Brazilian guidelines for diagnosis,treatment and follow-up of primary cutaneous melanoma - Part II

The last Brazilian guidelines on melanoma were published in 2002. Development in diagnosis and treatment made updating necessary. The coordinators elaborated ten clinical questions, based on PICO system. A Medline search, according to specific MeSH terms for each of the 10 questions was performed and articles selected were classified from A to D according to level of scientific evidence. Based on the results, recommendations were defined and classified according to scientific strength. The present Guidelines were divided in two parts for editorial and publication reasons. In this second part, the following clinical questions were answered: 1) which patients with primary cutaneous melanoma benefit from sentinel lymph node biopsy? 2) Follow-up with body mapping is indicated for which patients? 3) Is preventive excision of acral nevi beneficious to patients? 4) Is preventive excision of giant congenital nevi beneficious to patients? 5) How should stages 0 and I primary cutaneous melanoma patients be followed?     

Obesity and Excess Protein and Carbohydrate Consumption Are Risk Factors for Thyroid Cancer

Conflicting data concerning the association between obesity and differentiated thyroid cancer (DTC) may be attributed to the lack of records showing dietary intake and inadequate evaluation of nutrient composition. We evaluated 115 DTC patients carefully paired with 103 healthy control individuals by using a structured questionnaire, including a 24-h recordatory during 3 days, to investigate calorie intake and macronutrient (proteins, carbohydrates, and lipids) composition of the diet. We observed that excess weight (body mass index > 25 kg/m²) increased individual susceptibility to DTC [odds ratio (OR) = 3.787; 95% confidence interval (CI) = 1.115–6.814; P < 0.0001). This augmented risk was evident in women (OR = 1.925; 95% CI = 1.110–3.338; P = 0.0259) but not in men (P = 0.3498). Excess calorie intake was more frequent in patients with DTC than in controls (OR = 5.890; 95% CI = 3.124–11.103; P < 0.0001), and both excess protein (OR = 4.601; 95% CI = 1.634–12.954; P = 0.0039) and carbohydrate (OR = 4.905; 95% CI = 2.593–9.278; P < 0.0001) consumption were associated with an increased risk of DTC, contrarily to lipid/fiber intake and physical activity (P = 0.894 and 0.5932, respectively). In conclusion, our data indicate that overweight and risk of DTC are associated with higher protein and carbohydrate consumption than the rates recommended by the World Health Organization. The nutritional orientation should be part of preventive strategy targets designed to combat the increasing incidence of both obesity and DTC.     

Contemporary results after surgical repair of type A aortic dissection in patients aged 80 years and older: a systematic review and meta-analysis

Objective: The benefits of surgical treatment of type A aortic dissection (AAD) in patients aged 80 years and older are questioned by the perceived high operative risk of these patients. This issue has been investigated in the present meta-analysis of observational studies. Methods: Studies on surgical repair of AAD in patients aged 80 years and older were identified up to January 2011. The results were expressed as pooled proportions with 95% confidence interval (95% CI). Results: Pooled analysis showed that patients aged 80 years and older included in six studies had a significantly higher risk of immediate postoperative mortality compared with younger patients (risk ratio 2.32, 95% CI 1.47–3.66, p < 0.0001, pooled estimates 45.7% vs 19.5%). Analysis of data retrieved from nine studies reporting on the results of surgical treatment of AAD in a total of 308 patients aged 80 years and older showed a pooled mortality rate of 36.7% (95% CI 23.8–51.8%, 111/308 patients). The pooled stroke rate was 11.9% (95% CI 7.3–18.7%, 37/347 patients). Pooled analysis of data from two studies evaluating patients surgically or medically treated showed a non-significant reduced risk of immediate postoperative death after surgery (risk ratio 0.42, 95% CI 0.14–1.29, pooled estimates: 25.2% vs 59.0%). Conclusions: Immediate postoperative survival rates after surgery for AAD in patients aged 80 years and older are satisfactory. These findings suggest a confident approach toward emergency repair of AAD in this fragile patient population. More data on the intermediate survival and quality of life of these patients are, however, needed to better establish the role of emergency surgery for AAD in octogenarians and nonagenarians.     

Perioperative coagulation assessment of patients undergoing major elective orthopedic surgery

Traditional coagulative parameters are of limited use in identifying perioperative coagulopathy occurring in patients undergoing major elective orthopedic surgery (MEOS). The aim of our study was to evaluate the coagulation changes in patients undergoing MEOS and to facilitate an early detection of perioperative coagulopathy in patients experiencing major intraoperative bleeding. We enrolled 40 consecutive patients (M/F 10/30, age range 34–90 years) who underwent MEOS at the Orthopedic Unit of the Padua University Hospital, Italy, between January 2014 and January 2015. Blood samples were obtained at the following time points: T0-pre: 30 min before surgery; T0-post: 30 min after the end of the procedure; T1: morning of the first postoperative day; T2: 7 ± 2 days after surgery. Patients who experienced an intraoperative blood loss ≥250 mL/h were considered as cases. Routine coagulative parameters, thromboelastometry and thrombin generation (TG) profiles were evaluated. At baseline, a significantly lower platelet count and FIBTEM MCF/AUC were observed in patents with excessive bleeding (p < 0.05 and 0.02/0.01, respectively). At T0-post and T1 intervals, cases showed hypocoagulation characterized by a significantly low platelet count (p = 0.001), prolonged CFT INTEM/EXTEM, reduction of alpha-angle and MaxV INTEM/EXTEM, MCF and AUC INTEM/EXTEM/FIBTEM (p < 0.05 in all comparisons). The only TG parameter standing out between study groups was time to peak at T0-pre. A low platelet count and fibrinogen activity were associated with significant intraoperative bleeding in patients undergoing MEOS. Thromboelastometry performed by ROTEM^® identifies patients with coagulopathy.     

The Influence of Deep Brain Stimulation Intensity and Duration on Symptoms Evolution in an OFF Stimulation Dystonia Study

BackgroundDeep brain stimulation (DBS) of the internal globus pallidus (GPi) is an established therapy for primary generalized dystonia. However, the evolution of dystonia symptoms after DBS discontinuation after years of therapy has only rarely been reported. We therefore longitudinally studied the main physiological measurements known to be impaired in dystonia, with DBS ON and then again after termination of DBS, after at least five years of continuous DBS.ObjectiveWe studied whether dystonia evolution after DBS discontinuation in patients benefiting from long-term GPi DBS is different from that observed in earlier stages of the therapy.MethodsIn eleven DYT1 patients treated with bilateral GPi DBS for at least 5 years, dystonia was assessed ON-DBS, immediately after switch-off (OFF-DBS1) and 48 h after DBS termination (OFF-DBS2). We studied the influence of DBS intensity on dystonia when DBS was discontinued.ResultsOn average a significant difference in symptoms was measured only between ON-DBS and OFF-DBS1 conditions. Importantly, none of the patients returned to their preoperative dystonia severity, even 48 h after discontinuation. The amount of clinical deterioration in the OFF conditions positively correlated with higher stimulation current in the chronic ON-DBS condition.ConclusionsThe duration of DBS application influences symptom evolution after DBS termination. DBS intensity seems to have a prominent role on evolution of dystonic symptoms when DBS is discontinued. In conclusion, DBS induces changing modulation of the motor network with less worsening of symptoms after long term stimulation, when DBS is stopped.