The clinical and economic burden of proximal femur periprosthetic fractures.

BACKGROUND: The number of hip replacements is constantly and progressively increasing, resulting in an increase in periprosthetic fractures. The main aim of this study is to analyze costs and outcomes of surgical treatment for those fractures. MATERIALS AND METHODS: A retrospective study was performed on periprosthetic proximal femur fracture presented a single-level I trauma center. Medical records were reviewed in terms of demographic data, diagnosis (according to Vancouver classification), type of surgical treatment, hospitalization length and follow-up. Patients were interviewed about number of consultations after discharge, medications and physiotherapy sessions. Clinical outcome was evaluated with WOMAC score at the last follow-up, and patient health status was evaluated with the EQ5D5L score pre-trauma and at the last follow-up. Patients were divided into two groups according to surgical treatment: reduction and internal fixation alone and revision plus fixation. A further group was also considered: patients underwent a Girdlestone procedure. Global costs for each group were calculated. RESULTS: We initially recruited 117 patients, 17 of them were lost at follow-up. Furthermore, 19 patients (19%) died during the follow-up, and 81 of them were therefore included in the study. Mean follow-up was 26.5 months. Mean postoperative WOMAC score was 39.44, and EQ5D5L score was 9.12 for the preoperative period and 12.35 at the last follow-up. A significant worsening of clinical conditions was found comparing the period before fracture to the last follow-up (p < 0.01). Quality of life after surgery resulted to be poor or fair in 40% of the patients at a mean follow-up of 26.5 months. No significant differences between groups were found according to patients' health status. Mean global costs for mayor surgeries were 18,822 Euros; mean costs for fixation alone were 17,298 Euros while for fixation and revision were 20,966 Euros, but no statistically difference was found between these two groups. Mean cost for Girdlestone group was 12,664 Euros. CONCLUSIONS: In proximal femur periprosthetic fractures, either fixation or revision plus fixation presents high costs but patients' postoperative quality of life is poor.

Tumorigenic effect mediated by ROS/eicosanoids and their regulation on TP53 expression in a murine mammary gland adenocarcinoma.

The aim of this study was to investigate the in vivo and in vitro effects of dietary ω-6 and ω-3 polyunsaturated fatty acids (PUFAs) and their derivatives on the expression of TP53 and their relationship with cellular proliferation and death in a murine mammary adenocarcinoma model. BALB/c mice were divided in three diet groups: chia oil (ChO) rich in ω-3, corn oil (CO) rich in ω-6/ω-3 and safflower oil (SO) rich in ω-6 and subcutaneously inoculated with LMM3 mammary tumor cell line. Results demonstrated that diets with higher concentration of omega-6 PUFAs induced an increment of linoleic and arachidonic acid on tumor cell membranes increasing ROS liberation, 12(S)-HHT generation, TP53, Ki67 expression and cell proliferation. However, diets enriched with high content in omega-3 PUFAs induced higher tumor cell apoptosis and tumor infiltration of CD3+ lymphocytes, lowest cell viability and proliferation. Dietary omega-3 PUFAs nutritional intervention can be used as a potential preventative strategy to inhibit the molecular signaling pathways involved in the mammary tumor growth process as the TP53.

Primers on molecular pathways - lipoxygenases: their role as an oncogenic pathway in pancreatic cancer.

Different evidence supports a functional role of enzymes involved in lipid metabolic pathways, such as lipoxygenases (LOXs) and their metabolite derivatives, in carcinogenesis. LOX enzymes catalyze the dioxygenation of arachidonic acid into hydroxyperoxyeicosatetraenoic acids, which is followed by their conversion to their corresponding eicosanoids as hydroxyeicosatetraenoic acids, leukotrienes, lipoxins and hepoxilins, which in turn act as cellular messengers. Subcellular LOX enzyme localization varies according to the LOX and cellular type regulating different cell functions. LOX enzymes or their products may exert their biological effects in different modes, either intracellular or in other cells. Numerous clinical studies on expression of LOXs in human tumors as well as in animal models indicate different roles of distinct LOX isoforms in carcinogenesis. In fact, different LOXs exhibit either protumorigenic or antitumorigenic activities and modulate the tumor response in a tissue-specific manner. Moreover, the LOX pathways are involved in the spread and metastasis of several cancers, including pancreas, through the activation of several cellular signaling pathways which modify gene expression affecting cellular proliferation, survival, migration and extracellular matrix production. In this review we focus on the important role and different mechanisms of action of LOX pathways in the regulation of pancreatic cancer initiation and progression. A novel approach for pancreatic cancer chemoprevention would involve targeting LOX activities, alone or in combination with other pathways as a major anticancer strategy.

The role of early radiological studies after gastric bariatric surgery.

BACKGROUND: The authors investigated early radiological findings after gastric surgery for morbid obesity to evaluate their usefulness in avoiding complications or facilitating treatment. MATERIAL AND METHODS: 413 patients underwent gastric bariatric surgery: 327 had vertical banded gastroplasty (VBG), 55 Roux-en-Y gastric bypass (RYGBP), 22 adjustable silicone gastric banding (ASGB), and 9 biliopancreatic diversion (BPD). A radiological upper gastrointestinal investigation employing water-soluble contrast medium was performed in each patient between the 2nd and 8th postoperative day. Several techniques were employed to assess different radiological findings related to the anatomic modifications after the bariatric surgery. RESULTS: In VBGs, delayed emptying was found in 10 patients (3%), gastric leak in 3 patients (0.9%), vertical suture breakdown in 1 patients (0.3%), and a wide pouch in 4 patients (1.2%). In RYGBP, a leak was detected in 2 patients (3.6%), delayed emptying in 2 (3.6%), and a wide pouch in 5 (9.1%). ASGB required band enlargement for stomal stenosis in 6 patients (27.2%). Temporary delayed emptying from stomal stenosis was also observed in 2 BPDs (22.2%). Overall complications were 35/413 (8.2%). Two cases of gastric leak after VBG were reoperated. Stomal stenosis after ASGB were treated by percutaneous band deflation; other cases were medically treated until complete healing. CONCLUSIONS: Early radiological study after gastric bariatric surgery is advisable, since it detected postoperative complications (gastric perforation, stomal stenosis, etc.) and modified the clinical approach. As the interpretation of these radiographs is often difficult, involving different projections or patient's positions or other technical managements, surgeons and radiologists must interact and be knowledgable.

A randomised phase II study of oxaliplatin alone versus oxaliplatin combined with 5-fluorouracil and folinic acid (Mayo Clinic regimen) in previously untreated metastatic colorectal cancer patients.

The aim of this study was to examine the efficacy and safety of both oxaliplatin as a single agent and oxaliplatin in combination with dailyx5 bolus 5-fluorouracil and folinic acid (5-FU/FA, Mayo clinic regimen) in the first-line treatment of metastatic colorectal cancer (CRC) patients. 73 advanced CRC patients were randomised to receive either oxaliplatin 85 mg/m(2) every 2 weeks (35 patients), or the same treatment combined with 5-FU 425 mg/m(2)/day and FA 20 mg/m(2)/dayx5 days every 4 weeks (38 patients). Treatment was continued until disease progression or unacceptable toxicity. All patients had documented inoperable disease and no previous chemotherapy for advanced disease. Based on the investigators' assessment of best response, objective response rate was 9% (95% confidence interval (CI) 2-24%) in the oxaliplatin arm, and 45% (95% CI 27-64%) in the oxaliplatin+5-FU/FA arm. Median progression-free survival (PFS) was 2 months (95% CI 1.7-2.4 months) in the oxaliplatin arm and 3.9 months (95% CI 2.9-5 months) in the oxaliplatin+5-FU/FA arm. Severe neutropenia was seen in 23% of patients in the oxaliplatin+5-FU/FA arm, and none in the oxaliplatin arm. There were two treatment-related deaths, both in the oxaliplatin+5-FU/FA arm. In the oxaliplatin+5-FU/FA arm, severe diarrhoea, vomiting and stomatitis were seen in 34, 14 and 14% of the patients, respectively. In conclusion, oxaliplatin at a dose of 85 mg/m(2) given every 2 weeks was well tolerated and has limited activity in metastatic CRC, while the combination of this treatment with the full-dose Mayo clinic regimen (5-FU bolus 425 mg/m(2)/day+FA 20 mg/m(2)/dayx5 days every 4 weeks), although active, was unfeasible due to a high level of myelosuppression and gastrointestinal toxicity. Alternative lower dosing or other regimens are to be explored to ascertain the value of bolus 5-FU/FA combined with oxaliplatin.

Evaluation of carboxymethylcellulose, hydroxypropylmethylcellulose, and aluminum hydroxide as potential carriers for rhBMP-2.

Conventional iliac crest nonvascularized corticocancelous bone grafts and bone flaps have been used to treat bony defects. However, these treatments have some limitations, namely, the availability of donor tissue, donor site morbidity, difficulty to shape the bone flap to the defect, and complexity of the surgery. The bone morphogenetic protein (rhBMP-2) is osteoinductive. However, its implantation requires a matrix (carrier) in order to define the shape of the resulting bone and to retain the protein at the site for the time required for induction to occur. When the ideal carrier is found, an unlimited supply of material would be available for all applications where bone is needed. In this in vitro study, we evaluated the suitability of some potential carriers for rhBMP-2 by measuring the alkaline phosphatase (ALP) activity of fibroblast cultures. Either rhBMP-2 or sodium carboxymethylcellulose significantly increased the ALP activity, when used alone. When sodium carboxymethylcellulose was combined with rhBMP-2, there was an increase in the ALP activity, but lower than those obtained when the products were used alone. Hydroxypropylmethylcellulose alone did not affect ALP activity. However, the combination of rhBMP-2 with hydroxypropylmethylcellulose did not increase the ALP activity, despite the presence of rhBMP-2. Aluminium hydroxide proved to be an unsuitable rhBMP-2 adsorbent.

The control of progesterone receptor expression in MCF-7 breast cancer cells: effects of estradiol and sex hormone-binding globulin (SHBG).

Estradiol controls the gene transcription and expression of many proteins in breast cancer cells, like the progesterone receptor, PR, that is up-regulated by the hormone. Moreover, estradiol is one of the crucial factors inducing the proliferation of breast cancer cells. Sex Hormone-Binding Globulin (SHBG), the plasma carrier for both estradiol and androgens, inhibits the estradiol-induced growth of MCF-7 cells (estrogen-dependent breast cancer cells), through its membrane receptor (SHBG-R), cAMP and PKA. The anti-estrogenic effect of SHBG, which has been described only as far as cell proliferation is concerned, could also play a meaningful role in the estradiol control of other factors in breast cancer cells. In the present study, the effect of SHBG on the estradiol control of PR expression (both mRNA and protein) and function (receptor binding capacity) in MCF-7 cells was examined. SHBG inhibited the estradiol-induced up-regulation of PR mRNA as well as protein level and function. Moreover, the effect of SHBG on estradiol control of PR expression and function was showed to be specific and mediated by PKA. The intermediacy of PKA in the PR expression control, together with the observation that it is effective in the condition in which the SHBG receptor is activated, supports the hypothesis that the anti-estrogenic effect of SHBG could be receptor-mediated. The ability of SHBG to inhibit estradiol action in a specific way in estrogen-dependent breast cancer cells has, therefore, to be taken into account for the development of future therapeutic strategies.

Single-agent gemcitabine in pretreated patients with non-small-cell lung cancer: results of an Argentinean multicentre phase II trial.

The activity and mild toxicity profile of single-agent gemcitabine therapy in untreated (chemonaive) patients with non-small-cell lung cancer (NSCLC) is well documented. This phase II trial was conducted to determine the objective tumour response rate and toxicity profile of single-agent gemcitabine in pretreated patients with NSCLC. Patients with histological evidence of advanced NCSLC stage IIIB or IV; at least one prior chemotherapy regimen including a platinum or taxane analogue; an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2; clinically measurable disease; adequate bone marrow reserve; and adequate renal function; received 1000 mg m(-2) gemcitabine administered over 30 min on days 1, 8 and 15 of a 28-day cycle defined as 3 weekly treatments followed by 1 week of rest. Twenty-nine patients were evaluated for efficacy and 32 for toxicity. One patient achieved a complete response and five patients had a partial response resulting in a total response rate of 20.6% (95% confidence interval (CI) 6-34). Median response duration was 7 months (range 4-11 months). Twelve (41%) patients reached stable disease after two cycles of therapy and 11 (38%) patients had disease progression. Median progression-free survival time was 3 months and median overall survival time was 5.5 months. Toxicity was generally mild (grades 0-2). Severe (grade 3 or 4) haematological toxicities included grade 3 anaemia in one patient and grade 3 thrombocytopenia in two patients. Severe non-haematological toxicities included one patient each with grade 3 liver transaminase elevations, nausea/vomiting and diarrhoea. This study confirms the activity and safety of single-agent gemcitabine in pretreated patients with advanced NSCLC who are refractory or sensitive to first-line therapy.

Sex hormone-binding globulin, its membrane receptor, and breast cancer: a new approach to the modulation of estradiol action in neoplastic cells.

The role of human Sex Hormone-Binding Globulin (SHBG), the plasma carrier of sex steroids, and its membrane receptor, SHBG-R, in estrogen-dependent breast cancer has been investigated in our laboratory in the past few years. SHBG-R is expressed in MCF-10 A cells (not neoplastic mammary cells), MCF-7 cells (breast cancer, ER positive) and in tissue samples from patients affected with ER positive breast cancer, but not in estrogen-insensitive MDA-MB 231 cells. The SHBG/SHBG-R interaction, followed by the binding of estradiol to the complex protein/receptor, causes a significant increase of the intracellular levels of cAMP, but does not modify the amount of estradiol entering MCF-7 cells. The estradiol-induced proliferation of MCF-7 cells is inhibited by SHBG, through SHBG-R, cAMP and PKA. Similarly, the proliferation rate of tissue samples positive for SHBG-R was significantly lower than the proliferation rate of negative samples. SHBG and SHBG-R could thus trigger a 'biologic' anti-estrogenic pathway. In order to get a more detailed knowledge of this system, we first examined the frequence of the reported mutated form of SHBG in 255 breast cancer patients. The mutated SHBG is characterized by a point mutation (Asp 327 --> Asn) causing an additional N-glycosylation site, which does not affect the binding of steroids to SHBG. The frequence of the mutation was significantly higher (24.5%) in estrogen-dependent breast cancers than in healthy control subjects (11.6%). This observation confirms the close relationship between SHBG and estrogen-dependent breast cancer and suggests that the mutation could modify SHBG activity at cell site. Lastly, the possibility of using SHBG to modulate the estradiol action in breast cancer was further studied by transfecting MCF-7 cells with an expression vector carrying the SHBG cDNA (study in collaboration with G.L. Hammond). Transfected cells are able to produce significant amount of SHBG in their medium, but their SHBG-R is reduced to undetectable levels. The SHBG produced by transfected MCF-7 cells is, however, able to inhibit estradiol-induced proliferation of MCF-7 cells expressing a functional receptor. Thus, the local production of SHBG obtained with transfection could be a useful tool to control cell growth in estrogen-dependent breast cancer.

[Free flaps in the reconstruction of head and neck. Clinical experience]. / Retaehos livres na reconstrução da cabeça e pescoço. Experiência clínica.

The reconstruction of head and neck defects, due to trauma, tumor resection or other, begins with a careful assessment of the patient and the respective defect. Ideally, it ends with the successful reconstructive procedure that optimally restores form and function to the patient. Free flaps have often been used as a last resort reconstructive option in the head and neck because of the need for added technical skill, a longer operating time and a perception of poor reliability. This study reviews our experience with forty-eight patients submitted to microvascular reconstructive procedures. Twelve different kinds of free flaps have been involved as the preferred choice for free flap reconstruction of a specific defect of the head and neck. The latissimus dorsi flap was used for scalp and skull reconstruction, whereas the serratus anterior or rectus abdominis free flaps were used for the reconstruction of complex defects of the middle third of the face. The radial forearm flap and the free jejunal transfer have become the preferred choices for intraoral and pharyngo-esophageal reconstruction, respectively. Good results were obtained with both functional and social rehabilitation. There were three flap losses probably due to thrombosis of the microvascular anastomosis. There was no surgical mortality. The indications for each free flap are discussed.

Sex steroid binding protein receptor (SBP-R) is related to a reduced proliferation rate in human breast cancer.

In the last years, an increasing amount of studies described a membrane receptor for the Sex Steroid Binding Protein (SBP) on several androgen-estrogen dependent tissues. One of the suggested biological roles of the interaction between SBP and its receptor seems to be a negative control of the E2 induced proliferation of human breast cancer cells through the cAMP pathway. In the present work, SBP membrane receptor was evaluated on human breast cancer specimens with a radio-binding assay. Each tissue sample was also evaluated for ER and PGR status. Cytosol Thymidine Kinase levels were measured in tissue samples in order to evaluate cell proliferation rate. SBP binding to membranes of ER +/PGR + samples was time and temperature dependent, specific and at high affinity. In addition, SBP recognized on breast cancer membranes two sites at different affinity, as previously described for other human tissues and cultured cells. Membrane SBP-R was detected in a significantly higher number of samples positive for both ER and PGR than in negative samples. SBP-R positive samples showed a significantly lower proliferation rate than SBP-R negative samples as demonstrated by TK activity. The present study contains evidences for the existence of a specific membrane receptor for SBP in breast cancer sample membranes and the presence of SBP-R seems to be strictly related to a lower proliferation rate of the sample.

Reverse dorsal metacarpal osteocutaneous flap.

There are a number of possibilities for local and vascularized bone transfer when a small amount of cortico-cancellous bone is required in the hand and fingers. The authors describe the dissection technique and a clinical application of a reverse dorsal metacarpal osteocutaneous flap to reconstruct the proximal phalanx of a fifth finger. They emphasise the bone vascularisation, studied 48 hours postoperatively with a bone scan and confirmed with bone healing 4 weeks later. The advantages are: it is a compound flap, easy to dissect under tourniquet in one operation, it can be done in an emergency care situation and it does not require ligation of an important vascular axis. The essential precaution is to visualise the patency of the fourth dorsal metacarpal artery before flap dissection, acknowledging that in only 63% of cases is there a vascular pattern that allows flap dissection with a long arc of rotation.

A new approach in axillary hidradenitis treatment: the scapular island flap.

The scapular island flap technique has been used in the treatment of seven cases of axillary hidradenitis suppurativa. This flap, providing a smooth skin surface with good elastic properties, easily covers the axilla and permits the cutaneous reconstruction of the involved axillary tissue excision with satisfying aesthetic, functional results and a rapid local cicatrization. The donor site was closed by primary suture.

[Extrahepatic gastrinoma. Report of a clinical case]. / Gastrinoma extrapancreatico. Descrizione di un caso clinico.

Gastrinoma is a rare neoplasia producing gastrina, the hormone responsible of the clinic manifestations related to Zollinger-Ellison syndrome. The localization of gastrinoma is pancreatic or extrapancreatic (usually in Stabile and Passaro triangle). We present a case report concerning an extra-pancreatic gastrinoma not localized in this area and included in a lymph node. This is an extremely infrequent localization (2.4%). There are two different opinions about this localization. Some authors think that this is always a secondary lesion of a small primary neoplasia usually asymptomatic. Other authors think that there are primary lymph nodal gastrinomas that could be safely removed with excision of lymph node. The infrequent localisation of this case induced us to report this experience in order to contribute to the comprehension of this pathology.

[Utilization of forearm island flaps in reconstructive surgery of the hand. Which one is the best option?]. / A utilização de retalhos antebraquiais em ilha na cirurgia reconstrutiva da mão. Qual a melhor opção?

The authors report their clinical experience after seventy-six forearm island flaps, and analyse the different possible forearm flap options in hand reconstructions. The different flaps-based on the radial, ulnar, interosseous and septocutaneous ulnar vessels-are compared in what, concerns the importance of the sacrificed artery, adverse sequelae of the donor area and their versatility to close large skin defects as well as their capacity to reach distal areas of the hand. Their ability to provide sensate coverage and to replace bone and tendons is also compared.

Sex steroid binding protein exerts a negative control on estradiol action in MCF-7 cells (human breast cancer) through cyclic adenosine 3',5'-monophosphate and protein kinase A.

Estradiol is considered to be a critical factor in the growth induction of some breast cancer cells, like MCF-7 cell line. Among other compounds involved in the control of neoplastic mammary cell growth, cAMP has been suggested, on the other hand, to exert an antiproliferative effect. Sex steroid binding protein (SBP) sex hormone binding globulin (SHBG), the plasma carrier for both androgens and estradiol, recognizes a specific receptor located on membranes of estrogen- and androgen-sensitive tissue and cultured cells (e.g. MCF-7 cell). The interaction of estradiol with the receptor-bound SBP has been reported to induce a significant accumulation of cAMP in MCF-7 cells; in addition, a negative modulation of estradiol induced proliferation of these cells has been described after treatment with SBP. We report here a more detailed observation about the effect of SBP on MCF-7 cell estradiol-induced growth as well as the possible linkage between SBP and its membrane receptor and protein kinase A activity. MCF-7 cell growth was induced by estradiol, but the effect of estradiol was completely abolished by cell treatment with both SBP and estradiol. The inhibitory effect of SBP was highly specific. Because it was suggested that SBP might act through cAMP, we investigated the effect of SBP and estradiol in cells treated with protein kinase A inhibitor peptide (6-22) amide, a specific inhibitor of the cAMP target protein kinase A. The blockade of PKA had no effect on estradiol action on cell growth but masked completely the effect of SBP because MCF-7 increased growth sustained by estradiol was fully detectable also in the presence of SBP. We also observed that MCF-7 cells treated with increasing doses of 8Br-cAMP, cAMP analog and PKA activator, showed a progressive reduction of their growth. 8Br-cAMP was also able to inhibit estradiol promotion of MCF-7 cell growth. The inhibitory effect of 8Br-cAMP on estradiol-induced proliferation was already detectable at analog concentration of 100 nM, which has been reported to be the level reached by cAMP in MCF-7 cells treated with SBP and estradiol. In conclusion, the present study strongly confirms our previous observation that SBP inhibits the estradiol induction of MCF-7 cell growth, appropriately suggesting that this SBP action, a consequence of the interaction with the receptor, is likely to be mediated by cAMP and PKA. In addition, the study implies a significant role of cAMP in the control of breast cancer cell growth.

Sex steroid-binding protein and its membrane receptor in estrogen-dependent breast cancer: biological and pathophysiological impact.

Data obtained in our laboratory about the membrane receptor for sex steroid-binding protein (SBP-R) in human breast cancer are reported. SBP-R was detected in MCF-7 cells (estrogen receptor positive, ER+), while MDA-MB 231 cells (ER-) did not bind SBP. MCF-7 cells treated with SBP and E2 showed a marked increase of intracellular cAMP, and a significant reduction of both E2 induced cell proliferation and E2-mediated increase of progesterone receptor (PGR). The inhibition of E2 effects in MCF-7 cells was shown to be highly specific for SBP and mediated by protein kinase A, the target of cAMP. Membrane SBP-R was also evaluated in primary breast cancers. SBP-R was detectable only on ER+/PR+ samples and SBP-R+ samples presented a lower proliferation rate than negative samples. Our data, thus suggest that SBP-R and ER could be functionally related and also that SBP could modulate estrogen action at target cell site.

The receptor-mediated action of sex steroid binding protein (SBP, SHBG): accumulation of cAMP in MCF-7 cells under SBP and estradiol treatment.

The interaction of sex steroid binding protein (SBP) with its specific receptor in MCF-7 cell (estrogen-sensitive human breast cancer cells), followed by the binding of estradiol (E2) to the complex SBP-receptor, induced a significant accumulation of intracellular cAMP. SBP alone as well as E2 alone did not elicit any modification of the nucleotide. The maximal increase in cAMP was observed with 1 nM SBP + 1 nM E2. Increasing doses of both SBP and E2, even raising cAMP levels with respect to basal, did not give any higher response. Both testosterone and dihydrotestosterone, used instead of E2, were not able to induce any significant modification of cAMP. E2-induced MCF-7 cell proliferation was significantly reduced by 8Br-cAMP. MDA-MB 231 cells (estrogen-insensitive breast cancer cells) were not shown to bind SBP, or to respond to SBP + E2 as far as both their proliferation and cAMP content are concerned. In summary, the present study provides evidence that the SBP receptor is part of the G-protein receptor family, and that SBP can act as modulator of E2 action at cell site through the second messenger cAMP.