Adjuvant Therapy After Upfront Resection of Resectable Pancreatic Cancer: Patterns of Omission and Use-A Prospective Real-Life Study

BACKGROUND

Little is known about adjuvant therapy (AT) omission and use outside of randomized trials. We aimed to assess the patterns of AT omission and use in a cohort of upfront resected pancreatic cancer patients in a real-life scenario.

METHODS

From January 2019 to July 2022, 317 patients with resected pancreatic cancer and operated upfront were prospectively enrolled in this prospective observational trial according to the previously calculated sample size. The association between perioperative variables and the risk of AT omission and AT delay was analyzed using multivariable logistic regression.

RESULTS

Eighty patients (25.2%) did not receive AT. The main reasons for AT omission were postoperative complications (38.8%), oncologist's choice (21.2%), baseline comorbidities (20%), patient's choice (10%), and early recurrence (10%). At the multivariable analysis, the odds of not receiving AT increased significantly for older patients (odds ratio [OR] 1.1, p < 0.001), those having an American Society of Anesthesiologists score ≥II (OR 2.03, p = 0.015), or developing postoperative pancreatic fistula (OR 2.5, p = 0.019). The likelihood of not receiving FOLFIRINOX as AT increased for older patients (OR 1.1, p < 0.001), in the presence of early-stage disease (stage I-IIa vs. IIb-III, OR 2.82, p =0.031; N0 vs. N+, OR 3, p = 0.03), and for patients who experienced postoperative major complications (OR 4.7, p = 0.009). A twofold increased likelihood of delay in AT was found in patients experiencing postoperative complications (OR 3.86, p = 0.011).

CONCLUSIONS

AT is not delivered in about one-quarter of upfront resected pancreatic cancer patients. Age, comorbidities, and postoperative complications are the main drivers of AT omission and mFOLFIRINOX non-use.

CLINICALTRIALS REGISTRATION

NCT03788382.

Advanced bipolar vessel sealing devices vs conventional bipolar energy in minimally invasive hysterectomy: a systematic review and meta-analysis

PURPOSE

To compare conventional bipolar electrosurgery with advanced bipolar vessel sealing (ABVS) devices for total laparoscopic hysterectomy (TLH).

METHODS

A systematic review was conducted by searching Scopus, PubMed/MEDLINE, ScienceDirect, and Cochrane Library from January 1989 to November 2021. We identified all studies comparing ABVS devices with conventional bipolar electrosurgery in TLH and reporting at least one of the following outcomes: total blood loss, total operative time, hospital stay, perioperative complications, or costs. Meta-analysis was conducted with a random effect model reporting pooled mean differences and odds ratios (ORs) with related 95% confidence intervals (CIs).

RESULTS

Two randomized controlled trials and two retrospective studies encompassing 314 patients were included out of 615 manuscripts. The pooled estimated total blood loss in the ABVS devices group was lower than conventional bipolar electrosurgery of 39 mL (95% CI - 65.8 to - 12.6 mL; p = .004). The use of ABVS devices significantly reduced the total operative time by 8 min (95% CI - 16.7 to - 0.8 min; p = .033). Hospital stay length did not differ between the two groups, and a comparable overall surgical complication rate was observed [OR of 0.9 (95% CI 0.256 - 3.200; p = .878].

CONCLUSIONS

High-quality evidence comparing ABVS devices with conventional bipolar electrosurgery for TLH is lacking. ABVS devices were associated with reduced total blood loss and operative time; however, observed differences seem clinically irrelevant. Further research is required to clarify the advantages of ABVS devices over conventional bipolar electrosurgery and to identify cases that may benefit more from their use.

Independent, additive and interactive effects of acute normobaric hypoxia and cold on submaximal and maximal endurance exercise

PURPOSE

To evaluate the independent and combined effects of hypoxia (FiO2 = 13.5%) and cold (- 20 °C) on physiological and perceptual responses to endurance exercise.

METHODS

14 trained male subjects ( V . O2max: 64 ± 5 mL/kg/min) randomly performed a discontinuous maximal incremental test to exhaustion on a motorized treadmill under four environmental conditions: Normothermic-Normoxia (N), Normothermic-Hypoxia (H), Cold-Normoxia (C) and Cold-Hypoxia (CH). Performance and physiological and perceptual responses throughout exercise were evaluated.

RESULTS

Maximal WorkLoad (WL) and WL at lactate threshold (LT) were reduced in C (- 2.3% and - 3.5%) and H (- 18.0% and - 21.7%) compared to N, with no interactive (p = 0.25 and 0.81) but additive effect in CH (- 21.5% and - 24.6%). Similarly, HRmax and Vemax were reduced in C (- 3.2% and - 14.6%) and H (- 5.0% and - 7%), showing additive effects in CH (- 7.7% and - 16.6%). At LT, additive effect of C (- 2.8%) and H (- 3.8%) on HR reduction in CH (- 5.7%) was maintained, whereas an interactive effect (p = 0.007) of the two stressors combined was noted on Ve (C: - 3.1%, H: + 5.5%, CH: - 10.9%). [La] curve shifted on the left in CH, displaying an interaction effect between the 2 stressors on this parameter. Finally, RPE at LT was exclusively reduced by hypoxia (p < 0.001), whereas TSmax is synergistically reduced by cold and hypoxia (interaction p = 0.047).

CONCLUSION

If compared to single stress exposure, exercise performance and physiological and perceptual variables undergo additive or synergistic effects when cold and hypoxia are combined. These results provide new insight into human physiological responses to extreme environments.

Fatal cardiac air embolism after CT-guided percutaneous needle lung biopsy: medical complication or medical malpractice?

Computed tomography (CT)-guided percutaneous needle biopsy of the lung is a well-recognized and relatively safe diagnostic procedure for suspicious lung masses. Systemic air embolism (SAE) is a rare complication of transthoracic percutaneous lung biopsies. Herein, we present a case of an 81-year-old man who underwent CT-guided percutaneous needle biopsy of a suspicious nodule in the lower lobe of the right lung. Shortly after the procedure, the patient coughed up blood which prompted repeat CT imaging. He was found to have a massive cardiac air embolism. The patient became unresponsive and, despite resuscitation efforts, was pronounced dead. The pathophysiology, risk factors, clinical features, radiological evidence, and autopsy findings associated with SAE are discussed, which may, in light of the current literature, assist with the dilemma between assessing procedural complications and medical liability. Given the instances of SAE in the setting of long operative procedures despite careful technical execution, providing accurate and in-depth information, including procedure-related risks, even the rarest but potentially fatal ones, is recommended for informed consent to reduce medicolegal litigation issues.

The Association Between Neurocognitive Disorders and Gustatory Dysfunction: A Systematic Review and Meta-Analysis

Olfactory and gustatory dysfunction have been reported in mild and major neurocognitive disorders (NCDs), with variable results. While olfactory dysfunction has been consistently explored, reports on gustatory alterations are limited. We systematically reviewed case-control studies evaluating gustatory function in NCDs with various etiologies and different neuropathology. Eighteen studies were included in the systematic review, and eight were included in the meta-analysis. Most studies were on Alzheimer's disease (AD) and Parkinson's disease (PD). Pooled analyses showed worse global taste threshold and identification (sour in particular) scores in AD than controls and worse global, sweet, and sour scores in AD compared to mild cognitive impairment (MCI). PD with MCI showed worse global, sweet, salty, and sour scores than controls and cognitively unimpaired PD. Taste dysfunction was differentially associated with the severity of cognitive deficits. Gustatory dysfunction may represent a potential cross-disease chemosensory biomarker of NCD. Whether gustatory alterations may be a pre-clinical biomarker of NCD requires further studies.

Insights into single-timepoint ASL hemodynamics: what visual assessment and spatial coefficient of variation can tell

PURPOSE

Arterial spin labeling (ASL) represents a noninvasive perfusion biomarker, and, in the study of nonvascular disease, the use of the single-timepoint ASL technique is recommended. However, the obtained cerebral blood flow (CBF) maps may be highly influenced by delayed arterial transit time (ATT). Our aim was to assess the complexity of hemodynamic information of single-timepoint CBF maps using a new visual scale and comparing it with an ATT proxy, the "coefficient of spatial variation" (sCoV).

MATERIAL AND METHODS

Individual CBF maps were estimated in a memory clinic population (mild cognitive impairment, dementia and cognitively unimpaired controls) and classified into four levels of delayed perfusion based on a visual rating scale. Calculated measures included global/regional sCoVs and common CBF statistics, as mean, median and standard deviation. One-way ANOVA was performed to compare these measures across the four groups of delayed perfusion. Spearman correlation was used to study the association of global sCoV with clinical data and CBF statistics.

RESULTS

One hundred and forty-four participants (72 ± 7 years, 53% women) were included in the study. The proportion of maps with none, mild, moderate, and severe delayed perfusion was 15, 20, 37, and 28%, respectively. SCoV demonstrated a significant increase (p < 0.05) across the four groups, except when comparing none vs mild delayed perfusion groups (pBonf > 0.05). Global sCoV values, as an ATT proxy, ranged from 67 ± 4% (none) to 121 ± 24% (severe delayed) and were significantly associated with age and CBF statistics (p < 0.05).

CONCLUSION

The impact of ATT delay in single-time CBF maps requires the use of a visual scale or sCoV in clinical or research settings.

Postoperative outcomes of transperitoneal versus retroperitoneal robotic partial nephrectomy: a propensity-score matched comparison focused on patient mobilization, return to bowel function, and pain

Literature meta-analyses comparing transperitoneal versus retroperitoneal approach to robotic partial nephrectomy (RPN) suggested some advantages favoring retroperitoneoscopy. Unfortunately, patient-centered data about mobilization, canalization, pain, and use of painkillers remained anecdotally reported. The present analysis aimed to compare transperitoneal versus retroperitoneal RPN focusing on such outcomes. Study data including baseline variables, perioperative, and postoperative outcomes of interest were retrieved from prospectively maintained institutional database (Jan 2018-May 2023) and compared between treatment groups (transperitoneal versus retroperitoneal). Propensity score matching was performed using the STATA command psmatch2 considering age, sex, body mass index, previous abdominal surgery, RENAL score, tumor size and location, and cT stage. The logit of propensity score was used for matching, with a 1:1 nearest neighbor algorithm, without replacement (caliper of 0.001). A total of 442 patients were included in the unmatched analysis: 330 underwent transperitoneal RPN 112 retroperitoneal RPN. After propensity score, 98 patients who underwent retroperitoneal RPN were matched with 98 patients who underwent transperitoneal RPN. Matched cohorts had comparable patients' demographics and tumor features. We found similarity between the two laparoscopic accesses in all outcomes but in blood loss, which favored retroperitoneoscopic RPN (median 150 (IQR 100-300) versus 100 (IQR 0-100) ml, p = 0.03). No differences were found in terms of time to mobilization with ambulation, return to complete bowel function, postoperative pain, but higher painkillers consumption was reported after transperitoneal RPN (p < 0.004). The present study compared the transperitoneal versus the retroperitoneal approach to RPN, confirming the similarity between the two approaches in all perioperative outcomes. Based on our findings, the choice of the surgical approach to RPN may remain something that the surgeon decides.

Predictors of hospital readmission rate in geriatric patients

BACKGROUND

Hospital readmissions among older adults are associated with progressive functional worsening, increased institutionalization and mortality.

AIM

Identify the main predictors of readmission in older adults.

METHODS

We examined readmission predictors in 777 hospitalized subjects (mean age 84.40 ± 6.77 years) assessed with Comprehensive Geriatric Assessment (CGA), clinical, anthropometric and biochemical evaluations. Comorbidity burden was estimated by Charlson Comorbidity Index (CCI). Median follow-up was 365 days.

RESULTS

358 patients (46.1%) had a second admission within 365 days of discharge. Estimated probability of having a second admission was 0.119 (95%C.I. 0.095-0.141), 0.158 (95%C.I. 0.131-0.183), and 0.496 (95%C.I. 0.458-0.532) at 21, 30 and 356 days, respectively. Main predictors of readmission at 1 year were length of stay (LOS) > 14 days (p < 0.001), albumin level < 30 g/l (p 0.018), values of glomerular filtration rate (eGFR) < 40 ml/min (p < 0.001), systolic blood pressure < 115 mmHg (p < 0.001), CCI ≥ 6 (p < 0.001), and cardiovascular diagnoses. When the joint effects of selected prognostic variables were accounted for, LOS > 14 days, worse renal function, systolic blood pressure < 115 mmHg, higher comorbidity burden remained independently associated with higher readmission risk.

DISCUSSION

Selected predictors are associated with higher readmission risk, and the relationship evolves with time.

CONCLUSIONS

This study highlights the importance of performing an accurate CGA, since defined domains and variables contained in the CGA (i.e., LOS, lower albumin and systolic blood pressure, poor renal function, and greater comorbidity burden), when combined altogether, may offer a valid tool to identify the most fragile patients with clinical and functional impairment enhancing their risk of unplanned early and late readmission.

Prevalence of portal vein thrombosis in non-alcoholic fatty liver disease: a meta-analysis of observational studies

Portal vein thrombosis (PVT) is a common complication of cirrhosis as a result of portal hypertension and modification in the hemostatic balance. Accumulating evidence now suggests that patients with non-alcoholic fatty liver disease (NAFLD), especially those with advanced forms, have an increased risk of PVT. Hence, we performed a meta-analysis of observational studies to estimate the overall prevalence of PVT in patients with NAFLD and its advanced forms compared with patients with advanced liver diseases from other etiologies. We systematically searched PubMed, Scopus and Web of Science databases from the inception date to December 30th 2022, using predefined keywords, to identify observational studies. Meta-analysis was performed using random-effects modeling. We included five observational studies for a total of 225,571 patients. Of these, 26,840 (11.9%) patients had NAFLD, whereas the PVT prevalence was 8.5% (n = 2,280). When compared with patients with advanced liver diseases from other etiologies, patients with NAFLD and its advanced forms had a higher risk of prevalent PVT (OR 1.34, 100% CI 1.07-1.67 p < 0,01). The between-study heterogeneity was substantial (I2 = 88%). This meta-analysis suggests that compared with patients with advanced liver diseases from other etiologies, patient with NAFLD and its advanced forms had a higher risk of prevalent PVT. Further research is required to understand the complex link between NAFLD/NASH and PVT development.

H3 K27M mutation in rosette-forming glioneuronal tumors: a potential diagnostic pitfall

According to the fifth edition of the World Health Organization (WHO) classification of tumors of the central nervous system (CNS), diffuse midline glioma H3 K27-altered is a grade 4 infiltrative glioma that arises from midline anatomical structures and is characterized by the loss of H3 K27me3 and co-occurring H3 K27M mutation or EZHIP overexpression. However, the H3 K27M mutation has also been observed in circumscribed gliomas and glioneuronal tumors arising in midline anatomical structures, which may result in diagnostic pitfalls.Rosette-forming glioneuronal tumor (RGNT) is a CNS WHO grade 1 neoplasm that histologically features neurocytic and glial components and originates in midline anatomical structures.This study aimed to assess whether RGNTs, similar to other midline tumors, may exhibit immunohistochemical loss of H3 K27me3 and harbor the H3 K27M mutation.All seven analyzed RGNTs displayed immunohistochemical loss of H3 K27me3 in all tumor cells or H3 K27me3 mosaic immunostaining. In one case, H3 K27me3 loss was associated with the H3 K27M mutation, whereas the other six cases did not exhibit any H3 mutations or EZHIP overexpression. During a follow-up period of 23 months, the H3 K27M-mutant case remained unchanged in size despite partial resection, indicating that the H3 mutation may not confer higher biological aggressiveness to RGNT.The immunohistochemical loss of H3 K27me3 co-occurring with the H3 K27M mutation may result in the potential misdiagnosis of RGNT, especially in cases of small biopsy specimens consisting of only the glial component.

The effects of virtual reality environmental enrichments on craving to food in healthy volunteers

RATIONALE

Environmental enrichment (EE) is a non-pharmacological approach that has been shown to be effective in reducing food-taking in rats. Studies in human volunteers are still in their infancy, given the difficulty to translate the complexity of EE in clinical practice. Virtual reality (VR) is a promising methodological approach, but no study has yet applied it to model and test EE in humans.

OBJECTIVES

The present study is the first to assess the effects of virtual EE on craving for palatable food.

METHODS

Eighty-one healthy volunteers (43 women) were divided into three groups: (i) exposure to a virtual EE (VR-EE), (ii) exposure to a virtual neutral environment (VR-NoEE), and (iii) without exposure to VR (No VR). Craving for palatable food at basal level and evoked by neutral and palatable food images was assessed before and after the VR simulation. Behavior during VR exposure and subjective measures related to the experience were also collected.

RESULTS

VR-EE group showed a significantly greater decrease in pre-post craving difference compared to No VR for all assessments and at basal level compared to VR-NoEE. Interestingly, an inverse correlation between craving and deambulation in the VR simulation emerged in VR-EE group only.

CONCLUSIONS

The study highlighted the feasibility of exposing human subjects to an EE as a virtual simulation. Virtual EE induced effects on basal craving for food that suggest the potential for further improvements of the protocol to extend its efficacy to palatable food cues.

Endoscopic posterior ventricular cordectomy with contact diode laser: how I do it

BACKGROUND

The treatment of bilateral vocal fold paralysis is mainly surgical and several procedures can be used to guarantee adequate breathing. Furthermore, other causes of the narrowing of the natural airways could coexist and the treatment should consider all of them.

METHODS

A supraglottic extension of posterior cordectomy to the false homolateral chord is described, which provides a further widening of the airway while maintaining acceptable voice quality.

CONCLUSION

Endoscopic posterior ventricular cordectomy performed by contact diode laser may be a viable and safe option, especially in those patients who present bilateral vocal fold paralysis associated with various degrees of laryngospasm.

Trimester-specific reference intervals for thyroid function parameters in pregnant Caucasian women using Roche platforms: a prospective study

BACKGROUND

Standard thyroid function parameters reference intervals (RI) are unsuitable during pregnancy, potentially resulting in incongruous treatments that may cause adverse effects on pregnancy outcomes. We aimed at defining trimester-specific TSH, FT4 and FT3 RI, using samples longitudinally collected from healthy Caucasian women.

MATERIALS AND METHODS

Blood samples from 150 healthy Caucasian women, who had a physiological gestation and a healthy newborn at term, were collected in each trimester and at around six months post-partum. They showed mild iodine deficiency. After excluding women with overt TSH abnormalities (> 10 mU/L) and/or TPO antibodies, data from 139 pregnant women were analyzed by means of widely used Roche platforms, and TSH, FT4 and FT3 trimester-specific RI were calculated. Post-partum data were available for 55 subjects.

RESULTS

Serum TSH RI were 0.34-3.81 mU/L in the first trimester, and changed slightly to 0.68-4.07 U/L and 0.63-4.00 mU/L in the second and third trimester, respectively. Conversely, both FT4 and FT3 concentrations progressively decreased during pregnancy, the median values in the third trimester being 14.8% and 13.2% lower, respectively, than in the first trimester. Thyroid function parameters in the first trimester were similar to those measured after the end of pregnancy.

CONCLUSIONS

This study calculates trimester-specific RI for thyroid function parameters in pregnancy, and proposes the reference limits that should be adopted when using Roche platforms in Caucasian women.

mTOR eosinophilic renal cell carcinoma: a distinctive tumor characterized by mTOR mutation, loss of chromosome 1, cathepsin-K expression, and response to target therapy

In the spectrum of oncocytic renal neoplasms, a subset of tumors with high-grade-appearing histologic features harboring pathogenic mutations in mammalian target of rapamycin (mTOR) and hitherto clinical indolent behavior has been described. Three cases (2F,1 M) with histologically documented metastases (lymph node, skull, and liver) were retrieved and extensively investigated by immunohistochemistry, FISH, and next-generation sequencing. Tumors were composed of eosinophilic cells with prominent nucleoli (G3 by ISUP/WHO) arranged in solid to nested architecture. Additionally, there were larger cells with perinuclear cytoplasmic shrinkage and sparse basophilic Nissl-like granules, superficially resembling the so-called spider cells of cardiac rhabdomyomas. The renal tumors, including the skull and liver metastases, showed immunoexpression PAX8, CK8-18, and cathepsin-K, and negativity for vimentin. NGS identified mTOR genetic alterations in the three cases, including the skull and liver metastases. One patient was then treated with Everolimus (mTOR inhibitors) with clinical response (metastatic tumor shrinkage). We present a distinct renal tumor characterized by high-grade eosinophilic cells, cathepsin-K immunohistochemical expression, and harboring mTOR gene mutations demonstrating a malignant potential and showing responsiveness to mTOR inhibitors.

Concordance study on Y-STRs typing between SeqStudio™ genetic analyzer for HID and MiSeq™ FGx forensic genomics system

BACKGROUND

Massively Parallel Sequencing (MPS) allowed an increased number of information to be retrieved from short tandem repeat (STR) analysis, expanding them not only to the size, as already performed in Capillary Electrophoresis (CE), but also to the sequence. MPS requires constant development and validation of the analytical parameters to ensure that the genotyping results of STRs correspond to those obtained by CE. Given the increased frequency of usage of Y-STRs as supplementary markers to the autosomal STRs analysis, it is urgent to validate the concordance of the typing results between CE and MPS analyses.

METHODS AND RESULTS

DNA extracted from 125 saliva samples of unrelated males was genotyped using Yfiler™ Plus PCR Amplification Kit and ForenSeq™ DNA Signature Prep Kit, which were analyzed by SeqStudio™ Genetic Analyzer for HID and MiSeq™ FGx Forensic Genomics System, respectively. For each shared Y-STR, allele designation, number of length- and sequence-based alleles per locus, stutter percentage, and the intra-locus balance of multicopy Y-STRs were screened.

CONCLUSIONS

Although the number of forensic genetics laboratories that are applying the MPS technique in routine analysis is small and does not allow a global assessment of MPS limitations, this comparative study highlights the ability of MPS to produce reliable profiles despite the generation of large amounts of raw data.

Serum HMGB1 levels are independently associated with glucose clamp-derived measures of insulin resistance in women with PCOS

PURPOSE

PCOS is associated with low grade inflammation which could play a role in insulin resistance and ovarian dysfunction. Preliminary findings suggested that serum levels of HMGB1, a cytokine involved in inflammation, might be altered in women with PCOS. Primary aim of this study was to assess whether HMGB1 serum concentrations are associated with PCOS and with the state of insulin resistance of these women.

METHODS

Sixty women with PCOS, selected to have a similar proportion of subjects with altered or normal insulin sensitivity, and 29 healthy controls were studied. Serum HMGB1 levels were compared in subgroups of PCOS women and controls. In PCOS women, insulin sensitivity was assessed by the glucose clamp technique and HMGB1 was measured at baseline and after acute hyperinsulinemia.

RESULTS

HMGB1 levels were similar in women with PCOS and controls and no elements used for diagnosing PCOS were associated with serum HMGB1. However, HMGB1 concentrations were higher in insulin-resistant vs insulin-sensitive PCOS women (p = 0.017), and inversely associated with insulin-induced total and non-oxidative glucose metabolism. In both subgroups of PCOS women, serum HMBG1 levels significantly increased after acute hyperinsulinemia.

CONCLUSIONS

These data suggest that HMGB1 levels are not associated with PCOS per se, but with insulin resistance. Further research should establish the underlying nature of this relationship, and whether this protein might play a role in the metabolic complications of PCOS.

Personal experience with the remote check telehealth in cochlear implant users: from COVID-19 emergency to routine service

PURPOSE

To critically illustrate the personal experience with using the "Remote Check" application which remotely monitors the hearing rehabilitation level of cochlear implant users at home and further allows clinicians to schedule in-clinic sessions according to the patients' needs.

METHODS

12-month prospective study. Eighty adult cochlear implant users (females n = 37, males n = 43; age range 20-77 years) with ≥ 36 months of cochlear implant experience and ≥ 12 months of stable auditory and speech recognition level volunteered for this 12-month long prospective study. For each patient, at the beginning of the study during the in-clinic session to assess the stable aided hearing thresholds and the cochlear implant integrity and patient's usage, the "Remote Check" assessment baseline values were obtained. "Remote Check" outcomes were collected at different times in the subsequent at-home sessions, to identify the patients that had to reach the Center. Chi-square test has been used for statistical analysis of the comparison of the "Remote Check" outcomes and in-clinic session results.

RESULTS

"Remote Check" application outcomes demonstrated minimal or no differences between all sessions. The at-home Remote Check application reached the same clinical outcomes as the in-clinic sessions in 79 out 80 of participants (99%) with high statistical significance (p < 0.05).

CONCLUSIONS

"Remote Check" application supported hearing monitoring in cochlear implant users that were not able to attend the in-clinic review during COVID-19 pandemic time. This study demonstrates that the application can be a useful routine tool also for clinical follow-up of cochlear implant users with stable aided hearing.

Clinical outcomes and periodontal conditions of dental implants placed in free fibula flaps (FFF): a retrospective study with a mean follow-up of 6 years

OBJECTIVES

Up-to-date literature regarding long-term success of implant rehabilitations after microvascular reconstructions with free fibula flap (FFF) is still very scarce. This study aimed to evaluate clinical outcomes, especially related to oral hygiene conditions, of patients rehabilitated with this technique.

MATERIALS AND METHODS

A total of 25 patients who underwent maxillofacial reconstructive surgery with FFF were retrospectively evaluated for soft tissues conditions, oral hygiene habits, and implant survival and success, assessed with a mean follow-up of 6 (range 2-15) years after loading.

RESULTS

Fourteen patients received full-arch fixed prostheses and 11 removable bar-supported overdentures. At the follow-up evaluation, 52% of prostheses did not allow proper accessibility for oral hygiene. Overall prosthetic survival was 100%, and implant survival and success were respectively 93.6% and 72%. Prevalence of peri-implantitis was 29% at implant level and that at patient level 96%.

CONCLUSIONS

Six-year clinical outcomes of this study reveal that poor oral hygiene practices and compliance by patients who underwent maxillofacial reconstruction with FFF are significantly associated with peri-implant disease.

CLINICAL RELEVANCE

Findings of the present study underline the need by clinicians for a careful assessment, in reference to a specific implant therapy, of patient's prosthetic accessibility for oral hygiene procedures.

Recombinant protein delivery enables modulation of the phototransduction cascade in mouse retina

Inherited retinal dystrophies are often associated with mutations in the genes involved in the phototransduction cascade in photoreceptors, a paradigmatic signaling pathway mediated by G protein-coupled receptors. Photoreceptor viability is strictly dependent on the levels of the second messengers cGMP and Ca2+. Here we explored the possibility of modulating the phototransduction cascade in mouse rods using direct or liposome-mediated administration of a recombinant protein crucial for regulating the interplay of the second messengers in photoreceptor outer segments. The effects of administration of the free and liposome-encapsulated human guanylate cyclase-activating protein 1 (GCAP1) were compared in biological systems of increasing complexity (in cyto, ex vivo, and in vivo). The analysis of protein biodistribution and the direct measurement of functional alteration in rod photoresponses show that the exogenous GCAP1 protein is fully incorporated into the mouse retina and photoreceptor outer segments. Furthermore, only in the presence of a point mutation associated with cone-rod dystrophy in humans p.(E111V), protein delivery induces a disease-like electrophysiological phenotype, consistent with constitutive activation of the retinal guanylate cyclase. Our study demonstrates that both direct and liposome-mediated protein delivery are powerful complementary tools for targeting signaling cascades in neuronal cells, which could be particularly important for the treatment of autosomal dominant genetic diseases.

Effect of exercise across the head and neck cancer continuum: a systematic review of randomized controlled trials

PURPOSE

This study aims to systematically explore the impact of physical exercise as supportive therapy for head and neck cancer.

METHODS

A systematic search on PubMed/MEDLINE, Cochrane, and SPORTDiscus was conducted. Randomized controlled trials exploring the effects of a physical exercise intervention in comparison with usual care on outcomes in patients with head and neck cancer were selected. The RoB 2 tool was used to determine the study quality. The extracted data are reported as qualitative synthesis.

RESULTS

Among the 527 records examined, nine studies were included. No trials investigating exercise as prehabilitation were found, whereas eight studies involving 452 patients with head and neck cancer were conducted during anticancer treatment. Most trials did not report improvements in body mass index or body composition, while 2/4 and 3/5 investigations found a significant increase in muscle strength and cardiorespiratory fitness, respectively. Regarding the patients' reported outcomes, 4 out of 7 studies observed enhancements in some domains of quality of life, and two trials out of 3 detected an amelioration in fatigue following the exercise intervention. Analyzing the exercise programs, it seems that combining aerobic and resistance training could be more beneficial compared to a single type of full-body exercise in counteracting physical decline and controlling symptoms in the anticancer therapy phase. One trial has investigated the effect of resistance exercise on patients who had terminated the anticancer treatments, reporting significant improvements in lean mass, muscle strength, and quality of life.

CONCLUSION

Exercise may be a promising approach in patients with head and neck cancer. Future studies are needed to consolidate these results.

Does Renal Denervation a Reasonable Treatment Option in Hemodialysis-Dependent Patient with Resistant Hypertension? A Narrative Review

PURPOSE OF REVIEW

This narrative review aims to assess the pathophysiology, diagnosis, and treatment of resistant hypertension (RH) in end-stage kidney disease (ESKD) patients on dialysis, with a specific focus on the effect of renal denervation (RDN) on short-term and long-term blood pressure (BP) control. Additionally, we share our experience with the use of RDN in an amyloidotic patient undergoing hemodialysis with RH.

RECENT FINDINGS

High BP, an important modifiable cardiovascular risk factor, is often observed in patients in ESKD, despite the administration of multiple antihypertensive medications. However, in clinical practice, it remains challenging to identify RH patients on dialysis treatment because of the absence of specific definition for RH in this context. Moreover, the use of invasive approaches, such as RDN, to treat RH is limited by the exclusion of patients with reduced renal function (eGFR < 45 mL/min/1.73 m3) in the clinical trials. Nevertheless, recent studies have reported encouraging results regarding the effectiveness of RDN in stage 3 and 4 chronic kidney disease (CKD) and ESKD patients on dialysis, with reductions in BP of nearly up to 10 mmhg. Although multiple underlying pathophysiological mechanisms contribute to RH, the overactivation of the sympathetic nervous system in ESKD patients on dialysis plays a crucial role. The diagnosis of RH requires both confirmation of adherence to antihypertensive therapy and the presence of uncontrolled BP values by ambulatory BP monitoring or home BP monitoring. Treatment involves a combination of nonpharmacological approaches (such as dry weight reduction, sodium restriction, dialysate sodium concentration reduction, and exercise) and pharmacological treatments. A promising approach for managing of RH is based on catheter-based RDN, through radiofrequency, ultrasound, or alcohol infusion, directly targeting on sympathetic overactivity.

Pancreatic steatosis and metabolic pancreatic disease: a new entity?

Overweight and obesity are some of the most important health challenges. Many diseases are related to these metabolic disorders, and, among them, the pancreatic fat accumulation, also called "pancreatic steatosis" or "nonalcoholic fatty pancreas", seems to have an emerging role in different conditions. There are different method to evaluate the fat content in the pancreas, such as histology, different imaging techniques and endoscopic ultrasound, but there is no gold standard for the correct diagnosis and for the identification of "inter/intralobular" and "intra-acinar" pancreatic fat. However, the fat storage in the pancreas is linked to chronic inflammation and to several conditions, such as acute and chronic pancreatitis, type 2 diabetes mellitus and pancreatic cancer. In addition, pancreatic fat accumulation has also been demonstrated to play a role in surgical outcome after pancreatectomy, in particular for the development of postoperative pancreatic fistula. Different possible therapeutic approaches have been proposed, but there is still a lack of evidence. The aim of this review is to report the current evidence about the relationship between the obesity, the pancreatic fat accumulation and its potential role in pancreatic diseases.

IGF1 and PPARG polymorphisms are associated with reduced estimated glomerular filtration rate in a cohort of children and adolescents with type 1 diabetes

INTRODUCTION

Several genetic loci have been associated with diabetic nephropathy; however, the underlying genetic mechanisms are still poorly understood, with no robust candidate genes identified yet.

AIM

We aimed to determine whether two polymorphisms, previously associated with renal decline, influence kidney impairment evaluating their association with markers of renal function in a pediatric population with type 1 diabetes (T1D).

MATERIAL AND METHODS

Renal function was evaluated by glomerular filtration rate (eGFR) and albumin-to-creatinine ratio (ACR) in a cohort of pediatric subjects with T1D (n = 278). Risk factors for diabetes complications (diabetes duration, blood pressure, HbA1c) were assessed. The IGF1 rs35767 and PPARG rs1801282 SNPs were genotyped by TaqMan RT-PCR system. An additive genetic interaction was calculated. Association analysis between markers of renal function and both SNPs or their additive interaction were performed.

RESULTS

Both SNPs showed a significant association with eGFR: the A allele of rs35767 or the C allele of rs1801282 were associated to reduced eGFR compared to G alleles. Multivariate regression analysis adjusted for age, sex, z-BMI, T1D duration, blood pressure and Hba1c values showed that the additive genetic interaction was independently associated with lower eGFR (β = -3.59 [-6.52 to -0.66], p = 0.017). No associations were detected between SNPs, their additive interaction and ACR.

CONCLUSIONS

These results provide new insight into the genetic predisposition to renal dysfunction, showing that two polymorphisms in IGF1 and PPARG genes can lead to a reduction in renal filtration rate leading these patients to be exposed to a higher risk of early renal complications.

Insights on the role of L-lactate as a signaling molecule in skin aging

L-lactate is a catabolite from the anaerobic metabolism of glucose, which plays a paramount role as a signaling molecule in various steps of the cell survival. Its activity, as a master tuner of many mechanisms underlying the aging process, for example in the skin, is still presumptive, however its crucial position in the complex cross-talk between mitochondria and the process of cell survival, should suggest that L-lactate may be not a simple waste product but a fine regulator of the aging/survival machinery, probably via mito-hormesis. Actually, emerging evidence is highlighting that ROS are crucial in the signaling of skin health, including mechanisms underlying wound repair, renewal and aging. The ROS, including superoxide anion, hydrogen peroxide, and nitric oxide, play both beneficial and detrimental roles depending upon their levels and cellular microenvironment. Physiological ROS levels are essential for cutaneous health and the wound repair process. Aberrant redox signaling activity drives chronic skin disease in elderly. On the contrary, impaired redox modulation, due to enhanced ROS generation and/or reduced levels of antioxidant defense, suppresses wound healing via promoting lymphatic/vascular endothelial cell apoptosis and death. This review tries to elucidate this issue.

Prognostic impact of palpable prostate tumors on disease progression after robot-assisted radical prostatectomy: a single-center experience

OBJECTIVE

This study aimed to evaluate the impact of palpable prostate tumors on digital rectal exam (DRE) on the disease progression of prostate cancer (PCa) treated with RARP surgery in a tertiary referral center.

MATERIALS AND METHODS

Overall, 901 patients were evaluated in a period ranging from January 2013 to October 2020. In the surgical specimen, unfavorable pathology included ISUP grade group ≥3, seminal vesicle invasion (SVI), and pelvic lymph node invasion (PLNI). Disease progression was defined as the occurrence of biochemical recurrence and/or local recurrence and/or distant metastases; its association with the primary endpoint was evaluated by Cox's proportional model.

RESULTS

Palpable prostate tumors were detected in 359 (39.8%) patients. The overall median (IQR) follow-up was 40 months (17-59). PCa progressed in 159 cases (17.6%). Nodularity or induration of the prostate at DRE was significantly associated with features of unfavorable pathology, increased risk of PCa progression (hazard ratio, HR = 1.902; 95% CI: 1.389-2.605; p < 0.0001) and, on multivariable analysis, was an independent prognostic factor for disease progression after adjusting for clinical and pathological variables.

CONCLUSIONS

Prostate tumors presenting with an abnormal DRE finding have an independent adverse outcome for disease progression after PCa surgery. They provide also independent prognostic information, as they may be more aggressive than impalpable PCa.

Ultrasound-derived fat fraction for detection of hepatic steatosis and quantification of liver fat content

PURPOSE

To compare ultrasound (US) and US-derived fat fraction (UDFF) with magnetic resonance proton density fat fraction (MRI-PDFF) for the detection of hepatic steatosis and quantification of liver fat content.

MATERIALS AND METHODS

Between October and December 2022, 149 patients scheduled for an abdominal MRI agreed to participate in this study and underwent MRI-PDFF, US and UDFF. Inclusion criteria were: (a) no chronic liver disease or jaundice; (b) no MRI motion artifacts; (c) adequate liver examination at US. Exclusion criteria were: (a) alcohol abuse, chronic hepatitis, cirrhosis, or jaundice; (b) MRI artifacts or insufficient US examination. The median of 10 MRI-PDFF and UDFF measurements in the right hepatic lobe was analyzed. UDFF and MRI-PDFF were compared by Bland-Altman difference plot and Pearson's test. Sensitivity, specificity, positive and negative predictive values, accuracy, and area under the receiver-operator curve (AUC-ROC) of US and UDFF were calculated using an MRI-PDFF cut-off value of 5%. p values ≤ 0.05 were statistically significant.

RESULTS

122 patients were included (61 men, mean age 60 years, standard deviation 15 years). The median MRI-PDFF value was 4.1% (interquartile range 2.9-6); 37.7% patients had a median MRI-PDFF value ≥ 5%. UDFF and MRI-PDFF had high agreement (p = 0.11) and positive correlation (⍴ = 0.81, p < 0.001). UDFF had a higher diagnostic value than US for the detection of steatosis, with AUC-ROCs of 0.75 (95% CI 0.65, 0.84) and 0.53 (95% CI 0.42, 0.64), respectively.

CONCLUSIONS

UDFF reliably quantifies liver fat content and improves the diagnostic value of US for the detection of hepatic steatosis.

Intraoperative neurophysiology in pediatric neurosurgery: a historical perspective

INTRODUCTION

Intraoperative neurophysiology (ION) has been established over the past three decades as a valuable discipline to improve the safety of neurosurgical procedures with the main goal of reducing neurological morbidity. Neurosurgeons have substantially contributed to the development of this field not only by implementing the use and refinement of ION in the operating room but also by introducing novel techniques for both mapping and monitoring of neural pathways.

METHODS

This review provides a personal perspective on the evolution of ION in a variety of pediatric neurosurgical procedures: from brain tumor to brainstem surgery, from spinal cord tumor to tethered cord surgery.

RESULTS AND DISCUSSION

The contribution of pediatric neurosurgeons is highlighted showing how our discipline has played a crucial role in promoting ION at the turn of the century. Finally, a view on novel ION techniques and their potential implications for pediatric neurosurgery will provide insights into the future of ION, further supporting the view of a functional, rather than merely anatomical, approach to pediatric neurosurgery.

SARS-CoV-2 antibodies in inflammatory neurological conditions: a multicentre retrospective comparative study

It is well established that neurological and non-neurological autoimmune disorders can be triggered by viral infections. It remains unclear whether SARS-CoV-2 infection induces similar conditions and whether they show a distinctive phenotype. We retrospectively identified patients with acute inflammatory CNS conditions referred to our laboratory for antibody testing during the pandemic (March 1 to August 31, 2020). We screened SARS-COV-2 IgA/IgG in all sera by ELISA and confirmed the positivity with additional assays. Clinical and paraclinical data of SARS-COV-2-IgG seropositive patients were compared to those of seronegative cases matched for clinical phenotype, geographical zone, and timeframe. SARS-CoV-2-IgG positivity was detected in 16/339 (4%) sera, with paired CSF positivity in 3/16. 5 of these patients had atypical demyelinating disorders and 11 autoimmune encephalitis syndromes. 9/16 patients had a previous history of SARS-CoV-2 infection and 6 of them were symptomatic. In comparison with 32 consecutive seronegative controls, SARS-CoV-2-IgG-positive patients were older, frequently presented with encephalopathy, had lower rates of CSF pleocytosis and other neurological autoantibodies, and were less likely to receive immunotherapy. When SARS-CoV-2 seropositive versus seronegative cases with demyelinating disorders were compared no differences were seen. Whereas seropositive encephalitis patients less commonly showed increased CSF cells and protein, our data suggest that an antecedent symptomatic or asymptomatic SARS-CoV-2 infection can be detected in patients with autoimmune neurological conditions. These cases are rare, usually do not have specific neuroglial antibodies.

Trait-related neural basis of attentional bias to emotions: a tDCS study

Negative emotional stimuli can strongly bias attention, particularly in individuals with high levels of dispositional negative affect (NA). The current study investigated whether the prefrontal cortex (PFC), a brain region involved in the top-down regulation of emotional processing, plays a different role in controlling attention to emotions, depending on the individual NA. Sham and anodal transcranial direct current stimulation (tDCS) was delivered over the right or left PFC while assessing attentional bias (AB) to emotions (happy, angry, sad faces) in individuals with higher and lower trait NA. When tDCS was inactive (sham), individuals with higher trait NA showed AB toward angry and away from sad faces, while individuals with lower trait NA presented with no AB. Right anodal-tDCS abolished the AB toward angry faces and induced an AB toward sad faces in individuals with higher trait NA, while no effect was found in individuals with lower trait NA. Left anodal-tDCS abolished any AB in individuals with higher trait NA and induced an AB away from happy faces in individuals with lower trait NA. These findings confirm a critical role of trait NA in AB to emotions and demonstrate a different involvement of PFC in emotional processing based on dispositional affect.

Evaluation of the ACS-NSQIP Surgical Risk Calculator in Patients with Hepatic Metastases from Colorectal Cancer Undergoing Liver Resection

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator (ACS-NSQIP SRC) has been designed to predict morbidity and mortality and help stratify surgical patients. This study evaluates the performance of the SRC for patients undergoing surgery for colorectal liver metastases (CRLM).

METHODS

SRC was retrospectively computed for patients undergoing liver or simultaneous colon and liver surgery for colorectal cancer (CRC) in two high tertiary referral centres from 2011 to 2020. C-statistics and Brier score were calculated as a mean of discrimination and calibration respectively, for both group and for every level of surgeon adjustment score (SAS) for liver resections in case of simultaneous liver-colon surgery. An AUC ≥ 0.7 shows acceptable discrimination; a Brier score next to 0 means the prediction tool has good calibration.

RESULTS

Four hundred ten patients were included, 153 underwent simultaneous resection, and 257 underwent liver-only resections. For simultaneous surgery, the ACS-NSQIP SRC showed good calibration and discrimination only for cardiac complication (AUC = 0.720, 0.740, and 0.702 for liver resection unadjusted, SAS-2, and SAS-3 respectively; 0.714 for colon resection; and Brier score = 0.04 in every case). For liver-only surgery, it only showed good calibration for cardiac complications (Brier score = 0.03). The SRC underestimated the incidence of overall complications, pneumonia, cardiac complications, and the length of hospital stay.

CONCLUSIONS

ACS-NSQIP SRC showed good predicting capabilities only for 1 out of 5 evaluated outcomes; therefore, it is not a reliable tool for patients undergoing liver surgery for CRLM, both in the simultaneous and staged resections.

Metabolic-associated fatty liver disease and liver fibrosis scores as COVID-19 outcome predictors: a machine-learning application

Patients with COVID-19 and metabolic-dysfunction associated fatty liver disease (MAFLD) appear to be at higher risk for severe manifestations, especially in the youngest decades. Our aim was to examine whether patients with MAFLD and/or with increased liver fibrosis scores (FIB-4) are at risk for severe COVID-19 illness, using a machine learning (ML) model. Six hundred and seventy two patients were enrolled for SARS-CoV-2 pneumonia between February 2020 and May 2021. Steatosis was detected by ultrasound or computed tomography (CT). ML model valuated the risks of both in-hospital death and prolonged hospitalizations (> 28 days), considering MAFLD, blood hepatic profile (HP), and FIB-4 score. 49.6% had MAFLD. The accuracy in predicting in-hospital death was 0.709 for the HP alone and 0.721 for HP + FIB-4; in the 55-75 age subgroup, 0.842/0.855; in the MAFLD subgroup, 0.739/ 0.772; in the MAFLD 55-75 years, 0.825/0.833. Similar results were obtained when considering the accuracy in predicting prolonged hospitalization. In our cohort of COVID-19 patients, the presence of a worse HP and a higher FIB-4 correlated with a higher risk of death and prolonged hospitalization, regardless of the presence of MAFLD. These findings could improve the clinical risk stratification of patients diagnosed with SARS-CoV-2 pneumonia.

Trends in hospital volume and operative mortality in hepato-biliary surgery in Veneto region, Italy

Hepatobiliary resections are among the most complex and technically challenging surgical procedures. Even though robust evidence showed that complex surgical procedures such as hepatobiliary surgery have better short- and long-term outcomes and lower mortality rate when performed in high-volume centers, the minimal criteria of centers that can perform hepatobiliary activity are not clearly defined. We conducted a retrospective population study of patients who underwent hepatobiliary surgery for malignant disease in a single Italian administrative region (Veneto) from 2010 to 2021 with the aim to investigate the hospitals annual surgical volume for hepatobiliary malignant diseases and the effect of hospital volume on in-hospital, 30- and 90-day postoperative mortality. The centralization process of hepatobiliary surgery in Veneto is rapidly increasing over the past 10 years (rate of performed in highly specialized centers increased from 62% in 2010 to 78% in 2021) and actually it is really established. The crude and adjusted (for age, sex, Charlson Index) mortality rate after hepatobiliary surgery resulted significantly lower in centers with high-volume activity compared to them with low-volume activity. In the Veneto region, the "Hub and Spoke" model led to a progressive centralization of liver and biliary cancer treatment. High surgical volume has been confirmed to be related to better outcomes in terms of mortality rate after hepatobiliary surgical procedures. Further studies are necessary to clearly define the minimal criteria and associated numerical cutoffs that can help define the characteristics of centers that can perform hepatobiliary activities.

Pediatric Sinogenic Subdural Empyema: Case Report and Operative Technique

Intracranial complications of sinusitis in the pediatric age are rare but potentially life threatening. They usually occur with nonspecific symptoms such as headache, fever, nausea and vomiting rather than a classic neurological presentation, but they may evolve in few hours, leading to significant morbidity with permanent brain damage and sometimes to death. For this reason, early diagnosis and prompt treatment are essential. Our case demonstrates a sinogenic subdural empyema in an immunocompetent young boy who reached our Emergency Department due to a continuous right-sided headache, unresponsive to pain relievers. The clinical history and the diagnostic process are described: at first, laboratory exams, neurologic and otolaryngological assessment were performed, together with a cranial CT scan showing an inflammatory involvement of the right frontal, ethmoidal and maxillary sinuses. Intravenous antibiotic therapy was initiated. After a few hours the patient showed a sudden worsening of his clinical conditions: he was drowsy with left lower extremity hyposthenia and ipsilateral deep tendon reflexes absence. Considering the patient's aggravated clinical presentation an emergent MRI with contrast enhancement was conducted, showing left midline shift, a widening of the liquor space on the right frontal and parietal convexity and noticeable meningeal enhancement after contrast injection. After a Neurosurgical and ENT evaluation the patient was taken to the operating room for a combined craniotomy and trans-nasal endoscopic drainage of the empyema. We present the surgical procedure with a pictorial step-by-step description. After the surgical procedure the patient's condition gradually improved. He regained full neurological function, was accompanied by a rehabilitation team on recovering full force on the left extremities. At discharge the patient had no apparent neurological deficits. Subdural empyema is a rare but severe complication of pediatric sinusitis. Early diagnosis with combined medical and surgical therapies play a key role to reduce morbidity and mortality.

Telemedicine and Digital Medicine in the Clinical Management of Hypertension and Hypertension-Related Cardiovascular Diseases: A Position Paper of the Italian Society of Arterial Hypertension (SIIA)

High blood pressure is the leading cause of death and disability globally and an important treatable risk factor for cardiovascular, cerebrovascular and chronic kidney diseases. Digital technology, including mobile health solutions and digital therapy, is expanding rapidly in clinical medicine and has the potential to improve the quality of care and effectiveness of drug treatment by making medical interventions timely, tailored to hypertensive patients' needs and by improving treatment adherence. Thus, the systematic application of digital technologies could support diagnosis and awareness of hypertension and its complications, ultimately leading to improved BP control at the population level. The progressive implementation of digital medicine in the national health systems must be accompanied by the supervision and guidance of health authorities and scientific societies to ensure the correct use of these new technologies with consequent maximization of the potential benefits. The role of scientific societies in relation to the rapid adoption of digital technologies, therefore, should encompass the entire spectrum of activities pertaining to their institutional role: information, training, promotion of research, scientific collaboration and advice, evaluation and validation of technological tools, and collaboration with regulatory and health authorities.

Advanced age is an independent prognostic factor of disease progression in high-risk prostate cancer: results in 180 patients treated with robot-assisted radical prostatectomy and extended pelvic lymph node dissection in a tertiary referral center

OBJECTIVES

This study aimed to assess more clinical and pathological factors associated with prostate cancer (PCa) progression in high-risk PCa patients treated primarily with robot-assisted radical prostatectomy (RARP) and extended pelvic lymph node dissection (ePLND) in a tertiary referral center.

MATERIALS AND METHODS

In a period ranging from January 2013 to October 2020, RARP and ePLND were performed on 180 high-risk patients at Azienda Ospedaliera Universitaria Integrata of Verona (Italy). PCa progression was defined as biochemical recurrence/persistence and/or local recurrence and/or distant metastases. Statistical methods evaluated study endpoints, including Cox's proportional hazards, Kaplan-Meyer survival curves, and binomial logistic regression models.

RESULTS

The median age of included patients was 66.5 [62-71] years. Disease progression occurred in 55 patients (30.6%), who were more likely to have advanced age, palpable tumors, and unfavorable pathologic features, including high tumor grade, stage, and pelvic lymph node invasion (PLNI). On multivariate analysis, PCa progression was predicted by advanced age (≥ 70 years) (HR = 2.183; 95% CI = 1.089-4377, p = 0.028), palpable tumors (HR = 3.113; 95% CI = 1.499-6.465), p = 0.002), and PLNI (HR = 2.945; 95% CI = 1.441-6.018, p = 0.003), which were associated with clinical standard factors defining high-risk PCa. Age had a negative prognostic impact on elderly patients, who were less likely to have palpable tumors but more likely to have high-grade tumors.

CONCLUSIONS

High-risk PCa progression was independently predicted by advanced age, palpable tumors, and PLNI, which is associated with standard clinical prognostic factors. Consequently, with increasing age, the prognosis is worse in elderly patients, who represent an unfavorable age group that needs extensive counseling for appropriate and personalized management decisions.

Use of non-invasive respiratory supports in high-intensity internal medicine setting during the first two waves of the COVID-19 pandemic emergency in Italy: a multicenter, real-life experience

During the first two waves of the COVID-19 emergency in Italy, internal medicine high-dependency wards (HDW) have been organized to manage patients with acute respiratory failure (ARF). There is heterogeneous evidence about the feasibility and outcomes of non-invasive respiratory supports (NIRS) in settings outside the intensive care unit (ICU), including in patients deemed not eligible for intubation (i.e., with do-not-intubate, DNI status). Few data are available about the different NIRS modalities applied to ARF patients in the newly assembled internal medicine HDW. The main aim of our study was to describe a real-life experience in this setting of cure, focusing on feasibility and outcomes. We retrospectively collected data from COVID-19 patients with ARF needing NIRS and admitted to internal medicine HDW. Patients were treated with different modalities, that is high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), or non-invasive mechanical ventilation (NIMV). Switching among different NIRS during the hospitalization and the success rate (weaning with the same NIRS) or failure (endotracheal intubation-ETI or in-hospital death) were recorded. Three hundred thirty four ARF patients (median age 74 years), of which 158 (54%) had a DNI status, were included. CPAP, NIMV, and HFNC's success rates were 54, 33, and 13%, respectively. Although DNI status was strongly associated with death (Gehan-Breslow-Wilcoxon test p < 0.001), an acceptable success rate was observed in these patients using CPAP (47%). Multivariate regression models showed older age (odds ratio-OR 4.74), chronic ischemic heart disease (OR 2.76), high respiratory rate after 24 h (OR 7.13), and suspected acute respiratory distress syndrome-ARDS (OR 21.1) as predictors of mortality risk or ETI. Our real-life experience shows that NIRS was feasible in internal medicine HDW with an acceptable success rate. Although DNI patients had a worse prognosis, the use of NIRS represented a reasonable chance of treatment.

Exploring the Use of Monoclonal Antibodies and Antiviral Therapies for Early Treatment of COVID-19 Outpatients in a Real-World Setting: A Nationwide Study from England and Italy

BACKGROUND

Real-world data on early treatment of coronavirus disease 2019 (COVID-19) outpatients with newly approved therapies are sparse.

AIM

To explore the pattern of use of monoclonal antibodies (mAbs)/antiviral therapies approved for early COVID-19 treatment in non-hospitalized patients from England and Italy from December 2021 to October 2022.

METHODS

Public national dashboards on weekly mAb/antiviral use and/or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection diagnoses from the Italian Medicines Agency, the Italian National Institute of Health, National Health Service in England and the UK Government were explored. Prevalence of antiviral use in outpatients during the entire study period and every two weeks was calculated, as a whole and by class and compounds. An interrupted time-series (ITS) analysis was carried out to assess the impact of predominant SARS-CoV-2 variants over time on the prevalence of use of mAbs/antivirals in England and Italy.

RESULTS

Overall, 77,469 and 195,604 doses of mAbs/antivirals were respectively administered to a total of 10,630,903 (7.3 per 1000) and 18,168,365 (10.8 per 1000) patients diagnosed with SARS-CoV-2 infection in England and Italy. Prevalence of use every two weeks increased from 0.07% to 3.1% in England and 0.9% to 2.3% in Italy during the study period. Regarding individual compounds, sotrovimab (prevalence of use, 1.6%) and nirmatrelvir/ritonavir (1.6%) in England, and nirmatrelvir/ritonavir (1.7%) and molnupiravir (0.5%) in Italy, reported the highest prevalence during a 2-week period. In the ITS analysis, the transition from Delta to Omicron variant predominance was associated with a significant increase in the use of sotrovimab, molnupiravir, remdesivir and nirmatrelvir/ritonavir in both England and Italy, with a reduction of other marketed mAbs. The extent of the increase was higher in England than in Italy for all these drugs except for nirmatrelvir/ritonavir.

CONCLUSIONS

In this dual nationwide study, the prevalence of use of mAbs/antivirals against SARS-CoV-2 for early outpatients' treatment increased slowly up to 2.0-3.0% of all patients diagnosed with SARS-CoV-2 infection in both England and Italy from December 2021 to October 2022. The trend of individual drug use varied in relation to predominant SARS-CoV-2 variants with some differences across countries. In line with scientific societies' guidelines, nirmatrelvir/ritonavir was the most frequently prescribed antiviral in both countries in the most recent period.

Oxidized cellulose-based reaction mimicking thyroidal recurrence of disease: a case report and literature review

Oxidized cellulose is a hemostatic agent currently used in surgery. Foreign body reactions have been described after its use. This paper describes a foreign body reaction caused by oxidized cellulose in a young woman who underwent thyroid surgery. A patient underwent two thyroid surgeries for treatment of papillary carcinoma. Five years after the last surgery, an asymptomatic mass was detected with a routine ultrasound in the left thyroid cavity. After surgical removal, the mass turned out to be a foreign body granuloma based on oxidized cellulose sheets used in the previous surgery. The patient was discharged from the hospital without complications. The follow-up period was uneventful. Oxidized cellulose is a useful tool in surgery to control and prevent intra and post-operative bleeding. Even if it is a biodegradable material, sometimes it persists in the human body causing foreign body reactions that can be misdiagnosed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03556-0.

Intracoronary physiology-guided percutaneous coronary intervention in patients with diabetes

OBJECTIVE

The risk of vessel-oriented cardiac adverse events (VOCE) in patients with diabetes mellitus (DM) undergoing intracoronary physiology-guided coronary revascularization is poorly defined. The purpose of this work is to evaluate the risk of VOCE in patients with and without DM in whom percutaneous coronary intervention (PCI) was performed or deferred based on pressure-wire functional assessment.

METHODS

This is a retrospective analysis of a multicenter registry of patients evaluated with fractional flow reserve (FFR) and/or non-hyperaemic pressure ratio (NHPR). Primary endpoint was a composite of VOCE including cardiac death, vessel-related myocardial infarction (MI), and ischemia-driven target vessel revascularization (TVR).

RESULTS

A large cohort of 2828 patients with 3353 coronary lesions was analysed to assess the risk of VOCE at long-term follow-up (23 [14-36] months). Non-insulin-dependent-DM (NIDDM) was not associated with the primary endpoint in the overall cohort (adjusted Hazard Ratio [aHR] 1.18, 95% CI 0.87-1.59, P = 0.276) or in patients with coronary lesions treated with PCI (aHR = 1.30, 95% CI 0.78-2.16, P = 0.314). Conversely, insulin-dependent diabetes mellitus (IDDM) demonstrated an increased risk of VOCE in the overall cohort (aHR 1.76, 95% CI 1.07-2.91, P = 0.027), but not in coronary lesions undergoing PCI (aHR 1.26, 95% CI 0.50-3.16, P = 0.621). Importantly, in coronary lesions deferred after functional assessment IDDM (aHR 2.77, 95% CI 1.11-6.93, P = 0.029) but not NIDDM (aHR = 0.94, 95% CI 0.61-1.44, P = 0.776) was significantly associated with the risk of VOCE. IDDM caused a significant effect modification of FFR-based risk stratification (P for interaction < 0.001).

CONCLUSION

Overall, DM was not associated with an increased risk of VOCE in patients undergoing physiology-guided coronary revascularization. However, IDDM represents a phenotype at high risk of VOCE.

Bidirectional Approach with PIPAC and Systemic Chemotherapy for Patients with Synchronous Gastric Cancer Peritoneal Metastases (GCPM)

BACKGROUND

This study evaluated the efficacy of pressurized intraperitoneal aerosol chemotherapy (PIPAC) with systemic chemotherapy as a bidirectional approach for gastric cancer (GC) patients with synchronous peritoneal metastases (SPM).

METHODS

A retrospective analysis of a prospective PIPAC database was queried for patients who underwent a bidirectional approach between October 2019 and April 2022 at two high-volume GC surgery units in Italy (Verona and Siena). Surgical and oncological outcomes were analyzed.

RESULTS

Between October 2019 and April 2022, 74 PIPAC procedures in 42 consecutive patients with Eastern Cooperative Oncology Group performance status ≤2 were performed-32 patients treated in Verona and 10 in Siena. Twenty-seven patients (64%) were female and median age at first PIPAC was 60.5 years (I-III quartiles: 49-68 years). Median Peritoneal Cancer Index (PCI) was 16 (I-III quartiles: 8-26) and 25 patients (59%) had at least two PIPAC procedures. Major complications according to the Common Terminology Criteria for Adverse Events (CTCAE; 3 and 4) occurred in three (4%) procedures, and, according to the Clavien-Dindo classification (>3a), one (1%) severe complication occurred. There were no reoperations or deaths within 30 days. Median overall survival (mOS) from diagnosis was 19.6 months (range 14-24), and mOS from first PIPAC was 10.5 months (range 7-13). Excluding cases with very heavy metastatic peritoneal burden, with PCI from 2 to 26, treated with more than one PIPAC, mOS from diagnosis was 22 months (range 14-39). Eleven patients (26%) underwent curative-intent surgery after a bidirectional approach. R0 was achieved in nine (82%) patients and complete pathological response was obtained in three (27%) cases.

CONCLUSIONS

Patient selection is associated with bidirectional approach efficacy and feasibility for SPM GC treatment, which may allow potentially curative surgical radicalization in highly selected cases.

Characterization and digital spatial deconvolution of the immune microenvironment of intraductal oncocytic papillary neoplasms (IOPN) of the pancreas

Intraductal oncocytic papillary neoplasm (IOPN) of the pancreas is a distinct entity from intraductal papillary mucinous neoplasms (IPMNs) and is considered one of the precursor lesions of pancreatic cancer. Through immunohistochemistry (IHC) and an artificial intelligence (AI)-based approach, this study aims at characterizing its immune microenvironment. Whole-slide IHC was performed on a cohort of 15 IOPNs, 2 of which harboring an associated adenocarcinoma. The following markers were tested: CD3, CD4, CD8, CD20, CD68, CD163, PD-1, PD-L1, MLH1, PMS2, MSH2, and MSH6. The main findings can be summarized as follows: (i) CD8+ T lymphocytes were the predominant immune cells (p < 0.01); (ii) the vast majority of macrophages were concurrently CD68+ and CD163+; (iii) all tumors showed an activated PD-1/PD-L1 axis, but none had mismatch repair deficiency; (iv) AI-based analysis revealed the presence of 2 distinct regions in each case, namely, Re1, localized at the center of the tumor, and Re2, located at tumor periphery; (v) the infiltrating component of the 2 invasive IOPNs showed a smaller extent of Re1 and a reduced rate of CD4+ cells, as well as a larger extent of Re2 and increased rate of CD8+ cells. IOPNs are lesions enriched in immune cells, with a predominance of CD8+ T lymphocytes and class 2 macrophages. Differently from IPMN-oncogenesis, the progression towards invasive carcinoma is accompanied by an increased rate of CD8+ lymphocytes. This finding may suggest the presence of an active self-immune surveillance in invasive IOPNs, potentially explaining, at least in part, the excellent survival rate of IOPN patients.

Spur cells in liver cirrhosis are predictive of acute-on-chronic liver failure and liver-related mortality regardless of severe anaemia

Chronic anaemia in advanced liver disease is a frequent finding. The aim was to explore the clinical impact of spur cell anaemia, a rare entity typically associated with end-stage of the disease. One-hundred and nineteen patients (73.9% males) with liver cirrhosis of any etiology were included. Patients with bone marrow diseases, nutrients deficiencies and hepatocellular carcinoma were excluded. In all patients, a blood sample was collected to check for the presence of spur cells on blood smear. A complete blood biochemical panel was recorded together with Child-Pugh (CP) score and Model for End-Stage Liver Disease (MELD) score. For each patients, clinically relevant events, such as acute-on-chronic liver failure (ACLF) and 1 year liver-related mortality, were registered. Patients were then grouped according to the percentage of spur cells at smear (> 5%, 1-5%, < 1%). Severe anaemia was defined as haemoglobin levels lower than 8 g/dL. 9.2% of subjects had > 5% spur cells, only 2 had evidence of haemolysis. In patients with > 5% spur cells, haemoglobin and albumin were lower compared with the other sub-group, while MELD score, CP score, International Normalized Ratio, ferritin, creatinine and unconjugated bilirubin were higher. Patients with more spur cells were more decompensated and developed more frequently ACLF. ACLF and liver-related mortality were significantly and independently associated with the presence of > 5% spur cells but not with baseline severe anaemia. Cirrhotic patients have a fairly high prevalence of spur cells, not always associated with severe haemolytic anaemia. The presence of spur red cells is per se associated with a worse prognosis and, therefore, should be always evaluated to prioritize patients for intensive management and eventually liver transplantation.

Concurrent metaboreflex activation increases chronotropic and ventilatory responses to passive leg movement without sex-related differences

Previous studies in animal models showed that exercise-induced metabolites accumulation may sensitize the mechanoreflex-induced response. The aim of this study was to assess whether the magnitude of the central hemodynamic and ventilatory adjustments evoked by isolated stimulation of the mechanoreceptors in humans are influenced by the prior accumulation of metabolic byproducts in the muscle. 10 males and 10 females performed two exercise bouts consisting of 5-min of intermittent isometric knee-extensions performed 10% above the previously determined critical force. Post-exercise, the subjects recovered for 5 min either with a suprasystolic circulatory occlusion applied to the exercised quadriceps (PECO) or under freely-perfused conditions (CON). Afterwards, 1-min of continuous passive leg movement was performed. Central hemodynamics, pulmonary data, and electromyography from exercising/passively-moved leg were recorded throughout the trial. Root mean square of successive differences (RMSSD, index of vagal tone) was also calculated. Δpeak responses of heart rate (ΔHR) and ventilation ([Formula: see text]) to passive leg movement were higher in PECO compared to CON (ΔHR: 6 ± 5 vs 2 ± 4 bpm, p = 0.01; 3.9 ± 3.4 vs 1.9 ± 1.7 L min-1, p = 0.02). Δpeak of mean arterial pressure (ΔMAP) was significantly different between conditions (5 ± 3 vs  - 3 ± 3 mmHg, p < 0.01). Changes in RMSSD with passive leg movement were different between PECO and CON (p < 0.01), with a decrease only in the former (39 ± 18 to 32 ± 15 ms, p = 0.04). No difference was found in all the other measured variables between conditions (p > 0.05). These findings suggest that mechanoreflex-mediated increases in HR and [Formula: see text] are sensitized by metabolites accumulation. These responses were not influenced by biological sex.

Integrated effects of top-down attention and statistical learning during visual search: An EEG study

The present study aims to investigate how the competition between visual elements is solved by top-down and/or statistical learning (SL) attentional control (AC) mechanisms when active together. We hypothesized that the "winner" element that will undergo further processing is selected either by one AC mechanism that prevails over the other, or by the joint activity of both mechanisms. To test these hypotheses, we conducted a visual search experiment that combined an endogenous cueing protocol (valid vs. neutral cue) and an imbalance of target frequency distribution across locations (high- vs. low-frequency location). The unique and combined effects of top-down control and SL mechanisms were measured on behaviour and amplitudes of three evoked-response potential (ERP) components (i.e., N2pc, P1, CNV) related to attentional processing. Our behavioural results showed better performance for validly cued targets and for targets in the high-frequency location. The two factors were found to interact, so that SL effects emerged only in the absence of top-down guidance. Whereas the CNV and P1 only displayed a main effect of cueing, for the N2pc we observed an interaction between cueing and SL, revealing a cueing effect for targets in the low-frequency condition, but not in the high-frequency condition. Thus, our data support the view that top-down control and SL work in a conjoint, integrated manner during target selection. In particular, SL mechanisms are reduced or even absent when a fully reliable top-down guidance of attention is at play.

Desmin mutations impact the autophagy flux in C2C12 cell in mutation-specific manner

Desmin is the main intermediate filament of striated and smooth muscle cells and plays a crucial role in maintaining the stability of muscle fiber during contraction and relaxation cycles. Being a component of Z-disk area, desmin integrates autophagic pathways, and the disturbance of Z-disk proteins' structure negatively affects chaperone-assisted selective autophagy (CASA). In the present study, we focused on alteration of autophagy flux in myoblasts expressing various Des mutations. We applied Western blotting, immunocytochemistry, RNA sequencing, and shRNA approach to demonstrate that DesS12F, DesA357P, DesL345P, DesL370P, and DesD399Y mutations. Mutation-specific effect on autophagy flux being most severe in aggregate-prone Des mutations such as DesL345P, DesL370P, and DesD399Y. RNA sequencing data confirmed the most prominent effect of these mutations on expression profile and, in particular, on autophagy-related genes. To verify CASA contribution to desmin aggregate formation, we suppressed CASA by knocking down Bag3 and demonstrated that it promoted aggregate formation and lead to downregulation of Vdac2 and Vps4a and upregulation of Lamp, Pink1, and Prkn. In conclusion, Des mutations showed a mutation-specific effect on autophagy flux in C2C12 cells with either a predominant impact on autophagosome maturation or on degradation and recycling processes. Aggregate-prone desmin mutations lead to the activation of basal autophagy level while suppressing the CASA pathway by knocking down Bag3 can promote desmin aggregate formation.

Determinants of life expectancy at birth: a longitudinal study on OECD countries

This paper analyses the influence of several determinants on life expectancy at birth in 36 OECD countries over the 1999-2018 period. We utilized a cross-country fixed-effects multiple regression analysis with year and country dummies and used dynamic models, backward stepwise selection, and Arellano-Bond estimators to treat potential endogeneity issues. The results show the influence of per capita health-care expenditure, incidence of out-of-pocket expenditure, physician density, hospital bed density, social spending, GDP level, participation ratio to labour, prevalence of chronic respiratory diseases, temperature, and total size of the population on life expectancy at birth. In line with previous studies, this analysis confirms the relevance of both health care expenditure and health care system (physicians and hospital beds in our analysis) in influencing a country's population life expectancy. It also outlines the importance of other factors related to population behaviour and social spending jointly considered on this outcome. Policy makers should carefully consider these mutual influences when allocating public funds, particularly after the COVID-19 pandemic period.

Tracking social provenance in chains of retweets

In the era of massive sharing of information, the term social provenance is used to denote the ownership, source or origin of a piece of information which has been propagated through social media. Tracking the provenance of information is becoming increasingly important as social platforms acquire more relevance as source of news. In this scenario, Twitter is considered one of the most important social networks for information sharing and dissemination which can be accelerated through the use of retweets and quotes. However, the Twitter API does not provide a complete tracking of the retweet chains, since only the connection between a retweet and the original post is stored, while all the intermediate connections are lost. This can limit the ability to track the diffusion of information as well as the estimation of the importance of specific users, who can rapidly become influencers, in the news dissemination. This paper proposes an innovative approach for rebuilding the possible chains of retweets and also providing an estimation of the contributions given by each user in the information spread. For this purpose, we define the concept of Provenance Constraint Network and a modified version of the Path Consistency Algorithm. An application of the proposed technique to a real-world dataset is presented at the end of the paper.

The Impact of COVID-19 Pandemic on Psychiatric Rehabilitation in Residential Facilities: Perspectives of Staff and Residents

The coronavirus pandemic imposed significant changes in the care of patients in psychiatric residential facilities, especially during lockdown periods. The aim of this study was to assess the impact of the pandemic on patients and staff of psychiatric residential facilities (RFs). This cross-sectional survey was conducted between 30 June and 30 July 2021 and involved 31 RFs located in the province of Verona (Italy). In total, 170 staff members and 272 residents participated in this study. Staff showing clinically significant symptoms of anxiety, depression and burnout were, respectively, 7.7%, 14.2% and 6%. Staff were concerned about the risk that COVID-19 infection might spread among residents (67.6%) and that residents could not receive an acceptable service due to service reconfiguration because of the pandemic (50.3%). Residents found it very unpleasant not to be permitted to attend family members (85.3%), and not to be allowed to engage in outdoor activities due to the restrictions (84%). Both staff and residents agree that the main problematic areas for the residents was the interdiction to meet family members or friends and the interdiction to outdoor activities, whereas problems related to the COVID-19 infection were considered by the staff members as more frequently problematic than reported by residents. The COVID-19 pandemic had a significant impact on the rehabilitation care and recovery journeys of the residents of psychiatric RFs. Therefore, sustained, and careful attention is needed to ensure that the rehabilitation needs of people with severe mental disorders are not neglected in time of pandemics.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40737-023-00343-6.

The 'scientist', the 'analyst' and the 'novelist': science or metrics?

An overwhelming number of meta-analyses and reviews are published by scientific journals. In part this may reflect some preference of editors and publishers for these types of papers, which are more frequently cited and can increase the impact factor of their journals. Meta-analyses and reviews are also attractive for investigators looking for a greater chance of having successful publications with several citations, and therefore an improved personal h-index. This greater 'promise of success' might have a deleterious effect on the intellectual maturation of investigators, particularly early career investigators, who might neglect original research and concentrate their efforts on meta-analyses and reviews. However, while meta-analyses and reviews are useful for emphasising data and disseminating concepts, progress in science requires original ideas, original experiments and original papers. 'Analysts' and 'novelists' are welcome, but 'scientists' are indispensable.