Nodule size as predictive factor of efficacy of radiofrequency ablation in treating autonomously functioning thyroid nodules.

CONTEXT: No defined pre-treatment factors are able to predict the response to radiofrequency ablation (RFA) of an autonomously functioning thyroid nodule (AFTN). OBJECTIVE: Primary endpoint was to evaluate the success rate of RFA to restore euthyroidism in a cohort of adult patients with small solitary AFTN compared with medium-sized nodules. Secondary endpoints included nodule volume reduction and rate of conversion from hot nodules to cold using scintiscan. METHODS: This was a 24-month prospective monocentric open parallel-group trial. Twenty-nine patients with AFTN were divided into two groups based on thyroid volume: 15 patients with small nodules (<12 mL) in group A and 14 patients with medium nodules (>12 mL) in group B. All patients underwent a single session of RFA and were clinically, biochemically, and morphologically evaluated at baseline and at 1, 6, 12 and 24 months after treatment. RESULTS: After RFA, there was greater nodule volume reduction in group A compared with group B (p < 0.001 for each follow-up point). In group A, there was a greater increase in TSH levels than in group B at 6 (p = 0.01), 12 (p = 0.005), and 24 months (p < 0.001). At 24 months, the rate of responders was greater in group A than in group B (86 vs. 45%; p < 0.001). In group A, 86% of nodules converted from hot to cold compared with 18% in group B (p < 0.001). CONCLUSIONS: A single session of RFA was effective in restoring euthyroidism in patients with small AFTNs. Nodule volume seems to be a significant predictive factor of the efficacy of RFA in treating AFTN.

Radioembolisation using yttrium 90 (Y-90) in patients affected by unresectable hepatic metastases.

PURPOSE: This study was done to evaluate the effectiveness of radioembolisation of liver metastases with yttrium 90 (Y-90) in patients with no response to chemotherapy. MATERIALS AND METHODS: From February 2005 to January 2008, we treated 110 patients affected by liver metastatic disease from colorectal, breast, gastric, pancreatic, pulmonary, oesophageal and pharyngeal cancers and from cholangiocarcinoma and melanoma. We excluded patients with bilirubin level >1.8 mg/dl and pulmonary shunt >20% but not patients with minor extrahepatic metastases. RESULTS: We obtained a complete /partial response in 45 patients, stable disease in 42 patients and progressive disease in 23 patients. In 90 cases, we obtained a decrease in specific tumour marker level. The technical success rate was 96%, and technical effectiveness estimated at 3 months after treatment was 83.6%. Side effects were grade 4 hepatic failure in one case, grade 2 gastritis in six cases and grade 2 cholecystitis in two cases. The median survival and progression-free survival calculated by Kaplan-Meier analysis were 323 days and 245 days, respectively. CONCLUSIONS: According to our 3-year experience, Y-90 radioembolisation (SIR-spheres) is a feasible and safe method to treat liver metastases with an acceptable level of complications and a good response rate.

Osteoporosis: recent physiopatologic acquisitions and new therapeutic perspectives.

The World Health Organization (WHO) declared osteoporosis "social disease". The present revision of the literature will focus on the recent acquisitions in bone pathophysiology and the efforts in the formulation of new molecules able to change successfully the course of the disease. Osteocyte cell is now thought to be the main biomechanical transducer of bones, able to release sclerostin that produces inhibition on osteosynthesis and on the other hand to release substances like nitrid oxide and prostaglandins that provide a stimulus to osteosynthesis through direct or indirect activation of osteoblasts. In this work the authors analyze the most important clinical trials involving the use of new molecules, like denosumab, integrin avb3 inhibitor, cathepsin k inhibitors, able to interfere in the new osteometabolic pathways. Two trials, phase I and II, have been conducted using denosumab. The endpoint of the first phase was the evaluation of the markers of resorption and bone formation, while the second phase II trial focused on the use of this molecule in double-blind matching placebo and open alendronate with the evaluation of bone mass density (BMD) over one year in lumbar area. Another clinical trial in double-blind versus placebo was carried on and published on the use of a competitive integrin avb3 inhibitor in various dosages for the evaluation of bone mass modification in the lumbar and femoral area and of bone markers modification. Many studies focus on the use of cathepsin k inhibitors. Odanacatib has demonstrated to have worked on dose-dependent increase of densitometric value and to have reduced the bone turnover.

[Massive haemoperitoneum due to traumatic rupture of multifocal hepatocarcinoma in the right hepatic lobe. Case report]. / Emoperitoneo massivo da rottura di epatocarcinoma multifocale del lobo destro. Case report.

UNLABELLED: Abdominal blunt trauma is the main cause of death in people younger than 40 years old. The liver injury still represents a challenging problem. Isolated hepatic injury is rare and it occurs more frequentely in polytraumatizated patients and causes massive haemoperitoneum. The Authors report a case of a 83 years-old woman admitted to Emergency Department for syncope due to an active bleeding arising from a rupture of a right hepatic lobe unsuspected tumor. The computer tomography (CT) scans showed a clear pattern of liver laceration of the VI segment with contrast enhancement spreading in the surrounding tissues, and detected a multifocal hepatocarcinoma located in the VI, VII and VIII segments. Patient's haemodinamically unstable conditions suggested an urgent laparotomy. An accurate perihepatic packing with sterile-drape were successfully employed to control liver hemorrage. Temporary abdominal closure, followed by hepatic arteriography and the right hepatic artery embolization, completed the damage control. Re-exploration laparotomy after 72 hours confirmed the definitive haemostasis and the pack removal was performed without complications. CONCLUSIONS: CT plays a leading role in the diagnosis of liver damage. The patient's haemodynamic status is the principal criterion determining conservative or operative therapy in blunt liver injury. The early perihepatic packing followed by artheriographic embolization to stop liver hemorrhage showed efficacy and safety for the patient. The packing performed with sterile-drape is able to avoid removal complications and 72 hours timing for the pack removal is effective to avoid re-bleeding.

[A case of arterial chemoembolization for hepatocellular carcinoma with 11 years of survival]. / Un caso di epatocarcinoma trattato con chemio-embolizzazione arteriosa transcatetere con sopravvivenza di 11 anni.

Hepatocellular carcinoma (HCC) is the most common malignancy of the liver and the third most common cause of cancer mortality worldwide. The major risk of developing HCC is associated with HBV and HCV hepatitis. Liver transplant (LT) is the gold standard for "small" HCC (HCCs) in Child-Pugh class A cirrhotic patients. However its use has been restricted by the severe shortage of donors, so that hepatic resection (HR) is often performed in these patients. In the last two decades image-guided interventional catheterization and ablative regional treatment procedures have revolutionized the therapy of unresectable primary and secondary liver tumors. The Authors present a case of a 61-years old man with Child-Pugh class A HCCs. The age and the previous history of bladder carcinoma made the patient not suitable for LT. The patient refused HR so that transarterial chemoembolization combined to thermo-ablation therapy and oral intake of tamoxifen were proposed. Patient's tolerance to the treatments has been good. During 11-year follow-up there was earlier intrahepatic progression of the tumor followed by reduction in size and number of the lesions. In spite of the scarce prognosis, chemoembolization and immunotherapy allowed to achieve a satisfactory local control of disease in our patient and guaranteed a good quality of life at long-term follow-up.

Evidence based medicine and effective interventions of pharmacological therapy for the prevention of osteoporotic fractures.

Osteoporosis and fractures associated with it constitute a real and serious socio-medical problem, which only recently has come to the forefront of social consciousness. The authors are carrying out a critical re-examination of the medical literature of osteoporosis pharmacological treatment. Particular attention has been paid to studies which show a clear reduction of the primary endpoint that, in the case of this pathology, consists of a reduction of the fracturing event. According to the examination of the clinical studies introduced, antiresorptive bone agents, such as alendronate and risenderonate, turn out to be molecules with higher levels of evidence implicated on the reduction of the main osteoporotic fractures, in particular the reduction of vertebral and femoral fractures. The 10 years long-term extension studies, in particular those that have seen the employment of alendronate, found a positive outcome regarding densitometry data and a favorable trend in antifracture effectiveness. Ibandronate is another amino-bisphosphonate which was recently validated as an effective drug for the treatment of osteoporosis with its documented ability to meaningfully reduce vertebral fractures. Also ranelate of strontium, a drug that seems to explain its own result in a different way from the other antiresorptive bone agents, constitutes another valid alternative in the treatment of this pathology. Both of these molecules however, need further studies in order to estimate their antifracture effectiveness in the long term, particularly those related to femoral fractures. Teriparatide and the entire molecule paratohormone are usually not prescribed for its high cost in treatment and because, typically, patients with high-risk level fractures that are already affected, produce more vertebral fractures from moderate to severe intensity.

[Massive lower gastrointestinal bleeding due to diverticular disease during antiplatelet therapy. Case report]. / Enterorragia massiva da diverticolosi sigmoidea in corso di terapia antiaggregante. Caso clinico.

Diverticular disease is very frequent in Western countries; in 5% of the cases it is the cause of serious bleeding, haemodynamic instability and death. The authors report a case of 74 years old patient with severe lower gastrointestinal bleeding. She was in antiplatelet treatment with acetylsalicylic acid (100 mg/die) and clopidogrel (75 mg/die) for preventing the restenosis of medicated stents positioned to treat an acute coronary syndrome. At the same time the patient was under treatment for primary hypercholesterolemia with rosuvastatin (20 mg/die). The severe haemorrhage demanded haemodynamic stabilization, achieved by colloid infusion and blood transfusions. The bleeding continued; selective arteriography showed it's origin from the areas of the sigmoid and superior hemorrhoidal arteries. During the procedure, embolization of the inferior mesenteric artery using spiral type BALT was performed, with consequent bleeding interruption. Fifteen days after the embolization, a rectosigmoid colonoscopy showed a sigmoid diverticular disease. The treatment with acetylsalicylic acid and clopidogrel has surely contributed to the severity of the hemorrhage. Recent experimental and clinical evidence suggests a possible antiplatelet effect of the statins.

Massive pulmonary embolism as a rare complication of a stab in the inguinal region in a HIV-positive patient: a case report.

OBJECTIVE: Venous thromboembolism (VTE) is a severe preventable disease; HIV-infection represents a prothrombotic condition, because of specific factors due to the virus itself, the host response and the antiretroviral therapy. Our aim is to raise awareness of thromboembolic risk when dealing with HIV-positive patients presenting to the Emergency Department for treatment of injuries, even though small. CASE REPORT: We present a case of a 33-year-old woman suffering from HIV-infection who presented to the Emergency Department with two small stab wounds. Laboratory tests and radiologic examinations were normal. About 8 hours after admission the patient developed a syncopal attack: a CT scan performed after hemodynamic stabilization revealed a massive pulmonary embolism (PE); the patient was then transferred to the Intensive Care Unit and treated with systemic thrombolysis. CONCLUSIONS: This case confirms that HIV-positive patients carry a higher risk for VTE and PE compared to general population, similarly to patients suffering from cancer: emergency physicians must be aware even in case of minor wounds.

Effectiveness and safety of calcium and vitamin D treatment for postmenopausal osteoporosis.

Imbalance of bone resorption and bone formation is responsible for osteoporosis that is characterized by decreased bone mass and mineral density. The aim of this study was to evaluate the available data that could clarify the effectiveness and safety of supplementations with calcium and vitamin D, alone or in combination, to slow down bone loss in postmenopausal and elderly women. Using search key words, we performed a research both in the PubMed and Cochrane Library in order to find all meta-analysis, prospective and randomized clinical studies published from 2000 to 2014 that had investigated the effectiveness of calcium and vitamin D in the treatment of osteoporosis. At the moment it is not possible either to provide reassurance that calcium supplements given with vitamin D do not cause adverse cardiovascular events or to link them with certainty to increased cardiovascular risk. According to the data now available, vitamin D, at dosage of at least 800 IU/day, alone or in combination with antiresorptive drugs, should be administered in osteoporotic and osteopenic patients for a primary and secondary prevention. Further studies are needed and the debate remains ongoing. However, every administration needs the calculation of the absolute fracture risk of the patient. Especially considering the high cost of osteoporosis prevention, more studies are mandatory to clarify indications and contraindications.

Long-term survival after transarterial chemoembolization for hepatocellular carcinoma.

Hepatocellular carcinoma is a main challenge in oncologic care. Surgery is the mainstay of treatment. Transarterial chemoembolization is the most widely used palliative treatment for hepatocellular carcinoma. The Authors present a case report of a 61-year old man with hepatocellular carcinoma, belonging to Child-Pugh class A. The advanced age and the previous history of bladder carcinoma made the patient not suitable for liver transplantation. The patient refused hepatic resection so that transarterial chemoembolization was proposed. During 14-year follow-up there was intrahepatic progression of the tumor after the first treatment, followed by reduction in size and number of the lesions after subsequent treatments. In spite of the ominous prognosis of hepatocellular carcinoma, in this case-report transarterial chemoembolization allowed us to achieve a unique long-term survival.

[Using parathyroid hormone 1-84 in the treatment of osteoporosis: presentation and comments of main clinical trial]. / Terapia dell'osteoporosi con paratormone 1-84: presentazione e commento dei principali trial clinici.

Osteoporosis and associated fractures associated constitute a real and serious socio-medical problem. The purpose of this research is to report the most important clinical studies regarding the effect of parathyroid hormone PTH 1-84 for osteoporosis. TOP study has demonstrated the antifracture effectiveness of PTH 1-84 in patients of primary prevention and particular attention has been paid to show a clear achievement of the primary end-point that consists in a reduction of the vertebral fracturing event. PATH study has evidenced that the administration for one year of alendronate after one year of PTH 1-84 reduced the risk of osteoporotic fractures. The primary endpoint has been the evaluation of the densitometry values in the femoral and lumbar side and the evaluation of markers of bone turnover. In this case it is possible to assume that the above mentioned therapy could offer benefits in the long term.