Effectiveness and safety of carotid endarterectomy under remifentanil.

AIM: The aim of this study was to evaluate the effectiveness and safety of carotid endarterectomy (CEA) with conscious sedation under remifentanil (Remifentanil anesthesia - RA) vs conventional loco-regional anesthesia (Conventional-LRA) in the current practice of a vascular surgery unit. METHODS: We introduced the ''Remifentanil-RA'' in our practice according to a two-step protocol. In the first step we performed a pilot prospective study to assess the procedure's safety and reproducibility in our setting on 60 consecutive patients with symptomatic and/or high-grade (>70%) internal carotid artery stenosis and alternately assigning them either to ''Remifentanil-RA'' or ''Conventional-LRA'' CEA. In the second step we analysed our routine operative records as to effectiveness and safety on 533 patients who consecutively underwent ''Remifentanil-RA'' CEA. We compared them with 533 age- and sex-matched historical controls who underwent ''Conventional-LRA'' CEA. RESULTS: The patients' mean age was 71.2+/-6.8 vs 71.8+/-6.1 (''Remifentanil-RA'' vs ''Conventional-LRA''). About 73% of them were male and 56% had a symptomatic carotid stenosis. Neither the pilot study nor second step comparison showed differences in outcome measures. We found only higher peri-operative nausea/ vomit (3.6% vs 0.4% ''Remifentanil-RA'' vs ''Conventional-LRA'', P<0.0002) and fewer re-operations for post-operative hematomas (3% vs 5.4% respectively, P=0.048). CONCLUSIONS: We found that ''Remifentanil-RA'' CEA was safe, effective and satisfactory. Nevertheless, with the potential problems of intubation and those already found with side effects, a randomized control trial (RCT) is needed in order to prove that this method is superior to ''Conventional-LRA'' CEA.

Use of dose-volume histograms and biophysical models to compare 2D and 3D irradiation techniques for non-small cell lung cancer.

For non-small cell lung cancer (NSCLC), unsatisfactory local control (LC) still remains an important cause of failure. It has been suggested that improved LC can be achieved with both higher radiation dosage and adequate target coverage. Modern three-dimensional treatment planning systems (3D-TPSs) offer many tools for planning optimization. Biophysical models, which estimate the normal tissue complication probability (NTCP), are gaining in importance in comparing plans. This study compares conventional two-dimensional (2D) with 3D irradiation techniques using parameters related to volumetric dose distribution and two different biophysical models predicting normal tissue tolerance to radiotherapy (RT). Nine patients with inoperable locally advanced NSCLC were treated with a beam's eye view-based 3D technique. For the same patients, a conventional treatment was simulated; the irradiation geometry and beam contour were fully defined at the simulator and then transferred to the 3D-TPS to calculate the dose distribution. Both techniques gave the same prescribed dose at the reference point. Dose-volume histograms (DVHs) and dose statistics of organs at risk (OARs) (heart, lung(s), parenchyma lung, spinal cord and oesophagus) were analysed. The probability of side effects was estimated using two different biophysical models: the integrated normal ("empirical") model and the relative seriality model. Apart from contralateral lung, the 3D irradiation technique significantly reduced the average mean doses to all OARs. The current analysis suggests that in the treatment of locally advanced NSCLC, the use of 3D irradiation techniques allows a large sparing of OARs; this advantage is confirmed by both dose statistics analysis and NTCP values.

Variations of tumor control and rectum complication probabilities due to random set-up errors during conformal radiation therapy of prostate cancer.

BACKGROUND AND PURPOSE: The effect of random set-up errors on tumor control probability (TCP) and rectum complication probability (NTCP) on 3D conformal treatment planning of prostate cancer has been investigated by applying the convolution method originally proposed by Leong (Leong, J. Implementation of random positioning error in computerized radiation treatment planning systems as a result of fractionation. Phys. Med. Biol. 32: 327-334, 1987). MATERIALS AND METHODS: The combined influence of the standard deviation of the random shifts probability distribution (sigma) of the dose and of the Beam's-eye-view margin (M) between the clinical target volume (CTV) and the edge of the blocks have been investigated in two patients. RESULTS AND CONCLUSIONS: Random set-up error has been found to decrease TCP (for a typical 70 Gy CTV mean dose) by up to 6% for a 1 cm margin (sigma = 7 mm). When M is equal to or larger than 1.5 cm, no relevant effects on TCP are obtained. Maximum acceptable TCP values (corresponding to a rectum NTCP equal to 5%) have been derived and the dependence on sigma and M has been investigated.

[Hematoma of the rectus abdominis as a complication of anticoagulant therapy with subcutaneously administered heparin calcium]. / Ematoma del muscolo retto addominale quale complicanza della terapia anticoagulante con eparina calcica s.c.

The use of anticoagulant therapy with subcutaneous heparin calcium has long become an established routine for both arterial and venous pathologies. However, albeit with a lower percentage than in intravenous anticoagulant therapy, it is not free from complications. The authors report their experience regarding two cases of hematoma of the rectus abdominis muscle that occurred after anticoagulant treatment with full dose subcutaneous heparin calcium in patients suffering from severe chronic obliterating arterial disease of the lower limbs. From a diagnostic point of view, in addition to the clinical examination of the patient, which often does not results in the decisive confirmation of diagnosis, ultrasound and computerized tomography are essential not only to confirm the suspected diagnosis but also to monitor the evolution of the hematoma over time. In both cases the hematoma resolved spontaneously following gradual resorption, although treatment, especially in cases in which the hematoma is not blocked by the suspension of anticoagulant therapy, may include surgical draining. In view of the frequency with which this treatment is used in arteriopathic or phlebopathic subjects, including elderly patients who may present concauses for the formation of a hematoma of the rectus abdominis muscle (connectivitis, chronic or acute renal insufficiency, hemodyscrasia in terms of hypocoagulation), the authors suggest that high-risk patients should be identified for the possible use of an alternative route of administration.

[Non-specific vaginitis and topical treatment. Comparison of flunoxaprofen and benzydamine]. / Vaginiti aspecifiche e trattamento topico. Confronto tra flunoxaprofene e benzidamina.

The efficacy and tolerability of a new NSAID-flunoxaprofen-have been evaluated in patients suffering from non specific vaginitis, by topical application for 20 days (vaginal washings with water solution of the preparation). The activity of flunoxaprofen has been compared with that of benzidamine with regard to normalization of bacterial vaginal flora, taking into consideration the increase of Döderlein bacillus. A remarkable significant improvement of all the symptoms has been observed in the group of patients treated with flunoxaprofen with respect to that receiving benzidamine; moreover 57.9% of the subjects treated with flunoxaprofen showed a significant increase of Döderlein bacillus while in the benzidamine group the percentage reached a value of 11.8%. Flunoxaprofen may be considered a useful and active tool for the topical treatment of non specific vaginal diseases.

[Cervical conization in the diagnosis and treatment of cervical epithelial neoplasms]. / La conizzazione cervicale nella diagnosi e nel trattamento della CIN.

Thirty-seven patients who underwent cone biopsy for cervical intraepithelial neoplasia (CIN) of varying gravity have been considered. The follow-up points to the therapeutic as well as diagnostic value of this intervention (92% success). Analysis of the responses provided by colpocytology in comparison with those provided by biopsy, evidences the poor diagnostic reliability of the pap-test with respect to intraepithelial lesions of the uterine cervix (under-estimated in 51% of cases compared to biopsy). Operation did not substantially modify patients' reproductive capability (5 pregnancies of which 3 developing, during the control period) an extremely important factor in view of the young age of patients (average 31 years).