Sarcopenic obesity derived from PET/CT predicts mortality in lymphoma patients undergoing hematopoietic stem cell transplantation.

BACKGROUND: Sarcopenic Obesity (SO) is associated with worse survival among chemotherapy recipients. Research on SO is scarce among lymphoma patients receiving Hematopoietic Stem Cell Transplantation (HSCT). AIM: assess prevalence of SO pre-HSCT (T0) and 3 months post-HSCT (T1) in lymphoma patients and determine the power of SO at T0 and T1 in predicting survival. METHODS: Consecutive patients (age ≥16 years) having B and T cell lymphoma who underwent SCT and who had PET/CT scan pre-SCT and 3 months post SCT were included in the study. A cross sectional image was analyzed at the level of the 3rd Lumber Vertebrae to assess body composition parameters. RESULTS: 93 patients [mean age: 38 (range: 17-70 years), 52 (55.9%) males, 45 (48%) Hodgkin and 48 (52%) Non-Hodgkin lymphoma, 81 (87%) autologous and 12 (13%) allogeneic SCT)] met the inclusion criteria. From T0 to T1, Sarcopenia rates increased (27% at T0 to 38% at T1, p = 0.013), Visceral adiposity decreased (46% at T0 to 30% at T1, p = 0.03) and SO decreased (42% at T0 to 20% at T1, p < 0.01). Length of stay, overall survival and progression free survival were significantly better in patients without sarcopenic obesity at T1. Cox-regression revealed SO at T1 was a risk factor for mortality [Adjusted Hazards Ratio = 8.2 (95% Confidence Interval: 1.9-36.2)]. CONCLUSION: Sarcopenic obesity, prevalent in 42% of patients pre-HSCT, decreased 3 months post HSCT as lymphoma patients lost skeletal muscle and visceral adipose tissues. SO at T1 was the most impactful risk factor for mortality.

Vocal fold paralysis in preterm infants: prevalence and analysis of risk factors.

OBJECTIVE: To calculate the prevalence of vocal fold paralysis (VFP) in preterm (<37 weeks of gestation) infants at a single neonatal intensive care unit (NICU) and identify risk factors for the development of VFP. STUDY DESIGN: This is a case control study of all surviving preterm infants admitted to the NICU at Children's Hospital of Wisconsin from 2006 to 2012, comparing those with and without VFP. Multivariate analysis was performed to identify significant risk factors for VFP. RESULTS: Of the 2083 patients included, 73 (3.5%) had VFP, including 18% of those at <26 weeks of gestation. On multivariate analyses, VFP was associated with patent ductus arteriosus (PDA) ligation (P<0.001, odds ratio (OR) 15.9, 95% confidence interval (CI) 8.9 to 28.1), history of invasive ventilation (P=0.008, OR 4.5, 95% CI 1.5 to 13.6) and black vs non-black race (P=0.001, OR 2.5, 95% CI 1.5 to 4.3). CONCLUSION: Given the prevalence of VFP and its associated morbidity, efforts to decrease PDA ligation and invasive ventilation in preterm infants are warranted.

Role of cyclins D1 and D3 in vestibular schwannoma.

BACKGROUND: Vestibular schwannomas in younger patients have been observed to be larger in size and grow more quickly. OBJECTIVE: This study aimed to evaluate the expression of three important cell cycle proteins, cyclin D1, cyclin D3 and Ki-67, in vestibular schwannoma patients separated into two age groups: ≤ 40 years or > 40 years. METHOD: Immunohistochemical detection of cyclin D1, cyclin D3 and Ki-67 was undertaken in 180 surgically resected vestibular schwannomas. RESULTS: The proliferation index of vestibular schwannomas was statistically higher in the ≤ 40 years age group compared to that in the > 40 years age group (mean of 4.52 vs 3.27, respectively; p = 0.01). Overexpression of cyclin D1 and cyclin D3 was found in 68 per cent and 44 per cent of tumours, respectively. CONCLUSION: There was an increased Ki-67 proliferation index in the younger age group that appears to correlate with clinical behaviour. Vestibular schwannomas in both age groups show increased expression of cyclin D1 and cyclin D3.

Flow-mediated dilation benefits of mesoglycan in peripheral artery disease.

AIM: Mesoglycan, composed of natural glycosaminoglycans, is used for treatment in arterial and venous disease for its benefits on endothelial glicocalix. Little is known about mesoglycan impact on endothelial blood flow regulation. We sought to evaluate the effects of mesoglycan intermittently added to back-ground treatments on impairment of endothelial function in peripheral arterial disease (PAD) patients. METHODS: We studied the effects of a 2+2 months oral treatment with 50 mg b.i.d. of mesoglycan, intervalled by 2 months without mesoglycan, in 540 PAD patients on four occasions (visit 1: baseline, visit 2: 2 months, visit 3: 4 months and visit 4: 6 months). At these time visits we assessed brachial artery endothelial-dependent flow-mediated dilation (FMD), together with femoral intima-medial thickness (IMT), and walking distance (WD). RESULTS: There were significant changes in FMD (1.88%, CI 95%: 1.13, 2.63; P<0.001), IMT (-0.05 mm, CI 95%: -0.07,-0.02; P<0.001) and WD (38,9%, CI 95% 33.2, 44.8; P<0.001). The positive effects and benefit were maintained during the two-months interval without mesoglycan treatment. Significant changes in FMD were observed in a number of patient groups, stratified for risk factors (aging, sex, smoke, diabetes, dyslipidemia, hypertension). CONCLUSION: Two months cycles with mesoglycan improved endothelial function in PAD patients, with a parallel reduction of atherosclerotic damage and amelioration of clinical condition.

Laryngeal sensory neuropathy in patients with diabetes mellitus.

OBJECTIVE: To determine the prevalence of laryngeal sensory neuropathy in patients with type 2 diabetes mellitus. METHODS: A cross-sectional study was performed, comprising 50 patients diagnosed with type 2 diabetes mellitus and 36 healthy controls. In the diabetic group, glycaemic control level, disease duration and presence of neuropathy were assessed. Participants were diagnosed with laryngeal sensory neuropathy if they had a cough, globus pharyngeus or throat clearing lasting for more than six weeks, in the absence of laryngopharyngeal reflux disease, allergies, asthma, angiotensin-converting enzyme inhibitor intake or psychogenic disorders. RESULTS: In the diabetic group, the mean age ± standard deviation was 44.66 ± 10.07 years. Sixty per cent of patients were male, 42 per cent had had diabetes for more than five years and 52 per cent had average to poor glycaemic control. The prevalence of laryngeal sensory neuropathy was 42 per cent in the diabetic group, compared with 13.9 per cent in controls; this difference was statistically significant (p = 0.005). There was no association between the prevalence of laryngeal sensory neuropathy and glycaemic control level, disease duration or presence of neuropathy. CONCLUSION: Laryngeal sensory neuropathy is more common in patients with type 2 diabetes mellitus than in controls.

CEA versus CAS: short-term and mid-term results.

AIM: Ischemic stroke represents a major health problem and it is an important cause of long-term disability. The aim of this study was to compare short-term and mid-term results of carotid endarterectomy and stenting. METHODS: During a three-year period, we enrolled 300 patients with carotid stenosis that fit with Stroke Prevention and Educational Awareness Diffusion (SPREAD) guidelines and we performed 150 carotid endarterectomy operations (CEA) and 150 carotid artery stenting procedures (CAS) with distal protection devices. All patients underwent preoperative and postoperative: neurological examination, ultrasound imaging, magnetic resonance imaging (MRI) and cognitive tests; moreover all patients were submitted to preoperative, intraoperative and postoperative Transcranial Doppler (TCD) monitoring, in order to detect microembolic signals (MES). RESULTS: Mortality was zero; two patients developed myocardial infarction in the CEA group during follow-up. The main post-operative results after endarterectomy versus CAS were respectively: neurological deficit: 1.3% vs. 3.3%, embolic lesions at postoperative MRI: 4% vs. 34% and worsening of cognitive tests: 4% vs. 25.3%. CONCLUSION: CEA seems to be the treatment of choice for carotid stenosis, due to its low rate of mortality and morbidity, especially in asymptomatic patients; CAS should be carried out only in particular subgroup of cases, such as: restenosis, previous neck surgery or radian therapy, anatomical high bifurcation or extended lesions. Ongoing multicenter randomized trials may give a definitive answer to this matter.

Metastatic Crohn's disease: a review.

Metastatic Crohn's disease (MCD) indicates the presence of non-caseating granuloma of the skin at sites separated from the gastrointestinal tract by normal tissue and is the least common dermatologic manifestation of CD. In adults, MCD usually appears after the initial diagnosis of CD in 70% of cases, whereas in children, it appears at the same time as CD in almost half of the cases. The most frequent skin lesions in adults are nodules, plaques with or without ulceration on the extremities and ulcers on the genitals. In children, genital swelling with or without erythema is the most frequent presentation of MCD. Simultaneous presence of perianal CD affects more females (60%) and particularly children. Associated gastrointestinal symptoms are present in one third of the cases in adults and in half of the cases in children. Treatment is often unsatisfactory. Randomised controlled trials are lacking. Various chemotherapeutic agents have been used such as oral metronidazole, topical and/or oral steroids, azathioprine, cyclosporine, sulfasalazine, tetracyclines, topical or systemic tacrolimus, infliximab alone or with methotrexate, and surgical treatment with oral zinc sulphate. MCD represents another 'great imitator'. This reviews the most relevant characteristics of this disease, in order to increase awareness and to avoid delay in diagnosis and improve management of the whole CD complex.

Factors associated with persistent risk of depression in older people following discharge from an acute cardiac unit.

BACKGROUND: This longitudinal study aims to describe the prevalence and characteristics associated with persistent risk of depression in a group of older, hospitalized patients. METHODS: We examined patients at two time-points: baseline and one month post-discharge from hospital. Patients in this study comprised those who had been admitted to the cardiology unit, with no cognitive impairment, aged 60 years and over, and those who were followed up at both time points (N = 155). Questionnaires administered included risk of depression (Geriatric Depression Scale-15; GDS-15), cognitive impairment (Mini-mental State Examination), social support (7-Item Subjective Social Support Index), co-morbidity (Charlson's Comorbidity Index), sociodemographic variables, physical functioning (Modified Barthel's Index) and clinical variables. RESULTS: The prevalence of risk of depression (GDS-15 score > or = 5) among older inpatients at baseline was 34%. At one month post-discharge this had fallen to 17% and this group was identified as those at persistent risk of depression. Factors associated with a risk of persistent depression were: hospitalization within the last six months; length of stay of four days or more; discharge diagnosis of angina; and impaired Subjective Social Support Score. CONCLUSION: Depression occurs commonly among older hospitalized patients and may resolve spontaneously. The identification of factors associated with persistent risk of depression can be helpful when looking at which patients may benefit most from screening and treatment for depression after discharge.

Classic and endovascular surgical management of isolated iliac artery aneurysms.

AIM: Isolated iliac artery aneurysm is a rare pathology that is often asymptomatic for long periods; this late diagnosis exposes patients to a high risk of death following aneurysm rupture. The aim of this study was to establish the most suitable diagnostic approach, the correct indications for treatment, and the most appropriate tactics and surgical technique. METHODS: Twenty-eight patients were observed over 13 years. Aneurysmal involvement was unilateral in 22 cases and bilateral in the remaining 6 patients. Preoperative diagnostic tests included eco-colour Doppler (ECD) and angio-CT in all cases, with angio-MR and angiography as more selective procedures. Seventeen patients underwent conventional open surgery with prosthetic replacement of the aneurysmatic tract, 7 patients were treated using endovascular exclusion, and lastly 4 were monitored over time. RESULTS: There was no perioperative mortality for either treatment. During the postoperative period following conventional open surgery, complications included one case of severe respiratory failure, one microembolism of the lower limb, and 2 periprosthetic hematoma. During the follow-up, we observed one pseudo-aneurysm, 3 cases of retrograde ejaculation and one patient with erectile dysfunction after traditional surgery; there was one minor endoleak after endovascular exclusion. CONCLUSIONS: Our experience suggests that ECD is a useful method for arriving at an early diagnosis, while angio-CT imaging is essential for a correct preoperative study. Aneurysms with a diameter equal or greater than 3 cm or that present annual increases in excess of 5 mm represent a correct indication for treatment. Conventional open surgery is the treatment of choice for young patients in good general conditions. Endovascular exclusion is indicated when the patient's clinical conditions contraindicate open surgery and the morphology of the aneurysmal arterial district allows the endoprosthesis to be safely implanted.

Occult carcinoma of the lung presenting as pain in the hallux: a case report.

Metastatic tumors to the hands and feet (acrometastases) are rare. We report a case in which the primary presentation of a lung carcinoma was a metastatic lesion to the distal phalanx of the hallux. A 60-year-old woman was evaluated for pain in her big toe. Radiographs and computed tomography suggested a benign lesion in the distal phalanx of the hallux, but curettage and biopsy revealed metastatic adenocarcinoma. A chest x-ray revealed a mass in the right perihilar region, which was confirmed by CT, bronchoscopy, and biopsy as carcinoma of the lung. A review of the literature reveals that there is a tendency toward delayed diagnosis in similar cases, especially when the primary lesion is asymptomatic. A high index of suspicion is needed for early diagnosis in such cases.

The reliability of lymph-node staging in rectal cancer after preoperative chemoradiotherapy.

AIMS: To determine the prognostic significance of the nodal stage and number of nodes recovered in the surgical specimen after preoperative synchronous chemoradiation (SCRT) and surgery for locally advanced or unresectable rectal cancer. MATERIALS AND METHODS: One hundred and eighty-two consecutive patients with locally advanced or unresectable (T3/T4) rectal carcinomas were entered on a prospective database and treated in this department with preoperative chemoradiation, followed 6-12 weeks later by surgical resection. Most patients received chemotherapy in the form of low-dose folinic acid and 5-fluorouracil (5-FU) 350 mg/m2 via a 60-min infusion on days 1-5 and 29-33 of a course of pelvic radiotherapy delivered at a dose of 45 Gy in 25 fractions over 33 days to a planned volume. After resection, patients with a positive circumferential margin (< or = 1 mm), extranodal deposits or Dukes' C histology received adjuvant 5-FU-based-chemotherapy (n = 40). RESULTS: After SCRT, 161 patients underwent resection. Twenty-one patients remained unresectable or refused an exenterative operation. Median follow-up is 36 months. Down-staging was achieved in most patients, with 19 having a complete pathological response (pT0). The median number of lymph nodes recovered for all patients was five (range 0-21). The 3-year survival rate for node-positive patients is 47%, for node-negative patients with less than three lymph nodes recovered is 62% and for node-negative patients with three or more lymph nodes recovered is 70%. Compared with node-positive patients, simple regression models revealed a reduced hazard ratio (HR) of 0.72 (0.36-1.43) for node-negative patients with less than three nodes recovered and 0.48 (0.26-0.89) for node-negative patients with three or more lymph nodes recovered. In a multivariate model, including nodal status, excision status, age and sex only positive excision margins significantly predicted a poor outcome: HR = 3.05 (1.55-5.97). CONCLUSIONS: The number of nodes found after preoperative chemoradiation is a significant prognostic factor by univariate analysis. In this study, patients with node-negative histology, and at least three nodes recovered, had better long-term survival than patients in whom two or less nodes were recovered or with positive nodes. This effect was attenuated by the inclusion of excision status in multivariate models.

Long-term tolerability of sumatriptan nasal spray in adolescent patients with migraine.

OBJECTIVE: This 1-year, open-label, multicenter study was designed to assess the long-term tolerability and efficacy of sumatriptan nasal spray 20 mg in adolescent patients with migraine. METHODS: A prospective, multicenter, open-label study was conducted in patients aged 12 to 17 years who were allowed to treat an unlimited number of migraines at severe, moderate, or mild pain intensity with sumatriptan nasal spray for up to 1 year. All patients started the study at the 20-mg dose of sumatriptan nasal spray. Dose could be adjusted downward to 5 mg at the discretion of the investigator to optimize therapy. RESULTS: A total of 484 adolescent migraineurs treated 4676 migraines with sumatriptan nasal spray 20 mg (3593 during the first 6 months and 1083 during the second 6 months). A total of 3940 migraines and 699 migraines were treated with one and two 20-mg doses of sumatriptan nasal spray, respectively. Only 10 patients (treating 42 migraines) took the 5-mg dose of sumatriptan nasal spray. The overall percentage of migraines treated with either one 20-mg dose or one, two, or three 20-mg doses with at least 1 drug-related adverse event was 19%. The most common specific drug-related adverse event was unpleasant taste, reported in 17% of migraines. No other single drug-related adverse event was reported in more than 1% of migraines over the 1-year treatment period. When unpleasant taste was excluded from the adverse-event tabulations, the percentages of migraines with at least 1 drug-related adverse event after one or one, two, or three 20-mg doses declined to 4% and 3%, respectively. No patient experienced any drug-related changes in 12-lead ECGs, vital signs, or nasal assessments; and no clinically meaningful changes in clinical laboratory values were observed. Across all migraines with evaluable efficacy data (n=4334), headache relief was reported in 43% of migraines at 1 hour and in 59% at 2 hours after dosing with sumatriptan nasal spray 20 mg. Of the 2561 migraines with headache relief 2 hours postdose, headache recurrence was reported within 24 hours of initial dosing in 7% of migraines. None of the efficacy or tolerability results varied as a function of time in the study (ie, first 6 months vs. second 6 months). CONCLUSION: Sumatriptan nasal spray 20 mg is generally well tolerated and may be beneficial during long-term use by adolescent migraineurs ages 12 to 17 years.

Epididymal metastasis from carcinoma of the prostate.

Epididymal Metastasis from a primary carcinoma of the prostate gland is a rare but recognised phenomena. We describe a case of such metastasis which, unlike previous reports, presents as a painful epididymal mass. Therefore it is important for urologists to consider epididymal metastasis as part of the differential diagnosis in a patient with known carcinoma of the prostate and a tender epididymal mass.

Pharmacokinetics of sumatriptan nasal spray in children.

The authors studied the pharmacokinetics of sumatriptan nasal spray after a single dose in children migraineurs outside of migraine attack. Seventeen subjects (9 females) ages 6 to 11 years were given one dose of sumatriptan nasal spray based on age and weight; children 6 to 8 years of age weighing 25 kg and children ages 9 to 11 years of age weighing 40 kg received 20 mg (n = 4). Plasma sumatriptan concentrations were determined in serial blood samples obtained over 8 hours. Pharmacokinetic analysis included both noncompartmental and population modeling methods. The pharmacokinetic parameter estimates (geometric mean [95% confidence interval]) following 5, 10, and 20 mg sumatriptan were, respectively, as follows: maximum concentration = 8.1 ng/mL (3.6-18.4), 10.8 ng/mL (7.7-15.4), and 12.3 ng/mL (7.6-19.9); half-life = 1.4 hours (1.2-1.8), 1.7 hours (1.4-2.0), and 1.7 hours (1.3-2.3); and AUC = 27.8 ng*h/mL (9.7-79.8), 42.4 ng*h/mL (30.6-58.8), and 49.2 ng*h/mL (32.9-73.7). The median time to maximum concentration for all groups was 2 hours. Population pharmacokinetic modeling included pooled data from this study and from an adolescent study (n = 16). Clearance (CL/F) was 197 L/h for a 30-kg child with between-subject variability of 28%, and the volume of distribution was 751 L, normalized for an 11-year-old child with variability of 43%. The covariate analysis showed that volume increases with age and clearance increases with body size. The absorption was complex, often displaying double-peak plasma concentrations, with a rapid absorption phase and a delayed and rate-limited absorption phase. The dosing scheme based on age and weight resulted in maximal concentrations (C(max)) and systemic exposure (AUC) that were comparable to those observed in adolescents and adults treated with 20 mg. The age- and weight-adjusted dosing scheme appears to an appropriate initial dosing regimen for children with migraine headache. Appropriate safety and efficacy trials will need to be completed in children prior to recommending its use in children.

Pharmacokinetics of sumatriptan nasal spray in adolescents.

Sumatriptan is a potent and selective vascular 5-HT1 receptor agonist effective for the treatment of migraine. In adults, intranasal sumatriptan is well absorbed and tolerated. The authors evaluated the pharmacokinetics and tolerability of a single dose of 20 mg intranasal sumatriptan in healthy adolescent migraineurs ages 12 to 17 years, administered outside of migraine attack. Serum sumatriptan levels were measured by high-performance liquid chromatography (HPLC) with electrochemical detection in serial samples collected over 8 hours. Physical exam, vital signs, clinical laboratory tests, and electrocardiogram measurements were monitored to assess safety and tolerability. A total of 16 subjects (10 males and 6 females) had pharmacokinetic data that could be analyzed, 2 withdrew from the study 30 and 60 minutes after dosing following the loss of venous access for blood sampling, and a bioanalysis failure resulted in loss of data from 3 subjects. Noncompartmental pharmacokinetic parameters (geometric mean and 95% confidence interval) for the remaining 16 subjects were as follows: Cmax was 13.9 (11.0, 17.6) ng/mL, AUC infinity was 57.3 (47.6, 69.0) ng/mL.h, and t1/2 was 2.0 (1.8, 2.3) hours. Population pharmacokinetic analysis for all subjects (n = 21) showed that clearance and volume of distribution increase slightly with age and body size, but the changes were minimal and would not warrant dose adjustment: CL/F was 316 L (coefficient of variance [CV] = 25%) and Vd/F was 1070 L (CV = 46%). Sumatriptan was well tolerated with only minor adverse events reported, which all resolved spontaneously. The pharmacokinetic parameters in these adolescent subjects were similar to those previously reported in adults, suggesting that adolescents should be dosed similar to adults.

[Indications and short term results of subfascial endoscopic perforator surgery (SEPS)]. / Indicazioni e risultati preliminari dell'interruzione endoscopica sottofasciale delle vene perforanti (SEPS).

BACKGROUND: The aim of this study is to evaluate diagnostic methods, indications and surgical technique in SEPS procedure and to analyze short term results. METHODS: Eighteen patients affected by chronic venous insufficiency (CVI) have been analyzed. According to NAVS (North American Vascular Society) classification three patients were included in class 6 (C6), 3 (C5), 6 (C4), 2 (C3) and 4 (C2). From 2 to 5 selective subfascial endoscopic ligation of perforator veins, especially I and II Cockett perforator veins' were performed. In 7 cases, total stripping of the great (6) or less (1) saphenous vein was associated with SEPS procedure. After the operation, an elastic bandage of the lower limbs was performed and a medical treatment with LMVH was started. RESULTS: In 6 patients of the C2 and C3 groups, neither recurrence or pathological reflux were observed at clinical examination and at color duplex. In 12 patients of C4, C5 and C6 groups a reduction of the perimalleolar oedema was observed. In the last 3 patients, with leg ulceration, a resolution of the lesion in 2 cases, and a reduction in diameter in the last one, were observed. CONCLUSIONS: SEPS is particularly advised in those patients belonging to C5 and C6 groups, especially in presence of leg ulceration. This operations is suggested also in patients with CVI and incontinence of perforator veins detected by at color duplex. This diagnostic investigation seems to be adequate in the diagnosis of CVI and in the mapping of perforator veins of the leg.

A case of weak muscles.

BACKGROUND: Gut involvement in inflammatory myositis is rare but causes significant morbidity and mortality. CASE REPORT: A case of eosinophilic gastroenteritis and polymyositis occurring in the same patient is described. The interface of visceral and striated muscle involvement is discussed. The pathophysiology of eosinophilic gastroenteritis and the spectrum of gastrointestinal involvement in inflammatory myositis are also discussed. RESULTS: Both gastrointestinal and skeletal muscle symptoms improved with immunosuppression, suggesting a possible common underlying mechanism.