Activation of Ca2+ phosphatase Calcineurin regulates Parkin translocation to mitochondria and mitophagy in flies

Selective removal of dysfunctional mitochondria via autophagy is crucial for the maintenance of cellular homeostasis. This event is initiated by the translocation of the E3 ubiquitin ligase Parkin to damaged mitochondria, and it requires the Serine/Threonine-protein kinase PINK1. In a coordinated set of events, PINK1 operates upstream of Parkin in a linear pathway that leads to the phosphorylation of Parkin, Ubiquitin, and Parkin mitochondrial substrates, to promote ubiquitination of outer mitochondrial membrane proteins. Ubiquitin-decorated mitochondria are selectively recruiting autophagy receptors, which are required to terminate the organelle via autophagy. In this work, we show a previously uncharacterized molecular pathway that correlates the activation of the Ca2+-dependent phosphatase Calcineurin to Parkin translocation and Parkin-dependent mitophagy. Calcineurin downregulation or genetic inhibition prevents Parkin translocation to CCCP-treated mitochondria and impairs stress-induced mitophagy, whereas Calcineurin activation promotes Parkin mitochondrial recruitment and basal mitophagy. Calcineurin interacts with Parkin, and promotes Parkin translocation in the absence of PINK1, but requires PINK1 expression to execute mitophagy in MEF cells. Genetic activation of Calcineurin in vivo boosts basal mitophagy in neurons and corrects locomotor dysfunction and mitochondrial respiratory defects of a Drosophila model of impaired mitochondrial functions. Our study identifies Calcineurin as a novel key player in the regulation of Parkin translocation and mitophagy.

USP8 Down-Regulation Promotes Parkin-Independent Mitophagy in the Drosophila Brain and in Human Neurons

Stress-induced mitophagy, a tightly regulated process that targets dysfunctional mitochondria for autophagy-dependent degradation, mainly relies on two proteins, PINK1 and Parkin, which genes are mutated in some forms of familiar Parkinson's Disease (PD). Upon mitochondrial damage, the protein kinase PINK1 accumulates on the organelle surface where it controls the recruitment of the E3-ubiquitin ligase Parkin. On mitochondria, Parkin ubiquitinates a subset of mitochondrial-resident proteins located on the outer mitochondrial membrane, leading to the recruitment of downstream cytosolic autophagic adaptors and subsequent autophagosome formation. Importantly, PINK1/Parkin-independent mitophagy pathways also exist that can be counteracted by specific deubiquitinating enzymes (DUBs). Down-regulation of these specific DUBs can presumably enhance basal mitophagy and be beneficial in models in which the accumulation of defective mitochondria is implicated. Among these DUBs, USP8 is an interesting target because of its role in the endosomal pathway and autophagy and its beneficial effects, when inhibited, in models of neurodegeneration. Based on this, we evaluated autophagy and mitophagy levels when USP8 activity is altered. We used genetic approaches in D. melanogaster to measure autophagy and mitophagy in vivo and complementary in vitro approaches to investigate the molecular pathway that regulates mitophagy via USP8. We found an inverse correlation between basal mitophagy and USP8 levels, in that down-regulation of USP8 correlates with increased Parkin-independent mitophagy. These results suggest the existence of a yet uncharacterized mitophagic pathway that is inhibited by USP8.

Mitochondrial autophagy in the sleeping brain

A significant percentage of the mitochondrial mass is replaced on a daily basis via mechanisms of mitochondrial quality control. Through mitophagy (a selective type of autophagy that promotes mitochondrial proteostasis) cells keep a healthy pool of mitochondria, and prevent oxidative stress and inflammation. Furthermore, mitophagy helps adapting to the metabolic demand of the cells, which changes on a daily basis.

Core components of the mitophagy process are PINK1 and Parkin, which mutations are linked to Parkinson’s Disease. The crucial role of PINK1/Parkin pathway during stress-induced mitophagy has been extensively studied in vitro in different cell types. However, recent advances in the field allowed discovering that mitophagy seems to be only slightly affected in PINK1 KO mice and flies, putting into question the physiological relevance of this pathway in vivo in the whole organism. Indeed, several cell-specific PINK1/Parkin-independent mitophagy pathways have been recently discovered, which appear to be activated under physiological conditions such as those that promote mitochondrial proteome remodeling during differentiation or in response to specific physiological stimuli.

In this Mini Review we want to summarize the recent advances in the field, and add another level of complexity by focusing attention on a potentially important aspect of mitophagy regulation: the implication of the circadian clock. Recent works showed that the circadian clock controls many aspects of mitochondrial physiology, including mitochondrial morphology and dynamic, respiratory activity, and ATP synthesis. Furthermore, one of the essential functions of sleep, which is controlled by the clock, is the clearance of toxic metabolic compounds from the brain, including ROS, via mechanisms of proteostasis. Very little is known about a potential role of the clock in the quality control mechanisms that maintain the mitochondrial repertoire healthy during sleep/wake cycles. More importantly, it remains completely unexplored whether (dys)function of mitochondrial proteostasis feedbacks to the circadian clockwork.

P1763Derivation and validation of a risk score to predict incomplete ST segment resolution in STEMI patients undergoing primary PCI: association with the benefit of Glycoprotein IIb-IIIa inhibitors Use

Incomplete ST segment resolution (iSTR) is a well-known marker of poor outcome in patients undergoing primary percutaneous coronary intervention (pPCI) for ST elevation myocardial infarction (STEMI). The use of glycoprotein IIbIIIa inhibitors (GPIs) was suggested to be associated with a survival benefit in high-risk patients. A simple score to predict the risk for developing iSTR could help early identification of these patients and could allow a tailored use of pharmacological tools, such as GPIs.

The aim of this study was to create and validate a numerical score to predict iSTR occurrence in STEMI patients undergoing pPCI and to assess its association with the potential benefit of GPIs use.

We prospectively enrolled all STEMI patients undergoing pPCI in our University Hospital (2005–2017). iSTR was defined as a <70% resolution of initial ST segment shift in the lead with maximal ST deviation 60 min after reperfusion. Our population was randomly divided in two group: a derivation cohort (60%) and a validation cohort (40%). Potential predictors of iSTR were selected at univariate analysis and were then inserted in a multivariate binary stepwise-backward logistic regression. To create a risk score, numerical values were obtained considering the odds ratio of each independent predictor rounding to the nearest unit or half. A ROC curve with its c-statistic was then used to test the discrimination power of the score both in the derivation and in the validation cohort.

Out of a total of 2959 patients, 1774 were included in the derivation: 480 (27%) of them presented iSTR. All-cause mortality at 30 days was significantly higher in patients with iSTR (OR 3.2, 95% CI 2.1–4.9, p<0.001). Anterior MI (OR 2.46, 95% CI 1.90–3.14, p<0.001, score 2.5), anemia at admission (OR 1.76, 95% CI 1.29–2.4, p<0.001, score 2), blood glucose >198 mg/dl at admission (OR 1.77, 95% CI 1.29–2.49, p<0.001, score 2), age >75 years (OR 1.54, 95% CI 1.15–2.10, p=0.004, score 1.5), female sex (OR 1.41, 95% CI 1.06–1.88, p=0.02, score 1.5) and Killip class >2 (OR 1.44, 95% CI 1.05–1.98, p=0.024, score 1.5) were identified as independent predictors of iSTR, creating a ISTR-score that ranged from 0 to 11. The validation cohort consisted in 1185 patients, with 31% showing iSTR. The c-statistic was 0.67 and 0.66 in the derivation and validation cohorts. Patients with score ≥4 versus <4 showed present a worst prognosys but a similar GPI use. Notably, GPIs were associated with a significant survival benefit among patients≥4 but not among patients <4 (Figure). The use of GPIs was not associated to any clinically relevant difference, the increase in bleeding risk appeared similar.

6118Mid- and long-term percentage of ventricular pacing in patients implanted with a pacemaker after a transcatheter aortic valve replacement procedure: potential clinical implications

Background

Cardiac conduction disturbances frequently occur following transcatheter aortic valve replacement (TAVR). As this procedure is getting more and more common, more research efforts should focus on post procedural rhythm disturbances and their evolution over time

Purpose

To evaluate the percentage of pacing in patients who underwent a TAVR procedure and developed a conduction disturbance requiring a transvenous pacemaker (PM) implantation

Methods

We considered all the patients who underwent a TAVR procedure between march 2009 and november 2018 in our centre. Patients implanted with a PM or an ICD before the TAVR procedure or 30 days after the TAVR were not considered eligible for our analysis, because likely not related to TAVR. The percentage of effective right ventricular pacing was assessed both at mid- and long-term follow-up

Results

265 patients underwent TAVR in the study period (45% males, 81±6 years). 20 patients already had a PM and were excluded. 39 of the 245 patients (16%) were implanted with a PM after TAVR, 26 of them were implanted within 30 days (median time TAVR-PM implant: 8±7 days). The rate of PM implant within 30 days after TAVR was 8% (20/246) for patients implanted with an Edward Sapien valve, 25% (4/16) for patients with an Evolute Pro valve and 66% (2/3) in patients with a Lotus Edge valve. The indication for PM implant was a permanent 3rd degree A-V block in 12 patients, a paroxysmal A-V block in 4, a bifascicular A-V block with an infra-hisian disease in 5, a II degree Mobitz II A-V block in 2, an atrial fibrillation with slow A-V conduction in 2 and a 2:1 A-V block with infra-hisian disease in 1. The first follow-up after the PM implantation was available in 24 patients (mean 78±87 days after PM implant) and the second in 15 patients (372±267 days after PM implant). The patients were divided into two groups based on the presence/absence of permanent 3rd degree AV block at the time of implantation. At the first follow-up the percentage of pacing was significantly higher in patients implanted with vs. without a permanent 3rd degree AV block (98.5% vs 11%, p<0.001). Notably, in none of the patients without a permanent 3rd AV block at baseline conduction disturbances progressed toward a permanent AV block during long-term follow-up. Accordingly, at the second follow-up patients without permanent 3rd AV block at baseline showed a significantly lower percentage of pacing (1% vs 100%; p<0.01)

Conclusion

Patients implanted with a PM after TAVR in the absence of a permanent 3rd AV block have a very low likelihood of progression to a permanent AV conduction disturbance and show a negligible percentage of pacing during follow-up. Our results may impact the choice of the correct timing of PM implantation after TAVR and the potential indication for a leadless PM.

Pathways of flower infection and pollen-mediated dispersion of Pseudomonas syringae pv. actinidiae, the causal agent of kiwifruit bacterial canker

Flowers can provide a protected and nutrient-rich environment to the epiphytic microflora, thus representing a sensible entry point for pathogens such as Pseudomonas syringae pv. actinidiae (Psa). This bacterium can colonize both male and female Actinidia flowers, causing flower browning and fall, and systemic invasion of the host plant, eventually leading to its death. However, the process of flower colonization and penetration into the host tissues has not yet been fully elucidated. In addition, the presence of Psa in the pollen from infected flowers, and the role of pollination in the spread of Psa requires confirmation. The present study employed a Psa strain constitutively expressing the fluorescent GFPuv protein, to visualize in vivo flower colonization. Microscopy observations were performed by means of confocal laser scanning and wide-field fluorescent microscopy, and were coupled with the study of Psa population dynamics by quantitative PCR (q-PCR). The pathogen was shown to colonize stigmata, move along the stylar furrow, and penetrate the receptacles via the style or nectarhodes. Once the receptacle was invaded, the pathogen migrated along the flower pedicel and became systemic. Psa was also able to colonize the anthers epiphytically and endophytically. Infected male flowers produced contaminated pollen, which could transmit Psa to healthy plants. Finally, pollinators (Apis mellifera and Bombus terrestris) were studied in natural conditions, showing that, although they can be contaminated with Psa, the pathogen's transmission via pollinators is contrasted by its short survival in the hive.

Role of Metcalfa pruinosa as a Vector for Pseudomonas syringae pv. actinidiae

After 20 years of steady increase, kiwifruit industry faced a severe arrest due to the pandemic spread of the bacterial canker, caused by Pseudomonas syringae pv. actinidiae (Psa). The bacterium penetrates the host plant primarily via natural openings or wounds, and its spread is mainly mediated by atmospheric events and cultural activities. Since the role of sucking insects as vectors of bacterial pathogens is widely documented, we investigated the ability of Metcalfa pruinosa Say (1830), one of the most common kiwifruit pests, to transmit Psa to healthy plants in laboratory conditions. Psa could be isolated both from insects feeding over experimentally inoculated plants, and from insects captured in Psa-infected orchards. Furthermore, insects were able to transmit Psa from experimentally inoculated plants to healthy ones. In conclusion, the control of M. pruinosa is recommended in the framework of protection strategies against Psa.

Influence of carbon dioxide stunning procedure on quality of turkey meat

1. The objective of this study was to evaluate the effect of sex and gas stunning on quality attributes of turkey breast meat. 2. One hundred B.U.T. Premium turkeys (50 males and 50 females) were divided into four groups of 25 animals and subjected to one of two CO₂ stunning procedures: G1 stepwise (step 1: 30% CO₂, 15 s; step 2: 55% CO₂, 40 s; step 3: 70% CO₂, 45 s) or G2 fixed concentration (80% CO₂, 100 s). The pH and meat colour at 20 min post-mortem, and pH, colour (L*, a*, b*), water holding capacity (WHC), drip loss (DL), cooking loss (CL) and Warner-Bratzler shear force (WBSF) in breast samples at 24 h and 7 d post-mortem were assessed. 3. There were significant differences between stunning groups for pH, meat colour and CL, whereas no significant differences were found for DL and WBSF. Sex had a significant effect on pH and b* and ageing of meat affected pH, colour coordinates, DL and WBSF. 4. It was concluded that the G2 treatment affected negatively the pH value and colour coordinates. However, G2 stunning affected positively the WHC parameters. Female turkeys had better results than males for pH, and the colour of female turkey breast meat was less yellow than male breast meat.

The effect of real-time electronic monitoring of patient-reported symptoms and clinical syndromes in outpatient workflow of medical oncologists: E-MOSAIC, a multicenter cluster-randomized phase III study (SAKK 95/06)

BACKGROUND

Patients with advanced, incurable cancer receiving anticancer treatment often experience multidimensional symptoms. We hypothesize that real-time monitoring of both symptoms and clinical syndromes will improve symptom management by oncologists and patient outcomes.

PATIENTS AND METHODS

In this prospective multicenter cluster-randomized phase-III trial, patients with incurable, symptomatic, solid tumors, who received new outpatient chemotherapy with palliative intention, were eligible. Immediately before the weekly oncologists' visit, patients completed the palm-based E-MOSAIC assessment (Edmonton-Symptom-Assessment-Scale, ≤3 additional symptoms, estimated nutritional intake, body weight change, Karnofsky Performance Status, medications for pain, fatigue, nutrition). A cumulative, longitudinal monitoring sheet (LoMoS) was printed immediately. Eligible experienced oncologists were defined as one cluster each and randomized to receive the immediate print-out LoMoS (intervention) or not (control). Primary analysis limited to patients having uninterrupted (>4/6 visits with same oncologist) patient-oncologist sequences was a mixed model for the difference in patients global quality of life (G-QoL; items 29/30 of EORTC-QlQ-c30) between baseline (BL) and week 6. Intention-to-treat (ITT) analysis included all eligible patients.

RESULTS

In 8 centers, 82 oncologists treated 264 patients (median 66 years; overall survival intervention 6.3, control 5.4 months) with various tumors. The between-arm difference in G-QoL of 102 uninterrupted patients (intervention: 55; control: 47) was 6.8 (P = 0.11) in favor of the intervention; in a sensitivity analysis (oncologists treating ≥2 patients; 50, 39), it was 9.0 (P = 0.07). ITT analysis revealed improvement in symptoms (difference last study visit-BL: intervention -5.4 versus control 2.1, P = 0.003) and favored the intervention for communication and coping. More patients with high symptom load received immediate symptom management (chart review, nurse-patient interview) by oncologists getting the LoMoS.

CONCLUSION

Monitoring of patient symptoms, clinical syndromes and their management clearly reduced patients' symptoms, but not QoL. Our results encourage the implementation of real-time monitoring in the routine workflow of oncologist with a computer solution.

The structure of insulin at the air/water interface: monomers or dimers?

The hydrophobic character of the air/water interface affects the oligomeric composition of insulin. By using interface-specific vibrational sum frequency spectroscopy and calculations of insulin monomer and dimer second-order nonlinear susceptibilities χ((2)), we show that insulin monomers segregate to the air/water interface.

Vertebral augmentation for neoplastic lesions with posterior wall erosion and epidural mass

BACKGROUND AND PURPOSE

The presence of a cortical erosion of the posterior wall or an epidural mass is commonly considered a contraindication to performing a vertebral augmentation, considering the perceived increased risk of an epidural cement leak. Our aim was to assess technical and clinical complications of vertebral augmentation procedures performed for pain palliation and/or stabilization of neoplastic lytic vertebral body lesions, with cortical erosion of the posterior wall, often associated with a soft-tissue epidural mass.

MATERIALS AND METHODS

In 48 patients, we performed retrospective vertebral augmentation assessment on 70 consecutive levels with cortical erosion of the posterior wall, as demonstrated by preprocedural CT/MR imaging. An epidural mass was present in 31/70 (44.3%) levels. Cavity creation was performed with Coblation Wands before cement injection in 59/70 levels. Injection of high-viscosity polymethylmethacrylate was performed under real-time continuous fluoroscopic control. Postprocedural CT of the treated levels was performed in all cases. Clinical follow-up was performed at 1 and 4 weeks postprocedurally.

RESULTS

In 65/70 (92.8%) levels, the vertebral augmentation resulted in satisfactory polymethylmethacrylate filling of the lytic cavity and adjacent trabecular spaces in the anterior half of the vertebral body. An epidural leak of polymethylmethacrylate occurred in 10/70 (14.2%) levels, causing radicular pain in 3 patients, which spontaneously resolved within 1 week in 2 patients, while 1 patient with a T1-T2 foraminal leak developed severe weakness of the intrinsic hand muscles and a permanent motor deficit.

CONCLUSIONS

In our series of vertebral augmentation of neoplastic lytic vertebral lesions performed for palliation of pain and/or stabilization, we observed a polymethylmethacrylate epidural leak in only 14.2% of levels, despite the presence of cortical erosion of the posterior wall and an epidural mass, with an extremely low rate of clinical complications. Our data seem to justify use of vertebral augmentation in patients with intractable pain or those at risk for vertebral collapse.

Home enteral nutrition in Spain; NADYA registry 2011-2012

OBJECTIVE

To describe the results of the home enteral nutrition (HEN) registry of the NADYA-SENPE group in 2011 and 2012.

MATERIAL AND METHODS

We retrieved the data of the patients recorded from January 1st 2011 to December 31st 2012.

RESULTS

There were 3021 patients in the registry during the period from 29 hospitals, which gives 65.39 per million inhabitants. 97.95% were adults, 51.4% male. Mean age was 67.64 ± 19.1, median age was 72 years for adults and 7 months for children. Median duration with HEN was 351 days and for 97.5% was their first event with HEN. Most patients had HEN because of neurological disease (57.8%). Access route was nasogastric tube for 43.5% and gastrostomy for 33.5%. Most patients had limited activity level and, concerning autonomy, 54.8% needed total help. Nutritional formula was supplied from chemist's office to 73.8% of patients and disposables, when necessary, was supplied from hospitals to 53.8% of patients. HEN was finished for 1,031 patients (34.1%) during the period of study, 56.6% due to decease and 22.2% due to recovery of oral intake.

CONCLUSIONS

Data from NADYA-SENPE registry must be explained cautiously because it is a non-compulsory registry. In spite of the change in the methodology of the registry in 2010, tendencies regarding HEN have been maintained, other than oral route.

Phenotypic heterogeneity and mutational spectrum in a cohort of 45 Italian males subjects with X-linked ectodermal dysplasia

Ectodermal dysplasias (EDs) are a group of genetic disorders characterized by the abnormal development of the ectodermal-derived structures. X-linked hypohidrotic ectodermal dysplasia, resulting from mutations in ED1 gene, is the most common form. The main purpose of this study was to characterize the phenotype spectrum in 45 males harboring ED1 mutations. The study showed that in addition to the involvement of the major ectodermal tissues, the majority of patients also have alterations of several minor ectodermal-derived structures. Characterizing the clinical spectrum resulting from ED1 gene mutations improves diagnosis and can direct clinical care.

Oncology Nursing Minimum Data Set (ONMDS): can we hypothesize a set of prevalent Nursing Sensitive Outcomes (NSO) in cancer patients?

Background

The nursing minimum data set (NMDS) was created in 1977 in the United States to collect uniform standardised data that could be comparable among different nursing areas or patients. So far, in the literature, an NMDS in an oncology setting has not yet been described. Considering an oncology nursing minimum data set (ONMDS), which data could be chosen to define this tool regarding cancer patient care?

Material and methods

At the European Institute of Oncology (IEO), 20 experienced oncology nurses representing surgical, medical, and critical areas participated in a nursing record working group. All nurses followed an educational course on NMDS, and they shared clinical experiences to find which data common among different areas could be useful to care. To identify these data, nurses considered three issues: what is nursing care for nurses in the IEO? What is the nurses’ responsibility in the IEO? What is the organisational nursing model in the IEO? Nurses in the IEO are autonomous in decision making and recognised by patients and by a multi-professional team; the organisational nursing model is primary nursing with patient-centred care. Nursing data must therefore show the quality and results of this care. With this in mind, the working group decided to orient the ONMDS toward nursing-sensitive outcomes (NSOs), meeting also with psychologists, physiotherapists, and dieticians. Nurses analysed Oncology Nursing Society outcomes, and through focus groups, experiential meetings, role playing, and case studies, they integrated them with other NSOs.

Results

The ONMDS is composed of 49 NSOs recognised as the most common and frequent oncologic outcomes regardless of the treatment that the patient undergoes. These outcomes were clustered into 15 categories. The categories are: gastrointestinal outcomes, genitourinary outcomes, respiratory outcomes, skin outcomes, fluid and electrolyte balance outcomes, neurological outcomes, security, functional status, vascular access outcomes, nutritional status, pain, psychosocial discomfort, activities of daily living (ADL), instrumental activities daily living (IADL), and self-care outcomes.

Conclusions

Efforts to identify an ONMDS based on NSOs allow us to develop an tool that can standardise language, assessment, and intervention, but overall could be used to measure nursing care. To evaluate these potentialities, the ONMDS was introduced into nursing records, and it was tested with a pre–post research study.

Nasopharyngeal endoscopic resection in the management of selected malignancies: ten-year experience

OBJECTIVE

To evaluate the feasibility of endoscopic surgery in the management of selected nasopharyngeal cancers. Three different types of nasopharyngeal endoscopic resections (NER) are described.

METHOD OF STUDY

From January 1997 to October 2008, 17 consecutive patients (mean age: 50 years) with previously untreated (5) or recurrent nasopharyngeal tumours (12) were treated with curative intent by pure endoscopic resection. The extent of surgical resection was classified as follows: type I NER: resection limited to the postero-superior nasopharyngeal wall; type 2 NER: resection superiorly extended to the sphenoid sinus; type 3 NER: resection with lateral extension including the cartilaginous portion of the Eustachian tube and parapharyngeal space.

RESULTS

Type 1 NER was performed in 4 cases, type 2 in 6, and type 3 in 7. No intra- or post-operative complications were observed. Mean hospitalization time was 4 days (range: 1-7). Follow-up ranged from 10 to 138 months (mean: 41.2±38). At the time of writing, 12 (71/%) patients were free of disease, 3 (17%) alive with disease, and 2 (12%) dead of disease.

CONCLUSIONS

NER is a feasible surgical technique that can be tailored in relation to tumour extension. Larger series and longer follow-up are needed to further validate the long-term results.

Endoscopic repair of cerebrospinal fluid rhinorrhea: learning from our failures

Endoscopic repair of cerebrospinal fluid (CSF) rhinorrhea is becoming a common procedure. The purpose of this study was to perform a literature analysis centering cases of treatment failure and to review our 31 cases with a 1-year minimum follow-up. An extensive search of the literature was conducted, which focused on success rate, follow-up, diagnostic techniques, graft material used, failure rate, and comments on failures. A retrospective analysis of our 31 patients was carried out, and all cases were treated with the endoscopic approach with a 1-year minimum follow-up. From the literature analysis, the median success rate at the first endoscopic attempt is 90%. Our success rate was 87.1%. Failures were analyzed. A unique protocol for CSF leak diagnosis does not exist; we suggest our diagnostic algorithm. Graft material used depends on the authors' experience, and based on this review of cases to date, did not significantly influence the success rate. The analysis of cases of failure shows that the majority of authors omit details. More research is needed to improve prevention of failures.

Spontaneous compressive orbital emphysema of rhinogenic origin

We report the case of a young patient who developed spontaneous compressive orbital emphysema after an attack of coughing. At admission the patient presented left proptosis, diplopia, vision impairment and headache. Computer tomography showed air in the lateral part of left orbit compressing the eyeball and the optic nerve medially. It also revealed a sphenoid bone dysplasia with hyperpneumatization of the left greater wing and with two dehiscences in its wall. It was very intriguing to discover that this sphenoid dysplasia and the flap of mucosa covering one dehiscence were causing a ball-valve effect, allowing air to enter but not leave the orbit. Endoscopic sinus surgery was successfully used to treat this case.

Is there a role for sentinel node biopsy in early N0 tongue tumors?

BACKGROUND

Detecting metastases to the cervical lymph nodes is the main problem in the management of squamous cell carcinoma of the tongue. We investigated the ability of sentinel node (SN) biopsy to predict neck status in 11 patients with lateral T1-T2, N0, and M0 squamous cell carcinoma of the tongue who underwent ipsilateral neck dissection 30 to 40 days after primary surgery.

METHODS

In 5 patients, technetium 99m-labeled particles were injected close to the operation scar on the day before neck dissection, and the labeled neck nodes were revealed by lymphoscintigraphy. The next 6 patients underwent lymphoscintigraphy both before surgery and before neck dissection. During neck dissection, the ipsilateral SNs were identified by using a hand-held probe and removed separately.

RESULTS

Three patients (27%) had metastatic neck nodes. In all cases, labeled nodes were revealed by scintigraphy. Ipsilateral SNs were removed from 8 patients and correctly predicted the state of the neck (6 negatives and 2 positives). Lymphoscintigraphy before and after surgery revealed that drainage was modified after surgery in 5 of 6 patients; the pre-surgery drainage pattern varied markedly among the 5 pN0 patients.

CONCLUSIONS

The technique allows easy and safe identification of SNs and shows promise in guiding selective neck dissection. Surgery on the primary tumor often modifies lymphatic drainage, so that SN biopsy may only be useful if the primary operation and neck dissection are performed at the same time.

Acute metabolic alkalosis in cystic fibrosis: prospective study and review of the literature

Between January 1993 and April 1994, 5 patients with cystic fibrosis, aged 4-9 months, were admitted to the Department of Pediatrics, University of Berne, Switzerland, with acute, severe metabolic alkalosis (sodium < 133 mmol/l, plasma potassium < 3.5, chloride < 85, bicarbonate > 35.0 mmol/l, blood pH > 7.43). 87 cases of acute metabolic alkalosis complicating cystic fibrosis reported in the literature between 1951 and 1995 were also reviewed. Our cases and those described in the literature demonstrate that acute metabolic alkalosis occurs in patients aged 2 years or less. Anorexia, vomiting, respiratory exacerbation, fever, and body weight loss often precede metabolic alkalosis. Furthermore, metabolic alkalosis is a common initial presentation of cystic fibrosis, suggesting that this diagnosis should be considered in the context of unexplained metabolic alkalosis.

Surfing prognostic factors in head and neck cancer at the millennium

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

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Totally implantable central venous access ports for long-term chemotherapy. A prospective study analyzing complications and costs of 333 devices with a minimum follow-up of 180 days

BACKGROUND

A few data are available from analyses of the complications and costs of central venous access ports for chemotherapy. This prospective study deals with the complications and global costs of central venous ports connected to a Groshong catheter for deliverance of long-term chemotherapy.

PATIENTS AND METHODS

Patients with a variety of solid neoplastic diseases requiring chemotherapy who were undergoing placement of implantable ports over a 30-month period (1 October 1994 to 31 March 1997) have been prospectively studied. Follow-up continued until the device was removed or the study was closed (30 September 1997); patients with uneventful implant experience and subsequent follow-ups of less than 180 days were not considered for this study. A single port, constructed of titanium and silicone rubber (Dome Port, Bard Inc., Salt Lake City, USA), was used, connected to an 8 F silastic Groshong catheter tubing (Bard Inc., Salt Lake City, USA). Two-hundred ninety-six devices were placed in the operating room under fluoroscopic control even in the patients treated and monitored in a day-hospital setting: 37 of them were in an angiographic suite. A central venous access form was filled in by the operator after the procedure and all ports were followed prospectively for device-related and overall complications. The average purchase cost of the device was obtained from the hospital charges, based on the costs applied during the 30-month period of the study. Insertion and maintenance costs were estimated by obtaining the charges for an average TIAP implant and its subsequent use; the costs of complication management were assessed analytically. The total cost of each device was defined as the purchase cost plus the insertion cost plus the maintenance cost plus the cost of treatment of the complications, if any. The cost of removing the TIAP was also included in the economic analysis when required by the treatment of the complication.

RESULTS

Three hundred thirty-three devices, for a total of 79,178 days in situ, were placed in 328 patients. Five patients received second devices after removal of the first. In all cases the follow-up was appropriate (median 237 days, range 180-732). Early complications included 10 pneumothoraxes (3.4%; six tube-thoracostomies were applied, 1.8%) and six revisions for port and/or catheter malfunction (overall early complications = 16, 4.48%). Late complications comprised five instances of catheter rupture and embolization (1.5%, 0.063 episodes/1000 days of use), five of venous thrombosis (1.5%, 0.063 episodes/1000 days of use), one of pocket infection (0.3%, 0.012 episodes/1000 days of use), and eight of port-related bacteremia (2.4%, 0.101 episodes/1000 days of use). The infections were caused by coagulase-negative Staphylococcus aureus (five cases), Bacillus subtilis (one case), Streptococcus lactaceae (one case) and an unknown agent (one case); port removal was necessary in six of eight cases. The total cost per patient treated for a six-month period, consisting of the costs of purchase and implantation, treatment of early and late complications, and of maintenance of the device, is US$1,970.

CONCLUSIONS

This study represents the largest published series of patients with totally implantable access ports connected to a Groshong catheter. We have shown that US$2,000 are sufficient to cover six months of chemotherapy in one patient using the most expensive commercially available implantable port. According to the present study, totally implantable access ports connected to a Groshong catheter are associated with high purchase and insertion costs, a low complication rate and low maintenance costs. These data support their increasing use in current oncologic medical practice.

Paroxysmal positional vertigo

Paroxysmal positional vertigo (PPV) is the peripheral vertiginous syndrome that is most frequently encountered in clinical practice. It is characterised by paroxysmal vertiginous attacks that are triggered by head movements and last no more than a few seconds, and is often accompanied by nausea and vomiting. The aim of this review is to provide a complete and updated description of the two principal manifestations of the syndrome: posterior semicircular canal (PSC-PPV) and horizontal semicircular canal PPV (HSC-PPV).

Long-term, totally implantable central venous access ports connected to a Groshong catheter for chemotherapy of solid tumours: experience from 178 cases using a single type of device

The aim of this study was to examine the early and late complications rate of central venous access ports connected to the Groshong catheter for long-term chemotherapy delivering. All patients suffering from a neoplastic disease, who required long-term chemotherapy and underwent insertion of implantable ports during a 21-month period (1 October 1994-30 June 1996) were prospectively studied. A single type of port was used, constructed of titanium and silicone rubber (Dome Port, Bard Inc., Salt Lake City, U.S.A), connected to an 8 F silastic Groshong catheter tubing (Bard Inc.). A team of different operators (two general surgeons, one interventional radiologist and four anaesthesiologists) was involved in inserting the port. All devices were placed in the operating room under fluoroscopic control. A central venous access form was filled in by the operator after the procedure and all ports were followed prospectively for device-related and overall complications. Data from the follow-up of these patients were entered in the form and collected in a database. Follow-up continued until the device was removed, the patient died or the study was closed. 178 devices, comprising a total of 32,089 days in situ, were placed in 175 patients. Three patients received a second device after removal of the first. Adequate follow-up was obtained in all cases (median 180 days, range 4-559). 138 devices (77.5%) were still in situ when the study was closed. Early complications included six pneumothoraxes, three arterial punctures and two revisions for port and/or catheter malfunction (overall early complications in 8 patients). Late complications included 3 cases (1.68% of devices) of catheter rupture and embolisation (0.093 episodes/1000 days of use), 2 cases (1.12% of devices) of venous thrombosis (0.062 episodes/1000 days of use), 1 case (0.56% of devices) of pocket infection (0.031 episodes/1000 days of use), and 4 cases (2.24% of devices) of port-related bacteraemias (0.124 episodes/1000 days of use). Infections were caused by coagulase-negative Staphylococcus aureus (4 cases) and Bacillus subtilis (1 case); they required port removal in 3 out of 5 cases. This study represents the largest published series of patients with totally implantable access ports connected to Groshong catheters; this device is a good option for long-term access to central veins and delivery of chemotherapeutic regimens, including continuous intravenous infusions. The low incidence of major complications related to implantation and management of these devices support increased use in oncology patients.

Unusual bleeding manifestations in a case of primary amyloidosis with factor X deficiency but elevations of in vivo markers of thrombin formation and activity

We describe a case of primary amyloidosis (AL) with severe factor X (FX) deficiency in an amateur cyclist presenting with muscular pain at rest and ecchymoses in his legs. No circulating inhibitor of FX was found by mixing studies and there was no deficiency of other vitamin K-dependent coagulation factors and inhibitors or of alpha 2-antiplasmin. Thrombin-time and reptilase time were abnormally prolonged and were not corrected by mixing with normal plasma. Administration of plasma or prothrombin complex concentrate (PCC) were unsuccessful in controlling bleeding: the apparent half-life of transfused FX was 6 minutes. Resting resulted in cessation of muscular pain and bleeding. Renal and cardiac deterioration led the patient to death 3 years after presentation. No further bleeding manifestations did occur during this period. FX levels remained consistently below 3%, but prothrombin fragment 1.2 and thrombin-antithrombin complex--measured at distance from PCC administration and prior to deterioration of renal and cardiac function--were markedly elevated. At autopsy, disseminated amyloidosis was found with sparing of the skeletal muscles and of the skin. This is the first report of increased in vivo prothrombin activation and activity in AL-associated FX deficiency.

Chronic metabolic alkalosis: not uncommon in young children with severe cystic fibrosis

The acid-base balance of 199 patients with cystic fibrosis, seen from 1987 through 1992 at the Bern Outpatient Clinic, were evaluated. Simple metabolic alkalosis was demonstrated in 16 and mixed metabolic alkalosis and respiratory acidosis in 9 patients. When compared with 10 patients with simple respiratory acidosis and 16 with normal hydrogen ion balance, those with simple metabolic alkalosis were significantly younger. The need for pancreatic enzymes was significantly higher and the relative underweight significantly more severe in patients with either simple or mixed metabolic alkalosis and respiratory acidosis. The results indicate the rather common occurrence of chronic metabolic alkalosis in cystic fibrosis. It is observed in young patients, in patients who need high doses of pancreatic enzymes and in the those with poor nutritional status.

[Value and significance of CEA in the monitoring of patients with neoplasms and in the evaluation of their cure]

An assessment was made of the determination of carcinoembryonic antigen (CEA) in patients with tumours and non-neoplastic diseases. Positivity in relation to hepatic cirrhosis and stasis was noted in only 3.9% of non-oncological patients, whereas this figure rose to 28.8% in those with tumors, with higher frequencies in forms involving the intestine, lung, liver, and stomach. Variations in the result of the examination were noted in relation to the progress of the disease, and also in relation to chemotherapy in some cases. The results of the investigation indicate that CEA is of little use as an early diagnosis test. Its importance lies in its indication of the effectiveness of treatment, and as an early sign of the approach of recurrences.