Resistance or pseudo-resistance?

Introduction

Treatment-Resistant Depression continues to represent a great challenge for clinicians.

Objectives

We investigated patients with history of resistance, assessing prognostic factors, response to treatments, and remission over time.

Methods

We recruited 202 unipolar and bipolar depressed inpatients. According to anamnestic backgrounds, patients were assigned to: A) Non-resistant : responders, with no characteristics of resistance in the current episode. B) Resistant: resistant to two antidepressant trials of adequate doses and duration. C) Pseudo-resistant : non-responders, not classifiable as Resistant because of inadequate trials. During hospitalization, patients were treated by clinical judgment, following a rehabilitation program.

Results

Table 1 Non-resistant (111) Resistant (54) Pseudo-resistant (35) p-value Age 59.1±11.9 63.0±12.6 57.0±11.3 0.036* Episodes of illness 3.8±2.1 4.0±1.9 3.0±1.8 0.036* Personality disorders 27.0% 18.9% 48.6% 0.009** Therapies: 0.014** SSRI 62.4% 40.4% 69.7% SNRI 19.8% 42.3% 15.1% TCA 17.8% 17.3% 15.1% Augmentation 24.3% 38.9% 17.1% 0.05** Remission 76.5% 59.5% 81.2% CvsB:0.045** CvsA:0.587**

On the day of admission, non-responders were 44.5% of the sample, but 39.3% of them did not meet the Resistant criteria, defining the Pseudo-resistant group. Pseudo-resistant differed from others by younger age, fewer illness episodes, higher rate of personality disorders, and different therapies during hospitalization [Fig.1,2,3]. Pseudo-resistant remission rate, significantly greater than Resistant one, was comparable to Non-resistant [Tab.1]. *Kruskal-Wallis Test **Chi-Squared Test

Conclusions

This study outlines a new group of depressed patients that, apparently drug-resistant, displays the same outcome as responders when treated with first-line drugs during hospitalization, certainly taking benefit from the psychoeducational program. Quick recognition of these patients could be crucial to giving optimal care.

Disclosure

No significant relationships.

P143 EDOXABAN EFFECT IN A BREAST CANCER PATIENT WITH LIVER ARTERIAL INFUSION CHEMOTHERAPY (LAIC) AND BOTH JUGULAR VEIN AND HEPATIC ARTERY THROMBOSIS. A UNIQUE CLINICAL CASE

 

41 y–o woman, without cardiovascular risk factors, was diagnosed with breast cancer (pT2N1aMx, G3, ER:70%, PgR:30%, HER–2/NEU:2+, Ki67:60%). Treated (2010) with adjuvant antracyclines, taxanes and hormonal therapy. Subsequently, developed (2012) bone lesions treated with radiotherapy and hepatic metastases (2016) treated with systemic infusions of bevacizumab and taxanes. Started (2017) chemoembolization (CE), due to further liver severe progression configuring a main hepatic disease. Started LIVER ARTERIAL INFUSION CHEMOTHERAPY (LAIC) with 5fluoruracil and concomitant venous systemic chemotherapy (CT) with taxanes and bevacizumab. Developed (2020) arterial catheter–related thrombosis (ACRT) recurrent after urokinase, clopidogrel and enoxaparin, in spite of thromboprohylaxis with aspirin/clopidogrel. LAIC was discontinued and CT with taxanes and trastuzumab was administrated by systemic route. Left jugular deep vein thrombosis (DVT) occured (2021), treated for 8 months with low–molecular–weight heparin (LMWH): firstly with enoxaparin 100 IU/kg twice a day and secondly, because of lack of efficacy and patient’s request for a more manageable therapy, with parnaparin 6400 IU once a day. After 8 months the patient refused any more injectable anticoagulant drugs, asking for oral root of administration. LMWH were replaced by direct oral anticoagulant (DOAC), edoxaban 30 mg/die (weight: 43 kg). After 3 months of edoxaban a duplex ultrasound showed an almost total DVT regression; neither bleedings nor dru–drug interactions with the ongoing CT were detected. Instead, the 3 months follow–up CT–scan revealed persistence of the ACRT, despite of edoxaban.

Conclusions

Thromboembolism is the second leading cause of death in malignancy. Venous thromboembolic events are prevalent compared to the arterial ones. However, in active cancer hypercoagulable burden is common to both kind of thrombosis and sometimes occur simultaneously. In this case, a young woman with advanced breast cancer treated with CE and LAIC developed both DVT and ACRT. According to inefficacy and patient’s preference, we replaced LMWH with edoxaban. Arterial thrombosis was persistent although treated with several antithrombotic agents, whereas edoxaban resulted effective in the DVT regression. The take home message of this case report is that DOACs could be a feasible, efficient and safe anticoagulant choice for venous cancer related thrombosis.

Italian law no. 1/2021 on the subject of vaccination against Covid-19 in people with mental disabilities within the nursing homes

Abstract

The Coronavirus Disease-19 (Covid-19) pandemic, in the last year, has resulted in a significant number of infections and deaths among nursing homes' residents. This phenomenon has set up the necessity to subject these patients, often suffering from mental disabilities to a vaccination against Covid-19. However, vaccination has long been the subject of public atten-tion, being regulated differently in many European countries. In Italy, the Ministry of Health has given priority, vaccination-wise, to health facilities' patients. The government has regulated through-law no. 1 of January 5, 2021, art. 5, the manifestation of consent to be Covid-19 vac-cinated in incapacitated subjects admitted to assisted health facilities. This rule arose from the need to protect fragile individuals as well as providing real dispositions for the involved health professionals. Nursing homes' elderly guests could be divided into four catego-ries: a) subjects capable to express their will (affected by physical problems); b) subjects who, due to varying degrees of incapacitation, have their own legal guardian, curator or support administrator, ap-pointed in accordance with the law; c) incapacitated subjects without legal representatives d) subjects who, pursuant to law no. 219/2017, have appointed their own trustee. This paper provides for a clear exemplification of all the possible scenarios identified by the Italian law no.1/2021.

Uninformed consent: Who knows what Ivan Ilyich would have thought?

Abstract

In the modern era, when prolonging life is not an option, the end-of-life discussions are unavoidably influenced by Neuroethics. Despite this, it is interestingly evident how the sentiments of a terminal patient of 1885 and a physician of 2020, are still comparable. This paper pre-sents the arguments behind the so-called "Therapeutic Misconception" and the aim of palliative care to provide dying patients support. It is essential to address priorities of informed consent, signed before any remedy is provided. A key component of the newest Neuroscience research is the analysis of motivation and free will. So, it is necessary to comprehend if the patient struggles to feel at peace with these aspects of his "right to die": Is he free to choose or is he influenced by the doctors? Is this confusion an example of "Therapeutic Misconception"? Is his Informed Consent totally "Informed"? In order to broaden our understanding, we account for many critical situations, such as the mentally impaired Psychiatric patients or the famous Italian case of Eluana Englaro. In addition, we suggested some current approaches such as Artificial Intelligence, useful in preserving some cognitive functions the patient may have lost. Furthermore, research in this field is very critical and in some Catholic countries like Italy, people faced difficulties accepting the idea of the "Anticipated directives". In general, whatever the mental status and whatever the terminal state, the patients seem still far from handling their own auto-determination and their Consent, even if the ultimate goal is to die with dignity.

Comparative study between conventional and new methods in defining the cause of death from anaphylactic shock

Abstract

Anaphylaxis is defined as a rapid systemic reaction that develops in individuals previously exposed to specific allergens. The new exposure causes systemic cellular degranulation, which in turn leads to cardiovascular and respiratory changes that are fatal if not treated immediately. One of the main problems of this scenario in the forensic field is the determination of a correct post-mortem diagnosis. Traditional methods, such as histopathological examination of the respiratory tract and the use of specific antibodies used in immunohistochemistry, are sensitive but not always specific and therefore do not guarantee a high degree of probability in the diagnosis of anaphylaxis. For this reason, a new and promising research frontier in this field of forensic pathology could be represented by the application of miRNAs as biomarkers, as has been done in other areas of medicine.

Local treatment with deep percutaneous electrochemotherapy of different tumor lesions: pain relief and objective response results from an observational study

OBJECTIVE

The aim of this investigation focuses on the evaluation of the efficacy of deep-seated Electrochemotherapy (ECT) in terms of pain relief and local objective response, in pre-treated patients with neither further available pharmacological treatments nor eligible for surgery.

PATIENTS AND METHODS

Deep percutaneous ECT has been performed in 20 patients subjected to systemic anaesthesia. Bleomycin was administrated intravenously before the application of the electrical pulses on the target area, employing multiple single needles depending on the size and location of the target tumor.

RESULTS

Pain assessment based on Visual Analogue Scale showed significant pain relief one month after treatment in all patients, reducing from 7.5 to 3 as a median value (p-value at Wilcoxon test <0.001). Local symptom-free survival median value was 5.5 months. At the first follow-up (1-2 months), a local disease control rate (LDCR) was observed in 19/20 (95%) patients: complete responses in 2 (10%), partial responses in 8 (40%) and stable disease in 9 (45%). Local progression-free survival median value was 5.7 months. Overall, no major adverse effects were observed.

CONCLUSIONS

Our study indicates that deep percutaneous ECT can produce a significant pain reduction and a high LDCR in different tumor lesions, for anatomical site or histotype. In particular, ECT has demonstrated to be effective in various histotypes and deep-seated tumor lesions never treated before by this approach giving a new chance to physicians for reducing oncological pain in patients not eligible to other therapeutic routes. The innovative peculiarity of our study was the successful application of deep percutaneous ECT on adrenal metastasis, malignant pleural mesothelioma, uterine leiomyosarcoma and the uncommon case of a male müllerian tumor.

Rules on informed consent and advance directives at the end-of-life: the new Italian law

End-of-life decisions are an emergent issue for bioethical debates and practical concerns among health professionals. On December 2017, Italy enacted a new law named "Rules about informed consent and advance directives", which promotes the relationship of care in a fiduciary sense through the implementation of a correct and exhaustive information. It is also prescribed to record in writing all the patients' decisions about consent or refusal. Furthermore, the law explicitly forbids unreasonable therapeutic obstinacy for terminal patient, legitimizing deep palliative sedation. Finally, the law establishes the use of "advance directives" as a written document by which adults and capable people can express their wishes regarding health treatments and diagnostic tests in anticipation of a possible future incapacity. The law provides that doctors must comply with these directives, unless they appear clearly incongruous or not corresponding to the patient's current clinical condition.

A rare case of Spinal Epidural Abscess following mesotherapy: a challenging diagnosis and the importance of clinical risk management. Considerations concerning uncommon risk factor for development of Spinal Epidural Abscess and its prevention

Spinal Epidural Abscess (SEA) is a rare pyogenic infection localized between dura mater and vertebral periostium. The development of SEA is associated with the presence of medical co-morbidities and risk factors that facilitate bacterial dissemination. It is possible distinguish two type of SEA: primary SEA due to pathogen hematogenous dissemination and secondary SEA resulting from direct inoculation of pathogen. This entity, very uncommon, shows a prevalence peak between the 5th and the 7th decade of life with predominance in males. The case is a 44 years old Caucasian man with chronic low back pain, treated with physiotherapy and anti-inflammatory drugs. Following an episode of acute severe exacerbation of pain, the patient underwent four session of dorsal and lumbo-sacral area mesotherapy. One month after the last session, the patient experienced acute sever lumbar pain, radiated to left lower limb and accompanied by fever and vomiting. During hospitalization, elevated levels of white blood cells and C Reactive Protein (CRP) were found. Moreover, a vertebral magnetic resonance imaging revealed the presence of intramedullary lesion. Furthermore, methicillin sensitive staphylococcus aureus was isolated from three blood cultures and antibiotic therapy was performed. In our case the patient had the typical SEA onset, without any specific risk factors excepting the execution of four session of mesotherapy. Aim of this study is to explain risk factors for the SEA development and to clarify how act as preventive measure, because also acupuncture can promote bacterial infection.

P658 Impact of hyperuricemia on left ventricular longitudinal systolic function in uncomplicated hypertensive patients

Background

Hyperuricemia has been reported to accelerate the occurrence and worsening of cardiovascular disease, being a risk factor for coronary heart disease and cardiac mortality. Elevated uric acid (UA) is also associated with left ventricular (LV) hypertrophy and with LV diastolic dysfunction. The effect of hyperuricemia (HU) on LV systolic function is still unclear.

Purpose

Aim of our study was to evaluate the impact of elevated UA serum levels on LV systolic function, also evaluating longitudinal deformation, in a population of hypertensive patients.

Methods

We enrolled 160 treated hypertensive patients (M/F = 104/56, age 58.2 ± 13.3 years, blood pressure = 136.7 ± 16.8/81.3 ± 10.9 mmHg), who underwent standard echo-Doppler exam, including speckle tracking quantification of global longitudinal strain (GLS, considered in absolute value). HU was defined as UA≥7 mg/dL and the study population was divided in two groups: patients with (n = 63) and without (n = 97) HU. Exclusion criteria were coronary artery disease, overt heart failure, hemodynamically significant valve heart disease, primary cardiomyopathies, permanent atrial fibrillation and inadequate echo imaging.

Results

The two groups were comparable for sex prevalence, blood pressure and heart rate. Patients with HU were older and had higher body mass index (BMI) (both p &lt; 0.0001). Prevalence of diabetes mellitus was higher in the group of patients with HU than in patients with normal UA (69% vs. 12% p &lt; 0.0001). Fasting glycaemia was higher (p &lt; 0.0001) and glomerular filtration rate (GFR) lower in HU hypertensives (both p &lt; 0.0001). LV mass index (LVMi) was higher in patients with HU (p &lt; 0.0001). Among diastolic parameters, transmitral E/A ratio (p &lt; 0.0001) was lower, whereas E/e’ ratio (p &lt; 0.0001), E velocity deceleration time and left atrial volume index (both p &lt; 0.001) were higher in HU hypertensives. GLS resulted to be lower in patients with HU (20.8 ± 1.5 vs. 22.3 ± 2.2%, p &lt; 0.0001). LV ejection fraction, despite still in normal range values, was also slightly lower in comparison with controls (60.6 ± 4.0 vs. 62.2 ± 3.9%, p &lt; 0.01). Serum UA levels resulted to be negatively correlated with GLS (r=-0.28, p &lt; 0.0001) (Figure), but not with ejection fraction. By a multiple linear regression analysis performed in the pooled hypertensive population, after adjusting for age, BMI, GFR, fasting glycaemia and LVMi, the association between UA levels and GLS remained significant (standardized beta coefficient =-0.25, p &lt; 0.01), besides the significant impact of age (beta=-0.19 , p &lt; 0.05).

Conclusions

In hypertensive patients with multiple cardiovascular risk factors, the presence of HU is associated with LV diastolic and systolic dysfunction. Serum UA levels and GLS resulted independently associated even after adjusting for several clinical and echo confounders. Acid uric might be considered as an independent marker of early LV dysfunction, able to identify hypertensive patients at increased risk for heart failure.

Abstract P658 Figure. Relation between uric acid and GLS

Personalized medicine in psychiatric disorders: prevention and bioethical questions

Personalized medicine is an emerging approach to medicine that applies scientific knowledge to predict individual susceptibility to certain pathologies and to identify their response to pharmacological treatments. The aim of the study is to analyze the ethical implications of the use of personalized medicine in the prevention of psychiatric disorders, through the study of specific genetic variations and epigenetic modifications. However, the use of technologies aimed at studying the human genome, in order to prevent these pathologies, cause many bioethical questions.

Response to letter to the Editor regarding physical restraint in psychiatric setting

The following letter addresses the issues of the applicability of physical restriction, with particular attention to the therapeutic regime and its meaning as a therapeutic or restrictive provision, while considering possible alternative measures in the context of Italian jurisprudence. The letter, in response to the questions posed by Cioffi and Tomassini, examines the possible legal implications for doctors and suggests that the integration of jurisprudence and psychiatry seems to be mandatory to define the operational protocols for the management of physical restraint. La seguente lettera affronta il problema relativo all'applicabilità della contenzione fisica, con particolare riferimento al regime terapeutico, nonché la sua valenza giuridica quale misura terapeutica o restrittiva, considerando eventuali approcci alternativi. La lettera, in risposta alle domande poste da Cioffi e Tomassini, esamina le possibili implicazioni legali cui possono incorrere i medici nell'applicare la contenzione fisica, suggerendo la necessità di un'integrazione tra le norme giurisprudenziale e la scienza psichiatrica, al fine di definire i protocolli operativi di gestione della contenzione fisica.

The importance of Post Mortem Computed Tomography (PMCT) in the reconstruction of the bullet trajectory

INTRODUCTION

Post Mortem Computed Tomography (PMCT) and 3D reconstruction provide a powerful tool in the evaluation of the causes of death, distinguishing between those findings related to traumas and those related to post mortal changes. It has proven to be extremely useful in case of violent deaths as a support to the traditional autopsy.

AIM OF THE STUDY

The aim of the study is to prove the essential role of PMCT in the determination of the cause of death. For this purpose, we present a case of homicide where CT scans were performed before the autopsy, thus bringing to the resolution of an otherwise controversial death.

CASE PRESENTATION

A 17 years old male died from a gunshot fired by a policeman during a chase. There were some controversies in this case that brought it to the national mediatic attention. PMCT reconstructed images showed the entry point and the ballistic trajectory of the bullet, moreover, PMCT high sensitivity in the evaluation of bone lesions, made the technique diriment in the clarification of the sequence of events that brought to the death of the subject, resolving the controversies of the case. In fact, it showed that the trajectory of the bullet could have not been compatible with the victim's family thesis.

Impact of risk factors for gestational diabetes (GDM) on pregnancy outcomes in women with GDM

PURPOSE

In this study, we evaluated the impact of risk factors for gestational diabetes on clinical/biochemical parameters and maternal/fetal outcomes.

METHODS

One hundred eighty-three (n 183) women (age 33.8 ± 5.5 years, 59% Caucasians, 41% non-Caucasians) with gestational diabetes were included in the study. Anamnestic information, anthropometric and laboratory parameters, and maternal and fetal outcomes at delivery were collected.

RESULTS

Insulin therapy prevalence was higher in Asians vs Caucasians (p = 0.006), despite lower pre-pregnancy BMI in Asians (p = 0.0001) and in pre-pregnancy overweight vs normal weight patients (p = 0.04). Insulin-treated patients had higher fasting OGTT glucose than patients on diet therapy (p = 0.003). In multivariate analysis, Asian ethnicity, age ≥ 35 years and pre-pregnancy BMI ≥ 25 kg/m² were independent predictors of insulin therapy. Cesarean section occurred more in women aged ≥ 35 years than < 35 years (p = 0.02). Duration of pregnancy and age showed inverse correlation (r - 0.3 p = 0.013). Week of delivery was lower in patients ≥ 35 years vs patients < 35 years (p = 0.013). Fasting OGTT glucose was higher in overweight than in normal weight patients (p = 0.016). 1-h OGTT glucose was lower in obese vs normal weight (p = 0.03) and overweight patients (p = 0.03). Prevalence of prior gestational diabetes was higher in overweight/obese women (p = 0.002).

CONCLUSIONS

Ethnicity, age, and BMI have the heaviest impact on pregnancy outcomes.

Primacy of surgery for colorectal cancer

BACKGROUND

The optimal technique for curative resection of colonic cancer includes high ligation of the mesenteric vessels, wide excision of the colonic mesentery and prevention of tumour cell spillage. This article reports results from the authors' institution for patients in whom complete mesocolic excision was performed long before the term was coined.

METHODS

Patients operated on for cure for primary adenocarcinoma of the colon between January 1994 and December 2004 were identified from a prospectively maintained, institutional review board-approved, colorectal cancer registry. Medical records and operation notes were reviewed. The primary outcomes were recurrence (local and distal) and age-adjusted 5-year survival.

RESULTS

Some 1013 patients (560 men and 453 women) were identified, with a median age of 69 (range 21-96) years. The most common location of the cancer was the sigmoid colon (32·9 per cent), followed by the caecum (26·7 per cent) and ascending colon (17·0 per cent). Operations were performed laparoscopically in 134 patients (13·2 per cent). Median duration of hospital stay was 7 (range 1-64, mean 8·2) days. Overall morbidity and mortality rates were 13·5 and 2·2 per cent respectively; there were 20 anastomotic leaks (2·0 per cent). Some 282 patients (27·8 per cent) had stage I, 386 (38·1 per cent) stage II and 345 (34·1 per cent) stage III disease. Median lymph node yield was 28·3 (range 0-241, mean 28·3), and 12 or more nodes were examined in 88·1 per cent of patients. Adjuvant chemotherapy was administered to 277 patients (80·3 per cent) with stage III disease. Overall local and distant recurrence rates at 5 years were 5·1 and 17·1 per cent respectively. The 5-year local recurrence rate was 2·2, 5·3 and 7·7 per cent for American Joint Committee on Cancer stages I, II and III respectively. Corresponding distant recurrence rates were 4·0, 14·7 and 30·5 per cent. The 5-year overall cancer-free age-standardized survival rate was 85·3 per cent. Five-year age standardized survival rates for patients with disease stages I, II and III were 97·7, 90·8 and 69·8 per cent respectively.

CONCLUSION

These data define modern results of surgery for colonic cancer with conservative use of chemotherapy.

Prevalence of simple nodular goiter and Hashimoto's thyroiditis in current, previous, and never smokers in a geographical area with mild iodine deficiency

Simple nodular goiter and Hashimoto's thyroiditis are 2 frequent nonmalignant thyroid diseases. Tobacco smoking has detrimental effects on the endocrine system and in particular on thyroid function and morphology. The objective of this cross-sectional study, involving 1800 Caucasian adults from a geographical area with mild iodine deficiency, was to evaluate the relationship between tobacco smoking, smoking cessation, and the prevalence of simple nodular goiter and Hashimoto's thyroiditis. Thyroid status was evaluated by ultrasonic exploration of the neck, measurement of FT3, FT4, TSH, antibodies against thyroid peroxidase and thyroglobulin, and urinary iodine excretion. The fine-needle aspiration biopsy of significant nodules was also performed. Smoking habits were evaluated by a specific questionnaire and the calculation of number of pack years. Both current and previous smokers showed an increased risk of simple nodular goiter compared to never smokers after adjustment for potential confounders and known goitrogen factors. Interestingly, the simple nodular goiter risk was similar for never smokers and for previous smokers declaring a time since cessation of smoking for more than 69 months. Smoking habit was not associated to an increased risk of Hashimoto's thyroiditis.Smoking appears to be an independent risk factor for simple nodular goiter but not for Hashimoto's thyroiditis in an area with mild iodine deficiency. A prolonged withdrawal of smoking dramatically reduces the risk of simple nodular goiter occurrence.

Tailored rectal cancer treatment--a time for implementing contemporary prognostic factors?

AIM

To report data supporting the development of tailored treatment strategies for rectal cancer.

METHOD

A comprehensive review of the literature on the impact of prognostic factors cur-rently not included in international guidelines in rectal cancer management.

RESULTS

There is considerable variation in treatment guidelines for rectal cancer worldwide, especially for Stage II and Stage III disease. Long-term side effects of chemoradiotherapy are not considered in any guideline. Detailed knowledge, and the prognostic impact, of the circumferential resection margin, tumour grade and venous invasion should be factored into the development of a treatment strategy.

CONCLUSION

Factors additional to the TNM system should improve decision making for contemporary rectal cancer treatment. Optimized radiological and pathological evaluations, and a focus on detailed clinical factors, should be the basis for treatment decisions. International guidelines should consider all known prognostic factors for long-term oncological and functional outcomes.

Oesophageal motility and bolus transit abnormalities increase in parallel with the severity of gastro-oesophageal reflux disease

BACKGROUND

Limited data are available regarding the frequency of oesophageal motility and bolus transit abnormalities in subgroups of patients with gastro-oesophageal reflux disease (GERD).

AIM

To assess oesophageal motility and bolus transit in endoscopically defined GERD subgroups.

METHODS

Patients (N=755) with typical reflux symptoms underwent upper endoscopy, conventional or impedance oesophageal manometry and/or impedance-pH testing. They were divided into: erosive oesophagitis (EO; N=340), Barrett Oesophagus (BO; N=106), non-erosive reflux disease (NERD; endoscopy-, abnormal pH and/or SAP/SI+; N=239) and functional heartburn (FH; endoscopy-, normal pH and SAP/SI-; N=70). Manometric patterns and bolus transit were defined according to previously published criteria.

RESULTS

Increasing GERD severity was associated with decreased lower oesophageal sphincter resting pressure (P< 0.05) and distal oesophageal amplitude (P<0.01), higher prevalence of hiatal hernia (P<0.01) and increased prevalence of ineffective oesophageal motility (P<0.01). Patients with EO and BO had a significantly lower percentage of complete bolus transit compared with NERD and FH (P<0.01). Overall, abnormal bolus transit (ABT) for liquid swallows was found in 12% of FH, 20% of NERD, 54% of EO and 56% of BO (P<0.01). Combined impedance-manometry showed abnormal oesophageal function in 4% of FH, 4% of NERD, 22% of EO and 21% of BO patients with normal oesophageal manometry.

CONCLUSIONS

Oesophageal motility abnormalities increase in parallel with the severity of GERD from NERD to EO and BO. Bolus transit abnormalities in severe reflux disease underscore the importance of impaired oesophageal function in the development of mucosal injury.

Minimally invasive surgical wound infections: laparoscopic surgery decreases morbidity of surgical site infections and decreases the cost of wound care

AIM

The morbidity of surgical site infections (SSIs) were compared in patients who underwent open (OS) vs laparoscopic (LS) colorectal surgery.

METHOD

Data from 603 consecutive LS patients and 2246 consecutive OS patients were prospectively recorded. Morbidity of SSIs was assessed by the need for emergency department (ED) evaluation, subsequent hospital re-admission and re-operation. The cost of wound care was measured by the need for home healthcare, wound vacuum assisted closure (VAC) or independent patient wound care.

RESULTS

SSIs were identified in 5.8% (n = 25) of LS patients and 4.8% (n = 65) of OS patients. ED evaluation for the infection was needed in 24% of the LS group and 42% of the OS group. Hospital re-admission was needed in one LS patient and in 52% OS patients. No LS patient needed re-operation compared with 12% of OS patients. HHC ($162/dressing change) was required in 63% of the OS group compared with 8% of LS group. A home wound VAC system ($107/day) was utilized in 12% of the OS patients but in none of the LS patients. Dressing changes were managed independently by the patient in 92% of the LS compared with 37% of the OS patients.

CONCLUSION

Laparoscopic colorectal surgery patients experience less morbidity when they develop SSIs incurring less cost compared with open colorectal surgery patients.

Clinical trial: the combination of rifaximin with partially hydrolysed guar gum is more effective than rifaximin alone in eradicating small intestinal bacterial overgrowth

BACKGROUND

Abnormal intestinal clearance is involved in the pathogenesis of small intestinal bacterial overgrowth (SIBO). It is known that partially hydrolysed guar gum affects intestinal motility. Eradication therapy of SIBO is based on antibiotic treatment: no data are available on the role of fibre supplementation in eradicating SIBO.

AIM

To assess whether the combination of partially hydrolysed guar gum and rifaximin is more effective than rifaximin alone in the treatment of SIBO.

METHODS

A 50 g-glucose breath test was given to 500 consecutive patients. Patients with a positive glucose breath test and predisposing conditions to SIBO entered into the study, and were randomized to receive rifaximin 1200 mg/day or rifaximin 1200 mg/day plus partially hydrolysed guar gum 5 g/day for 10 days. Patients completed a symptom questionnaire and glucose breath test both in basal condition and 1 month after withdrawal of therapy.

RESULTS

Seventy-seven patients had SIBO. Eradication rate of SIBO was 62.1% in the rifaximin group (both on per-protocol and intention-to-treat analyses), and 87.1% (per-protocol, P=0.017) and 85.0% (intention-to-treat, P=0.036) in the rifaximin-plus-partially hydrolysed guar gum group. Clinical improvement was observed in 86.9% and 91.1% of eradicated cases in rifaximin and rifaximin-plus-partially hydrolysed guar gum groups respectively (P=0.677).

CONCLUSION

The combination of rifaximin with partially hydrolysed guar gum seems to be more useful in eradicating SIBO compared with rifaximin alone.

Hand-assisted laparoscopic surgery may be a useful tool for surgeons early in the learning curve performing total abdominal colectomy

OBJECTIVE

We evaluated outcomes after hand-assisted (HALC) and straight laparoscopic (LC) techniques for the initial laparoscopic total abdominal colectomy (TAC) procedures performed by surgeons starting their laparoscopic careers.

METHOD

The first eight HALC cases of two surgeons performing TAC by this technique (Group A) were compared with the first (Group B) and last eight (Group C) TAC cases of three surgeons performing LC. Groups A and B were compared with a matched group of open total colectomy cases (Group D) and to the eight cases performed by an experienced surgeon (Group E). Demographics, intra-operative and postoperative outcomes including operation time, morbidity, conversion and readmission rates and length of hospital stay (LOS) were compared using Wilcoxon or Chi-squared tests.

RESULTS

Demographics of the patients were similar. Groups A, B C and E had similar operating time (P = 0.10) which was significantly longer than Group D (P < 0.0001). Morbidity (P = 0.75) and readmission rates were similar (P = 0.89). Conversion rate was significantly higher for Group B (Group B: 41.7%vs Group A: 0%, P = 0.008), in the early period. LOS was comparable between minimally invasive groups but significantly shorter than open surgery group (P = 0.0005). For Groups A and C, operating time (P = 0.55), conversion rate (P = 0.11), morbidity (P = 0.83) and LOS (P = 0.12) were similar.

CONCLUSIONS

Hand-assisted laparoscopic colectomy may be associated with a significantly shorter learning curve for TAC as results are better than early LC and comparable with LC performed by experienced laparoscopic surgeons. It may be a better option for surgeons early in their laparoscopic career.

Endoscopic treatment for pill bezoars after continent ileostomy

Difficulty intubation is the most common long-term complication after continent ileostomy, which can be associated with nipple valve slippage, parastomal hernia, stenosis. Diagnosis and management of a patient with nipple valve stricture and partial bowel obstruction associated with dietary supplement retention in the pouch reservoir is described. A 50-year-old female patient with ulcerative colitis and a 15-year history of continent ileostomy after total proctocolectomy reported 5-week symptoms of abdominal pain and difficulty in intubating the pouch. Pill bezoar composed of dietary supplement was found in diagnostic pouch endoscopy. Therapeutic pouch endoscopy was performed with balloon dilation of a nipple valve stenosis and retrieval of 224 dietary supplement tablets. Pill bezoar in the pouch is rare. However, patients with continent ileostomy should be advised to avoid taking hard-to-dissolve foods and medications.

Tobacco smoke: a critical etiological factor for vascular impairment at the blood-brain barrier

Active and passive tobacco smoke are associated with the dysfunction of endothelial physiology and vascular impairment. Studies correlating the effects of smoking and the brain microvasculature at the blood-brain barrier (BBB) level have been largely limited to few selective compounds that are present in the tobacco smoke (TS) yet the pathophysiology of smoking has not been unveiled. For this purpose, we characterized the physiological response of isolated human brain microvascular endothelial cells (HBMEC) and monocytes to the exposure of whole soluble TS extract. With the use of a well established humanized flow-based in vitro blood-brain barrier model (DIV-BBB) we have also investigated the BBB physiological response to TS under both normal and impaired hemodynamic conditions simulating ischemia. Our results showed that TS selectively decreased endothelial viability only at very high concentrations while not significantly affecting that of astrocytes and monocytes. At lower concentrations, despite the absence of cytotoxicity, TS induced a strong vascular pro-inflammatory response. This included the upregulation of endothelial pro-inflammatory genes, a significant increase of the levels of pro-inflammatory cytokines, activated matrix metalloproteinase, and the differentiation of monocytes into macrophages. When flow-cessation/reperfusion was paired with TS exposure, the inflammatory response and the loss of BBB viability were significantly increased in comparison to sham-smoke condition. In conclusion, TS is a strong vascular inflammatory primer that can facilitate the loss of BBB function and viability in pathological settings involving a local transient loss of cerebral blood flow such as during ischemic insults.

Effect of downstaging without complete pathologic response after neoadjuvant treatment on cancer outcomes for cIII and cII rectal cancers

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Background: Neoadjuvant chemoradiation followed by surgery is standard of care for locally advanced rectal cancer. The impact of downstaging on prognosis when pathologic complete response (pCR) cannot be achieved remains unclear. The aim of this study was to evaluate whether downstaging impacts prognosis in patients with cII vs. cIII rectal cancer. Methods: We identified from our colorectal cancer database 233 patients with primary cII and cIII rectal cancer staged by CT and ERUS/MRI who received 5FU-based chemoradiation followed by R0 surgery after a median interval of 7 weeks during 1997–2007. Median radiotherapy dose was 5040 cGy. We excluded 58 patients with pCR and. Compared among the remaining 175 patients pathologic downstaging (cII to ypI, cIII to ypII or ypI) vs. No pathologic downstaging (c stage ≤ yp stage). Outcomes evaluated were 5-year overall survival, 3-year recurrence-free survival, overall recurrence, local recurrence and distant recurrence. Results: Median age was 58 years and median follow-up was 48 months. Patients with cII vs. cIII stage were statistically comparable regarding demographics, chemoradiation regimen, interval to surgery after neoadjuvant treatment, tumor distance from anal verge, operations performed and follow-up. The incidence of downstaging was increased in stage cIII vs. cII patients (68% vs. 21%, p <0.001). With the exception of local recurrence rates, downstaging resulted in significantly improved cancer outcomes for cIII but not cII ( Table ). Conclusions: Downstaging without pCR is a significant prognostic factor for patients with stage cIII rectal cancer. A larger sample size is required to confirm lack of downstaging benefits in stage cII.

[Table: see text]

No significant financial relationships to disclose.

Patterns of HER2/neu, hormonal receptor expression, and proliferative activity in primary and metastatic breast cancer

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Background: The modification of biological features of metastatic sites (MS) in breast cancer patients arise some debatable questions regarding clinically usefull information and safe/efficient methods to detect them. Fine needle aspiration (FNA) of visceral MS is an available tool to characterize tumoral lesion and liquid based citology technique provides usefull cell samples for immunocytochemical and/or molecular assays. Methods: The aim of this study was to compare prognostic and predictive factors obtained from primary tumors (PT) and corresponding MS. Fluorescent in situ hybridization (FISH) was performed for HER2/Neu determination, while ER, PgR, and MIB-1 were detected by immunochemistry using specific monoclonal antibodies on monolayered cell sample and in the corresponding cytoinclusion. FNA with a 21–23 G needle was performed in 20 consecutive breast cancer patients with distant metacronous MS. Results: In 8/20 patients, both ER and PgR were absent in PT and in MS, in 7 were both present, in 4 cases only ER was detected, and only 1 case was ER negative with a low PgR. About the proliferative activity (MIB-1 index: cut off value >20%) only 3 MS presented an higher value. With regard to HER2/Neu, 4/20 cases were amplified and no discrepancies were found between cytological and cytoinclusion specimens. No substantial changes were found about kinetic activity. HER2/Neu status as assessed in PT was confirmed in MS in 10/12 cases; a lung mestastasis showed amplification while primary was not amplified and a liver lesion lost the amplification which was detected in the PT. Conclusions: Our study strongly suggest the opportunity in using FNA for detection of prognostic and predictive factors in MS. Pectasides et al. (Anticancer Res. 2006) found in patients with altered or conserved HER2/Neu in PT and in MS different response rates between the two groups and a significant poorer prognosis in patients with altered Neu. We think that liquid-based cytology applied on FNA of distant metastases could help us to understand some more in this issue.

No significant financial relationships to disclose.

Precision pulmonary trans-arterial chemoembolization (PPTACE) plus percutaneous RFA for unresectable lung neoplasms: Initial experience in twelve cases

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Background: The study aimed to evaluate the feasibility and safety of precision pulmonary arterial chemoembolization (PPTACE) followed by percutaneous RFA in patients with unresectable lung neoplasms Methods: From November 2007 to October 2008, twelve patients (5 male, 7 female, median age 57) and 20 nodules were treated in 14 sessions. Patients had lung metastases from the following tumors: uterine cancer (2), colorectal carcinoma (7), breast carcinoma (1) and two patients had primary unresectable NSCLC. Median diameter of neoplasms was 2 cm. Both RFA and pulmonary TACE were performed under general anesthesia. Two patients underwent two sessions of treatment due to bilateral disease. After subclavian vein puncture and mapping of arterial vascularization of the segment including the tumoral nodule, antiblastic agents loaded on microspheres (Hepasphere, 50–100 micron in diameter) were selectively perfused in a subsegmental sector. Doxorubicin was used in 3 sessions, as well as mitomycin C, while irinotecan was administered in six cases and cisplatin in one case (one session was performed only with microspheres). Percutaneous CT-guided RFA of lung nodules was performed 2–7 days after PPTACE. Pretreatment work-up included: contrast-enhanced CT-scan, (18-F)Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (18F-FDG PET/CT) and Ventilation Lung Single Photon Emission Tomography (VL-SPET). Results: The treatment was well tolerated; pneumothorax, requiring chest- tube placement, occurred in two sessions (14%). Technical success was achieved in all treated nodules. In all cases, the impedance during RFA decreased from 30 to 50%, with an increase of the delivered energy (expressed by Watts). Morphological response showed a necrotic area, without contrast-enhancement at CT scan, including the neoplasm plus a large safety zone. VL-SPET showed a wide area without ventilation in lung parenchyma submitted to PPTACE and extending over it; the changes on alveolar ventilation detected by VL- SPET after PPTACE could explain the better heat conduction during RFA. Conclusions: Lung RFA after pulmonary TACE is feasible and safe. These preliminary data deserve further investigation.

No significant financial relationships to disclose.

[Identification of candidate genes and expression profiles, as doping biomarkers]

Administration of prohibited substances to enhance athletic performance represents an emerging medical, social, ethical and legal issue. Traditional controls are based on direct detection of substances or their catabolites. However out-of-competition doping may not be easily revealed by standard analytical methods. Alternative indirect control strategies are based on the evaluation of mid- and long-term effects of doping in tissues. Drug-induced long-lasting changes of gene expression may be taken as effective indicators of doping exposure. To validate this approach, we used real-time PCR to monitor the expression pattern of selected genes in human haematopoietic cells exposed to nandrolone, insulin-like growth factor I (IGF-I) or growth hormone (GH). Some candidate genes were found significantly and consistently modulated by treatments. Nandrolone up-regulated AR, ESR2 and PGR in K562 cells, and SRD5A1, PPARA and JAK2 in Jurkat cells; IGF-I up-regulated EPOR and PGR in HL60 cells, and SRD5A1 in Jurkat; GH up-regulated SRD5A1 and GHR in K562. GATA1 expression was down-regulated in IGF-1-treated HL60, ESR2 was down-regulated in nandrolone-treated Jurkat, and AR and PGR were down-regulated in GH-treated Jurkat. This pilot study shows the potential of molecular biology-based strategies in anti-doping controls.

Extended lamivudine treatment in patients affected by chronic active anti-Hbe positive hepatitis

The aim of the study was to evaluate the biochemical and virological response and the histological changes in 34 chronic hepatitis B anti-Hbe-positive patients treated with lamivudine at 100 mg/day orally for five years. Liver biopsies were performed in all patients at least 6 months before starting therapy and 3 months after the stop of treatment. After 12 months of therapy, 70.6% of patients showed evidence of HBV DNA clearance and normal ALT levels; 64.7% and 55.8% of patients maintained a complete response after two and three years of therapy, respectively, 47% after four years and 44.1% after five years. The histological activity index improved in 13%, remained unchanged in 61% and worsened in 26% of patients with tyrosine-methionine-aspartate-aspartate (YMDD) variants compared to 63, 27 and 0% without variants, respectively. The authors conclude that the clinical benefit of lamivudine is greatest for patients without YMDD variants after 5 years of extended treatment.

Cryoglobulinemia in subjects with HCV infection alone, HIV infection and HCV/HIV coinfection

OBJECTIVES

To assess the prevalence of cryoglobulinemia in three groups of patients: HCV-positive/HIV-negative, HCV/HIV co-infected and HIV mono-infected.

METHODS

From September 2002 to December 2003, 58 patients with documented HCV infection, 70 subjects with HIV/HCV co-infection, and 48 subjects with HIV infection alone were enrolled. Serum samples were tested for detectable cryoglobulins, liver enzymes, HCV viral load and HCV genotypes. Plasma HIV-RNA levels and CD4+ cell count were also evaluated in HIV-positive subjects.

RESULTS

Cryoglobulinemia was detected in 24.1% HCV mono-infected, 14.2% HCV/HIV co-infected and 6% HIV mono-infected patients. A significant statistical correlation was found between the presence of cryoglobulins and HCV infection (P = 0.03), while cryoglobulins were unrelated to HIV mono-infection (P = 0.16) and HCV/HIV co-infection (P=0.7). No significant correlation was observed between the presence of cryoglobulinemia and alanine transaminase (ALT) levels, HCV viremia and duration of HCV infection. Circulating cryoglobulins in HIV patients were not correlated with plasma HIV viral load, CD4+ cell count or duration of HIV infection. Only two HCV mono-infected patients complained of arthralgia.

CONCLUSION

A similar rate of cryoglobulinemia prevalence was detected in the patient groups with an HCV-related infection. HIV infection does not appear to play a significant role in cryoglobulin production.

Peginterferon alfa-2b treatment for patients affected by acute hepatitis C: presentation of six case reports

Acute hepatitis C often progresses to chronic infection (70%). In this clinical study, we evaluated if early treatment with peginterferon alfa-2b can prevent acute hepatitis C from developing into a chronic disease. Six patients with acute hepatitis C, based on a well-documented hepatitis C virus (HCV) seroconversion with high alanine aminotransferase (ALT) levels (> 10 x ULN) and persistent HCV RNA titers after 3 months from disease onset, were consecutively treated with peginterferon alfa-2b at 1.5 microg/kg/weekly/sc for 24 weeks. The viral load was quantified by PCR assay. Response was defined as undetectable HCV RNA and normal ALT levels at the end of therapy and after a 6-month follow-up. All patients completed therapy; at the end of therapy, 5/6 patients (83%) responded and no relapses were observed during follow-up. No correlation was found between treatment response and pretreatment viral load, viral genotype, and interval between acute infection diagnosis and start of therapy.

Association between HLA class II antigens and hepatitis C virus infection

The aim was to confirm the influence of HLA Class II antigens on the progression of HCV infection and to assess the relationship between these antigens and histological damage, HCV viral load and HCV genotype. 143 patients were enrolled and divided into three groups. Group A included 34 anti-HCV positive, HCV-RNA negative patients with ALT persistently normal; group B included 39 patients with HCV-RNA positive and abnormal ALT level; group C included 70 normal subjects. Serological HCL typing was performed with lymphocytotoxicity test by Terasaky and McClelland, using lymphobeads HLC class II. The frequency of HLA DR11 (5) was significantly higher in the control group (52.9%) and in group A (64.7%), than in group B (28.2%). Allele HLA DR6 was demonstrated in a similar proportion (26%) among control group and group B, while HLA DR14 (6) was less frequent among controls (18% vs 1.4%). In group A the frequency of HLA DR14 (6) was 3% compared to group B, HLA DR17 (3) was prevalent (15.4%) in group B. Liver damage was associated with the detection of HLA DR14 (6) and HLD DR17 (3) antigens. Significantly lower levels of HCV-RNA were measured in subjects with HLA DR11 (5) than in these with either DR6 or DR17 (3). HLA class II antigens appear crucial for resolution or progression of HCV hepatitis. The punctual identification of these genetic factors may, therefore, prove to be useful in predicting disease evolution, in guiding the appropriate therapy for patients with poor prognosis, and in encouraging the development of now therapeutic strategies.

[Association between chronic hepatitis C virus infection and cryoglobulinemia]

Hepatitis C virus infection (HCV) causes both acute and chronic liver disease and can be also associated with cryoglobulinemia (SC). SC is a systemic vasculitic disease, typically characterized by lower extremity purpure, arthralgias and fatigue and by circulating immune complexes which precipitate at low temperatures. We examined the prevalence of SC in a prospective study of 84 patients with chronic HCV hepatitis. Cryoglobulinemia was detected in 44 patients (53.4%) and was associated with the severity of liver damage and the duration of the disease. The analysis of HCV genotypes demonstrated a prevalence of 1 b. The amount of cryoglobulinemia was low in all the patients with SC and only 20% showed a clinical syndrome.