The pattern of failure after Stereotactic Radiation Therapy (SRT) for oligo-metastases: predictive factors for poly-progression.

PURPOSE: Patients with oligo-metastatic disease (OMD) can be safely treated with Stereotactic Radiation Therapy (SRT). Further disease progression is common in these patients. In most cases, patients relapse again with oligo-metastases, however some can experience a poly-progression after a local ablative treatment (LAT). The purpose of this study was to retrospectively identify factors associated with poly-progression in patients receiving SRT for OMD. METHODS: Data from a monocentric database were retrospectively analyzed. Patients treated with SRT for OMD and who developed progression after LAT were selected. Patients were categorized as oligo- or poly-progressive according to the number of new/progressing metastases (≤ or > 5). Herein, we analyzed data about patients' characteristics, oligo-metastatic presentation and radiation treatment characteristics to evaluate their relationship with progression type. RESULTS: From 2013 to 2021, data on 700 patients progressing after LAT were analyzed. Among them, 227 patients (32.4%) experienced a poly-progression; the median time to poly-progression was 7.72 months (range 1-79.6). Five variables associated with poly-progression were found to be statistically significant in the univariate analysis: performance status (p < 0.001), site of the primary tumor (p = 0.016), ablative dose (p = 0.002), treated site (p = 0.002), single or double organ (p = 0.03). Of those, all but the number of involved organs retained their significant predictive value on the multivariate analysis. CONCLUSION: Our study identified four independent factors associated with poly-progression in patients with OMD receiving SRT. Our data may support comprehensive characterization of OMD, better understanding of factors associated with progression.

Risk factors for cefepime nonsusceptible Gram-negative infections in allogeneic hematopoietic cell transplant recipients.

PURPOSE: Allogeneic hematopoietic cell transplant recipients undergo myelosuppressive chemotherapy to allow engraftment of stem cells and are at particularly high risk for bacterial infections and adverse outcomes. Patients undergoing hematopoietic cell transplant are at increased risk for healthcare-associated infections, including infections with multidrug-resistant pathogens. Cefepime is a commonly prescribed antibiotic for empiric therapy in hematopoietic cell transplant patients, but there is minimal data describing cefepime resistance rates, risk factors for resistance, and clinical outcomes associated with cefepime-resistant infections. METHODS: Adult (≥18 years old) allogeneic hematopoietic cell transplant recipients with a culture positive for a gram-negative rod between January 2010 and January 2016 were spilt into two groups: cefepime susceptible and cefepime nonsusceptible . The primary objective of this study was to identify risk factors for cefepime nonsusceptible through multivariable logistic regression. RESULTS: A total of 107 patients were included (27 cefepime nonsusceptible, 80 cefepime-susceptible), yielding a 25.2% nonsusceptibility rate. Multivariable analysis yielded age >60 years old, Klebsiella spp. infection, Acinetobacter spp. infection, healthcare exposures within 90 days, acute gastrointestinal graft-vs-host-disease, and chronic graft-vs-host-disease at multiple locations as significant risk factors for cefepime nonsusceptible. The receiver operating characteristic area under the curve of the model was 0.851. Thirty-day all-cause mortality (29.6% versus 16.3%, p = 0.13) and length of hospitalization (19 versus 12.5 days, p = 0.0650) were numerically higher in the cefepime nonsusceptible group. CONCLUSIONS: Hematopoietic cell transplant patients with acute gastrointestinal graft versus host disease, extensive chronic graft-vs-host-disease, advanced age, previous healthcare exposures, or infections with Klebsiella and Acinetobacter are at increased risk for cefepime nonsusceptible. Patients infected with cefepime nonsusceptible pathogens may have higher rates of mortality and length of hospitalization.

Risk factors for recurrent Clostridium difficile infection in hematopoietic stem cell transplant recipients.

BACKGROUND: Recurrent Clostridium difficile infection (CDI) represents a significant burden on the healthcare system and is associated with poor outcomes in hematopoietic stem cell transplant (HSCT) patients. Data are limited evaluating recurrence rates and risk factors for recurrence in HSCT patients. METHODS: HSCT patients who developed CDI between January 2010 and December 2012 were divided into 2 groups: non-recurrent CDI (nrCDI) and recurrent CDI (rCDI). Risk factors for rCDI were compared between groups. Rate of recurrence in HSCT patients was compared to that in other hospitalized patients. RESULTS: CDI was diagnosed in 95 of 711 HSCT patients (22 rCDI and 73 nrCDI). Recurrence rates were similar in HSCT patients compared with other hospitalized patients (23.2% vs. 22.9%, P > 0.99). Patients in the rCDI group developed the index case of CDI significantly earlier than the nrCDI group (3.5 days vs. 7.0 days after transplant, P = 0.05). On univariate analysis, patients with rCDI were more likely to have prior history of CDI and neutropenia at the time of the index CDI case. Neutropenia at the time of the index CDI case was the only independent predictor of rCDI (78.8 vs. 34.8%, P = 0.006) on multivariate analysis. CONCLUSIONS: The rate of rCDI was similar between HSCT and other hospitalized patients, and the majority of patients developed the index case of CDI within a week of transplantation. Neutropenia at the index CDI case may be associated with increased rates of rCDI.

Frontal cortical perfusion abnormalities related to gluten intake and associated autoimmune disease in adult coeliac disease: 99mTc-ECD brain SPECT study.

OBJECTIVE: Since brain perfusion abnormalities have been described by single-photon emission computed tomography in some autoimmune diseases, the aim of the present study was to evaluate the incidence of perfusion abnormalities by brain single-photon emission computed tomography in a group of coeliac disease patients, and to investigate whether gluten intake and associated autoimmune diseases may be considered risk factors in causing cerebral impairment. METHODS: Thirty-four adult coeliac patients (16 on a gluten-free diet and 18 on a gluten-containing diet, 18 (53%) with autoimmune diseases) underwent 99mTc-ethyl cysteinate dimer brain single-photon emission computed tomography and qualitative evaluation of brain perfusion was performed together with a semiquantitative estimation using the asymmetry index. Ten subjects on our database, matched for sex, age and ethnic group, who were proved normal by histology ofjejunal mucosa (four males and six females; median age 39 years, range 27-55 years), were included as control group. RESULTS: Twenty-four out of 34 patients (71%) showed brain single-photon emission computed tomography abnormalities confirmed by abnormal regional asymmetry index (>5%; range 5.8-18.5%). Topographic comparison of the brain areas showed that the more significant abnormalities were localised in frontal regions, and were significantly different from controls only in coeliac disease patients on unrestricted diet. The prevalence of single-photon emission computed tomography abnormalities was similar in coeliac disease patients with (74%) and without (69%) associated autoimmune disease. CONCLUSIONS: Abnormalities of brain perfusion seem common in coeliac disease. This phenomenon is similar to that previously described in other autoimmune diseases, but does not appear to be related to associated autoimmunity and, at least in the frontal region, may be improved by a gluten-free diet.

Case control study on health-related quality of life in adult coeliac disease.

AIMS: To evaluate whether health-related quality of life in adult coeliac disease is related to: 1) adhesion to gluten-free diet; 2) manifestation of clinical features; and 3) associated diseases. PATIENTS AND METHODS: A total of 68 coeliac patients (54 female and 14 male) aged between 18 and 74 years, on gluten-free diet for at least two years were studied. The subjective health status was measured by means of the Short Form 36 Health Survey. A series of 136 subjects, matched according to sex, age and ethnic group, were evaluated as control group. RESULTS: Patients obtained worse scores with respect to healthy controls at all domains of Short Form 36 Health Survey (p<0.05); compliers showed better results than non-compliers. The lowest scores were obtained in patients with more than six symptoms, mostly in non-compliers, the highest in compliers with less than six symptoms. Patients with two or more associated diseases presented significantly worse scores than patients with only one associated disease. CONCLUSIONS: The importance of gluten-free diet in clinical management of coeliac disease is confirmed by results of the present study; moreover, the results seem to indicate that a complex interplay of factors should be taken into account in evaluating health-related quality of life in adult coeliac disease. Accordingly, our data show that health-related quality of life of coeliac patients is impaired not only by poor compliance but also by different negative factors such as severity of illness (in terms of number of symptoms) at diagnosis and comorbidity.

Transesophageal Doppler ultrasonography evaluation of hemodynamic changes during videolaparoscopic cholecystectomy.

BACKGROUND: The aim of this study was to assess the changes of hemodynamic and oxyphoretic parameters induced by pneumoperitoneum in a series of patients undergoing laparoscopic cholecystectomy, by using the transesophageal Doppler ultrasonography (TEDU). DESIGN: prospective study. SETTING: a medico-surgical intensive care unit of an University Hospital. PATIENTS: 11 patients who underwent laparoscopic cholecystectomy because of gallbladder stones. INTERVENTIONS: a central venous line, a radial artery line were placed before the induction of anesthesia. End expiratory CO2 (EtCO2) was monitored by using a capnometer (Dräger, Germany). Cardiac output (CO) was measured using the transesophageal Doppler system Abbott ODM II (Abbott Critical Care Systems, Ireland), which was positioned in the esophagus after stabilization of anesthesia. MEASUREMENTS: hemodynamic parameters, including CO, central venous pressure, mean arterial pressure, measurement of EtCO2 and arterial and central venous samples were performed: after reaching a stable anesthesia but before any surgical manipulation (T0); after induction of pneumoperitoneum (T1); 15 min after T1 (T2); 30 min after T1 (T3). RESULTS: SVR increased significantly at T1 and T2 compared to T0; PaCO2 and PvCO2 at T2 and T3. HR and MAP increased significantly at T1, and CVP significantly at all the times. CONCLUSIONS: Laparoscopic surgery is a mini-invasive technique of increasing success among both surgeons and patients. The widening of candidate patients raises the question of eligibility for individuals with known cardiopulmonary disease. In these patients, only a careful and thorough anesthesiologic monitoring allows the prompt identification and treatment of any relevant hemodynamic and/or ventilatory changes.

Nutritional assessment in head injured patients through the study of rapid turnover visceral proteins.

BACKGROUND & AIMS: Nutritional monitoring of rapid turnover visceral protein is important in the recognition of malnutrition in patients admitted to the Intensive Care Unit (ICU). We studied prealbumin and retinol-binding protein in patients who received three different kinds of artificial nutrition in order to evaluate the appropriateness of artificial nutrition. METHODS: 45 consecutive head injury patients received enteral (Group A), parenteral (Group B) or both enteral and parenteral nutrition (Group C) at random. We considered these parameters: prealbumin, retinol binding protein and nitrogen balance before (T1), after 3 (T2), 7 (T3) and 11 (T4) days after the beginning of study. Statistical analysis was performed with Kruskal-Wallis test and Bonferroni's t -test. RESULTS: Plasma prealbumin and Retinol binding protein (RBP) showed an increasing of basal values during the study period in all groups (<< 0.0001) and more significantly in group A (Enteral nutrition P < 0. 001 vs Total parenteral nutrition (TPN) and Enteral P<< 0.01 vs Enteral and parenteral nutrition). CONCLUSION: Data obtained in the present study indicate that a laboratory is essential for monitoring nutritional assessment and for checking the appropriateness of nutritional therapy. We found prealbumin to be the most sensitive measure and found it to be the test of choice for early assessment and intervention.

Institutionalized older adults' perceptions of nurse caring behaviors. A pilot study.

The purpose of this article is to identify which behaviors performed by nursing staff were important indicators of caring as perceived by older adults residing in institutional settings. Using Watson's Theory of Transpersonal Care as the framework for the study, the Caring Behavior Assessment (CBA) instrument, which is congruent with Watson's carative factors, was used to interview residents. A convenience sample of 21 residents residing in long-term care and assisted-living facilities answered the 63-item CBA. Descriptive statistics were used to analyze the importance of each identified behavior. The analyses revealed that the highest indicator of nurse caring focused on the nurses' technical competency (instrumental activities). This study noted a significant gender-specific perception of caring. This may reflect differences in gender communication styles and interpersonal processes which may affect connotations of caring expressions. Humanistic caring (expressive activities) was the second most important indicator of care. Older adults desired care which preserved and enhanced individual dignity.

Recurrent external ophthalmoparesis during hormonal therapy after thyroid ablation. Case report.

We here report the case of a patient who had undergone total thyroid ablation for Graves' disease. After the beginning of oral therapy with 1-thyroxine, she developed a left external ophthalmoparesis that remitted with the discontinuation of the drug and recurred whenever the replacement therapy (1-thyroxine or tri-iodothyronine) was reintroduced.

Testicular germ cell tumors and human immunodeficiency virus infection: a report of 26 cases. Italian Cooperative Group on AIDS and Tumors.

PURPOSE: Besides tumors that are diagnostic of AIDS, such as non-Hodgkin's lymphoma, Kaposi's sarcoma, and invasive carcinoma of the cervix, other tumors have been described in the human immunodeficiency virus (HIV) setting. Some case reports on testicular cancer in HIV-infected patients have appeared in the literature. We present a retrospective study on 26 cases of testicular germ cell tumors (TGCTs) observed within the Italian Cooperative Group on AIDS and Tumors (GICAT) between November 1986 and September 1994. PATIENTS AND METHODS: Twenty-six patients with TGCT and HIV-infection from the GICAT were retrospectively analyzed. RESULTS: Fourteen patients had seminoma and 12 had nonseminoma. Four patients underwent only orchidectomy, one patient received only chemotherapy, nine patients were treated with postsurgical chemotherapy, 10 patients (38%) received postsurgical radiotherapy, one patient received postsurgical chemotherapy plus radiotherapy, and one patient was lost for follow-up evaluation immediately after diagnosis. The complete response (CR) rate was 95%. Relapse occurred in 32% of patients. The median follow-up time was 33 months. The mortality rate was 37%. Causes of death were neoplasia in three of nine patients, AIDS in five of nine patients, and fortuitous event in one of nine patients. The overall 3-year survival rate was 65%, and the 3-year disease-free survival rate was 65%. Severe hematologic toxicity was observed in seven of 15 patients. CONCLUSION: HIV-infected patients with testicular cancer should be offered standard oncologic therapy, irrespective of their HIV status, since the majority can be cured of their tumor and have a good quality of life. Use of concomitant prophylaxis for opportunistic infections is recommended.

[Idiopathic cupulolithiasis: vasomotor reactivity evaluation of the vertebro-basilar artery by transcranial doppler ultrasonography and acetazolamide test]. / La cupulolitiasi idiopatica: studio della reattività vasomotoria del circolo vertebro-basilare con sonografia Doppler transcranica e test all'acetazolamide.

Benign paroxysmal positional vertigo (BPPV) or cupulolithiasis is one of the more common peripheral vestibular disorders. Diagnosis is made on the observation of typical positioning nystagmus brought about by the Hallpike manoeuver. In most cases of BPPV, etiology is unknown. Microcirculatory disorders have often been considered responsible for idiopathic BPPV. Few reports have been published on this specific aspect of the problem. In our study we evaluated vertebro-basilar haemodynamics and vasomotory reactivity after Acetazolamide administration in 12 patients with idiopathic BPPV. The results obtained reveal the absence of macrocirculatory impairment in the vertebro-basilar district in basal conditions, but significative vasoreactivity variation after acetazolamide, both in vertebral and basilar arteries. Poor vasomotor reactivity in one vertebral artery was observed in 5 patients and, in two cases, in the basilar artery. Altered vasoreactivity in the middle cerebral arteries was not observed in any case. In the light of these findings, we suggest that a possible inadequate response if microcirculation in the labyrinth, in some particular haemodynamic situations, might cause otolithic damage.

[Solid tumors associated with HIV infection]. / Tumori solidi in associazione all'infezione da HIV.

Between December 1986 and December 1991, the Italian Cooperative Group on AIDS-related tumours documented 94 HIV related solid tumours. Of 21 germinal testicular tumours collected, ten were seminomas. Cervical carcinoma was observed observed in 28 IVDAs (intraepithelial in 8 and advanced, with rapid progression, in one). Lung cancer associated with HIV infection was reported in 14 patients. Also reported were two cases of colorectal carcinoma, one anorectal carcinoma, one pancreatic carcinoma, one carcinoid, one oral carcinoma. Of the central nervous system tumours, were diagnosed 3 cases of glioblastomas, one medulloblastoma and one meningioma. This retrospective study shows that while oral and anorectal tumours were very rarely observed, a wide spectrum of other HIV-related solid tumours were found in this series. The required therapeutic approaches may not necessarily be influenced by the HIV infection, in contrast with the observed pattern for treatment of EKS and lymphomas in HIV infected subjects.

Association of large granular lymphocyte/natural killer cell proliferative disease and second hematologic malignancy.

We describe the first three patients with a large granular lymphocytosis/lymphocytic leukemia and another blood malignancy. In two, a myeloproliferative disorder developed soon after the diagnosis of abnormal proliferation of large granular lymphocytes-natural killer (LGL-NK) cells, a myelodysplastic syndrome evolving to acute leukemia and a Philadelphia-positive chronic myelogenous leukemia. In these cases, LGLs expressed the phenotype of CD3+ NK and CD3- NK cells, respectively, and were clonal in the first patient as demonstrated by T-cell receptor gene rearrangement study. In the third case, a similarly clonal excess of LGLs, phenotypically CD3+ NK cells, was detected following a diagnosis of B-cell hairy-cell leukemia. Clinically, the concurrence of LGL proliferation and other leukemia did not seem to confer a worse prognosis on the patients. Although an association by chance remains a possible explanation, a common origin from an altered precursor cell for both myeloid and LGL proliferations in the first two cases is discussed, whereas in the third it might be related to the severe immune derangement frequently observed in hairy-cell leukemia.

Therapeutic efficacy of danazol in myelodysplastic syndromes.

Sixteen unselected untreated patients with primary myelodysplastic syndromes (MDS) and various combinations of blood cytopenia were treated with danazol, an attenuated androgen reported to be of some value in these conditions. After a 12 week trial (danazol 600 mg/day/p.o.), anaemia improved in 4/14 patients, with transfusional requirements being reduced by 50% or more in four other cases (response 57%). An enhanced reticulocyte production was documented in 6/13 cases (46%), and thrombocytopenia resolved in 5/8 (62%). Results of the granulocyte count were less satisfactory, with only one partial response obtained among five cases. A normalization of the monocyte count was seen in 3/5 patients with chronic myelomonocytic leukaemia, with one of them achieving a complete haematological and clinical remission lasting 6 months. Circulating blast cells decreased significantly (50% or more) in 4/6 cases. Although clinical symptoms from anaemia and bleeding disappeared in responsive cases, four patients developed acute non-lymphocytic leukaemia. Danazol was well tolerated and produced no acute or chronic toxicity. The drug appears useful in the management of anaemic and thrombocytopenic MDS patients.

Investigation of chronic lymphocytosis in adults.

Thirteen cases of idiopathic chronic lymphocytosis are the subject of this report. Patients showed a lymphocyte count between 4 and 15 X 10(9)/L for at least six months, marrow lymphocytosis not exceeding 25%, absence of lymphomegaly and hepatosplenomegaly, and no associated infections, immune, or neoplastic disease. Morphologic examination of smears revealed a lymphocytosis of large granular lymphocytes in five. A selected battery of polyclonal and monoclonal antisera to antigens commonly found on B-, T-, and natural killer cells allowed the identification of six cases of early B-cell chronic lymphocytic leukemia, two cases of T-cell lymphocytosis with a suppressor or helper T-cell phenotype, and five cases of large granular lymphocyte/natural killer cell proliferative disease. The results demonstrate the usefulness of combining morphologic and phenotype studies for the investigation of chronic lymphocytosis, which often appears as an early leukemia or a benign clonal proliferative disorder of lymphocyte subsets.

Elevated prostaglandins and suppressed parathyroid hormone associated with hypercalcemia and renal cell carcinoma.

A patient with renal cell carcinoma and hypercalcemia was found to have suppressed serum parathyroid hormone levels but striking elevations of immunoreactive prostaglandins in plasma and metastatic tissue. It was hypothesized that prostaglandins may have either played a role in the hypercalcemia or were part of a counterregulatory event.