Ustekinumab safety and effectiveness in patients with ulcerative colitis: results from a large real-life study

BACKGROUND

Ustekinumab (UST) is an interleukin-12/interleukin-23 receptor antagonist recently approved for treating ulcerative colitis (UC) but with limited real-world data. Therefore, we evaluated the effectiveness and safety of UST in patients with UC in a real-world setting.

RESEARCH DESIGN AND METHODS

This is a multicenter, retrospective, observational cohort study. The primary endpoints were the clinical remission rate (partial Mayo score, PMS, ≤1) and the safety of UST. Other endpoints were corticosteroid-free remission (CSFR) rate, clinical response rate (PMS reduction of at least 2 points), and fecal calprotectin (FC) reduction at week 24.

RESULTS

We included 256 consecutive patients with UC (M/F 139/117, median age 52). The clinical remission and clinical response rates at eight weeks were 18.7% (44/235) and 53.2% (125/235), respectively, and 27.6% (42/152) and 61.8% (94/152) at 24 weeks, respectively. At 24 weeks, CSFR was 20.3% (31/152), and FC significantly dropped at week 12 (p = 0.0004) and 24 (p = 0.038). At eight weeks, patients naïve or with one previous biologic treatment showed higher remission (p = 0.002) and clinical >response rates (p = 0.018) than patients previously treated with ≥ 2. Adverse events occurred in six patients (2.3%), whereas four patients (1.6%) underwent colectomy.

CONCLUSION

This real-world study shows that UST effectively and safely treats patients with UC.

Hospital resource utilisation from HPV-related diseases in England: a real-world cost analysis

BACKGROUND AND OBJECTIVE

HPV (human papillomavirus) is the virus most often responsible for sexually transmitted infections. The burden of HPV-related diseases on hospital resources represents a major public health problem. The objective of this study was to quantify the lifetime economic burden of HPV-related diseases based on hospital resources from the perspective of National Health Service (NHS) in England.

METHODS

Patients' data were extracted, anonymised and aggregated by NHS digital from Hospital Episode Statistics (HES) database of patients admitted in 2015 and followed for three years. Data on hospitalizations were identified according to the International Classification of Diseases (ICD-10 CM). Health Resource Group (HRG) tariffs and National Reference Costs were used to estimate the hospitalization costs of anal, cervical, genital, oropharyngeal cancers as well as anogenital warts and cervical dysplasia.

RESULTS

A total of 19,296 hospitalized patients were included in the estimation model, (39% was male and 61% female. At admission, the average age was 60 and 50 years old, respectively). Life-time costs per patients diagnosed with oropharyngeal cancer were £16,911 (£17,142 for male and £16,334 for female), penile cancer £12,539, vaginal cancer £12,676, anal cancer £13.773 (£12,590 for male, £14,525 for female). Cervical cancer accounted for £12,721, whereas cervical dysplasia for £3932. Resource used for hospitalized patients with anogenital warts was equal to £872 (£884 and £856 for men and women, respectively). On average, outpatient accounted for 39% of the total lifetime costs.

CONCLUSION

The results of this study highlight that a substantial amount of resources is utilized for the treatment of HPV-related diseases at hospital level in England. These measures have the potential to inform policy decisions to ensure an optimal use of the NHS resources.

Hepatic Encephalopathy by Manganese Deposition: A Case Report and a Review of Literature

BACKGROUND

Hepatic encephalopathy is defined as a spectrum of neuropsychiatric disorders in patients with liver dysfunction, usually cirrhosis, after exclusion of brain disease. This study reports the role of manganese in brain alterations and therefore in clinical manifestations of hepatic encephalopathy.

CASE PRESENTATION

Male patient, 67 years old, suffering from alcoholic liver cirrhosis and two previous episodes of hepatic encephalopathy, developed drowsiness, asterixis, amnesia, disorientation in time and space, and psychomotor retardation. Brain MRI without contrast showed: initial signs of cerebral atrophy, a hyperintense signal of globi pallidi and bilateral substantia nigra. The hyperintense signal of globi pallidi is the result of manganese deposition in the brain.

CONCLUSION

The case report presented supports the data reported in the literature indicating that the increase in plasma manganese levels in subjects with liver dysfunction is correlated with the onset of extrapyramidal symptoms.

Gut microbiota in inflammatory bowel disease: a target for therapy not to be missed

In the last years, the gut microbiota achieved great importance, since several studies demonstrated its correlation with the immune system and with the maintenance of intestinal homeostasis, as well as with the regulation of the integrity of the epithelium and the intestinal motility. An imbalance in microbial species promotes a dysbiosis, which has been associated with chronic diseases such as metabolic syndrome, inflammatory diseases, and some behavior disorders. The association with gut microbiota and dysbiosis has been demonstrated mostly in inflammatory bowel disease (IBD). Several studies investigated the application of antibiotics, prebiotics, probiotics, and fecal microbiota transplantation in the treatment strategies for IBD. In this review, we discuss the recent findings on the potential role of the gut microbiota manipulation, with particular attention to bacterial microbiota, which could be implicated for a successful IBD therapeutic approach.

P947dST-Tiso index, a new shallow ECG marker in response to ajmaline for predicting ventricular fibrillation induction in Brugada patients

Introduction - No study has been performed to investigate the role of drug-induced ECG morphology modifications as potential risk factors for the development of malignant arrhythmias in patients with Brugada syndrome.

Purpose - The aim of this study is to introduce a new index to improve asymptomatic patient stratification  and to report the first case of a patient with Brugada syndrome undergoing ajmaline testing that has been evaluated using a diagnostic 252-lead ECG vest.

Methods - From December 2018 to April 2019, 26 consecutive patients [mean age 39.9 (30–59) years, 18 male] with no cardiovascular risk factors underwent ajmaline testing. By evaluating ECG recordings after ajmaline administration, we calculated an index that we called "dST-Tiso", that is the duration of the positive component of the ST-T wave to the isoelectric line, in V1 and/or V2.

Results- Out of 26 patients, 16 (61.5%) had a positive test, with type 1 (coved-type) ECG diagnostic pattern in leads V1-V2 from the 2nd, 3rd and 4th intercostal spaces.  The mean recorded dST-Tiso value was 239 ± 76 ms. The ECG showed T-wave above the isoelectric line in 5 patients with a significantly higher dST-Tiso value (on average 360 ± 56 ms), and biphasic T-waves below the isoelectric line in 11 patients with a dST-Tiso value of 209 ± 42 ms (Mann-Whitney, p = 0.039). All patients with positive ajmaline test underwent programmed electrical stimulation (PES). Ventricular fibrillation was induced during PES in all 5 patients with stretched dST-Tiso. In the remaining 11 patients without stretched dST-Tiso, no ventricular arrhythmia was induced by PES.  Fig 1 Moreover, using non-invasive high-density electrocardiographic mapping (252-lead ECG vest), 3 patients with dST-Tiso positive pattern received a second ajmaline protocol, with assessment of both the depolarization and repolarization phases.

Conclusion - The ECG pattern of prolonged dST-Tiso seems to have a significant impact on safety during PES and may have potential for stratifying risk of sudden death in patients with PES-induced ventricular tachycardia/fibrillation.

Abstract Figure 1. Patients’ flowchart.

Study of the role of telomerase in colorectal cancer: preliminary report and literature review

AIM

The aim of our study is to focus on hTERT (human Telomerase Reverse Transcriptase) expression to identify tumoral tissue after a comparison to TP53 and KRAS. More than 85% of cancer cells contain genetic aberrations and also overexpression of hTERT, and, in fact, the promoter of hTERT characterizes all malignant cells.

PATIENTS AND METHODS

Our sample is composed of 18 patients, including 10 with CRC that underwent surgical procedure and 8 patients without CRC, which represent the control group. The hTERT gene expression, KRAS and p53 were evaluated by methodical Real Time - PCR on RNA extracted from tumor tissues, peritumoral tissue and control cases.

RESULTS

Within the CRC group the evaluation of the tumor tissue showed an increase of hTERT expression with a statistical significance (> 0.1) in 5 of these, also associated with substantial increase of KRAS (> 0.2). The peritumoral tissue assessment showed important increase in KRAS in 4 patients (> 0.2), while hTERT is not found to be particularly increased. The value of p53 did not show any particular significance (<0.1).

DISCUSSION

The analysis of our data leads us to consider that the increase of hTERT is evident in patients suffering from CRC and that some of them will become significant in relation to the increase of KRAS and independent of p53. In peritumoral tissues, however, KRAS increases considerably, instead hTERT maintains a low concentration and this is compatible with the cellular evolution of the neoplastic tissue adjacent to the tumor.

CONCLUSIONS

hTERT could be used for diagnosis and prognosis in the future, to be able to identify the risk of tumor progression and to set up an adequate therapy.

Rationale and budget impact of bimonthly use of Cetuximab in patients with recurrent and/or metastatic head and neck cancer

BACKGROUND

In recurrent and/or metastatic head and neck squamous cell cancer, Cetuximab is administered once a week, followed by weekly doses. We present the clinical rationale of a different schedule of maintenance Cetuximab and we estimate the potential economic benefits on the health care budget from a societal perspective in Italy.

METHODS

A budget impact (BI) excel-based model was developed comparing a base case scenario of 100% weekly administration with a dose of 250 mg/m² to an every-other-week (EOW) administration at 50% or 100% with a dose of 500 mg/m² .

RESULTS

In the EOW, 50% scenario it was calculated a cost reduction of €347 000 of which 70% attributable to indirect costs, increasing to €694 000 after 4 months.

CONCLUSIONS

In our analysis, we showed that this simplified schedule could also reduce the costs of treatments both for the health system (direct costs) and for the society (indirect costs).

Squamous carcinoma in pilonidalis sinus: case report and review of literature

AIM

We report a case of squamous carcinoma arising from a pilonidal sinus.

CASE REPORT

Patient of 83 years old, that after 30 years had a recurrence of pilonidal sinus revealed by a sacral abscess studied with pelvic CT scan and MRI. After clinical investigation, traditional open surgical technique was performed and pathologic studies revealed a squamous carcinoma. The patient performed a new CT scan with persistence of disease, and a second surgical look with mass excision until the presacral fascia and V-Y flap was performed. Histological exami-nation was found to be positive for squamous carcinoma on the margin and the patient underwent adjuvant radiotherapy cycles with a close follow-up with evidence of free disease survival. He died after 5 years for old age.

DISCUSSION

The incidence of carcinoma arising from a pilonidalis sinus is about 0.1% and the most important risk factor is represented by a chronic abscess from 20-30 years. In literature there are about 100 cases. Gold standard treatment is surgery with complete excision of the presacral fascia, while radiotherapy decrease the risk of recurrence.

CONCLUSION

All cases reported in literature are submitted as case report. Sacro-coccyxal fistula should be treated early because chronic inflammation can determine neoplastic degeneration. Histological examination should be performed routinely. Gold standard is surgery with wide excision. There is no evidence about the gold standard for the reconstructive time.

Colonic lipomas. Three surgical techniques for three different clinical cases

Colonic lipomas larger than 2 cm in diameter are likely to be symptomatic. In some cases a complication is the first clinical sign. Massive lower intestinal bleeding or obstruction, acute bleeding, prolapse or perforation or, rarely, acute intussusception with intestinal obstruction require urgent surgery. Diagnosis is often made following colonoscopy, which can also have a therapeutic role. Imaging procedures such as CT has a secondary role. Patients with small asymptomatic colonic lipomas need regular follow up. For larger (diameter > 2 cm) and/or symptomatic lipomas, resection should be considered, although the choice between endoscopic or surgical resection remains controversial. We believe that even lipomas > 2 cm can safely be removed by endoscopic resection. If surgery is indicated, we consider laparoscopy to be the ideal approach in all patients for whom minimally invasive surgery is not contraindicated.

[Overexpression of laminine-5( LN-5) in peritoneal lavage of colorectal cancer patients preliminary results]

Recent studies show that interaction between LN (heterotrimeric protein formed by a3/b3/g2 chains) and cancer cells plays an important role in tumor invasion, also in colorectal cancer. The overall survival was significantly worse in patients with free peritoneal cancer cells(FPTCs): detection of FPTCs after curative surgery is a challenge, because could improve staging and prognosis. Peritoneal citology is the current standard procedure with very low sensivity. We aimed to study the expression of LN5 in the peritoneal lavage of colorectal cancer pts and in controls with semiquantitative reverse trancriptase-polymerase chain reaction (RT-PCR). LN-5 overexpression was evaluated observing PCR- products intensity at electrophoresis: high intensity is correlated to overexpression. Pre and post-operative peritoneal lavages of 30 pts with colorectal cancer (13M;17F), with median age of 69 (58-84), and of 10 controls, were analyzed by conventional cytology and a semiquantitative RT-PCR. No cancer pts showed pre/postoperative negative cytology and did not express LN-5. In cancer pts. cytology was positive in 2 pts in pre/postoperative lavage. LN-5 overexpression was observed in 56,6% preoperatively and in 76,6% postoperatively. LN-5 g 2 chain was most frequent chain. Our study suggests a relationship between LN-5 and FPTCs, as shown by the low expression of lamimine in controls. LN-5 could be a useful marker to identify a subgroup of early-stage patients at increased risk of recurrence; moreover, mortality seems to correlated to LAMB3 chain. The diagnostic accuracy could be improved by using a quantitative RT-PCR or western-blot and detecting serum laminine. Finally, to validate these findings a larger number of pts with follow-up study is required.

[Peritoneal adhesions: pathophysiology]

Peritoneal adhesions will form as a consequence of all types of trauma of the peritoneal serosa, be they mechanical, thermal, chemical, infective, or ischemic. Any stimulation induces deposition on the serosa of a fibrin-rich exudate that results in a weaker or stronger adhesion of the viscera to other viscera or to the wall parietal peritoneum. These adhesions are mostly temporary and are eliminated by the action of the fibrinolytic agents present in the peritoneum. In optimal conditions, repair of the injured peritoneum occurs thanks to early mesothelial proliferation over the entire damaged surface, with little production of permanent fibrous adhesions. Some traumatic events are more prone than others to inhibit fibrinolysis through the production of cytokines, that trigger the production of plasminogen inhibitors, thus determining a greater number of more tenacious adhesions. Some stimuli producing postoperative adhesions are iatrogenic in nature and can be individuated and corrected to reduce the production of such adhesions and avoid the onset of adhesion syndromes.

[Traumatic shock--physiopathologic aspects]

Traumatic shock is a complex phenomenon that represents the culminating element of a series of events. It is, in fact, the outcome of an imbalance-decompensation of the organism's defence mechanisms, in which the oxygen supply to the mitochondria is hampered by a macro and/or microcirculation failure. Basically, it is a form of hypovolemic shock in which further factors have a role, including the activation of inflammation mediators. It should also be stressed that part of the cellular damage is caused by tissue reperfusion. Good hemodynamic compensation is maintained with loss of up to 30% of the circulation mass but, beyond this amount, a fall of the cardiac index, peripheral pO2, and an increase of blood lactates will ensue. Hypoxia causes capillary injury and increased permeability, resulting in the formation of edema and finally in loss of the self-regulating power of the microcirculation. Moreover, it strongly stimulates pro-inflammatory activation of the macrophages and the release of vasoactive substances, such as prostaglandins and thromboxanes. The inflammatory response is triggered by cascade systems (such as the complement, coagulation, kinins, fibrinolysis), cell elements (endothelium, leukocytes, macrophages, monocytes, mast cells) and the release of mediators (cytokines, proteolytic enzymes, histamine, etc.) and others interacting factors. In severe trauma, the inflammatory process extends beyond the local limits, maintaining and aggravating the state of shock and causing a Systemic Inflammatory Response Syndrome (SIRS), with involvement and injury of healthy organs and tissues even at a distance from the site of trauma, raising a risk of onset of ARDS (Acute Respiratory Distress Syndrome), sepsis, MODS (Multiple Organ Dysfunction Syndrome). Tissue reperfusion (reoxygenation) also induces the production of toxic metabolites, such as hydroxylated anions, superoxide, hydrogen peroxide: peroxidation of the phospholipid cell membranes alters the barrier functions, permitting entry of substances such as calcium, which interfere with the intracellular enzymatic systems.

[Risk factors of surgical wound infection]

Surgical Site Infection (SSI) continues to be a major source of morbidity following operative procedures. The aging of the population means that not only will the number of operations likely increase, but the National Nosocomial Infections Surveillance (NNIS) Risk Index, which standardizes the risk of SSI for an aging population, will be greater. The NNIS report for 1986-1996 described an SSI rate of 2.6% for all operations at the reporting hospitals. It seems likely that overall SSI rates are likely to be greater than reported. All surgical wounds are contaminated by bacteria, but only a minority actually demonstrate clinical infection. The SSI are the biological summation of several factors: the inoculum of bacteria introduced into the wound during the procedure, the unique virulence of contaminants, the microenvironment of each wound, and the integrity of the patients host defense mechanisms. Risk factors were studied in single and multivariate analyses. Although an SSI rate of zero may not be achievable, continued progress in understanding the biology of infection at the surgical site and consistent applications of proven methods of prevention will allow us to further reduce the frequency, cost, and morbidity associated with SSI.

Factors affecting prognosis in patients with short bowel syndrome

Aim of the study is to analyse physiopathological implications of massive intestinal resection and factors affecting prognosis in patients with short bowel syndrome. Twenty massive intestinal resections were performed. The causes of bowel resection were: intestinal infarction (11 cases), Crohn's disease (5 cases), small bowel volvulus (4 cases). All intestinal resections were more than 50-60% of the intestinal length. In eighteen patients intestinal anastomosis was performed immediately. In all the patients postoperative therapy with parenteral nutrition (PN) was performed. The operative morbidity and thirty-day mortality were respectively 30% (6 cases) and 35% (7 cases). The diarrhea was the dominant symptom. The average weight was 20% lower compared to the initial weight. The length of residual small bowel and type of anastomosis strongly affect survival of patients underwent massive intestinal resections. Parenteral nutrition (PN) has great importance in postoperative treatment. A useful treatment, in severe short bowel syndrome, can be small bowel transplantation.

[Intraoperative pleural lavage for restaging of bronchogenic carcinoma]

BACKGROUND

Although lung cancer staging has been recently reviewed, a significant number of recurrences and an increased incidence of mortality is common also in the initial stages of the disease. All that is probably due to disease staging underestimation and emphasizes that an exact system of staging cannot be considered a stand-alone prognostic and therapeutic index.

METHODS

Between October 2000 and November 2001, 37 patients have undergone surgical intervention for NSCLC in our Surgical Unit; 28 of them were male (75.7%), 9 female (24.3%), aged between 55 and 70. Neither cancer-related pleural effusion, nor mediastinal lymphoadenopathy had been detected under Rx and TC inspection in any patient.

RESULTS

Pre-surgical pleural washing (PLC), which defines the positiveness of the cytological result (D+), in 17 patients (45.9%) was positive, in the remaining 20 (54.1%) negative. The positiveness of PLC was 35.3% (6/17) and 64.7% (11/17) in the initial stage of T (T1 and T2) and in the advanced stage (T3 and T4) respectively.

CONCLUSIONS

On the basis of personal experience, the authors, suggest that pre-surgical resection pleural washing searching premature microscopic pleural disseminations in NSCLC-affected patients should become an important prognostic factor for the disease outcome. Moreover, they emphasize how this procedure is easy, with a small increase in the surgical intervention time, and nearly costless.

[Ano-rectal traumatic lesions. Etiology and treatment]

From January 1976 to December 2000, in the Surgical and Specialistic Sciences Department, Ist Chair of Surgical Physiopathology, University of Bari, we observed 13 cases of ano-rectal trauma. Except in wartime, these traumas are unusual. The aetiology is variable. In our experience we found 3 lesions due to firearms (24%), 2 patients with polytrauma after car accidents (15%), 3 iatrogenic lesions (24%), 1 lesion due to compressed air (7%), and 4 lesions due to objects used for autoeroticism (30%). Timely diagnosis and treatment were essential for a good outcome. The surgical choice was based on the patient's condition, the aetiology of the lesion and its anatomical site. We constructed 7 temporary colostomies and performed 2 Hartmann's operations. In 4 patients we extracted objects from the rectum. Four patients died.

[Diaphragmatic trauma: retrospective analysis of 25 patients]

Traumatic diaphragmatic injuries are increasing and they must be considered in every thoraco-abdominal trauma. The Authors carried out a retrospective analysis of 25 cases, whose diagnosis was often difficult due to the predominant clinical effects of associated injuries. All patients underwent surgical operation with laparotomy to achieve reduction of herniated viscera and repair of the diaphragmatic lesion.

[Monitoring of postmenopausal women treated with tamoxifen for breast carcinoma]

The aim of this study was to evaluate the usefulness of different diagnostic tools in the screening for endometrial neoplasms in women receiving tamoxifen as adjuvant treatment after surgery for breast cancer. The Authors' experience, while confirming the importance of a very strict and careful follow-up, stresses the higher sensitivity and specificity of diagnostic hysteroscopy.

[Comparison of hernioplasty using the technic of Bassini and Trabucco. Comparative analysis and results]

We evaluated comparatively trough a randomized perspective study the hernioplasty by Bassini technique and the Trabucco repair, respectively using general and local anaesthesia, in a group of 80 patients. We studied incidence of complications and recurrences, surgery, in-patient hospitalization time, postoperative pain, costs and work resuming. Trabucco repair had better results in each considered parameter: hospitalization time, pain and costs respectively 80%, 50% and 66% lower vs Bassini technique; moreover we found no recurrence and work resuming two weeks shorter.

[Intestinal occlusion caused by cecal carcinoid]

It is possible that carcinoids present themselves by a surgical emergency, without a <<classic syndrome>>. For these reasons, whenever a rational treatment is requested, an intraoperative diagnosis should be performed. In fact these neoplasms--owing to a less intense aggressiveness--present more indications to undergo surgery. In fact the authors report a case of caecum carcinoid characterized by the lack of typical symptoms of the homonymous syndrome. Urgent surgery was performed because of intestinal occlusion; the ileocaecal valve involvement caused the necessity of a large ileocolic resection with a L-L ileo-transverse anastomosis. The diagnosis of carcinoid was revealed only by the definitive histopathological examination.

[Therapeutic problems in euthyroid multinodular goiter]

Now therapeutic different possibilities of goitre pathology seem well defined, in front of limit of suppressive therapeutic range in initial stages, prevalently diffuse, that interest young people and arise in jodic want lands; it's possible that medic theraphy ends can't be obtained because of not responders patient, or even for possibilities of controindications. Local presence of suspicious nodules and the need of goitre volumetric reduction for aesthetical and compressory ends, with the possibility in course of time of functional changes are sure reasons to surgery. Certainly main problems exist about surgery definition of multinodular disease with bilobar involvement where there is comparing between total and subtotal thyroid exeresis. Now by literature analysis and our School experience we think that surgery choice, considered before operation, must find absolute assurance after preoperative morphotopographic careful exploration of thyroid. We think that total thyroidectomy must be done when it's certain a total gland involvement, reserving subtotal thyroidectomy in the other cases; always employing a careful surgery technique, keeping operative field interely bloodless to identify important structures and dissection plan narrowly close by capsule.

[Structural changes demonstrable by optic and electron microscopy in cellular and support components of nevi in the phase of neoplastic transformation and their therapeutic treatment]

The mole can transform itself in melanoma. The transformation is caused in some's opinion by congenital cells, in some's opinion by external elements (metabolic, physical, caustic, etc.). The authors lean to external causes metabolic, physical caustic) and they consider useful the chirurgical and radiant treatment.

Hypertensive renal rhabdomyosarcoma

A case of renal rhabdomyosarcoma is presented. Besides the rarity of this tumor, the case is unique because an increased level of renin and hypertension was found, which was not due to compression of the main vessels.

A retrovesical echinococcal cyst: unusual cause of acute urinary retention

In a middle-aged man a rare case of echinococcal cyst of the retrovesical space is reported as a very unusual cause of acute urinary retention. The discussion points out the difference between primary and secondary hydatid cyst of the retroperitoneum, the diagnostic problems and a suggested treatment is given.

[Criteria of evaluation of hemorrhagic portal hypertension and surgical indications]

Massive, active bleeding of the oesophageal varices in cirrhotics requires immediate, comprehensive and continuing appraisal of determining risk parameters (liver function and morphology, hyperdynamic syndrome, renal function, dynamic angiography of the splanchnic circulation). When survival is linked with stopping the haemorrhage, indications must not be looked at restrictively and operation has to be fast. Minor surgical measures aimed at temporary control of the haemorrhage are not satisfactory. Side-to-side portacaval anastomosis is effective in terms of reducing portal pressure and controlling the haemorrhage. Mesenterico-caval shunt with H-dacron graft interposition is sufficient dynamically and has less effect on porto-hepatic flow. Long-term results with this technique requires further study.