Overview on surgical management of papillary thyroid microcarcinoma.

Particular interest is now being given to the best treatment of papillary thyroid microcarcinoma (PTMC) due to its significantly increased incidence. PTMC typically shows indolent organic behavior but, in a low percentage of cases, it can express a relative aggressive behavior. Several risk factors have been shown to negatively influence the rate of regional recurrences and metastases such as tumor diameter, Romaage, sex, multifocality, capsular invasion, extracellular diffusion, lymph node metastases, histological variants, mutated Braf and incidentality. The identification of patients with aggressive PTMCs among the majority with low risk lesions is very important to plan an adequate clinical management, thus the most appropriate surgical treatment. The latter includes thyroid lobectomy and total thyroidectomy with central compartment lymphadenectomy, though several studies did not show statistically significant differences in terms of recurrence and mortality rates between the two techniques. At last, it seems crucial to better define those biological features able to improve selection making process of patients with PTMCs aiming to reserve more radical surgery to those patients carrying more aggressive clinicopathologic features and worse prognosis.

Papillary thyroid microcarcinoma in super obese patient.

Papillary thyroid microcarcinoma (PTMC) typically has an indolent behavior with a good prognosis but it is not always completely harmless. Surgical treatment varies from thyroid lobectomy to total thyroidectomy eventually associated with lymph node dissection and radioiodotherapy. The ability to identify patients with aggressive PTMCs from the majority of low risk patients is critical to planning proper clinical management. Several studies don't report any statistically significant differences about recurrence and mortality among patients undergone lobectomy and patients undergone total thyroidectomy. Recently, higher body mass index (BMI) has been associated with aggressive pathologic features of papillary thyroid carcinoma. For differentiated thyroid cancers, an elevated BMI has been linked to a higher incidence of thyroid cancer in some cohorts. The risk factors for a more aggressiveness of PTMC don't yet clearly defined such as their biological features enable to condition the surgical treatment. In order to elucidate the precise mechanism contributing to the relationship between obesity and thyroid cancer aggressiveness, future studies must be performed.

Laparoscopic Deloyers procedure for tension-free anastomosis after extended left colectomy: technique and results.

BACKGROUND: The Deloyers procedure, which includes inversion of the right colon around the axis of the ileocolic vessels, can be used to achieve a well vascularized, tension-free colorectal anastomosis after extended left colectomy. The aim of this study is to report our technique and outcome in a series of ten consecutive patients who underwent right colonic transposition by laparoscopic approach. METHODS: Charts were retrospectively reviewed to analyze postoperative outcome and bowel function. A video was recorded to demonstrate the procedure. RESULTS: Conversion was required in one (10%) patient due to extensive adhesions. No intraoperative complications were recorded. Anastomotic leakage occurred in one (10%) case and was managed with peritoneal lavage and ileostomy. Six months after surgery, all patients reported a median number of 2.5 (range 2-3) bowel movements per day with solid stool consistency. Neither anastomotic stricture nor bowel ischemia was found at 1-year endoscopic follow-up. CONCLUSION: Our experience shows that laparoscopic right colonic transposition is a safe and feasible procedure and provides good functional outcomes.

Double loop reconstruction following pancreaticoduodenectomy for malignant tumor: Short-term outcome.

BACKGROUND: To evaluate the use of a double loop reconstruction following pylorus preserving proximal pancreaticoduodenectomy (PPPPD). METHODS: Morbidity and mortality were evaluated in 55 patients undergoing PPPPD for malignant tumors, followed by a double loop reconstruction. RESULTS: The mean intra-operative blood loss was 908mL±531. In-hospital mortality was 5.4% (3/55 pts). The mean length of hospital stay was 17±5 days (range 12-45 days). Postoperative complications occurred in 25 patients (46.2%). Five patients developed an anastomotic leak, one biliary and four pancreatic (4/55; 7%). Delayed gastric emptying occurred in 8 patients (14.5%). Reoperation was required in two patients for hemorrhage. CONCLUSIONS: A double loop alimentary reconstruction following PPPPD led to a low incidence of DGE and pancreatic fistula. Although mortality rate was higher than that reported by referral centres, this technique has been performed in a not specialized unit attaining acceptable results.

Acellular bovine pericardium dermal matrix in immediate breast reconstruction after Skin Sparing Mastectomy.

INTRODUCTION: Mastectomy for breast cancer may bring the patient to develop long term issues concerning the psychological and physical status. Immediate breast reconstruction (IBR) should be considered and proposed by physicians as an integrated procedure in the surgical approach to breast cancer to reduce further surgery. Acellular dermal matrix (ADM) has been used in revision breast reconstruction for fold malposition, capsular contracture and rippling also, showing good outcomes with low risk of complications. Aim of this study was to verify if the known advantages in using ADM for IBR would led to lower rates of seroma formation, infection, skin flap necrosis and overall complication related to the implant. METHODS: We performed a prospective study, including all consecutive patients undergone to IBR with biological graft with ADM between January 2012 and January 2013 at our Institution. Data on major issues of the patients and complications were recorded. All patients underwent to IBR with ADM (Tutomesh) implant with or without fibrin sealant positioning. RESULTS: A total of 24 patients underwent 28 immediate breast reconstruction with Tutomesh ADM implant. Main postoperative complications included seroma formation in 20.8% (5 pts), infection in 8.3% (2 pts) and hematoma in 4.2% (1 pt). There were any skin flap necrosis in the study. Diabetes was associated in two cases with edema and ecchymosis; hypertension with infection in one case (implant removal) and seroma in one case. First class of obesity (BMI 30-32.7) was associated with seroma in 3 cases, and with infection in one. In patient without fibrin sealant (12 patients - 13 breasts) complications were represented by hematoma (1 pt. 4.2%), infection (1 pt. 4.2%; implant removal) and seroma (4 pts 16.8%). CONCLUSIONS: The use of Tutomesh(®) bovine pericardium for immediate breast is safe and technically useful. Complications rate is not high, except for seroma formation that can be reduced by the contemporary use of fibrin sealant.

Reliability and validity of the DSM-IV diagnostic category of schizoaffective disorder: preliminary data.

BACKGROUND: Concerns have been expressed about the reliability and validity of the DSM-IV criteria for schizoaffective disorder, but no systematic study has been published up to now. METHODS: The Cohen's kappa for the individual items of the DSM-IV definition of schizoaffective disorder, manic episode and major depressive episode was evaluated in 150 patients independently interviewed by two psychiatrists using the Composite International Diagnostic Interview. The two-year outcome of patients with a consensus DSM-IV diagnosis of schizoaffective disorder was compared to that of patients with DSM-IV schizophrenia and schizophreniform disorder, using the Strauss-Carpenter Outcome Scale. RESULTS: The Cohen's kappa was 0.22 for the diagnosis of schizoaffective disorder, 0.71 for that of manic episode, and 0.82 for that of major depressive episode. Schizoaffective patients had a significantly better outcome than those with schizophrenia but a worse outcome than those with schizophreniform disorder. CONCLUSIONS: The inter-rater reliability of the DSM-IV criteria for schizoaffective disorder is not satisfactory. The better outcome of DSM-IV schizoaffective disorder compared with schizophrenia seems to depend more on the inclusion, in the definition of schizophrenia but not in that of schizoaffective disorder, of the six-month duration and functional impairment criteria than on the different symptomatological patterns of the two conditions. LIMITATION: The size of the sample of patients fulfilling DSM-IV criteria for schizoaffective disorder was small. CLINICAL RELEVANCE: The study suggests that the clinical implications of the currently problematic diagnosis of schizoaffective disorder may be modest.

Reliability and validity of four alternative definitions of rapid-cycling bipolar disorder.

OBJECTIVE: This study tested the reliability and validity of four definitions of rapid cycling. METHOD: Two trained psychiatrists, using the Schedule for Affective Disorders and Schizophrenia, independently assessed 210 patients with bipolar disorder. They checked whether each patient met four definitions of rapid cycling: one consistent with DSM-IV criteria, one waiving criteria for duration of affective episodes, one waiving such criteria and requiring at least one switch from mania to depression or vice versa during the reference year, and one waiving duration criteria and requiring at least 8 weeks of fully symptomatic affective illness during the reference year. The interrater reliability was calculated by Cohen's kappa statistic. Patients who met each definition according to both psychiatrists were compared to those who did not meet any definition (nonrapid-cycling group) on demographic and clinical variables. All patients were followed up for 1 year. RESULTS: Kappa values were 0.93, 0.73, 0.75, and 0.80, respectively, for the four definitions of rapid cycling. The groups meeting the second and third definitions included significantly more female and bipolar II patients than did the nonrapid-cycling group. Those two groups also had the lowest proportion of patients with a favorable lithium prophylaxis outcome and the highest stability of the rapid-cycling pattern on follow-up. The four groups of rapid-cycling patients did not differ significantly among themselves on any of the assessed variables. CONCLUSIONS: The expression "rapid cycling" encompasses a spectrum of conditions. The DSM-IV definition, although quite reliable, covers only part of this spectrum, and the conditions that are excluded are very typical in terms of key validators and are relatively stable over time.

[Total thyroidectomy with identification of parathyroid glands. Functional implications]. / Tiroidectomia totale con identificazione delle ghiandole paratiroidi. Implicazioni funzionali.

UNLABELLED: Several factors have been involved in the pathogenesis of postoperative hypocalcemia after total thyroidectomy (TT). The real cause is yet unclear, but postoperative (p.o), hypoparathyroidism seem s to be the most important factor. MATERIAL AND METHOD: 337 patients underwent TT; a systematic and accurate identification and preservation of parathyroid glands was always performed. In all patients calcemia was evaluated before and after surgery (1St, 2nd, 4th, 15th, and 30th day), moreover in 90 patients was also evaluated phosphorus, magnesium, alkaline phosphatase, total proteins, PTH, calcitonin serum levels and urinary levels of calcium and phosphorus. RESULTS: No permanent hypocalcemia was observed and transient hypocalcemia was present in 13.6% of patients. Among 90 patients, 84 showed normal calcium serum levels like the others parameters; the other 6 showed a post-operative hypocalcemia associated with clinical symptoms, an increase of phosphoremia and a decrease of PTH and phosphaturia in early p.o days; in these patients calcemia and PTH levels reached normal values within 30 days after surgery. CONCLUSION: The surgical manipulation of parathyroid glands should be the cause of lowering of PTH serum concentration and transient hypocalcemia.

Long-term outcome of lithium prophylaxis in bipolar disorder: a 5-year prospective study of 402 patients at a lithium clinic.

OBJECTIVE: In this prospective study, information was collected on all bipolar I patients who started lithium prophylaxis at a lithium clinic during more than 15 years. METHOD: Patients were evaluated bimonthly with standardized instruments for as long as they took lithium. Treatment surveillance conformed to internationally accepted guidelines. Five years after starting prophylaxis, each patient was contacted for a follow-up interview. RESULTS: Of the 402 enrolled patients, 27.9% were no longer taking lithium at follow-up; 38.1% were taking lithium and had had at least one recurrence of the disorder; and 23.4% were taking lithium and had had no recurrence. Among patients still taking lithium whose plasma lithium levels had been below 0.5 mmol/liter on no more than 10% of checks, 88.0% had at least a 50% reduction in mean annual time spent in the hospital compared to a reference pretreatment period, and 43.0% had had no recurrence. Patients not taking lithium at follow-up had a poorer outcome than those taking lithium, but patients no longer taking any psychotropic drug did not differ from those taking lithium. Patients no longer taking lithium had had a higher frequency of psychotic features in the index episode than those still taking lithium. CONCLUSIONS: The impact of lithium prophylaxis on the course of bipolar disorder is severely limited by the high dropout rate. In bipolar patients taking lithium regularly for several years, a drastic reduction of time spent in the hospital is almost the rule; these patients represent a self-selected population in which at least one group at high risk of poor outcome is under-represented.

Late non-response to lithium prophylaxis in bipolar patients: prevalence and predictors.

65 bipolar patients who had shown a complete response to lithium prophylaxis over a 5-year period were followed up for a further period of 5 years. 12.7% of them had at least two affective episodes during the latter period, despite persistently adequate compliance. These late non-responders, as compared with stable responders, had a significantly higher number of previous affective episodes and hospitalizations and a significantly longer duration of illness. It is suggested that the main determinant of late non-response is the 'driving force' of the illness, finally overwhelming the prophylactic effect of lithium.

Nonresponse to reinstituted lithium prophylaxis in previously responsive bipolar patients: prevalence and predictors.

OBJECTIVE: The authors explored the prevalence and predictors of nonresponse to reinstituted lithium prophylaxis in bipolar patients who had relapsed after discontinuation of successful lithium treatment. METHOD: The study was conducted with 54 bipolar patients for whom lithium had been reintroduced after one or more recurrences following discontinuation of successful prophylaxis. They were followed up, through bimonthly personal interviews, for 1 year after recovery from the episode during which lithium treatment had been resumed, or up to the first recurrence with onset after lithium reinstitution. RESULTS: During the follow-up period, 44 patients did not have any affective episodes, whereas 10 had at least one recurrence. The only significant difference between the two patient groups was the longer duration of prediscontinuation lithium treatment for the patients who relapsed. CONCLUSIONS: Nonresponse to reinstituted prophylaxis should be considered among the possible risks of the interruption of effective long-term lithium treatment.

Validity of rapid cycling as a course specifier for bipolar disorder.

OBJECTIVE: This study's aim was to test the validity of rapid cycling, defined by criteria consistent with those proposed in the DSM-IV draft, as a course specifier for bipolar disorder. METHOD: The study was conducted at a university center for affective disorders on patients fulfilling Research Diagnostic Criteria for bipolar disorder. Thirty-seven rapid-cycling patients, i.e., patients with at least four affective episodes during the previous year, were compared with 74 nonrapid-cycling patients on several demographic and clinical variables. All patients were then followed up prospectively for 2-5 years by monthly personal interviews. RESULTS: The rapid-cycling group was significantly older and had a significantly longer illness duration than the nonrapid-cycling group but did not have a significantly higher percentage of women or frequency of current hypothyroidism. During each year of follow-up, the mean number of affective episodes and the percentage of patients with at least four affective episodes were significantly higher among rapid-cycling patients. Rapid-cycling patients with a pole-switching pattern during the year preceding intake were significantly more likely than other rapid-cycling patients to have at least four affective episodes during each of the first 4 years of follow-up. CONCLUSIONS: These findings support the practical usefulness of rapid cycling as a course modifier for bipolar disorder, since it identifies a patient subgroup with a high recurrence rate. The predictive value of the modifier may be enhanced by the requirement of a pole-switching pattern. Since no external (i.e., unrelated to course) validator was found, the idea that rapid cycling represents one extreme of a continuum of episode frequency in bipolar disorder remains viable.

Pattern of recurrence of illness after recovery from an episode of major depression: a prospective study.

OBJECTIVE: This study assessed prospectively the pattern of recurrence of illness after recovery from an episode of major depression. METHOD: Seventy-two patients who had recovered from an episode of primary, nonbipolar, nonpsychotic major depression were evaluated bimonthly with the Comprehensive Psychopathological Rating Scale for a period ranging from 20 to 108 months (median = 66 months). New ("prospective") episodes were ascertained with a structured diagnostic interview. The probabilities of remaining well after the index episode and after the first prospective episode were assessed by the life-table method. The severity and duration of prospective episodes and the index episode were compared by linear regression analysis. RESULTS: The probability of remaining well after recovery from the index episode was 76% at 6 months, 63% at 1 year, and 25% at 5 years. The risk of recurrence was lower among patients receiving prophylactic treatment with antidepressants and/or lithium and among those with histories of fewer than three previous episodes. The probability of remaining well was significantly lower 2 years after the first prospective episode than 2 years after the index episode. A pattern of increasing severity from the index episode to the first, second, and third prospective episodes was observed and was not affected by treatment. CONCLUSIONS: Major depression has a high rate of recurrence, even when bipolar and psychotic cases are excluded. The highest rate is observed during the first months after recovery from an episode. Prophylactic drug treatment reduces the risk of recurrence but apparently does not affect the trend toward increasing severity of subsequent episodes.

A family study of DSM-III-R schizoaffective disorder, depressive type, compared with schizophrenia and psychotic and nonpsychotic major depression.

OBJECTIVE: To assess the validity of DSM-III-R schizoaffective disorder, the authors explored the morbid risks for schizophrenia and major affective disorders in the first-degree relatives of patients with schizoaffective disorder and relevant other diagnoses. METHOD: In addition to patients with DSM-III-R schizoaffective disorder, depressive type (N = 21), the probands included patients with mood-incongruent psychotic depression (N = 22), mood-congruent psychotic depression (N = 19), nonpsychotic depression (N = 27), or schizophrenia (N = 28) and normal subjects (N = 18). The patients were consecutively recruited from the outpatient facilities of a university psychiatry department; the normal subjects were students and nurses. All probands were directly interviewed, with the Schedule for Affective Disorders and Schizophrenia--Lifetime Version (SADS-L), by a psychiatrist blind to information about relatives. Consenting relatives were directly interviewed, with the SADS-L, by two psychiatrists blind to the probands' diagnoses. The direct interview was supplemented--or replaced, when an interview was not possible (24%)--by family history data from all available sources. Morbid risks in relatives were calculated according to the Weinberg method. RESULTS: The relatives of the schizoaffective patients had almost the same risk for schizophrenia as the relatives of the schizophrenic patients. In the relatives of the patients mood-incongruent psychotic depression, the morbid risk for major affective disorders was about one-half that of the relatives of the patients with mood-congruent psychotic depression and one-third that of the relatives of the patients with nonpsychotic depression, but these differences did not reach statistical significance. CONCLUSIONS: These results suggest that DSM-III-R schizoaffective disorder is close to schizophrenia and largely corresponds to mainly schizophrenic schizoaffective disorder in the Research Diagnostic Criteria, whereas DSM-III-R mood-incongruent psychotic depression is probably quite heterogeneous and should be studied further.

Major depression with mood-congruent psychotic features: a distinct diagnostic entity or a more severe subtype of depression?

The nosological status of major depression with mood-congruent psychotic features was explored by a cross-sectional demographic, clinical and biological assessment and a 7-year prospective follow-up of 2 samples of patients fulfilling, respectively, DSM-III criteria for this condition and for major depression without psychotic features. The 2 patient groups did not differ with respect to demographic and historical features, response to DST and outcome. The global severity of the index episode was greater in psychotics. All nonpsychotics and 69% of psychotics were treated with antidepressants alone or in combination with benzodiazepines, whereas the addition of neuroleptics was required only in 31% of psychotics. A tendency towards an interepisodic diagnostic stability was verified in nonpsychotics more than in psychotics, but was less pronounced than that reported by the authors advocating the nosological autonomy of delusional depression. These data support the view that major depression with mood-congruent psychotic features is not a distinct diagnostic entity, but rather a more severe depressive subtype.

Previous pattern of course of the illness as a predictor of response to lithium prophylaxis in bipolar patients.

The response to lithium prophylaxis was assessed in a sample of bipolar patients subdivided into the following groups on the basis of the previous pattern of course of their illness: MDI (sequence mania-depression-free interval), DMI (sequence depression-mania-free interval), CC-LC (continuous circular course with long cycles), CC-RC (continuous circular course with rapid cycles), IRR (irregular course). A significant reduction of the mean number of morbid episodes and of the mean total morbidity during lithium treatment was observed only in patients with a previous MDI or IRR course. The percentage of responders to prophylaxis was significantly different among the five groups, and the difference could be mainly ascribed to the high response rate in the MDI group and the low response rate in the DMI and CC-RC groups. These results suggest that the classification of bipolar patients according to the previous pattern of course of their illness may be useful for the prediction of lithium response.

Long-term outcome of lithium prophylaxis in patients initially classified as complete responders.

The long-term outcome of lithium prophylaxis was explored in 43 bipolar and 36 unipolar patients who had been classified as complete responders after the first 2 years of treatment. These patients were followed up prospectively for a further period of 5 years (treatment period II), during which their psychopathological state was assessed monthly or bimonthly. Forty-nine patients completed treatment period II, 2 died during this period, 7 did not attend the unit any more and could not be traced, and 21 definitively interrupted lithium treatment before the end of the period. In 18 cases the decision to stop lithium was taken by the patient. Twenty-five patients relapsed during the treatment period II. Four relapsers had three or more episodes concentrated during the last 2 years of treatment. These results suggest that the predictive value of an initial favourable response to lithium should not be overrated, and that the impact of the drug on the long-term course of major affective disorders in ordinary clinical conditions might be less dramatic than currently believed.

Clinical, biological, and neuropsychological features associated with lateral ventricular enlargement in DSM-III schizophrenic disorder.

Clinical, historical, neuropsychological, and biological correlates of lateral ventricular enlargement on computed tomography (CT scan) were explored in a sample of DSM-III schizophrenics. Patients with enlarged ventricles, as compared with those whose ventricles were normal, presented a longer duration of illness and mean duration of hospitalization, and higher scores on the subscales alogia, affective flattening, and attentional impairment of the Scale for the Assessment of Negative Symptoms (SANS), on the scales self-care, participation in household activities, work performance, and behavior in crises and emergencies of the Disability Assessment Schedule, on the scales rhythm, writing, reading, arithmetic, and left hemisphere of the Luria-Nebraska Neuropsychological Battery, and on the subtests digit span, digit symbol and block design of the Wechsler Adult Intelligence Scale. Furthermore, on the computerized electroencephalogram, beta relative activity was significantly higher in patients with normal ventricles on the right frontal, left frontal, and right central leads. On stepwise discriminant function analysis, the patient groups with enlarged and normal ventricles could be separated statistically, and duration of illness and summary score on the SANS were found to be the best discriminators.

Factors associated with response to lithium prophylaxis in DSM III major depression and bipolar disorder.

The relationship of some clinical, personality and biological variables to the outcome of lithium prophylaxis was investigated in two patient samples fulfilling, respectively, the DSM III definitions of "major depression, recurrent" and "bipolar disorder". In major depressives, the presence of psychomotor retardation and melancholia during the index episode was associated with a favorable response to treatment, whereas the presence of mood-incongruent psychotic features during the same episode, a high score on the "anxiety" and "phobic" subscales of the Middlesex Hospital Questionnaire and a high score on the "neuroticism" subscale of the Eysenck Personality Questionnaire were related to a poor response. These findings are discussed in the light of the heterogeneity of DSM III major depression and of the reported common occurrence of an "anxiety-phobic" personality profile in unipolar depressives. In bipolar patients, a family history of bipolar affective illness and a high lithium ratio were associated with a good response to treatment, and the presence of the HLA-A3 antigen with an unfavorable response. These findings seem to support a role of pharmacogenetic factors in conditioning response to lithium prophylaxis.