Endoscopic "retrograde" dacryocystorhinostomy: A fast route to the lacrimal sac

Endoscopic Dacryocystorhinostomy (DCR) is an established surgical technique for the management of peripheral nasolacrimal duct (NLD) obstruction. Its main points are the correct identification of the lacrimal sac and the execution of surgical procedures that allow a rapid and accurate healing of the surgical field. The main endoscopic landmarks used for the identification of the lacrimal sac are the middle turbinate and the maxillary line. However, in some cases, this procedure can be difficult due to several factors (e.g. anatomical variations, former surgery). In the present study, a variation of "classic" endoscopic DCR, named "retrograde" endoscopic endonasal DCR (rDCR), is described. rDCR is performed through the quick identification of the NLD at the level of the most anterior insertion of the inferior turbinate in the lateral nasal wall. In most cases, at this level only a very thin shell of bone is present (crack point), easily fractured by using blunt angled dissector. The duct is then followed upward along its course by removing the overlying bone in order to correctly identify the lacrimal sac and unequivocally drill along the lacrimal pathway. This technique proved to be a safe, quick and effective procedure, even in patients with difficult anatomy.

COVID-19 VACCINE REACTIONS AND SUSPECTED POLYETHYLENE GLYCOL ALLERGY: A PEDIATRIC CASE SERIES

Introduction

Studies have demonstrated tolerance in high risk patients receiving Covid-19 m-RNA vaccines containing polyethylene glycol (PEG) with rare reactions.There is limited pediatric data regarding safety in receiving PEG containing Covid-19 vaccines with a history of prior hypersensitivity reactions to PEG containing chemotherapy (PEG-CTX).

Methods

Retrospective chart review from referred Pediatric Oncology patients with a history of prior reactions to PEG-CTX (01/2020-04/2022). Selective skin testing was completed using PEG molecular weigh 3350 and m-RNA Covid-19 vaccines with controls.

Results

Four pediatric patients (≤18 years old) had evidence suggestive of an immediate, hypersensitive reaction to PEG-CTX following treatment for acute lymphoblastic leukemia (ALL). All 4 patients experienced prior reactions to chemotherapy (L-Asparaginase). Symptoms included: hypotension, flushing, urticaria, angioedema, emesis and tachycardia. Due to prior reactions, these high-risk patients were not administered PEG containing Covid-19 vaccines due to safety concerns. Non-PEG containing Covid-19 vaccines were not approved for use in pediatric patients. Allergy skin testing (skin prick and intradermal) was completed in all four patients. One of 4 patients tested positive to both PEG and PEG containing Covid-19 vaccine. The 3 negative patients were administered PEG containing Covid-19 vaccine with monitoring for one hour without symptoms.

Conclusion

Pediatric patients in our study with prior reactions to PEG-CTX tolerated PEG containing Covid-19 vaccines. Further studies are needed in assessing PEG allergy in high-risk patients with a past history of reactions to PEG-CTX.

Mitochondrial alterations induced by serum amine oxidase and spermine on human multidrug resistant tumor cells

Multidrug resistance (MDR) has been studied extensively because it is one of major problems in cancer chemotherapy. The MDR phenotype is often due to overexpression of P-glycoprotein (P-gp), that acting as an energy-dependent drug efflux pump exports various anticancer drugs out of cells. The major goal of our investigation is to establish whether bovine serum amine oxidase (BSAO), which generates the products H(2)O(2) and aldehyde(s), from the polyamine spermine, is able to overcome MDR of human cancer cells. The cytotoxicity of the products was evaluated in both drug-sensitive (LoVo WT) and drug-resistant (LoVo DX) colon adenocarcinoma cells. A clonogenic cell survival assay demonstrated that LoVo DX cells were more sensitive than LoVo WT cells. Exogenous catalase protected cells against cytotoxicity mainly due to the formation of H(2)O(2). However, spermine-derived aldehyde(s) still induced some cytotoxicity. The cytotoxic effect was totally inhibited in the presence of both enzymes, catalase and NAD-dependent aldehyde dehydrogenase (ALDH). Transmission electron microscopy investigations showed that BSAO and spermine induced evident mitochondria alterations, more pronounced in MDR than in LoVo WT cells. The mitochondrial activity was checked by flow cytometry studies, labelling cells with the probe JC1, that displayed a basal hyperpolarized status of the mitochondria in multidrug-resistant cells. After treatment with amine oxidase in the presence of polyamine-spermine, the cells showed a marked increase in mitochondrial membrane depolarization higher in LoVo DX than in LoVo WT cells. Our findings suggest that toxic oxidation products formed from spermine and BSAO could be a powerful tool in the development of new anticancer treatments, mainly against MDR tumor cells.

Shunt-related abdominal metastases in an infant with medulloblastoma: long-term remission by systemic chemotherapy and surgery

This is the first reported case of long remission of abdominal metastases spread through a ventriculo-peritoneal shunt in an infant diagnosed, four years ago, at age 1 year and 10 months, to have cerebral medulloblastoma. Two years later, while in second complete remission of his cerebral tumor, he showed abdominal metastases, successfully treated by platinum based chemotherapy and surgery. One year later, a second abdominal relapse and hepatic metastases were treated by doxorubicin administration and surgery. Since then the child remained in continuous complete remission. This unusual favorable outcome can be explained by an extreme responsiveness of the tumor, unprotected by the blood brain barrier, to systemic chemotherapy, particularly to doxorubicin administration. The need for careful surveillance of patients with ventriculo-peritoneal shunts is emphasized. Searching for new tools, such as entrapment of doxorubicin in liposomes, able to overcome the blood-brain barrier and to expose brain tumors to effective drugs, probably represents the best choice for future treatment strategies of CNS tumors.

[Effectiveness and side effects of the treatment with propafenone and flecainide for recent-onset atrial fibrillation]

BACKGROUND

The authors report their experience in recent-onset atrial fibrillation treated with intravenous flecainide and propafenone, in comparison with the placebo group.

METHODS

We randomized 352 (138 in the flecainide group, 164 in the propafenone group and 50 in the control group) consecutive patients (167 males, 185 females, mean age 59 +/- 12 years) with recent-onset atrial fibrillation. The electrocardiogram of all patients was monitored for at least 24 hours.

RESULTS

The restoration of sinus rhythm occurred in 72.5, 80.4, 86.2 and 89.8% of patients in the flecainide group; in 54.3, 68.3, 75 and 92.1% in the propafenone group; in 22.2, 27.8, 35.2 and 46.3% in the control group, at 1, 3, 6 and 24 hours respectively. The occurrence of side effects was the same in all treatment groups, and occurred in about 10% of patients in the flecainide and propafenone groups, and in 4% in the control group. In our study population the treatment of recent-onset atrial fibrillation with flecainide was faster in converting the arrhythmia to sinus rhythm (p < 0.005 at 1 hour, p < 0.05 at 3 hours, p = 0.05 at 6 hours). However within 24 hours the efficacy of either flecainide or propafenone was the same (p = NS at 24 hours).

CONCLUSIONS

Side effects were similar in both treatment groups. In particular malignant arrhythmias did not occur in the treatment groups and in the control group.

Electrocardiographic patterns in acute inferior myocardial infarction with and without right ventricle involvement: classification, diagnostic and prognostic value, masking effect

BACKGROUND

In acute inferior myocardial infarction (AIMI), the ST depression from V1 to V4 has been the subject of many papers, while the ST changes in other leads, their association, and the right ventricular (RV) involvement have been studied less.

HYPOTHESIS

This study was performed to contribute to the meaning of the ST changes and RV involvement in AIMI.

METHODS

Seventy-one patients, admitted within 6 h from symptom onset, all thrombolysed, were enrolled. We classified them according to ST patterns and RV involvement. We divided the right coronary artery into three segments, considering the origin of RV branch and the crux as dividing points. We established a coronary score attributing 2 points to each terminal branch. Comparisons were performed between the electrocardiographic (ECG) findings at onset, the creatine phosphokinase (CPK) peaks, the radionuclide ejection fractions, and the coronary angiographies.

RESULTS

We found that the ST changes give indications regarding the site, extension, and extent of AIMI; RV involvement can mask posterior extension, points to the right coronary as the culprit vessel (100%), and, with high probability, indicates the proximal segment as the site of the lesion; the ECG signs of isolated AIMI indicate a peripheral obstruction; and a collateral circulation may appear relatively early.

CONCLUSIONS

Our findings prove the diagnostic and prognostic value of the ST changes and RV involvement at the onset of AIMI and suggest that the higher in-hospital mortality and complication rates found with RV involvement and reported in the literature are related more to posterior extension, masked by RV involvement than to this involvement per se. Furthermore, these findings prove the clinical value of our classification of the AIMIs and distinction in segments of the right coronary artery.

Antisperm antibodies in cryptorchidism before and after surgery

PURPOSE

We verified the prevalence of serum antisperm antibodies at diagnosis in a large group of cryptorchid boys, and determined whether it may be influenced by orchiopexy.

MATERIALS AND METHODS

We prospectively evaluated serum antisperm antibodies in 186 and 23 boys 0.67 to 14.25 years old with unilateral and bilateral cryptorchidism, respectively, before, and 3, 12 and 24 months after surgery. At diagnosis Tanner stage was 1 and 2 or 3 in 188 and 21 cases, respectively. During the 2-year followup 23 boys entered puberty. A total of 111 normal prepubertal (Tanner stage 1) and 54 pubertal (Tanner stage 2 or 3) boys served as controls. Antisperm antibodies were detected using the tray agglutination and indirect immunobead tests.

RESULTS

At diagnosis 29 cryptorchid boys (13.8%) were antisperm antibody positive, including 21 of the 188 prepubertal (11.1%) and 8 of the 21 pubertal (38%) boys (significantly different, chi-square test p <0.001). In 27 cases the tray agglutination test was positive with titers between 1:16 and 1:512, in 18 the indirect immunobead test was positive for IgG with titers between 1:10 and 1:100, and in 16 both tests were positive. There was no statistical difference when antisperm antibody results were analyzed for unilateral and bilateral cryptorchidism or testis location. All normal boys were antisperm antibody negative. During the 2-year followup antisperm antibodies appeared in 1 previously negative case, and the antibody titer increased to 128 to 512 in the tray agglutination and to 1:100 in the indirect immunobead tests in 4 positive cases. In all of these cases pubertal changes were also observed.

CONCLUSIONS

Our study indicates that cryptorchidism may elicit an autoimmune response against sperm antigen in childhood independent of testis location and orchiopexy. Moreover, patients of pubertal age appear to be at higher risk for antisperm antibody development.

[Nephroblastoma and polycystic dysplastic kidney]

The Authors pass on the case of a nephroblastoma, associated to Wilms Tumorlet and combined nephroblastomatosis, arose on a multicystic dysplastic kidney. They examine the relationships between the nephroblastoma and the kidney malformations, the possibility of malignant degeneration of a multicystic dysplastic kidney and the necessity of the nephrectomy as a prevention of the degeneration. At the moment the statistic data don't justify the nephrectomy a the birth to prevent the arising of a nephroblastoma.

[Generalized lymphatic dysplasia in a 6-month-old nursing infant]

G.L.D. is a rare syndrome characterized by chylothorax, chylous ascites and lymphedema associated to minor symptoms following from lymphangiectasis or to lymphangiomatosis. This syndrome is caused by congenital dysplasia of lymphatic vessels and has, generally, an extremely severe prognosis. In the present papers the authors describe one case of G.L.D. in a six months old infant with chylous ascites, chylothorax, lymphedema, hemangioma and a history of fetal ascites. The preservative (dietetic and evacuative) therapy was not resolutive, therefore an exploratory laparotomy was necessary, but no surgical solution was possible because of the absence of chylous vessels in the anatomical region of the principal lymphatic route. However, laparatomy led to a progressive recovery of ascites and chylothorax, probably due to thrombosis of dysplasic lymph vessels and to neoformation of collateral circulation.

[Hormonal investigation in the diagnosis of anorchia in childhood]

We have stimulated seventeen children (4-12 years old) with bilateral non palpable testes with LH-RH and HCG. The differential diagnosis between anorchia (5 patients) and bilateral cryptorchidism (12 patients) was possible with evaluation of FSH and Testosterone plasma levels before and after hormonic stimulation.