Time interval between neoadjuvant radio-chemotherapy and surgery in rectal cancer: is the long interval correct for all patients?

BACKGROUND

Optimal time between neoadjuvant radio-chemotherapy period and surgery remains controversial in patients with rectal cancer: an increasing number of studies show results in favour of a long interval.

METHODS

We conducted a retrospective analysis of the cases of low-middle rectal adenocarcinoma undergoing neoadjuvant RT-CT and surgery: the primary endpoint was the complete pathological response rate and the secondary endpoint the rate of complications. We analysed cases from 1/01/2003 to 31/12/2018 divided in two periods: from 2003 to 2010 (23 pts) and from 2011 to 2018 (23 pts). The two periods were characterised by two different surgical teams which use different time intervals (≤vs>8 weeks).

RESULTS

The pCR rate is 21.7% in both groups; as regards the complications, the difference between the two groups is in grade IIIb: 8.7% in the first group and 17.4% in the second group (p 0.66).

CONCLUSIONS

Although our study is based on a small number of patients, it shows the same rate of pCR with respect to two different time intervals; this suggests the need for studies based on the division of patients into subgroups and the evaluation of different time intervals in order to reach the best oncological outcomes.

Association of Obesity With Survival Outcomes in Patients With Cancer: A Systematic Review and Meta-analysis

Importance

Obesity, defined as a body mass index (BMI) greater than 30, is associated with a significant increase in the risk of many cancers and in overall mortality. However, various studies have suggested that patients with cancer and no obesity (ie, BMI 20-25) have worse outcomes than patients with obesity.

Objective

To assess the association between obesity and outcomes after a diagnosis of cancer.

Data Sources

PubMed, the Cochrane Library, and EMBASE were searched from inception to January 2020.

Study Selection

Studies reporting prognosis of patients with obesity using standard BMI categories and cancer were included. Studies that used nonstandard BMI categories, that were limited to children, or that were limited to patients with hematological malignant neoplasms were excluded. Screening was performed independently by multiple reviewers. Among 1892 retrieved studies, 203 (17%) met inclusion criteria for initial evaluation.

Data Extraction and Synthesis

The Meta-analysis of Observational Studies in Epidemiology (MOOSE) and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines were reporting guideline was followed. Data were extracted by multiple independent reviewers. Risk of death, cancer-specific mortality, and recurrence were pooled to provide an adjusted hazard ratio (HR) with a 95% CI . A random-effects model was used for the retrospective nature of studies.

Main Outcomes and Measures

The primary outcome of the study was overall survival (OS) in patients with cancer, with and without obesity. Secondary end points were cancer-specific survival (CSS) and progression-free survival (PFS) or disease-free survival (DFS). The risk of events was reported as HRs with 95% CIs, with an HR greater than 1 associated with a worse outcome among patients with obesity vs those without.

Results

A total of 203 studies with 6 320 365 participants evaluated the association of OS, CSS, and/or PFS or DFS with obesity in patients with cancer. Overall, obesity was associated with a reduced OS (HR, 1.14; 95% CI, 1.09-1.19; P < .001) and CSS (HR, 1.17; 95% CI, 1.12-1.23; P < .001). Patients were also at increased risk of recurrence (HR, 1.13; 95% CI, 1.07-1.19; P < .001). Conversely, patients with obesity and lung cancer, renal cell carcinoma, or melanoma had better survival outcomes compared with patients without obesity and the same cancer (lung: HR, 0.86; 95% CI, 0.76-0.98; P = .02; renal cell: HR, 0.74; 95% CI, 0.53-0.89; P = .02; melanoma: HR, 0.74; 95% CI, 0.57-0.96; P < .001).

Conclusions and Relevance

In this study, obesity was associated with greater mortality overall in patients with cancer. However, patients with obesity and lung cancer, renal cell carcinoma, and melanoma had a lower risk of death than patients with the same cancers without obesity. Weight-reducing strategies may represent effective measures for reducing mortality in these patients.

The role of bacteriotherapy in the prevention of adenoidectomy

OBJECTIVE

Adenoidectomy is a surgical procedure with potential adverse events. Effective nonsurgical therapy could reduce patient risk and harm. The aim of this study was to evaluate the role of bacteriotherapy to reduce the necessity of adenoid surgery.

PATIENTS AND METHODS

This experimental study was conducted as an open study in 44 children (30 males and 14 females, mean age 4.9 years) who were candidates for adenoidectomy and tympanocentesis as treatment for adenoidal hypertrophy and otitis media with effusion. Twenty-two children were treated with Streptococcus salivarius 24SMB and Streptococcus oralis 89a nasal spray, administered as 2 puffs per nostril twice a day for a week for 3 months (study group). The other half of the children was treated with hypertonic saline nasal lavage on the same schedule (control group). Tympanometry and adenoid size assessment were evaluated throughout the intervention period.

RESULTS

In the study group, 6/22 children required surgery, compared to 20/22 children in the study group (p<0.0001). The clinical change in the treated children was a significant reduction of adenoid size (p<0.0001) and improvement of middle ear effusion measured with tympanometry (p<0.0001).

CONCLUSIONS

Bacteriotherapy with Streptococcus salivarius 24SMB and Streptococcus oralis 89a nasal spray could significantly reduce the need for adenoid surgery.

A systematic review of salvage therapies in refractory metastatic colorectal cancer

PURPOSE

Established that the only approved agents in previously treated metastatic colorectal cancer (CRC) are trifluoridine/tipiracil and regorafenib, we conducted a systematic review of all the published phase 2-3 trials, with the scope to evaluate the benefit of any later-line regimens in refractory metastatic CRC.

METHODS

Phase 2-3 studies that enrolled patients with stage IV disease receiving salvage therapies for refractory CRC were identified using electronic databases (Pubmed, EMBASE, and Cochrane Library). Clinical outcomes were pooled using a point estimates for the weighted values of median overall survival (OS), progression-free survival (PFS), response rate (ORR), stable disease rate (SD), and 6-month and 1-year OS.

RESULTS

Overall, 7556 patients were included from 67 studies (n = 70 arms). Overall, the pooled ORR and SD were 15.4% (95% CI 13-18%) and 36.9% (95% CI 33.5-40.6%). Median PFS, 6-month and 1-year OS, and median OS were 3.2 (95% CI 2.9-3.3) months, 65.4% (95% CI 61.9-68.8%), 36% (95% CI 32.3-39.9%) and 8.8 (95% CI 8.3-9.2) months. Overall survival was different in the monochemotherapy, polychemotherapy, chemotherapy + targeted therapy, and targeted therapy alone arms (7.6, 9.5, 10.3, and 7.9 months, respectively, P for difference = 0.01). Median PFS were respectively 2.3, 3.9, 3.8, and 2.6, respectively (P for difference < 0.01).

CONCLUSIONS

Overall, combination therapy (polychemotherapy with or without targeted agents) is associated with a higher control of disease and better outcome than approved agents. Treatment, if possible, should be personalized according to the patients' conditions, physician preference and molecular profile of disease.

Microsatellite Instability and Survival in Stage II Colorectal Cancer: A Systematic Review and Meta-analysis

BACKGROUND/AIM

About 15-20% of colorectal cancers (CRCs) have deficiency in a mismatch repair (MMR) protein. MMR has a high level of microsatellite instability (MSI-H). We have conducted this review and meta-analysis to determine the prognostic role of MSI-H status in stage II CRC.

MATERIALS AND METHODS

We searched PubMed, EMBASE, The Cochrane Library, Web of Science, and SCOPUS for studies reporting data on overall survival (OS) and disease-free or relapse-free survival (DFS or RFS) for MSI-H compared to microsatellite stable (MSS) CRC.

RESULTS

A total of 39 studies were analysed, including 12,110 patients. MSI-H status was associated with a significantly reduced risk of death (HR=0.64, 95%CI=0.52-0.8, p<0.01) and relapse (HR=0.59, 95%CI=0.45-0.77, p<0.01) in stage II CRC.

CONCLUSION

MSI-H represents an important prognostic determinant in stage II CRC and may be considered when estimating the risk of recurrence in stage II CRC.

Adjuvant radiotherapy for Merkel cell carcinoma: A systematic review and meta-analysis

Merkel cell carcinoma (MCC) is a rare and aggressive cutaneous malignancy with a high propensity for local recurrence and regional and distant metastases. The main treatment is surgery with narrow excision margins and draining nodes, plus or minus adjuvant radiotherapy (RT) on the surgical bed and/or lymph nodes. We performed a systematic review and meta-analysis of the benefits of adjuvant RT in MCC treatment. PubMed, EMBASE, and the Cochrane Library were systematically searched to identify relevant studies published before September 2018. Prospective trials and retrospective series comparing adjuvant RT vs. no RT in resected primary MCCs were included. Primary endpoint was to evaluate the outcomes of MCC patients who received adjuvant RT in term of overall survival (OS) and disease-free survival (DFS). Hazard ratios (HRs) for OS and DFS were aggregated according to a fixed or random effect model. Secondary endpoints were local, locoregional, and distant DFS. A total of 17,179 MCCs across 29 studies were analysed. There was a significant difference in OS between the RT and no RT arms (HR = 0.81, 95%CI 0.75-0.86, P < 0.001). There was also a significant difference in DFS in favour of adjuvant RT (HR = 0.45, 95%CI 0.32-0.62, P < 0.001). Adjuvant RT improved locoregional DFS and local DFS but not distant DFS (HR = 0.3, 95%CI 0.22-0.42; HR = 0.21, 95%CI 0.14-0.33, and HR = 0.79, 95%CI 0.49-1.14, respectively). Meta-regression analysis showed that high Newcastle-Ottawa scale scores, stage I-II MCCs, shorter follow-up durations, size >2 cm, and being of a younger age were associated with increased OS. This systematic review and meta-analysis suggests a survival and DFS benefit for postoperative radiation of MCCs. Intermediate stage MCCs derive the maximum benefit with local and regional relapses reduced by 80% and 70%, respectively. Conversely, distant metastases were not significantly prevented.

Inhaled Tobramycin in Children with Acute Bacterial Rhinopharyngitis

Antibiotic abuse for treating rhinopharyngitis induces the occurrence of resistant bacteria. As topical drugs might reduce this phenomenon, the aims of our study were to evaluate inhaled tobramycin in children with acute bacterial rhinopharyngitis and to compare it with oral amoxicillin/clavulanate. The trial was conducted as randomized, parallel group and double blind. Children, aged 3–6 years, with acute bacterial rhinopharyngitis were treated with 15 mg of aerosolized tobramycin (Group A) or 50 mg/Kg of amoxicillin/clavulanate (Group B) twice daily for 10 days. The following parameters were assessed: nasal obstruction, mucopurulent rhinorrhea, post-nasal drip, adenoidal hypertrophy, tympanic inflammation, tympanogramm, rhinomanometry and cultures. Of 416 patients screened, 311 children (178 females and 133 males), median age 4.5 years, completed the study: 156 in Group A and 155 in Group B. Both treatments improved all parameters (p<0.01 for all). Intergroup analysis showed that inhaled tobramycin induced a better improvement versus amoxicillin/clavulanate concerning nasal obstruction (p<0.05), adenoidal hypertrophy (p<0.01), tympanic inflammation (p<0.01), rhinomanometry (p<0.01) and cultures (p<0.05). In conclusion, inhaled tobramycin may represent a valid treatment for acute bacterial rhinopharyngitis in children, as it is effective, safe, economic and simple to use.

The relevance of the Mometasone furoate nasal spray in clinical practice

Allergic rhinitis (AR) is characterized by mucosal inflammation, therefore anti-inflammatory drugs are indicated for its treatment, mainly concerning intranasal administration. Mometasone furoate nasal spray (MFNS) has been on the market under the brand Nasonex® for 20 years and has high effectiveness and an excellent safety profile. From a clinical point of view, an ideal topical medication should respect a series of requirements, including handy device, good sensory characteristics, aptitude to the reach posterior nasal cavity, long residence time, and optimal pharmacokinetic and pharmacodynamic activities. MFNS fully satisfies these claims, as underlined by 20 years of worldwide prescriptions.

Salso-bromo-iodine thermal water: a nonpharmacological alternative treatment for postnasal drip-related cough in children with upper respiratory tract infections

Postnasal drip (PND)-related cough is a very common symptom in patients with upper respiratory tract infections (URTIs). At present, there is not a standard treatment for postnasal drip and postnasal drip-related cough. The aim of this pilot study was to evaluate the efficacy of a specific salso-bromo-iodine thermal water containing hyaluronic acid and grapefruit seed extract (SBI-H-GSE) comparing it with a normal saline solution in children with URTIs who refer PND-related symptoms. The study was randomized, single-blind, and controlled. Study group (75 children) was treated with SBI-H-GSE and control group (65 children) was treated with a normal saline solution; both compounds were administered by nasal nebulization with Rinowash nasal douche twice/day for 10 days a month for 3 consecutive months. Parent Cough-Specific Quality of Life questionnaire (PC-QOL) average score, the prevalence of symptoms and signs related to post-nasal drip, nasal mucociliary transport time (NMTT), duration and number of URTI episodes, antibiotic usage and days of absence from school were evaluated at baseline and after treatment. SBI-H-GSE therapy shows better and statistically significant trend after treatment when compared to control group for PC-QOL average score (p=0.011), NMTT (p=0.047), symptoms and signs related to post-nasal drip (all p<0.005, except for the cobblestone appearance of the mucosa), duration (in days) with URTI symptoms (p=0.023) and a usage of antibiotic therapy (p=0.011). The current randomized-controlled pilot study demonstrated that SBI-H-GSE solution was effective in the treatment of children with URTIs who refer PND-related symptoms.

Inflammation in Respiratory Allergy Treated by Sublingual Immunotherapy

The most common allergic diseases, such as rhinitis, asthma and atopic dermatitis, are sustained by allergic inflammation, the treatment of which requires anti-inflammatory activity. Among the available treatments, allergen immunotherapy (IT) has a documented impact on allergic inflammation which persists after its discontinuation and modifies the natural course of allergy. The anti-inflammatory effects of IT, and particularly of sublingual IT (SLIT), are based on the ability to modify the phenotype of T cells which, in allergic subjects, are characterized by a prevalence of the Th2 type, with production of IL-4, IL-5, IL-13, IL-17, and IL-32 cytokines. IT-induced changes result in a Th1-type response (immune deviation) related to an increased IFN-gamma and IL-2 production or in a Th2 reduced activity, through a mechanism of anergy or tolerance. It is now known that T cell tolerance is characterized by the generation of allergen-specific Treg cells, which produce cytokines such as IL-10 and TGF-beta with immunosuppressant and/or immunoregulatory activity. Recent studies suggest that the anti-inflammatory mechanism of SLIT is similar to classical, subcutaneous IT, with a prominent role in SLIT for mucosal dendritic cells. The tolerance pattern induced by Treg accounts for the suppressed or reduced activity of inflammatory cells and for the isotypic switch of antibody synthesis from IgE to IgG, and especially to IgG4. Data obtained from biopsies clearly indicate that the pathophysiology of the oral mucosa plays a pivotal role in inducing tolerance to the sublingually administered allergen.

Sinuclean Nebules treatment in children suffering from otitis media with effusion

OBJECTIVE

Otitis media with effusion (OME) is an ear disorder defined by the presence of fluid in the middle ear without signs or symptoms of acute infection. The current randomized, double-blind, controlled study aimed to evaluate whether Sinuclean Nebules treatment, administered by nasal douche (Rinowash), could induce ear healing better than isotonic saline in children with OME.

METHODS

The study was randomized, double-blind, and controlled. Group A (30 children) was treated with Sinuclean Nebules 45 and Group B (31 children) was treated with isotonic saline; both compounds were administered by nasal nebulization with Rinowash nasal douche twice/day in the morning and in the evening for 10 days, followed by a one-week suspension, and after by a second course as the first. Tympanogram and audiometry were performed at baseline and after treatment.

RESULTS

Considering the global evaluation of the treatment: in Group A, 28 (93.3%) patients had complete resolution and 2 (6.7%) had partial resolution; in Group B, all patients had failure of treatment. There was a significant difference between groups (p < 0.0001).

CONCLUSION

The current randomized-controlled study demonstrated that Sinuclean Nebules was effective and in the treatment of children with OME.

Natural history, diagnosis, treatment and outcome of thyroid microcarcinoma (TMC) A mono-institutional 5 year experience

Thyroid microcarcinoma (TMC) it's a rare type of differentiated thyroid cancer, which according to the World Health Organization measures 10 mm or less. Accounting 7-16 % of all thyroid carcinomas, it occurs at any age, more frequently in men, with a female to male ratio of 1:3. More frequently histotype is the papillary subset, PTCM. Aim of this study is to retrospectively evaluate the patients diagnosed with TMC in terms of their clinical and histopathological features. In our institution we collected 23 cases of TMC sampled on 338 plongeant being operated. All the tumors, in our study, were found incidentally during the treatment of benign thyroid diseases. All the sample were analyzed and prepared using the same frozen section technique. Surgical pathology identified 11 papillary microcarcinomas, 10 follicular microcarinomas, 1 oncocytary microcarcinomas and in 1 patient was found only a focal tireocitary transformation. TMC's prognosis and treatment is still a subject of controversy We propose our approch consisting in total thyroidectomy (less than 5 gr residual thyroid tissue), being considered the low rate of post-operative complications, and recurrences: all patients are disease-free at the median follow-up of 78 months (range 96 to 30 months). We have considered either the less malignancy habit of this neoplasia either its well prognosis.

Inhaled hyaluronic acid as ancillary treatment in children with bacterial acute rhinopharyngitis

Acute rhinopharyngitis (ARP) is the most common upper respiratory infection in children and represents a social problem for both the pharmaco-economic impact and a burden for the family. Topical antibiotic therapy is usually effective in bacterial ARP, but ancillary treatment might improve its efficacy. Hyaluronic acid (HA) is a promising molecule that has been recently proposed in upper respiratory disorders. Therefore, the purpose of this study was to evaluate the effects of ancillary HA treatment in children with bacterial ARP. Globally, 51 children (27 males, mean age 5.9 ± 2.1 years) with bacterial ARP were enrolled in the study. At baseline, children were randomly assigned to the treatment with: 125 mg of thiamphenicol diluted in 4 mL of saline isotonic solution twice daily (group A) or with 125 mg of thiamphenicol plus 4 ml of sodium hyaluronate 0.2% plus xylitol 5% (Aluneb, Sakura Italia) twice daily (group B) administered by the nasal device Rinowash (Airliquide Medical System, Italy) and connected to an aerosol nebulizer with pneumatic compressor (1.5 bar per 5 L/min) Nebula (Airliquide Medical System, Italy), for 10 days. sVAS, nasopharyngeal spotting, neutrophils and bacteria were assessed at baseline and after the treatment. Both treatments induced significant reduction of symptom perception, spotting, neutrophil and bacteria count. However, thiamphenicol plus HA was able to significantly induce a greater effect on sVAS (p=0.006), neutrophil count (p=0.01), and bacteria count (p=0.0003) than thiamphenicol alone. In conclusion, this study provides the first evidence that intranasal HA, as ancillary treatment, may be able to improve topical antibiotic efficacy in children with bacterial ARP.

Is primary surgery for locally advanced/metastatic breast cancer a better choice than chemotherapic treatment?

INTRODUCTION

A part of the literature supports the undoubtful advantage of neoadjuvant chemotherapy on the overall survival and for the possibility of surgical conservative treatment in locally advanced tumours after downstaging. Other authors report that primitive tumour's surgical removal at first, improves survival in cases with locally advanced /metastatic disease. The advantages were improvement of patient's health status, removal of a reservoir of neoplastic cell neoangiogenic cytokines and growth factors,and cytoreduction.

MATERIALS AND METHODS

Aim of this study is to evaluate the effectiveness on the survival of a primary surgical treatment of the locally advanced tumours comparing two homogeneous groups. In the first group (GROUP 1) 40 patients were enrolled with stage III A, III B,IV tumours and were treated with primary surgery. The second group (GROUP 2) was made up of 40 patients with similar stage treated with neoadjuvant chemotherapy. The surgical treatment had the intention to remove the entire primary tumour.

RESULTS

After a median follow up of 48,2 months,22,5 % of GROUP 1 died and 30 % of GROUP 2. The average survival of patients in GROUP 1 was 27,1 months while in GROUP 2 there was an average survival of 16,8 months.

CONCLUSION

In conclusion surgical treatment plays a key role in the treatment of advanced/metastatic disease and is an independent factor associated with survival.

Successful use of rFVIIa for major breast surgery prophylaxis in congenital factor VII deficiency: a case report

INTRODUCTION

Factor VII deficiency is a rare cause of haemorrhagic syndrome. The Authors describe a case of a 46 years old patient with congenital factor VII deficiency that successfully underwent breast surgery after treatment with Novoseven® before the procedure.

MATERIALS AND METHODS

The AA used the schedule reported below to value the levels of PT and aPTT in the patient. Blood Collection: Venous blood from patient and control was collected in glass tubes for routine serum preparation and into plastic tubes (0.129 M sodium citrate, Becton-Dickinson Vacutainer Systems) in a ratio of blood to anticoagulant of 9:1. Platelet Poor Plasma (PPP) was obtained by centrifugation at 4.000 x g for 15 minutes at room temperature. The plasma was recentrifuged for another 10 min at 12000 g to fully eliminate platelet concentration. A normal control plasma pool was prepared by mixing equal volumes of platelet-free plasma obtained from at least 50 normal volunteers. Prothrombin time (PT) was measured with Recombiplastin (IL, Milano Italy). Activated partial thromboplastin times (APTT) was measured with APTT-SP (IL, Milano Italy). They were performed on the coagulation analyzer ACL 1000 (IL, Milano Italy).

RESULTS

The results were interpreted from the ratio of the patient times to the normal control times (Table I).

CONCLUSION

The infusion of Novoseven solved the clotting problems enabling the surgical procedure, without risks for the patient.

Successful use of rFVIIa for major breast surgery prophylaxis in congenital factor VII deficiency

INTRODUCTION

Factor VII deficiency is a rare cause of haemorrhagic syndrome. The Authors describe a case of a 46 years old patient with congenital factor VII deficiency that successfully underwent breast surgery after treatment with Novoseven® before the procedure.

MATERIALS AND METHODS

The AA used the schedule reported below to value the levels of PT and aPTT in the patient. Blood Collection: Venous blood from patient and control was collected in glass tubes for routine serum preparation and into plastic tubes (0.129 M sodium citrate, Becton-Dickinson Vacutainer Systems) in a ratio of blood to anticoagulant of 9:1. Platelet Poor Plasma (PPP) was obtained by centrifugation at 4.000 x g for 15 minutes at room temperature. The plasma was recentrifuged for another 10 min at 12000 g to fully eliminate platelet concentration. A normal control plasma pool was prepared by mixing equal volumes of platelet-free plasma obtained from at least 50 normal volunteers. Prothrombin time (PT) was measured with Recombiplastin (IL, Milano Italy). Activated partial thromboplastin times (APTT) was measured with APTT-SP (IL, Milano Italy). They were performed on the coagulation analyzer ACL 1000 (IL, Milano Italy).

RESULTS

The results were interpreted from the ratio of the patient times to the normal control times (Table I).

CONCLUSION

The infusion of Novoseven solved the clotting problems enabling the surgical procedure, without risks for the patient.

KEY WORDS

Breast cancer, Factor VII deficiency, Major surgery, Recombinant fVIIa.

Salso-sulphide thermal water in the prevention of recurrent respiratory infections in children

Recurrent respiratory infections (RRI) represent a social problem for both the pharmaco-economic impact and the burden on the family. Thermal water is popularly well accepted. However, there is no scientific evidence of its preventive activity on recurrent respiratory tract infections (RRI). Therefore, the purpose of this study was to evaluate the effects of Agnano thermal water nasal irrigation on RRI prevention in children.A total of 107 children (70 males, mean age 4.5 plus minus1.2 years) with RRI were enrolled in the study. At baseline, children were randomly assigned to the treatment with: A) inhaled crenotherapy with salso-sulphide water or B) isotonic saline (NaCl 0.9 percent). Inhaled therapy was performed using nasal washing by Rino-jet (ASEMA srl, Milan, Italy) b.i.d. for 12 days. Nasal washing lasted 2 minutes per nostril. Immediately before washing, children inhaled 1 l of water by stream inhalation per 2 minutes. Crenotherapy was capable of significantly reducing: the number of respiratory infections, nasal symptoms, neutrophil and bacteria count, turbinate and adenoidal hypertrophy, presence of biofilm, and blockage of ostiomeatal complex (OCM). In conclusion, this study provides the first evidence that Agnano crenotherapy may be capable of preventing RRI in children as it exerts some positive effects, such as reduction of nasal obstruction, OCM blockage, biofilm, and inflammatory events.

Laparoscopic treatment of celiac axis compression syndrome (CACS) and hiatal hernia: Case report with bleeding complications and review

INTRODUCTION

Median arcuate ligament (MAL) malposition is a rare cause of celiac axis compression syndrome (CACS) or Dunbar syndrome.

PRESENTATION OF CASE

A 26-year-old female presented with severe postprandial epigastric pain, weight loss, heartburn and regurgitation unresponsive to medical therapy. CT angiography and duplex ultrasound demonstrated the MAL crossing anterior to the celiac artery (CA). Reconstructions demonstrated CA compression, while the superior mesenteric artery (SMA) was normal. The MAL was laparoscopically divided, releasing the celiac axis. A concomitant Nissen fundoplication was performed. At 3-months follow-up, the CT-scan demonstrated no evidence of CACS with complete symptom resolution.

DISCUSSION

Dunbar's syndrome can be treated with endovascular surgery, laparoscopic MAL division or vascular surgery.Six anatomical and morphologic variations of aortic and esophageal hiatus are described. The result of the analysis of these anatomical data leads to the conclusion that hiatus hernia, Dunbar's syndrome and GERD have a common etiopathogenesis and physiopathology.

CONCLUSION

Laparoscopic treatment is useful and feasible in centers with experience in majorlaparoscopic surgery with reduced invasiveness, better cosmetic effect and shorter postoperative course.

Reconstruction with cutaneous flap after resection for breast cancer's skin metastases in a chemoresistant patient

We reported a case of a breast cancer's skin metastases in a patient that had sustained 3 lines of chemotherapy. At first she received surgical treatment with Madden's mastectomy with dissection of axillary limphnodes and positioning of an expander. After that she underwent to chemo- and radiotherapy. The schedules we performed were: FEC, TC,Vinorelbine and Capecitabine. Only after the FEC there was a clinical remission just for 1 year. After that she underwent to surgery for the removal of a lozenge of skin on the right hemithorax, including also the subcutaneous tissue, a strip of muscular tissue, and a residue of the breast implant. The histology showed a multiple-nodules infiltration involving the dermis, the hypodermis, and the muscle. This pattern was valuated as a G3 breast cancer recurrence with ER 70%, PgR<5%, Ki67 50% Her2neu-. During the second line chemotherapy with TC she developed an high grade LCIS with lymphovascular infiltration on the left breast; on the right hemithorax there were cutaneous metastases with dermis' infiltration. Surgery with local excision was performed, and a cutaneous flap was realized.

Hypertonic saline is more effective than normal saline in seasonal allergic rhinitis in children

Allergic rhinitis (AR) is a very common childhood disease that is associated with a significant reduction in the patients' quality of life. Its treatment combines educating the patients and their parents, immunotherapy and drug administration. However, even the best approach does not relieve the symptoms of a number of patients. Alternative therapies are particularly needed for children because the fear of adverse events frequently reduces parental compliance to the prescribed drugs, and immunotherapy is less easy to administer than in adults. In this prospective investigator-blinded study we evaluated whether children, with a documented history of seasonal grass pollen-related AR, benefit from nasal irrigation by assessing the effects on nasal signs and symptoms, on middle ear effusion and on adenoidal hypertrophy. We randomized children aged 5 to 9 years (median age 82 months) to normal saline or hypertonic saline (a 2.7% sodium chloride solution), administered twice-daily using a disposable 20 ml syringe, or no treatment. Nasal symptoms (rhinorrhea, itching, sneezing, nasal obstruction), swelling of turbinates, adenoid hypertrophy or middle ear effusion were assessed at baseline and after 4 weeks of treatment. Two hundred and twenty children (normal saline: 80; hypertonic saline: 80; no treatment: 60) completed the study. After four weeks, all the considered items were significantly reduced in the group receiving hypertonic saline (P < 0.0001), whereas in the group receiving normal saline only rhinorrhea (P = 0.0002) and sneezing (P = 0.002) were significantly reduced. There was no significant change in any of the items in the control group. The duration of oral antihistamines was significantly lower in the children receiving hypertonic saline than in those treated with normal saline or in controls. No adverse events were reported and parental satisfaction and compliance with the procedure were globally very good, regardless of the solution used. Using our procedure, hypertonic saline is effective, inexpensive, safe, well tolerated and easily accepted by children with seasonal grass pollen-related AR and their parents. Our data suggest that nasal irrigation with hypertonic saline might be included in the wide spectrum of therapies recommended for grass-pollen AR.

Intranasal flunisolide treatment in patients with non-allergic rhinitis

Non-allergic rhinitis (NAR) is a heterogeneous disease, characterized by nasal hyperreactivity and inflammation. Its treatment is still debated, intranasal corticosteroids may be an option. The present study is aimed at evaluating the effect of the use of intranasal flunisolide in patients with NAR, considering both clinical and cytological parameters. Sixty patients were treated with intranasal flunisolide (30) or saline solution (30) for 8 weeks. Symptom severity, turbinate size, and inflammatory cell counts were assessed, before and after treatment. Intranasal flunisolide induced a significant reduction of symptoms, turbinate size, and cellular infiltrate. Thus, intranasal flunisolide might be a therapeutic option for NAR.

Impact of allergic rhinitis on asthma in children: effects on bronchodilation test

BACKGROUND

Relevant relationship exists between upper and lower airways. Bronchial obstruction is a paramount feature of asthma and its reversibility is considered a diagnostic step for asthma diagnosis.

OBJECTIVE

This study aimed at evaluating a large group of children with allergic rhinitis alone for investigating the degree of brochodilation and possible factors related to it.

METHODS

Two hundred patients with allergic rhinitis and 150 normal subjects were consecutively evaluated. Clinical examination, skin prick test, spirometry, and bronchodilation test were performed in all patients.

RESULTS

Rhinitics showed a significant FEV(1) increase after bronchodilation test (P < 0.0001) in comparison both to basal values and to controls' levels. More than 20% of rhinitics had reversibility (> or =12% basal levels). Patients with reversibility had lower FEV(1) levels, longer rhinitis duration, and perennial allergy.

CONCLUSION

This study highlights the close link between upper and lower airways and the relevance of performing bronchodilation test in patients with allergic rhinitis and these characteristics.

The nose and paranasal sinuses

The airways should be considered as a functional unit. Indeed, disorders involving the upper respiratory tract (URT) spread to the lower respiratory tract (LRT). Modern functional anatomy divides URT in three, mutually dependent, junction boxes: i) the ostio-meatal complex (OMC), ii) the spheno-ethmoidal recess (SER), and iii) the rhinopharynx (RP). The first is the most interesting as it joins the anterior paranasal sinuses with the nose. The correct ventilation and the effective mucociliary clearance of these three pathophysiologic junction boxes condition the healthy physiology of the entire respiratory system. The OMC, SER and RP obstruction is the first pathogenic step in the inflammatory cascade of the rhino-sinusal-pharyngeal disorders. The inflammation of the respiratory mucosa is the main pathogenic factor for airway obstruction that may be generically defined as a heterogeneous group of pathologies. Moreover, the bacterial biofilms are an important local cause of recurrent diseases: they are a strategic modality of survival set up by bacteria and the main cause of their resistance to systemic antibiotic therapy.

Prevention of surgery in children with adenoidal hypertrophy treated with intranasal flunisolide: a 12-month follow-up

Adenoidal hypertrophy (AH) represents one of the most frequent indications for surgery in children. Recently, treatment with intranasal corticosteroids has been suggested to decrease the size of AH. The aim of the study is to evaluate the long-term effect of intranasal flunisolide on AH during a 12-month follow-up. One hundred seventy-eight children with a grade III or IV AH at baseline endoscopic examination were enrolled in this randomised and controlled study. Children were treated with intranasal flunisolide or isotonic saline solution for 8 weeks. Subsequent assessment, including history and fiberoptic endoscopy, was made at 8 weeks, and 6 and 12 months after treatment suspension. Flunisolide treatment was initially associated with significant (p<0.01) reduction of the degree of AH. However, during follow-up all but one of the non-allergic children relapsed, whereas most allergic children maintained AH size reduction (p<0.05). No clinically important adverse events were reported. In conclusion, this preliminary study demonstrates that an 8-week treatment with intranasal flunisolide is significantly associated with reduction of AH, however, the adenoidectomy avoidance was warranted only for allergic children.

Inhaled thiamphenicol and acetylcysteine in children with acute bacterial rhinopharyngitis

Antibiotic abuse for treating rhinopharyngitis induces the occurrence of resistant bacteria. As topical drugs might reduce this phenomenon, the aims of our study are to evaluate inhaled thiamphenicol associated with acetylcysteine in children with acute bacterial rhinopharyngitis and to compare it with the use of saline solution. The trial was conducted as randomized, parallel group, and single blind. Children, aged 3-6 years, with acute bacterial rhinopharyngitis were treated with aerosolized thiamphenicol associated with acetylcysteine (250 mg: 1/2 vial in the morning and 1/2 vial in the evening) (Group A) or saline solution twice daily (Group B), both of them for 5 days. Both treatments were administered using a new device: Rinowash. The following parameters were assessed: nasal obstruction, mucopurulent rhinorrhea, post-nasal drip, cough, sore throat, fever, and cultures. Of 104 patients screened, 90 children, median age 3.7 years (44 females and 46 males), completed the study: 60 in Group A and 30 in Group B. Actively-treated children achieved a significant improvement of all parameters, but fewer than the control group. In conclusion, inhaled thiamphenicol associated with acetylcysteine may represent a valid treatment for acute bacterial rhinopharyngitis in children, as it is effective, safe, economic, and simple to use.

Intranasal flunisolide treatment in children with adenoidal hypertrophy

Adenoidal hypertrophy (AH) represents one of the most frequent indications for surgery in children and it has been proposed that treatment with intranasal corticosteroids can decrease the size of AH. Therefore, the aim of the study is to evaluate the effect of the use of intranasal flunisolide among children affected by AH. 178 children with AH were evaluated in this randomised and controlled study. Inclusion criteria for the study required that each patient had to have a III or IV degree of AH on the initial endoscopic examination. Children were treated with intranasal flunisolide or isotonic saline solution for 8 weeks. After treatment, endoscopy was performed to re-evaluate AH degree. Flunisolide treatment was associated with significant (p less than 0.04) reduction of AH degree. There was moreover a consistent reduction of children (46 out of 58) proposed to adenoidectomy. No clinically important adverse events were reported. In conclusion, this preliminary study demonstrates that an 8-week treatment with intranasal flunisolide is significantly associated with reduction of AH, thus preventing the recurrence to adenoidectomy, and is safe.

Hypertonic Saline Solution in Children with Adenoidal Hyperytrophy: Preliminary Evidence

Adenoidal hypertrophy (AH) is a frequent problem in children. A preliminary study evidenced that intranasal hypertonic solutions may exert an anti-inflammatory activity. The aim of the study is to evaluate the effect of intranasal hypertonic or isotonic solutions in children affected with AH. For this purpose, 78 children with AH were evaluated in a randomised and controlled study. Inclusion criteria for the study required that each patient had to have a III or IV degree of AH on the initial endoscopic examination. Children were treated with intranasal hypertonic or isotonic saline solution for 8 weeks. After treatment, endoscopy was performed to evaluate AH degree. Hypertonic treatment was associated with significant (p<0.05) reduction of AH degree. There was a consistent reduction of children with III degree of AH. No adverse events were reported. This preliminary study demonstrates that an 8-week treatment with intranasal hypertonic solution is associated with significant reduction of AH. Therefore, this study evidences that hypertonic solution may exert an anti-inflammatory activity and is safe.

Inhaled tobramycin in children with acute bacterial rhinopharyngitis

Antibiotic abuse for treating rhinopharyngitis induces the occurrence of resistant bacteria. As topical drugs might reduce this phenomenon, the aims of our study were to evaluate inhaled tobramycin in children with acute bacterial rhinopharyngitis and to compare it with oral amoxicillin/clavulanate. The trial was conducted as randomized, parallel group and double blind. Children, aged 3-6 years, with acute bacterial rhinopharyngitis were treated with 15 mg of aerosolized tobramycin (Group A) or 50 mg/Kg of amoxicillin/clavulanate (Group B) twice daily for 10 days. The following parameters were assessed: nasal obstruction, mucopurulent rhinorrhea, post-nasal drip, adenoidal hypertrophy, tympanic inflammation, tympanogram, rhinomanometry and cultures. Of 416 patients screened, 311 children (178 females and 133 males), median age 4.5 years, completed the study: 156 in Group A and 155 in Group B. Both treatments improved all parameters (p<0.01 for all). Intergroup analysis showed that inhaled tobramycin induced a better improvement versus amoxicillin/clavulanate concerning nasal obstruction (p<0.05), adenoidal hypertrophy (p<0.01), tympanic inflammation (p<0.01), rhinomanometry (p<0.01) and cultures (p<0.05). In conclusion, inhaled tobramycin may represent a valid treatment for acute bacterial rhinopharyngitis in children, as it is effective, safe, economic and simple to use.

Nasal application of immunotherapy

BACKGROUND

In patients with allergic rhinitis local nasal immunotherapy (LNIT) appears to offer considerable advantages over other hyposensitization methods. The aim of our study was to obtain further confirmation of the validity of LNIT.

METHODS

A randomized, double-blind, placebo-controlled study of LNIT in patients allergic to Parietaria and Dermathophagoides was performed. Patients were evaluated, before and after treatment, with symptom and medication scores, specific nasal provocation tests, anterior rhinomanometry and mucociliary clearance time.

RESULTS

Compared to placebo the clinical efficacy of LNIT was confirmed by a reduction of clinical symptoms and drug intake. In the active group the reduction of allergen-specific nasal reactivity was significant. No local or systemic side effects were observed.

CONCLUSIONS

The clinical efficacy of LNIT suggests that this therapy is effective in the prophylaxis of allergic rhinitis. Finally, there is no conflict between LNIT and drug treatment.

Chondroid chordoma of the lateral skull base

A rare case of chondroid chordoma of the lateral skull base with laterocervical extension is reported. Clinical, radiological and pathological features of the tumor are described. This unusual location of chondroid chordoma enabled total resection of the neoplastic tissue through a combined laterocervical and far lateral transjugular approach.

Noninvasive assessment of left and right internal mammary artery graft patency with high-frequency transthoracic echocardiography

OBJECTIVES

The aim of this study was (1) to visualize internal mammary artery grafts (IMAG) on coronary artery by transthoracic echocardiography and (2) to assess the patency of the grafts.

METHODS

Twenty-three patients (21 men, 56 +/- 6 years) with previous coronary artery bypass grafting were studied at baseline and after they underwent low-dose dipyridamole infusion. The parameters obtained were systolic (SPV) and diastolic (DPV) peak velocities and their ratio (DPV/SPV); the dipyridamole infusion to baseline ratio of DPV was an index of IMAG blood flow reserve (FR). Two groups of patients were selected at baseline: group A, (n = 12) with a DPV/SPV >1, and group B (n = 11), with a DPV/SPV <1.

RESULTS

The IMAG was identified in all patients. Intraluminal flow signals obtained with pulsed wave Doppler showed a biphasic pattern (1 systolic and 1 diastolic wave). After dipyridamole infusion was administered, flow velocities increased in 11 of 12 patients in group A and in 5 of 11 patients in group B. In group A the DPV/SPV increased from 1.79 +/- 0.47 to 1.8 +/- 0.43 (P = not significant), and the FR was 1.8 +/- 0.4. In group B the DPV/SPV increased from 0. 46 +/- 0.05 to 0.5 +/- 0.09 (P = not significant), and the FR was 1. 3 +/- 0.41. Coronary angiography showed the graft patency in all patients in group A and in 5 patients in group B with increased flow velocity after dipyridamole infusion. In the identification of graft stenosis at baseline, DPV/SPV showed 100% sensibility and 58% specificity, and FR showed 92% sensibility and 84% specificity.

CONCLUSION

Doppler echocardiographic evaluation of the IMAG is a simple noninvasive method to assess the functional impairment of the vessel.

Effect of low dose Amiodarone on the incidence of sudden death in elderly patients with congestive heart failure: a double-bind, placebo-controlled study

To determine if low-dose Amiodarone could reduce sudden death (SD) among patients with congestive heart failure, a prospective, double-blind, placebo-controlled study was conducted. The study group consisted of 46 patients (36 men and 10 women, mean age 71 +/- 5 years) with complex ventricular ectopy documented by 48-hour Holter monitoring. Randomization divided the patients into two treatment groups: the first group received Amiodarone (400 mg/day for 1 week and then 100 mg/day), while the second group received placebo. The drug significantly reduced ventricular arrhythmias, but then was no decrease in incidence of SD. This study demonstrates not only that low-dose Amiodarone can be safely administered to elderly patients with congestive heart failure and it will significantly suppress ventricular arrhythmias, but also that reduction in ventricular arrhythmias and the risk of SD are not linearly related.

Isoproterenol test and head-up tilt test for diagnosis of vasovagal syncope in elderly patients

The elderly can be affected by vasovagal syncope, but they often do not have preceding symptoms. The head-up tilt test (HTT) is successfully used in half of the patients in which the diagnosis is difficult. In young people the association with the isoproterenol test improves the sensitivity of the HTT. In the elderly the effect of such an association is still debated, therefore, the present study was aimed at evaluating the usefulness of the association between the two tests in old subjects to unmask the vasovagal nature of some syncopes of unknown origin. Twenty-four patients with negative HTT (18 males and 6 females; mean age 65 years) 10 with and 14 without organic heart disease were studied. The test protocol consisted of a continuous intravenous infusion of isoproterenol in successive stages starting from a dosage of 1 gamma/min for 5 min in supine position and then for 10 min in passive upright position at 80 (1st stage) up to maximum of 5 gamma/min (5th stage). The results obtained were: 12 patients (50%) had a positive test (reproduction of syncope) with a vasodepressor response in 6 of them and a mixed response in 6 patients. The mean time to syncope was during the 4th min of the 4th stage of treatment. The heart rate increase was 36% between the initial and peak values achieved during the test in patients with a positive test, and 10.5% in patients with negative test (p < 0.05). These results indicate that the isoproterenol test seems to increase the sensitivity of HTT in elderly patients with syncope of unknown origin.