Completion of radical hysterectomy does not improve survival of patients with cervical cancer and intraoperatively detected lymph node involvement: ABRAX international retrospective cohort study.

BACKGROUND: The management of cervical cancer patients with intraoperative detection of lymph node involvement remains controversial. Since all these patients are referred for (chemo)radiation after the surgery, the key decision is whether radical hysterectomy should be completed as originally planned, taking into account an additional morbidity associated with extensive surgical dissection prior to adjuvant treatment. The ABRAX study investigated whether completing a radical uterine procedure is associated with an improved oncological outcome of such patients. PATIENTS AND METHODS: We performed retrospective analyses of 515 cervical cancer patients (51 institutions, 19 countries) who were referred for primary curative surgery between 2005 and 2015 (stage IA-IIB, common tumour types) in whom lymph node involvement was detected intraoperatively. Patients were stratified according to whether the planned uterine surgery was completed (COMPL group, N = 361) or abandoned (ABAND group, N = 154) to compare progression-free survival. Definitive chemoradiation was given to 92.9% patients in the ABAND group and adjuvant (chemo)radiation or chemotherapy to 91.4% of patients in the COMPL group. RESULTS: The risks of recurrence (hazard ratio [HR] 1.154, 95% confidence intervals [CI] 0.799-1.666, P = 0.45), pelvic recurrence (HR 0.836, 95% CI 0.458-1.523, P = 0.56), or death (HR 1.064, 95% CI 0.690-1.641, P = 0.78) were not significantly different between the two groups. No subgroup showed a survival benefit from completing radical hysterectomy. Disease-free survival reached 74% (381/515), with a median follow-up of 58 months. Prognostic factors were balanced between the two groups. FIGO stage and number of pelvic lymph nodes involved were significant prognostic factors in the whole study cohort. CONCLUSION: We showed that the completion of radical hysterectomy does not improve survival in patients with intraoperatively detected lymph node involvement, regardless of tumour size or histological type. If lymph node involvement is confirmed intraoperatively, abandoning uterine radical procedure should be considered, and the patient should be referred for definitive chemoradiation. CLINICAL TRIALS IDENTIFIER: NCT04037124.

Adnexal Torsion in Pediatric Age: Does Bolli's Score Work? Report of Two Cases.

Adnexal torsion is a surgical emergency requiring early diagnosis in order to avoid demolitive surgery. Adnexal torsion's diagnosis could be very difficult in pediatric patients because children cannot explain symptoms accurately. Furthermore reproductive organs lie high in abdomen, causing unclear examinations findings. For reducing diagnostic mistakes or delay clinical and hematological criteria could be useful. No radiological criteria (CT or MRI) should be taken in count because of the costs and the required time. By combining clinical presentation in patients with OT three useful diagnostic variables have been identified: age, duration of pain, vomiting. Presence of vomiting, short duration of abdominal pain and high CRP levels have great predictive value for the diagnosis of adnexal torsion. In those patients an exploratory laparoscopy should be performed without any doubt and/or delay. These data may aid physicians in the evaluation of abdominal pain in premenarchal girls.

Baseline Tryptase Levels Are Related to Age, Total IgE, and Anti-rPru p 3 IgE Levels in Peach-Allergic Patients

No disponible

Is adjuvant chemotherapy indicated in stage I pure immature ovarian teratoma (IT)? A multicentre Italian trial in ovarian cancer (MITO-9).

OBJECTIVE: Conservative surgery followed by platinum-based chemotherapy is considered the standard approach for stage I immature ovarian teratoma (IT), except for stage IA G1. Nevertheless the use of chemotherapy in stage IA G2-3 and IB-IC is controversial. The aim of this study was to evaluate the outcome of patients with IT in order to define the role of chemotherapy in stage I disease. METHODS: Twenty-eight patients with stage I IT treated in MITO centers were retrospectively reviewed. Grade, stage, age, surgical and postoperative treatment were analyzed using χ(2) test and T test looking for association with recurrence. RESULTS: Median age was 25.5. Twenty-four patients underwent fertility-sparing surgery. FIGO stages were 19 IA, 2 IB, and 7 IC. Nine patients had grade 1 tumor, 12 grade 2, and 7 grade 3. Nine patients received adjuvant chemotherapy. Overall recurrence rate was 21.4% (2 in chemotherapy group and 4 in the group without treatment). No patients with G1 had recurrence, whereas 25% of G2 and 42.9% of G3 relapsed. Recurrence rate was not significantly different according to stage, grade or adjuvant chemotherapy, whereas it was greater in the group not operated in a MITO center, not staged and of age lower than 20 years, with statistical significance. At recurrence 4 patients presenting with mature teratoma were treated with surgery alone, whereas 2 recurring with IT were treated with surgery plus chemotherapy. After a median follow-up of 59 months all patients are NED. CONCLUSIONS: Our study suggests that chemotherapy may be withheld for primary therapy and utilized only for recurrence.

Improving outcomes in tumour necrosis factor a treatment: comparison of the efficacy of the tumour necrosis factor a blocking agents etanercept and infliximab in patients with active rheumatoid arthritis.

AIM: The aim of this study was to evaluate the differences between infliximab and etanercept, in terms of clinical efficacy and rapidity of action. METHODS: We selected 32 patients with rheumatoid arthritis (RA) with an incomplete response to disease modifying anti-rheumatic drugs (DMARDs), and randomly assigned them to etanercept or infliximab. We evaluated the efficacy after 14, 22, 54 weeks of treatment, using the American College of Rheumatology (ACR) 20, 50 and 70 criteria, and the improvement of quality of life using the Health Assessment Question-naire (HAQ). RESULTS: After 14 weeks, the 54.4% of patients was considered ACR-responders in the etanercept group, whereas, in the infliximab group, the percentage of responders was 74.4%: infliximab gave better results for the tender joint count and for physician's global assessment. After 22 weeks, no significant difference was present. After 54 weeks, etanercept resulted more effective than infliximab for tender joint count (TJC) value, for visual analogic scale (VAS) for pain score, for global disease assessment value, with 74.4% of patients considered ACR-responders in the group treated with etanercept and 60% in the group treated with infliximab. As regards HAQ, patients in the infliximab group presented higher scores at week 14, but in weeks 22 and 54, patients in the etanercept group showed better results. Therefore, both infliximab and etanercept are efficacious in RA, but infliximab is more efficacious than etanercept in week 14. Vice versa, in week 54 etanercept is the most efficacious drug. CONCLUSIONS: Physicians have 2 weapons in their armamentarium, with the same target but distinct clinical, pharmacokinetic and pharmacodynamic properties.

[Tuberculoma complicating tuberculous meningitis: description of one paediatric case]. / Tubercoloma complicante la meningite tubercolare: descrizione di un caso pediatrico.

Intracranial tuberculoma is a possible complication of meningeal, miliary or pulmonary tuberculosis. In developing countries it represents 30% of space-occupying intracranial lesions, in industrialised countries only 0.1-0.2%. One recently recognised phenomenon is the development ex novo or the enlargement of the tuberculoma during antitubercular chemo-antibiotic therapy. Here we report the clinical case of an immunocompetent Italian baby girl who presented an intracranial tuberculoma during tuberculous meningitis. We underline how such an event is possible, the need for early neuroradiological evaluation and its favourable course, maintaining adequate antitubercular therapy associated with steroid therapy.

Rheumatic symptoms in patients with human immunodeficiency virus are related to levels of tumor necrosis factor-alpha but not to viral load.

Infection with human immunodeficiency virus (HIV) can lead to osteoarticular involvement, usually in the late stages. The pathogenesis of these symptoms has usually been attributed to viral load or to dysregulated cytokine production. We evaluated the presence of rheumatic symptoms and levels of tumor necrosis factor (TNF)-alpha viral load and CD4 count in 46 patients with HIV from southern Italy. The prevalence of rheumatic symptoms was 23.9%; CD4 count and viral load presented no statistically significant differences between patients with rheumatic symptoms and patients without osteoarticular involvement, whereas TNF-alpha levels were increased in HIV patients with arthralgias compared with those in patients without arthralgias (p = 0.02). Evidence that TNF-alpha is increased in patients with osteoarticular or soft tissue involvement is a clear index of the pivotal role this cytokine plays in the pathogenesis of these manifestations.

Ovarian cystic teratoma with primary epithelial cell melanoma.

We report a rare case of malignant melanoma arising in a cystic teratoma of the ovary occurring in a 60-year-old woman who died in four months despite the combined treatment administrated (surgery and chemotherapy). Diagnosis of ovarian melanoma was confirmed by immunohistochemical positivity to S-100 protein and HMB 45. There was no evidence of extra-ovarian primary melanoma on clinical examination; therefore the diagnosis was primary ovarian melanoma. Melanoma metastases were detected on the uterus, the right ovary, the omentum and in one of the three excised left external iliac lymph nodes. A review of the literature is analyzed and discussed.

[Peritonectomy and hyperthermic chemoperfusion in peritoneal carcinomatosis. Preliminary results]. / Peritonectomia e chemioperfusione ipertermica nella carcinomatosi peritoneale. Risultati preliminari.

BACKGROUND: Peritoneal carcinomatosis can be actually treated by new surgical and oncological techniques. Aim of this work is to report preliminary results of a group of patients with peritoneal carcinomatosis, submitted to peritonectomy and intraperitoneal hypertermic chemoperfusion (IPHC). METHODS: Age, sex, type of neoplasm, peritoneal carcinomatosis index (PCI), completeness of cytoreduction (CC), operative time, morbidity and mortality of patients submitted to IPHC have been considered. RESULTS: From May 2001 to December 2004, 10 patients were submitted to peritonectomy and IPHC: 9 (90%) females and 1 (10%) male, aged from 49 to 72 years. Seven patients (70%) were affected of peritoneal carcinomatosis from ovarian tumor, three patients (30%) from colon cancer. The PCI was ranged from 8 to 25. The operative time was ranged from 6 to 14 hours. Two patients with a CC of 2 developed relaps and died respectively after 2 and 4 months. The remaining patients had a CC between 0 and 1. Of these last patients, 1 affected by ovarian cancer died 24 months after, 1 patient died 3 days after surgery for septic shock; the other patients are still alive with a period ranged from 1 to 30 months. CONCLUSIONS: Our preliminary results suggest that the peritonectomy and IPHC can be effective only in patients with CC of 0 or 1, in the remaining cases these therapeutical methods should be avoided.

Increased frequency of the immunoglobulin enhancer HS1,2 allele 2 in coeliac disease.

BACKGROUND: Coeliac disease (CD) is characterized by increased immunological responsiveness to ingested gliadin in genetically predisposed individuals. This genetic predisposition is not completely defined. A dysregulation of immunoglobulins (Ig) is present in CD: since antiendomysium antibodies (anti-EMA) are of the IgA class. One polymorphic enhancer within the locus control region (LCR) of the immunoglobulin heavy chain cluster at the 3' of the C alpha-1 gene was investigated. The correlation of the penetrance of the four different alleles of the HS1,2-A enhancer of the LCR-1 3' to C alpha-1 in CD patients compared to a control population was analysed. METHODS: A total of 115 consecutive CD outpatients, on a gluten-free diet, and 248 healthy donors, age- and sex-matched, from the same geographical area were enrolled in the study. HS1,2-A allele frequencies were investigated by nested polymerase chain reaction (PCR). RESULTS: The frequency of allele 2 of the enhancer HS1,2-A gene was increased by 30.8% as compared to the control frequency. The frequency of homozygosity for allele 2 was significantly increased in CD patients. Crude odds ratio (OR) showed that those with 2/2 and 2/4 (OR 2.63, P < 0.001 and OR 2.01, P = 0.03) have a significantly higher risk of developing the disease. In contrast, allele 1/2 may represent a protective genetic factor against CD (OR 0.52, P = 0.01). CONCLUSIONS: These data provide further evidence of a genetic predisposition in CD. Because of the Ig dysregulation in CD, the enhancer HS1,2-A may be involved in the pathogenesis.

Angioplasty increases coronary sinus F2-isoprostane formation: evidence for in vivo oxidative stress during PTCA.

OBJECTIVES: Isoprostanes, stable end-products of oxygen free radical mediated-lipid peroxidation, were measured in the coronary vessels during percutaneous transluminal coronary angioplasty (PTCA) to provide direct evidence for enhanced oxidative stress in a local milieu in vivo. BACKGROUND: Percutaneous transluminal coronary angioplasty is associated with complications such as myocardial stunning and accelerated restenosis, which at least in part are mediated by oxygen free radicals. Because isoprostanes are markers of oxidant stress and potent vasoactive compounds, the formation of which is not inhibited by aspirin treatment in vivo, it is possible that these mediators are increased locally during PTCA. METHODS: In 12 coronary artery disease patients who were given aspirin and ticlopidine, blood samples from coronary sinus were taken immediately before and immediately upon balloon deflation during PTCA. Isoprostane F2alpha-III, isoprostane F2alpha-VI, and TxB2 were quantified after extraction and chromatography using a stable dilution isotope gas chromatography/mass spectrometry assay. RESULTS: Coronary sinus and left main coronary artery levels of iPF2alpha-III and iPF2alpha-VI at baseline were (mean +/- SEM) 40 +/- 9 pg/ml and 115 +/- 10 pg/ml, respectively. The TxB2 levels were undetectable. Following PTCA, isoprostane levels markedly increased (mean +/- SEM): iPF2alpha-III, 125 +/- 12 pg/ml (p < 0.001); iPF2alpha-VI, 295 +/- 20 pg/ml (p < 0.001), whereas TxB2 levels remained undetectable. CONCLUSIONS: These results indicate that PTCA induces coronary sinus increase in F2-isoprostane formation, and they also provide direct evidence for enhanced oxidative stress in a local milieu in vivo. Thus, an increased F2-isoprostane formation could play a role in the pathogenesis of some PTCA-associated untoward events.

Piver's radical hysterectomy (type III): Endo-Gia 30 stapler versus traditional forcipressure for resection of the cardinal ligament.

OBJECTIVE: Morbidity and costs associated with Piver's radical hysterectomy (type III) are noteworthy. The Endo-Gia stapler method for resection of cardinal ligaments can reduce duration of surgery and hospitalization, blood loss, costs and postoperative infection rates. METHOD: Two groups of patients (homogeneous for age, weight and medical condition) were studied: one group was operated on using the Endo-Gia stapler method (n=52) and the other with the traditional forcipressure (n=13). The size of parametrial tissue removed, blood loss, duration of surgery, duration of hospitalization, cost of materials and postoperative fever were compared in the two groups. RESULT: Mean operative times were lower in the Endo-Stapler group than in the controls (mean 180 min versus 220 min). Mean blood loss was 300 cc in the stapler group versus 450 cc in the forcipressure group. Mean cost of surgery (considering costs of materials, hospital stay. duration of surgery), was lower in the stapler group (3,095 euros) than in the group who underwent traditional surgery (3,434 euros). CONCLUSION: Our data suggest the Endo-Gia stapler method significantly reduces blood loss, operative time and cost.

Metabolic and cardiorespiratory responses to continuous box lifting and lowering in nonimpaired subjects.

STUDY DESIGN: A within-subject experimental design. OBJECTIVES: To compare the magnitude of metabolic and cardiorespiratory changes produced during box lifting and lowering among combinations of lift technique (leg lift and leg-torso lift) and lift weight (10.8 and 15.4 kg). BACKGROUND: Continuous box lifting and lowering can be used as an exercise in a low-back rehabilitation program. Awareness of the possible cardiovascular stress of this activity is important to the clinician because some patients may have existing cardiovascular pathologies or possess unknown risk factors for cardiovascular disease. METHODS AND MEASURES: A group of 17 nonimpaired men 26 +/- 8 years of age (mean +/- SD) performed the 4 experimental trials on different days in a counterbalanced order determined by a Latin Square design. Lifting and lowering was performed for 6 continuous minutes at a rate of 12 cycles per minute. Physiologic variables were oxygen uptake, minute ventilation, heart rate, systolic blood pressure, diastolic blood pressure, metabolic equivalent, and rate-pressure product. RESULTS: There were stepwise increases in the values for oxygen uptake, minute ventilation, heart rate, metabolic equivalent, and rate-pressure product from the leg-torso lift to the leg lift and from 10.8 to 15.4 kg of weight within each lift technique (with the exception that minute ventilation and heart rate did not differ between the leg-torso lift at 15.4 kg and the leg lift at 10.8 kg). For the 4 lifts, values (mean +/- SD) varied from 20.3 +/- 5.4 to 28.8 +/- 5.8 mL x kg x min(-1) for oxygen uptake, 42.2 +/- 11.1 to 66.4 +/- 15.2 L x min(-2) for minute ventilation,129 +/- 20.6 to 156 +/- 16.5 beats x min(-1) for heart rate, 5.8 +/- 1.6 to 8.2 +/- 1.6 for metabolic equivalent, and 197 +/- 49.4 to 245 +/- 41.2 for rate-pressure product (x10(-2)). CONCLUSION: The leg lift with the 15.4-kg weight produced the greatest physiologic stress. Because of the magnitude of the increase in the variables measured for all 4 types of lifts, clinicians should closely monitor patients' response to this type of exercise.

[The concept of "preclinical arterial hypertension" - in light of non-invasive, ambulatory blood pressure monitoring]. / Il concetto di "pre-ipertensione arteriosa" alla luce del monitoraggio ambulatorio non-invasivo della pressione arteriosa.

In clinical medicine it is possible to find subjects who show initial signs of hypertensive damage being normotensive at the "casual" sphygmomanometry. In order to verify whether or not these subjects are "true normotensives", it was applied the noninvasive ambulatory monitoring of blood pressure (BP). Five studies were performed: I. Normotensives with initial hypertensive retinopathy; II. normotensives with initial hypertensive cardiohypertrophy; III. Normotensives with initial hypertensive cardiohypertrophy of the transplanted heart; IV. Normotensive pregnant women with altered uterine blood flow; V. Normotensive pregnant women with intrauterine growth retardation. From all the studies, it was possible to derive that the subjects were all true normotensive. However, they were characterized by BP values on average higher than those of their controls, but below the reference limits given by WHO. Because of the relative elevation of BP, it was possible to argue that there exists a BP regimen which is potentially dangerous for the target organs, even though there is no evidence of manifest arterial hypertension. Such a hemodynamic condition causing hypertensive cardiovascular damage was defined "arterial pre-hypertension".

Attitude of potential users in Sicily towards preimplantation genetic diagnosis for beta-thalassaemia and aneuploidies.

This study aims to report the willingness of different populations of high-risk couples to undergo preimplantation genetic diagnosis (PGD) for beta-thalassaemia as an alternative to prenatal genetic diagnosis (PND), and the willingness of infertile couples to undergo PGD for aneuploidies. An information sheet and questionnaire presenting PGD and PND procedures were distributed to four population types: 54 high-risk couples for beta-thalassaemia coming for their first PND (population A); 51 similar couples coming for their second or further PND without previous experience of therapeutic abortion (population B-na); 50 similar couples coming for their second or further PND with previous experience of therapeutic abortion for beta-thalassaemia-affected fetus (population B-ab); and 74 infertile couples undergoing routine in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) (population C). Favourable first impressions towards PGD compared with PND were observed in all four populations in the following proportions: 79.6% population A; 76.5% population B-na; 92.0% population B-ab; and 96.0% population C. Willingness to undergo PGD for beta-thalassaemia was as follows: 44.4% population A; 47.1% population B-na; and 72.0% population B-ab. We conclude that previous experience of PND for beta-thalassaemia is a crucial point in the willingness to accept the PGD procedure, and that couples belonging to population B-ab are the most suitable to undergo PGD for beta-thalassaemia. Some 96.0% of infertile couples in population C were ready to undergo PGD for aneuploidies.

[Who are the "non-dippers": an insight from the ambulatory monitoring of arterial pressure in heart transplant patients]. / Chi sono i "non-dipper": un approfondimento dal monitoraggio ambulatorio della pressione arteriosa nei cardiotrapiantati.

This study was performed in order to define who are the "non-dippers", knowing that their present definition does not imply any explanation about the mechanisms. The investigation was performed on 34 heart transplanted patients, 28 males (mean age 52 +/- 11 years) and 6 women (mean age 35 +/- 14 years), knowing that the "non-dippers" were described as the hypertensives who are devoid of the expected nocturnal fall in blood pressure (BP). The "non-dipping" phenomenon was investigated by exploring the BP 24-h pattern via ambulatory non-invasive BP monitoring, and by applying the rhythmometric analysis for quantifying the BP circadian rhythm. The study provided evidence that the "non-dippers" can be found among the hypertensives as well as the normotensives, suggesting that high BP is not a necessary condition for the "non-dipping" phenomenon, and vice versa. Both the normotensive and hypertensive "non-dippers" were seen to show stereotypic changes in BP circadian rhythm. There are normotensive and hypertensive "non-dippers" with or without the BP circadian rhythm. The "rhythmic non-dippers" show a BP circadian rhythm which is inverted in phase or demodulated in amplitude. The "non-dippers" are, thus, a heterogeneous category.

Isometric handgrip exercise increases endothelin-1 plasma levels in patients with chronic congestive heart failure.

This study demonstrated an immediate and short-lasting endothelin-1 release in the circulation of patients with severe chronic congestive heart failure during isometric handgrip exercise, but not in normal subjects. Our data suggest that endothelin-1 levels may increase transiently during daily physical activity, thus contributing to progressive deterioration of left ventricular function.

The effects of therapeutic contact lenses on intraocular pressure measurement.

PURPOSE: To evaluate the accuracy of intraocular pressure (IOP) measurements taken through three commonly used therapeutic contact lenses, using both the Tono-Pen and pneumatonometer. METHODS: We measured the IOP of ten normal eyes and ten eyes with abnormal anterior segments using Tono-Pen, pneumatonometry, and Goldman application tonometry. Three different soft contact lenses (Acuvue, 04, and Permalens) were sequentially placed on the eyes and repeat measurements were taken. The readings obtained for each contact lens were compared to the baseline readings taken without a lens in place in order to assess the effect that each contact lens had on the accuracy of IOP measurements. RESULTS: All three contact lenses permitted accurate IOP measurements in eyes with both normal and abnormal anterior segments. Variations in water content and central thickness did not affect the accuracy of IOP measurements. CONCLUSIONS: Both Tono-Pen and pneumatonometry proved to be equally reliable in recording accurate IOP measurements through therapeutic contact lenses.