Early regression index (ERI) on MR images as response predictor in esophageal cancer treated with neoadjuvant chemo-radiotherapy: Interim analysis of the prospective ESCAPE trial

PURPOSE

The early regression index (ERI) predicts treatment response in rectal cancer patients. Aim of current study was to prospectively assess tumor response to neoadjuvant chemo-radiotherapy (nCRT) of locally advanced esophageal cancer using ERI, based on MRI.

MATERIAL AND METHODS

From January 2020 to May 2023, 30 patients with esophageal cancer were enrolled in a prospective study (ESCAPE). PET-MRI was performed: i) before nCRT (tpre); ii) at mid-radiotherapy, tmid; iii) after nCRT, 2-6 weeks before surgery (tpost); nCRT delivered 41.4 Gy/23fr with concurrent carboplatin and paclitaxel. For patients that skipped surgery, complete clinical response (cCR) was assessed if patients showed no local relapse after 18 months; patients with pathological complete response (pCR) or with cCR were considered as complete responders (pCR + cCR). GTV volumes were delineated by two observers (Vpre, Vmid, Vpost) on T2w MRI: ERI and other volume regression parameters at tmid and tpost were tested as predictors of pCR + cCR.

RESULTS

Complete data of 25 patients were available at the time of the analysis: 3/25 with complete response at imaging refused surgery and 2/3 were cCR; in total, 10/25 patients showed pCR + cCR (pCR = 8/22). Both ERImid and ERIpost classified pCR + cCR patients, with ERImid showing better performance (AUC:0.78, p = 0.014): A two-variable logistic model combining ERImid and Vpre improved performances (AUC:0.93, p < 0.0001). Inter-observer variability in contouring GTV did not affect the results.

CONCLUSIONS

Despite the limited numbers, interim analysis of ESCAPE study suggests ERI as a potential predictor of complete response after nCRT for esophageal cancer. Further validation on larger populations is warranted.

Immunotherapy in small bowel adenocarcinoma: a potential role?

Small bowel adenocarcinoma (SBA) is a rare tumor with an unfavorable prognosis, and due to its rarity, few studies on its treatment are available. Chemotherapy remains the standard of treatment in advanced disease. Recently immunotherapy has demonstrated to be a valid therapeutic option for many solid tumors. We reviewed the data published in literature to understand the impact of immunotherapy in this cancer.

How Can Machine Perfusion Change the Paradigm of Liver Transplantation for Patients with Perihilar Cholangiocarcinoma?

Perihilar cholangiocarcinomas (pCCA) are rare yet aggressive tumors originating from the bile ducts. While surgery remains the mainstay of treatment, only a minority of patients are amenable to curative resection, and the prognosis of unresectable patients is dismal. The introduction of liver transplantation (LT) after neoadjuvant chemoradiation for unresectable pCCA in 1993 represented a major breakthrough, and it has been associated with 5-year survival rates consistently >50%. Despite these encouraging results, pCCA has remained a niche indication for LT, which is most likely due to the need for stringent candidate selection and the challenges in preoperative and surgical management. Machine perfusion (MP) has recently been reintroduced as an alternative to static cold storage to improve liver preservation from extended criteria donors. Aside from being associated with superior graft preservation, MP technology allows for the safe extension of preservation time and the testing of liver viability prior to implantation, which are characteristics that may be especially useful in the setting of LT for pCCA. This review summarizes current surgical strategies for pCCA treatment, with a focus on unmet needs that have contributed to the limited spread of LT for pCCA and how MP could be used in this setting, with a particular emphasis on the possibility of expanding the donor pool and improving transplant logistics.

White matter integrity and pro-inflammatory cytokines as predictors of antidepressant response in MDD

Major depressive disorder (MDD) is a multifactorial, serious and heterogeneous mental disorder that can lead to chronic recurrent symptoms, treatment resistance and suicidal behavior. MDD often involves immune dysregulation with high peripheral levels of inflammatory cytokines that might have an influence on the clinical course and treatment response. Moreover, patients with MDD show brain volume changes as well as white matter (WM) alterations that are already existing in the early stage of illness. Mounting evidence suggests that both neuroimaging markers, such as WM integrity and blood markers, such as inflammatory cytokines might serve as predictors of treatment response in MDD. However, the relationship between peripheral inflammation, WM structure and antidepressant response is not yet clearly understood. The aim of the present review is to elucidate the association between inflammation and WM integrity and its impact on the pathophysiology and progression of MDD as well as the role of possible novel biomarkers of treatment response to improve MDD prevention and treatment strategies.

Mega-analysis of association between obesity and cortical morphology in bipolar disorders: ENIGMA study in 2832 participants

BACKGROUND

Obesity is highly prevalent and disabling, especially in individuals with severe mental illness including bipolar disorders (BD). The brain is a target organ for both obesity and BD. Yet, we do not understand how cortical brain alterations in BD and obesity interact.

METHODS

We obtained body mass index (BMI) and MRI-derived regional cortical thickness, surface area from 1231 BD and 1601 control individuals from 13 countries within the ENIGMA-BD Working Group. We jointly modeled the statistical effects of BD and BMI on brain structure using mixed effects and tested for interaction and mediation. We also investigated the impact of medications on the BMI-related associations.

RESULTS

BMI and BD additively impacted the structure of many of the same brain regions. Both BMI and BD were negatively associated with cortical thickness, but not surface area. In most regions the number of jointly used psychiatric medication classes remained associated with lower cortical thickness when controlling for BMI. In a single region, fusiform gyrus, about a third of the negative association between number of jointly used psychiatric medications and cortical thickness was mediated by association between the number of medications and higher BMI.

CONCLUSIONS

We confirmed consistent associations between higher BMI and lower cortical thickness, but not surface area, across the cerebral mantle, in regions which were also associated with BD. Higher BMI in people with BD indicated more pronounced brain alterations. BMI is important for understanding the neuroanatomical changes in BD and the effects of psychiatric medications on the brain.

Insulin resistance disrupts white matter microstructure and amplitude of functional spontaneous activity in bipolar disorder

BACKGROUND

Bipolar disorder (BD) is linked to several structural and functional brain alterations. In addition, BD patients have a three-fold increased risk of developing insulin resistance, which is associated with neural changes and poorer BD outcomes. Therefore, we investigated the effects of insulin and two derived measures (insulin resistance and sensitivity) on white matter (WM) microstructure, resting-state (rs) functional connectivity (FC), and fractional amplitude of low-frequency fluctuation (fALFF).

METHODS

BD patients (n = 92) underwent DTI acquisition, and a subsample (n = 22) underwent rs-fMRI. Blood samples were collected to determine insulin and glucose levels. The Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) and quantitative insulin sensitivity check index (QUICKI) were computed. DTI data were analyzed via tract-based spatial statistics and threshold-free cluster enhancement. From rs-fMRI data, both ROI-to-ROI FC matrices and fALFF maps were extracted.

RESULTS

Insulin showed a widespread negative association with fractional anisotropy (FA) and a positive effect on radial diffusivity (RD) and mean diffusivity (MD). HOMA-IR exerted a significant effect on RD in the right superior longitudinal fasciculus, whereas QUICKI was positively associated with FA and negatively with RD and MD in the left superior longitudinal fasciculus, left anterior corona radiata, and forceps minor. fALFF was negatively modulated by insulin and HOMA-IR and positively associated with QUICKI in the precuneus. No significant results were found in the ROI-to-ROI analysis.

CONCLUSION

Our findings suggest that WM microstructure and functional alterations might underlie the effect of IR on BD pathophysiology, even if the causal mechanisms need to be further investigated.

Imaging characterization of an adult H3 K27M-altered diffuse midline glioma of the medulla oblongata with a confounding steroid response

We report an uncommon, infratentorial localization of adult H3 K27M-altered diffuse midline glioma arising in a particularly rare site (medulla oblongata). In addition to this unusual presentation, the lesion exhibited a substantial contrast enhancement and size decrease after dexamethasone, generating diagnostic dilemmas. Histology, molecular details, advanced Magnetic Resonance imaging features and differential diagnoses are here described and discussed, as well as common misconceptions about steroid-sensitive mass lesions, and practical difficulties for clinicians involved in the process of making diagnosis.

An interdisciplinary intervention for health prevention and promotion in a Roman neighborhood

 

Influencing behavioral patterns through primary prevention, possibly addressing more risk factors at a time, is the most effective means to tackle cardiovascular diseases. Many interdisciplinary prevention activities have been coordinated by community nurses outside of specialist centers, resulting in a more effective control of risk factors. Our study aims at describing the impact of an 18-month prevention and promotion, interdisciplinary intervention on lifestyle habits and cardiovascular risk. From December 2018 to May 2020, patients were recruited by 4 General Practitioners (GPs) in the Roman neighborhood of Torresina and received nutritional, physical and psychological counselling to learn healthy lifestyles. Until May 2020 patients had to self-manage their new healthy habits, but during this phase the SARS-CoV-2 pandemic broke out. Patients were assessed at baseline, 6, 12 and 18 months by a nutritionist, a physiotherapist, a psychologist, the 4 GPs and community nurses, and the cardiovascular risk score (CRS) was estimated at every examination. 76 patients were included, with a mean age of 54,6 years. Mean CRS showed a significant reduction between baseline and 12 months (from 4.9 to 3.8, p < 0.001), but this trend was not maintained at 18 months. As for variables included in the calculation of the cardiovascular risk score, both total cholesterol and systolic blood pressure significantly decreased at 6 months of follow up (respectively, from 211.1 to 192 (p < 0.001) and from 133.1 to 123.1(p < 0.001)). Nontheless, the reduction was maintained in the remaining points in time only for systolic blood pressure. Our interdisciplinary educational intervention in a primary care setting resulted in a CRS improvement at 12 months, but this changes where not maintained at 18 months. Community nurses were facilitators in improving health outcomes and patient's satisfaction in the described primary care setting.

Key messages

Does immunotherapy change the treatment paradigm in metastatic gastric cancer?

Gastric cancer represents one of the leading causes of cancer-related death worldwide. Even if the last decade has witnessed an improvement in surgical and systemic treatments, with an increase of overall life expectancy, survival rates still remain unsatisfactory, especially for patients with metastatic disease. Systemic therapies represent the gold standard in the management of stage IV gastric cancer. In this scenario, the availability of effective second and third lines has represented for a long time the only hope to offer an overall survival improvement to these patients. Recently, the advent of immune checkpoint inhibitors has involved also gastric cancer with encouraging efficacy data in the metastatic setting, becoming integral part of the management of selected patients.

Diagnosis of bipolar disorders and body mass index predict clustering based on similarities in cortical thickness-ENIGMA study in 2436 individuals

AIMS

Rates of obesity have reached epidemic proportions, especially among people with psychiatric disorders. While the effects of obesity on the brain are of major interest in medicine, they remain markedly under-researched in psychiatry.

METHODS

We obtained body mass index (BMI) and magnetic resonance imaging-derived regional cortical thickness, surface area from 836 bipolar disorders (BD) and 1600 control individuals from 14 sites within the ENIGMA-BD Working Group. We identified regionally specific profiles of cortical thickness using K-means clustering and studied clinical characteristics associated with individual cortical profiles.

RESULTS

We detected two clusters based on similarities among participants in cortical thickness. The lower thickness cluster (46.8% of the sample) showed thinner cortex, especially in the frontal and temporal lobes and was associated with diagnosis of BD, higher BMI, and older age. BD individuals in the low thickness cluster were more likely to have the diagnosis of bipolar disorder I and less likely to be treated with lithium. In contrast, clustering based on similarities in the cortical surface area was unrelated to BD or BMI and only tracked age and sex.

CONCLUSIONS

We provide evidence that both BD and obesity are associated with similar alterations in cortical thickness, but not surface area. The fact that obesity increased the chance of having low cortical thickness could explain differences in cortical measures among people with BD. The thinner cortex in individuals with higher BMI, which was additive and similar to the BD-associated alterations, may suggest that treating obesity could lower the extent of cortical thinning in BD.

Pattern of recurrence and overall survival in esophagogastric cancer after perioperative FLOT and Clinical Outcomes in MSI-H population: The PROSECCO Study

e16068

Background: The FLOT4-AIO phase II/III trial established perioperative FLOT regimen as the new standard in Western countries for patients (pts) with locally advanced resectable gastric (GC) or gastroesophageal junction cancer (GEJC). Microsatellite instability (MSI-H) showed a favorable prognostic role and a concomitant negative predictive impact on the benefit of adjuvant and neoadjuvant 5-fluorouracil-based doublets, but its prognostic and predictive role in pts receiving perioperative FLOT treatment still remains unclear. Our study aims to explore the real-world efficacy of FLOT regimen and to describe histopathological features and clinical outcomes in the MSI-H subgroup population. Methods: This is a retrospective multi-center analysis including pts with GC and GEJC, treated with perioperative FLOT regimen in clinical practice and whose microsatellite status and survival data were available. The association of baseline characteristics, biomolecular and pathological features and overall survival (OS) were firstly assessed in univariate analyses by means of log-rank test, and significantly prognostic variables (p < .05) were included in a multivariable COX proportional hazard model. Results: A total of 250 pts (median age, 62, range 37-81, male 71.6%, ECOG PS 0, 82%) were treated at 11 Italian Oncology Units from January 2017 to June 2021. At a median follow-up time of 22.5 months (mos) (2.3 - 66.7 mos), 123/250 (49.2%) patients relapsed and 77/250 (30.8 %) died. In the global population the median disease-free survival (DFS) was 16,7 mos (95% CI 13,8–21,2) and the median OS 34,9 mos [95% confidence interval (CI) 28–NA]. MSI-H phenotype was found in 26 (10.4%) out of 250 analyzed tumors. Compared to MSS cases, MSI-H were more frequently identified in female (50% vs 25.9%, p = .001), elderly pts (age ≥ 70 years, 76.9% vs 9.4%, p = .003), Laurens’s intestinal type (54% vs 12%, p = .0076) and in pts with primary location tumor in antrum (38.5% vs 13.8%, p = .0004). No relevant differences have been noticed in R0 resections (88% and 96%, p = .06) and pathological complete responses (4.9 % and 3.8%, p = .718), however a statistically significant difference in the rate of pathological negative lymph-nodes between MSS and MSI-H cohort emerged (29.3% vs 65.4%, p = .0004). Compared to MSS tumor population, MSI-H subgroup has a tendency to better DFS (median not reached (NR) vs 15.7, p = .06), metastasis free survival (MFS, median NR vs 17.2 mos, p = .06) and OS (median 41 vs 34 mos, p = .07). Conclusions: These real-world data confirm the efficacy of FLOT perioperative regimen in pts with locally advanced GC/GEJC, maintained also in the MSI-H pts. Our study suggests a better outcome of MSI-H GC and GECJ pts treated with FLOT in comparison to MSS, due to increased rate of nodal status downstaging and despite a poor histological response in the resected tumor tissue of MSI-H pts.

White matter integrity and pro-inflammatory cytokines as predictors of antidepressant response in MDD

Introduction

Major depressive disorder (MDD) often involves immune dysregulation with high peripheral levels of pro-inflammatory cytokines that might have an impact on the clinical course and treatment response. Moreover, MDD patients show brain volume changes and white matter (WM) alterations that are already existing in the early stage of illness.

Objectives

The aim of the present review is to elucidate the association between inflammation and WM integrity and its impact on the pathophysiology and progression of MDD as well as the role of possible novel biomarkers of treatment response to improve MDD prevention and treatment strategies.

Methods

We conducted an electronic literature search of PubMed on studies that examined the role of inflammation in depression and that focused on WM integrity and pro-inflammatory cytokines as predictors of antidepressant response.

Results

There is evidence for central effects of peripheral inflammation which could activate microglia which, in turn, might trigger a cascade of inflammatory processes leading to neurotransmitter imbalances. Numerous studies indicated that both altered levels of peripheral inflammatory markers, particularly TNF-α, IL-6, and CRP as well as WM integrity might predict antidepressant treatment outcome.

Conclusions

Despite mounting evidence on the impact of the immune system on WM microstructure, no study has yet addressed the interaction between the two factors in influencing antidepressant response. There is a lack of reproducible biomarkers predicting treatment response on an individual basis. The availability of such biomarkers would enable more efficient and personalized treatments with a faster treatment response and better prevention of treatment resistance.

Disclosure

No significant relationships.

Association between body mass index and subcortical brain volumes in bipolar disorders-ENIGMA study in 2735 individuals

Individuals with bipolar disorders (BD) frequently suffer from obesity, which is often associated with neurostructural alterations. Yet, the effects of obesity on brain structure in BD are under-researched. We obtained MRI-derived brain subcortical volumes and body mass index (BMI) from 1134 BD and 1601 control individuals from 17 independent research sites within the ENIGMA-BD Working Group. We jointly modeled the effects of BD and BMI on subcortical volumes using mixed-effects modeling and tested for mediation of group differences by obesity using nonparametric bootstrapping. All models controlled for age, sex, hemisphere, total intracranial volume, and data collection site. Relative to controls, individuals with BD had significantly higher BMI, larger lateral ventricular volume, and smaller volumes of amygdala, hippocampus, pallidum, caudate, and thalamus. BMI was positively associated with ventricular and amygdala and negatively with pallidal volumes. When analyzed jointly, both BD and BMI remained associated with volumes of lateral ventricles  and amygdala. Adjusting for BMI decreased the BD vs control differences in ventricular volume. Specifically, 18.41% of the association between BD and ventricular volume was mediated by BMI (Z = 2.73, p = 0.006). BMI was associated with similar regional brain volumes as BD, including lateral ventricles, amygdala, and pallidum. Higher BMI may in part account for larger ventricles, one of the most replicated findings in BD. Comorbidity with obesity could explain why neurostructural alterations are more pronounced in some individuals with BD. Future prospective brain imaging studies should investigate whether obesity could be a modifiable risk factor for neuroprogression.

Coping Styles in the SARS-CoV-2 national lockdown: impact on behaviors for cardiovascular prevention

Background

Coping styles are the ways in which people deal with different stressor situations. Coping strategies can be categorized into three types: task-oriented, emotion-oriented, and avoidance-oriented. Several studies showed a strong relationship between coping styles and cardiovascular diseases. The aim of the study was to evaluate how much the SARS-CoV-2 national lockdown has impacted the coping strategies on behaviors for cardiovascular prevention.

Methods

62 participants from Rome were recruited to assess the impact of prevention and promotion of health on Individual Cardiovascular Risk. The Coping Inventory to Stressful Situations (CISS, Endler & Parker, 1990) is a self-report questionnaire that measures the three strategies of coping. Behaviors dealing with cardiovascular prevention were evaluated at the beginning of the observation period, and after 6, 12, and 18 months. During 12 (February 2020) and 18 months (July 2020) the SARS-CoV-2 national lockdown enabled us to inquire into coping strategies in stressful situations and cardiovascular risk factors.

Results

The Pearson correlation analysis was used to assess the existence of a correlation between coping strategies and the variation of cardiovascular risk factors and alcohol consumption at 12 and 18 months. Interestingly, results showed relations between Emotional-oriented (r = 0.26 p &lt; 0.05) and Task-oriented (r = -0.33 p &lt; 0.01) coping styles and Differential Cardiovascular Risk Reduction (DCRR). Furthermore, a positive relation between Task-oriented (r = 0.34 p &lt; 0.01) coping style and Differential Alcohol Consumption (DAC) was observed.

Conclusions

We found that the DCRR relates to the Emotional- and Task-oriented coping styles, while DAC is associated with the Task-oriented coping style. The strength of our study consists in the territorial and multidisciplinary dimension of the project, the main critical issue is represented by the small size of the patient sample.

Key messages

A relationship can be described between Differential Cardiovascular Risk Reduction and Emotional- and Task-oriented coping styles. There is a relationship between Differential Alcohol Consumption and the Task-oriented coping style.

Clinical assessment of liver metabolism during hypothermic oxygenated machine perfusion using microdialysis

Background

While growing evidence supports the use of hypothermic oxygenated machine perfusion (HOPE) in liver transplantation, its effects on liver metabolism are still incompletely understood.

Methods

To assess liver metabolism during HOPE using microdialysis (MD), we conducted an open‐label, observational pilot study on 10 consecutive grafts treated with dual‐HOPE (D‐HOPE). Microdialysate and perfusate levels of glucose, lactate, pyruvate, glutamate, and flavin mononucleotide (FMN) were measured during back table preparation and D‐HOPE and correlated to graft function and patient outcome.

Results

Median (IQR) MD and D‐HOPE time was 228 (210, 245) and 116 (103, 143) min. Three grafts developed early allograft dysfunction (EAD), with one requiring retransplantation. During D‐HOPE, MD glucose and lactate levels increased (ANOVA = 9.88 [p = 0.01] and 3.71 [p = 0.08]). Their 2nd‐hour levels were higher in EAD group and positively correlated with L‐GrAFT score. 2nd‐hour MD glucose and lactate were also positively correlated with cold ischemia time, macrovesicular steatosis, weight gain during D‐HOPE, and perfusate FMN. These correlations were not apparent when perfusate levels were considered. In contrast, MD FMN levels invariably dropped steeply after D‐HOPE start, whereas perfusate FMN was higher in dysfunctioning grafts.

Conclusion

MD glucose and lactate during D‐HOPE are markers of hepatocellular injury and could represent additional elements of the viability assessment.

Efficacy and safety of a novel hydrogel (HYADD4-G) in degenerative disc disease patients: a multicentric open label study

OBJECTIVE

In this premarket clinical study, we evaluated the efficacy and safety of a novel Hydrogel (HYADD4-G) for reducing low back pain (LBP) in patients with degenerative disc disease (DDD).

PATIENTS AND METHODS

Twenty-three patients with chronic LBP were enrolled. All patients presented with up to three lumbar black discs (Pfirrmann grade III or IV), LBP of at least 40 mm on the Visual Analogue Scale (VAS), and a Roland-Morris Disability Questionnaire (RMDQ) score of at least 9. Patients received a single 1.5 ml intradiscal injection of HYADD4-G (8 mg/ml), guided by X-ray. Our primary endpoint was the change in VAS score from baseline (day 0) to 4, 12, and 24 weeks. Our secondary endpoints were black disc hydration by Magnetic Resonance Imaging (MRI); the patient's therapeutic response according to the RMDQ; the quality of life, as determined by the EuroQol-5 Dimension (EQ-5D) Index; and a global assessment of patient health status, safety, and local tolerability.

RESULTS

Compared with baseline values, VAS score showed a significant reduction at each time point, and across the overall 24-week follow-up period (p < 0.0001). MRI scanning observed a significant reduction in Pfirrmann grade from baseline, by at least one grade, at both week 4 (p = 0.0039) and week 24 (p = 0.0010). Furthermore, compared with baseline values, there was a significant reduction in RMDQ score at each timepoint, and across the entire study period (p < 0.0001). The EQ-5D index increased significantly from baseline to week 24 (p = 0.0001). Finally, mean VAS scores for Patient Global Assessment (PTGA), and Clinical Observer Global Assessment (COGA), decreased significantly at each time point (p < 0.0001), except for week 4.

CONCLUSIONS

HYADD4-G proved to be an efficient reliever of low back pain due to DDD.

Clinical and diagnostic findings in COVID-19 patients: an original research from SG Moscati Hospital in Taranto Italy

The coronavirus disease 2019 (COVID-19) pandemic is a worldwide medical challenge due to the scarcity of proper information and remedial resources. The ability to efficiently avoid a further SARS-CoV-2 pandemic will, therefore, depend on understanding several factors which include host immunity, virus behavior, prevention measures, and new therapies. This is a multi-phase observatory study conducted in the SG Moscati Hospital of Taranto in Italy that was converted into COVID-19 Special Care Unit for SARS-Co-V2 risk management. Patients were admitted to the 118 Emergency Pre-Hospital and Emergency Department based on two diagnostic criteria, the nasopharyngeal swab assessed by reverse-transcriptase-polymerase-chain-reaction (RT-PCR) and CT-scan image characterized by ground glass opacity. Patients were divided into four groups, positive-positive (ER-PP), negative-positive (ER-NP), negative-negative (ER-NN) and a group admitted to the ICU (ER-IC). A further control group was added when the T and B lymphocyte subsets were analyzed. Data included gender, age, vital signs, arterial blood gas analysis (ABG), extensive laboratory results with microbiology and bronchoalveolar lavage fluid (BALF) which were analyzed and compared. Fundamental differences were reported among the groups. Males were significantly higher in PP, ICU, and NP groups, from 2 to 4-fold higher than females, while in the NN group, the number of females was mildly higher than males; the PP patients showed a marked alkalotic, hypoxic, hypocapnia ABG profile with hyperventilation at the time of admission; finally, the laboratory and microbiology results showed lymphopenia, fibrinogen, ESR, CRP, and eGFR were markedly anomalous. The total number of CD4+ and CD8+ T cells was dramatically reduced in COVID-19 patients with levels lower than the normal range delimited by 400/μL and 800/μL, respectively, and were negatively correlated with blood inflammatory responses.

Mediterranean Diet In Healthy Aging

The World elderly population is expected to double before 2050. Unhealthy habits and unhealthy lifestyles are commonly associated with age-related diseases or their worsening. Modification in daily lifestyle and diet may help preventing age-related diseases onset and efficiently affecting their evolution, thus promoting the Healthy Aging process, concept recently coined to describe the disease-free aging process. This review highlights the role of nutrition science in promoting healthy aging. Since the Mediterranean Model demonstrated to be a useful style in supporting healthy aging, promotion of this correct lifestyle by health policies seems to be the best approach to achieve this target.

Multidrug regimens for treatment of older patients with metastatic pancreatic cancer

BACKGROUND AND AIMS

Older patients with metastatic pancreatic adenocarcinoma (MPDAC) are under-represented in clinical trials.

METHODS

Our single-center, retrospective study enrolled MPDAC patients ≥ 70 treated with chemotherapy RESULTS: 105 patients were divided in groups based on the received treatments: 44 gemcitabine or capecitabine monotherapy (A), 34 nabpaclitaxel-gemcitabine (B) 27 4-drugs combinations (gemcitabine, cisplatin, capecitabine plus either nab-paclitaxel or epirubicin or docetaxel) (C). Group A: median age was 78 (70-87) and Karnofsky performance status (KPS) ≥80 was found in 84% of patients; Group B: median age 77 (71-84) and KPS ≥ 80 in 88% of patients; Group C: median age 73 (70-78) and KPS ≥ 80 in 93% of patients. Median OS was 7.9, 11.7 and 14.2 months in group A, B and C respectively; 1 and 2-year OS were 27% and 8% in group A; 44% and 5% in group B; 52% and 22% in group C. When lung metastatic only patients were excluded, patients <75 and ≥ 75 had similar OS in group A (6.4 vs 5.6 months) and in group B (12.3 vs 11.1 months). In group B grade 3 thrombocytopenia, fatigue and peripheral neuropathy were more frequent in patients ≥ 75.

CONCLUSIONS

In older patients, combination chemotherapy shows acceptable feasibility and promising efficacy.

How cosmetic tightening products modulate the biomechanics and morphology of human skin

The active and passive mechanical behavior of a cosmetic tightening product for skin anti-aging is investigated based on a wide range of in vivo and in vitro measurements. The experimental data are used to inform a numerical model of the attained cosmetic effect, which is then implemented in a commercial finite-element framework and used to analyze the mechanisms that regulate the biomechanical interaction between the native tissue and the tightening film. Such a film reduces wrinkles and enhances skin consistency by increasing its stiffness by 48-107% and reducing inelastic, non-recoverable deformations (-47%). The substrate deformability influences both the extent of tightening and the reduction of wrinkle amplitude. The present findings allow, for the first time, to rationalize the mechanisms of action of cosmetic products with a tightening action and provide quantitative evidence for further optimization of this fascinating class of biomaterials.

Multidisciplinary community approach to reduce cardiovascular risk factors in a neighborhood in Rome

Cardiovascular Diseases (CVDs) are one of the main causes of death and morbidity worldwide. To reduce the risk of occurrence it is necessary to promote a healthy lifestyle and consider health as a collective benefit. This study aims to evaluate how the implementation of preventive interventions and health promotion could reduce the impact of CVDs on the involved population.

This prospective study started 1 year ago and will last 18 months (July 2020). Participants have been recruited in General Practice clinic in Torresina neighbourhood in Rome. The intervention was a full year of multidisciplinary meetings scheduled with general practitioners, community nurses, dedicated professionals (nutritionist, physiotherapist, psychologist) and outdoor events with a coach to promote group physical activity, assisted by the use of social networks. Anthropometric data, blood chemistry tests and information about lifestyle, nutritional habits and physical activity were collected at time 0 and every 2-month follow-up and, additionally, the individual cardiovascular risk score (CVRS) was calculated. After 12 and up to 18 months, instead, the self-management ability of a correct lifestyle will be evaluated on the basis of the measured outcomes. Statistical analysis was performed using a paired t test with Jamovi software.

The sample size was 62 patients, 50% male with an average age of 54.6 years (±7.8). During the analyzed period there was a reduction in the percentage of smokers from 30.6% at baseline to 22.6% after 12 months. The baseline CVRS was 4.9% (±6.3). At 12 months the CVRS significantly decreased to 3.8% (±4.0) (p &lt; 0.01). Total cholesterol level was 211.1 mg/dl (±32.8) at baseline, with a significant reduction at 12 months (202.5 ± 37.8) (p = 0.01). The results are preliminary.

Multidisciplinary interventions resulted in a significant reduction of CVRS and cholesterol levels during the study period. Further studies are necessary to evaluate our approach.

Key messages

Cardiovascular Diseases are the main causes of deaths among the population, so primary prevention through tailored educational interventions is fundamental. A multidisciplinary approach has proven to be effective in reducing the risk of cardiovascular disease and the level of cholesterol.

Long-course temozolomide in aggressive pituitary adenoma: real-life experience in two tertiary care centers and review of the literature

PURPOSE

Aggressive pituitary adenomas (APAs) and pituitary carcinomas (PCs) are challenging for their invasive nature, resistance to treatment and recurrences. Temozolomide (TMZ) is used with benefit and well-tolerated toxicity profile in APAs and PCs. In most studies patients received ≤ 12 cycles but the best length of treatment is debated since other options after discontinuation are scarce and a second course is mainly unsuccessful.

METHODS

We report outcomes of 8 patients with APAs and PCs treated with TMZ for more than 12 continuous cycles with a literature review. Data were retrospectively collected from Padua and Milan University Hospitals. TMZ was used as a single agent (150-200 p.o. mg/m2 daily, 5/28 days) for 14 to 45 cycles.

RESULTS

Eight patients (7 M), 7 APAs and 1 PC. Previous treatments included neurosurgery and radiotherapy in all cases except two giant masses (ACTH-silent APA and prolactinoma). No patient had progression disease (PD) during long-term treatment nor toxicities. No one had complete response (CR) but four had partial response (PR). Four ACTH+ tumors maintained stable disease (SD) but the secretion pattern improved in all. After drug withdrawal, three had delayed PD (2 after 18 and one after 29 months, all ACTH+); two are still in SD.

CONCLUSIONS

TMZ may be useful and well-tolerated in APAs and PCs as a long-term therapy. PR appears within the first cycles with no escape throughout the treatment; most patients achieve SD. We suggest extended protocols particularly in responsive ACTH+  PAs and PCs, when further therapies may be unsuccessful.

Semimechanical anastomosis during oesophagectomy reduces leaks and stenosis: a propensity score matched analysis

OBJECTIVES

Several techniques for oesophageal anastomosis during oesophagectomy have been described, all of which are associated with variable leakage and stricture rates. Given the notable morbidity of oesophageal fistula, reducing its incidence is of paramount importance. We report our single-centre experience with the semimechanical (SM) technique as compared to a totally manual (TM) technique.

METHODS

Three hundred and twelve partial and subtotal oesophagectomies performed between January 1998 and April 2018 were analysed. The series was split into a training period (January 1998-September 2015), when both TM and SM techniques were used, and a validation period (October 2015-April 2018), during which SM technique became standard practice. Propensity score matching was used to reduce confounding.

RESULTS

The training period included 212 oesophagectomies (90 TM, 122 SM); SM technique was initially used in the neck and afterwards also in the thorax, mainly with gastric conduits (92%), whereas the TM group contained a prevalence of jejunal loops (48%). SM anastomosis was associated with a significant reduction in both leak (0.8% vs 12%; P < 0.001) and stricture rate (0% vs 7%; P = 0.005). After propensity score matching, the difference in leak (0% vs 14%; P = 0.013) and stricture rate (0% vs 10%; P = 0.022) was confirmed. During the validation period, which included 100 oesophagectomies performed with SM anastomosis, 1 leak (1%) and 1 stricture (1%) were observed.

CONCLUSIONS

SM technique for oesophageal anastomosis outperforms TM technique and allows achieving very low complication rates.

Surgical wound closure by staples or sutures?: Systematic review

AIM

To compare the effects of sutures and staples for skin closure of surgical wounds.

MATERIAL AND METHODS

We included published and unpublished randomized controlled trials (RCTs) and cluster-randomized trials comparing staples with sutures. Patients were adults (aged 18 years or over) who had undergone any type of surgery. The primary outcomes were risk of overall and severe wound infection. Secondary outcomes included length of hospital stay, readmission rate, adverse events, patient satisfaction with cosmetic results, postoperative pain.

RESULTS

Forty-two very low to low quality RCTs with a total of 11,067 patients were included. Sutures resulted in slightly fewer overall wound infections (4.90%) compared to staples (6.75%) but it is uncertain whether there is a difference between the groups (risk ratio [RR] 1.20, 95% confidence intervals [CI] 0.80-1.79; patients = 9864; studies = 34; I = 70%). The evidence was also insufficient to state a difference in terms of severe wound infection (staples 1.4% vs sutures 1.3%; RR 1.08, 95% CI 0.61-1.89; patients = 3036; studies = 17; I = 0%), grade of satisfaction (RR 0.99, 95% CI 0.91-1.07; patients = 3243; studies = 14; I = 67%) and hospital stay. Staples may increase the risk of adverse events (7.3% for staples vs 3.5% for sutures; RR 2.00, 95% CI 1.44-2.79; patients = 6246; studies = 21; I = 33%), readmission rate (RR 1.28, 95% CI 0.18-9.05; patients = 2466; studies = 5; I = 66%) and postoperative pain (standardized mean difference [SMD] 0.41,95%CI -0.35 to 1.16; I = 88%, patients = 390 patients, studies = 5).

CONCLUSIONS

Due to the lack of high quality evidence, we could not state if sutures are better than staples in terms of wound infection, readmission rate, adverse events, and postoperative pain. With a low quality of evidence, sutures reduce postoperative pain and improve grade of satisfaction with the cosmetic outcome.

Outcome of COVID-19 in liver transplant recipients: A preliminary report from Northwestern Italy

Covid‐19 pandemic is deeply affecting transplant activity worldwide. It is unclear whether solid organ transplant recipients are at increased risk of developing severe complications and how they should be managed, also concerning immunosuppression. This is a report about the course and management of SARS‐CoV‐2 infection in liver transplant recipients from a single center in Northwestern Italy in the period March‐April 2020. Three patients who were treated at our institution are reported in detail, whereas summary data are provided for those managed at peripheral Hospitals. Presentation varied from asymptomatic to rapidly progressive respiratory failure due to bilateral interstitial pneumonia. Accordingly, treatment and changes to immunosuppression were adapted to the severity of the disease. Overall mortality was 20%, whereas Covid‐related mortality was 10%. Two cases of prolonged (>2 months) viral carriage were observed in two asymptomatic patients who contracted the infection in the early course after transplant. Besides depicting Covid‐19 course and possible treatment scenarios in liver transplant patients, these cases are discussed in relation to the changes in our practice prompted by Covid‐19 epidemic, with potential implications for other transplant programs.

Predicting differential diagnosis between bipolar and unipolar depression with multiple kernel learning on multimodal structural neuroimaging

One of the greatest challenges in providing early effective treatment in mood disorders is the early differential diagnosis between major depression (MDD) and bipolar disorder (BD). A remarkable need exists to identify reliable biomarkers for these disorders. We integrate structural neuroimaging techniques (i.e. Tract-based Spatial Statistics, TBSS, and Voxel-based morphometry) in a multiple kernel learning procedure in order to define a predictive function of BD against MDD diagnosis in a sample of 148 patients. We achieved a balanced accuracy of 73.65% with a sensitivity for BD of 74.32% and specificity for MDD of 72.97%. Mass-univariates analyses showed reduced grey matter volume in right hippocampus, amygdala, parahippocampal, fusiform gyrus, insula, rolandic and frontal operculum and cerebellum, in BD compared to MDD. Volumes in these regions and in anterior cingulate cortex were also reduced in BD compared to healthy controls (n = 74). TBSS analyses revealed widespread significant effects of diagnosis on fractional anisotropy, axial, radial, and mean diffusivity in several white matter tracts, suggesting disruption of white matter microstructure in depressed patients compared to healthy controls, with worse pattern for MDD. To best of our knowledge, this is the first study combining grey matter and diffusion tensor imaging in predicting BD and MDD diagnosis. Our results prompt brain quantitative biomarkers and multiple kernel learning as promising tool for personalized treatment in mood disorders.

Time to CA19-9 nadir: a clue for defining optimal treatment duration in patients with resectable pancreatic ductal adenocarcinoma

BACKGROUND

Defining optimal treatment duration in patients with resectable pancreatic ductal adenocarcinoma (PDAC) receiving primary chemotherapy is an unmet need. The role of time to CA19-9 nadir and of nadir magnitude was explored in this study.

PATIENTS AND METHODS

The databases of our institution's prospective trials were queried to speculate on the time to maximum chemotherapy response. Patients with pathologically proven, metastatic (N = 356) or non-metastatic non-resected (N = 163) PDAC and elevated baseline (> 34 UI/mL) CA19-9 were analyzed. Survival curves were estimated using the Kaplan-Meier method and compared by means of the log-rank test for analyses including at least 45 patients. Multivariable Cox proportional hazards model was used to estimate clinical features for their association with OS. All probability values were from two-sided tests.

RESULTS

Time to CA19-9 nadir was ≥ 4 months in 184 of 346 (53%) metastatic and 121 of 163 (74%) non-metastatic patients (p = 0.002). The likelihood of a later nadir was higher with taxane-based chemotherapy as compared to taxane-free combinations (73% versus 56%; p = 0.02). Both metastatic and non-metastatic patients had significantly longer survival when nadir occurred later. Patients with a larger CA19-9 nadir magnitude had significantly longer survival. Metastatic patients with CA19-9 reduced by < 50%, 50-89%, or > 89% and had a median survival of 7.4, 9.8, and 14.7 months, respectively (p ≤ 0.001 for all comparisons). The corresponding figures for non-metastatic patients were 10.6; 17.0; and 18.7 months, respectively (p ≤ 0.02 for < 50% versus 50-89% or > 89%; p = 0.14 for 50-89% versus > 89%). Multivariable analyses showed that time to CA19-9 nadir but not CA19-9 nadir magnitude was independently predictive of survival.

CONCLUSION

The present study suggests that a 4-6 months program might be a more suitable candidate for prospective assessment in comparison to shorter pre-defined period in patients who are candidates to surgery after primary chemotherapy.

Metastatic incidence of (PET)CT positive lung hilar and retroperitoneal lymph nodes in esophageal cancer patients

BACKGROUND

Extra-regional lymph node metastases strongly determine treatment options in patients with esophageal cancer. Staging modalities such as (FDG-PET) CT scanning frequently show activity in retroperitoneal and lung hilar lymph nodes. This study evaluated the incidence of histologically confirmed metastases, treatment approach and recurrence patterns in patients with (FDG-PET) CT positivity in these regions.

METHODS

All patients with (FDG-PET-) CT positive hilar and/or retroperitoneal lymph nodes at primary staging or restaging discussed at a multidisciplinary tumor board meeting for staging of esophageal cancer between January 2012-December 2017 were included. Biopsies and follow-up were evaluated to determine the presence of metastases and progression rates.

RESULTS

From 2012 to 2017, 65 of 857 patients (7.6%) were selected with positive retroperitoneal and/or hilar lymph nodes. A total of 47/65 (72.3%) patients had positive retroperitoneal lymph nodes, which contained metastases in 19 (29.2%). When no biopsy was performed and curative treatment was given (n = 14), 9 patients had progression or locoregional and distant recurrence. Positive hilar lymph nodes were identified in 21 (32.3%) patients; 4 were biopsied and none contained metastases. In these patients no recurrence of disease was seen during follow-up.

CONCLUSIONS

The majority of biopsied (PET)CT-positive retroperitoneal lymph nodes at staging contained metastases, while biopsied (PET)CT-positive hilar nodes did not. Histological evaluation of (PET)CT -positive retroperitoneal lymph nodes at staging imaging is recommended, while based on this small series, (PET)CT-positive hilar lymph nodes most likely represent reactive lymphadenopathy.

Gender-specific differences in white matter microstructure in healthy adults exposed to mild stress

Stress is a powerful moderator of brain plasticity and may affect several physiological functions such as the endocrine and the immune system. The impact of stress can be protective or detrimental according to several factors such as level of the stressor and age of occurrence. Also, the impact may differ in males and females. We aim to analyze the effect of mild levels of early and recent stress on white matter microstructure in healthy volunteers. MRI acquisition of diffusion tensor images with a 3.0 T scanner was performed on 130 healthy subjects (71 males and 59 females). Severity of early and recent stress was rated, respectively, on the Risky Families Questionnaire and on the Schedule of Recent Experiences; subjects were divided into low stress and mild stress groups. Mild early stress associated with lower fractional anisotropy (FA) in the cingulate gyrus compared to low early stress. Females reported reduced FA compared to males in the low-stress group in the internal capsule, posterior corona radiata, posterior thalamic radiation, superior longitudinal fasciculus, and sagittal stratum whereas no difference was observed in the mild stress group. An additive effect of early and recent stress was observed in posterior corona radiata, retrolenticular part of the internal capsule, and superior longitudinal fasciculus. The impact of early stress on WM microstructure in healthy subjects is different in males and females. While males seem to be more sensitive to early stress, an additive effect of early and recent stress manifests itself in females.Layman summaryMild levels of early stress associate with lower white matter integrity measured by fractional anisotropy.Females and males show differences in white matter integrity when exposed to low levels of early stress with females showing lower white matter integrity compared to males.No difference in white matter integrity was observed for males and females exposed to mild levels of stress.Mild stress in females is associated with higher white matter integrity.Males seem to be more sensitive to early stress while females are more affected when early stress is followed by stress in adult life.

Obesity influences white matter integrity in schizophrenia

BACKGROUND

White matter (WM) alterations have been consistently described in patients with schizophrenia and correlated with the severity of psychotic symptoms and cognitive impairment. Obesity has been reported in over 40% of patients with schizophrenia and has been associated with cognitive deficits, cardiovascular diseases, metabolic alterations, and overall mortality. Moreover, studies among healthy subjects and subjects at risk for psychosis reported an influence of Body Mass Index (BMI) on structural connectivity. We therefore hypothesized that obesity and overweight could further disrupt WM integrity of patients affected by schizophrenia.

METHODS

Eighty-eight schizophrenia patients were evaluated for BMI. We divided the sample in overweight/obese and normal weight groups. We then performed whole brain tract-based spatial statistics in the WM skeleton with threshold-free cluster enhancement of DTI measures of WM microstructure: axial (AD), radial (RD), and mean diffusivity (MD), and fractional anisotropy (FA).

RESULTS

A significant difference between the two groups was observed: normal weight patients showed higher AD and a higher FA trend compared to obese patients in several fibers' tracts including longitudinal fasciculus, uncinate fasciculus, corona radiata, thalamic radiation, fronto-occipital fasciculus, cingulum and corpus callosum.

CONCLUSIONS

Elevated BMI might contribute to WM disruption of schizophrenia by hampering structural connectivity in critical cortico-limbic networks, known to play a crucial role in neurocognitive functioning, emotional processing and psychopathology whose dysfunction are prominent features of the disorder.

Correlating diameter, mechanical and structural properties of poly(l-lactide) fibres from needleless electrospinning

The development and application of nanofibres requires a thorough understanding of the mechanical properties on a single fibre level including respective modelling tools for precise fibre analysis. This work presents a mechanical and morphological study of poly-l-lactide nanofibres developed by needleless electrospinning. Atomic force microscopy (AFM) and micromechanical testing (MMT) were used to characterise the mechanical response of the fibres within a diameter range of 200-1400 nm. Young's moduli E determined by means of both methods are in sound agreement and show a strong increase for thinner fibres below a critical diameter of 800 nm. Similar increasing trends for yield stress and hardening modulus were measured by MMT. Finite element analyses show that the common practice of modelling three-point bending tests with either double supported or double clamped beams is prone to significant bias in the determined elastic properties, and that the latter is a good approximation only for small diameters. Therefore, an analytical formula based on intermediate boundary conditions is proposed that is valid for the whole tested range of fibre diameters, providing a consistently low error in axial Young's modulus below 10%. The analysis of fibre morphology by differential scanning calorimetry and 2D wide-angle X-ray scattering revealed increasing polymer chains alignment in the amorphous phase and higher crystallinity of fibres for decreasing diameter. The combination of these observations with the mechanical characterisation suggests a linear relationship between Young's modulus and both crystallinity and molecular orientation in the amorphous phase. STATEMENT OF SIGNIFICANCE: Fibrous membranes have rapidly growing use in various applications, each of which comes with specific property requirements. However, the development and production of nanofibre membranes with dedicated mechanical properties is challenging, in particular with techniques suitable for industrial scales such as needleless electrospinning. It is therefore a key step to understand the mechanical and structural characteristics of single nanofibres developed in this process, and to this end, the present work presents changes of internal fibre structure and mechanical properties with diameter, based on dedicated models. Special attention was given to the commonly used models for analyzing Young's modulus of single nanofibers in three-point bending tests, which are shown to be prone to large errors, and an improved robust approach is proposed.

Chemotherapy in elderly patients with pancreatic cancer: Efficacy, feasibility and future perspectives

By 2030 70% of newly diagnosed pancreatic ductal adenocarcinoma (PDAC) will occur in older adults. Elderly patients, defined by the World Health Organization (WHO) as people older than 65 years, represent a heterogeneous group with different biological and functional characteristics that need personalized anticancer treatments. Since older patients are under-represented in randomized phase III trials, their management is mostly extrapolated from studies performed in younger patients, without robust evidence-based recommendations. However, data from retrospective studies and case-control series show that elderly may benefit from chemotherapy in both the adjuvant and advanced disease settings. Although with discordant results, gemcitabine-based treatment and dose-adapted fluorouracil combination regimens seem to be effective and well tolerated in this subset of patients. A proper balance of potential treatment benefits and side effects represent the crucial point for managing elderly patients with PDAC. Therefore an appropriate patient selection is essential to maximize the therapeutic benefit in the older population: randomized studies aiming to better standardizing fitness parameters and implementing the routine use of comprehensive geriatric assessments are strongly warranted. In this light, the detection of molecular prognostic markers able to detect patients who may benefit more from oncological treatments should be a primary endpoint of age-focused clinical trials. Altogether, the field of geriatric oncology will expand in the next years, and the clinical management of elderly patients affected by PDAC will become a major public health issue.

Corrugated diaphragm shape design study for hemocompatible pulsatile ventricular assist devices

We aim to maximize the pumping volume of a pulsatile ventricular assist device, where the diaphragm is covered with an endothelial cell layer. These cells are estimated to survive a cyclic strain up to fifteen percent. To increase the pumping volume under this strain constraint we use an approach based on corrugation of the diaphragm in its reference configuration. The paper explains the parametrization scheme for finding corrugation shapes, addresses modeling and evaluation schemes and reports on the results of a parameter study. The results show that corrugated diaphragm shapes are effective for increasing pumping volumes under a strain constraint.

Experimental and Numerical Characterization of the Mechanical Masseter Muscle Response During Biting

Predictive simulations of the mastication system would significantly improve our understanding of temporomandibular joint (TMJ) disorders and the planning of cranio-maxillofacial surgery procedures. Respective computational models must be validated by experimental data from in vivo characterization of the mastication system's mechanical response. The present pilot-study demonstrates the feasibility of a combined experimental and numerical procedure to validate a computer model of the masseter muscle. An experimental setup is proposed that provides a simultaneous bite force measurement and ultrasound-based visualization of muscle deformation. The direct comparison of the experimentally observed and numerically predicted muscle response demonstrates the predictive capabilities of such anatomically accurate biting models. Differences between molar and incisor biting are investigated; muscle deformation is recorded for three different bite forces in order to capture the effect of increasing muscle fiber recruitment. The three-dimensional (3D) muscle deformation at each bite position and force-level is approximatively reconstructed from ultrasound measurements in five distinct cross-sectional areas (four horizontal and one vertical cross section). The experimental work is accompanied by numerical simulations to validate the predictive capabilities of a constitutive muscle model previously formulated. An anatomy-based, fully 3D model of the masseter muscle is created from magnetic resonance images (MRI) of the same subject. The direct comparison of experimental and numerical results revealed good agreement for maximum bite forces and masseter deformations in both biting positions. The present work therefore presents a feasible in vivo measurement system to validate numerically predicted masseter muscle contractions during mastication.

Two-Field Lymphadenectomy During Esophagectomy: The Presence of Thoracic Duct Lymph Nodes

BACKGROUND

Resection of the thoracic duct is part of the formal en bloc mediastinal esophagolymphadenectomy for cancer, although with the adaptation of minimally invasive techniques, some centers started to leave the thoracic duct compartment in situ. However, previous studies reported thoracic duct lymph nodes in this compartment that may contain metastasis. The aim of this study was to assess the presence and number of lymph nodes in the fatty tissue surrounding the thoracic duct.

METHODS

A right-sided thoracoscopic esophagectomy was performed on seven fresh-frozen human cadavers (male, n = 3; female, n = 4). The esophagus and lymph node stations 7, 8, and 9 were resected en bloc, followed by resection of the thoracic duct compartment consisting of the fatty tissue covering the aorta, the thoracic duct and thoracic duct lymph nodes. Lymph nodes were visualized by a hematoxylin and eosin stain and counted macroscopically and microscopically.

RESULTS

Thoracic duct lymph nodes were found in 6 of 7 cadavers (86%), with a median number of 1 (range, 0 to 6). Nodes were predominantly located in the area of the azygos vein. A median of 4 subcarinal nodes (range, 1 to 8) and 2 periesophageal nodes (range, 1 to 4) were present.

CONCLUSIONS

This study shows that thoracic duct lymph nodes are located within the fatty tissue surrounding the thoracic duct. Resection of this compartment during an esophagectomy for cancer increases lymph node yield.

Incidence of Sepsis in Central Venous Catheter-Bearing Patients with Hematologic Malignancies: Preliminary Results

Background

Indwelling central venous catheters (CVCs) are essential devices in the management of patients with hematological disorders treated with chemotherapy. However, their nature predisposes patients to unwanted complications.

Methods

CVC-related complications were retrospectively analyzed in 227 hematologic patients who were consecutively admitted to our hematology department between May 2002 and April 2004. Patients’ diagnoses comprised acute myeloid leukemia (36.8%), acute lymphoid leukemia (7.3%), lymphoproliferative disorders (28.3%), multiple myeloma (19.5%), myeloproliferative syndromes (5%) and others (3.1%). The CVCs used were polyurethane three lumen 7-Fr (111 patients) for chemotherapy and 12-Fr (114 patients) for chemotherapy and peripheral blood stem cell apheresis, plus two tunneled catheters.

Results

The pathological events were: bacteriaemias (n=46); occlusions (n=10); exit tunnel infections (n=8); thrombosis (n=6); lung emboli (n=2). Among febrile patients the bacteriemia frequency was 20%, of which 13.6% were CVC-related (with a higher incidence in leukemia patients (p=0.027). Among the isolates, gram-positive bacteria were found in 29 cases (23 CVC-related cases), and gram-negative bacteria in 16 cases (8 CVC-related cases). Only one patient had Candida albicans sepsis. At univariate and multivariate analysis significant risk factors for infection (p<0.0001) were only the number of days/catheters and neutropenia duration.

Conclusions

In our hematologic patients, the CVC complications were mainly septic, with only 10.1% of CVC-related bacteriemias, despite prolonged catheterization duration. Acute leukemia patients were at major risk for sepsis, probably due to a more severe neutropenia and prolonged catheterization duration.

The suture retention test, revisited and revised

A systematic investigation of the factors affecting the suture retention test is performed. The specimen width w and the distance a of the suture bite from the specimen free edge emerge as the most influential geometrical parameters. A conservative approach for the quantification of suture retention strength is identified, based on the use of a camera to monitor the incipient failure and detect the instant of earliest crack propagation. The corresponding critical force, called break starting strength, is extremely robust against test parameter variations and its dependence on the specimen geometry becomes negligible when a≥ 2mm and w≥ 10mm. Comparison of suture retention and mode I crack opening tests reveals a linear correlation between break starting strength and tearing energy. This suggests that the defect created by the needle and the load applied by the suture thread lead to a fracture mechanics problem, which dominates the initiation of failure.