Impact of COVID-19 pandemic on radiographers in the Republic of Cyprus. A questionnaire survey

INTRODUCTION

Imaging is essential for the initial diagnosis and monitoring of the novel coronavirus, which emerged in Wuhan, China. This study aims to assess the insight of radiographers on how the COVID-19 pandemic has affected their work routine and if protective measures are applied.

METHOD

A prospective observational study was conducted among radiographers registered in the Cyprus Society of Registered Radiologic Technologists & Radiation Therapy Technologists. A questionnaire composed of 28 multiple choice questions was utilised, and the data analysis was performed using SPSS software with the statistical significance assumed as p-value < 0.05.

RESULTS

Out of 350 registered radiographers, 101 responses were received. The results showed that there are statistically significant differences regarding the working hours, the feeling of stress, the work effectiveness, the average examination time, the presence of a protocol used among the different workplaces of the participants; a private radiology centre, a private hospital or a public hospital, with a p-value 0.0022, 0.015, 0.027, 0.001, 0.0001 respectively. Also, statistically significant differences were observed in the decontamination methods used for equipment (p-value 0.007), for air (p-value 0.04) and when decontamination takes place (p-value 0.00032) among the different workplaces of the participants. Nonetheless, the majority of radiographers believe that their workplace is sufficiently provided with PPE, cleaning supplies, equipment, and with cleaning personnel and are optimistic regarding the adequacy of these provisions in the next three months.

CONCLUSION

This study showed that in the Republic of Cyprus, there are protocols regarding protective measures against COVID-19, and the radiographers are adequately trained on how to face an infectious disease outbreak. However, work is needed in order to develop protocols that reassure the safety of patients and medical personnel while managing the excess workload effectively.

IMPLICATIONS FOR PRACTICE

This study indicates the importance of applying protective measures and protocols in the radiology departments in order to minimise the spread of the virus.

Metabolic effects of Ramadan fasting in patients at high risk of cardiovascular diseases

Background and aim

The effects of Ramadan fasting on health are a little controversial. The present study is aimed at evaluating the metabolic effects on a group of 517 patients with ≥2 cardiovascular risk factors over a period running from 2012 to 2014.

Methods

Each patient was assessed at three visits: before, during, and after Ramadan. Demographical, clinical and biological tests were performed at each visit.

Results

Metabolically, we noted a significant and discrete rise in blood glucose level (+1.2 mmol/L), triglycerides (+0.3 mmol/L), cholesterol (+0.12 mmol/L) and creatinine (+3 µmol/L) during Ramadan. These disturbances decreased significantly after Ramadan. The same variations were observed among diabetics (n=323). However, there was a significant decrease in HbA1c after Ramadan (9.0% vs 7.6%, p<0.001). Our findings also revealed there was no significant correlation between variations of metabolic parameters and dietary intake. No acute metabolic incidents were reported during the study period.

Conclusion

The current study showed that Ramadan is responsible for a transient but well tolerated disturbance of metabolic parameters followed by a significant post-Ramadan improvement. These changes did not seem to be directly related to dietary intake.

Neoadjuvant Chemotherapy with Continuous Infusion of Cisplatin and Fluorouracil in Stage II-IV, M0 Squamous Cell Carcinoma of the Head and Neck

Aims and Background

The aim of the study was to assess the activity and the toxicity of cisplatin (DDP) and fluorouracil (FU) administered by continuous infusion as neoadjuvant chemotherapy for patients with stage II-IV, MO squamous cell carcinoma of the head and neck.

Methods

Thirty previously untreated patients were submitted to chemotherapy with DDP (20 mg/m2) and FU (1000 mg/m2), both in continuous infusion for 5 days, repeated every 21 days, for a maximum of 5 cycles. Following completion of chemotherapy, the patients underwent radiotherapy; in some patients surgery was performed immediately after chemotherapy. All patients were monitored for response, time to failure, survival, treatment-related events and toxicity.

Results

All patients were evaluated for response; after chemotherapy the complete response rate was 27% and the partial response rate 33%. Twenty-four patients underwent radiotherapy: the overall response rate was 83% (complete response 79%). After a median follow-up of 34 months, the median survival time was 22 months with a median time to failure of 15 months. Acute vascular accidents were the main and unexpected adverse events, with 2 deaths for pulmonary embolism and 1 for stroke. The response rate to the regimen does not seem to be better than that obtained with the standard combination of cisplatin bolus and fluorouracil continuous infusion. The disadvantage of the regimen is that it causes more discomfort for the patient in that it requires hospitalization.

Conclusions

For this reason, we believe that there are no elements for recommending the schedule as neoadjuvant treatment of patients with squamous cell carcinoma of the head and neck or as an experimental arm in a randomized trial.

Ifosfamide Bolus Followed by Five Days Continuous Infusion in Extensively Pretreated Patients with Advanced Breast Cancer: A Phase II Study

PURPOSE

A phase II study with ifosfamide in pretreated patients with advanced breast cancer was performed to determine the objective response rate, the toxicity and the feasibility of the regimen.

METHODS & STUDY DESIGN

Patients enrolled had advanced breast cancer pretreated with at least one previous regimen of chemotherapy for advanced disease. Treatment consisted of ifosfamide infused at a dose of 2 g/m2 iv in 4 hrs followed by ifosfamide, 8 g/m2 iv in 120 hrs in ambulatory treatment, using a portable external pump system. The total dose of ifosfamide was 10 g/m2; mesna (4 g/m2 iv) was administered mixed with ifosfamide in 120 hrs Cycles were repeated every 3 weeks. Three patients were pretreated with neoadjuvant and 15 with adjuvant chemotherapy. All patients were treated for advanced disease (median number of regimens, 1; range, 1-3): 21 with the cyclophosphamide-containing regimen and 15 with adryamicin. Sixteen patients received one or more lines of endocrine therapy. Fifteen patients had dominant site in viscera, 6 in bone, and only one in soft tissue; 17 patients had more than one site of disease.

RESULTS

Twenty-two patients were enrolled and all were assessable for response and toxicity. A partial response was reached in 5 patients (23%; 95% confidence limits 5% to 60%). Hematologic toxicity was the dose-limiting side effect; grade 4 leukopenia occurred in 10 patients (46%).

CONCLUSIONS

Considering the response rate obtained in our series of intensively pretreated patients, the results seem to indicate that the regimen is active and could be included among the possible options in the treatment of patients with refractory, poor-prognosis, advanced breast carcinoma.

Inappropriate Doses of Chemotherapy in Italian Breast Cancer Patients Enrolled in Clinical Trials

Aims and background

The dose of delivered chemotherapy is important to evaluate the appropriateness of the anticancer treatment. This aspect has been scarcely studied in Italy. About 7 years ago, the Italian Group for Antiemetic Research (IGAR) published a large controlled study on the effectiveness of different antiemetic prophylaxis in patients submitted to moderately emetogenic chemotherapy, where the prescribed chemotherapy was recorded. The aim of our study was to evaluate the incidence of undertreatment and to detect clinical and nonclinical factors able to explain its variability.

Methods

An observational study on the IGAR databank was performed to evaluate the incidence of undertreatment in the prescription in conditions of clinical trial, where the doses belonged to the eligibility criteria, and to analyze the importance of clinical and nonclinical factors using multifactorial logistic models.

Results

317 patients receiving cyclophosphamide, methotrexate, and fluorouracil (CMF) and 224 anthracycline-based chemotherapy were considered. In the CMF-treated patients, 22.4% received full doses, whereas in 53.6% all three drugs of the schedule were down-dosed. In the anthracycline-treated group, 38.6% and 3.4% of patients submitted to chemotherapy containing epirubicin and doxorubicin, respectively, were undertreated. Logistic models showed that undertreatment in CMF-treated patients depended significantly on the geographic area and setting of chemotherapy administration. Although not significant, differences between age class and Karnofsky performance status were also detected. In the epirubicin-treated group, all these factors were significant.

Conclusions

The undertreatment of cancer patients is a relevant problem, because it could give, in daily clinical practice, worse results than those reported in clinical studies. Considering the setting of a clinical trial where our study was carried out, the incidence of undertreatment is surprisingly high. We do not know whether today, about 8 years after the IGAR study was carried out, the inappropriate dose of chemotherapy is still as frequent as we reported, but surely the topic deserves more attention.

Effects of Ramadan fasting on platelet reactivity in diabetic patients treated with clopidogrel

Background

The effects of Ramadan fasting (RF) on clopidogrel antiplatelet inhibition were not previously investigated. The present study evaluated the influence of RF on platelet reactivity in patients with high cardiovascular risk (CVR) in particular those with type 2 diabetes mellitus (DM).

Methods

A total of 98 stable patients with ≥2 CVR factors were recruited. All patients observed RF and were taking clopidogrel at a maintenance dose of 75 mg. Clinical findings and serum lipids data were recorded before Ramadan (Pre-R), at the last week of Ramadan (R) and 4 weeks after the end of Ramadan (Post-R). During each patient visit, nutrients intakes were calculated and platelet reactivity assessment using Verify Now P2Y12 assay was performed.

Results

In DM patients, the absolute PRU changes from baseline were +27 (p = 0.01) and +16 (p = 0.02) respectively at R and Post-R. In addition, there was a significant increase of glycemia and triglycerides levels with a significant decrease of high-density lipoprotein. In non DM patients there was no significant change in absolute PRU values and metabolic parameters. Clopidogrel resistance rate using 2 cut-off PRU values (235 and 208) did not change significantly in DM and non DM patients.

Conclusions

RF significantly decreased platelet sensitivity to clopidogrel in DM patients during and after Ramadan. This effect is possibly related to an increase of glycemia and serum lipids levels induced by fasting.

Trial registration

Clinical Trials.gov NCT02720133. Registered 24 July 2014.Retrospectively registered.

"Mycobacterium massilipolynesiensis" sp. nov., a rapidly-growing mycobacterium of medical interest related to Mycobacterium phlei

In French Polynesia, respiratory tract clinical isolate M26, displayed unusual phenotype and contradictory phylogenetic affiliations, suggesting a hitherto unidentified rapidly-growing Mycobacterium species. The phenotype of strain M26 was further characterized and its genome sequenced. Strain M26 genome consists in a 5,732,017-bp circular chromosome with a G + C% of 67.54%, comprising 5,500 protein-coding genes and 52 RNA genes (including two copies of the 16 S rRNA gene). One region coding for a putative prophage was also predicted. An intriguing characteristic of strain M26’s genome is the large number of genes encoding polyketide synthases and nonribosomal peptide synthases. Phylogenomic analysis showed that strain M26’s genome is closest to the Mycobacterium phlei genome with a 76.6% average nucleotide identity. Comparative genomics of 33 Mycobacterium genomes yielded 361 genes unique to M26 strain which functional annotation revealed 84.21% of unknown function and 3.88% encoding lipid transport and metabolism; while 48.87% of genes absent in M26 strain have unknown function, 9.5% are implicated in transcription and 19% are implicated in transport and metabolism. Strain M26’s unique phenotypic and genomic characteristics indicate it is representative of a new species named “Mycobacterium massilipolynesiensis”. Looking for mycobacteria in remote areas allows for the discovery of new Mycobacterium species.

[Diagnostic performance of graphical anomalies in the detection of large platelets and platelet clumps]

Thrombocytopenia is a current situation for making a blood smear in routine practice in a medical analysis laboratory. Recent automated hematology analyzers enumerate platelets and generate histograms and specific flags. Operators must be aware of the characteristics of their analyzer in order to avoid spurious results in the case where microscopy review is not possible.

OBJECTIVE

We evaluated the diagnostic performance of various graphical anomalies in the detection of large platelets and platelet clumps.

PATIENTS AND METHODS

Three hundred cases of thrombocytopenia were included in the study on the basis of a platelet count less than 150 × 10(9)/L. This evaluation is expressed by the results of the sensitivity, specificity, positive predictive value and negative predictive value compared to the microscopic review of blood smear.

RESULTS

Graphical performances are variable according to microscopic review of blood smears. Indeed, a not fitted curve is the most sensitive change on platelet histogram to the presence of large platelet. A high specificity to the presence of platelet clumps is announced when the platelet curve fails to return to the baseline. Moreover, characteristic findings on the DIFF scattergram are very specific to the presence of platelet clumps.

CONCLUSION

A normal platelet histogram can validate with great confidence thrombocytopenia in cases where a blood smear cannot be read immediately.

Multichromophoric electrochromic polymers: colour tuning of conjugated polymers through the side chain functionalization approach

Organic electrochromic materials have gained constantly increasing interest over the years with respect to their inorganic counterpart due to essentially two distinctive characteristics: their processability through solution based low cost processes and their wide colour palette. Such characteristic features enabled their application in displays, smart windows, electronic paper and ophthalmic lenses. Alongside the established concept of donor-acceptor polymers, side chain functionalized multichromophoric polymers are gaining attention as a highly performing and synthetically feasible alternative, particularly relevant to applications requiring a complete colourlessness in one of the accessible redox states of the material. The primary aim of the present article is to review all the results involving the tuning of the native electrochromic properties of simple conjugated polymers through the introduction of a discrete electrochromic molecule as a side chain substituent.

Lead biosorption using a dairy sludge--thermodynamic study and competition effects

Local diary sludge as a biosorbent was used in this study for lead ion adsorption from aqueous solution. Batch experiments were carried out as a function of temperature, initial concentration, and ionic strength. Lead uptake was significantly enhanced from 149 to 224 mg/g of dairy sludge by a temperature increase at pH 5. Equilibrium data for metal ion adsorption were analyzed using model equations, namely Langmuir and Freundlich isotherms, and the best fit to the experimental data was provided by the first isotherm model. Brunauer-Emett-Teller and Fourier transform infrared analyses were also performed to characterize the biosorbent. Ionic strength using NaCl, NaNO3, and Ca(NO3)2 did not affect Pb(+2) sorption, while there was a 20% decrease using CaCl2. A limited effect of Cd(+2) ions present in the binary system on lead sorption was observed. This study shows that this local dairy sludge can be an alternative to the commercially available adsorbents for the removal of heavy metals from liquid effluents.

Chemical evolution via beta decay: a case study in strontium-90

Using (90)Sr as a representative isotope, we present a framework for understanding beta decay within the solid state. We quantify three key physical and chemical principles, namely momentum-induced recoil during the decay event, defect creation due to physical displacement, and chemical evolution over time. A fourth effect, that of electronic excitation, is also discussed, but this is difficult to quantify and is strongly material dependent. The analysis is presented for the specific cases of SrTiO(3) and SrH(2). By comparing the recoil energy with available threshold displacement data we show that in many beta-decay situations defects such as Frenkel pairs will not be created during decay as the energy transfer is too low. This observation leads to the concept of chemical evolution over time, which we quantify using density functional theory. Using a combination of Bader analysis, phonon calculations and cohesive energy calculations, we show that beta decay leads to counter-intuitive behavior that has implications for nuclear waste storage and novel materials design.

Deep brain stimulation for treatment of refractory Tourette syndrome: long-term follow-up

BACKGROUND

Eighteen patients with severe and refractory Tourette Syndrome underwent bilateral thalamic deep brain stimulation. The surgical procedures and stimulation processes of the cohort were reported in 2008; the 2 year follow-up was reported in 2009. The aim of the research is the assessment of long-term outcome (5-6 years) on tics, obsessional behaviours, anxiety, mood, and on the overall general health of the patients and their general satisfaction.

METHOD

In this study, all 18 of the original patients will be discussed, pre- and post-DBS, according to our protocol using standardized objective schedules, as well as the clinical impressions of both clinicians and patients. As there were no substantial nor statistical differences on measures of cognitive functioning between pre-DBS and 2 year follow-up, we decided not to continue this aspect of the formal assessment, particularly as there were also no clinical indications.

RESULTS

At 5-6 year follow-up, there was a significant reduction in tic severity (p < 0.001), and significant improvements in obsessive compulsive behaviours (p = 0.003), anxiety (p < 0.001) and depressive (p < 0.001) symptoms. Patients, in general, required less medication for tics, co-morbid conditions and/or co-existent psychopathologies. The long-term outcome/satisfaction were not unanimous between patients and the medical team.

CONCLUSIONS

At long-term follow-up, DBS was very successful in terms of a significant improvement in tics and also a significant reduction in the potentially disabling symptoms of obsessionality, anxiety and depression. However, compared with our more positive overall results at 2 years, these later results demonstrate long-term difficulties as follows: non-compliance, long-term complications , and the differences in the opinions between the (a) medical, (b) the surgical teams and (c) the post-DBS patients as to their outcome/satisfaction with the procedures. Our experience highlights the need for controlled studies, for long-term follow up, and the need to improve the selection of patients for DBS.

[Time trends of incidence rates of work accident with blood contamination in a North Italian teaching hospital]

Unbiased estimates of incidence rates of accidents with blood contaminations (ABC) and time trends is the milieu for assessing the effectiveness of preventive interventions. A standardised procedure for registration and follow-up of ABC was et up in a North Italian hospital since 2002. Accurate estimates of rate denominator, as full-time equivalent (FTE) person-years, was calculated, for exposed workers only and excluding periods of prolonged absence. In the observation period (2004-2011), training courses for head nurses on security procedures were repeatedly carried out as well as the progressive introduction of vacuum blood collection systems (since 2009). 1287 ABC have been reported, corresponding to an overall annual crude incidence rate of 4.73 per 100 FTE. Temporal trends, calculated on the biennial incidence, resulted in a reductions over the time period considered, in particular for needlestick injuries. Our results support the notions on the efficacy of the adopted prevention measures.

Thalamic deep brain stimulation for treatment-refractory Tourette syndrome: two-year outcome

BACKGROUND

Eighteen patients with severe and refractory Tourette syndrome (TS) underwent bilateral thalamic deep brain stimulation (DBS).

OBJECTIVE

To assess the long-term outcome on tics, behavioral symptoms, and cognitive functions in the largest case series of thalamic DBS for TS to date.

METHODS

In this prospective cohort study, 15 of the original 18 patients were evaluated before and after surgery according to a standardized protocol that included both neuropsychiatric and neuropsychological assessments.

RESULTS

In addition to marked reduction in tic severity (p = 0.001), 24-month follow-up ratings showed improvement in obsessive-compulsive symptoms (p = 0.009), anxiety symptoms (p = 0.001), depressive symptoms (p = 0.001), and subjective perception of social functioning/quality of life (p = 0.002) in 15 of 18 patients. There were no substantial differences on measures of cognitive functions before and after DBS.

CONCLUSIONS

At 24-month follow-up, tic severity was improved in patients with intractable Tourette syndrome (TS) who underwent bilateral thalamic deep brain stimulation. Available data from 15 of 18 patients also showed that neuropsychiatric symptoms were improved and cognitive performances were not disadvantaged. Controlled studies on larger cohorts with blinded protocols are needed to verify that this procedure is effective and safe for selected patients with TS.

LEVEL OF EVIDENCE

This study provides class IV evidence that bilateral thalamic deep brain stimulation reduces global tic severity measured 24 months after implantation in patients with severe intractable Tourette syndrome.

Efficacy of treatment with percutaneous vertebroplasty and kyphoplasty for traumatic fracture of thoracolumbar junction

AIM

The aim of this paper was to assess the efficacy of a minimally invasive treatment with percutaneous vertebroplasty and kyphoplasty for traumatic fracture of thoracolumbar junction. Treatment of stable traumatic vertebral fractures of the thoracolumbar junction without neurological deficit is still controversy. Conservative treatment, characterized by discomfort and limitation in patient mobility, was progressively replaced by minimally invasive techniques such as percutaneous vertebroplasty and kyphoplasty.

METHODS

Between January 2003 and August 2005, 34 patients suffering from 42 thoracolumbar fractures were treated at Neurosurgical Department of Istituto Galeazzi (Milan). The treatment selected (vertebroplasty versus kyphoplasty), depended on age of patients, timing and type of fracture. Results were clinically assessed by Visual Analogue Score (VAS) and Oswestry Disability Index.

RESULTS

Mean preoperative VAS was 8.32 (range 5-10). Percutaneous vertebroplasty was performed in 25 cases (73.5%); while 9 patients were treated by kyphoplasty (27.5%); 27 patients showed a single level and 7 multilevel of the fractures. No complications occurred (infection, neurological deficit, embolic events) after treatment. At the early follow-up 91.7% of the patients achieved a good pain control already after 24 hours. Pain relief and disability, analyzed by VAS and Oswestry Disability Index, showed a good results at late follow-up time.

CONCLUSIONS

Percutaneous vertebroplasty and kyphoplasty are two safe and effective techniques for treatment of thoracolumbar traumatic fractures and allow a good pain-control and return to normal working activity and social life.

Deep brain stimulation in 18 patients with severe Gilles de la Tourette syndrome refractory to treatment: the surgery and stimulation

BACKGROUND

There have been several reports of successful deep brain stimulation (DBS) for the treatment of severe Gilles de la Tourette syndrome (GTS).

METHOD

18 cases of GTS who were resistant to at least 6 months of standard and innovative treatments, as well as to psychobehavioural techniques, underwent DBS. DBS was placed bilaterally in the centromedian-parafascicular (CM-Pfc) and ventralis oralis complex of the thalamus. Patients were evaluated after surgery, with immediate and formal assessments at least every 3 months, including "on-off" and "sham off" in the first nine patients.

RESULTS

All patients responded well to DBS, although to differing degrees. The duration of follow-up assessments ranged from 3 to 18 months. The comorbid symptoms of obsessive-compulsive behaviour, obsessive-compulsive disorder, self-injurious behaviours, anxiety and premonitory sensations decreased after treatment with DBS. There were no serious permanent adverse effects.

CONCLUSIONS

DBS is a useful and safe treatment for severe GTS. The results of ours and previous DBS reports suggest that the CM-Pfc and ventralis oralis complex of the thalamus may be a good DBS target for GTS.

[Mild cognitive impairment: a prevalence and sociodemographic factors study in the city of Córdoba, Argentina]

INTRODUCTION

The increase in life expectancy and the significant growth in the population of the elderly have generated an interest in secondary prevention of different diseases, especially from the age of 50. In Argentina, those over 65 represent 10% of the total population, what makes important to research into their mental health. A trans-sectional descriptive study has been carried out in four neuropsychology services in the city of Cordoba, within the framework of a campaign assessing memory for people over 50.

SUBJECTS AND METHODS

In three months, 418 volunteers took part, with an average age of 64.24 years and 12.76 years of instruction, mostly belonging to a urban environment (80%). They were administered Folstein's Minimental State, neuropsychological tests and behavioral measures in two work sessions.

RESULTS

The majority was found to have normal performances (75.6%, n = 316) at both behavioral and neuropsychological levels. A lower percentage was found at the borders of normality (8.6%, n = 36). 9.1% (n = 38) of those studied were found to have an amnesiac type of mild cognitive impairment, and 4.5% (n = 19) a multidomain type of deterioration. In sum, about 13.6% of people have a greater chance of developing dementia in coming years.

CONCLUSION

The socio-demographic variables that most influence cognitive state appear to be the female gender, age higher than 65 years, lower levels of instruction, fewer children and fewer siblings.

Multibody modeling of the cervical spine in the simulation of flexion-extension after disc arthroplasty

This paper presents a three-dimensional (3D) multibody model of the cervical spine implanted with an artificial disc. The model was used to predict prosthesis placement influence on the resulting cervical kinematics in a series of patients. The vertebral tract modeled was the C2-C7, and the vertebral geometries were reconstructed from computed tomography (CT) images. The model was used to simulate the flexion-extension motion of the cervical spine in 10 patients implanted with the Prestige commercial disc prosthesis at a single level. For each patient, a geometrical model of the prosthesis was scaled and included in the multibody model to match the size and positioning of the actual prosthesis, as assessed on post-operative radiographs. Simulations of complete flexion-extension were carried out for each patient, and the main parameters relevant to the motion of the vertebral bodies were calculated and compared to data measured from dynamic post-operative radiographs. At the implanted level, the simulated ranges of motion generally agreed with the measured ones, with an average deviation <2 degrees. In addition, the simulated relative angles between vertebral bodies agreed with the measured ones, with minor average differ-ences of 1.2, 1.8 and 2.1 degrees in full flexion, neutral alignment and full extension, respectively. The cervical kinematics after prosthesis placement was influenced both by the design of the artificial joint and by surgical positioning. Therefore, the model presented can be used both to support pre-operative planning for disc arthroplasty and in the optimization of new prostheses design.

Biomechanics of the C5-C6 Spinal Unit Before and After Placement of a disc prosthesis

The study consists of a biomechanical comparison between the intact C5-C6 spinal segment and the same segment implanted with the Bryan artificial disc prosthesis (Medtronic Ltd., Memphis, TN, USA), by the use of the finite element (FE) method. Our target is the prediction of the influence of prosthesis placement on the resulting mechanics of the C5-C6 spine unit. A FE model of the intact C5-C6 segment was built, employing realistic models of the vertebrae, disc and ligaments. Simulations were conducted imposing a compression preload combined to a flexion/extension moment, a pure lateral bending moment and a pure torsion moment, and the calculated results were compared to data from literature. The model was then modified to include the Bryan cervical disc prosthesis, and the simulations were repeated. The location of the instantaneous center of rotation (ICR) of C5 with respect to C6 throughout flexion/extension was calculated in both models. In general, the moment-rotation curves obtained from the disc prosthesis-implanted model were comparable to the curves obtained from the intact model, except for a slightly greater stiffness induced by the artificial disc. The position of the calculated ICRs was rather stable throughout flexion-extension and was generally confined to a small area, qualitatively matching the corresponding physiological region, in both models. These results imply that the Bryan disc prosthesis allows to correctly reproduce a physiological flexion/extension at the implanted level. The results of this study have quantified aspects that may assist in optimizing cervical disc replacement primarily from a biomechanical point of view.

An imported case of adult T cell leukemia in a HTLV-I-infected patient in Italy

In this study we report the case of an acute form of ATL in a HTLV-I-infected Nigeria-born 27-year-old female prostitute living in Italy from February, 2001. The presence of HTLV-I infection was demonstrated by the detection of serum antibody to HTLV-I by immunoenzymatic assay and western blot analysis. In addition, the presence of HTLV-I proviral DNA was confirmed by a hemi-nested PCR in a sample of peripheral blood mononuclear cells. From an epidemiological point of view, it is important to report new cases of imported ATL, as it may explain the otherwise untraceable origin of some rare and apparently autochthonous cases of ATL in non-endemic areas.

Type I collagen turnover and cross-linking are increased in irradiated skin of breast cancer patients

BACKGROUND AND PURPOSE

The effects of radiation therapy on the turnover and structure of type I collagen were studied in irradiated and contralateral skin of 18 breast cancer patients without clinically evident fibrosis.

MATERIALS AND METHODS

The rates of on-going type I collagen synthesis and degradation were assessed by the aminoterminal propeptide of type I procollagen (PINP) and by two different assays (ICTP and SP4) for the carboxyterminal telopeptide of type I collagen in the soluble tissue extracts, respectively. Also, TIMP-1, TIMP-2 and the MMP-2/TIMP-2 complex were measured in the tissue extracts. Insoluble skin matrices, containing the cross-linked type I collagen fibres, were heat-denatured and digested with trypsin. Then, the variants of the carboxyterminal telopeptide of type I collagen were separated by high performance liquid chromatography (HPLC). The major histidinohydroxylysinonorleucine (HHL)-cross-linked variant was quantified by the SP4 assay, and the minor pyridinoline analogue (PA)-cross-linked telopeptide was quantified by the ICTP assay.

RESULTS

Both the synthesis and degradation of type I collagen were increased (r=0.906; P<0.001) on the irradiated side, whereas the concentration of the MMP-2/TIMP-2 complex was decreased. In the insoluble tissue digests, the HHL-cross-linked telopeptides of type I collagen, also, when expressed/tissue hydroxyproline, were increased in the irradiated skin. TIMP-1, TIMP-2 or PA-cross-linked telopeptides of type I collagen showed no differences between the two sides.

CONCLUSIONS

Radiotherapy induces a long-term increase in the turnover of type I collagen and leads to the accumulation of cross-linked type I collagen in skin.

Gemcitabine, ifosfamide, cisplatin (GIP) for the treatment of advanced non-small cell lung cancer: a phase II study of the italian oncology group for clinical research (GOIRC)

The purpose of this study was to evaluate the activity and the toxicity of the combination of gemcitabine with ifosfamide and cisplatin (GIP) in chemonaive patients with advanced non small cell lung cancer (NSCLC). Eighty chemonaive patients with Stage IIIB-IV NSCLC were treated with the combination of gemcitabine 1 g/m(2) on Days 1 and 8, ifosfamide 2 g/m(2) on Day 1 and cisplatin 80 mg/m(2) on Day 2. Cycles were administered on an outpatient basis every 3 weeks. Hematologic toxicity was the main side effect; Grade III-IV thrombocytopenia was observed in 54 (67%) patients and Grade III-IV leucopenia in 44 (55%) patients, with 4 episodes of febrile neutropenia and 1 toxic death. Thirteen patients received platelet transfusions and 38 were transfused with packed red cells. All patients were evaluable for response. The overall response rate was 54% (95% confidence interval 43 to 65%) with 1 complete response. In patients with Stage IIIB and IV disease, response rates were 58% and 52%, respectively. Median time to progression was 40 weeks (range 0-114) and median overall survival was 12 months (16.6 months for stage IIIB and 10.4 months for stage IV). Median and minimum follow-up were 19 and 12 months, respectively. The GIP combination shows a response rate and overall survival of clinical interest. Hematologic toxicity was the main toxic effect, especially in patients with low performance status. This regimen will be tested in a Phase III randomized trial.

Gemcitabine and cisplatin versus mitomycin, ifosfamide, and cisplatin in advanced non-small-cell lung cancer: A randomized phase III study of the Italian Lung Cancer Project

PURPOSE

To compare gemcitabine and cisplatin (GC) with mitomycin, ifosfamide, and cisplatin (MIC) chemotherapy in patients with stage IIIB (limited to T4 for pleural effusion and N3 for supraclavicular lymph nodes) or stage IV non-small-cell lung cancer (NSCLC). The end points were the evaluation of quality of life (QoL), response rates, survival, and toxicity.

PATIENTS AND METHODS

Three hundred seven patients were randomized to receive either gemcitabine 1,000 mg/m(2) on days 1, 8, and 15 plus cisplatin 100 mg/m(2) on day 2, every 28 days, or mitomycin 6 mg/m(2), ifosfamide 3,000 mg/m(2), and mesna on day 1 plus cisplatin 100 mg/m(2) on day 2, every 28 days. The whole-blood cell count was repeated on day 1 in both arms and weekly in the GC arm before each gemcitabine administration.

RESULTS

No major differences in changes in QoL were observed between the two treatment arms. The objective response rate was 38% in the GC arm compared with 26% in the MIC arm (P =.029). The median survival time was 8.6 months in the GC arm and 9.6 months in the MIC arm (P =.877, log-rank test). Grade 3 and 4 thrombocytopenia was significantly worse in the GC arm (64% v 28%, P <.001), whereas grade 3 and 4 alopecia was reported more commonly in the MIC arm (39% v 12%, P <. 001).

CONCLUSION

We report an increased response rate without changes in QoL and a similar overall survival, time to progression, and time to treatment failure for the GC when compared with the MIC regimen in the treatment of advanced NSCLC.

Bolus versus 5-day continuous infusion of cisplatin with mitomycin and vindesine in the treatment of advanced non-small cell lung cancer (NSCLC): a phase III prospective randomised trial of the Italian Oncology Group for Clinical Research (GOIRC)

The aim of this randomised trial was to compare the efficacy of bolus versus continuous infusion cisplatin combined with mitomycin C and vindesine (MVP) for chemotherapy-naive patients with stage IIIB-IV non-small cell lung cancer (NSCLC). 97 patients (49 given bolus cisplatin-arm A and 48 given continuous infusion cisplatin--arm B) were evaluable for response. In arm A, 2 patients achieved a complete response (CR), 21 achieved a partial response (PR), whilst in arm B, 14 patients achieved a PR (29%) (P = 0.07). Median survival was 8 months in both arms. Myelosuppression was the most frequent and severe toxicity, with a higher incidence of grade 3-4 leucopenia in arm A when compared with arm B (44% versus 25%). In conclusion, there is no advantage for a cisplatin 5 day infusion in the MVP regimen.

Italian Breast Cancer Adjuvant Chemo-Hormone Therapy Cooperative Group Trials. GROCTA Trials

The first GROCTA trial compared 5-year tamoxifen treatment to ten chemotherapy cycles in a group of 504 pre-/post-menopausal, node-positive, ER-positive breast cancer patients. This study also included an arm combining tamoxifen with chemotherapy. Fifteen-year results showed no difference between tamoxifen and tamoxifen plus chemotherapy, while both treatments were significantly superior to chemotherapy alone. A confirmatory study (GROCTA 02) was performed in 244 pre-/perimenopausal patients by comparing 5 years of tamoxifen treatment (plus 2 years of goserelin) to six CMF cycles. No difference has emerged so far between the tamoxifen and CMF arms at a median follow-up time of 62 months. Post-menopausal women were scheduled to receive 3 years of tamoxifen treatment and then to be randomly allocated to further 2 years of tamoxifen or to 2 years of low-dose aminoglutethimide (GROCTA 04B). So far 662 patients have been entered, 375 of whom have been randomized to tamoxifen (n = 188) or aminoglutethimide (n = 187). Preliminary results (median follow-up time 32 months) show no major difference in patients' outcome. A new trial (ITA trial) with a similar design but employing anastrozole in place of aminoglutethimide has been activated in 1998. The GROCTA 03 study investigated the potential superiority of alternating adjuvant chemotherapy over standard CMF. This study, which included 107 node-positive ER-negative pre-menopausal women, was prematurely closed because more patients allocated to the triple alternated chemotherapy appeared to have relapsed and died at the first interim analysis. The use of high-dose chemotherapy (HDC) was explored by the GROCTA 06 trial which included 53 patients with ten or more involved nodes and a maximum age of 55 years. These patients were scheduled to receive three standard CEF cycles followed by one cycle of HDC (cyclophosphamide 5 g/m2; etoposide 1.5 g/m2; cisplatin 150 mg/m2) without any form of bone marrow rescue. This HDC program proved to be feasible but was not superior to CMF-based chemotherapy we had previously employed in a comparable group of patients in previous GROCTA trials. These findings prompted us to explore new HDC programmes with the use of peripheral stem cell support and in addition the possible value of new drugs such as Taxol and vinorelbine. New-generation trials will also explore the value of new prognostic indicators such as tumor proliferative activity, which are prospectively used to allocate patients to different treatment options.

Ondansetron

Ondansetron is the first selective antagonist of the 5-hydroxytryptamine receptors (type 3) marketed for the prevention of emesis induced by antineoplastic agents. Ondansetron has been shown to be more active and less toxic than high-dose metoclopramide in patients submitted to cisplatin chemotherapy. Furthermore, when dexamethasone was added to ondansetron, its antiemetic efficacy increased significantly. In the prevention of emesis induced by a high single dose of cisplatin or by repeated low doses, ondansetron combined with dexamethasone has been shown to be the more efficacious and less toxic antiemetic treatment. However, in the prevention of delayed emesis from cisplatin, its role is still to be defined. In patients submitted to moderately emetogenic chemotherapeutic agents, ondansetron has shown an efficacy superior or equal to standard doses of metoclopramide, but is less toxic. Moreover, when compared with dexamethasone, its antiemetic efficacy and tolerability is similar; in this group of patients ondansetron should be used only when steroids fail. Ondansetron toxicity is generally mild; in particular, it does not induce extrapyramidal reactions. The most frequent side-effects are headache and constipation.

[Prophylactic antibiotherapy using cefapirin in the surgery of duodenal ulcer: a randomized clinical trial]

A randomized clinical trial of antibiotic prophylaxis in patients undergoing gastroduodenal surgery for stenosing or bleeding duodenal ulcer was carried out from February 1990 to February 1991. Seventy-two patients were randomly assigned to either Group I (n = 33) and given 1 g of cefapirine intravenously every eight hours, four times, starting at induction of anaesthesia; or to Group II (n = 39), and not given any antibiotic. The surgical dressing was changed on the third postoperative day, and thereafter every two days in patients with fever. The efficiency of prophylaxis was assessed on the incidence of superficial or deep primary infection, and the length of hospital stay. Primary wound sepsis occurred in 7 Group II patients, and in none in Group I (n = 0.01). The results for those patients with stenosing ulcer (n = 53) were also significant: there was no primary wound infection in Group I (n = 25), whereas five occurred in Group II (n = 28) (p = 0.03). Hospital stay was shorter in Group I than in Group II (7 vs 9.5 days). Antibiotic prophylaxis also seemed to be efficient in patients with bleeding duodenal ulcers (n = 19), but their group was too small to reach levels of statistical significance. Again hospital stay was shorter in Group I than in Group II (8.5 vs 12.2 days). The efficiency of antibiotic prophylaxis was therefore confirmed for patients undergoing gastroduodenal surgery for stenosing duodenal ulcer.

Antiemetic activity of two different high doses and schedules of metoclopramide in dacarbazine-treated cancer patients

The antiemetic activity of two different high doses and schedules of metoclopramide in dacarbazine-treated cancer patients was compared in a double-blind crossover study. Regimen A consisted of metoclopramide [2 mg/kg x 4 intravenously (i.v.)] plus methylprednisolone (250 mg x 2 i.v.) plus diphenhydramine (50 mg x 2 i.v.). Regimen B consisted of metoclopramide (3 mg/kg x 2 i.v.) plus dexamethasone (20 mg i.v.) and diphenhydramine (50 mg i.v.). Both treatments were administered for the first 2 days of 5-day dacarbazine chemotherapy. Thirty-two patients (13 men and 19 women) affected by melanoma and sarcoma were entered in the study. Complete protection against nausea and vomiting for the first 2 days of chemotherapy in both antiemetic regimens was not significantly different. Patient preference and tolerance of the two antiemetic treatments were similar. Regimen B, employing a lower dosage of metoclopramide and steroids and using a more simple schedule of administration should be the preferred treatment.

Intra and interobserver variability in cancer patients' performance status assessed according to Karnofsky and ECOG scales

The Karnofsky (K) and ECOG (E) performance status (PS) scales are widely used to evaluate the functional status of cancer patients to determine their eligibility for clinical trials and their prognosis, but knowledge of inter and intraobserver variability of these scales is scarse. We therefore planned a prospective study on 209 consecutive cancer patients to evaluate this critical point. Two independent observers evaluated the KPS and EPS of each patient by interviewing them on the same day. After their interviews the patients were asked to fill in, again on the same day, a self-evaluation scale concerning their ability to perform the routine activities of daily life. The 209 patient self-evaluation scales were presented twice, randomly and blinded, to the two observers who had participated in the evaluation of PS as well as to one other observer who had not. The interobserver correlation for both scales was very high (K = 0.921 for KPS and K = 0.914 for EPS) as was the intraobserver correlation (for KPS: K = 0.993, K = 0.960, and K = 0.959 and, respectively, for EPS: K = 0.982, K = 0.970, and K = 0.920). On the basis of these results, it appears that evaluation of PS made by a clinical oncologist using K or E scales can be very reliable and is a guarantee of optimal selection of cancer patients for inclusion in clinical trials.

Double-blind crossover trial of single vs. divided dose of metoclopramide in a combined regimen for treatment of cisplatin-induced emesis

In a double-blind crossover antiemetic study in cisplatin-treated cancer patients, metoclopramide 4 mg/kg as a single intravenous dose (regimen A) was compared with 3 mg/kg in two doses (regimen B). In both regimens, metoclopramide was combined with dexamethasone and diphenhydramine. 65 consecutive, chemotherapy-naïve inpatients (45 males and 20 females) treated with high doses (at least 50 mg/m2) of cisplatin entered the study and 54 completed both treatments. Complete protection from vomiting and nausea, mean number of emetic episodes, mean maximum intensity of nausea and mean duration of emesis or nausea were similar with the two antiemetic regimens. 23 patients (43%) did not express a treatment preference, while 16 (30%) preferred regimen B and 15 (28%) preferred regimen A. Side-effects were similar with the two metoclopramide schedules. A combined antiemetic regimen of a single high dose of metoclopramide (4 mg/kg) can preserve efficacy and tolerability and thus should be preferred.

Etoposide versus etoposide plus high-dose cisplatin in the management of advanced non-small cell lung cancer. Results of a prospective randomized FONICAP trial. Italian Lung Cancer Task Force

Two hundred sixteen patients with unresectable non-small cell lung carcinoma were randomly allocated to receive etoposide (120 mg/m2, days 1-3) either alone or in combination with high-dose cisplatin (60 mg/m2, days 1-2). The patients' distribution and characteristics were similar in the two treatment arms. The objective response rate for etoposide was 7% versus 25.8% for etoposide plus cisplatin (P less than 0.005). Median progression-free survival in etoposide arm was 3.5 months versus 5 months in the combination arm (P = 0.43). The median survival time for etoposide was 6 months compared with 8 months for etoposide combined with cisplatin (P = 0.87). Significantly more nausea/vomiting (P less than 0.005), serum creatinine elevation (P less than 0.005), hearing loss and/or tinnitus (P less than 0.005), peripheral neuropathy (P less than 0.005), leukopenia (P less than 0.025), and anemia (P less than 0.005) occurred in the etoposide plus cisplatin arm. No statistically significant difference was recorded between the two arms in terms of performance status changes. In conclusion the addition of high-dose cisplatin to single-agent etoposide significantly increases the chance of obtaining tumor response in advanced non-small cell lung cancer at the cost of an increased toxicity without any significant long-term impact on survival and progression-free survival.