MO063DESCRIPTION OF GENETIC VARIANTS IN A COHORT OF TOLVAPTAN ADPKD PATIENTS

Background and Aims

Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most common inherited renal cystic disease. It is genetically heterogeneous: 72-75% of ADPKD cases are related to mutations in the PKD1, 15-18 % to PKD2 and the remaining 7–10% of affected are genetically unresolved (GUR). Recent years, new drugs have emerged as promising agents that may retard the progression of ADPKD, such as Tolvaptan. In Italy Tolvaptan is available since 2016 and commonly used since 2017 in ADPKD patients, which fulfill the criteria of “rapid disease progression”, according to the European recommendations. High intra-interfamilial variability in pedigrees was observed, despite the same germ-line mutation. This could be explained by other clinical or genetic factors (environmental, modifier genes, etc), that may affect disease severity. The aim of the study is to describe the genetic variants in a cohort of Tolvaptan ADPKD patients (pts) referral to Renal Genetic Disease Ambulatory of Nephrology Department.

Method

Patients with ADPKD and in Tolvaptan treatment were enrolled. Diagnosis of ADPKD was made upon the revised Ravine’s criteria and Eligibility Criteria for Tolvaptan was made upon Italian indication for Tolvaptan prescription according to Italian Medicine Agency (AIFA) and European Medicines Agency (EMA). We performed genetic analysis (PKD1, PKD2 and PKHD1 genes) to identify mutations by NGS capture-based target enrichment kit (Sophia Genetic™), sequencing on Illumina MySeq Platform® and Sanger Sequencing on 3500 Series Genetic Analyzer (Applied Biosystems™).

Results

Eighteen pts [median age 46 (IQR 39-48) yrs ], 12 male, were included in the analysis. We manage to perform genetic analysis in all pts. Genetic analysis was essential in 4 patients without family history for Tolvaptan eligibility. Sixteen pts (88,9%) have mutations in PKD1, confirming what is already known from the literature for rapid progressor subjects; 2 pts are characterized by PKD2 mutations, both truncating. In only one pt, concomitant with a PKD1 mutation, also a PKHD1 mutation was found. In order to better characterize the cohort it was decided to subdivide the pts into 3 groups, by gene involvement and mutation type:

1st group: 12 Subjects with truncated PKD1 mutation (66.7%). In 7 pts (58,3%) the mutations are within exons (5 and from exon 11 to 15 inclusive) that encode for Immunoglobulin-like repeats or PKD domain of Polycystin 1 (PC1).

2nd group: 4 Subjects with non-truncated PKD1 mutations (22.2%). 3 pts (75.0%) are characterized by missense variants, as previous studies highlighted (a higher percentage of missense mutations in subjects with non-truncating mutations). In 2 pts (50%) the mutations are within exons (2 and 6) that encode for C-type lectin domain (CTLs) di PC1 and typical domain of extracellular protein.

3rd group: 2 Subjects with a PKD2 mutation (11.1%), both truncating. These data confirmed the lower mutation rate of PKD2 compared to PKD1 and highlighted an effective prevalence of truncation mutations in rapid disease progressors as previous reported.

Conclusion

Although our cohort of patients is small, we manage to perform genetic analysis in all pts reaching a detection rate of 100%. In 9 of 16 pts (56,3%) with PKD1 mutation the presence of mutations in exons coding PKD domain in PC1 or Immunoglobulin-like repeats or typical domain of extracellular protein allows us to hypothesize that the resulting alteration of the polycystin-mediated cell recognition and communication processes play a crucial role in the pathogenesis of ADPKD.

Abstract WP289: Patient Satisfaction Survey Prior to Discharge in Neuroscience Unit: Evolving Gap in Hospital Operational Models and Patient Requests

Background: Patient satisfaction (1), is increasingly tied to Medicare payments. Current standardized surveys (2) collect data 48h to 6wk after discharge.

Hypotheses: Patient needs can be identified during the hospital stay, and inform clinical practices .

Methods: Prospective, patients hospitalized. All patients admitted to our Neuroscience Unit were eligible for inclusion. Exclusion criteria were patient refusal and inability to communicate. A 10 question survey was developed and administered to in-hospital patients. Two questions asked perceived health and prior hospital experiences. Eight questions competitively presented the following domains of patient care: 1. Skills of Physicians and Nurses; 2. Communication of Physicians and Nurses; 3. Patient Knowledge of Medical Condition 4. Empowerment; 5. Responsiveness to Needs; 6. Logistics of Care; 7. Amenities.

Results: Patients reporting hospital experiences as “frustrating, “mixed” or “good” selected Communication and Responsiveness as first and second most important domains respectively. Patients reporting “excellent” prior hospital experiences selected Knowledge and Skills of Physicians and Nurses as first and second most important domains respectively. See Table 1. During survey period, negative HCAPHS survey comments decreased from 46.9% to 2.4%.

Conclusion: In-hospital, real-time, satisfaction data improves identification of specific patient needs. This can be used to align the unique needs of the Stroke patient with hospital practices.

1. Centers for Medicare and Medicaid Services; Value-Based Purchasing; 2. Centers for Medicare and Medicaid Services; HCAPHS

Abstract P2-11-22: The use and influence of a 21 gene rearrangement assay in breast cancer: Clinical and pathologic predictors of recurrence score and chemotherapy receipt

Objective: Oncotype DxTM (ODx) is a gene expression profile test that is rapidly gaining popularity for its ability to stratify breast cancer patients according to risk of distant recurrence and suggest the potential benefit of adjuvant chemotherapy (CTx). Presently, National Comprehensive Cancer Network (NCCN) guidelines suggest use of ODx for all patients with node negative (or micrometastatic node positive disease), hormone receptor positive breast cancer with a primary tumor measuring over 5mm. However, if risk factors predictive of a high recurrence score (RS) were defined, clinicians would be better able to tailor use of ODx. This study was undertaken to identify standard clinicopathologic factors that correlate with a high RS by ODx, and to determine whether these factors or RS most influenced receipt of CTx. We also measured compliance with NCCN guidelines regarding ODx utilization.

Methods and Materials: We performed an IRB approved retrospective review of women with invasive breast cancer treated at Yale Cancer Center from 2008-2012 to identify patients that received ODx testing, and abstracted clinical and tumor characteristics including: age, tumor size, grade, histology, lymphovascular invasion (LVI), number of involved nodes, size of nodal metastasis, presence of extracapsular extension, hormone receptor status (including percent positive), HER2 status (by FISH), RS, and receipt of CTx. The RS was categorized into low (<18), intermediate (18-30), and high score (>30). We assessed the association between these characteristics and both high RS as well as CTx receipt using Chi squared tests and Wilcoxon ranked test as appropriate. Characteristics with a p-value <0.1 in bivariate analysis were included in logistic models to estimate the odds of a high RS and receiving CTx.

Results: We identified 432 women with a median age of 58 years. RS was low, intermediate, and high in 56%, 37%, and 7%, respectively. Median tumor size was 1.6cm (range 0.1-13.2). Differentiation was rated as well, moderate, or poor in 32%, 60%, and 8%, respectively. Tumors were hormone receptor positive in 99%. ODx was used outside of NCCN guidelines in 12%. CTx was given to 30% of patients. Younger age, HER2-positivity, LVI, poor differentiation, progesterone receptor positivity (PR+) 50% or less, and RS were associated with receipt of CTx (p< = 0.01) in bivariate analyses. High RS remained independently associated with CTx receipt in multivariate analysis. Poor differentiation, PR+ 50% or less, and HER2-positivity were significantly associated with a high RS (p<0.01), and all remained independently associated with high RS in multivariate analysis. Patients with any one of these three factors had 18% odds of a high RS, versus just 1% among those without such risk factors.

Conclusions: High RS independently influences recommendations for chemotherapy. Poor differentiation, PR+ 50% or less, and HER2-positivity were associated with a high RS. In the absence of any of these three factors, the likelihood of a high RS is minimal. Noncompliance with NCCN guidelines was observed.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-11-22.

Formation and Function of Acute Stroke–Ready Hospitals Within a Stroke System of Care Recommendations From the Brain Attack Coalition

Background and Purpose—

Many patients with an acute stroke live in areas without ready access to a Primary or Comprehensive Stroke Center. The formation of care facilities that meet the needs of these patients might improve their care and outcomes and guide them and emergency responders to such centers within a stroke system of care.

Methods—

The Brain Attack Coalition conducted an electronic search of the English medical literature from January 2000 to December 2012 to identify care elements and processes shown to be beneficial for acute stroke care. We used evidence grading and consensus paradigms to synthesize recommendations for Acute Stroke–Ready Hospitals (ASRHs).

Results—

Several key elements for an ASRH were identified, including acute stroke teams, written care protocols, involvement of emergency medical services and emergency department, and rapid laboratory and neuroimaging testing. Unique aspects include the use of telemedicine, hospital transfer protocols, and drip and ship therapies. Emergent therapies include the use of intravenous tissue-type plasminogen activator and the reversal of coagulopathies. Although many of the care elements are similar to those of a Primary Stroke Center, compliance rates of ≥67% are suggested in recognition of the staffing, logistical, and financial challenges faced by rural facilities.

Conclusions—

ASRHs will form the foundation for acute stroke care in many settings. Recommended elements of an ASRH build on those proven to improve care and outcomes at Primary Stroke Centers. The ASRH will be a key component for patient care within an evolving stroke system of care.

Abstract P259: Novel Risk Factors and Management Strategies for Transient Ischemic Attack and Stroke: The Inova Fairfax Stroke Database

INTRODUCTION Several studies suggest that obstructive sleep apnea (OSA) is a novel risk factor for cerebrovascular and cardiovascular disease. The Berlin Questionnaire (BQ) which is an inexpensive screen for OSA was used in the current study to examine potential associations between OSA (as measured by BQ), stroke and transient ischemic attack (TIA).

METHODS During the 2008 calendar year 1,434 stroke and/or TIA patients were evaluated by the stroke response nurses at Inova Fairfax Hospital. Although the original sample size provided by the Inova staff was 1,433, not all of the patients responded to the BQ. Of the 1,433 cases, 113 were eliminated because they had non-unique responses. Of the remaining cases, 60 cases were left that provided complete responses to the BQ and had no missing values.

STATISTICAL ANALYSIS We focused only on two outcomes, ischemic stroke and TIA. Demographic variables: Gender, race (white and non-white), and age. Descriptive statistics were performed for all variables. Univariate analyses were performed and associations between the dependent variables and the predictors were analyzed using exact tests. Logistic regression models were built to identify any potential risk factors for TIA and ischemic stroke.

RESULTS In this sample, approximately 28.3% were females and 71.6% were male. The sample was composed of 65% white and 35% non-white patients. The average age of the entire sample was 65.6 years (SD= 13.2 years). Further, 23.3% were identified as having TIA, 55.5% had suffered ischemic stroke while 21.6% had other type of stroke or no diagnosis.

Exact tests of significance failed to detect any significant associations between stroke type and OSA as measured by BQ. Furthermore, we did not find any significant associations or differences between age, race, gender, OSA and the outcome variables. Findings from the binary logistic regression models did not identify any significant predictors of TIA and ischemic stroke.

CONCLUSIONS Although in this study we did not find a significant association between OSA, TIA and ischemic stroke, we recommend that this study be replicated with larger samples. An analysis of the cause of such low number of complete responses will follow as well.

Abstract P258: Gender, Race, Age and Insurance Status in Patients Treated with tPA

BACKGROUND AND PURPOSE: At a large Stroke Certified Hospital serving a diverse population we analyzed Tissue Plasminogen Activator treatment (tPA) administration for ischemic stroke patients. tPA treatment is time dependent and we wanted to determine whether insurance type, race, age and/or gender affected the time frame of tPA treatment.

METHODS: We used data from our Stroke database which covered patients treated at Fairfax INOVA hospital from February 2004 to April 2010. A total of 144 patients were treated within this time for ischemic stroke. Of these 144 patients, 99 were White, 19 were Asian, 16 were Black, and 10 belonged to other races. In order to avoid computational and estimation problems associated with small cell sizes, all non-White races were combined into a single category (n = 45). We used time between last known well and treatment as our dependent variable. Our predictors were demographic controls including age, gender, and sex and other dummy variables and an ANOVA model was run to produce the results.

RESULTS: The factorial ANOVA results are presented in Table 1. As the p values indicate, no significant group differences were observed for race, gender, age or insurance type.

CONCLUSIONS: We found that ischemic stroke patients receiving tPA treatment did so in a timely manner and factors such as insurance type, race, gender or age had no significant effect on the likelihood of receiving treatment. There appeared to be no disparity based on the variables examined in our sample. In the future we recommend this study be replicated with a larger sample size.

Revised and updated recommendations for the establishment of primary stroke centers: a summary statement from the brain attack coalition

BACKGROUND AND PURPOSE

The formation and certification of Primary Stroke Centers has progressed rapidly since the Brain Attack Coalition's original recommendations in 2000. The purpose of this article is to revise and update our recommendations for Primary Stroke Centers to reflect the latest data and experience.

METHODS

We conducted a literature review using MEDLINE and PubMed from March 2000 to January 2011. The review focused on studies that were relevant for acute stroke diagnosis, treatment, and care. Original references as well as meta-analyses and other care guidelines were also reviewed and included if found to be valid and relevant. Levels of evidence were added to reflect current guideline development practices.

RESULTS

Based on the literature review and experience at Primary Stroke Centers, the importance of some elements has been further strengthened, and several new areas have been added. These include (1) the importance of acute stroke teams; (2) the importance of Stroke Units with telemetry monitoring; (3) performance of brain imaging with MRI and diffusion-weighted sequences; (4) assessment of cerebral vasculature with MR angiography or CT angiography; (5) cardiac imaging; (6) early initiation of rehabilitation therapies; and (7) certification by an independent body, including a site visit and disease performance measures.

CONCLUSIONS

Based on the evidence, several elements of Primary Stroke Centers are particularly important for improving the care of patients with an acute stroke. Additional elements focus on imaging of the brain, the cerebral vasculature, and the heart. These new elements may improve the care and outcomes for patients with stroke cared for at a Primary Stroke Center.

Leukotrienes in atherosclerosis: new target insights and future therapy perspectives

Atherosclerosis represents an important chronic inflammatory process associated with several pathophysiological reactions in the vascular wall. The arachidonic acid, released by phospholipase A2, is an important substrate for the production of a group of lipid mediators known as leukotrienes, which induce proinflammatory signaling through the activation of specific BLT and CysLT receptors. The interaction of these substances in the vascular wall determines important morphological alterations like the early lipid retention and the accumulation of foam cells, the development of intimal hyperplasia, and advanced atherosclerotic lesions, and it plays an important role in the rupture of atherosclerotic plaque. Many studies regarding myocardial ischemia and reperfusion show that leukotriene signaling may be involved in the development of ischemic injury. For these, reasons both leukotriene synthesis inhibitors and leukotriene receptor antagonists have been suggested for inducing beneficial effects at different stages of the atherosclerosis process and may represent a new therapeutic target in the treatment of atherosclerotic vessel diseases, in particular in acute coronary syndrome.

Early detection of psychosis: finding those at clinical high risk

AIM

In early detection work, recruiting individuals who meet the prodromal criteria is difficult. The aim of this paper was to describe the development of a research clinic for individuals who appear to be at risk of developing a psychosis and the process for educating the community and obtaining referrals.

METHODS

The outcome of all referrals to the clinic over a 4-year period was examined.

RESULTS

Following an ongoing education campaign that was over inclusive in order to aid recruitment, approximately 27% of all referrals met the criteria for being at clinical high risk of psychosis.

CONCLUSIONS

We are seeing only a small proportion of those in the community who eventually go on to develop a psychotic illness. This raises two important issues, namely how to remedy the situation, and second, the impact of this on current research in terms of sampling bias and generalizability of research findings.

Protective effect of lycopene in cardiovascular disease

Coronary artery disease (CAD) represents the primary cause of death in Western Countries with an high incidence on human health and community social costs. Oxidative stress induced by reactive oxygen species (ROS) plays an important role in the aetiology of this disease. In particular, the LDL-oxidization has a key role in the pathogenesis of atherosclerosis and cardiovascular heart diseases through the initiation of plaque formation process. Dietary phytochemical products such antioxidant vitamins (A,C,E) and bioactive food components (alpha- and beta-carotene) have shown an antioxidant effect in reducing both oxidative markers stress and LDL-oxidization process. Scientifical evidences support the beneficial roles of phytochemicals in the prevention of some chronic diseases. Lycopene, an oxygenated carotenoid with great antioxidant properties, has shown both in epidemiological studies and supplementation human trials a reduction of cardiovascular risk. However, controlled clinical trials and dietary intervention studies using well-defined subjects population haven't been provided a clear evidence of lycopene in the prevention of cardiovascular diseases. The present short review aims to evaluate the beneficial effect of lycopene in the prevention of cardiovascular disease.

Plasma lycopene and antioxidant vitamins in asthma: the PLAVA study

OBJECTIVE

Scientific evidence suggests that lycopene and antioxidant vitamins have significant antioxidant and protective effects.

METHODS

This case-control study included 96 subjects (40 asthmatics, 56 healthy control subjects). Baseline blood samples, pulmonary function tests, and clinical and alimentary histories were collected. All subjects were grouped by age, sex, cigarette smoking habit, body mass index, alimentary intake, and atopic status.

RESULTS

Serum lycopene concentration was significantly lower in asthmatic subjects than in healthy control subjects (0.10+/-0.7 micromoL/L vs. 0.16+/-0.8 micromoL/L--p<0.001). Serum vitamin A concentration was significantly lower in asthmatics (2.38+/-0.37 micromoL/L) in respect to control subjects (3.06+/-0.56 micromoL/L) (p<0.01). Plasma serum concentration of vitamin E and beta-carotene were not found to be different in the two groups.

CONCLUSIONS

Dietary supplementation or adequate intake of lycopene and vitamin A rich foods may be beneficial in asthmatic subjects.

Antileukotriene drugs: clinical application, effectiveness and safety

Cysteinyl leukotrienes (Cys-LTs) are potent proinflammatory mediators derived from arachidonic acid through the 5-lypoxigenase (5-LO) pathway. They exert important pharmacological effects by interaction with at least two different receptors: Cys-LT(1) and Cys-LT(2). By competitive binding to the Cys-LT(1) receptor, leukotriene receptor antagonist drugs such as montelukast, zafirlukast, and pranlukast, block the effects of Cys-LTs and alleviate the symptoms of many chronic diseases, especially bronchial asthma and allergic rhinitis. Evidence obtained by randomized clinical trials as also by direct experience derived from patients suffering from asthma and allergic rhinitis justifies a broader role for leukotrienes receptor antagonists (LTRAs). Recently published studies and case reports have demonstrated beneficial effects of LTRAs on other diseases commonly associated with asthma (exercise induced asthma, rhinitis, chronic obstructive pulmonary disease, interstitial lung disease, chronic urticaria, atopic dermatitis, allergic fungal disease, nasal polyposis, and paranasal sinus disease) as well as other diseases not connected to asthma (migraine, respiratory syncytial virus postbronchiolitis, systemic mastocytosis, cystic fibrosis, pancreatitis, vulvovaginal candidiasis, cancer, atherosclerosis, eosinophils cystitis, otitis media, capsular contracture, and eosinophilic gastrointestinal disorders). The aim of this review is to show the most recent applications and effectiveness in clinical practice of the LTRAs.

[Anastomotic dehiscence in colorectal surgery. Analysis of 1290 patients]

The most frightening complication following colorectal surgery is the anastomotic leakage which is associated with an high mortality rate, and the analysis of risk factors for the anastomotic leak is of great interest. The aim of this retrospective study is to evaluate the risk factor for the anastomotic leakage in personal series of patients who underwent colorectal surgery. We have analyzed a consecutive series of 1290 patients who underwent colorectal open surgery from 1970 to 2004. The associations between anastomotic leak and several risk factors were studied by univariate analysis. The variables considered were the following: age; sex; type of disease; elective or emergency surgery; type of surgery; type, design and site (intra or extra peritoneal) of the anastomosis; stapled or manual anastomosis; distance from anal verge of the colorectal anastomosis; intraoperative complications; protective stoma. The rate of anastomotic leakage was 4.8% (62/1290 patients). Significant factors were: the type of surgery (higher risk after restorative proctocolectomy or rectal resection), the site extra peritoneal of the anastomosis, the type of the anastomosis (higher risk after coloanal or ileal-pouch anal or colorectal), the stapled anastomosis, the intraoperative complications. After colorectal anastomosis the risk of leakage has progressively higher for low, ultra-low and coloanal anastomosis. In these conditions a protective stoma seems to be suitable.

Compliance therapy with anti-inflammatory antiasthmatic drugs: inhaled corticosteroids and leukotriene receptor antagonists

Bronchial asthma represents the commonest chronic respiratory disease in industrialized countries and its prevalence is increasing throughout the world. This is a chronic inflammatory disease in which the inflammation constitutes an important predisposing condition for airway remodelling and secondary irreversible airflow obstruction. The current approach for the treatment involves many classes of drugs, particularly anti-inflammatory such inhaled and oral corticosteroids and cysteinyl-leukotriene receptor antagonist. The pharmacology of drugs used in asthma represents an important factor that conditioning the effectiveness of therapy. In fact, many studies have demonstrated that some asthmatic patients have particular problems that deserve special treatment. Another important factor of asthma treatment is represented by delivery devices for the inhalation of medications and their correct use because, at the present, it is estimated that compliance to controller anti-asthmatic therapy is no more than 50%. The aim of this review is to focus on the compliance in the treatment of asthma and the use of antiinflammatory therapies with inhaled corticosteroids and leukotriene receptor antagonist drugs.

Predictive value of biochemical markers in stroke

Biochemical markers of cerebral ischemia and subsequent inflammation represent a potential diagnostic and predictive modality in acute ischemic stroke. Measurement of these markers may improve clinical functions ranging from diagnosis of ischemic stroke to prediction of functional outcome at 3 months. Predictive models, using various biochemical markers, continue to be investigated.

Antioxidant vitamin supplementation in cardiovascular diseases

Cardiovascular disease is the most important adult health problem in wealthy countries, where biological factors such as obesity, hypertension, dyslipidemia, diabetes, inappropriate diet, cigarette smoking, and sedentary life-style have contributed to its dissemination. Research concerning nutritional regimens has shown that persons who consume large amounts of fruit and vegetables have lower incidences of cardiovascular diseases, stroke, and tumors, although the precise mechanisms for this protective effect are elusive. Possible explanations include (a) increased consumption of dietary fiber, (b) reduced consumption of dietary cholesterol and other lipids, and (c) increased intake of the antioxidant vitamins (A, C, and E). Numerous studies have raised the question whether vitamin supplements help to prevent cardiovascular diseases. Results of randomized controlled trials of antioxidant vitamin supplements in large numbers of participants has been ambiguous or contradictory. This minireview examines the relevant clinical reports on dietary supplements of vitamins A, C, and E to determine whether they support the premise that patients at risk of cardiovascular disease may be candidates for this therapeutic option.

The role of the antioxidant vitamin supplementation in the prevention of cardiovascular diseases

Industrial and technological revolutions have resulted in dramatic shifts in the diseases that are responsible for illness and death. In particular, cardiovascular disease (CVD) has emerged as the dominant chronic disease in many parts of the world. Diet, tobacco smoking, physical inactivity, obesity, lipid levels, hypertension and diabetes mellitus have contributed to their wide diffusion. Oxidative damage and the production of free radicals in the endothelium are two of the main factors involved in the pathogenesis of the atherosclerotic process that causes CVD. One of the more important results of basic research on dietetic regimes has shown that people who consume large amounts of fruits and vegetables have a lower incidence of CVD, stroke and tumours, but the specific mechanisms of these foods (which have an apparently protective effect) are still not completely clear. Possible reasons could include a greater consumption of fruit and vegetables, and an increased consumption of dietetic fibres. Recently, it been proposed that micronourishments with an antioxidant activity could be responsible for the reduction of chronic diseases. Research supplies a hypothetical mechanism by which antioxidant substances may be reducing the risk of atherosclerosis through the inhibition of oxidative damage. Appropriate nutritional practices are of central importance in managing risk and treatment of CVD; in fact, many current guidelines for a healthy general population contain nutritional recommendations to reduce the risk of these diseases. A large number of descriptive and case-control studies suggests that the consumption of many antioxidant vitamins (A, C and E) reduces the risk of CVD. Such data raises the following problem of whether supplementation of vitamins A, C and E emerges as being useful in the primary prevention of CVD. Many important studies involving a great number of participants have not confirmed this hypothesis and the results are often contradictory. This review examines the studies published in the literature that document the effect of supplementation with antioxidant vitamins (A, C and E) in the primary and secondary prevention of CVD due to an atherosclerosis process.

De novo pure 12q22q24.33 duplication: First report of a case with mental retardation, ADHD, and Dandy-Walker malformation

We present a patient with a de novo 12q nonmosaic pure duplication characterized by multiple minor anomalies and Dandy-Walker malformation. A neurological and behavioral assessment revealed psychomotor retardation and attention deficit/hyperactivity disorder (ADHD), with neurobehavioral abnormalities (auto- and heteroaggressive behavior). Fluoxetine therapy in this case markedly improved the neurobehavioral profile, with a decreased level of aggression. To define the extension of the duplicated region, we performed FISH analyses by using YAC probes. The analyses revealed a tandem duplication of the 12q22q24.33 region, with the proximal breakpoint located between 96.5 and 97.6 cM and the distal one between 154 and 161 cM. This is the first case of pure de novo duplication involving the 12q22q24.33 region. To better define the clinical phenotype associated with 12q partial duplication, we compared our case with the four patients with similar pure duplications previously described.

Metabolic Syndrome: Contributing Factors and Treatment Strategies

Metabolic syndrome is associated with increased risk for cardiovascular and cerebrovascular disease. The World Health Organization and National Cholesterol Education Program Adult Treatment Panel III have identified physiologic abnormalities associated with metabolic syndrome, including impaired glucose metabolism, high blood pressure, elevated cholesterol levels, and abdominal obesity. It is estimated that 47 million Americans have metabolic syndrome. A variety of therapies may help reduce the incidence and risk, including diet, weight loss, physical exercise, glycemic control, and pharmacological treatments. Nursing care is focused on developing an individualized plan of care that includes family members and providing education, psychosocial support, close monitoring, and continued follow-up to ensure adherence and success in achieving patient outcomes.

The effects of 99mTc-HMPAO-labelled leucocyte scan on human karyotype

Technetium-99m hexamethylpropylene amine oxime (HMPAO) white blood cell scan (WBCS) requires separation and labelling of mixed leucocytes, which include particularly radiosensitive cells, lymphocytes. Lymphocytes labelled during the mixed leucocyte labelling procedure could represent a problem for patients owing to the possible induction of chromosomal aberrations. Lymphocytes labelled in mixed leucocyte preparations are probably killed by the high-dose radiation. Nevertheless, it has been reported that some of these lymphocytes can proliferate after in vitro stimulation. If these cells were to reproduce themselves in vivo, onset of, or increase over time in, chromosomal aberrations could occur on peripheral blood lymphocytes. The present study was performed on 21 patients who underwent WBCS for suspected infection/inflammation. Blood samples of these patients were submitted to cytogenetic study, comprising karyotype determination, evaluation of sister chromatid exchanges (SCE) and evaluation of induced chromosomal breakages or rearrangement rate (B/R). This study was performed 2 h before and 7 days and 6 months after the WBCS. The results demonstrated no statistically significant differences between SCE and B/R values before and after WBCS. No cause-effect relationship appeared to exist between WBCS and the onset of chromosomal aberrations in peripheral blood lymphocytes, at least during the first 6 months post WBCS and within the limits of this study's approach. The high-dose radiation administered to lymphocytes was almost certainly sufficient to kill these cells.

[Objectives of a bloodless surgery program. A comparative study (major surgery vs. minor-medium surgery) in 51 Jehova's Witnesses patients]

AIM

The purpose of this retrospective review of the charts of 51 Jehovah's Witness patients, who underwent surgery without blood transfusions, was to compare two study groups (major surgery vs minor-medium surgery).

METHODS

We compared the following variables: age, sex, length of stay, type of surgical operation, use of intraoperative red cell salvaging devices, hemodilution, number of drainages and their stay, postoperative blood loss, complications, need of reoperation and mortality rate. Between medical variables we focused on blood production therapy and nutritional support (administration of iron, folate, erythropoietin and albumin) and blood tests (at the first day of admission; intraoperative; at the first postoperative day; at the discharge).

RESULTS

In the two study groups, we detected statistically significant differences in the following variables: total of postoperative blood loss (p < 0.00001), complications rate (p = 0.0122) and in Hgb values (intraoperative: p = 0.0197; at the first postoperative day: p = 0.0028; at the discharge: p = 0.0100).

DISCUSSION

The aims of a bloodless surgery program are: 1) minimize blood loss, reducing iatrogenic anemia and intraoperative hemorrhage loss; 2) maximize blood production by administration of erythropoietin, iron and folate; 3) maximize cardiac output by alternatives to blood transfusions, as crystalloids, colloids and blood substitutes; 4) increase oxygen content; 5) decrease metabolic rate. We focused on advantages and disadvantages of the suggested procedures. Most interesting techniques are the normovolemic hemodilution and the intraoperative red cell salvaging devices, indispensable in emergency.

CONCLUSIONS

A close team-work between surgeons, anesthesiologists and hematologists is determinant in a reference center that guarantees experience, organization, professionality, respect for the patients' will and, above all, low morbidity and mortality rates, as those reported by our series.

[Severity of anemia and operative morbidity and mortality. Report on 3 clinical cases in Jehovah's Witnesses and review of the literature]

It has been reported that patients who refuse blood transfusions, such as Jehovah's witnesses, can undergo major surgery. In a review of the literature, however, we critically examined the severity of anaemia in relation to operative mortality and morbidity rates. We report three cases of Jehovah's witnesses who underwent major surgery and presented complication during the postoperative period. Case 1: a 50-year-old man with oesophageal achalasia who underwent Heller's myotomy and Nissen's fundoplication. The postoperative period was complicated by massive haemorrhage and the patient was reoperated on postoperative day 1. After four years, he underwent total oesophagectomy because of severe chronic oesophagitis. On postoperative day 13 the patient suffered anteroseptal myocardial ischaemia, which was treated with medical therapy. Case 2: a 40-year-old man, admitted for ulcerative rectocolitis, who underwent total colectomy. On postoperative day 1 he presented massive haemorrhage and shock. He was reoperated and the postoperative period was complicated by myocardial ischaemia, renal failure and an enterocutaneous fistula. Case 3: a 65-year-old woman with ulcerative rectocolitis who underwent total colectomy and a temporary ileostomy. She suffered venous thrombosis of the lower limbs and pulmonary oedema. The patient died 14 months after surgery as a result of massive haemolysis by cryoagglutinins and cardiac arrest.

Preoperative lymphoscintigraphy and sentinel lymph node biopsy in papillary thyroid cancer. A pilot study

BACKGROUND AND OBJECTIVES

Lymphadenectomy for papillary thyroid cancer is a matter of debate. After showing its usefulness as a prognostic factor in both melanoma and breast cancer, the concept of sentinel lymph node biopsy was also recently applied to differentiated thyroid cancer. To date, all attempts to locate and remove the sentinel node were based on the intraoperative injection of a vital dye. The feasibility and the technical details of using preoperative lymphoscintigraphy coupled with intraoperative vital dye and gamma probe scanning were investigated and discussed.

METHODS

Six patients diagnosed with papillary thyroid cancer were submitted to preoperative lymphoscintigraphy with (99m)Tc-labelled colloidal albumin at different dosages. The operation consisted in a total thyroidectomy with sentinel lymph node biopsy guided by intraoperative injection of a vital dye (Blu Patent V, 2.5%) and scanning with a hand-held gamma probe. Lymph node dissection was completed in the area in which the sentinel node was located.

RESULTS

The sentinel node was identified using all the three methods in all cases (100%). Considering one of the methods alone, identification rates were 66, 50, and 83% for preoperative lymphoscintigraphy, vital dye, and probe scanning, respectively. One sentinel node was identified in four cases and two in the other two cases. The optimal dosage of the tracer appeared to be at 22 MBq.

CONCLUSIONS

These results underline the necessity to use the combination of nuclear medicine imaging and lymphatic vital dye in order to enhance the identification rate of sentinel node also in thyroid cancer. It is now necessary to check the diagnostic accuracy of this procedure through a controlled trial involving a more extended lymph node dissection in the neck.

[Lymphangiomatosis of the spleen. Report of a clinical case]

Lymphangiomatosis confined to the spleen is a very are condition. The authors in this article describes one new case and briefly reviews the literature. In this case, after the exclusion of an hydatidosis of the spleen, a total splenectomy was performed. The histologic findings confirmed the lymphangiomatosis of the spleen. The authors emphasize the surgical strategy in splenic lymphangiomyomatosis, infact the total splenectomy is mandatory, because the splenic parenchyma is nearly completely substitute by the cysts. For this reason is preferably, before surgery, to perform the antibateric profilaxis against the OPSI.

[Benign thyroid disease: 20-year experience in surgical therapy]

This retrospective study compares recurrence and postoperative complication rates after isthmo-lobectomy and subtotal thyroidectomy (group I) vs near-total and total thyroidectomy (group II) for benign thyroid disease. Seven hundred and forty-three patients were operated on for thyroid diseases over the period from 1977 to 1998. We considered 202 patients operated on for benign thyroid disease from 1988 to 1998. The follow-up ranged from 1 to 10 years (mean: 3.4 yrs). One hundred and thirty-two patients (65.3%) were operated on for bilateral nodular goitre, 35 (17.3%) for unilateral nodular goitre, 14 (6.9%) for toxic goitre and 21 (10.4%) for thyroiditis. Over the period 1988-1992, 19 patients underwent isthmo-lobectomy and 71 subtotal thyroidectomy (group I). From 1993 to 1998, 39 patients underwent near-total thyroidectomy and 61 total thyroidectomy (group II). The relapse rate was 14.4% in group I, while there were no recurrences in group II (p = 0.000064). Temporary hypocalcaemia was significantly higher (p = 0.000001) in group II (29%) than in group I (2.2%). Within group II, the rate was significantly higher (p = 0.0013) after total thyroidectomy (37.7%) than after near-total thyroidectomy (15.4%). In our experience, near-total and total thyroidectomy are an appropriate approach for preventing recurrence in patients with benign thyroid disease despite the fact that the risk of temporary hypocalcaemia is higher than after less radical surgery. Near-total thyroidectomy and the exercise of all due care in the surgical technique may help to reduce its incidence.

A multidisciplinary approach to the treatment of small-cell lung cancer: the role played by surgery

The authors report their data on 344 cases of small-cell lung cancer treated according to indications with combined chemoradiotherapy and in selected cases with surgical intervention. In patients with limited disease, the results of pharmacologic therapy significantly improve the prognosis only in association with surgery. The role of surgery has been reappraised in the treatment of small-cell lung cancer which appears, nowadays, multidisciplinary.

Benign pancreatic tumor treated with duodenum-preserving resection of the head of the pancreas. Case report

Cystic neoplasms of the pancreas constitute about 9% of all cystic lesions of the pancreas and less than 1% of all pancreatic neoplasms. Authors report the case of a 70 year-old woman with microcystic cystadenoma. Computed tomography (CT) scan of the abdomen diagnosed a 5 cm multilocular septated cyst, with calcifications in the context, localized in the head-uncinate process of the pancreas. The mass was well separated by a sharp cleavage plane with portal vein and superior mesenteric vessels. An endoscopic retrograde cholangiopancreatography (ERCP) showed cephalic symmetrical stenosis (diameter: 3 mm) of the main pancreatic duct (MPD), mildly dilated in the remaining tract (diameter: 6 mm). An intra-operative biopsy of the cystic wall had been performed. Therefore, it was decided to proceed with a duodenum-preserving resection of the head of the pancreas (DPPHR), including stenosis tract of the MPD in the surgical specimen. The reconstructive procedure consisted, by i.v. jejunal loop transposition, of a side-to-side pancreatico-jejunostomy, including in the anastomosis both corpocaudal stump and the resection cavity of the pancreatic head, and an end-to-side Roux-en-Y jejuno-jejunostomy. With respect to long-lasting pain relief and preservation of the endocrine and exocrine functions of the pancreas, duodenum-preserving resection of the head of the pancreas is a highly effective surgical procedure with low early and late morbidity and mortality due to limited surgical resections. This technique, introduced into surgical practice in 1972 by Beger, is indicated in patients with chronic pancreatitis with an inflammatory mass in the head of the pancreas. The authors conclude that this procedure can also be performed in cases of pancreatic benign tumors, such as microcystic cystadenoma. Advantages of this technique make DPPHR an attractive alternative to pylorus-preserving pancreatico-duodenectomy (PPPD).

Lessons learned from a complicated case of cephalic obstructive chronic pancreatitis

The authors report the complex case of a 51 year-old man admitted to his local hospital for gallbladder and common bile duct lithiasis, 1 year before admission to our hospital. There, he was treated by cholecystectomy and transduodenal biliary sphincteroplasty. He was readmitted after 3 months because of a painful episode and was discharged with the diagnosis of "relapsing acute pancreatitis in chronic pancreatitis." At our hospital, he underwent laparotomy and revision of the previous transduodenal biliary sphincteroplasty. Pancreatic sphincteroplasty and septectomy were also performed. The night after surgery, the patient suffered from acute post-operative pancreatitis complicated by severe hemorrhage due to erosion of the superior pancreaticoduodenal arteries, treated with gastroduodenal artery embolization by tungsten coils. Three months later, the patient suffered from another acute episode. An endoscopic retrograde colangio pancreatography (ERCP) showed the complete patency of the sphincteroplasties but clearly identified the persistence of a severe cephalic stricture. Therefore, the patient was readmitted to our hospital and underwent another laparotomy. A pylorus-preserving pancreaticoduodenectomy (PPPD) was performed. The post-operative course was uneventful and at 14 months follow-up the patient was in good health. The discussion focuses on the surgical treatment of chronic pancreatitis with cephalic Wirsung duct stenosis, stressing the increasing role of PPPD as a first-choice option.

[A case of microcystic cystadenoma treated by duodenum preserving pancreatic head resection]

Cystic neoplasms of the pancreas constitute about 9% of all cystic lesions of the pancreas and less than 1% of all pancreatic neoplasms. The case of a 70 years-old woman with microcystic cystadenoma is reported. CT-scan of the abdomen diagnosed a 5 cm multilocular septated cyst, with calcifications in the context, localized in the head-uncinate process of the pancreas. The mass was well separated by a sharp cleavage plane with portal vein and superior mesenteric vessels. An ERCP showed cephalic symmetrical stenosis (diameter 3 mm) of the main pancreatic duct (MPD), mildly dilated in the remaining tract (diameter 6 mm). An intraoperative biopsy of the cystic wall was performed. Therefore, it was decided to proceed with a duodenum-preserving resection of the head of the pancreas (DPPHR), including the stenosis tract of the MPD in the surgical specimen. The reconstructive procedure consisted, by i.v. jejunal loop transposition, in a side-to-side pancreatico-jejunostomy, including in the anastomosis both corpocaudal stump and the resection cavity of the pancreatic head, and an end-to-side Roux-en-Y jejuno-jejunostomy. With respect to long-lasting pain relief and preservation of the endocrine and exocrine functions of the pancreas, DPPHR is a highly effective surgical procedure with a low early and late morbidity and mortality due to limited surgical resection. This technique, introduced into surgical practice by Beger, is indicated in patients with chronic pancreatitis with an inflammatory mass in the head of the pancreas. The authors conclude that this procedure can be performed also in case of pancreatic benign tumors, as microcystic cystadenoma. Advantages of this technique makes DPPHR an attractive alternative to Pylorus-Preserving-Pancreatico-Duodenectomy (PPPD).

[Palliative procedures in the treatment of non-resectable pancreatic tumors. Retrospective study of 294 cases and review of the literature]

At least two thirds of patients with pancreatic cancer are still unsuitable for resection, because of the extent of their disease or because of their high-risk conditions. In these cases, a palliative treatment is indicated to maximize the quality of life, in spite of the poor prognosis. During the years 1959-95, two-hundred-ninety-four patients, affected with pancreatic neoplasm, were observed. Resectability rate was 18%. One-hundred patients underwent surgical palliation (34%): 58 biliary-bypasses, 15 gastroenterostomies and 27 double-bypasses. Sixty-nine explorative laparotomies were performed (23.4%), of which thirty-six were carried out during the years 1959-70. Sixty-three patients did not undergo surgical treatment (21.6%), of which twenty-two underwent percutaneous biliary drainage, during the years 1981-95. Overall morbidity rate was 13% with decrease during the years of major postoperative complications. During the years 1959-70 operative mortality rate after surgical bypass was 13.6%, during 1971-80 was 10.5% and during 1981-95 decreased to 8.1%. Major percentages were reported after explorative laparotomies. During the years 1959-70 and 1971-80, operative mortality rate was 16.6%, compared with 9.5% during the years 1981-95. Patients with stage II tumours survived palliative surgery for about 12.8 months, compared with those with stage III and IV tumours, who survived for about 10.6 and 5 months, respectively. Patients who did not undergo surgical treatment survived 8.3, 4 and 1.3 months, respectively in II-III and IV stages. In this paper the authors examine advantages and disadvantages of palliative procedures, on the bases of their aims: relief of obstructive jaundice, duodenal obstruction and pain.

[Resective surgical treatment of exocrine pancreas neoplasms. Retrospective study of 294 cases and review of the literature]

Authors report their own experience on the treatment of pancreatic neoplasms. Two-hundred-ninety-four patients were observed during the years 1959-95. Resectability rate was 18%. Fifty-three patients underwent pancreatic resection: 22 distal pancreatectomies (41.5%), 2 total pancreatectomies (3.7%) and 29 pancreaticoduodenectomies (54.7%) (7 PPPD). Overall morbidity rate was 15.6% with decrease during the years of major postoperative complications. More frequent complications were renal failure (4%), bleeding (1.7%) and acute pancreatitis (5.6%), which was absent during the 1981-95 period. Pancreatic fistula occurred in 5.6%, but in the years 1981-95 only one patient suffered from it (1.8%). During the years 1959-70 operative mortality rate after pancreatic resection was 22.7%, during 1971-80 was 12.5% and during 1981-95 decreased to 4.3%. Patients with stage I tumours survived curative pancreatic resection for about 18.2 months, compared with those with stage II and III tumours, who survived for about 15 and 13 months, respectively. Recent studies have demonstrated a reduction in the morbidity and mortality of pancreatic resections and improvement in the actuarial 5-year survival for patients with resected ductal adenocarcinoma. In the presence of lymphnode metastases, pancreaticoduodenectomy offers good palliation and meaningful survival. In the absence of lymphnode metastases, pancreaticoduodenectomy offers encouraging long-term survival rates and a chance for cure.

Immunopathology of the Lens. III. The effect of experimental allergic uveitis on the cation balance in the lens

Rabbit lenses from eyes suffering from experimental allergic uveitis showed a clear enhancement in the 86Rb efflux as compared to the lenses from the fellow normal eyes. Intracellular K+ was also significantly decreased and Na+ significantly increased after several relapses of inflammation.

Immunopathology of the lens. II. 86Rb efflux and protein leakage from normal lenses exposed to antilens and antiuveoretina antibodies

Normal rabbit lenses exposed in vitro to heterologous antilens and antiuveoretina antibodies lose control of the intracellular 86Rb and this effect is followed by a late leakage of lenticular proteins; both phenomena take place only in the presence of complement. This antibody-induced complement-dependent membrane damage might be involved in the pathogenesis of complicated cataracts in uveitis and in the self-maintenance of recurrent uveal inflammations.

Immunopathology of the lens. I 86Rb efflux and protein leakage from normal lenses exposed to unrelated antigen-antibody interactions

Normal rabbit lenses exposed in vitro to heterologous antibody (Ab)--antigen (Ag) interactions lose control of the intracellular 86Rb; this membrane damage, which seems to be related to the quantitative ratio Ab/Ag, is relatively complement independent and is followed by a subsequent leakage of lenticular proteins. A possible implication of these findings in the development of complicated cataracts in uveitis (as 'permeability cataracts') and in the self-maintenance of recurrent uveal inflammation is shortly discussed.