Exploring perceptions of factors aiding the development of critical thinking in adult dysphagia: A study among fourth-year speech-language pathology students

BACKGROUND

The assessment and management of adult dysphagia in South Africa is complex as appropriate intervention requires a balance of theoretical knowledge and critical thinking to ensure service delivery is appropriate within a resource-constrained health care system. Critical thinking involves the skilful evaluation of information to make informed decisions for effective assessment and intervention. It is imperative for Speech-Language Pathologists (SLPs) to cultivate these skills from an early stage in their careers. This study therefore aims to investigate the factors perceived to enhance critical thinking to shed light on how students transition theory into clinical decision-making. This is vital to inform future practice in the realm of dysphagia and to enhance Speech Therapy education.

METHODS

A qualitative research design was utilised to identify what facilitators assist SLP students to develop critical thinking skills in adult dysphagia. Data were gathered from students across three universities. Fifteen participants answered a self-developed online survey, and of those, four participated in a follow-up focus group. The data were analysed using a top-down approach and reflexive thematic analysis.

RESULTS AND DISCUSSION

The results revealed that viewing videos on instrumental assessment measures, case studies and peer learning were perceived to expand critical thinking theoretically. Similarly, critical thinking was best supported in clinical contexts, which provided opportunities to observe expert clinicians at the bedside, obtain individual feedback and access supervision.

CONCLUSION

The findings yielded recommendations for clinical educators involved in dysphagia training. This is necessary to better prepare SLP students to provide contextually relevant and responsive dysphagia services.

Neuropsychological rehabilitation training in residential mental health services

The neuropsychological rehabilitation in our mental health service is a central pillar of psychosocial rehabilitation. These interventions are integrated into a more complex program of psychosocial rehabilitation based on cognitive behavioral method.

We devote particular attention to the empowerment of the cognitive functions: attention, memory, language, logical and abstract reasoning.

The aim of this research is to evaluate efficacy of neuropsycological rehabilitation training in cognitive rehabilitation of psychotic patients.

The subjects that took part to the training were psychotics patient, residents in a mental health Community. Patients were both females and males, aged between 18 and 55 years. They were divided in two experimental groups and a control group. The instrument used was a battery of neuropsycological standardized tests. Tests were managed by an eye-tracker specialist.

Preliminary results seem to confirm a certain degree of improvement due to the training. Eye tracking integration during assessment appears to be a powerful tool as well, in order to define more patient-tailored strategies.

The training based on the empowerment of cognitive functions (attention, memory, language, logical and abstract reasoning) seems to change significantly the cognitive functions of the psychotic patients.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Clinical neuroscience and psychosocial rehabilitation

There is a physical world and a world of meanings, symbols and social relationships. Neuroscience considers brain as a biological machine. Social science studies the human relationships.

Nowadays we know cerebral processes underlying several aspects of social behavior.

Cerebral damages or dysfunctions can influence the social behavior, as well as the social experiences can shape the development, structuring and functioning of the brain and, consequently, condition the further responses of the individuals to the social events. Humans are embodied subject. In an objective sense we are bodies with a brain, in a subjective sense we are individuals in a social world. This is a relevant matter for all the medical sciences, not only for psychiatry.

The real-life functioning of individuals with schizophrenia shows deficits in several daily-life abilities, in social relationships and in the work activities. According to literature and clinical practice, basic criterions are: bio-psycho-social vulnerability, stressful life events, coping strategies as well as social and relational competence.

Neurocognitive activity shows a straight correlation, albeit indirect, with the real-life functioning. Positive symptoms, negative symptoms and disorganized behavior can considerably influence the real-life functioning. While social and relational competence, the general functioning and resilience are protective factors that can positively condition real-life functioning. Moreover, welfare services (i.e. assisted job placement; disability subsidies; etc.) and a good family and social network can considerably influence the results.

According to the results above, we can affirm the importance to adopt integrated and personalized therapeutic-rehabilitative program for the treatment of schizophrenia and other serious mental disorders.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Selective inhibitors of aurora kinases inhibit proliferation, reduce cell viability and impair cell cycle progression in papillary thyroid carcinoma cells

The three members of the Aurora kinase family, Aurora-A, -B and -C, regulate several aspects of the mitotic process, and their aberrant expression and/or function causes mitotic abnormalities leading either to cell death or aneuploidy. They are found overexpressed in several human malignancies, including the papillary thyroid carcinoma (PTC). In the present study, we sought to establish whether Aurora kinase inhibition could be of any therapeutic value in the treatment of aggressive forms of PTC, enduring to radioactive iodide (RAI) ablation. To this end, the effects of selective inhibitors of Aurora-A (MLN8237) and Aurora-B (AZD1152) were analyzed on 3 human PTC cell lines expressing either wild-type (K1 and TPC1) or mutant p53 (BCPAP). The two inhibitors were capable of reducing cell proliferation in a time- and dose-dependent manner, with IC₅₀ comprised between 65.4 and 114.9 nM for MLN8237, and between 26.6 and 484.6 nM for AZD1152. Immunofluorescence experiments confirmed that AZD1152 inhibited Aurora-B phosphorylation of histone H3 on Ser10, however, it did not affect Aurora-A autophosphorylation. MLN8237 inhibited Aurora-A autophosphorylation as expected, but at concentrations required to achieve the maximum antiproliferative effects it also abolished H3 (Ser10) phosphorylation. Time-lapse videomicroscopy evidenced that both inhibitors prevented the completion of cytokinesis, and cytofluorimetric analysis showed accumulation of cells in G2/M phase and/or polyploidy. Apoptosis was induced in all the cells by both inhibitors independently from the p53 status. In conclusion, in the present preclinical study MLN8237 and AZD1152 have emerged as promising drug candidates for RAI-insensitive PTC.

PAPILLARY THYROID CANCER IS CHARACTERIZED BY ALTERED EXPRESSION OF GENES INVOLVED IN THE SUMOYLATION PROCESS

Small Ubiquitin–like MOdifier (SUMO) proteins are small protein modifiers capable of regulating cellular localization and function of target proteins. Over the last few years, a relevant role has been demonstrated for sumoylation in the modulation of important cellular processes, including gene transcription, DNA repair, cell-cycle regulation and apoptosis. Components of the sumoylation machinery have been found deregulated in different human cancers, and are thought to significantly affect cancer cell progression. In the present study we sought to analyze the expression of all the components of the sumoylation machinery in a case study comprising 77 papillary thyroid cancers (PTC) and normal matched tissues. In particular, we evaluated the expression of the SENP1 to SENP8 (SENtrin-specific proteases), SAE1 (SUMO1 activating enzyme subunit 1), UBA2 (UBiquitin-like modifier activating enzyme 2), UBC9 (UBiquitin conjugating enzyme 9), RanBP2 (RAN binding protein 2), MSMCE2 (Non- SMC element 2), CBX4 (ChromoBoX homolog 4), PIAS1 to PIAS4 (protein inhibitor of activated STAT), ZMIZ1 (zinc finger, MIZ-type containing 1) and ZMIZ2 (Zinc finger, MIZ-type containing 2) by means of quantitative RT-PCR. In most of the PTC examined we observed a significant alteration in the mRNAs of SENP8, ZMIZ1, SAE1, PIAS1 and PIAS2. These tended to be reduced in about 50 to 66% of cases, and unchanged or increased in the remaining ones. Univariate and Kaplan-Mayer analyses documented the lack of association between the expression of the above 5 genes and clinicopathological parameters. Only SAE1 was significantly higher in female PTC tissues, in respect to male PTC tissues (p=0.021), and SENP8 was significantly lower in TNM stages III-V, with respect to stages I-II (p=0.047). In conclusion, we demonstrated that the expression of SENP8, SAE1, PIAS1, PIAS2 and ZMIZ1 is deregulated in the majority of PTC tissues, likely contributing to the PTC phenotype. However, differently from other human cancers, their mRNA level does not represent a prognostic biomarker in PTC patients.

Metachronous elastofibromas

Elastofibroma Dorsi (EFD) is a rare pseudo-tumor characterized by the overgrowth of elastic fibers mixed to adipose and connective tissues typically growing in the subscapular region. This can be bilateral but only rarely synchronous affecting different anatomical sites at the same time. Hereby we present a case of a 42-year-old male patient found with three different metachronous elastofibromas: bilateral EFD and a further third localization by the right elbow. The two EFs in the subscapular region were resected. After surgery pain reoccurred on the right side. This required the implantation of a spinal electro-stimulator. The elbow lesion was not excised as it was asymptomatic.

Total thyroidectomy for Graves' disease treatment

OBJECTIVES

Graves' disease (GD) is the most common cause of hyperthyroidism, and accounts worldwide for 60-80% of all cases. The diagnosis is based on clinical findings, and is confirmed by the presence of TRAB, suppression of TSH, and elevation of free thyroxin (free T4), and triiodinethyronin (free T3). GD can be treated by antithyroid drugs, radioactive iodine, or surgery. The aim of this study was to review retrospectively the surgical management, in terms of safety and efficacy, in 50 patients operated in the Department of Surgical Sciences since 2005 through 2010 and followed up at the Endocrinology Unit A of the Experimental Medicine Department. We assessed postoperative complications, which included the presence, persistence and development of ophthalmopathy, transient hypocalcemia, permanent hypoparathyroidism and recurrent laryngeal nerve palsy.

MATERIALS AND METHODS

We analyzed data from 50 patients with GD who were eligible and underwent Total Thyroidectomy (TT). Thirty-nine patients underwent TT for recurrent hyperthyroidism after medical therapy and eleven patients for severe ophtalmopathy. The mean follow up was 41 months (range: 10-70).

RESULTS

Eleven patients had ophtalmopathy before surgery. Four patients developed an ophtalmopathy after surgery. Eleven patients presented hypocalcemia, transient in ten patients and permanent in one patient. Five patients developed a transient disphony. Conclusions. Total thyroidectomy is a safe and radical procedure in Graves' disease treatment. Complications of TT are not different than subtotal thyroidectomy if it's performed by expert surgeons.

The dual Aurora kinase inhibitor ZM447439 prevents anaplastic thyroid cancer cell growth and tumorigenicity

The anaplastic thyroid cancer (ATC) is among the most aggressive human tumors which fail to respond to all the currently available therapeutic approaches. As a consequence most patients die within a few months from diagnosis. In the present preclinical study, the effects of the ZM447439, a functional inhibitor of Aurora kinases, on the growth and tumorigenicity of a panel of ATC derived cell lines (CAL-62, 8305C, 8505C and BHT-101) were evaluated. The treatment of the different ATC cells with ZM447439 inhibited proliferation in a time- and dose-dependent manner, with IC50 comprised between 0.5 mM and 5 mM. Moreover, the drug remarkably impaired the formation of colonies in soft agar of all the cell lines. Consistently with Aurora inhibition, immunofluorescence and immunoblotting experiments demonstrated that Aurora auto-phosphorylation following drug treatment was completely abrogated, and treated cells were characterized by the presence of multiple spindles with short microtubules. In the same experiments we observed the loss of histone H3 phosphorylation on Ser10, specifically due to Aurora-B, after ZM447439 treatment. Time-lapse videomicroscopy and flow cytometric analysis demonstrated that in presence of ZM447439 the cells were able to enter mitosis but not to complete it, becoming polyploid. Almost all the ATC cell lines studied showed increased apoptosis after only 48 h of treatment. In conclusion, our data demonstrate that ZM447439 is effective in reducing cell growth and tumorigenicity of different ATC derived cell lines, and further investigations are needed to exploit its potential therapeutic value for ATC treatment.

Diagnostic utility of thyroglobulin measurement in the fine needle aspirates from cervical lymph nodes: a case report

Fine needle aspiration cytology (FNAC) is the more accurate diagnostic method for cervical lymph node (CLN) metastasis from differentiated thyroid cancers (DTC). However, FNAC diagnosis of cystic CLN is, in most cases, uninformative due to inadequate cellularity. Recently, thyroglobulin (Tg) detection in FNAC needle washout fluid has been shown to improve the diagnostic accuracy of FNAC, and its routine association with cytology is recommended. We here describe the case of a 20 yr old girl complaining of the recent appearance of palpable non-painful laterocervical nodes in the neck. Ultrasound examination revealed the presence of 3 cystic CLNs and 2 mixed thyroid nodules, with the larger one showing irregular margins. On the latter, and on 2 larger CLNs, FNAC was performed, and both Tg protein and mRNA were determined in the needle washout. The cytological analysis was not diagnostic for the two CLNs, while that of the thyroid nodule reported the presence of colloid and groups of thyrocytes with normal morphology. Both CLNs showed, however, high levels of Tg protein and were positive for Tg mRNA, suggestive of metastatic DTC. Based on these findings, the FNAC analysis was performed on the second smaller thyroid nodule suggesting (Tir4) the presence of PTC. The patient was then subjected to total thyroidectomy with lymph nodes resection of the central and homolateral compartments. The histological diagnosis confirmed the presence of a PTC in the small nodule and metastatic lymph nodes. In conclusion, this case confirms that the cytological diagnosis of cystic lymph nodes is challenging, and that the measurement of Tg protein and/or mRNA in the needle washout may overcome this limitation.

Aurora kinases: new molecular targets in thyroid cancer therapy

Genetic instability, a hallmark of solid tumors including thyroid cancers, is thought to represent the mean by which premalignant cells acquire novel functional capabilities responsible for cancer cell growth and tumour progression. Over the last few years, the knowledge of the molecular processes controlling the mitotic phase of the cell cycle has increased considerably, and different mitotic proteins, whose expression or function has been found altered in human cancer tissues, have been associated to tumour genetic instability and aneuploidy. These include the three members of the Aurora kinase family (Aurora-A, -B and -C), serine/threonine kinases that regulate multiple aspects of chromosome segregation and cytokinesis. The genes encoding the Aurora kinases have been shown to induce cell malignant transformation, and their overexpression has been detected in several tumor derived cell lines and tissues, being often associated with a poor prognosis. Over the last decade, specific inhibitors of Aurora kinases exhibited in preclinical and early phase clinical studies a good therapeutic efficacy against several tumour types, including the highly aggressive anaplastic thyroid cancer and the medullary thyroid cancer. In the present review we'll first focus on the Aurora mitotic functions in normal cells; then we shall describe the main implications of their overexpression in the onset of genetic instability and consequent aneuploidy. We shall finally discuss on the effects of the functional inhibition of Aurora kinases on thyroid cancer cells growth and tumorigenicity.

The urokinase plasminogen activating system in thyroid cancer: clinical implications

The urokinase plasminogen activator (uPA) system (uPAS) comprises the uPA, its cell membrane receptor (uPAR) and two specific inhibitors, the plasminogen activator inhibitor 1 (PAI-1) and 2 (PAI-2). The uPA converts the plasminogen in the serine protease plasmin, involved in a number of physiopathological processes requiring basement membrane (BM) or extracellular matrix (ECM) remodelling, including tumor progression and metastasis. The tumor-promoting role of PAS is not limited to the degradation of ECM and BM required for local diffusion and spread to distant sites of malignant cells, but widens to tumor cell proliferation, adhesion and migration, intravasation, growth at the metastatic site and neoangiogenesis. The relevance of uPAS in cancer progression has been confirmed by several studies which documented an increased expression of uPA, uPAR and PAI-1 in different human malignancies, and a positive correlation between the levels of one or more of them and a poor prognosis. For these reasons, the uPAS components have aroused considerable interest as suitable targets for anticancer therapy, and several pharmacological approaches aimed at inhibiting the uPA and/or uPAR expression or function in preclinical and clinical settings have been described. In the present manuscript, we will first glance at uPAS biological functions in human cancer progression and its clinical significance in terms of prognosis and therapy. We will then review the main findings regarding expression and function of uPAS components in thyroid cancer tissues along with the experimental and clinical evidence suggesting its potential value as molecular prognostic marker and therapeutic target in thyroid cancer patients.

Surgical strategies in patients with medullary thyroid carcinoma

OBJECTIVES

Aim of the study was to identify, in 59 operated patients affected by medullary thyroid carcinoma (MTC), the recurrence rate, survival, mortality and incidences of surgically derived hypoparathyroidism and recurrent laryngeal nerve injury (RLNI).

MATERIALS AND METHODS

Based on pre-surgical diagnosis of the 59 patients included in the study, 35 underwent total thyroidectomy with central neck dissection (Group A), 14 total thyroidectomy, central neck dissection and monolateral functional neck dissection (Group B) and 10 total thyroidectomy central neck dissection, bilateral functional neck dissection (Group C). Overall survival, recurrences, incidence of hypoparathyroidism and RLNI were evaluated.

RESULTS

The survival and recurrences were not statistically different among the three Groups. In Group B there was major probability of re-operation (p=0.042). The mortality rate was clearly major in Group C (p=0.003) due to the stage of pathology. Group C showed a high number of hypoparatiroidism compared to Group B, and B compared to A. In Group A there was only one unexpected RLNI; in 5 cases, 3 in Group B and 2 in Group C, there were a necessity laringeal section due to nerve tumor involvement.

CONCLUSIONS

From our data it appears clearly that disease outcome following the different surgical approaches is mainly determinated by the stage of the disease at diagnosis. However, the finding that patients in Group A and B showed a high rate of local-regional recurrences may suggest that homolateral lymphadenectomy in Group A patients and bilateral lymphadenectomy in Group B patients should be always performed.

Effects of the Aurora kinases pan-inhibitor SNS-314 mesylate on anaplastic thyroid cancer derived cell lines

OBJECTIVES

Anaplastic thyroid carcinomas (ATC) are highly aggressive tumours unresponsive to any available radio- or chemotherapeutic protocol, with a median survival rate of 4-5 months from the time of diagnosis. We previously demonstrated that ATC are characterized by increased expression of the kinases Aurora-A, -B and -C, involved in the regulation of multiple steps of the mitotic phase. In this study, the in vitro effects of SNS-314 mesylate, a pan-inhibitor of the Aurora kinases, on growth and tumorigenicity of ATC cells were evaluated.

MATERIALS AND METHODS

The effects of SNS-314 mesylate were assessed on the ATC derived cell lines CAL-62, 8305C, 8505C and BHT-101 by means of cell proliferation assay, immunofluorescence, cytofluorimetry, time lapse microscopy, and colony formation in soft agar.

RESULTS

Treatment of the different ATC cells with SNS-314 mesylate inhibited proliferation in a time- and dose-dependent manner, with IC(50) comprised between 2.6 nM and 26.6 nM. CAL-62 cells exposed for 24 h to SNS-314 mesylate 100 nM evidenced a significant augmentation of the apoptotic index. Time-lapse video-microscopy of CAL-62 cells showed that SNS-314 mesylate prevents the completion of mitosis leading to polyploidy. Western blot experiments demonstrated that the auto-phosphorylation of the Aurora kinases as well as histone H3 phosphorylation in CAL-62 treated cells was inhibited. Finally, the drug inhibited colony formation in soft agar of all cell lines.

CONCLUSIONS

Our results demonstrated that SNS-314 mesylate is capable to efficiently reduce cell growth and tumorigenicity of different ATC derived cell lines suggesting its potential therapeutic value for ATC treatment.

Elective endovascular vs. open repair for abdominal aortic aneurysm in patients aged 80 years and older: systematic review and meta-analysis

OBJECTIVES

Endovascular treatment (EVAR) of abdominal aortic aneurysm (AAA) is thought to be of benefit, particularly in patients aged ≥80 years. This issue was investigated in the present meta-analysis.

DESIGN

The study design involved a systematic review of the literature and meta-analysis.

METHODS

Systematic review of the literature and meta-analysis of data on elective EVAR vs. open repair of AAA in patients aged ≥80 years were performed.

RESULTS

Six observational studies reporting on 13,419 patients were included in the present analysis. Pooled analysis showed higher immediate postoperative mortality after open repair compared with EVAR (risk ratio 3.87, 95% confidence interval (CI) 3.19-4.68; risk difference, 6.2%, 95%CI 5.4-7.0%). The pooled immediate mortality rate after open repair was 8.6%, whereas it was 2.3% after EVAR. Open repair was associated with a significantly higher risk of postoperative cardiac, pulmonary and renal complications. Pooled analysis of three studies showed similar overall survival at 3 years after EVAR and open repair (risk ratio 1.10, 95%CI 0.77-1.57).

CONCLUSIONS

The results of this meta-analysis suggest that elective EVAR in patients aged ≥80 years is associated with significantly lower immediate postoperative mortality and morbidity than open repair and should be considered the treatment of choice in these fragile patients. These results indicate also that, when EVAR is not feasible, open repair can be performed with acceptable immediate and late survival in patients at high risk of aneurysm rupture.

Rectal cancer surgery. A ten years experience

Rectal cancer is one of the most common malignancies in the western world population. The management of rectal cancer has changed thoroughly in recent years owing to the rapid advances in surgical techniques, imaging and adjuvant therapy. The present study analyses extensively 152 patients operated for diagnosis of, rectal cancer in the First Clinic of General Surgery UHC "Mother Theresa" in Tirana, Albania, in a ten years period. In the medical and operative records were analysed demographic, diagnostic, clinic, operative, pathology and postoperative patient's data. M : F ratio was 1,5:1. The average age of all patients was 59,8 ± 12,2 (29 - 79) years. 48% of all patients were of the age group 61 - 70 years. The diagnosis interval was 6 ± 4,6 months. The mean distance of tumor from the anal verge was 8,3 ± 4,2 (3,7 - 16) cm. 30% of all patients resulted stage D, according to the Astler - Coller classification. Overall operability index was 97,5%. 30 % of patients were treated with palliative operative procedures. 67,5% of all patients were treated with curative intent. The most common curative operation was low anterior resection with mesorectal excision in 76 patients (51%). The mean postoperative hospital stay was 12 ± 9,7 (3 - 45) days. Overall postoperative morbidity and mortality were 30% and 2,6% respectively. The surgical treatment of rectal cancer has changed radically in recent years in Albania. Relatively new surgical techniques, like low anterior resection and use of adjuvant chemoradiotherapy have improved the outcome, quality of life and survival of our patients.

Angiomegaly and arterial aneurysms

Angiomegaly is characterized by an alteration in the elastic component of arterial and venous vessels determining their elongation and tortuousness. This involves an increased risk of thromboembolism and aneurysmal degeneration in affected subjects, even if they have been asymptomatic for a long time. The aim of this study is to demonstrate the correlation between angiomegaly and aneurysmal disease. A total of 163 patients suffering from a peripheral arterial aneurysm were included, 74 of these with an iliac aneurysm, 41 with a femoral aneurysm and 48 suffering from popliteal aneurysm. All patients were examined by color Doppler ultrasonography (CDU) and angio-CT with contrast medium. Eighteen cases of arteriomegaly were diagnosed, and the prevalence in the examined population was 11%. This study demonstrates the close association existing between aneurysms in peripheral arteries and arteriomegaly. Peripheral arterial aneurysms in association with arteriomegaly involve an increased risk of complications like thrombosis, embolism and rupture. The showed familiarity in the arteriomegaly incidence leads to predisposition of screening programs, using CDU, among relatives of patients affected by arteriomegaly and/or peripheral arterial aneurysms.

Thyroidectomy with ultrasonic dissector: a multicentric experience

INTRODUCTION

We have conducted a clinical controlled trial (CCT) on patients who had undergone thyroidectomy for goitre or thyroid carcinoma. The endpoint of this study was to evaluate the benefits of ultrasonic dissector vs conventional technique (vessel ligation and tight) in patients undergoing thyroid surgery.

PATIENT AND METHODS

Between January 2007 and December 2009 a CCT was conducted on 2.736 consecutive patients admitted to our clinical wards, who had undergone thyroidectomy for goitre or thyroid carcinoma. They were divided in two group: 1.021 patients (203 male and 818 female) underwent thyroidectomy with ultrasonic dissector (UAS) and 1.715 patients (369 male and 1.346 female) underwent throidectomy with conventional technique (vessel ligation and tight) (CT).

RESULTS

The operative time (UAS 80 minutes mean, 50 to 120 min., vs CT 120 minutes, 70 to 180 minutes) was much lower in the thryoidectomy with UAS group. The incidence of transient laryngeal nerve palsy (UAS 17/1.021 patients. 1.6% vs CT 16/1.715 patients, 0.9%) was higher in the thyroidectomy with UAS group; the incidence of permanent laryngeal nerve palsy was similar in two groups(UAS group; there are no relevant difference in the incidence of permanent hypocalcemia (UAS 26/1.021 patients, 2.5% vs 35/1.715 patients, 2%) which was similar in two groups. Also the average post-operative hospitalization was similar in two groups (2 days).

CONCLUSIONS

Actually, the only significant advantage shown from this CCT is represented in terms of cost-effectiveness (reduction of the usage of operating room and hospitalization) for patients treated with UAS, subsequent to the significant reduction of operative duration. Although the analysis showed that the patients who were treated with ultrasonic dissection don't present more favourable results in incidence of post-operative transient complication:transient laryngeal nerve palsy (1.6% in UAS vs 0.9% in CT) and transient hypocalcaemia (9.5% in UAS vs 7.7% in CT). There is no significant difference in the incidence of permanent laryngeal nerve palsy (0.9% in UAS vs in 1% CT). The experience of surgeon is the only important factor which can influence the appearance of these complications; the usage of Ultrasonic dissector can only help surgical action but can't repair the experience of the operator.

Radical axillary dissection in sentinel lymph node biopsy era: it's still a considerable technique in breast cancer management?

The new staging technique of sentinel node biopsy facilitates the identification of pathological node negative patients in whom axillary dissection may be avoided; however, patients with a positive sentinel node biopsy would require a thorough examination of their nodal status. Axillary dissection provides good local control, accurate staging and prognostic information for decisions about adjuvant therapy. We describe a technique of radical axillary clearance that includes levels I, II and III; this isn't associated with additional morbidity to patients and involves minimal extension of operative time.

[Micromedullary thyroid carcinoma: school experience]

Medullary microcarcinomas occurrence are rare and fortuitous, it's usually related to the calcitonin measurement, that's the gold standard for the diagnosis. In other cases performing a thyroidectomy for a benign thyroid disease it's found a sub-centimeter tumor. Actually it's not clear the most appropriate surgical treatment for those kind of tumors because the number of cases in literature is limited and because there are different surgical approaches. In this study 17 patients were operated for medullary thyroid microcarcinoma and the Authors found central lymph node metastases in 33.3% of cases. The Authors, analyzing those results, think that total thyroidectomy with lymphadenectomy of the central compartement is the best choice in a sporadic microcarcinoma, while a total thyroidectomy without lymphadenectomy should be performed when the microcarcinomas are incidentals.

[Case-mix index and length of hospitalization]

The ACG (Adjusted Clinical Groups) case-mix system is a classification method of diseases of patients, focused on the person. Depending on the pattern of these morbid conditions, the ACG system assigns each patient to a single group (an ACG group), which allows to capture the effects of a group of diseases in estimates of resource use. Diseases are classified into a diagnostic group (ADG) according to 5 clinical dimensions: duration (acute, recurrent or chronic), severity (minor/major vs stable/unstable), diagnostic assessment (symptoms vs diseases), etiology (infectious, traumatic or other), specialty (medical, surgical, obstetric, ...). All diseases can be classified into these dimensions and into one of 32 groups. The ACG case-mix system uses an algorithm to classify each patient into one of 93 ACG categories. Each person is assigned to an ACG according to his ADG combination, his age and his gender. With the repayment system "case-mix", surgery has become central for all great hospitals in virtue of its great productive potential. The case-mix index is one of the factors which influence the duration of hospitalization. The case-mix system has emphasized the importance of the duration of hospitalization, encouraging the planning of programs in order to discharge patients early after surgical operations. It has also stimulated the surgical activity in operating units with "budget" forecasts in which resources are provided according to an expected level of specialist surgery.

Is pattern III as evidenced by US color-Doppler useful in predicting thyroid nodule malignancy? Large-scale retrospective analysis

OBJECTIVE

To evaluate whether pattern III of color Doppler Ultra-sound may identify malignant nodules.

MATERIALS AND METHODS

We have retrospectively analyzed data pertaining to 1090 patients of both genders (230 males, 860 females), with an average age of 53 years (min 17 years, max 81 years), who underwent thyroidectomy in Department of Surgical Sciences of Sapienza University of Rome since January 2003 through June 2009. We correlated color-Doppler characteristics and histological features through statistical analysis so as to verify statistical correlation between them.

RESULTS

Our study showed that 164/273 (60.1%) patients with malignant disease were associated with vascularization pattern III. Regarding benign disease, 152/268 (56.7%) patients showed a pattern of vascularization 3 at ultrasonography. The statistical analysis was not able to show any correlation between pattern III and malignancy.

CONCLUSION

Pattern III cannot be used to predict malignancy with confidence, and FNA is still mandatory to rule out the nature of the nodule.

Thyroid tissue remnants after "total thyroidectomy"

Total Thyroidectomy (TT) is a gold standard for benign bilateral pathologies and malignant pathologies of the thyroid. TT has numerous advantages over less radical approaches, such as the resolution of the thyroid pathology, avoidance of recurrences, and improved response to life-long substitutive organotherapy. TT has a negligible rate of recurrence. Near Total Thyroidectomy (NTT) is associated with a low rate of recurrence. Subtotal Thyroidectomy (ST), in which a portion of the thyroid gland is deliberately left in the thyroid lodge, has a considerably higher rate of recurrence. The incidence of complications with TT is similar to that with other techniques of thyroid exeresis. However, despite the radical intent of surgeons, a real TT is not always carried out. The complete removal of all the thyroid tissue employing TT is not the norm and micro/macroscopic remnants almost always remain. The literature on these tissue remnants is often based on techniques that are not very accurate in terms of determining the diameters of the tissue remaining. In our study, conducted by colour echo-doppler of the thyroid lodge in 102 patients who had undergone TT for benign thyroid pathologies, we demonstrated significant thyroid tissue remnants after TT in 34 cases of 102 (33,3%). Therefore, out of a total of 102 so-called "total thyroidectomies", only 68 (66,7%) were really total, whereas 12 patients (11,76%) had near total thyroidectomy, leaving tissue remnants < 1 cm, and 22 patients (21,57%) had subtotal thyroidectomy, with tissue remnants > or = 1 cm.

Inhibitory Effect of Somatostatin on Abnormal GH Response to TRH in Primary Hypothyroidism

Thyrotropin releasing hormone (TRH) does not promote GH secretion in normal subjects but it stimulates GH in a proportion of hypothyroid patients. In this study the response of GH to thyrotropin releasing hormone (TRH) was evaluated in 21 patients with primary hypothyroidism of different origin: 12 with autoimmune thyroiditis, 3 idiopathic, 3 congenital, 3 iatrogenic. 11 of these patients had never been treated, the others were tested after a drug-free period of at least two weeks. Basal plasma concentration of GH was normal in all patients; after TRH administration, a significant increase in plasma GH was observed in 4 patients. In these responsive patients, somatostatin infusion inhibited the abnormal GH response to TRH. It is suggested that the abnormal GH response to TRH in primary hypothyroidism might be caused by a relative deficiency of somatostatinergic control, which is corrected by exogenous somatostatin administration.

[Medullary thyroid carcinoma: a study about 28 operated patients]

In this study on 28 operated patients, the Authors show that total thyroidectomy with elective central neck dissection and ipsilateral neck dissection is the most appropriate surgical treatment for medullary thyroid carcinoma. Pathologic study on lymph nodes removed in central and in latero-cervical compartments showed malignancy respectively in 75% and in 70% of the cases. However the role of elective ipsilateral lateral neck dissection remains controversial.

[Two cases of synchronous papillary and medullary thyroid carcinoma]

The Authors describe two cases of simultaneous association of papillary and medullary thyroid carcinoma. They emphasize the treatment of these cases stressing the correlation between the therapeutic criteria and the malignancy of medullary carcinoma.

Selective melanocortin MC4 receptor agonists reverse haemorrhagic shock and prevent multiple organ damage

BACKGROUND AND PURPOSE

In circulatory shock, melanocortins have life-saving effects likely to be mediated by MC4 receptors. To gain direct insight into the role of melanocortin MC4 receptors in haemorrhagic shock, we investigated the effects of two novel selective MC4 receptor agonists.

EXPERIMENTAL APPROACH

Severe haemorrhagic shock was produced in rats under general anaesthesia. Rats were then treated with either the non-selective agonist [Nle4, D-Phe7]-melanocyte-stimulating hormone (NDP--MSH) or with the selective MC4 agonists RO27-3225 and PG-931. Cardiovascular and respiratory functions were continuously monitored for 2 h; survival rate was recorded up to 24 h. Free radicals in blood were measured using electron spin resonance spectrometry; tissue damage was evaluated histologically 25 min or 24 h after treatment.

KEY RESULTS

All shocked rats treated with saline died within 30-35 min. Treatment with NDP--MSH, RO27-3225 and PG-931 produced a dose-dependent (13-108 nmol kg-1 i.v.) restoration of cardiovascular and respiratory functions, and improved survival. The three melanocortin agonists also markedly reduced circulating free radicals relative to saline-treated shocked rats. All these effects were prevented by i.p. pretreatment with the selective MC4 receptor antagonist HS024. Moreover, treatment with RO27-3225 prevented morphological and immunocytochemical changes in heart, lung, liver, and kidney, at both early (25 min) and late (24 h) intervals.

CONCLUSIONS AND IMPLICATIONS

Stimulation of MC4 receptors reversed haemorrhagic shock, reduced multiple organ damage and improved survival. Our findings suggest that selective MC4 receptor agonists could have a protective role against multiple organ failure following circulatory shock.

Antimicrobial properties of alpha-MSH and related synthetic melanocortins

The natural antimicrobial peptides are ancient host defense effector molecules, present in organisms across the evolutionary spectrum. Several properties of α-melanocyte stimulating hormone (α-MSH) suggested that it could be a natural antimicrobial peptide. α-MSH is a primordial peptide that appeared during the Paleozoic era, long before adaptive immunity developed and, like natural antimicrobial molecules, is produced by barrier epithelia, immunocytes, and within the central nervous system. α-MSH was discovered to have antimicrobial activity against two representative pathogens, Staphylococcus aureus and Candida albicans. The candidacidal influences of α-MSH appeared to be mediated by increases in cell cyclic adenosine monophosphate (cAMP). The cAMP-inducing capacity of α-MSH likely interferes with the yeast's own regulatory mechanisms of this essential signaling pathway. It is remarkable that this mechanism of action in yeast mimics the influences of α-MSH in mammalian cells in which the peptide binds to G-protein-linked melanocortin receptors, activates adenylyl cyclase, and increases cAMP. When considering that most of the natural antimicrobial peptides enhance the local inflammatory reaction, the anti-inflammatory and antipyretic effects of α-MSH confer unique properties to this molecule relative to other natural antimicrobial molecules. Synthetic derivatives, chemically stable and resistant to enzymatic degradation, could form the basis for novel therapies that combine anti-inflammatory and antimicrobial properties.

Change in gene expression profile induced by alpha-melanocyte stimulating hormone in a malignant mesothelioma cell line

We have previously reported that the peptide a-melanocyte stimulating hormone (alpha-MSH) has antiproliferative effects in human malignant mesothelioma cells. To determine the molecular mechanisms underlying such effects, we investigated the changes in gene expression profile induced by the alpha-MSH analog [Nle4 -DPhe7 ]-alpha-MSH (NDP-alpha-MSH) in a human malignant mesothelioma cell line. The cDNA macroarray technique revealed changes in expression of genes involved in cell growth, adhesion, signal transduction, and transcription. In particular, NDP-alpha-MSH down-regulated expression of B-Myb and Myc, two oncogenes considered of paramount importance for cell proliferation and cancer. Further, NDP-alpha-MSH exerted a favorable transcriptional regulation of certain integrins and their signaling pathways. Finally, peptide treatment was associated with a prominent inhibition of IL-13, a cytokine with tumor-promoting effects. The data indicate that the influences of alpha-MSH extend beyond the established anti-inflammatory effects in normal cells to include cell cycle regulatory properties in malignant cells.

Three-dimensional structure of the alpha-MSH-derived candidacidal peptide [Ac-CKPV]2

Previous research has shown that the immunomodulatory peptide alpha-melanocyte-stimulating hormone (alpha-MSH) and its carboxy-terminal tripeptide KPV (Lys-Pro-Val alpha-MSH11-13) have antimicrobial influences. By inserting a Cys-Cys linker between two units of KPV, we designed the dimer [Ac-CKPV]2 that showed excellent candidacidal effects in pilot tests and was the subject of further investigations. [Ac-CKPV]2 was active against azole-resistant Candida spp. Therefore, the molecule appeared a promising candidate for therapy of fungal infections and was the subject of a structural study. 1H-NMR and restrained mechanic and dynamic calculations suggest that the peptide adopts an extended backbone structure with a beta-turn-like structure. These results open a pathway to development of additional novel compounds that have candidacidal effects potentially useful against clinical infections.

Polymorphonuclear leukocyte membrane fluidity and cytosolic Ca(2+) content in young adults with acute myocardial infarction. Evaluation at the initial stage and after 12 months

Our aim was to examine two aspects of polymorphonuclear leukocyte (PMN) rheology (membrane fluidity and cytosolic Ca2+ content), at baseline and after in vitro activation, in a group of young adults with acute myocardial infarction (AMI) at the initial stage and after 12 months. We enrolled 21 AMI subjects aged < or = 45 years (mean age 41.1 +/- 3.5 years) and evaluated PMN membrane fluidity, labelling intact PMN cells with the fluorescent probe 1,4-(trimethylamino)-phenyl-4-phenylhexatriene and the PMN cytosolic Ca2+ content marking PMN cells with the fluorescent probe Fura 2-AM, at baseline and after in vitro activation with 4-phorbol 12-myristate 13-acetate (PMA) and N-formyl-methionyl-leucyl-phenylalanine (fMLP). During the initial stage PMN membrane fluidity and cytosolic Ca2+ content did not distinguish AMI patients from control subjects; after 12 months, when compared with the initial stage, PMN cytosolic Ca2+ content was significantly increased. In vitro PMN activation with PMA and fMLP caused no variation of the two PMN parameters in control subjects, while in AMI patients membrane fluidity decreased and cytosolic Ca2+ content increased; the same behaviour pattern was observed after 12 months. The constant functional alteration of PMN cells in young AMI patients highlights the role of activated leukocytes as a component of the inflammatory reaction that follows ischemia.

Treatment of "locally advanced" well-differentiated thyroid carcinomas

PURPOSE

To analyse thyroid carcinomas having an extrathyroid extension in order to identify the principal prognostic factors and outline an effective therapeutic strategy.

METHODS

We selected a sample of 160 patients suffering from locally advanced "well differentiated thyroid carcinoma (T4) who had undergone surgery at the Department of Surgery of University of Rome "La Sapienza". The sample was subdivided into three groups: T4, limited type I, and extensive type II, T4 microcarcinomas.

RESULTS

We obtained excellent results with the T4 microcarcinomas, above all in patients under the age of 45, with a 94.5% survival rate, compared with 88% in patients aged over 45. In the extensive type II T4 carcinoma we obtained a survival rate of 29.4% in patients aged over 45 years.

CONCLUSIONS

Age, combined with an aggressive histological variant (Sclerosing and tall-cell papillary carcinoma), is an important factor in prognosis. The radicality of surgical excision is considered an important prognostic factor, although the results reported in the literature are contradictory. Aggressive surgery can free from the disease a high percentage of patients over the age of 50 even with T4. We deem it fundamental to perform total thyroidectomy in all advanced cases of thyroid neoplasm and to extend neoplasm excision to the adjacent tissues, even involving justified surgical demolition.

Haemorheological profile in metabolic Syndrome

Metabolic Syndrome (MetS) has been defined as a clinical condition including impaired glucose tolerance or diabetes mellitus and/or insulin-resistance, associated with two or more of the following components: arterial hypertension, central obesity, dyslipidaemia, microalbuminuria. In a group of subjects with MetS we examined the macrohaemorheological profile, demonstrating a significant increase of blood, plasma and serum viscosity and a decrease of whole blood filterability. The results show that in these subjects a secondary hyperviscosity condition is present, but also that several significant correlations are present between the haemorheological variables and some aspects of MetS, especially those reflecting central obesity (waist to hip ratio) and insulin-resistance. The altered haemorheological profile likely contributes to explain the high cardiovascular risk present in MetS, but it may also participate, through its influence on haemodynamic pattern, in the pathogenesis of insulin-resistance.

Polymorphonuclear leukocyte integrin profile in diabetes mellitus

We examined the polymorphonuclear leukocyte (PMN) integrin pattern in 45 diabetic subjects without macrovascular complications, including 21 subjects with type 1 and 24 with type 2 diabetes mellitus. The PMN adhesion molecules (CD11a, CD11b, CD11c, CD18) were evaluated using indirect immunofluorescence and a flow cytometer, at baseline and after in vitro activation with 4-phorbol 12-myristate 13-acetate (PMA) and N-formyl-methionyl-leucyl-phenyl-alanine (fMLP). At baseline, in diabetic subjects the phenotypical expression of CD11a and CD11b was significantly reduced and CD11c was increased, whereas CD18 was unchanged in comparison with normals. Considering type 1 and 2 diabetic subjects separately, CD11a was reduced and CD11c was increased in both subgroups, CD11b was decreased only in type 1 diabetics and CD18, decreased in type 1, was increased in type 2 subjects. After activation with PMA and fMLP, in normal subjects we observed a significant increase of all PMN adhesion molecules whereas in diabetic subjects only CD11c increased significantly with both activating agents, and CD11b increased only after PMA activation. In type 1 diabetic subjects only CD11c expression was increased, and in type 2 diabetic subjects an increase of CD11b (with PMA) and an increase of CD11c (with fMLP) were noted. In conclusion, we found in diabetic subjects of type 1 and 2 an altered behaviour pattern of PMN integrins both at baseline and, in particular, after in vitro activation. These data may help in explaining the role of PMN in the evolution of diabetic vascular complications.

Haemorheological pattern in young adults with acute myocardial infarction

Acute myocardial infarction (AMI) in young people has recently received great attention. Its main characteristics include a typical risk factor profile and a good prognosis. We studied the haemorheological pattern (whole blood viscosity at high and low shear rates, plasma and serum viscosity, whole-blood filtration and erythrocyte aggregation) in 64 subjects, aged <46 years, with recent AMI. We observed marked alterations in blood, plasma and serum viscosity and whole-blood filtration. Subdividing the AMI subjects in accordance with the number of cardiovascular risk factors or the extent of coronary lesions, we did not observe any significative influence of these aspects on the haemorheological determinants, with the exception of low shear rate blood viscosity. The latter was in fact higher than in control subjects only in AMI subgroups with respectively more risk factors and more stenosed coronary vessels. Thirty-three AMI subjects were re-examined after three months and showed, on this occasion, a haemorheological pattern not significantly different from that of the first evaluation. These results demonstrate that in young subjects with AMI there is a hyperviscosity syndrome that persists during subsequent months, despite a good clinical course. Haemorheological impairment may unfavourably influence the long-term prognosis of AMI in young subjects and therefore, in our opinion, management should take into account the monitoring of the haemorheological pattern.

Retroperitoneal lipoma. Unusual presentation with detrusor instability

Retroperitoneal lipomas are a heterogeneous group of mesenchymal tumors. They are usually large and occur most frequently in the retroperitoneal, perineal and pelvic regions. Lipomas grow slowly surrounding the retroperitoneal and pelvic organs, with a displacement of bowel and vascular axis. A case of a 61-year-old male patient which referred urinary frequency, urgency and nocturia is presented. Urodynamics evidenced a detrusor instability in a low capacity bladder. CT scan demonstrated a bladder dome compression due to a huge retroperitoneal mass extending from the right hepatic lobe to the hypogastric region and the right thigh. Surgical complete resection was performed: histology demonstrated a lipoma with areas of well differentiated myxoid degeneration. After surgery the irritative urinary symptoms disappeared. This is the first case described in literature of detrusor instability due to bladder compression by retroperitoneal lipoma.

Polymorphonuclear leukocyte membrane fluidity, at baseline and after in vitro activation, in obesity with or without diabetes mellitus

We studied a group of 28 obese subjects (mean age 38.2+/-13.5 years, body mass index 35.0+/-5.6 kg/m2) with insulin resistance demonstrated employing an euglycemic hyperinsulinemic clamp, subdivided into a subgroup with normal glucose tolerance (NGT) and a subgroup with type 2 diabetes mellitus (DM). We examined the polymorphonuclear leukocyte (PMN) membrane fluidity at baseline and after activation with 4-phorbol 12-myristate 13-acetate (PMA) or N-formyl-methionyl-leucylphenylalanine (fMLP). At baseline, PMN membrane fluidity was significantly decreased in both subgroups compared to normals. In obese subjects with NGT no correlation was found between this PMN determinant and the parameters reflecting the insulin-resistance degree (glucose disposal [M] and metabolic clearance rate of glucose [MCR]), while in type 2 DM subjects the PMN membrane fluidity was correlated to M and MCR. After activation with PMA and fMLP, no variation in PMN membrane fluidity was observed in normals, while in obese subjects with NGT an early decrease was present only after fMLP activation, and in obese subjects with type 2 DM there was a constant and significant decrease of this PMN parameter after activation with PMA and fMLP. Our interest in the study of the PMN membrane fluidity emerges from its known role in PMN function, especially considering that PMN cells, together with monocytes, may be mediators of vascular damage.

Scintigraphy with 99mTc-MIBI and echography in the study of primitive hyperparathyroidism

BACKGROUND

The authors analyse the value of the exams preoperative for the identification of the pathological parathyroid glands.

METHODS

The authors examined 58 patients affected by primitive hyperparathyroidism (HPTp) who had undergone surgical treatment for primary hyperparathyroidism at the Third Surgical Department of University "La Sapienza" of Rome, in 175 patients affected by primitive hyperparathyroidism observed between January 1970 and June 2000; all patients had undergone echotomography of the neck and 99mTc-MIBI scintigraphy in the diagnostic phase. The histological valuation confirmed the diagnosis by I.P.

RESULTS

99mTc-MIBI scintigraphy demonstrated the pathological glands in 56 cases (96.6%), the echography in 57 cases (98.2%). The comparison of the two exams demonstrated the pathological glands in 100% of the cases. In 45 cases the scintigraphy localized the side (77.6%), and the echography in 41 cases (70.7%). In one case demonstrated I.P. persistent (1.7%) and never one case demonstrated relapsed.

CONCLUSIONS

The authors think that the scintigraphy together with the echography show high sensibility to identification the pathological glands. Neck surgical exploration can still give the side good when the diameter of the parathyroids is inferior to 5 mm.

Increased plasma nitrites in migraine and cluster headache patients in interictal period: basal hyperactivity of L-arginine-NO pathway?

Nitrite concentrations in plasma were investigated in a population of migraine and cluster headache patients and a group of healthy non-headache controls. A hundred migraine patients and 69 cluster headache patients in the interictal period, and 112 controls, were studied. Significantly higher nitrite concentrations were found in migraine patients, with and without aura, and cluster headache patients, in remission and cluster phase, than in controls. These findings suggest that a basal dysfunction in the L-arginine-NO pathway may be involved in the peripheral mechanisms predisposing subjects with neurovascular headaches to individual attacks.