Microbiota, Immune System and Autism Spectrum Disorders: An Integrative Model Towards Novel Treatment Options

The functioning of the central nervous system (CNS) is the result of the integration of bidirectional messages between the brain and peripheral organs. Despite the anatomical separation, gut microbiota, i.e., the microorganisms colonising the gastrointestinal tract, is related to the CNS through the so-called “gut–brain axis” that is also involved in immune processes. The recent literature indicates that the gut microbiota may affect brain functions through endocrine and metabolic pathways, antibody production and the enteric network, while supporting its possible role in the onset and maintenance of several neuropsychiatric and neurodevelopmental disorders, such as autism spectrum disorders (ASDs). The term ASDs includes autistic disorder, Asperger’s syndrome, childhood disintegrative and pervasive developmental disorders not otherwise specified different. All these conditions are characterised by persistent deficits in social communication and social interaction, as well as limited and repetitive behaviours, interests or activities. In the last two decades, an impressive number of cross-sectional studies reported significant differences in microbiota composition between children with an ASD and controls, thus strengthening the hypothesis of a possible link between GI dysbiosis and ASD. The amount of studies documenting the possible involvement of microbiota in ASD pathogenesis led to considering whether treatments acting on gut flora could ameliorate ASD symptoms. The available findings, although preliminary, would indicate data gut microbiota might represent an interesting field of research for a better understanding of the pathophysiology of ASD (of also of other neuropsychiatric disorders), and possibly a target for the development of innovative treatments just labelled as “psychobiotics”.

Disclosure

No significant relationships.

Focus on neuroenhancement: a systematic review and its ethical implications

Introduction

Pharmacological and cognitive neuroenhancement refer to the non-medical use of prescription drugs, alcohol, illegal drugs, or the so-called soft enhancers, to enhance cognition, mood, work or school performance, or to promote pro-social behaviour. Literature on the topic is meagre, and available data only partially enlightens their use.

Objectives

The aim of this paper is to review and comment on the available literature on pharmacological neuroenhancement and, secondary, on emotional enhancement.

Methods

A systematic review was conducted according to the PRISMA guidelines. Pubmed, Scopus, Embase, PsychInfo and Google Scholar databases were accessed to select English language articles, published from 1980 to April 2020. 11746 papers were initially selected and 123 papers were finally included.

Results

Available literature indicates a widespread and increasing use of different kinds of substances, drugs and food supplements mainly with neuroenhancing purposes, especially amongst specific populations of young healthy subjects. The evidence regarding their efficacy is controversial. Further, a limited or no awareness regarding the possible consequences of their abuse/misuse emerges amongst users.

Conclusions

Despite the limited evidence that some substances may improve cognitive functions in healthy subjects and neglecting their detrimental side effects and potential risk of misuse, abuse and addiction, there is an increasing worldwide use of the so-called neuroenhancers, especially in some categories of individuals, such as university students. Further studies are needed to collect reliable data on the effects of neuroenhancers in healthy subjects. Neuroenhancement puts into question the concept of authenticity, so that the problem requires to be analyzed within a complex ethical conceptual frame.

Disclosure

No significant relationships.

Effect of clinical signs, endocrinopathies, timing of surgery, hyperlipidemia, and hyperbilirubinemia on outcome in dogs with gallbladder mucocele

Gallbladder mucocele (GBM) is a common extra-hepatic biliary syndrome in dogs with death rates ranging from 7 to 45%. Therefore, the aim of this study was to identify the association of survival with variables that could be utilized to improve clinical decisions. A total of 1194 dogs with a gross and histopathological diagnosis of GBM were included from 41 veterinary referral hospitals in this retrospective study. Dogs with GBM that demonstrated abnormal clinical signs had significantly greater odds of death than subclinical dogs in a univariable analysis (OR, 4.2; 95% CI, 2.14-8.23; P<0.001). The multivariable model indicated that categorical variables including owner recognition of jaundice (OR, 2.12; 95% CI, 1.19-3.77; P=0.011), concurrent hyperadrenocorticism (OR 1.94; 95% CI, 1.08-3.47; P=0.026), and Pomeranian breed (OR, 2.46; 95% CI 1.10-5.50; P=0.029) were associated with increased odds of death, and vomiting was associated with decreased odds of death (OR, 0.48; 95% CI, 0.30-0.72; P=0.001). Continuous variables in the multivariable model, total serum/plasma bilirubin concentration (OR, 1.03; 95% CI, 1.01-1.04; P<0.001) and age (OR, 1.17; 95% CI, 1.08-1.26; P<0.001), were associated with increased odds of death. The clinical utility of total serum/plasma bilirubin concentration as a biomarker to predict death was poor with a sensitivity of 0.61 (95% CI, 0.54-0.69) and a specificity of 0.63 (95% CI, 0.59-0.66). This study identified several prognostic variables in dogs with GBM including total serum/plasma bilirubin concentration, age, clinical signs, concurrent hyperadrenocorticism, and the Pomeranian breed. The presence of hypothyroidism or diabetes mellitus did not impact outcome in this study.

A novel neurocognitive approach for placebo analgesia in neurocognitive disorders

Neural correlates of placebo analgesia (PA) in patients with neurocognitive disorders have not yet been elucidated. The present study aimed to evaluate how and to what extent executive (dys)functions of the medial prefrontal cortex (MPFC) may be related to PA. To this end, twenty-three subjects complaining of different cognitive deficits (from mild cognitive impairment likely due to Alzheimer's disease to mild AD) were recruited. PA was investigated by a well-known experimental venipuncture pain paradigm (open versus hidden [O-H] application of lidocaine). Patients also underwent a comprehensive neuropsychological evaluation and a functional magnetic resonance imaging (fMRI) GO/No-GO task for eliciting selective activation of the MPFC. Selected neuropsychological variables were correlated to the OH-PA paradigm. The association between the fMRI response on the "No-GO" versus "GO" contrast and PA was investigated over the whole-brain by regression analysis. We showed the existence of a relationship between a lower PA and MPFC dysfunctions through the neuropsychological and fMRI assessment. A separate voxel-based morphometry (VBM) analysis controlled for possible influence of grey matter (GM) volume reduction on both fMRI results and PA. fMRI results were not directly affected by, and therefore independent of, disease-specific GM atrophy, which was indeed located more anteriorly within the rostral anterior cingulate and inversely correlated with PA. Our findings shed new light on the underestimated contribution of executive (dys)functions mediated by the MPFC (response-inhibition, self-monitoring and set-shifting abilities) in PA pathogenesis, with a special purely (i.e. independently from brain structural alterations) functional role played by the MCC. Results are discussed in terms of possible clinical relevance in the management of patients with neurocognitive disorders.

Levodopa/carbidopa intestinal gel infusion and weight loss in Parkinson's disease

BACKGROUND AND PURPOSE

Weight loss (WL) is a frequent yet under-recognized complication of levodopa/carbidopa intestinal gel (LCIG) infusion, as well as a milestone of Parkinson's disease (PD) disability progression. The complex association between WL, poor nutritional status, motor complications and PD progression, however, remains unclear.

METHODS

Consecutive consenting patients with PD treated with LCIG (n = 44; PD duration, 18.3 ± 6.5 years) were enrolled in an open-label observational study assessing the extent of WL occurring during LCIG treatment. As secondary aims, we correlated the nutritional status, as detected by the Mini Nutritional Assessment, with the severity of motor symptoms [Movement Disorder Society Unified Parkinson's Disease Rating Scale part III], motor complications (Unified Parkinson's Disease Rating Scale part IV), activities of daily living (Schwab and England scale), cognitive impairment (Mini Mental State Examination), depression (Beck Depression Inventory), difficulties in feeding (Edinburgh Feeding Evaluation in Dementia Questionnaire) and levodopa equivalent daily dose (LEDD).

RESULTS

There was an average WL of 9.9 ± 10.5% (7.6 ± 7.1 kg) over an LCIG treatment period of 51.6 ± 28.5 months. The extent of WL correlated with the percentage of the waking day spent with dyskinesia (P < 0.05). The nutritional status correlated with motor symptom severity (P < 0.01), dysphagia (P < 0.01) and LEDD (P < 0.01).

CONCLUSIONS

Weight loss may occur in patients with PD undergoing LCIG in correlation with the percentage of the waking day spent with dyskinesia. Regardless of the extent of WL, the nutritional status correlated with higher LEDD, as well as with indices of disease progression, such as motor symptom severity and dysphagia.

What to Do, and What Not to Do, When Diagnosing and Treating Breakthrough Cancer Pain (BTcP): Expert Opinion

Clinical management of breakthrough cancer pain (BTcP) is still not satisfactory despite the availability of effective pharmacological agents. This is in part linked to the lack of clarity regarding certain essential aspects of BTcP, including terminology, definition, epidemiology and assessment. Other barriers to effective management include a widespread prejudice among doctors and patients concerning the use of opioids, and inadequate assessment of pain severity, resulting in the prescription of ineffective drugs or doses. This review presents an overview of the appropriate and inappropriate actions to take in the diagnosis and treatment of BTcP, as determined by a panel of experts in the field. The ultimate aim is to provide a practical contribution to the unresolved issues in the management of BTcP. Five ‘things to do’ and five ‘things not to do’ in the diagnosis and treatment of BTcP are proposed, and evidence supporting said recommendations are described. It is the duty of all healthcare workers involved in managing cancer patients to be mindful of the possibility of BTcP occurrence and not to underestimate its severity. It is vital that all the necessary steps are carried out to establish an accurate and timely diagnosis, principally by establishing effective communication with the patient, the main information source. It is crucial that BTcP is treated with an effective pharmacological regimen and drug(s), dose and administration route prescribed are designed to suit the particular type of pain and importantly the individual needs of the patient.

Unawareness of bipolar disorder: the role of the cingulate cortex

Reduced awareness of illness is a well-known phenomenon that has been understudied in remitted patients with bipolar disorder. In particular, the relationship between reduced awareness and executive dysfunction is an intriguing question that has yet to be resolved. The aim of the current study is to analyze the link between reduced awareness, brain dysfunction, and concomitant cognitive-behavioral disturbances from a neurocognitive perspective. In previous studies, we demonstrated the role of the anterior cingulate cortex (ACC) in the unawareness of distinct pathologies that exhibit overlapping symptoms in the context of overlapping circuit-specific dysfunction. Given the clinical importance of the results obtained, the present study considers six aware and four unaware remitted bipolar disorder patients. Cingulate functionality was assessed with functional magnetic resonance imaging while patients performed a go/no-go task. Patients were also studied on an overall cognitive task battery and with behavioral assessment of mood changes in terms of apathy and disinhibited behavior. Unaware patients showed frontoparietal hypo-perfusion, with a significant reduction of task-sensitive activity in the bilateral superior and middle frontal gyrus, putamen, insular, and ACCs.

Unawareness of deficits in ischemic injury: role of the cingulate cortex

Reduced awareness of illness is a well-known phenomenon that has been studied in patients with vascular disease, but the precise nature of their executive dysfunction is an intriguing question that still has to be resolved. It would be particularly interesting to study patients with reduced awareness of disease possibly related to vascular lesions of the prefrontal cortex. Due to the clinical importance of the case, here we present a patient with a selective right anterior cingulate ischemic injury and impaired awareness of deficits. We suggest that the cingulo-frontal area dysfunction may represent one of the corresponding neurobiological substrates of his persistent unawareness, which has not yet been evaluated in the literature on patients with acquired brain injury (ABI).

[Henoch-Schönlein purpura resulting in an obstructive bladder mass]

Henoch-Schönlein purpura (HSP) is the most common form of an immunological systemic vasculitis of childhood. The classic clinical symptoms include purpuric rash, abdominal pain, arthralgias, and haematuria, but the spectrum of HSP may vary to very rare forms. This article reports on an 8-year-old girl with a Henoch-Schönlein purpura (HSP) which resulted in an obstructive bladder mass and subsequent urinary retention. This is the first case reported in the literature, describing such a course.

Validation of RiskCheck Bladder Cancer ©, version 5.0 for risk-adapted screening of bladder cancer

INTRODUCTION

The aim of the study was to assess the strength of the online tool RiskCheck Bladder Cancer©, version 5.0 (RCBC) for early detection of bladder cancer (BC).

MATERIALS AND METHODS

RCBC was evaluated retrospectively based on the data of 241 patients, of which 141 were suffering from BC. Statistical analysis was performed by descriptive statistics, nonparametric group comparison, classification tree analysis and ROC analysis.

RESULTS

ROC analysis of the risk classification showed a sensitivity of 71.6%, a specificity of 56.5%, a positive predictive value of 67.8%, a negative predictive value of 52% and an accuracy of 63.5%. BC risk factors ranked by importance are time of smoking (p < 0.0001), gender (within the nonsmoking group: p < 0.009), occupational toxin exposure (within the group <35 years of smoking: p < 0.048) and amount of consumed cigarettes resulting in a 95% association with BC (within the group >35 years of smoking: p < 0.0001).

CONCLUSIONS

The high predictive power of RCBC for the identification of asymptomatic patients living under risk could be demonstrated.

Subfascial endoscopic perforator surgery (SEPS) in chronic venous insufficiency. A 14 years experience

INTRODUCTION

Subfascial Endoscopic Perforator Surgery (SEPS) enables the direct visualization and section of perforating veins. Morbidity and duration of hospitalization are both less than with conventional open surgery (Linton's or Felder's techniques).

PATIENTS AND METHODS

A total of 322 legs from 285 patients with a mean age of 56 years (range 23-90) were treated at our Department from May 1996 to January 2010. In 309 cases, an endoscope (ETM Endoskopische Technik GmbH, Berlin, Germany) was introduced through a transverse incision approximately 1.5 cm in length and 10 cm from the tibial tuberosity, as with Linton's technique. A spacemaker balloon dissector for SEPS, involving a second incision 6 cm from the first, was used in only 13 cases.

RESULTS

The procedure used in each case was decided on the basis of preoperative evaluation. SEPS and stripping were performed in 238 limbs (73.91%), SEPS and short stripping in 7 limbs (2.17%), SEPS and crossectomy in 51 limbs (15.84%), and SEPS alone in 26 limbs (8.07%). 103 patients presented a total of 158 trophic ulcers; the healing time was between 1 and 3 months, with a healing rate of 82.91% after 1 month and 98.73% after 3 months.

CONCLUSION

Subfascial ligature of perforating veins is superior to sclerotherapy and minimally invasive suprafascial treatment for the treatment of CVI. It is easy to execute, minimally invasive and has few complications.

Postoperative pain treatment SIAARTI Recommendations 2010. Short version

The aim of these recommendations is the revision of data published in 2002 in the "SIAARTI Recommendations for acute postoperative pain treatment". In this version, the SIAARTI Study Group for acute and chronic pain decided to grade evidence based on the "modified Delphi" method with 5 levels of recommendation strength. Analgesia is a fundamental right of the patient. The appropriate management of postoperative pain (POP) is known to significantly reduce perioperative morbidity, including the incidence of postoperative complications, hospital stay and costs, especially in high-risk patients (ASA III-V), those undergoing major surgery and those hospitalized in a critical unit (Level A). Therefore, the treatment of POP represents a high-priority institutional objective, as well as an integral part of the treatment plan for "perioperative disease", which includes analgesia, early mobilization, early enteral nutrition and active physiokinesitherapy (Level A). In order to improve an ACUTE PAIN SERVICE organization, we recommend: --a plan for pain management that includes adequate preoperative evaluation, pain measurement, organization of existing resources, identification and training of involved personnel in order to assure multimodal analgesia, early mobilization, early enteral nutrition and active physiokinesitherapy (Level A); --the implementation of an Acute Pain Service, a multidisciplinary structure which includes an anesthetist (team coordinator), surgeons, nurses, physiotherapists and eventually other specialists; --referring to high-quality indicators in establishing an APS and considering the following key points in its organization (Level C): --service adoption; --identifying a referring anesthetist who is on call 24 hours a day; --patient care during the night and weekend; --sharing, drafting and updating written therapeutic protocols; --continuous medical education; --systematic pain assessment; --data collection regarding the efficacy and safety of the implemented protocols; --at least one audit per year. --a preoperative evaluation, including all the necessary information for the management of postoperative analgesia (Level C); --to adequately inform the patient about the risks and benefits of drugs and procedures used to obtain the maximum efficacy from the administered treatments (Level D). We describe pharmacological and loco-regional techniques with special attention to day surgery and difficult populations. Risk management pathways must be the reference for early identification and treatment of adverse events and chronic pain development.

[Micromedullary thyroid carcinoma: school experience]

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

Thyroid tissue remnants after "total thyroidectomy"

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

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

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

[Retroperitoneal giant mixed sarcoma. Case report]

The Authors present a rare case of voluminous retroperitoneal tumor in a 41 years old woman. CT scan showed a solid abdominal expansive mass, with compression and displacement of the left lobe of the liver, spleen, stomach, pancreas, and left kidney. The patient underwent surgery for excision of a giant retroperitoneal mass. Surgery was uneventful. The patients recovered well. Histology showed a mixed liposarcoma and angiosarcoma with high grade of malignancy and positivity for vimentin, factor VIII, CD34, CD31 and negativity for S-100, CD68, AMS, AML. The prognosis of these tumours is closely related to local recurrence, histological type, size and radical surgery. A low-grade malignancy tumor, small sized and completely resected leads to a good prognosis. Radiation therapy and chemotherapy do not seem to have a strong influence on the prognosis. An aggressive surgical approach is the first choice for the treatment of such tumors. The resection of adjacent organs may be required for radical surgery.

[Two cases of synchronous papillary and medullary thyroid carcinoma]

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

Multiprobe fluorescence in situ hybridisation: prognostic perspectives in superficial bladder cancer

AIM

To establish independent prognostic factors on a chromosomal basis in superficial bladder cancer, using a multicolour fluorescence in situ hybridisation (FISH) probe mix.

PATIENTS AND METHODS

In 2002, voided urine from 75 consecutive patients (mean age 71.7, range 52-93) years under follow-up for superficial urothelial cancer was studied prospectively. The patients were observed for a mean (standard deviation (SD)) period of 39.3 (6.8) months (range 27-58) until July 2005. A multicolour FISH on liquid-based voided urinary cytology was carried out on all patients. Univariate analysis, using a log rank test, was used to determine the prognostic relevance of a low-risk pattern and a high-risk pattern. Progression-free survival time was calculated from the date of first diagnosis to first recurrence or progression according to the Kaplan-Meier product-limit method.

RESULTS

One patient was lost to follow-up. 27 of the 74 remaining (36.8%) patients showed recurrent disease. In 9 (33.3%) patients with a low-risk pattern disease recurred after a mean (SD) observation time of 29.7 (1.9) months (range 8.3-52.3, median 30.8 (12.4)). 18 (66.7%) patients with a high-risk pattern developed recurrence within a mean (SD) of 17.6 (2.0) months (range 4-38.8, median 16.7 (11.6)). The Kaplan-Meier curve for progression-free survival showed marked differences between the low-risk and the high-risk groups.

CONCLUSION

Patients with a high-risk chromosomal pattern have a markedly shorter disease-free survival time and higher progression rate than patients with a low-risk pattern. High-risk patients can therefore be treated more aggressively to prevent tumour spreading.

Perioperative analgesia in pulmonary surgery

AIM

In pulmonary surgery many studies have shown how pain associated with residual doses of anaesthetic drugs can cause a decrease in pulmonary volumes and depression of the cough reflex. Both these phenomena are responsible for a rising incidence of postoperative mortality and morbidity. The most widely used postoperative analgesic techniques are continuous systemic analgesia and epidural analgesia. The aim of this study is to verify the advantages and the disadvantages of both analgesic techniques.

METHODS

Fifty patients, undergoing pulmonary surgery, were recruited and divided, after randomization into 2 groups. Patients included in A group received an epidural administration of naropina 0.2%+fentanyl 4 microg/mL by elastomeric pump (rate 5 ml/h). Patients included in B group received an ev continuous infusion of tramadol 600 mg+ketorolac trometamina 120 mg+ranitidina 200 mg+ondansetron 16 mg by elastomeric pump (rate 5 ml/h for 48 hours).

RESULTS

Both groups showed good analgesic effects. Pain rest relief was between 3 and 1.7 points in group B and between 2.5 and 0.4 points in group A. Incident pain was 4.8 at awakening time and it decreased to 4 after 48 hours in group B while in group A it was from 3.2 to 1.8 in the same period of B group.

CONCLUSIONS

Our data show that both analgesic techniques are able to guarantee a good rest pain relief after thoracotomy. Epidural analgesia showed more efficacy as far as incident pain relief but it was more difficult to realise and it showed less acceptance by patients.

Liquid-based cytology as a tool for the performance of uCyt+ and Urovysion Multicolour-FISH in the detection of urothelial carcinoma

The aim of the study was to assess the value of liquid-based urinary cytology as a tool to perform uCyt+ and Multicolour-FISH in patients under follow-up after urothelial cancer. Therefore, standard cytology was compared to liquid-based cytology with the addition of the uCyt+ test, which traces the three monoclonal antibodies M344, LDQ10 and 19A211 in exfoliated urothelial cells; and Multicolour-FISH (including centromere-specific probes for chromosomes 3, 7, 17 and a locus-specific probe for 9p21/p16) performed on thin-layer specimens. UCyt+ showed an overall sensitivity of 86.2% and cytology of 45.0%. Overall sensitivity of both the tests combined was 90%. Sensitivity of Multicolour-FISH was 96.4%. All conventional cytology diagnoses were confirmed by liquid-based cytology. Liquid-based cytology is a valid tool for the performance of adjunctive analyses, such as uCyt+ and Multicolour-FISH, on residual cellular material.

Prostate biopsy

Transrectal ultrasound guided (TRUS) prostate biopsies is the standard method in the diagnosis of prostate cancer. The use of prostate specific antigen (PSA) and digital rectal examination for prostate cancer screening has led to a dramatic increase in the number of TRUS guided biopsies. Frequently urologists are faced with the dilemma of treating a patient with a high suspicion of prostate cancer, but an initial set of negative biopsies. In this review we focus on the current knowledge of prostate biopsies, the indication to perform a biopsy, the impact of prostate volume in the number of cores taken, the technique of an initial and repeat biopsies and when to stop.

Perioperative thoracic epidural analgesia in aortic surgery: role of levobupivacaine

AIM

Perioperative pain management in patients undergoing surgery is an essential target in order to improve intraoperative outcome and reduce postoperative complications occurrence. The combination of a local anesthetic with an opiate for epidural administration can ensure both analgesic effect (opiate) and neuroendocrine protection (local anesthetic). Levobupivacaine, S(-)-enantiomer form of bupivacaine, produces a sensitive-motor blockade similar to the racemate, with less cardiotoxicity; also ropivacaine is not cardiotoxic, but it has less anesthetic efficacy than levobupivacaine; both anesthetics could be administered through the epidural catheter in order to ensure adequate analgesia without any hemodynamic effects. Aim of our study was to evaluate a thoracic epidural analgesia for abdominal aortic surgery.

METHODS

Through a randomized mono-blind study, involving 28 patients undergoing aortic surgery, we performed a clinical evaluation of 2 different perioperative thoracic epidural analgesic techniques; 2 different local anesthetics (levobupivacaine versus ropivacaine) in combination with the same opiate (fentanyl) were compared.

RESULTS

The results obtained show that both techniques ensure an excellent perioperative analgesia without any cardiotoxicity, with only moderate adverse effects due to opiate; the absence of postoperative mortality (within 30 days from operation) and the modest perioperative morbidity underline the qualities of this analgesic technique.

CONCLUSION

The combination of fentanyl with levobupivacaine or ropivacaine for use in thoracic epidural administration ensured both analgesic and neuroendocrine effect; significative differences between the 2 local anesthetics cannot be demonstrated, even if levobupivacaine, which presents a higher anesthetic efficacy, requires lower dosages.

[Predisposing factors for development of cardial adenocarcinoma]

After a careful revision of the various papers and on the basis of their personal experience, the persons responsible for this project analyse the factors that, today, influence the development of an adenocarcinoma in the region of the gastro-esophageal junction. They also study therapeutic strategies on the basis of new findings in anatomic-physiological matters of this region. From this analysis, specialists notice an increase in adenocarcinomas which affect the gastric region of the cardia, in comparison with carcinomas which affects the gastric region in toto. By considering Barrett, Hayward, Riedel and Ruol's studies, they maintain that the fundamental factor which causes the development of cardial adenocarcinoma is the gastroesophageal reflux. This reflux acts as a chronic irritative stimulus on the esophageal wall and therefore it provokes an increase in mucous secretion and the formation of metaplasia. This metaplasia is initially mucosecreting, acid-secreting and in the end it becomes intestinal. This also leads to the appearance of absorbent calciform cells; the absorption of toxic or mutagenic substance for the cell itself, will be the next step for the development of an adenocarcinoma. Nowadays the therapy of intestinal metaplasia provides for different therapeutic levels: from the endoscopic monitoring (which is used for the most serious cases of dysplasia), to the PPI medical treatment(today in disuse), to the surgical laparoscopic treatment with non-refluxing plasty (Nissen, Toupet). This last treatment is today associated with endoscopic esophageal mucosectomy in order to achieve a better effectiveness. This happens through the use of various methodologies, for example the multipolar electrocoagulation.

Abnormal bone scintigraphy and acute-onset severe primary hyperparathyroidism

Acute-onset primary hyperparathyroidism in a previously asymptomatic individual is uncommon. We herein report the case of a 61-yr old woman who underwent bone scintigraphy for severe, rapidly worsening, diffuse bone pain, associated with weight loss, anxiety and confusion. The patient was asymptomatic until a few days before presentation. A marked redistribution of the tracer was observed, with poor bone uptake and relevant accumulation in liver, kidneys, lungs and spleen. Blood chemistry unequivocally allowed the diagnosis of primary hyperparathyroidism due to multiple parathyroid adenomas, as suggested by parathyroid scan. Unfortunately, the patient critically worsened and surgery was made impossible. She died despite intensive critical care. Autopsy confirmed both massive intraparenchymal calcium deposition in the kidneys, lungs, liver and spleen, as well as multiple parathyroid adenomas. One may speculate that some adaptation of the organism to progressively increasing blood calcium levels and to slowly increasing intraparenchymal calcium salt deposition occurred, until critically high concentrations were attained.

A large Calabrian kindred segregating frontotemporal dementia

Frontotemporal dementia (FTD) displays significant neuropathological and genetic heterogeneity among and within affected families. An early diagnosis is often difficult because cognitive symptoms are manifest only at a late stage of the disease. We have been studying a large pedigree segregating frontotemporal dementia (FTD) to which belong 34 identified affected persons, 11 of whom were personally examined. The kindred has been genealogically reconstructed; all FTD patients have been linked to the same ancestors who lived in the early 18(th) century (11 generations before the present one). Autosomal dominant transmission was evident. Clinical features were uniform within the kindred and met the Lund-Manchester criteria. Personality changes with absence of insight, lack of empathy and of social awareness manifested up to 5 years before medical advice was sought. Loss of fluency was the earliest neuropsychological sign, in the absence of memory, orientation and praxis deficits, which evolved late, together with hyperorality. Akinesia was observed early, rigidity appeared late, tremor was absent. Two patients showed myoclonus late in their evolution. No ALS signs were observed in this kindred. Mutations of the MAPt gene, coding for the Tau protein, were not detected in affected family members. Linkage studies excluded chromosomes 3 and 9 and gave indeterminate results that were model dependent for chromosome 17.

Identification, cloning and characterisation of a novel copper-metallothionein in tetrahymena pigmentosa. Sequencing of cDNA and expression

The protist Tetrahymena pigmentosa accumulates large amounts of metal ions, particularly cadmium and copper. This capability is linked to the induction of metallothioneins (MTs), cysteine-rich metal-binding proteins found in protists, plants and animals. The present study focuses on a novel inducible MT-isoform isolated from Tetrahymena after exposure to a non-toxic dose of copper. The cDNA sequence was determined utilising the partial peptide sequence of purified protein. The Cu-MT cDNA encodes 96 amino acids containing 28 cysteine residues (29%) arranged in motifs characteristic of the metal-binding regions of vertebrate and invertebrate MTs. Both the amino acid and nucleotide sequences differ, not only from other animal MTs, but also from the previously characterised Tetrahymena Cd-MT. Both MTs contain the structural pattern GTXXXCKCXXCKC, which may be proposed as a conservative sequence of Tetrahymena MTs. Cu-dependent regulation of MT expression was also investigated by measuring MT-mRNA and MT levels. MT synthesis occurs very quickly and MT contents increase with Cu accumulation. The induction of Cu-MT mRNA is very rapid, with no observable lag period, and is characterised by transient fluctuation, similar to that described for Cd-MT mRNA. The data reported here indicate that, also in the unicellular organism Tetrahymena, two very different MT isoforms, which perform different biological functions, are expressed according to the inducing metal, Cu or Cd.

[Lung surgery in the elderly]

Lung surgery in the elderly, once considered a major risk, to be avoided if possible has become more popular in recent years as a result of many factors. First: lung cancer incidence has increased significantly in every age group but mostly in the elderly. Second: diagnosis at an early stage of the disease is higher in patients over 70 due to more frequent medical control in old subjects. Third: we now have more and more humans over 80 and a life expectancy increasing over the years. Fourth: preoperative, operative and postoperative medical supports are now safer and more reliable than previously. Operability criteria in the elderly are substantially the same as in younger group of patients for lung cancer. There are no reasons to refuse surgery in a subject over 80 because he is old. Lobectomy is the procedure of choice for lung cancer even in the elderly. Pneumonectomy must be avoided preferring a less radical procedure (wedge resection) so avoiding the risk of a postoperative respiratory failure that is often fatal for a patient with in border line functional respiratory tests, as often happens in the elderly. Thoracoscopic atypical resections must be considered in patients when a wedge resection is indicated preoperatively and almost always metastatic pulmonary lesion.

[Spontaneous retroperitoneal hematoma: a case report]

The A.A. present a case report of retroperitoneal spontaneous hematoma and put in evidence the difficulties in making an etiopathogenetic diagnosis of spontaneous renal cyst rupture. The patient was a 72 years old man admitted to the hospital in emergency for a painful ipogastric syntomatology and biliary vomit. The ecography showed a distanced gallbladder and the endoscopy evidenced a duodenal stenosis with compression of the gastric posterior wall, so that we were initially directed towards a pancreatic tumor even if the modest increase of the serum bilirubinemy and mostly the fact that direct component was almost normal, gave us strong doubts. The spiral TC gave finally the diagnosis of retroperitoneal hematoma and the presence of a bilateral polycystic kidney with several subcapsular cyst, let us suggest, as well as the anamnestic report of a physical stress, a renal origin of the bleeding. A wild literature review did not evidence other similar cases, but the ecclusion of other possible causes of retroperitoneal hematoma, suggested this conclusion.

[Secondary costal myxoid chondrosarcoma. Presentation of a clinical case]

A type of malignant neoplasm of not frequent observation is reported and the difficulties concerning the distinction from the benign counterpart are underlined, for which a detailed instrumental study is made necessary, integrated with pre and, above all, postoperative histologic analysis. A white male patient of 83, affected by plurirecidivant chondromyxoma of the rib, was admitted for local recurrence. The lesion objectively appeared not dissimilar from the preceding ones, as an ovalar mass fixed on the underlying plains. Radiologic and ultrasonographic examinations seemed to confirm the admission diagnosis; at the end the patient underwent a new intervention. Histologic examination of the lesion yielded a diagnosis of chondromyxosarcoma. The clinical case is made even more interesting by the finding, through the TC technique, preoperatively performed, of a metastatic repetition on the opposite side. The authors examine the problem of the early recognition of a malignant neoplasm developing, in a patient with a clinical history of recidival chondromyxoma. Physical examination and laboratory analysis are not useful in the assessment of the occurring transformation. At molecular level chondromyxosarcoma is characterized by several genomic rearrangements and mutations. Though primitive chondromyxosarcoma often involves the ribs, chondromyxoma's transformation into its malignant counterpart is not a common event. The development of distant metastasis characterizes long term cases. Given the lack of encouraging results about chemo and radio-therapy efficacy in influencing the natural course of the disease, a systematic approach will be made necessary in patient management.

[Ileal occlusion caused by enterolith migrated from Meckel's diverticulum]

The authors present a case report of an intestinal obstruction due to a relatively big coprolite migrated from a large Meckel's diverticulum to the distal Ileum. The patients apparently healthy and a vegetarian, complained on admission of the absence of emission of faeces and gas since four days before with noticeable abdominal distension. In the physical examination he presented intestinal meteorism, a hard abdomen, painful on deep palpation in the median quadrants, especially in the epigastric and mesogastric ones. The abdominal X-RAY in the standing position confirms: an occlusive state with numerous liquid levels in the Ileum. Because of a worsening of the symptomatology and the appearance of generalized comprimission, two days later an exploratory laparotomy was performed. The intervention showed the presence of a Meckel's diverticulum with approximately 10 cm in length, with an ample neck, the distal Ileum for approximately 15 cm in dilation returned rapidly to a normal calibre, after a pastous endoluminal formation borne in the Meckel's diverticulum (Meckel resection presented actually a large niche at the fundus level with a eroded wall) and migrated in the distal Ileum where it could cause the obstruction. In the present case it is probably useful to perform a preoperative CT scan in order to get a precise etiology and perform an ascending Colonscopy, so avoiding a surgical procedure. According to the authors a CT scan is indicated in all cases of intestinal occlusion of unknown case, in order to have a more precise definition of the physiopathology of the occlusion.

[Surgery of large ventral hernias. Personal experience in 1990-1997]

BACKGROUND

The surgical treatment of large wall defects conventionally defined as an extension over 10 cm is discussed. The difficulty to contain the bowels that have lost law of domicile in the abdominal hollow, constitutes motive for notable increase of the endo-abdominal Pressure with serious consequences in the postoperative course and this leads to the use of prothesis meshes that allow the closing of the abdominal hollow with the Tension-Free technique.

METHODS

Personal experience embraces 45 patients, with large wall defects, divided into 21 patients with overumbilical location, 14 with umbilical location, 10 with periumbelical location; a simple suture has been used in 7 cases, the reconstruction of the wall according to Stoppa in 36 cases and the apposition of Goretex net internally and Marlex net externally in 2 cases.

RESULTS

There have been neither mortality, neither recidivists of illness, but only some complications: 9 cases of superficial infection, 1 case of intestinal occlusion and 2 of subcutaneous seroma.

CONCLUSIONS

According to their experience and wide literature review, the authors draw some conclusions: an accurate toilet and a careful evaluation of the respiratory functionality are fundamental; it's necessary to postpone surgical intervention in presence of local inflammation and, where this is improrogable it's opportune to avoid the use of prothesis meshes or refold on readsorbible prothesis; special care must be taken to the hemostasis and an aspirative drain for 24-48 hrs preserves from the risk of postoperative hematomas and following local infections. The submuscular mesh permits a Tension-Free suture and for this reason it would have nowdays a more extensive use. Finally it's pointed out the choice of a PTFEe mesh in contact with the intestinal skein.

[Surgery of dysphagic diseases. Personal experience (349 surgical interventions)]

The authors report their surgical experience relating to dysphagic diseases of the esophagus (349 cases). In the light of these results, they describe the different surgical techniques used in the various pathologies: 1) Esophageal diverticula: The value of a careful evaluation of subdiverticular spasm is emphasised using preoperative manometry in cervical and epiphrenic diverticula, leading to subdiverticular myotomy when present. 2) esophageal achalasia and intermediate motor disorder: A clear difference must be drawn between these two diseases owing to the different motor behaviour of the esophagus. Dilatation of the LES is only useful in intermediate motor disorder and should be avoided in esophageal achalasia where a gastroesophageal reflux is produced if dilatation fails. Intraoperative manometry is very useful during the extramucosa myotomy phases as an indication of the complete removal of the sphincteric barrier, thus avoiding the risk of persisting disease. 3) Non-neoplastic stenosis. In primary stenosis (caused by caustic agents, primary GER or associated with JE) a conservative approach is advisable, whereas in iatrogenic stenosis (mainly linked to dilatation or cardiac surgery), owing to the anatomic complexity of the esophagogastric junction, a more radical approach is often required in the form of esophagogastric resection or even sub-total esophagectomy. 4) Neoplastic stenosis: Leiomyomas, although unusual, represent a clear indication for thoracoscopic access, provided that the dimensions allow it. Esophageal cancers represent a major surgical problem. A radical approach is represented by TE and the subsequent use of the stomach, or more rarely, the colon to reconstruct the alimentary tract. In spite of the very low resectability rate owing to locoregional spreading, until recently palliative surgery was essential to allow patients to eat. The introduction of autoexpanding prostheses, positioned using endoscopic methods, has provided a better solution to this problem.

Multicenter trial comparing tramadol and morphine for pain after abdominal surgery

Seventy patients (40 male, 30 female), mean (SD) age 60.8 +/- 13.7 years were treated with parenteral morphine (10 mg/1 ml ampul) or tramadol (100 mg/2 ml ampul) to verify their analgesic effects in pain following abdominal surgery. The multicenter trial followed an open, controlled experimental design between patients, randomized within the centers. The drugs were given by intramuscular injection, as requested by patients, starting in the postoperative period when pain was more than 70 mm, assessed on a visual analog scale. Patients were allowed up to six ampuls of tramadol or morphine in the 24-h trial but in the first 4 h, if they asked for supplementary analgesic, only diclofenac (75 mg in a 3-ml ampul) was allowed. Both test drugs gave rapid and constant pain relief. After the first dose, pain intensity was reduced 36.2% with tramadol, and 51% with morphine; the pain-free interval was similar for both treatments. The quality of sleep and the number of hours of sleep the night after surgery were similar for both groups. Tramadol was tolerated better, giving rise to no untoward reactions; with morphine there was one case of mild respiratory depression. In abdominal surgery, therefore, tramadol given by intramuscular injection has postoperative analgesic activity similar to morphine, but is better tolerated.

Symptomatic metabolic radiotherapy (with Sr-89) of bone metastases in prostatic cancer. Personal experience

The authors report their experience with 20 patients subjected to metabolic radiotherapy with Sr-89 for palliation of bone metastases in advanced prostatic cancer. Sr-89 is an effective symptomatic treatment, generally well tolerated, with minimal adverse effects.

[Long term central venous catheterization revisited]

The authors describe their experience about long-term VAD (Venous Access Devices) placement and in particular of placement techniques types of catheters, complications, and risk and benefit. 243 placements of VAD in 112 males and 131 females mainly affected by leukemia or breast cancer have been analyzed. 145 Leonard, 54 Groshong and 44 Hickman type silicon catheters have been implanted. The preferred access vein was the right internal jugular vein in 75% of patients and the right subclavian vein in the remained. The results show implant success in 98.7% of the patients. Complications have been rare and not serious and they have been divided into: 1) complications due to venipuncture, 2) complications during implant, 3) complications during the staying of catheter, 4) complications during the removal. The authors underline the advantages of puncture access through the right internal jugular vein in comparison with access through the right subclavian vein. Groshong type catheter is better than Leonard and Hickman. Very few infections have been noticed and patients seem to accept more willingly percutaneous placement than surgical one.

[Changes in immune status due to anesthesia and surgical intervention. The role of thymopentin and interleukins]

OBJECTIVE

Purpose of the study was clinical evaluation of thymopentin and interleukins in the changes of immunity due to anesthesia and surgical operation.

DESIGN

After randomization the patients were divided into four groups according to starter type (thiopental or propofol) and immunological pre-treatment (tymopentin or saline of control group) administered for three days before and two days after operation.

SETTING AND PATIENTS

The study was effected on 40 patients undergoing venous vascular surgery in operating rooms of Medical School of University of Genoa.

MEASUREMENT

At pre-established times (basal, before and after induction, recovery and 72 postoperative hours) were measured some immunological data (plasmatic concentrations of red blood cells, white blood cells, lymphocyte cells, antibodies, complement analysis, interleukins 1 and 2).

RESULTS

The results show a depression of immunity with hypoleucocistosis and hyperlymphocytosis due to surgical trauma or to anesthesia drugs.

CONCLUSIONS

Pre-treatment with thymopentin no change perioperative immunity and the role of interleukins isn't clear; the immunological depression is the same in thiopental of propofol groups.

[Clinical and neuropsychologic evaluation of different anesthesia techniques (propofol vs isoflurane) in general surgery]

Different anaesthetic techniques in the perioperative period (induction and maintenance of anesthesia, recovery and 48 postoperative hours) were evaluated in 200 patients undergoing general surgery. After randomization, results from 4 groups, were clinically and statistically compared according to the anesthetic techniques performed (propofol + fentanyl in air/O2; isoflurane + fentanyl in air/O2; propofol + fentanyl in N2O/O2; isoflurane in N2O/O2). The results show that anesthesia without N2O is difficult and fentanyl isn't the ideal analgesic; but no difference was found between the anesthetic techniques in quality of induction and maintenance, speed of recovery and quality of postoperative period.

[Blood levels of cortisol and prolactin. Are they indices of the degree of protection against surgical stress?]

The paper evaluates the level of analgesic protection by assaying cortisol and prolactin levels in two groups of 20 patients each undergoing general anesthesia using two different techniques: TIVA with propofol and fentanyl, and BPN-nitrous oxide. The results showed that TIVA caused a very slight increase in residue cortisol which was, however, within normal limits. With BPN-nitrous oxide anesthesia there was a greater increase in cortisol, reaching a statistically significant level in blood collected one hour after the end of surgery. With regard to prolactin, there was a marked increase in this hormone using both techniques although in percentage terms this increase was lower in TIVA. These results show that plasma prolactin is a more sensitive test than cortisol assay in evaluating antalgic protection and that, of the two anesthetic techniques used, the most protective appears to be TIVA with propofol and fentanyl.

[Respiratory function tests and operative risk in thoracic surgery]

In a retrospective study on 145 patients who underwent anesthesia for thoracic surgery, perioperative variables and preoperative pulmonary function tests influencing mortality and morbidity were evaluated. 3 patients (2.07%) died and 6 (4.14%) had cardiac, respiratory and other complications in postoperative 48 hours. Clinical-statistic analysis has shown the perioperative variables predictive on mortality and morbidity and operative risk: the operation type, FEV1, MVV (% theoretical), postexclusion gas analysis, Motley index (TLC/RV), intraoperative PaCO2, muscle-relaxant dose, preoperative myocardial infarction, weight, ASA, abnormal ECG, hypercreatininemia and loss of blood. MVV, FEV1, Motley index and residual FEV1 are the useful preoperative pulmonary function tests for evaluation of operative risk and surgical resection. Evaluation of operative risk in thoracic surgery shows the necessity of preoperative pulmonary function tests.

[Clinical evaluation of pre-surgical anxiety: changes in plasma levels of the anxiety peptide (diazepam binding inhibitor)]

The score scale of anxiety (STAI, Y, 1-2) and haematic levels of DBI (diazepam binding inhibitor) were used in 48 surgical patients for clinical evaluation of preoperative anxiety, before and after drugs for preoperative medication. After randomization, were clinically and statistically compared 6 groups according to premedicant drugs (diazepam 0.3 mg/kg; flunitrazepam 0.03 mg/kg; saline; prometazine 0.7 mg/kg); before and after preoperative medication were evaluated the anxiety relief with the score scale, haematic levels of DBI and haemodynamics (systolic and diastolic AP and HR). The results show that DBI can objectively measure the anxiety relief, that not are correlate haematic levels of DBI and score scale, that the best benzodiazepines are diazepam (0.3) and flunitrazepam (0.015) and that the prometazine might give anxiety relief for 5-HT antagonist action. Even if there are limits to study (scanty cases, are missing the range and the brain values of DBI and blood test of DBI is slow method) may be useful the use of score scale and haematic levels of DBI in clinical evaluation of preoperative anxiety relief.