Risk factors for postoperative morbidity following appendectomy in the elderly: a nationwide prospective cohort study.

BACKGROUND: A limited number of studies investigating perioperative risk factors associated with emergency appendectomy in elderly patients have been published to date. Whether older age may be associated with poorer outcomes following appendectomy is still a matter of debate. The primary aim of this study was to determine the predictors of postoperative morbidity following appendectomy in patients aged ≥ 65 years. METHODS: Data regarding all elderly patients who underwent emergency appendectomy from January 2017 to June 2018 admitted 36 Italian surgical departments were prospectively collected and analyzed. Baseline demographics and perioperative variables were evaluated. Uni- and multivariate analyses adjusted for differences between groups were carried out to determine possible predictors of adverse outcomes after appendectomy. RESULTS: Between January 2017 and June 2018, 135 patients aged ≥ 65 years with a diagnosis of AA met the study inclusion criteria. Twenty-six patients (19.3%) were diagnosed with some type of postoperative complication. Decreasing the preoperative hemoglobin level showed a statistically significant association with postoperative complications (OR 0.77, CI 0.61-0.97, P = 0.03). Preoperative creatinine level (P = 0.02, OR 2.04, CI 1.12-3.72), and open appendectomy (P = 0.03, OR 2.67, CI 1.11-6.38) were significantly associated with postoperative morbidity. After adjustment, the only independent predictor of postoperative morbidity was preoperative creatinine level (P = 0.04, OR 2.01, CI 1.05-3.89). CONCLUSIONS: In elderly patients with AA, perioperative risk assessment in the emergency setting must be as accurate as possible to identify modifiable risk factors that can be addressed before surgery, such as preoperative hemoglobin and creatinine levels.

KPNA2/ERG Coexpression is Associated With Early Recurrence in Advanced Prostate Cancers.

Most prostate cancers (PC) overexpress the ERG oncogene and karyopherin α 2 (KPNA2). These genes play a role in prostatic carcinogenesis, but their prognostic significance is still debated. The aim of this study was to determine the prognostic significance of ERG and KPNA2 expression, and their association to early prostate-specific antigen (PSA) biochemical recurrence in advanced PC with lymph node metastases. A series of 65 consecutive pN1 M0 R0 PC samples obtained by radical prostatectomy with lymphadenectomy has been analyzed for ERG and KPNA2 expression by immunohistochemistry. For each case, the following clinical data were collected: age, preoperative serum PSA levels, Gleason grade group, TNM stage, and follow-up. PC recurrence was investigated by serum PSA assay and defined by a PSA concentration >0.2 ng/mL after a nadir of <0.1 ng/mL following radical prostatectomy. ERG-positive staining was found in 25/65 cases (38%), and KPNA2 in 56/65 cases (86%); neither was detected in normal prostatic tissue. Immunohistochemical concordance was found between primary tumor and lymph node metastases in 24/25 (96%) of ERG and 53/56 (95%) of KPNA2-positive cases. The follow-up was known in all cases, and early PSA recurrence occurred in 25/65 cases (38%). ERG positivity, both alone and in conjunction with KPNA2 positivity, was strongly associated with early PSA recurrence [both ERG+ and KPNA+, odds ratio: 22.2 (95% confidence interval, 6.0-82.3); ERG+ alone odds ratio: 17.9 (95% confidence interval, 5.1-63.5); P<0.0001 for both]. KPNA2 expression was significantly associated with the tumor stage (P<0.00001). The results suggest that the ERG+ phenotype might be selected in metastasis-initiating clones. ERG and KPNA2 may have a prognostic value, and their positivity in PC might warrant more aggressive treatments.

Glioma surgery: From preservation of motor skills to conservation of cognitive functions.

The first step of glioma treatment is surgery. Extent of resection (EOR) improves patient survival if surgery does not negatively impair a patient's neurological status. However, how surgery affects the patient's quality of life (QOL) has been less studied, especially as regards cognitive aspects. In our study, we retrospectively analyzed our cases with awake surgery. In all patients, surgical excision was stopped when active functions were intraoperatively identified. A neuropsychological assessment was performed both before and after surgery (5 days and 1 month after). Writing, motor speech, comprehension, expression, reading, pragmatics, attention, memory, problem solving and visuoperceptive functions were evaluated and scored with the NOMS scale. We found no differences in the median values of writing and motor speech, while there was a difference in the following variables: comprehension, expression, reading, pragmatics, attention, memory, problem solving and visuoperceptive functions. Moreover, the Dunn test did not show any difference between preoperative evaluation and evaluation performed 30 days after surgery regarding comprehension, expression, reading, pragmatics, attention, problem solving and visuoperceptive functions. However, there was a difference between preoperative and postoperative evaluation for memory. This retrospective study shows that awake surgery could be a reasonable possibility to preserve a patient's QOL achieving an EOR >82% of the Total Tumor Volume (Fluid-attenuated inversion recovery (FLAIR) hyperintense region in low-grade gliomas and enhancing nodules plus FLAIR hyperintense region in high-grade gliomas). In this series memory was the only aspect that had an impairment after surgery without a complete recovery at one month after surgery.

Supratotal Resection of Glioblastoma: Is Less More?

BACKGROUND: A relationship between the extent of resection (EOR) and survival has been demonstrated in patients with glioblastomas (GBMs). However, despite gross total resection (GTR) of the enhancing nodule (EN), GBMs usually relapse, generally near the surgical cavity. OBJECTIVE: The aim of this study was to determine the prognostic role of FLAIR resection of GBMs by analyzing pre- and post-operative MRIs to estimate the EOR of EN, FLAIR-hyperintense regions and total tumor volume (TTV). METHODS: Radiologic and clinical outcomes were analyzed retrospectively. Pre- and post-operative EN volume, pre- and postoperative FLAIR volume (POFV), and pre- and postoperative TTV were analyzed. EOR was then calculated for each component. Time-dependent ROC curves and cut-off values for pre- and post-operative volumes and EOR were calculated. A Kaplan-Meier analysis with the log-rank test and Cox regression analysis were then used to analyze progression-free survival (PFS) and overall survival (OS). RESULTS: We did not find any correlation between EOR of FLAIR-altered regions and patient survival. On the other hand, there were statistically significant relationships between the prognosis and both a preoperative EN volume less than 31.35 cm3 (p=0.032) and a postoperative EN volume less than 0.57 cm3 (p=0.015). Moreover, an EOR of EN greater than 96% was significantly associated with the prognosis (p=0.0051 for OS and p=0.022 for PFS). CONCLUSION: Our retrospective, multi-center study suggests that survival in patients with GBM is not affected by the extent of resection of FLAIR-hyperintense areas.

Noninvasive Interactive Neurostimulation Therapy for the Treatment of Low-Grade Lateral Ankle Sprain in the Professional Contact Sport Athlete Improves the Short-Term Recovery and Return to Sport: A Randomized Controlled Trial.

Ankle injuries are very common between professional athletes and recreational sports. Lateral stable ligaments injury can be treated conservatively. Noninvasive interactive neurostimulation (NIN) is a form of electric therapy that works by locating areas of lower skin impedance. The objective of this prospective, double-blinded, randomized controlled trial was to compare the results in terms of improvement of a foot functional score, lower level of reported pain, and return to sports in 2 groups of contact sport athlete affected by a grade I or II lateral ankle sprain. Patients were randomized using random blocks to the NIN program (group I) or a sham device (group II). The outcome measurements were the use of a self-reported Inability Walking Scale, patient-reported subjective assessment of the level of pain using a standard visual analogue scale, and daily intake of nonsteroidal antiinflammatory drugs (etoricoxib 60 mg). Patients were also reached by telephone at 2 and 4 months of follow-up to register their return to sport activity. Beyond baseline evaluation, follow-ups were done after 5 (1 week) and 10 sessions (2 weeks) of treatment, and then at 30 days after the end of therapy. Of the 70 athletes admitted to the study, 61 eligible patients were randomized using random blocks to group I (n = 32) and group II (n = 29). Group I patients showed better improvement in terms of functional impairment (Inability Walking Scale), reported pain (visual analogue scale), and daily intake of etoricoxib 60 mg. Athletes of group I registered a faster resuming of sport activities. This prospective, randomized trial showed NIN can improve short-term outcomes in athletes with acute grade I or II ankle sprain and that it can hasten resuming of sport activities.

Management of clinical and subclinical actinic keratoses with histological and immunohistochemical assessments by confocal microscopy.

Reflectance confocal microscopy has been used to monitor treatment efficacy in non-melanoma skin cancer, but few studies have compared different therapies using the same confocal criteria. We compare a single score designed in previous study to evaluate confocal, histological, and immunohistochemical results obtained before and after two treatments of actinic keratosis (AK) and in field cancerisation area. Thirty volunteer male patients, aged >50-year old, with at least three clinically visible AKs on the bald scalp, were included in this study: 15 patients were submitted to 3% diclofenac therapy and 15 to 5% fluorouracil therapy. Confocal imaging was performed on a 5 × 5 cm skin area. In five patients of each group we performed cutaneous biopsies. Scaling, upper nucleated cells, and inflammatory cells showed a higher percentage reduction in field cancerisation, especially in diclofenac treatment group, while in AK inflammatory cells showed a greater percentage reduction in 5-fluorouracil treatment group. Both therapies are efficacious, but their effectiveness is different on the single parameters of the confocal, histology, immunohistochemically.

Tumor location and patient age predict biological signatures of high-grade gliomas.

Prognostic factors for high-grade gliomas include patient age, IDH1 mutation, MGMT methylation, and Ki67 value. We assessed the predictive role of topographic location of gliomas for their biological signatures. Collecting all neuroradiological and histological data of patients with histologically proven HGG, we performed a retrospective monocentric study. A predictive value of frontal location for a lower Ki67 value (especially in the left hemisphere) and mutation of IDH1 (especially in the right hemisphere) was found. Temporal location was predictive for IDH1 wild-type. Involvement of the parietal lobe was found to be predictive of methylated MGMT, while insular lobe involvement predicted an unmethylated MGMT. There was no statistically significant difference of IDH1 mutation and MGMT methylation between left and right sides.

Serum IGF-1 is associated with cognitive functions in early, drug-naïve Parkinson's disease.

OBJECTIVE: Cognitive deficits are common in Parkinson's disease (PD) since the early stages and many patients eventually develop dementia. Yet, occurrence of dementia in PD is unpredictable. Evidence supports the hypothesis that insulin-like growth factor-1 (IGF-1) is involved in cognitive deficits. Our aim was to evaluate the relationship between serum IGF-1 levels and neuropsychological scores in a large cohort of drug-naïve PD patients during the earliest stages of the disease. METHODS: Serum IGF-1 levels were determined in 405 early, drug-naïve PD patients and 191 healthy controls (HC) enrolled in the Parkinson's Progression Markers Initiative (PPMI). The association between serum IGF-1 levels and neuropsychological scores was evaluated with linear regression analysis. RESULTS: IGF-1 levels were similar in PD and HC. In PD patients the lowest IGF-1 quartile was a predictor of lower performances at the Semantic Fluency task (ß = -3.46, 95%CI: -5.87 to -1.01, p = 0.005), the Symbol Digit Modalities Score (ß = -2.09, 95%CI: -4.02 to -0.15, p = 0.034), and Hopkins Verbal Learning Test Retention (ß = -0.05, 95%CI: -0.09 to -0.009, p = 0.019). CONCLUSIONS: Lower serum IGF-1 levels are associated to poor performances in cognitive tasks assessing executive function, attention and verbal memory in a large cohort of early PD patients. Follow-up studies are warranted to assess if IGF-1 is related to the development of dementia in PD.

Mobility recovery after arthroscopic rotator cuff repair.

BACKGROUND: Mobility recovery after arthroscopic rotator cuff repair in different tears size. AIM: To investigate, after arthroscopic rotator cuff repair, the range of motion (ROM) progression in different sized tears (small, large and massive), and evaluating ROM changes in the pre- and postoperative periods of each group. DESIGN: Cohort study. SETTING: Policlinico Umberto I, "Sapienza" University, Rome, Italy. POPULATION: Ninety-two patients with reparable rotator cuff tears. METHODS: Patients were divided in three groups: group A (small lesions), group B (large lesions) and group C (reparable massive lesions) composed by 29, 31 and 32 patients, respectively. ROM were measured preoperatively (T0), and after 45 (T1), 70 (T2) and 100 (T3) days after the arthroscopic treatment. RESULTS: From T0 to T3, small lesions are associated to excellent results, with an improvement of all parameters; the same in patients with large lesions, except for flexion parameter; in reparable massive lesions only external and internal rotation improved. CONCLUSIONS: Not all parameters recover in the same way: postoperative rehabilitative protocol is an integral contributor to favorable outcomes in patients with rotator cuff tears. CLINICAL REHABILITATION IMPACT: The knowledge about ROM recovering after arthroscopic rotator cuff repair is a strategic information for the patient, as well as for the surgeon and physiatrist.

Understanding the relationship between Sentinel Events and Sources of Work Related Stress for prevention programmes. An Italian survey.

OBJECTIVES: According to Legislative Decree n. 81/08 and Ministerial Circular of 18/11/2010, this paper proposes to verify the relationship between the sources of risk of stress, sentinel events and gender. METHODS: Sentinel events and their variations are mapped for three years. Successively, a self-reported OPRA (Organizational and Psychosocial Risk Assessment) questionnaire was administered. The sample was not probabilistic and balanced for two categories: Inside Sentinel Event and Outside Sentinel Event. 249 subjects were extracted from a population of 770 subjects of a debt collection firm. A two-way ANOVA was applied. RESULTS: The results show that sentinel events and Gender have no relationship with the inventory of sources of risk. CONCLUSIONS: Future research should consider the relationship between stressors and their exposure time, considering the working environment dynamics. In this way, the relationship between stressors and sentinel events can be studied and tested in greater detail, showing empirical evidence that may be useful for health prevention programmes.

Lower serum uric acid is associated with mild cognitive impairment in early Parkinson's disease: a 4-year follow-up study.

Cognitive deficits are common in Parkinson's disease (PD) and many patients eventually develop dementia; however, its occurrence is unpredictable. Serum uric acid (UA) has been proposed as a biomarker of PD, both in the preclinical and clinical phase of the disease. The aim of this pilot study was to evaluate relationships between baseline serum UA levels and occurrence of mild cognitive impairment (MCI) at 4-year follow-up in a cohort of early PD patients. Early PD patients, not presenting concomitant diseases, cognitive impairment or treatment possibly interfering with UA levels, underwent neuropsychological testing at baseline and 4-year follow-up. UA levels were determined in serum at baseline. MCI was found in 23 out of 42 PD patients completing 4-year follow-up. Patients presenting MCI had significantly higher age at onset and lower Frontal Assessment Battery scores at baseline as compared with patients cognitively intact. Logistic regression analysis showed that both serum UA levels (OR = 0.54, p = 0.044) and age (OR = 1.16, p = 0.009) contribute to the occurrence of MCI at 4-year follow-up. Our pilot study suggests that lower levels of serum UA in the early disease stages are associated to the later occurrence of MCI. These results need to be confirmed by further studies on larger samples.

FFR prediction model based on conventional quantitative coronary angiography and the amount of myocardium subtended by an intermediate coronary artery stenosis.

BACKGROUND: Coronary angiography has poor predictive value for functionally significant coronary artery stenosis. The Fractional Flow Reserve (FFR) currently represents the gold standard to define the ischemic potential of epicardial stenosis and, recently, the instantaneous wave-free ratio (iFR), has also been introduced as alternative to the FFR, but it still remains an invasive procedure. We aimed this study in order to evaluate the accuracy of the "Angiography-DeriveD hEmoDynamic index" (ADDED index) to predict the FFR as compared with the iFR. METHODS AND RESULTS: Consecutive patients with at least one equivocal stenosis in one major coronary artery were enrolled. Both the FFR and iFR were measured. The amount of jeopardized myocardium was evaluated using the Duke Jeopardy Score (DJS). Two-dimensional quantitative coronary angiography (QCA) was used to assess the angiographic features of the coronary stenosis and both the reference vessel diameter (RVD) and minimal lumen diameter (MLD) were calculated. The ADDED index was defined as the ratio between DJS and MLD. We evaluated 100 intermediate coronary artery stenoses in 83 patients. Both FFR and iFR inversely correlated with the ADDED index (respectively, r2=0.59, p<0.001 and r2=0.61, p<0.001). This latter also showed high accuracy in predicting the FFR value (ROC analysis: 0.94[0.90-0.99], p<0.001) as well as the iFR (0.91[0.86-0.97], p<0.001, difference: 0.03 SD 0.04, p=0.52). CONCLUSIONS: The ADDED index, taking into account both the MLD and DJS, showed high accuracy to predict FFR and it might be used to detect functionally significant coronary artery stenosis.