Dose and volume de-escalation of radiotherapy in head and neck cancer.

Radiotherapy plays a key role in the treatment of head and neck cancer. However, irradiation of the head and neck region is associated with high rates of acute and chronic toxicity. Technological advances have led to better visualisation of target volumes and critical structures and improved dose conformality in the treatment volume. Despite this, acute toxicity has not been substantially reduced and late toxicity has a significant impact on patients' quality of life. The greater radiosensitivity of tumours associated with the HPV and the development of new imaging techniques have encouraged research into new deintensified strategies to reduce the side effects of radiotherapy. The aim of this paper is to review the literature on the strategies of de-escalated treatment in dose and/or volume in head and neck cancer.

Oligometastatic non-small cell lung cancer: Current management.

BACKGROUND: In the past decade, major developments have improved the survival of patients with oligometastatic non-small cell lung cancer (NSCLC). About 20% - 50% of patients with NSCLC present with oligometastases at diagnosis. For this group of patients, it seems that an increase in survival would justify aggressive local therapies. The development of minimally invasive surgery and advanced radiotherapy techniques like stereotactic body radiation therapy (SBRT) makes local control possible for selected patients with metastatic NSCLC. The advantage of SBRT over surgery is that it is a non-invasive technique, with minimum side effects, and is more suitable for fragile and elderly patients, non-candidates for surgery, or patients who refuse surgery. AIM: The purpose of this review is to summarize the latest scientific evidence on the management of oligometastatic NSCLC, focusing on the role of radiotherapy. RELEVANCE FOR PATIENTS: The initial treatment recommended for patients with oligometastatic NSCLC is systemic therapy. Patients should be considered for radical treatment to both the primary tumor and oligometastases. Aggressive local therapy comprises surgery and/or definitive radiotherapy such as SRS or SBRT, and may be preceded or followed by systemic treatment. Recent clinical evidence from Phase II trials reports benefits in terms of PFS in patients with good performance status and long disease-free periods, with good response to systemic therapy, especially in EGFR wild-type tumors. Phase I and II trials have shown that radiotherapy combined with immunotherapy can improve tumor response rate and possibly overall survival. The recommendation is also to include OM patients in ongoing clinical trials.

Body size phenotypes comprehensively assess cardiometabolic risk and refine the association between obesity and gut microbiota.

OBJECTIVE: The gut microbiota associates with obesity and related disorders, but recent meta-analyses have found that this association is, at best, of small effect. We argue that such analyses are flawed by the use of body mass index (BMI) as sole proxy for disease, and explore a classification method that distinguishes the cardiometabolic health status of individuals to look for more comprehensive associations between gut microbes and health. DESIGN: We analyzed a 441 community-dwelling cohort on which we obtained demographic and health information, anthropometry and blood biochemistry data that served to categorize participants according to BMI, cardiometabolic health status and body size phenotypes. In addition, the participants donated fecal samples from which we performed 16S rRNA gene sequencing to analyze the gut microbiota. RESULTS: We observed that health-related variables deteriorate with increased BMI, and that there are further discrepancies within a given BMI category when distinguishing cardiometabolically healthy and unhealthy individuals. Regarding the gut microbiota, both obesity and cardiovascular disease associate with reductions in α-diversity; having lean, healthy individuals the most diverse microbiotas. Moreover, the association between the gut microbiota and health stems from particular consortia of microbes; the prevalence of consortia involving pathobionts and Lachnospiraceae are increased in obese and cardiometabolically abnormal subjects, whereas consortia including Akkermansia muciniphila and Methanobrevibacter, Oscillospira and Dialister have higher prevalence in cardiometabolically healthy and normoweight participants. CONCLUSIONS: The incorporation of cardiometabolic data allows a refined identification of dissimilarities in the gut microbiota; within a given BMI category, marker taxa associated with obesity and cardiometabolic disease are exacerbated in individuals with abnormal health status. Our results highlight the importance of the detailed assessment and classification of individuals that should be carried out prior to the evaluation of obesity treatments targeting the gut microbiota.

Cdc42p controls yeast-cell shape and virulence of Paracoccidioides brasiliensis.

Paracoccidioides brasiliensis is characterized by a multiple budding phenotype and a polymorphic cell growth, leading to the formation of cells with extreme variations in shape and size. Since Cdc42 is a pivotal molecule in establishing and maintaining polarized growth for diverse cell types, as well as during pathogenesis of certain fungi, we evaluated its role during cell growth and virulence of the yeast-form of P. brasiliensis. We used antisense technology to knock-down PbCDC42's expression in P. brasiliensis yeast cells, promoting a decrease in cell size and more homogenous cell growth, altering the typical polymorphism of wild-type cells. Reduced expression levels also lead to increased phagocytosis and decreased virulence in a mouse model of infection. We provide genetic evidences underlying Pbcdc42p as an important protein during host-pathogen interaction and the relevance of the polymorphic nature and cell size in the pathogenesis of P. brasiliensis.

Differences in cardiovascular mortality in smokers, past-smokers and non-smokers: findings from the FRENA registry.

BACKGROUND: The influence of smoking on outcome in patients with coronary artery disease (CAD) is controversial. Even less is known about its influence in patients with cerebrovascular (CVD), or peripheral artery (PAD) disease. PATIENTS AND METHODS: FRENA is an ongoing, observational registry of consecutive outpatients with symptomatic CAD, CVD, or PAD. We reviewed their cardiovascular mortality according to smoking status. RESULTS: As of May 2008, 2501 patients had been enrolled in FRENA. Of these, 439 (18%) were current smokers, 1086 (43%) past-smokers, 976 (39%) had never smoked. Current- and past-smokers were 10 years younger, more often males, and more likely to have chronic lung disease, but had diabetes, hypertension, heart failure, or renal insufficiency less often than non-smokers. Over a mean follow-up of 14 months, 123 patients died (cardiovascular death, 68). On univariate analysis, current smokers had a significantly lower rate of cardiovascular death: 1.1 (95% CI: 0.4-2.4) per 100 patient-years in current smokers; 1.9 (95% CI: 1.2-2.8) in past-smokers; 3.5 (95% CI: 2.5-4.7) in non-smokers, with no differences between patients with CAD, CVD or PAD. Mean age at cardiovascular death was 82+/-6.4; 70+/-9.9 and 67+/-15 years, respectively. On multivariate analysis, smoking status was not independently associated with a lower risk for cardiovascular death. CONCLUSIONS: Current and past-smokers with CAD, CVD or PAD had a less than half cardiovascular mortality than those who never smoked, but this may be explained by the confounding effect of additional variables. They died over 10 years younger than non-smokers.

Antithrombotic potential of olive oil administration in rabbits with elevated cholesterol.

Olive oil is the main source of dietary fatty acids in the Mediterranean region. The objective of this study was to evaluate the effect of dietary supplementation with virgin olive oil in an experimental model with rabbits fed an atherogenic diet (saturated fat 48% of total fat). Four different groups of 10 animals each were studied: (1) normolipemic diet (NLD), (2) atherogenic diet or saturated fatty acid-enriched diet (SFAED), (3) NLD with 15% olive oil (NLD+OLIV), and (4) SFAED with 15% virgin olive oil (SFAED+OLIV). The animals were fed the experimental diets for 6 weeks, after which we determined serum lipid profile (total cholesterol, HDL-cholesterol, and triglycerides), platelet aggregation, platelet thromboxane B(2), aortic prostacyclin, and platelet and vascular lipid peroxidation. Scanning electron microscopic images of the vascular endothelium were studied, as were morphometric parameters in the arterial wall and thrombogenicity of the subendothelium (annular perfusion chamber). Animals fed the SFAED showed platelet hyperactivity and increased subendothelial thrombogenicity. Animals fed the SFAED+OLIV showed, compared with the SFAED group, an improved lipid profile with decreased platelet hyperactivity and subendothelial thrombogenicity and less severe morphological lesions of the endothelium and vascular wall. We conclude that supplementation of the SFAED with 15% olive oil reduced vascular thrombogenicity and platelet activation in rabbits. Although the percentage of olive oil in the diet was higher than the amount in the human diet, these results may be helpful in determining the effect of olive oil in the human thrombogenic system.

Antiplatelet effect of the anaesthetic drug propofol: influence of red blood cells and leucocytes.

1. The present study was designed to investigate the mechanism of the antiplatelet action of the anaesthetic propofol in vitro. 2. Human whole blood was incubated with different concentrations of propofol and its solvent Intralipid(R). We determined, platelet aggregometry in whole blood, platelet-enriched plasma (PRP), PRP plus red blood cells (RBC), and PRP plus leucocytes (LC); platelet production of thromboxane B2 (TxB2), ATP release by platelet dense granules, adenosine uptake by RBC, intraplatelet levels of cyclic adenosine monophosphate (cyclic AMP) and cyclic guanosine monophosphate (cyclic GMP), and LC production of nitric oxide (NO). 3. Propofol-induced inhibition of platelet aggregation was greater in whole blood (IC50 80 - 136 microM) than in PRP (IC50>600 microM), except when aggregation was induced by arachidonic acid, in which case the antiaggregatory effect of the anaesthetic was similar in both media (IC50 72 - 85 microM). Inhibition of platelet aggregation correlated significantly with inhibition of TxB2 synthesis (r2=0.83). Propofol also inhibited granular ATP release; this effect was greatest in whole blood. 4. The presence of RBC or LC increased the antiaggregatory effect of propofol, mainly when collagen was used as aggregating agent. Intralipid inhibited the uptake of adenosine by RBC, however this effect probably does not contribute significantly to its antiaggregatory effect. 5. The anaesthetic potentiated the NO-cyclic GMP pathway, mainly by increasing the synthesis of NO by LC. Intralipid had no effect on the NO-cyclic GMP pathway in the LC-platelet interaction. 6. Propofol inhibited platelet aggregation in human whole blood, possibly through the sum of the effects of Intralipid on the platelet-RBC interaction and the increased synthesis of NO by LC in the platelet-LC interaction.

The effect of propofol on oxidative stress in platelets from surgical patients.

UNLABELLED: We investigated the changes in oxidative stress in platelets from surgical patients anesthetized with propofol. We studied 60 surgical patients (ASA physical status I and II) and 12 healthy volunteers. The patients were divided into three groups: anesthesia induced with an IV bolus dose of 4 mg/kg thiopental; anesthesia induced with an IV bolus dose of 2 mg/kg propofol; and total IV anesthesia (induction with propofol 2 mg/kg, infusion with propofol 10 mg/kg during the first 10 min, then 8 mg/kg for 10 min, and 6 mg/kg during the rest of the operation). Healthy volunteers were given an IV bolus dose of 10% fat emulsion (Intralipid). We measured the following variables in platelets: thiobarbituric acid reactive substances content, glutathione content, and glutathione peroxidase, reductase, and transferase activities. Thiopental did not modify any of the variables. Propofol decreased thiobarbituric acid reactive substances production by 25.7% and increased total glutathione content by 24.6%. The percentage of glutathione in oxidized form was 29.5% smaller in patients anesthetized with propofol. Glutathione peroxidase activity was 28.3% less, glutathione transferase was 44.5% more, and glutathione reductase was not significantly different. Intralipid had no effect on any of the variables. After infusion of propofol for 1 h, the effects were, in qualitative terms, the same as those seen after an initial bolus dose. In conclusion, our findings show that propofol has an antioxidant effect in humans. This effect may be beneficial in patients who have diseases in which free radicals play an important role. IMPLICATIONS: This study demonstrates that propofol inhibits cellular oxidative damage, measured in platelets from surgical patients. Neither thiopental nor the fat emulsion (Intralipid) showed any effect. Moreover, propofol increased the antioxidant defense of glutathione. This could be applied in the protection of tissues from ischemic damage.

Effect of dietary supplementation with evening primrose oil on vascular thrombogenesis in hyperlipemic rabbits.

The dietary intake of saturated fatty acids affects arteriosclerosis. We studied the effect of supplementation (15% wt/wt) of a hyperlipemic diet (1.3% cholesterol) with evening primrose oil (Oenothera biennis) in four groups of 10 rabbits each. After 6 weeks the aortic endothelium was analyzed morphologically with scanning electron microscopy, and the arterial wall was studied with morphometric techniques and cell nucleus counts. Endothelial functioning was analyzed by measuring prostacyclin synthesis, and thrombogenicity of the subendothelium was studied by perfusion in a Baumgartner annular chamber. Evening primrose oil reduced hypercholesterolemia (from 29 +/- 3 to 12 +/- 2 nmol/l), increased HDL-cholesterol (from 0.5 +/- 0.06 to 0.8 +/- 0.09 nmol/l) and doubled prostacyclin synthesis (from 2.7 +/- 2 to 6.2 +/- 0.7 ng/mg aorta) in rabbits on the hyperlipemic diet, reduced subendothelial surface occupied by platelets (from 6.9 +/- 0.4 to 4.8 +/- 0.3%), and reduced human platelet adhesion on the subendothelium (from 53.3 +/- 6% to 38 +/- 8%, respect to total occupation). Morphological analyses showed that evening primrose oil diminished endothelial lesions caused by the atherogenic diet, reducing area of the arterial wall (from 6.9 +/- 0.2 to 4.7 +/- 0.2 microm2 x 10(6)) and the degree of neointimal proliferation (from 0.6 +/- 0.02 to 0.4 +/- 0.09 microm2 x 10(6)). We conclude that in our experimental model, this dietary supplement enhanced the antithrombotic capacity of the endothelium, reduced subendothelial thrombogenicity, and diminished the extent of vascular wall lesions caused by the hyperlipemic diet.

The in vitro effects of propofol on tissular oxidative stress in the rat.

UNLABELLED: This study was designed to evaluate the in vitro effects of propofol on lipid peroxide formation and the glutathione antioxidant system in some tissues of Wistar rats (n = 8-10 per experiment). We measured thiobarbituric acid reactive substances (TBARS), and the activities of glutathione peroxidase (GSHpx), reductase (GSSGrd), and transferase (GSHtf). Propofol inhibited TBARS formation in a concentration-dependent manner. Etomidate and thiopental sodium 10(-6) to 10(-3) M had no effect. The effect of propofol was apparent immediately and was observed for up to 15-20 min after the start of TBARS formation. Propofol inhibited GSHpx activity by a maximum of 75.1%+/-8.4%, increased GSSGrd activity by a maximum of 188%+/-12.6%, and increased GSHtf activity by a maximum of 230%+/-20%. The solvent intralipid had no significant effect on any of the enzyme activities or on lipid peroxidation. We conclude that propofol not only inhibits lipid peroxidation, but also enhances the cellular antioxidant defense system. Propofol is thus able to prepare tissues against oxidative attack by boosting stores of reduced glutathione. IMPLICATIONS: This study demonstrates that the anesthetic propofol increases one of the most important mechanisms against cellular damage, the glutathione system. The study was performed in several tissues of healthy rats. This could be applied as a possible protection in surgical patients suffering from an ischemic process (cerebrovascular disease, coronary ischemia, etc.).

Effect of evening primrose oil on platelet aggregation in rabbits fed an atherogenic diet.

Evening primrose oil (Oenothera biennis) is a rich source of omega-6 series fatty acids. We report here the effects of dietary supplementation with evening primrose oil (EPO) on platelet aggregation as the main factor in arterial thrombus formation in an experimental model of atherogenesis in rabbits. A total of 40 male white New Zealand rabbits were divided into four groups (n = 10 animals/group): 1: normal diet, 2: atherogenic diet (ATD), 3: normal diet enriched with 15% EPO, 4: ATD + EPO. Each group was kept on the diet for 6 weeks. We determined serum lipid profile, platelet aggregation in whole blood, platelet thromboxane B2 production and platelet lipid peroxides. The atherogenic diet increased platelet aggregation (135% when ADP was used, and 185% when collagen was used as the inducer). Evening primrose oil reduced hyperaggregation to the values obtained in rabbits fed with the normal diet. Thromboxane synthesis was increased from 0.18 to 2.28 nmol/10(9) platelets); EPO reduced this value to 1.38 nmol/10(9) platelets. Lipid peroxides were increased by ATD from 0.27 to 0.81 nmol/10(8) platelets; EPO prevented this increase (0.35 nmol/10(8) platelets). In conclusion, EPO reduced platelet hyperaggregability in rabbits fed an atherogenic diet.

Hybridogenetic reproduction and maternal ancestry of polyploid Iberian fish: the Tropidophoxinellus alburnoides complex.

Iberian minnows collectively known as the Tropidophoxinellus alburnoides Steindachner complex comprise diploid and polyploid forms with highly female biased sex ratios. Previous investigators suggested that all-female clonal reproduction and interspecific hybridization may occur in this complex. We examined nuclear (allozymes) and cytoplasmic genes (mtDNA) to assess the evolutionary origins, relationships, and reproductive modes of T. alburnoides from western Spain. The multi-locus allozyme data clearly revealed the hybrid nature of all polyploid forms of this fish and some diploid forms as well. Diagnostic markers identified fish from the genus Leuciscus as the paternal ancestor of hybrids in the Duero and Guadiana River Basins. Additionally, analysis of nuclear markers revealed that hybridogenetic reproduction occurs in the diploid and triploid hybrids. The hybrids fully express the paternal Leuciscus genome and then discard it during oogenesis. Hybridogenetic ova contain only maternal nuclear genes and mtDNA from a non-hybrid T. alburnoides ancestor. Apparently diploid and triploid hybrids of T. alburnoides persist as sperm parasites on males of a sexually reproducing Leuciscus host species.

Risks of the minimal access approach for laparoscopic surgery: multivariate analysis of morbidity related to umbilical trocar insertion.

The objective of this study was to determine the morbidity associated with trocar and needle insertion for laparoscopic surgery and to identify risk factors for complications. Data from a prospectively collected database of all laparoscopic operations performed at a major teaching hospital over a 4-year period were analyzed. In 203 patients closed laparoscopy (Veress needle plus blind trocar insertion) was used to establish the pneumoperitoneum. Open laparoscopy with a Hasson's trocar was performed in 200 patients. A total of 1206 operative trocars were inserted (mean +/- SD 2.99 +/- 0.4). Sixty-nine percutaneous punctures for cholangiography or liver biopsy were carried out. Of the 403 patients undergoing laparoscopic surgery, 20 (3%) had developed complications specifically related to the access to the abdominal cavity after a minimum follow-up of 3 months, abdominal wall hematoma being the most frequent (n = 8, 2.0%), followed by umbilical hernias (n = 6, 1.5%) and umbilical wound infection (n = 5; 1.2%). The rate of penetrating injuries was 0.2% (n = 1). Of 20 complications, 15 (75%) were related to the umbilical insertion site. Female sex and closed laparoscopy were associated with umbilical morbidity by univariate analysis. In a multivariate analysis, closed laparoscopy was the only factor associated with these complications (odds ratio = 6.0; p = 0.04). Age, gender, obesity, diabetes mellitus, previous abdominal surgery, and the specific procedure had no influence. In conclusion, gaining access to the peritoneal cavity for laparoscopic surgery may cause severe complications, most of which are related to the umbilical trocar. Although closed laparoscopy can be safely used, open laparoscopy is associated with a lower morbidity rate; therefore its utilization is recommended.

Propofol inhibits in vitro platelet aggregation in human whole blood.

To help clarify the mechanism of propofol-induced vasodilation, we investigated whether propofol, at concentrations ranging from 10(-6) to 10(-3) M, inhibited platelet aggregation in human whole blood. Propofol inhibited platelet aggregation induced by adenosine diphosphate, collagen, or arachidonic acid in a concentration-dependent manner, with a 50% inhibited concentration (micromol/L) of 136 +/- 9.8 for adenosine diphosphate, 77.8 +/- 6.6 for collagen, and 71.8 +/- 5.4 for arachidonic acid. In platelet-rich plasma, propofol had no significant antiaggregant effect except when arachidonic acid was used as the aggregant (50% inhibited concentration 105 +/- 9.9 micromol/L). The antiaggregant effect of propofol in platelet-rich plasma was increased in the presence of red blood cells or leukocytes in a cell number-dependent manner. We conclude that propofol reduces the platelet activity in human whole blood in vitro.

Alterations in anorectal function after anterior resection for cancer of the rectum.

We have evaluated by means of a clinical and functional study the alterations in anorectal function of a group of 50 consecutive patients who have undergone an anterior resection of the rectum. Results are correlated with the anastomosis location and the time passed after the operation. According to research data this operation changes the patient's defaecation habits and the manometric and radiological parameters of anorectal function. These alterations are more evident in patients with a low anastomosis. The qualitative characteristics of defaecation did not change significantly in relation to the time passed since operation. However, there was a significant increase in compliance 6 months after operation, and the threshold rectal volume and the maximum tolerated volume also showed a significant increase 12 months following operation.

Granuloma anular gigante en napa, factor de error diagnostico / Giant anular granuloma in layer, diagnostic error factor

Con el objetivo de recordar la forma de granuloma anular gigante en napa se presentan dos observaciones con diagnóstico erróneo de lepra indeterminada y sarcoidosis respectivamente. Esta forma clínica ha sido motivo de atención bibliográfica desde 1930 a 1950. La tendencia actual de la misma es buscar las diferencias histológicas entre el granuloma anular localizado y el generalizado, del cual el gigante en napa es sólo una de sus formas con un aspecto característico. Su imagen clínica debe ser recordada para orientar a la histopatología

Colohepatic fistula due to hydatid disease. Report of a case.

A patient with colohepatic fistula due to hydatid disease is reported. Only two similar cases have been described in the medical literature. This case illustrates that medical treatment with mebendazole is ineffective.