0.84 (.75-.93), and 0.84 (.72-.99) and 0.75 (.62-.92), respectively. Eleven of 22 participants carried polymorphisms in the CYP2B6 gene associated with slow EFV metabolism.

Conclusions

INH/RIF coadministration was associated with limited changes in EFV400 AUC (<25%), and EFV400 concentrations were maintained within ranges of those measured in PLWH in the ENCORE-1 study, irrespective of CYP2B6 genotype. The coadministration of EFV400 with anti-TB treatment can be considered and this is being confirmed in PLWH with TB.

Clinical Trials Registration

NCT02832778.

Effective management of extensive tissue loss after abdominoperineal resection for Buschke-Loewenstein tumor

The giant condyloma acuminatum or Buschke-Loewenstein tumor is a rare, sexually transmitted disease. It is an epithelial tumor characterized by its high potential of malignancy towards developing into a highly invasive squamous cell carcinoma. The present case concerns a drug addicted 40-year-old man who smuggled drugs using his rectum. He had a partially ulcerated mass in the perianal area of about 20 x 10 cm. He reported a progressive growth of this neoplasm during the last 3 years associated with perianal pain, obstructed defecation, bad sitting posture, no fever and weight loss. Our first approach was a left laparoscopic loop colostomy for a fecal diversion and antalgic purpose, and biopsy of the perineal mass. Then, he underwent a complete excision of the perianal neoplasm. The pathologist's positive diagnosis of a well differentiated squamous cell carcinoma, evidently necessitated the radicalization of the surgical procedure of abdominal perineal resection. In consideration of the surgical wound depth and size, a VAC Therapy with Negative Pressure Wound Therapy was applied. The BLT incidence rate has been steadily increasing over the last decade especially among male patients. An aggressive surgical approach is usually to get the best oncologic outcome but the difficult management of the perianal wound is challenging. In our experience VAC therapy has been shown to be an effective tool in promoting the healing of the perineal wound after abdominoperineal resection.

Study of the role of telomerase in colorectal cancer: preliminary report and literature review

AIM

The aim of our study is to focus on hTERT (human Telomerase Reverse Transcriptase) expression to identify tumoral tissue after a comparison to TP53 and KRAS. More than 85% of cancer cells contain genetic aberrations and also overexpression of hTERT, and, in fact, the promoter of hTERT characterizes all malignant cells.

PATIENTS AND METHODS

Our sample is composed of 18 patients, including 10 with CRC that underwent surgical procedure and 8 patients without CRC, which represent the control group. The hTERT gene expression, KRAS and p53 were evaluated by methodical Real Time - PCR on RNA extracted from tumor tissues, peritumoral tissue and control cases.

RESULTS

Within the CRC group the evaluation of the tumor tissue showed an increase of hTERT expression with a statistical significance (> 0.1) in 5 of these, also associated with substantial increase of KRAS (> 0.2). The peritumoral tissue assessment showed important increase in KRAS in 4 patients (> 0.2), while hTERT is not found to be particularly increased. The value of p53 did not show any particular significance (<0.1).

DISCUSSION

The analysis of our data leads us to consider that the increase of hTERT is evident in patients suffering from CRC and that some of them will become significant in relation to the increase of KRAS and independent of p53. In peritumoral tissues, however, KRAS increases considerably, instead hTERT maintains a low concentration and this is compatible with the cellular evolution of the neoplastic tissue adjacent to the tumor.

CONCLUSIONS

hTERT could be used for diagnosis and prognosis in the future, to be able to identify the risk of tumor progression and to set up an adequate therapy.

Lymph node assessment in colorectal cancer surgery: laparoscopic versus open techniques

AIM

The aim of our study is to compare the outcomes of laparoscopic resection (LR) and open resection (OR) for colorectal cancer surgery evaluating lymph node assessment. It may be important to remove and examine an adequate number of lymph nodes because a more extensive nodal resection has been associated to higher survival rate and lower recurrences.

PATIENTS AND METHODS

150 patients (74 females and 76 males) with colorectal cancer were enrolled and analyzed from January 2006 to March 2010 in our Unit. 100 procedures were performed with traditional laparotomy and 50 procedures laparoscopically. A strict follow-up was scheduled every 1-3-6 months after surgery and, therefore, every year.

RESULTS

Laparoscopic techniques require a longer operating time. 2484 total lymph nodes examined with a mean of 16,56 removed per resection in all procedures. 1632 lymph nodes were removed during open procedures and 852 removed during laparoscopy. The scheduled follow-up demonstrated that local recurrence and distant metastasis presented with no significant differences between two groups and overall survival and disease-free survival were assessed over 5 year in 80% of patients.

CONCLUSIONS

According to our experience, laparoscopic colorectal surgery is safe and feasible, with better short-term outcomes and oncological adequacy comparable to open approach.

Gallstone ileus in a ninety-two years old colecistectomized patient after endoscopic biliary sphincterotomy: a case report

INTRODUCTION

Gallstone ileus is an uncommon condition of mechanical bowel obstruction caused by the passage of a gallstone into the bowel. It occurs more frequently in female patients older than 65 years and often for a biliary-enteric fistula. The pathognomonic features of gallstone ileus - the Rigler's triad - are pneumobilia, ectopic gallstone and bowel obstruction. Less commonly, a gallstone may enter the intestinal lumen through the common bile duct, after endoscopic retrograde cholangiopancreatography, and very rarely in colecistectomized patient.

CASE REPORT

A 92-year old colecistectomized male patient was admitted to our unit for the clinical suspicion of bowel obstruction. He was also submitted to ERCP seven months before. Physical examination revealed tenderness in the lower abdomen and CT showed intrahepatic and extrahepatic biliary dilatation and small bowel obstruction with a hyperdense formation in right iliac fossa as gallstone ileus. It was performed an emergency laparotomy with enterotomy and a 5x3 cm gallstone removal. There were no post-operative complications and the patient was discharged 8 days after surgery.

DISCUSSION

Cholecysto-duodenal fistulas are most frequently described in worldwide-reports. There are only few cases in literature of gallstone which enter the gastrointestinal tract following endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy through papilla of Vater, without a biliary-enteric fistula, causing gallstone ileus. If the patient is cholecistectomized, gallstone removal alone is required.

CONCLUSION

The differential diagnosis in case of small bowel obstruction should always include gallstone ileus, even if the patient previously underwent a cholecystectomy.

Squamous carcinoma in pilonidalis sinus: case report and review of literature

AIM

We report a case of squamous carcinoma arising from a pilonidal sinus.

CASE REPORT

Patient of 83 years old, that after 30 years had a recurrence of pilonidal sinus revealed by a sacral abscess studied with pelvic CT scan and MRI. After clinical investigation, traditional open surgical technique was performed and pathologic studies revealed a squamous carcinoma. The patient performed a new CT scan with persistence of disease, and a second surgical look with mass excision until the presacral fascia and V-Y flap was performed. Histological exami-nation was found to be positive for squamous carcinoma on the margin and the patient underwent adjuvant radiotherapy cycles with a close follow-up with evidence of free disease survival. He died after 5 years for old age.

DISCUSSION

The incidence of carcinoma arising from a pilonidalis sinus is about 0.1% and the most important risk factor is represented by a chronic abscess from 20-30 years. In literature there are about 100 cases. Gold standard treatment is surgery with complete excision of the presacral fascia, while radiotherapy decrease the risk of recurrence.

CONCLUSION

All cases reported in literature are submitted as case report. Sacro-coccyxal fistula should be treated early because chronic inflammation can determine neoplastic degeneration. Histological examination should be performed routinely. Gold standard is surgery with wide excision. There is no evidence about the gold standard for the reconstructive time.

A novel reconstructive strategy for pancreaticoduodenectomy following Roux-en-Y distal gastrectomy

The rate of pancreaticoduodenectomy (PD) performed for both benign and malignant periampullary diseases has increased. In addition, Roux-en-Y reconstruction after distal gastrectomy for cancer or ulcer is still widely used. Therefore, a surgeon may be confronted with a partially- gastrectomized patient who needs a PD. This is a very challenging circumstance for surgeons because of adhesions, bloodstream, anatomical changes and length of the remnant intestine. In our experience, we performed two pancreaticoduodenectomies after distal gastrectomy in patients with periampullary tumors. We preserve gastrojejunal anastomosis and perform an end-to-side pancreaticojejunostomy (PJ) on the afferent limb of gastrojejunal anastomosis and a termino-lateral hepaticojejunal anastomosis on an independent transmesocolic Roux-en-Y limb. In literature, few cases of PD after distal gastrectomy are reported and most of them consider only PD after Billroth II reconstruction. Many authors have demonstrated pancreaticogastrostomy (PG) is superior to PJ in terms of lower risk of pancreatic and biliary fistula, but it is not possible to anastomose pancreas stump with gastric wall in patients who have been undergone distal gastrectomy. For this reason, we retrospectively review our experience about PD following distal gastrectomy and suggest a novel standardized technique which allow surgeons to benefit from same advantages of a typical PG also in this group of patients.

Small bowel adenocarcinoma in a patient with a 5-year history of untreated Crohn's disease: a case report

AIM

Complication of Crohn's disease (CD) of the small intestine is small bowel adenocarcinoma (SBA). A lot of studies on Crohn's disease have estimated the increased relative risk of small bowel carcinoma compared to the general population. In clinical settings, it is difficult to detect SBA in CD, therefore most of cases are diagnosed after surgery for strictures without suspicion of malignancy.

CASE REPORT

The present case concerns a 48-year-old man with a suspicious 5-year history of untreated chronic inflammatory bowel disease. The patient was admitted to our unit with persistent abdominal pain, 20 kg weight loss and intestinal obstruction, confirmed at CT scans. It was performed an emergency laparotomy, terminal ileus was resected and intestinal continuity was restored. Histological examination revealed a poorly differentiated adenocarcinoma.

DISCUSSION

The risk factors of SBA include long-standing and extensive Crohn's disease, young age, male sex, smoke, early onset, complications such as strictures and fistulas The most common clinical presentation of small bowel carcinoma in Crohn's disease is intestinal obstruction accompanied by wheight loss. The diagnosis is very difficult because imaging techniques may not be able to differentiate areas of small bowel carcinomas from benign fibrotic or acute inflammatory strictures.

CONCLUSION

Small bowel adenocarcinoma is a rare disease but this evenience must be considered in patients with strictures for Crohn's disease. Preoperative diagnosis is still highly challenging despite significant radiological and endoscopic progress.

Oral manifestations of systemic disease

While the majority of disorders of the mouth are centred upon the direct action of plaque, the oral tissues can be subject to change or damage as a consequence of disease that predominantly affects other body systems. Such oral manifestations of systemic disease can be highly variable in both frequency and presentation. As lifespan increases and medical care becomes ever more complex and effective it is likely that the numbers of individuals with oral manifestations of systemic disease will continue to rise. The present article provides a succinct review of oral manifestations of systemic disease. In view of this article being part of a wider BDJ themed issue on the subject of oral medicine, this review focuses upon oral mucosal and salivary gland disorders that may arise as a consequence of systemic disease.

Total laparoscopic splenectomy for giant epidermoid cyst: a case report

INTRODUCTION

Splenic cysts are benign tumors, accidentally detected using US or CT scan. They are classified into true cyst (primary, 25%) and pseudocyst (secondary, 75%). Conventional treatment of splenic cyst, especially giant, symptomatic and complicated has been open or laparoscopic total splenectomy. Recently, partial splenectomy is recommended as well to preserve its hematopoietic function and homeostasis of blood, but it is not considered safe for complications as intra and post operative bleeding.

CASE REPORT

A 46 years old man, martial arts practitioner, underwent US abdomen scan because of left upper quadrant pain, with evidence of a splenic mass. He underwent also CT and MRI, which revealed "oval giant splenic mass of 12 cm diameter located in superior splenic pole that can be firstly referred to cyst". Considered patient's frequency to thoraco-abdominal traumas, we decided to perform a total laparoscopic splenectomy. Surgical treatment was performed with a three trocar technique and lasted 150 minutes. Post-operative follow-up was regular and abdominal drain was removed in 4th POD (Post Operative Day). Patient was discharged in 5th POD. Pathological examination revealed epidermoid cyst.

CONCLUSIONS

Total splenectomy needs to be performed in cases of giant cyst and in our limited experience it is a safe approach.

Patient-reported outcome measures in recurrent aphthous stomatitis: A critical assessment of quality properties

OBJECTIVES

To analyse the range of existing patient-reported outcome measures (PROMs) used in studies of recurrent aphthous stomatitis (RAS) and to evaluate their quality properties via the assessment of psychometric properties and interpretability.

MATERIALS AND METHODS

Electronic databases were searched to identify relevant publications related to PROMs used in RAS. Publications were selected based on predefined criteria. All identified PROMs were then classified by measuring concepts and assessed for instrument characteristics and evidence for quality properties for RAS patients.

RESULTS

Twenty-eight PROMs were used in studies of RAS patients. Instruments focused upon oral symptoms (n = 4), psychosocial status (n = 15) and quality of life (n = 9). Five PROMs (Oral Health-related Quality of Life-UK, Chronic Oral Mucosal Disease Questionnaire, Oral Health Impact Profile-14, Medical Outcome Study Short Form-36 and Mumcu's composite index) were found to have some evidence of psychometric performance. No PROMs showed evidence for interpretability of their scores in RAS patients.

CONCLUSION

There was a wide range of PROMs used in clinical studies of RAS. The majority of these PROMs lack evidence of measurement properties and interpretability for RAS patients. Further studies are required to confirm whether these instruments are suitable and useful for this patient group.

Time to onset of bisphosphonate-related osteonecrosis of the jaws: a multicentre retrospective cohort study

OBJECTIVES

Osteonecrosis of the jaw (ONJ) is a potentially severe adverse effect of bisphosphonates (BP). Although the risk of ONJ increases with increasing duration of BP treatment, there are currently no reliable estimates of the ONJ time to onset (TTO). The objective of this study was to estimate the TTO and associated risk factors in BP-treated patients.

SUBJECTS AND METHODS

Retrospective analysis of data from 22 secondary care centres in seven countries relevant to 349 patients who developed BP-related ONJ between 2004 and 2012.

RESULTS

The median (95%CI) TTO was 6.0 years in patients treated with alendronate (n = 88) and 2.2 years in those treated with zoledronate (n = 218). Multivariable Cox regression showed that dentoalveolar surgery was inversely associated, and the use of antiangiogenics directly associated, with the TTO in patients with cancer treated with zoledronate.

CONCLUSIONS

The incidence of ONJ increases with the duration of BP therapy, with notable differences observed with respect to BP type and potency, route of administration and underlying disease. When data are stratified by BP type, a time of 6.0 and 2.2 years of oral alendronate and intravenous zoledronate therapy, respectively, is required for 50% of patients to develop ONJ. After stratification by disease, a time of 5.3 and 2.2 years of BP therapy is required for 50% of patients with osteoporosis and cancer, respectively, to develop ONJ. These findings have significant implications for the design of future clinical studies and the development of risk-reduction strategies aimed at either assessing or modulating the risk of ONJ associated with BP.

A dielectrophoretic method of discrimination between normal oral epithelium, and oral and oropharyngeal cancer in a clinical setting

Despite the accessibility of the oral cavity to clinical examination, delays in diagnosis of oral and oropharyngeal carcinoma (OOPC) are observed in a large majority of patients, with negative impact on prognosis. Diagnostic aids might help detection and improve early diagnosis, but there remains little robust evidence supporting the use of any particular diagnostic technology at the moment. The aim of the present feasibility first-in-human study was to evaluate the preliminary diagnostic validity of a novel technology platform based on dielectrophoresis (DEP). DEP does not require labeling with antibodies or stains and it is an ideal tool for rapid analysis of cell properties. Cells from OOPC/dysplasia tissue and healthy oral mucosa were collected from 57 study participants via minimally-invasive brush biopsies and tested with a prototype DEP platform using median membrane midpoint frequency as main analysis parameter. Results indicate that the current DEP platform can discriminate between brush biopsy samples from cancerous and healthy oral tissue with a diagnostic sensitivity of 81.6% and a specificity of 81.0%. The present ex vivo results support the potential application of DEP testing for identification of OOPC. This result indicates that DEP has the potential to be developed into a low-cost, rapid platform as an assistive tool for the early identification of oral cancer in primary care; given the rapid, minimally-invasive and non-expensive nature of the test, dielectric characterization represents a promising platform for cost-effective early cancer detection.

Long-term effectiveness of intralesional triamcinolone acetonide therapy in orofacial granulomatosis: an observational cohort study

Summary

What's already known about this topic?

What does this study add?

Is oral bisphosphonate-related osteonecrosis of the jaw an endemic condition?

Since the introduction of bisphosphonates to treat diseases that affect bone remodelling, there has been an increasing number of cases of bisphosphonate (BP)-related osteonecrosis of the jaw (BRONJ). Epidemiological data regarding BRONJ vary widely between studies, and a number of potential methodological biases have been detected. In some small preliminary studies, single nucleotide polymorphisms associated with an increased risk of BRONJ among cancer patients have been identified. However, genetic susceptibility to oral BP-related BRONJ has not previously been discussed. We suggest that epidemiological variability could be related to the existence of a susceptibility factor particularly prevalent in the population of a well-defined geographical region. To support our hypothesis we performed a search for published case series, only including those with at least 10 patients detected in a single city or a delimited geographical region; this showed that 55% of reports came from Mediterranean countries such as Italy, Israel, Spain and France. The finding does not appear to be conditioned by publication bias. Furthermore, conditions such as classic Kaposi sarcoma and beta-thalassaemia, though not exclusive to the Mediterranean region, also have a high prevalence in that area. We speculate that some of the patients included in the selected US and Australian series may be of Spanish or Italian descent. With an ageing population, the prevalence of osteoporosis will increase, and the number of cases of oral BP-related BRONJ may rise exponentially. Identification of risk groups with susceptibility to BRONJ will arise caution when prescribing BPs and will allow new preventive and therapeutic strategies to be developed.

Peri-Tumoral Inflammatory Cell Infiltration in OSCC: A Reliable Marker of Local Recurrence and Prognosis? An Investigation Using Artificial Neural Networks

The presence of inflammatory reaction in peri-tumoural connective tissue is generally considered as a defense mechanism against cancer, but inflammation tissue in malignant transformation and early steps of oncogenesis has been recently proven to play a supporting and aggravating role in some carcinomas. Aims of this retrospective study were to evaluate in OSCCs the independent association of peri-tumoral inflammatory infiltrate (PTI) with local recurrence (LR) or survival outcome, and to verify whether PTI can be considered a marker of prognosis. Data from 211 cases of OSCC, only surgically treated between 1990 and 2000, were collected and retrospectively analyzed for PTI and the event LR (5 yrs follow-up at least) by means of univariate-multivariate and neural networks analyses. Patients (mean age 65.3 ± 12.4 yrs, M/F = 2.98) showed presence of PTI in 68.2% (144/211): (+) in 27.0%, (++) in 25.6%, (+++) 15.6%; PTI was found reduced in 24.7% of cases and absent in 7.1%. In overall PTI+ve group (n=144), 66 were TNM Stage I, 33 Stage II, 45 Stage III, none Stage IV. LR (mean 6 ± 4 months) was present in 87/211 (41.2%) patients, of which 43/144 (29.8%) in OSCCs with PTI [23 (+),. 13 (++) and 7 (+++)] vs. 44/67 (65.7%) in OSCC with PTI -/+ or PTI–ve ones. By univariate analysis, PTI+ve cases showed a significant lower risk to have LR (p<0.0001; OR= 0.2297; CI= 0.1277:0.4134) vs PTI -/+ or –ve ones, especially among cases with higher PTI value (+++) (OR= 0.1718; CI= 0.0749:03939). Multivariate analyses (Logit model and neural networks) confirmed the same datum: presence of PTI was an independent predictive variable accounting for a better tumoural outcome without LR (Logit and neural networks values: OR' 0.226; CI= 0.113:0.454; ROC Area = 0.66, respectively). In terms of prognostic significance, elevated PTI was found to have an independent association with the poorest overall survival rate (P = 0.056). Our findings strongly suggest the importance to investigate routinely PTI in OSCCs, as useful marker of tumoral behavior and prognosis, and warrant further studies on its specific cellular nature.

Taste dysfunction in head and neck malignancy

Disturbance of taste is common following radiotherapy of head and neck malignancy, that adversely affect systemic health and quality of life. Therapy remains problematic and there is thus a need for effective preventative and curative strategies for radiotherapy-associated taste disturbance. The present article reviews current knowledge of taste dysfunction associated with head and neck malignancy.

Randomised controlled trial of the efficacy of HybenX in the symptomatic treatment of recurrent aphthous stomatitis

BACKGROUND

The treatment of recurrent aphthous stomatitis (RAS) is principally directed towards reducing the pain and duration of each episode of ulceration; however, there remain few agents for which there is definitive evidence of benefit.

AIMS

The aims of the present study were to determine the efficacy of HybenX (Epien Medical Inc., Minneapolis, MN, USA), vs another device used for the treatment of RAS (Salicept; Carrington Laboratories Inc., lrving, TX, USA) to reduce the symptoms and duration of RAS and determine the safety of HybenX for this clinical application.

MATERIAL AND METHODS

Sixty-three individuals (36 male, 27 female, group median age 25 years, range 17.8-57.9 years) were entered into a prospective randomised controlled trial of HybenX vs an occlusive covering device (Salicept oral patches; Carrington Laboratories).

RESULTS

Painful symptoms over a 5-day posttreatment period were reduced by both agents although HybenX was statistically more effective at day 2 than Salicept, and there was a trend for HybenX to cause greater pain reduction than Salicept over this 5-day period. Both agents gave rise to few adverse side effects--a total of nine adverse events in eight patients were recorded. All were unlikely to be related to the treatment devices. HybenX was only applied on one occasion to the HybenX group, while individuals in the Salicept group were able to self medicate as required. The mean number of Salicept patches used per day per subject was three (s.d. 3.3) on day 1 posttreatment, 3.4 (s.d. 3.1) on day 2 and 2.7 (s.d. 1.9) on day 3. Thereafter, the number of applications fell to a mean of 0.8 on day 7.

CONCLUSION

It is concluded that HybenX safely and effectively reduces the painful symptoms of RAS.

Dental management of patients at risk of osteochemonecrosis of the jaws: a critical review

Osteonecrosis of the jaw bones is a complication of bisphosphonate (BP) drug usage characterised by trans-mucosal exposure of necrotic bone, often followed by infection and pain. Osteonecrosis is observed in cancer patients on high-potency intravenous BP more frequently than in osteoporotic individuals using low-potency oral BP. The management of osteonecrosis caused by BP is often unsatisfactory and control of risk factors is considered the most effective means of prevention. Surgical manipulation and dental infection of the jawbone are the major risk factors, hence it is suggested that careful management of oral health and relevant dental procedures may decrease the risk of osteonecrosis in individuals on BP. Recommendations for dentists and oral surgeons have been suggested by different groups of clinicians but they are often controversial and there is no clear evidence for their efficacy in reducing the likelihood of osteonecrosis development. This report critically reviews current dental recommendations for individuals using BP with the aim of helping the reader to transfer them into practice as part of pragmatic and non-detrimental clinical decisions making.

Analysis of thromboembolic risk related to high-dose intravenous immunoglobulin treatment: a preliminary clinical study of 10 patients with autoimmune mucocutaneous blistering diseases

BACKGROUND

Intravenous immunoglobulin (IVIg) treatment is a well-known treatment that has been used successfully in a broad spectrum of autoimmune diseases. Currently no data are available in the literature about the role of IVIg in the pathogenesis of thromboembolic events in patients with autoimmune blistering diseases refractory to conventional immunosuppressive treatment.

AIM

To determine the relationship between IVIg and thromboembolism in patients with autoimmune blistering diseases and to establish a protocol to deal with the thromboembolic risk.

METHODS

In our preliminary clinical study, 10 patients with autoimmune blistering diseases underwent IVIg cycles to a total of 133 cycles in all (total number of infusions in the patient group: 399), at a standard dose of 2 g/kg/infusion accompanied by an accurate and a complete clinical and laboratory screening for thromboembolism. Preventive measures, such as hydration before and after IVIg, and administration of 100 mg of acetyl salicylic acid (aspirin) or 1000 IU of subcutaneous heparin calcium per day for 3 weeks, were introduced to reduce the thromboembolic risk.

RESULTS

Throughout the 2 years of IVIg treatment, no patient developed a superficial and/or deep venous or arterial thrombosis, even though some of the patients had underlying thromboembolic risk factors and had tested positive for some congenital and acquired thrombophilia markers.

CONCLUSIONS

Our results indicate that thromboembolic events are uncommon, despite the presence of risk factors. However, as these disorders are very rare and the percentage of nonresponder patients is very low, further investigations are needed to better understand whether IVIg alone is able to trigger these fatal events in blistering disorders.

[An electro-stimulating oral splint for dry mouth treatment]

Dentists encounter regularly patients with xerostomia, which is the accepted term for dry mouth complaint. Left untreated, xerostomia can lead to psychosocial distress and to impaired quality of life. Oral complications of the most frequent cause of xerostomia, salivary gland hypofunction, include dental caries and candidiasis. In addition, quality of life is significantly hampered. The etiology of xerostomia is multiple, but the most common conditions are Sjögren's syndrome, radiotherapy to the head and neck and use of medications. Current therapies offered by dentists rely on saliva substitutes and stimulants such as chewing gum, and are somewhat limited by their short-term efficacy. Oral mucosal electro-stimulation increases salivary secretion and relieves symptoms of dry mouth in patients with xerostomia. Therefore, intra-oral electronic devices have been developed aimed at stimulating salivary gland function. They offer promise as an optional safe and non-chemical treatment of xerostomia.

Onset and progression of clinical manifestations of orofacial granulomatosis

BACKGROUND

There remain few studies describing in detail the early occurrence and long-term progression of clinical manifestations of orofacial granulomatosis (OFG) in a substantial number of patients.

OBJECTIVES

The aim of this study was to determine the early and late clinical manifestations of a large case series of patients with OFG.

PATIENTS/METHODS

Clinically relevant data of 49 patients with OFG who attended an Oral Medicine unit in the UK were examined retrospectively. The analyzed parameters included occurrence and typology of initial manifestations at onset and with respect to long-term follow-up.

RESULTS

Five major patterns of disease onset were observed. Recurrent facial swelling with/without intra-oral manifestations was the single most common presentation at onset followed by intra-oral ulcers, and other intra-oral and neurological manifestations. The majority of patients later developed a spectrum of additional features.

CONCLUSIONS

OFG results in multiple manifestations at different time points. The disease onset is characterized by manifestations other than facial swelling in about half of affected individuals. However, patients can develop cosmetically unacceptable lip/facial swelling at a later stage. Nearly all affected individuals ultimately develop lip/facial swelling while about half of all patients develop oral ulceration.

Oral and pharyngeal cancer in South Asians and non-South Asians in relation to socioeconomic deprivation in South East England

From UK Thames Cancer Registry data, after controlling for socioeconomic deprivation of area of residence, South Asian males showed a higher relative risk of oral (1.36; 95% CI: 1.11, 1.67), but not of pharyngeal cancer than non-South Asian males, whereas South Asian females had much higher risks of these cancers (3.67; 95% CI: 2.97, 4.53 and 2.06; 95% CI: 1.44, 2.93), respectively, than non-South Asians.

Electrostimulating device in the management of xerostomia

INTRODUCTION

The present study was undertaken to evaluate the safety and effectiveness of a recently developed electrostimulating device mounted on an individualized intra-oral removable appliance.

MATERIALS AND METHODS

The device, containing electrodes, a wetness sensor, an electronic circuit and a power source, was tested on patients with xerostomia in a crossover, randomized, sham-controlled, double-blinded, multicenter study. Electrical stimulation and also sham were delivered during 10 min to the oral mucosa, in the mandibular third molar region. Oral dryness was measured by the sensor. As the primary outcome, sensor dryness and xerostomia symptom changes as a result of device wearing were assessed, and compared between active and sham modes. In addition, side-effects were recorded.

RESULTS

Electrostimulation resulted in a significant decrease in sensor dryness, leading to a beneficial effect on patients' subjective condition. No significant side-effects were observed.

Macroscopic classification of superficial neoplastic lesions of the oral mucosa: a preliminary study

BACKGROUND

Careful endoscopic classification of macroscopic appearance of superficial neoplasias of the gastrointestinal tract is essential in the early detection and appropriate treatment of cancer. It has contributed to introduce minimally invasive endoscopic surgery and has significantly improved survival of patients with colon and gastric cancers. Squamous cell carcinoma of the oral cavity has been characterized, in past and present times, by poor prognosis and lack of progress in treatment outcome. Failure in diagnosing oral malignancy at an early stage is a major culprit, and the lack of a worldwide adopted classification of its macroscopic appearance, similar to that of gastrointestinal neoplasias, may have contributed to it.

AIM

To test the hypothesis that is possible to extend the diagnostic benefit of a classification based upon the macroscopic appearance of superficial tumours of the digestive tract to superficial carcinoma of the oral mucosa.

METHODS

We retrospectively examined a group of patients who developed multiple intraepithelial and early invasive malignant oral neoplasias, applying a modified version of the Paris classification of superficial GI neoplastic lesions.

RESULTS

One hundred and ten out of 116 (94.9%) of the study lesions had morphological features that accorded with the prepared classification.

CONCLUSIONS

These preliminary data suggest that most superficial early neoplastic lesions of the oral cavity can be easily detected using a well-defined classification system similar to that employed in the diagnosis of early gastrointestinal malignancy.

Field cancerization in oral lichen planus

BACKGROUND

The concept of field cancerization describes the tendency of patients with premalignant and malignant lesions of head and neck mucosal sites to develop multiple carcinomas of the upper aerodigestive tract. Here we address whether this concept should be extended also to patients affected by oral lichen planus (OLP), an inflammatory disorder associated with an increased risk of cancer development.

METHODS

Data from a cohort of 45 patients with OLP who subsequently developed severe dysplastic changes and/or oral squamous cell carcinoma were retrospectively reviewed. Patients who presented more than one oral neoplastic event were considered for further data analysis as regards incidence, localization, management and prognosis.

RESULTS

Twenty (44.4%) patients were affected by one single neoplastic event while 25 (55.6%) developed multiple and often multifocal oral dysplastic and/or malignant events. In most cases, a careful surveillance programme led to diagnosis and effective treatment of oral neoplasias at an early intraepithelial and microinvasive stage, leading to long-term survival. In some patients, however, additional primary tumours occurred suddenly with rapid invasion, leading to advanced stage diagnosis and poor prognosis. Overall, three patients (12%) died due to malignant oral disease.

CONCLUSIONS

Patients with OLP and subsequent development of dysplasia/ oral squamous cell carcinoma are at risk of having multiple and multifocal neoplastic events of the oral cavity, a phenomenon which parallels the concept of field cancerization of traditional head and neck cancers. If detected at an early stage, these neoplasias can be managed with superficial and complete resection. However a small number of patients have loco-regional tumour spread despite a standard surveillance protocol.

Treatment of Gorham’s disease with zoledronic acid

Gorham's disease (GD) is a rare disorder characterized by spontaneous and progressive osteolysis of one or more bones and thought to belong to lymphangiomatoses spectrum of diseases. Surgical, radiation and medical therapies have been performed with variable and often discouraging outcomes and currently there is no recognized effective treatment. In this paper we describe a 24-year-old girl with GD localized to mandible who was effectively managed with zoledronic acid, a nitrogen-containing high-potency bisphosphonate.

Sjögren's syndrome: the diagnostic potential of early oral manifestations preceding hyposalivation/xerostomia

Sjögren's syndrome (SS) is a systemic autoimmune exocrinopathy that affects mainly the salivary and lacrimal glands, leading to progressive reduction in saliva and tear flow. Although the underlying immuno-mediated glandular destruction is thought to develop slowly over several years, a long delay from the start of the symptoms to final diagnosis has been frequently reported. A limited knowledge concerning SS natural history is among the major causes of the actual diagnostic delay. Although very few studies have been focused on the analysis of SS early clinical onset, a series of oral features preceding xerostomia/hyposalivation development in patients eventually diagnosed as having SS have been reported. Sialochemistry alterations, salivary gland swelling, early dental loss and sialorrhea have been observed before the onset of typical signs and symptoms (namely xerostomia and/or hyposalivation), which usually lead to SS clinical presentation and diagnosis. Here we suggest, after evaluating available data, that the traditional 'untouchable' association between SS and xerostomia/hyposalivation might probably be reconsidered, and that astute clinicians should not underestimate the possible presence or development of SS in patients without xerostomia/hyposalivation and presenting these atypical early oral features.

The World Cancer Report and the burden of oral cancer

The WHO has recently provided the most comprehensive global examination of cancer to date, through the publication of the World Cancer Report (WCR). According to IARC-WHO estimates, cancer rates are set to increase at an alarming rate, from 10 million new cases globally in 2000, to 15 million in 2020. However, the report states that we have the opportunity to stem the predicted sharp increase in new cancer cases by taking action now, especially through planning effective cancer control strategies, such as reducing tobacco consumption, suggesting healthy lifestyle and diet, and performing early detection through screening. Although cancer of the oral cavity is largely related to lifestyle and can be easily detected and diagnosed at early stages through a 5 min visual inspection of the oral mucosa, actual figures concerning its prevention and early detection are dismal. Most oral cancers are detected at a late stage, requiring complex, costly and often ineffective therapies. Similarly, current research, educational and financial resources are focused on procedures burdened by high cost, high morbidity and unacceptable high mortality. Here we suggest that it is time to change this common point of view towards this disease and to alter this trend, stressing that there is no other oncologic specialty in which the WCR preventive guidelines could be applied in such an easy and effective manner, as in the field of oral cancer.

Effectiveness of small-volume, intralesional, delayed-release triamcinolone injections in orofacial granulomatosis: a pilot study

BACKGROUND

Orofacial granulomatosis (OFG) is an idiopathic disorder characterized by chronic orofacial swellings causing significant cosmetic and functional problems. Treatment with high-volume triamcinolone injections has been shown to be effective but requires nerve block anesthesia and causes a dramatic temporary increase of lip swelling.

OBJECTIVE

We have performed a noncomparative open-label pilot study in 7 patients with OFG in order to evaluate the effectiveness of small volumes of extended-release high-concentrate triamcinolone injections in reducing lip swelling and preventing recurrences.

METHODS

Seven patients with OFG were studied. Small-volume, intralesional, high-concentrate, extended-release triamcinolone was injected on the basis of a weekly schedule. A standard cycle consisted of 2 or 3 injection sessions over 14 or 21 days, depending on the clinical response.

RESULTS

After cycle completion, all patients remained without recurrences or with cosmetically acceptable slight lip enlargement for a mean time of 19 months (range, 8-30 months). No side effects were observed, except in one patient with hypopigmentation of the skin of the upper lip.

CONCLUSIONS

Slow-volume, intralesional, high-concentrate, extended-release triamcinolone injections appear to be effective in reducing lip enlargement in patients with OFG and do not require nerve block anesthesia or cause a temporary troublesome increase of swelling. A long disease-free period is generally obtained.

HCV infection and oral lichen planus: a weak association when HCV is endemic

Oral lichen planus (OLP), an immune-mediated disorder, has been reported as an extra-hepatic manifestation of Hepatitis C virus (HCV) infection, especially in HCV hyperendemic areas such as southern Europe and Japan. The aim of this study was to investigate from an epidemiological standpoint whether HCV infection is an important factor affecting the relative risk of OLP in a Mediterranean population or whether this relates to the degree of HCV endemicity. Two cohorts of OLP patients resident in two different regions of southern Italy (Campania and Sicily; n = 859) were evaluated for HCV infection status and categorized into five age classes to respective region-matched controls. No significant difference was found between OLP patients and the general population in this area, when data were corrected by the age-stratified prevalence of HCV. Therefore, the age-specific prevalence of HCV infection in OLP patients shows a close trend of direct association with increasing age, without significant differences with the general population of each geographical area. An aetiological link between OLP and HCV cannot be inferred solely by epidemiological data.

Anorexia/bulimia-related sialadenosis of palatal minor salivary glands

In patients affected by alimentary disorders sialadenosis is frequently observed. This non-inflammatory condition is described to affect major salivary glands, leading to the characteristic parotid and/or submandibular swelling. Thus fine-needle aspiration cytology or parotid open biopsy are generally required to diagnose histologically the disorder. We report the case of a 28-year-old patient affected by bulimia/anorexia nervosa who presented, in addition to parotid enlargement, a bilateral symmetric painless soft swelling of the hard palate. The lesion was biopsied and histopathological examination showed the classical features of sialadenosis. To our knowledge, this is the first case of sialadenosis affecting palatal minor salivary glands. It underlines that when sialadenosis is clinically suspected, clinicians could check also patients' oral cavity for minor salivary glands involvement, in order to potentially avoid invasive extra-oral procedures and to easily confirm diagnosis with an intra-oral biopsy.

Clinical behaviour of malignant transforming oral lichen planus

AIMS

At present oral lichen planus (OLP) is classified among precancerous conditions but very few data are available in literature regarding prognosis of OLP-related cancers. The aim of this paper is to evaluate clinical long-term behaviour of OLP-related oral squamous cell carcinomas (OSCCs).

METHODS

Clinical history and data from follow-up regarding 21 patients undergoing malignant transformation of OLP have been critically revised.

RESULTS

In a mean time of 2.6 years from diagnosis of OLP, patients developed OSCCs. Histopathologically, two carinomas showed a moderate degree of differentiation, while the others were well differentiated. Six (28.5%) were in situ OSCC, in eight (30%) was found a microinvasive pattern of infiltration, one was a stage II tumour and the remaining (6 cases) were stage I tumours. During follow up, four patients (19%) have developed another OSCC in a mean time of 11 months from the first occurrence. In two men (10% of cases), multiple OSCCs occurred and in five cases (24%) lymph nodal metastases were detected.

CONCLUSIONS

Our study points out an alarming tendency in developing second primary metachronous tumours (33.3%) of the oral cavity and nodal metastases (23.8%), especially if we consider their early stages. Thus we always recommend a strict follow-up of OLP patients with clinical oral and neck examination every 2 months for 6-9 months since OSCC diagnosis is made and, after, three times a year.

Costs and effectiveness in the care of patients with oral and pharyngeal cancer: analysis of a paradox

Oropharyngeal cancer is estimated to be the ninth most common cancer worldwide. Its prognosis is largely dependent upon tumour-stage at the time of diagnosis. Stage I and II oropharyngeal cancers are characterized by a 5-year survival rate ranging from 70% to 90%, and the management of these early carcinomas is usually of short duration, easy and very cost-effective. On the other hand, the diagnostic evaluation, treatment and management of complications and recurrences of advanced stage oral tumours (stage III and IV) are often very long, complex and costly. They also have very poor prognosis with survival figures dropping to about 20%. Nowadays, most oropharyngeal cancers are detected at a late stage with an overall 5-year survival rate of around 45-50%, and with a conspicuous increase in treatment costs and a worsening of prognosis. Even if formal and comprehensive cost-effectiveness and cost-benefit analyses are not currently available in the oropharyngeal cancer literature, it seems clear that, in the care of these patients, the enormous consumption of resources is not associated with acceptable outcomes. New initiatives should be evaluated, planned and developed for the care of patients with oral and pharyngeal cancer. These strategies should be directed at prevention and early diagnosis in order to increase patient survival and quality of life and decrease the consumption of health care resources.

Metastases in small thickness oral squamous-cell carcinoma arising in oral lichen planus

Oral lichen planus (OLP) is classified among precancerous conditions, as it is considered a generalized state associated with a significantly increased risk of cancer. The objective of this study was to discuss ultra-structural aspects of OLP that could play a role in enhancing metastatic potential, thus worsening the prognosis in oral squamous-cell carcinoma (OSCC). We report four cases of microinvasive OSCC which have occurred in OLP patients. All of them were stage I tumors, with a mean thickness of 1.75 mm. Recent studies indicate a tumor thickness over 4 mm as predictive of nodal metastases, but within 6 mo, our four patients with OSCC arising from OLP developed lymphnodal metastases. Our findings suggest that OLP-related OSCC may have a worse prognosis because of increased metastatic potential; obviously, further investigation is required, but this preliminary evidence emphasizes that extremely careful management of OLP patients is mandatory, and in cases of OSCC arising from OLP, a more radical treatment is probably required.

Glucose-insulin-potassium treatment in combination with dipyridamole inhibits ischaemia-reperfusion-induced damage

AIMS/HYPOTHESIS

Treatment with intravenous glucose-insulin-potassium has beneficial effects in reperfused patients, reducing mortality in patients with myocardial infarction by 28 %. We hypothesized that insulin response to glucose-insulin-potassium infusion might lead to vasodilation in ischemia/reperfusion (I/R). Hyperglycaemia and hyperinsulinaemia determine oxidative stress. We therefore investigated the microcirculatory changes following I/R after glucose-insulin-potassium or in association with glucose-insulin-potassium dipyridamole in hamster cheek pouch.

METHODS

The control (I/R), glucose-insulin-potassium groups with and without dipyridamole were treated with saline, 300 g/l, 50 U/l insulin and 80 meq/l KCl infused at 0.2 ml. 100 g-1. h-1, and GIK plus dipyridamole (0.084 mg. 100 g-1 intravenously) at beginning, 30 min before ischaemia, and continuing through reperfusion. We measured microvessel diameter changes, arteriolar red blood cell velocity, permeability increase, capillary perfused length, leukocyte and platelet adhesion.

RESULTS

Hyperglycaemia and hyperinsulinaemia did not cause vasodilation whereas in the glucose-insulin-potassium group with dipyridamole there was a marked arterial vasodilation with increased red blood cell velocity and perfused capillary length at reperfusion. Glucose-insulin-potassium infusion reversed the arterial vasoconstriction caused by I/R at reperfusion. Adhering leukocytes to venules decreased by 56 and 86 % while platelets adhering to microvessels was reduced by 52 and 72 % at reperfusion in glucose-insulin-potassium groups with and without dipyridamole, respectively. The permeability was decreased by GIK and completely suppressed by GIKD after I/R. Conclusion hypothesis: We demonstrated that GIK, when used in combination with dipyridamole, had beneficial effects on the capillary perfusion against I/R-induced injury. There was a marked reduction of leukocyte and platelet adhesion that can be explained by the antioxidant properties of dipyridamole.

Orofacial granulomatosis with gingival onset

BACKGROUND, AIMS

Orofacial granulomatosis (OFG) is a descriptive term used for granulomatous disorders of the face and oral cavity that may occur for a variety of reasons, some of which result in significant morbidity and mortality. Although rarely, a granular enlargements of the gingiva may be the first clinical manifestation of OFG, preceding other local or systemic manifestations.

METHOD

We will report a case of OFG that showed an atypical and monosymptomatic onset with a generalized hyperplastic gingivitis that preceded other facial and mucosal features by several weeks.

RESULT

Considering the variable clinical onset of OFG and its apparent increase in incidence, we emphasize that in some cases, the periodontologist, as first consulted health care professional, plays an important role to detect this disorder. Early diagnosis of OFG is a crucial step to prevent and cure its unsightly sequelae and sometimes avoid progression of systemic potentially life-threatening OFG-related diseases.

CONCLUSION

Thus, when none of the common causes of gingival enlargement can be detected, OFG diagnosis should be suspected.

Non-invasive prediction of angiographic progression of coronary artery disease by dipyridamole-stress echocardiography

BACKGROUND

Coronary angiography is the currently accepted standard means for assessing progression of coronary artery disease. A dipyridamole-echocardiography test (DET) might provide an alternative non-invasive functional imaging method for this purpose.

OBJECTIVE

To assess whether variations in results of serial DET match variations in angiographic assessments of coronary artery disease.

METHODS

From the Pisa Institute of Clinical Physiology stress-echocardiography data bank (1983-1998), we selected 60 patients satisfying the inclusion criteria of coronary angiography and DET having each been performed and interpreted twice independently and within 1 week. The second angiographic and stress-echocardiographic assessment was performed 45+/-31 months after the initial one. Angiographic progressors were defined a priori as patients with any progression of stenosis to occlusion and those with any stenosis > 30% with > 20% progression of stenosis measured by visual and quantitative coronary angiography. Stress-echocardiography progressors were defined as those patients who had previously had a negative test of a test having a positive result and those patients who had positive results of tests both in initial testing and in a second session of testing with the latter having a peak wall-motion-score index > 0.12 (on a scale of 1, normal to 4, dyskinetic in a 16-segment model) larger than the former.

RESULTS

Of the 60 patients, 44 were angiographic 'progressors' and 16 were 'non progressors'. Stress-echocardiographic responses were concordant with angiographic identification for 39 of 44 progressors and 15 of 16 non-progressors, with an overall concordance of 90%.

CONCLUSIONS

Measurement of dipyridamole-stress-echocardiographic response allows one to separate angiographic progressors and non-progressors efficiently, simply by taking into account the presence, extent and severity of stress-induced abnormalities of wall motion.