Quantitative flow ratio for the functional assessment of extracranial internal carotid artery stenosis

Background

In asymptomatic patients at high surgical risk presenting with significant extracranial internal carotid artery stenoses, a selective invasive angiography is performed before carotid artery stenting (CAS). Sometimes, the angiographic findings of the stenosis could be discordant from those observed at the non-invasive imaging evaluation and the use of a pressure-wire to evaluate the hemodynamic potential of the stenosis, might be dangerous for the higher risk of cerebrovascular events.

Purpose

The Quantitative Flow Ratio (QFR), by estimating the contrast flow velocity and based on a 3-dimensional quantitative angiography, might be of value as an online angiography-based functional assessment of internal carotid stenoses, in order to guide the physicians in the decision-making process to proceed or not to revascularization.

Methods

We prospectively enrolled 14 asymptomatic patients with an indication for invasive treatment of internal carotid artery stenosis. The echo-colour-Doppler was performed in 28 vessels and the Peak Systolic Velocity (PSV, cm/sec) was used to identify functionally significant stenoses (PSV >120cm/sec). At the angiography, internal carotid artery stenosis degree was obtained according to NASCET criteria (%DSNASCET) and the lesion considered angiographically significant if >60%. After the exclusion of 4 vessels, QFR, Area Stenosis (AS, %) and Minimal Lumen Area (MLA, mm2) were obtained in the remaining 24 vessels (Figure 1, Panel A and B).

Results

At the linear regression analysis, QFR values significantly correlated with PSV (r2=0.71, p<0.001) as well as with %DSNASCET (r2=0.81, p<0.001). In addition, using the PSV as reference, QFR showed good accuracy to predict the presence of a functionally significant stenosis (AUC=1.00, p<0.001) with a cut-off value of 0.90. Similarly, the MLA significantly correlated with both the PSV and %DSNASCET (respectively, r2=0.61 and r2=0.60, p<0.001) as well as the AS (respectively, r2=0.68 and r2=0.87, p<0.001) (Figure 2).

Conclusion

This study suggests the possibility to adopt QFR for the functional assessment of extracranial internal carotid artery stenoses and should be considered as hypothesis generating to design a larger validation trial.

Funding Acknowledgement

Type of funding sources: None.

Step-by-step illustrated guide to central neck dissection

BACKGROUND

The incidence of thyroid carcinoma has been increasing worldwide and surgery is the primary treatment. Central compartment dissection of the neck is a very delicate procedure given the risks of recurrent laryngeal nerve injury and hypoparathyroidism.

METHODS

This paper gives a detailed description of this surgical technique in a patient affected by papillary carcinoma of the thyroid gland, supported by highly representative iconographic materials from a tertiary department.

RESULTS

A stepwise description is provided, along with high-quality pictures and specific tips and tricks. Although neck dissection is a well-codified procedure, the fine details of this surgical technique are not currently available and are still the prerogative of the expert surgeon.

CONCLUSION

The central neck compartment contains several vulnerable structures; damage to these structures would affect patients' lives, possibly permanently. Anatomical knowledge and standardisation are needed for all surgeons, particularly new surgeons (such as residents) who cannot rely simply on experience.

Metabolic syndrome and cardiovascular risk prediction in peripheral arterial disease

BACKGROUND AND AIMS

Metabolic syndrome (MetS) was reported to be associated with increased cardiovascular risk in various settings, however its prognostic impact in peripheral arterial disease (PAD) is scanty.

METHODS AND RESULTS

We prospectively studied 173 patients with intermittent claudication and ankle/brachial index (ABI)<0.90, in whom MetS was defined using the criteria of both the revised version of the Adults Treatment Panel III (rATP III) and the International Diabetes Federation (IDF). Of these patients, 52.6% met the rATP III and 54.9% the IDF criteria for MetS. During a median follow-up of 31 months, 54 cardiovascular events occurred. Kaplan-Meier curves showed a greater incidence of ischemic events in patients with MetS than in those without. However, adjusted Cox analyses revealed that only IDF-MetS was independently associated with increased cardiovascular risk (HR=1.91, 95% CI 1.03-3.51, p=0.038). Kaplan-Meier curves for the four groups of patients delineated according to the bootstrapped ABI cut-off value (0.73) and the presence or absence of IDF-MetS revealed that the syndrome improved the predictive power of ABI alone. Actually, among patients with an ABI≤0.73, those with IDF-MetS had a higher cardiovascular risk than those without the syndrome (HR=2.55, 95% CI 1.22-5.12, p=0.012). This was confirmed by c-statistic, which was 0.56 for ABI alone and increased to 0.65 (p=0.046) when IDF-Mets was added to the pressure index.

CONCLUSION

In PAD, IDF-MetS, but not rATP III-MetS, is associated with an increased risk of cardiovascular events. Furthermore, IDF-MetS adds to the prognostic value of ABI, currently the most powerful prognostic indicator in PAD.

Interleukin-20 circulating levels in obese women: effect of weight loss

BACKGROUND AND AIMS

Obesity is associated with an increased risk of developing atherosclerosis. Interleukin-20 (IL-20) is a pleiotropic cytokine thought to be involved in the onset and progression of atherosclerosis. The aim of this study was to determine whether circulating levels of IL-20 are elevated in obese women and whether they could be affected by a substantial decrease in body weight.

METHODS AND RESULTS

Fifty obese and 50 age-matched, normal weight, premenopausal women participated in the study. Obese women entered into a medically supervised weight loss program aimed at reducing body weight to 90% of baseline. We measured anthropometric, glucose and lipid parameters, and IL-20, C-Reactive Protein (CRP) and interleukin-10 (IL-10) circulating levels. Circulating IL-20 and CRP levels were significantly higher in obese than control women (P=0.01), while IL-10 levels were significantly lower; IL-20 levels were positively associated with body weight (r=0.35; P=0.02) and visceral fat (waist-hip ratio; r=0.32; P=0.025). Caloric restriction-induced weight loss (>10% of original weight) over 6 months reduced IL-20 levels from 152 (112/184) to 134 (125/153)pg/ml (median and 25%/75%; P=0.03), and it was positively associated with changes in body mass index and waist-hip ratio.

CONCLUSION

In premenopausal obese women, IL-20 levels are higher than matched normal weight control women, are associated with body weight and waist-hip ratio, and are reduced by weight loss.

Occult thyroid carcinoma

Some medical definitions remain the same for many years, others change due to the progress in the diagnostic tools, which are able to distinguish markers and symptoms until then undetectable. Occult thyroid carcinoma is a general term indicating clinically different situations, whereas the incidentally detected papillary thyroid microcarcinoma is the most important from the clinical point of view. It is fundamental, for therapeutic management, to determine biological parameters which would define a small group of papillary thyroid microcarcinomas with aggressive biological behaviour. The most promising genetic and molecular markers for papillary thyroid carcinoma risk stratification are discussed in this review. Preoperative evaluation of these markers, obtained through analysis of ultrasonography-guided fine needle biopsy specimens of papillary thyroid microcarcinoma, could be very valuable in guiding treatment of this type of cancer.

Thyroid stem cells--danger or resource?

The thyroid gland has long since been known for its self-renewal ability, mainly in cases of hyperplastic disease such as goitre. Recently the amazing improvement in knowledge about stem cells has explained this potentiality. Some stem cell features and their clinical usefulness are summarized here, reviewing data from the literature: (1) the proven presence of adult stem cells in thyroid tissue, either normal, goitrous or neoplastic, bring with it important implications regarding tissue regeneration and oncogenesis; (2) modifying culture conditions and micro-environment stem cells have led to mature tissue with specialized functions. This has considerably changed the attitude of regenerative medicine and cancer research; (3) finally, identification of stem cells and stem cell markers in thyroid cancer, gives hope for the development of new therapeutic approaches in recurrent or treatment-resistant thyroid cancer.

Compartmental surgery in tongue tumours: description of a new surgical technique

The aim of curative surgical oncology is to remove the primary tumour with a wide margin of normal tissue. What constitutes a sufficiently wide margin particularly in oral cancer is fundamentally unclear. The currently accepted standard is to remove the primary lesion with a 1.5-2 cm circumferential macroscopic margin. In the last ten years, anatomical considerations in the approach to primary, advanced and untreated tumours of the tongue led us to develop and improve a new surgical approach to their demolition and reconstruction. From July 1999 to July 2009, at the European Institute of Oncology in Milano, Italy, 155 patients were treated, while defining and refining the concept of compartmental tongue surgery (CTS) and its main components: 1) anatomical approach to the disease that requires removal of the primary lesion and all of the potential pathways of progression--muscular, lymphatic and vascular; 2) identification of a distinct territory at risk of metastatic representation of the disease: the parenchymal structures between the primary tumour and the cervical lymphatic chain that include the muscular (mylohyoid), neuro-vascular (lingual nerve and vein) and glandular (sublingual and submandibular) tissues; 3) preparation for a rational reconstruction in consideration of a functional defect resulting from this anatomical demolition.

Role of perfusion computed tomography (CTp) for pretherapy assessment and induction chemotherapy monitoring (IC) in patients with squamous cell carcinoma (SCC) of the head and neck

e17015

Background: Reliable assessment of the response to IC is required to stratify further treatments, as responders are considered the best candidates for organ preservation strategies. We evaluated the role of CTp for pre-therapy assessment and IC monitoring in patients with SCC of the head and neck. Methods: From November 2004, 28 consecutive patients with locally advanced SCC of the head and neck were enrolled, undergoing CTp and volumetric CT before and after IC with cisplatin, administered at a dose of 100 mg/m2 iv, on day 1, and 5-fluorouracil, administered at a dose of 1,000 mg/m2 ci from day 1 to day 5, q3wks for 2 or 3 cycles. Perfusion parameters were calculated for tumor: blood flow (BF), blood volume (BV), mean transit time (MTT) and capillary permeability-surface (PS). The Wilcoxon rank sum test was used to test for differences in the pre-therapy perfusion parameters between the different tumor grades, as well as between responders and nonresponders to IC. The post-therapy perfusion parameters were compared with the pre-therapy ones by the Wilcoxon signed rank test and percent changes in perfusion parameters were correlated with percent changes in tumor volume calculated by volumetric CT after IC by the Spearman correlation coefficient. Results: Pre-therapy BF was significantly higher in G3 tumors, compared to G1 and G2 (p = 0.01) and G2 tumors (p = 0.03), and pre-therapy BV significantly higher in responders than in nonresponders (p = 0.01). Of the 20 patients who underwent post-therapy CTp, the 17 responders had significant reduction of BF (p = 0.003) and BV (p = 0.014) and increase of MTT (p = 0.04) in the post-therapy CTp, whereas the 3 non responders no significant changes in perfusion parameters. In the 17 responders, percent reduction in BF and BV showed correlation (Spearman R = 0.71, p = 0.0013 and R = 0.82, p = 0.00005, respectively) with percent reduction in tumor volume after IC. Conclusions: In our cohort of patients with SCC of the head and neck, CTp showed potential for pre-therapy assessment, as well as for IC monitoring; further studies are required to confirm our preliminary results.

No significant financial relationships to disclose.

Intra- and interobserver agreement and impact of arterial input selection in perfusion CT measurements performed in squamous cell carcinoma of the upper aerodigestive tract

BACKGROUND AND PURPOSE

CT Perfusion (CTP) has shown potential for assessing head and neck tumors. Our purposes were to assess the inter- and intraobserver agreement of CTP measurements and to investigate whether the selection of arterial input, ipsilateral versus contralateral to the tumor or left-versus-right external carotid artery (ECA), may affect CTP measurements in patients with squamous cell carcinoma (SCCA) of the upper aerodigestive tract.

MATERIALS AND METHODS

Twenty-six patients with SCCA were enrolled in this prospective study and underwent CTP. Data were analyzed by 2 expert readers and by an inexperienced reader for interobserver agreement and by the 2 expert readers for intraobserver agreement assessment, by using the ECA ipsilateral to tumor site as arterial input. All 3 readers repeated their analysis by using the ECA contralateral to tumor site as arterial input. Inter- and intraobserver agreement was assessed by using the Bland-Altman approach; CTP measurements by using ipsilateral-versus-contralateral or left-versus-right ECA were compared by using the Wilcoxon signed rank test.

RESULTS

The geometric mean of the ratios (95% limits of agreement) for inter- and intraobserver agreement ranged from 0.96 (0.75-1.23) to 1.00 (0.92-1.10) for blood flow (BF), from 0.88 (0.63-1.21) to 1.00 (0.88-1.14) for blood volume (BV), from 0.96 (0.64-1.44) to 0.98 (0.76-1.27) for mean transit time (MTT), and from 0.85 (0.41-1.76) to 1.14 (0.70-1.86) for permeability surface area product (PS). Significantly higher tumor PS and MTT for 2 readers and lower tumor BF for 1 of 3 readers were observed when the arterial input was placed in the left ECA.

CONCLUSIONS

BF, BV, and MTT demonstrated higher inter- and intraobserver agreement than PS. The selection of arterial input, right-versus-left ECA, may determine changes in CTP measurements in patients with SCCA of the upper aerodigestive tract.

Role of prophylactic central neck dissection in cN0 papillary thyroid cancer

Prophylactic central neck dissection in papillary thyroid cancer is controversial. In this retrospective cohort study, the aim was to assess possible advantages of prophylactic central neck dissection with total thyroidectomy in cN0 papillary thyroid cancer. A total of 244 consecutive patients with papillary thyroid cancer, without clinical and ultrasound nodal metastases (cN0), were evaluated out of 1373 patients operated for a thyroid disease at the Istituto Europeo di Oncologia, Milan, Italy from 1994 to 2006. Of these 244 patients, 126 (Group A) underwent thyroidectomy with central neck dissection, while 118 (Group B) underwent thyroidectomy alone. Demographic, clinical and pathological features were analysed. Overall recurrence rate was 6.3% (8/126) in Group A and 7.7% (9/118) in Group B, with a mean follow-up of 47 (Group A) and 64 (Group B) months. In Group A patients, 47% were pN1a and all patients with recurrence had nodal involvement (p = 0.002). Survival rate did not differ in the two groups. Nine patients were lost to follow-up. Group A patients were older and their tumours were larger in size; according to the pT distribution, a higher extra-capsular invasion rate was observed. The two groups were equivalent as far as concerns histological high risk variants and multifocality. Nodal metastases correlated with stage: pT1-2 vs. pT3-T4a, p = 0.0036. A lower risk of nodal metastases was related to thyroiditis (p = 0.0034). In conclusion, central neck metastases were predictive of recurrence without influencing prognosis. From data obtained, possible greatest efficacy of central neck dissection in pT3-4 papillary thyroid cancer without thyroiditis is suggested.

The impact of comorbidity burden on the cardiovascular risk in the Peripheral Arteriopathy and Cardiovascular Events study

BACKGROUND

A comprehensive evaluation of comorbidity is important in predicting outcome of patients affected by a chronic disease because of the role of competing risk.

AIM

To assess the prognostic impact of the Cumulative Illness Rating Scale (CIRS) on the cardiovascular risk of subjects participating in the Peripheral Arteriopathy and Cardiovascular Events (PACE) study.

DESIGN

Prospective study.

METHODS

The study included 60 patients with peripheral arterial disease (PAD) and 163 no-PAD subjects. CIRS-illness severity (IS) score and CIRS-comorbidity index (CI) were calculated.

RESULTS

After a 42-month follow-up, 18/223 participants had a myocardial infarction or stroke. These subjects had a higher CIRS-IS score (1.99 +/- 0.52 vs. 1.71 +/- 0.37, P = 0.003) and a higher CIRS-CI (4.00 +/- 2.81 vs. 2.65 +/- 1.85, P = 0.005) vs. the 205 subjects without event. However, the significant association of CIRS scores with the outcome disappeared when conditions considered to be 'concordant' with the endpoint were excluded from the calculation of the scores. Importantly, among the 163 no-PAD subjects CIRS scores did not differ between those with and without an event. Conversely, in the 60 PAD patients, the CIRS-IS score calculated excluding the 'concordant' conditions was associated with an increased cardiovascular risk (RR = 4.03, 95% confidence interval (CI) 1.05-15.37, P = 0.042) after adjustment for potential confounders. The corresponding RR for the CIRS-CI was 1.43 (95% CI 1.03-1.98, P = 0.032). Furthermore, both CIRS scores improved the predictive value of ankle/brachial index, which is the most powerful prognostic indicator in PAD.

CONCLUSION

Our findings indicate that overall comorbidity, and not only cardiovascular comorbidity, must be considered for prediction of myocardial infarction and stroke in PAD.

Role of sentinel lymph node biopsy in oral cancer

Squamous cell carcinoma of the oral cavity represents about 2% of all malignant neoplasms and 47% of those developing in the head and neck area. The tongue is the most common site involved, and this incidence is increasing mainly in young people, possibly related to human papilloma virus infections. Prognosis depends on the stage: the 5-year survival rate of tongue squamous cell carcinoma, whatever the T stage, is 73% in pN0 cases, 40% in patients with positive nodes without extracapsular spread (pNl ECS-), and 29% when nodes are metastatic with extracapsular spread (pNl ECS+: p > or = 0.0001). Nodal micrometastases (cN0 pN1) are found in up to 50% of cN0 tongue squamous cell carcinoma patients operated on the neck. At present, no clinical, imaging staging modalities or biological markers are available to diagnose nodal micrometastases. The sentinel node biopsy has been tested since 1996 in order to find a solution to this problem. The sentinel node is the first node reached by the lymphatic stream, assuming an orderly and sequential drainage from the tumour site, and should be predictive of the nodal stage. According to the literature, sentinel node biopsy is a reliable technique in selected cN0 cases, but the procedure is still experimental and should not be performed outside validation trials. Successful application of sentinel node biopsy in the head and neck region requires surgical experience and specific technical devices, including pre-operative lymphoscintigraphy and intra-operative gamma-probe. Moreover, dynamic lymphoscintigraphy seems to be able to show the lymphatic stream from the primary tumour and could allow a selective neck dissection to be tailored thus reducing the related morbidity.

Mediterranean diet improves erectile function in subjects with the metabolic syndrome

Men with the metabolic syndrome demonstrate an increased prevalence of erectile dysfunction (ED). In the present study, we tested the effect of a Mediterranean-style diet on ED in men with the metabolic syndrome. Men were identified in our database of subjects participating in controlled trials evaluating the effect of lifestyle changes and were included if they had a diagnosis of ED associated with a diagnosis of metabolic syndrome, complete follow-up in the study trial, and intervention focused mainly on dietary changes. Sixty-five men with the metabolic syndrome met the inclusion/exclusion criteria; 35 out of them were assigned to the Mediterranean-style diet and 30 to the control diet. After 2 years, men on the Mediterranean diet consumed more fruits, vegetables, nuts, whole grain, and olive oil as compared with men on the control diet. Endothelial function score and inflammatory markers (C-reactive protein) improved in the intervention group, but remained stable in the control group. There were 13 men in the intervention group and two in the control group (P=0.015) that reported an IIEF score of 22 or higher. Mediterranean-style diet rich in whole grain, fruits, vegetables, legumes, walnut, and olive oil might be effective per se in reducing the prevalence of ED in men with the metabolic syndrome.

Schwannoma of thyroid bed. A case report and considerations on interdisciplinary collaboration

Schwannoma of the thyroid bed is extremely rare, but is known to simulate a thyroid nodule. A retrospective review is reported of a 64-year-old female patient with a thyroid nodule who had been submitted to pre-operative fine-needle aspiration biopsy, judged inadequate, following which total thyroidectomy was performed. On histological examination, the nodule (in the thyroid bed) was found to be a schwannoma. This case report stresses the importance of interdisciplinary collaboration. Better co-operation between surgeon, pathologist and radiologist may have led to correct pre-operative diagnosis with sparing of at least half the thyroid.

Thyroid disease in northern Italian children born around the time of the Chernobyl nuclear accident

BACKGROUND

The Chernobyl nuclear accident of 1986 caused a dramatic increase in the incidence of thyroid cancers in exposed children in Belarus. Airborne radioactivity from the reactor spread over northern Italy, where rainout gave rise to low levels of radioactivity at ground level.

PATIENTS AND METHODS

As the latency between exposure to ionising radiation and development of thyroid cancer is thought to be about 10 years, in 1996/1997 all children born in 1985 and 1986 and attending school in an area of Milan, Italy were examined for thyroid nodules. A total of 3949 children were examined by two physicians blinded to the examination and diagnosis of the other. The children were to be reassessed in 2001/2002.

RESULTS

In total, 1% had palpable nodules. The nodule diagnoses were: Hurtle cell adenoma (one), thyroglossal duct cyst (one), thyroid cyst (four) and thyroiditis (four). The prevalence of thyroid disease in the cohort was indistinguishable from that of populations not exposed to radioactive pollution. Only 10 children re-presented for examination 5 years later; all were negative. The direct costs of the study were estimated at 21,200 Euros.

CONCLUSION

The high cost of the study in relation to reassuring lack of increase in thyroid nodule prevalence suggests that further studies are not justified.

Erectile dysfunction associates with endothelial dysfunction and raised proinflammatory cytokine levels in obese men

Erectile and endothelial dysfunction may have some shared pathways through a defect in nitric oxide activity. We evaluated associations between erectile function, endothelial function and markers of systemic vascular inflammation in 80 obese men, aged 35-55 yr, divided into two equal groups according to the presence/absence of erectile dysfunction. Compared with non-obese age-matched men [no.=50, body mass index (BMI)=24 +/- 1], obese men (all) had impaired indices of endothelial function as suggested by the reduced mean blood pressure and platelet aggregation responses to L-arginine, and higher circulating concentrations of the proinflammatory cytokines interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-18 (IL-18), as well as C-reactive protein (CRP). The mean erectile function score was 14 +/- 4 (range 7-19) in obese men with erectile dysfunction and 23.5 +/- 1 (range 22-25) in obese men without erectile dysfunction. Endothelial function showed a greater impairment in impotent obese men as compared with potent obese men. The mean blood pressure and platelet aggregation decreases following L-arginine were -1.5 +/- 1.1 mmHg and -1.1 +/- 1.2%, respectively, in obese men with erectile dysfunction, and -3.4 +/- 1.2 mmHg and -5.6 +/- 2.1%, respectively, in obese men without erectile dysfunction (p < 0.01). Circulating CRP levels were significantly higher in obese men with erectile dysfunction as compared with obese men without erectile dysfunction (p < 0.05). Erectile function score was positively associated with mean blood pressure responses to L-arginine and negatively associated with BMI, waist-to-hip ratio (WHR), and CRR Erectile and endothelial dysfunction associate in obese men and may contribute to their raised cardiovascular risk through impaired nitric oxide availability elicited by a low-grade inflammatory state.

Effect of liposuction on insulin resistance and vascular inflammatory markers in obese women

Liposuction is one of the more common elective surgical procedures in the US and is supposed to be on the increase. There are no reported studies specifically addressing the metabolic sequelae of liposuction in obesity. The aim of the present study was to investigate the role of large-volume liposuction on insulin resistance and circulating inflammatory markers in obese people. Thirty healthy premenopausal obese (body mass index (BMI) from 30 to 45) and 30 age-matched normal weight (BMI<25) women were studied. In obese women, insulin sensitivity, as measured by the Homeostasis Model Assessment (HOMA=fasting plasma glucose x fasting serum insulin divided by 25), as well as serum adiponectin, the novel adipocytokine with insulin sensitising properties, were significantly lower, as compared with nonobese women (p<0.01), indicating insulin resistance; on the contrary, serum concentrations of the proinflammatory cytokines IL-6, IL-18 and TNF-alpha, as well as the sensitive marker of inflammation C-reactive protein, were significantly higher (p<0.01). All obese women were submitted to a single large volume liposuction (superwet technique): the mean aspirate volume was 3540 ml (range 2550-4670), corresponding to a net lipid loss of 2.7+/-0.7 kg (mean+/-SD). After six months of stable body weight after liposuction, women were less insulin resistant (p<0.05), had reduced concentrations of IL-6, IL-18, TNF-alpha and CRP (p<0.05-0.02), and increased serum levels of adiponectin (p<0.02) and HDL-cholesterol (p<0.05). There was a significant correlation between the amount of fat aspirate and changes in HOMA (r=0.28, p<0.05), TNF-alpha (r=0.31, p<0.02), and adiponectin (r=-0.34, p<0.02), as well as between the decrease in TNF-alpha and the increase in adiponectin after the surgical procedure (r=-0.45, p<0.01). Our study demonstrates that liposuction is safe and free of metabolic sequelae in obese women, pending a careful screening of the patient. Moreover, it is associated with amelioration of insulin resistance and reduced circulating markers of vascular inflammation which may help obese subjects to reduce their cardiovascular risk.

Verapamil inhibits interleukin-6 and vascular endothelial growth factor production in primary cultures of keloid fibroblasts

An increased secretion of cytokines and growth factors has been hypothesised to play a role in the abnormal growth of keloid fibroblasts. The aim of this study was to evaluate the effect of the calcium antagonist verapamil on the interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF) secretion, as well as on cellular growth, in primary cultures of fibroblasts derived from the central part of keloid lesions. These cells grew faster than peripheral keloid and nonkeloid fibroblasts, and, in long-term cultures, became stratified assuming a three-dimensional structure. Compared with peripheral and nonkeloid fibroblasts, central keloid fibroblasts presented an increased production of both IL-6 and VEGF (P<0.03 and P<0.005, respectively). Verapamil (100 microM) decreased IL-6 and VEGF production (P<0.03 and P<0.005, respectively) in central keloid fibroblasts cultures at 72 h. Moreover, verapamil decreased cellular proliferation by 29% and increased apoptosis to an absolute value of 8%. The results of this study demonstrate that in primary cultures of central keloid fibroblasts verapamil reduces the sustained basal IL-6 and VEGF production and inhibits cell growth; these data may offer the link with the beneficial effect of calcium antagonists on keloid scars in vivo.

Effect of a multidisciplinary program of weight reduction on endothelial functions in obese women

Obesity is associated with an increased risk of developing atherosclerosis and atherosclerotic lesions are essentially an inflammatory response. The aim of this study was to evaluate the effect of a medically supervised, multidisciplinary weight loss program on endothelial functions and circulating levels of proinflammatory cytokines in obese women. Twenty healthy pre-menopausal obese women and 20 age-matched normal weight women were studied. Endothelial functions were assessed by evaluating the response of blood pressure and platelet aggregation to an intravenous bolus of L-arginine (3 g), the natural precursor of nitric oxide. In obese women, the vascular and rheological responses to L-arginine were significantly lower (p < 0.05) at baseline, as compared with non-obese women, indicating endothelial dysfunction; on the contrary, basal concentrations of tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) were significantly higher (p < 0.01). After one year of a multidisciplinary program of weight reduction consisting of diet, exercise and liposuction surgery, all obese women lost at least 10% of their original weight (10.5 +/- 1.7 kg, range 7.9-13.9 kg). Compared with baseline, sustained weight loss was associated with reduction of cytokine (p < 0.01) concentrations and with improvement of vascular responses to L-arginine. In conclusion, a multidisciplinary approach aimed at inducing a sustained reduction of body weight in obese women is feasible and is associated with improvement of endothelial functions and reduction of circulating proinflammatory cytokine concentrations.

Elevated plasma free fatty acid concentrations do not modify cardiac repolarization in patients treated by electrolyte-glucose-insulin infusion

Fat emulsion infusion is routinely used as a source of calories and essential fatty acids for critically ill patients who may be at risk for acquired ventricular repolarization alterations due either to drugs or electrolyte disturbances. The aim of this study was to evaluate whether acute elevations of plasma free fatty acid concentrations influence the corrected Q-T interval (Q-Tc), Q-Tc dispersion and sympathetic nervous system activity in patients requiring parenteral nutrition. Thirty hospitalized patients (mean +/- SD: 62 +/- 17 yr of age) requiring total parenteral nutrition received an infusion of 10% (500 ml) triacylglycerol emulsion as a source of calories (450 Kcal); on another occasion, and in random order, the same patients received an infusion of 20% (500 ml) triacylglycerol emulsion (900 Kcal). The infusion lasted 8 h and was preceded by a sc injection of heparin (5,000 U). Infusions of both 10% and 20% triacylglycerol emulsion increased plasma free fatty acid (p<0.00 1) and triacylglycerol (p<0.01) concentrations, and was associated with no significant change in mean BP, heart rate, and plasma catecholamines. At baseline, Q-Tc and Q-Tc dispersion were within the normal range (<440 milliseconds for QTc and <40 ms for QTc-d) and did not show any significant change at any time during infusion of triacylglycerol emulsion at both concentrations. In the setting of a balanced parenteral nutrition, acute elevation of plasma free fatty acid concentrations in critically ill patients do not modify ventricular repolarization.

Mandible reconstruction and autogenous frozen bone graft: experimental study on rats

The aim of this study was to evaluate the biological behaviour of a frozen bone graft in orthotopic and heterotopic sites in the rat. The previous experimental study on this subject was published 25 years ago without sufficient detail about the histology and comparison between the orthotopic and ectopic sites. Therefore, being very important for future clinical application, we decided to evaluate the frozen bone graft using rats. The procedure was performed on two groups of five rats each (Charles River). After wide dissection of the inferior border of the mandible from the surrounding muscle, an inferior segmental resection 4 mm in length was performed, taking care not to fracture the superior part and to maintain mucosal integrity. This segment was placed in liquid nitrogen for two periods of 10 minutes each with a third period to allow it to reach room temperature. In the first group (A), the frozen segment was placed ectopically in a gluteal muscle pocket, and in the second group (B), the frozen bone was fixed in the same position in the same mandible. After 1 month of follow-up, the animals were killed, the bone graft was removed, and histology was performed. Results were consistent in both groups. In group A, the segment was surrounded by strong inflammatory reaction, with no vital cells or bone cells, but some vascular penetration. We concluded that there was no bone deposition and no bone rehabitation. In group B, the initial segment was strongly fixed to the remaining mandible, there was an increase of the macroscopic dimension that paralleled the increase in the dimension of the remaining mandible and the growth of the animal. The cortical part had thinned down, the medullary part presented signs of bone deposition as well as bone resorption and vascular penetration. The periosteum from the adjacent normal mandible was growing and covering the frozen bone graft, offering additional stimulus to the bone deposition. In conclusion, the frozen bone graft acts as a normal bone graft. It needs to be placed in contact with vascularised bone and surrounded by well vascularised soft tissue to allow deposition of new bone. If the frozen graft is placed ectopically, it will be surrounded by chronic inflammatory reaction with no bone deposition.

Sentinel node biopsy in head and neck cancer

The purpose of this study was to assess the value of sentinel node (SN) biopsy in oral cancer by means of a lymphoscintigraphic technique and intraoperative detection by blue-dye combined with gamma-ray probe to facilitate identification of the SN. Forty-one T1-T2N0 patients underwent lymphoscintigraphy, SN biopsy, and modified radical neck dissection. An SN was identified in 39 of 41 patients by the combined use of intraoperative blue dye and the probe and was removed. Complete neck dissections were performed and the histological evaluation compared. Thirty-eight SNs in 35 patients were negative at final pathology and correctly predicted the pathological status of the specimens from the full-neck dissections. Five SNs in four patients had micrometastases and were the only metastatic nodes identified. The results of this study on a homogenous series of patients show that SN biopsy is a valuable staging technique in T1 and T2 oral cancer with uninvolved neck, provided that no previous surgery or radiotherapy has altered lymphatic drainage in the oral cavity or in the neck. In a large number of patients, SN biopsy can avoid unnecessary neck dissection and its relevant morphofunctional sequelae.

Learning curve for translaryngeal tracheotomy in head and neck surgery

OBJECTIVES

Translaryngeal tracheotomy (TLT) is a widely accepted procedure in intensive-care units for its simplicity of execution, low morbidity, rapid wound closure after cannula removal, good esthetic results, and lack of long-term sequelae. The aim of this study was to evaluate the feasibility and use of adopting TLT in patients with cancer undergoing major head and neck surgery.

STUDY DESIGN

Prospective analysis of learning curve and incidence of complications in 41 patients with cancer who underwent TLT at the Division of Head and Neck Surgery of the European Institute of Oncology from November 1997 to June 1999.

METHODS

Patient characteristics, pathology, anatomic characteristics of the neck, and surgical short-term and long-term complications were noted. The patients were divided into consecutive groups of six or seven patients, and time trends in occurrence of complications and time to execute the procedure were assessed.

RESULTS

TLT performance time decreased from 50 minutes in the first seven patients to 24 minutes in the last group. The technique was easy to perform and safe, with only two minor complications during surgery. However, minor complications occurred in three and major complications in 17 patients in the days immediately following surgery, almost entirely attributable to lack of counter-cannula and stylet.

CONCLUSIONS

In view of the high proportion of major complications, TLT using the presently available kit is unsuitable for major head and neck surgery. However, the considerable advantages of the technique would recommend it as a valid alternative to surgical tracheotomy if the kit included a counter-cannula and stylet.

Papillary carcinoma in thyroglossal duct remnants: presentation of four cases and decision procedure for prophylactic thyroid gland dissection

Papillary carcinoma in thyroglossal duct remnants is a rare and usually unexpected finding. It is controversial whether or not prophylactic thyroid gland dissection is necessary in such circumstances. We present our experience of four cases. Based on this, a consideration of published risk factors, and evaluation of the likelihood of a primary versus metastatic origin of the malignancy, we present a therapeutic decision procedure. When the thyroid is normal, the patient presents low-risk factors for thyroid cancer, and there is evidence that the malignancy is primary, removal of all thyroglossal duct remnants by the Sistrunk procedure is sufficient.

Surfing prognostic factors in head and neck cancer at the millennium

The ability to reliably predict cancer outcome could tailor therapy to the aggressiveness of the tumour to achieve the best results in terms of loco-regional control, overall survival and quality of life. Retrospective and prospective clinical trials involving large series of patients have validated some predictive clinical and pathological factors, whereas the utility of many other prognostic factors has not been established. This has led to some confusion in clinical practice. In order to clarify the significance, role and cost of these prognostic factors we carried out a Medline search of all papers published between 1993 and 1998 concerning the reliability and cost of markers with prognostic significance, in head and neck squamous cell carcinoma, and assessed the results according to a number of criteria relating to reliability and cost. Regarding reliability we classified prognostic factors into: (1) those with a proven significance based on the fact that they were unanimously reported as having an independent statistical correlation with outcome and prognosis; and (2) those for which results were not unanimous, and which significance is still controversial. Cost analysis showed a substantial difference between validated tests which are of low cost and experimental tests which are expensive. Based on these data regarding both the reliability and cost of each prognostic factor, we propose guidelines for their use in clinical practice in the year 2000.

Prognostic factors in head and neck oncology: a critical appraisal for use in clinical practice

BACKGROUND

An ideal prognostic factor would provide information about the biological behaviour of a tumour, permitting the prediction of the outcome and response to therapy. Nowadays there is a considerable confusion concerning the value, significance and use of the know prognostic factors in head and neck cancer.

MATERIAL AND METHODS

A meta-analysis of works published in literature between 1993 and August 1997 on prognostic factors in head and neck oncology was carried out.

RESULTS

Prognostic factors were analysed and classified according to Wennenberg in the following groups: patient-related factors, tumour-related factors and factors predicting response to therapy.

CONCLUSIONS

We propose a classification of prognostic factors in head and neck cancer according to their significance and reliability: factors of proven significance and experimental factors. This classification might be useful to select guidelines to use in clinical practice.

Evaluation of a pneumonia practice guideline in an interventional trial

There are few available data to define the medically necessary duration of stay for patients hospitalized with pneumonia. Therefore, we investigated the safety and effectiveness of a practice guideline that provided information about switching patients from parenteral to oral antimicrobials and early hospital discharge. The study was a prospective controlled study with an alternate month design. The practice guideline was studied in 146 "low-risk" pneumonia patients hospitalized during a 22-month period. Medical care consistent with the practice guideline occurred in 64% and 76% of patients during control and intervention periods, respectively (p=0.15). There were no differences in patient outcomes in the control and intervention groups when measured 1 mo after hospital discharge, including hospital readmission rates, health-related quality of life, and patient satisfaction. Explicit and implicit review revealed that 98.6% (95% confidence interval [CI]: 95.1%, 99.8%) of low-risk patients would not have benefited from continued hospitalization after the fourth hospital day. The 30-d survival rate of the low-risk pneumonia patients was 99.3% (95% CI: 96.2%, 100%) and patient outcomes appeared to be favorable compared with previously published values. We conclude that duration of hospital stay was frequently consistent with the practice guideline in both study groups, and patient outcomes remained unchanged. The guideline will require additional testing before it can be recommended for use.

Synthesis and biological evaluation of proline derivatives as potential angiotensin converting enzyme inhibitor

The synthesis of a series of proline derivatives (1a-e and 2a-b) as pure isomers is described. These compounds were evaluated in vitro for their ability to inhibit angiotensin converting enzyme (ACE) and compared to the potency of captopril taken as a reference drug. They showed only a weak ACE inhibitory activity.

[Circumscribed peritonitis of colonic origin]

The Authors present their personal experience of circumscribed peritonitis of colic origin. They review some physiopathological aspects of these peritonitis and then emphasize the new therapeutic possibilities offered by percutaneous prick echo or TC guided.