Suicidal fall from heights trauma: difficult management and poor results.

BACKGROUND: Self-inflicted injuries represent a consistent cause of trauma and falls from heights (FFH) represent a common dynamic used for suicidal attempts. The aim of the current report is to compare, among FFH patients, unintentional fallers and intentional jumpers in terms of demographical characteristics, clinical-pathological parameters and mortality, describing the population at risk for suicide by jumping and the particular patterns of injury of FFH patients. MATERIALS AND METHODS: The present study is a retrospective analysis of prospectively collected data regarding FFH patients, extracted from the Trauma Registry of the Papa Giovanni XXIII Hospital in Bergamo, Italy. Demographic characteristics, clinical-pathological parameters, patterns of injury, outcomes including mortality rates of jumpers and fallers were analyzed and compared. RESULTS: The FFH trauma group included 299 patients between April 2014 and July 2016: 259 of them (86.6%) were fallers and 40 (13.4%) were jumpers. At multivariate analysis both young age (p = 0.01) and female sex (p < 0.001) were statistical significant risk factors for suicidal attempt with FFH. Systolic blood pressure (SBP) at the arrival was lower and ISS was higher in the self-inflicted injury group (SBP 133.35 ± 23.46 in fallers vs 109.89 ± 29.93 in jumpers, p < 0.001; ISS in fallers 12.61 ± 10.65 vs 18.88 ± 11.80 in jumpers, p = 0.001). Jumpers reported higher AIS score than fallers for injuries to: face (p = 0.023), abdomen (p < 0.001) and extremities (p = 0.004). The global percentage of patients who required advanced or definitive airway control was significantly higher in the jumper group (35.0% vs 16.2%, p = 0.005). In total, 75% of jumpers and the 34% of fallers received surgical intervention (p < 0.001). A higher number of jumpers needed ICU admission, as compared to fallers (57.5% vs 23.6%, p < 0.001); jumpers showed longer total length of stay (26.00 ± 24.34 vs 14.89 ± 13.04, p = 0.007) and higher early mortality than fallers (7.5% vs 1.2%, p = 0.008). CONCLUSIONS: In Northern Italy, the population at highest risk of suicide by jumping and requiring Trauma Team activation is greatly composed by middle-aged women. Furthermore, FFH is the most common suicidal method. Jumpers show tendency to "feet-first landing" and seem to have more severe injuries, worse outcome and a higher early mortality rate, as compared to fallers. The Trauma Registry can be a useful tool to describe clusters of patients at high risk for suicidal attempts and to plan preventive and clinical actions, with the aim of optimizing hospital care for FFH trauma patients.

Endoscopic versus surgical treatment for a rare form of gallstone ileus: Bouveret's syndrome. Two case reports and review of the literature.

BACKGROUND: Bouveret's syndrome is a gastric outlet obstruction due to a gallstone impacted in the duodenal lumen or in the stomach via a bilioenteric fistula. It's the rarest form of gallstone ileus, with few cases reported in medical literature. Typically, this condition affects elderly people and causes high morbidity and mortality rates. METHODS: We present a review of the published cases of Bouveret's syndrome between 2006, year of publication of the largest case series, and 2015 with particular regard to the operative management and treatment options. Two demanding cases of Bouveret's syndrome reported in our Hospital are also described. RESULTS: Bouveret's syndrome is a rare clinical condition and data reported in medical literature only derive from single case reports and case series. Therefore no clear management indications have been ruled out and treatment options are still matter of debate. CONCLUSION: Bouveret's syndrome is a rare clinical entity with a challenging operative management. Surgical or endoscopic treatments should be tailored on patient medical conditions and clinical presentation. KEY WORDS: Bouveret's Syndrome, Cholelithiasis, Gallstone Ileus, Gastric Outlet Obstruction, Intestinal Obstruction.

Comparison of frequencies and prognostic effect of molecular subtypes between young and elderly breast cancer patients.

PURPOSE: To compare the distribution and prognostic effect of the breast cancer molecular subtypes in young and elderly breast cancer patients. PATIENTS AND METHODS: Our study population (n = 822) consisted of all early breast cancer patients primarily treated with surgery in our center between 1985 and 1996. A total of 142/822 fresh frozen tissues were available with good quality RNA and analyzed by gene expression microarray. Gene expression molecular subtypes were determined by correlation to the expression centroids of 534 "intrinsic" genes. Sections of a tissue micro array containing formalin-fixed paraffin-embedded tumor tissue of 714/822 patients were immunohistochemically (IHC) stained for Ki67, EGFR, CK5/6. Tumor expression of ER, PR, HER2 was previously determined. IHC molecular subtypes were defined based on expression of these markers: Luminal A: ER+ and/or PR+, HER2- and Ki67-; Luminal B: ER+ and/or PR+ and ki67+; ERBB2: ER-, PR- and HER2+; Basal-like: ER-, PR-, HER2- and EGFR+ and/or CK5/6+; Unclassified: ER-, PR-, HER2-, EGFR- and CK5/6-. IHC molecular subtypes were validated against gene expression defined molecular subtypes. Assessment of distribution and prognostic effect of molecular subtypes was stratified to age (<65 versus ≥65 years). RESULTS: Validation of molecular subtypes determined by IHC against gene expression revealed a substantial agreement in classification (Cohen's kappa coefficient 0.75). A statistically significant association (p = 0.02) was found between molecular subtypes and age, where Luminal tumors were more often found in elderly patients, while ERBB2, basal-like and unclassified subtypes were more often found in young patients. Molecular subtypes showed a prognostic association with outcome in young patients concerning relapse-free period (RFP) (p = 0.01) and relative survival (RS) (p < 0.001). No statistically significant prognostic effect was found for molecular subtypes in elderly patients (RFP p = 0.5; RS p = 0.1). Additional analyses showed that no molecular subtypes showed a statistically significant difference in outcome for elderly compare to young patients. CONCLUSION: We have shown that molecular subtypes have a different distribution and prognostic effect in elderly compared to young breast cancer patients, emphasizing the fact that biomarkers may have different distributions and prognostic effects and therefore different implications in elderly compared to their younger counterparts. Our results support the premise that breast cancer clinical behavior is significantly affected by patient age. We suggest that competing risks of death in elderly patients, ER-driven differences and micro-environmental changes in biology are underlying these age-dependent variations in patient prognosis.

The prognostic value of apoptotic and proliferative markers in breast cancer.

Increasing ability of early breast cancer (BC) diagnosis leading to more early stage detection, better survival, and low relapse marks one of the milestones achieved over the decades. Foregoing poses a challenge for clinicians regarding optimal treatment, in which over- and under-treatment should be avoided. Classical prognostic and predictive factors fall short for individualized adjuvant therapy selection in this patient group. The key to better characterization may be found in the biology underlying individual tumors. We hypothesized that markers related to cellular proliferation and apoptosis and the balance between these two processes in tumor development will be predictive for clinical outcome. Our study population (N = 822) consisted of all early stage BC patients primarily treated with surgery in our center between 1985 and 1996. Sections of available tumor tissue (87 %, 714/822) were immunohistochemically stained for expression of p53, active-caspase-3, and Ki67. In 43 % (304/714) and 18 % (126/714) of this cohort, respectively, a biochemical C2P(®) risk prediction and caspase-3 assay were performed. Expression data of the mentioned markers, single, or combined, were analyzed. Results showed that both the single and combined markers, whether of apoptotic or proliferative origin had associations with clinical outcome. An additive effect was seen for the hazard ratios when data on p53, active caspase-3, and Ki67 status were combined. The assembled prognostic apoptotic-proliferative subtype showed significant association for both the overall survival (p = 0.024) and relapse-free period (p = 0.001) in the multivariate analyses of grade I breast tumors. Combined markers of tumor cell apoptosis and proliferation represent tumor aggressiveness. The apoptotic-proliferative subtypes that we present in this study represent a clinical prognostic profile with solid underlying biological rationale and pose a promising method for accurate identification of grade I BC patients in need of an aggressive therapeutic approach, thus contributing to precision medicine in BC disease.