The challenge of basilar artery occlusion wake-up stroke: too late for intravenous thrombolysis?

We describe the case of a patient carried to our emergency department, with the wake-up finding of dysarthria, right hemiplegia and worsening consciousness impairment (NIHSS 12). After performing a CT angiography, which showed complete basilar occlusion, we determined the MR DWI-FLAIR mismatch to estimate the stroke onset time. Because of the favorable mismatch (DWI hyperintensity in the left pons, no FLAIR hyperintensity in the same region), the patient underwent thrombolysis with sudden neurological improvement. In addition, the DWI hyperintensity first observed in the left pons totally regressed after thrombolysis. Wake-up stroke constitutes about 14 % of all strokes, while the percentage of basilar artery occlusion wake-up strokes is still unknown. Although thrombolysis in patients with unknown-onset time is still an off-label therapy, basilar artery occlusion is a potentially fatal event. In our case we used RM DWI-FLAIR mismatch to rapidly estimate the stroke onset time and to treat the patient with an off-label but potentially effective and safe therapy.     

Unilateral varus osteotomy of the proximal femur in children with cerebral palsy: a five-year follow-up of the development of both hips

Background  

Varus osteotomy of the proximal femur (VOPF) is one treatment option to prevent hip dislocation in children with cerebral palsy (CP). It is questioned whether the osteotomy should be performed in the displaced hip only, or if it should be performed bilaterally to prevent later displacement of the contralateral hip. CPUP is a register and healthcare programme for children with CP that was initiated in 1994 in southern Sweden. In the programme, range-of-motion and radiographic examination of the hips is performed regularly. These data have been analysed preoperatively and for 5 years postoperatively in children treated with unilateral VOPF.     

Surgical treatment of symptomatic cerebral cavernous malformations in eloquent brain regions

Background

Despite the increased risk of hemorrhage and deteriorating neurological function of once-bled cerebral cavernous malformations (CM), the management of eloquently located CMs remains controversial.

Methods

All eloquently located CMs (n?=?45) surgically treated between 03/2006 and 04/2011 in our department were consecutively evaluated. Eloquence was characterized according to Spetzler and Martin's definition. The following locations were approached: brainstem, n?=?16; sensorimotor, n?=?8; visual pathway, n?=?7; cerebellum (deep nuclei and peduncles), n?=?7; basal ganglia, n?=?4, and language, n?=?3. Follow-up data was available for 41 patients (91 %) with a median interval of 14 months. Outcomes were evaluated according to the Glasgow outcome and the modified Rankin scale.

Results

Immediately after surgery, 47 % (n?=?21) had a new deficit. At follow-up, 80 % (n?=?36) recovered to at least preoperative status or were better than before surgery, 9 % (n?=?4) exhibited a slight, and 7 % (n?=?3) had a moderate neurological impairment. Only two cases (4 %) with a new permanent severe deficit were observed, both related to dorsal brainstem surgery. The outcome after the surgery of otherwise located brainstem CMs was as beneficial as that for non-brainstem CMs. Patients with initially poor neurological performance fared worse than oligosymptomatic patients.

Conclusions

Despite the high postoperative transient morbidity, the majority improved profoundly during follow-ups. Compared with natural history, surgical treatment should be considered for all eloquent symptomatic CMs. Dorsal brainstem location and poor preoperative neurological status are associated with an increased postoperative morbidity.

     

Adjuvant PEFG (Cisplatin, Epirubicin, 5-Fluorouracil, Gemcitabine) or Gemcitabine Followed by Chemoradiation in Pancreatic Cancer: A Randomized Phase II Trial

Background

Information from randomized trials on the role of combination chemotherapy in the adjuvant treatment of pancreatic adenocarcinoma is limited. This randomized phase II trial aimed to identify the most promising regimen warranting phase III evaluation.

Methods

Therapy-naive patients, age 18?C75?years, Karnofsky Performance Status (KPS) >60, gross total resection of stage IB?CIII pancreatic adenocarcinoma, stratified for center and surgical margins, were randomly assigned to receive either gemcitabine 1?g/m² weekly on days 1, 8, and 15 (arm A) or the PEFG regimen (cisplatin and epirubicin 40?mg/m², day 1; gemcitabine 600?mg/m², days 1, 8; 5-fluorouracil 200?mg/m² daily, days 1?C28) (arm B). Chemotherapy was administered every 4?weeks for 3?months and followed by irradiation concurrent to continuous infusion of 5-fluorouracil 250?mg/m² daily. Primary endpoint was the probability of being disease-free at 1?year from surgery. Assuming P0?=?35% and P1?=?55%, ???=?.05 and ???=?.10, the study was to enroll 51 patients per arm.

Results

A total of 102 patients were randomized; 100 were eligible (arm A: 51; arm B: 49). Baseline characteristic (A/B) were: Median age was 61/60?years; 75% had KPS >80 75/76%; 36% grade 3 tumor 29/43%, 79% stage IIB/III 75/84%, 31% R1 resection 35/29%. Survival figures (A/B) were: Median disease-free survival was 11.7 and 15.2?months; 1-year disease-free survival 49.0% (95% confidence interval [95% CI] 35?C63%) and 69.4% (95% CI 56?C83%); median survival 24.8 and 28.9?months. Combination chemotherapy produced more hematological toxicity without relevant differences in nonhematological toxicities.

Conclusions

The 4-drug regimen deserves further assessment in resectable pancreatic cancer.     

Predictive value of peripheral blood lymphocyte count in breast cancer patients treated with primary chemotherapy

Peripheral blood lymphocyte (PBL) count may reflect the immune status of cancer patients. We retrospectively analyzed the predictive and prognostic impact of baseline and post-chemotherapy PBL counts in a homogeneous group of 103 breast cancer patients treated with neoadjuvant chemotherapy (anthracyclines and taxanes). In univariate analysis, baseline PBL under 1500 × 10(6)/L (p = 0.013; hazard ratio [HR]: 2.80, 95%CI 1.24-6.61), and PBL decrease >200 × 10(6)/L after the first cycle of chemotherapy (p = 0.047; HR: 2.82, 95%CI 1.01-7.86) were significantly related to disease free survival. In multivariate analysis, both baseline PBL count less than 1500 × 10(6)/L (p = 0.034; HR: 3.32, 95%CI 1.09-10.02) and PBL decrease >200 × 10(6)/L after first cycle (p = 0.032; HR: 3.25, 95%CI 1.10-9.56) showed independent prognostic value for worse disease free survival. No effect was observed for overall survival. Our data support the relevance of pre- and post-chemotherapy PBL for breast cancer recurrence after neoadjuvant chemotherapy.     

Donor operation for face transplantation

The first clinical face allotransplantation was performed by Devauchelle et al in 2005, and currently 13 facial allotransplantations have been performed worldwide. Reports on almost half of the cases were published in the literature, focusing on technical details of facial allograft inset to the recipient face. There are only few reports describing technical details of recovery of the facial allograft from the human donor. In this article, we summarize our cadaveric studies describing the methods of facial flap recovery in the cadaveric model and as well as mock facial transplantation. Based on our experience with the first case of face transplantation, we describe the sequence of facial graft procurement from the human donor and compare similarities and differences between our case and previously published cases. Furthermore, we discuss different methods of restoration of the donor face and have outlined proposed guidelines for the sequence of donor operation for facial graft procurement.     

Designing the selenium and bladder cancer trial (SELEBLAT), a phase lll randomized chemoprevention study with selenium on recurrence of bladder cancer in Belgium

Background

Growing evidence indicates that oxidative stress can be a primary cause of male infertility. Non-enzymatic antioxidants play an important protective role against oxidative damages and lipid peroxidation. Human seminal plasma is a natural reservoir of antioxidants. The aim of this study was to determine glutathione (GSH) concentrations, trace element levels (zinc and selenium) and the lipid peroxidation end product, malondialdehyde (MDA), in the seminal plasma of men with different fertility potentials.

Methods

Semen samples from 60 fertile men (normozoospermics) and 190 infertile patients (74 asthenozoospermics, 56 oligozoospermics, and 60 teratozoospermics) were analyzed for physical and biochemical parameters. Zinc (Zn) and selenium (Se) levels were estimated by atomic absorption spectrophotometry. Total GSH (GSHt), oxidized GSH (GSSG), reduced GSH (GSHr) and MDA concentrations were measured spectrophotometrically.

Results

Zn and Se concentrations in seminal plasma of normozoospermics were more elevated than the three abnormal groups. Nevertheless, only the Zn showed significant differences. On the other hand, Zn showed positive and significant correlations with sperm motility (P = 0.03, r = 0.29) and count (P < 0.01, r = 0.49); however Se was significantly correlated only with sperm motility (P < 0.01, r = 0.36). GSHt, GSSG and GSHr were significantly higher in normozoospermics than in abnormal groups. We noted a significant association between seminal GSHt and sperm motility (P = 0.03). GSSG was highly correlated to sperm motility (P < 0.001) and negatively associated to abnormal morphology (P < 0.001). GSHr was significantly associated to total sperm motility (P < 0.001) and sperm count (P = 0.01). MDA levels were significantly higher in the three abnormal groups than in normozoospermics. Rates of seminal MDA were negatively associated to sperm motility (P < 0.01; r = -0.24) and sperm concentration (P = 0.003; r = -0.35) Meanwhile, there is a positive correlation between seminal lipid peroxidation and the percentage of abnormal morphology (P = 0.008).

Conclusions

This report revealed that decreased seminal GSH and trace element deficiencies are implicated in low sperm quality and may be an important indirect biomarker of idiopathic male infertility. Our results sustain that the evaluation of seminal antioxidant status in infertile men is necessary and can be helpful in fertility assessment from early stages.     

Fear of Cancer Recurrence after Curative Pancreatectomy: A Cross-sectional Study in Survivors of Pancreatic and Periampullary Tumors

Background

Fear of disease recurrence is well documented among cancer survivors, but its significance among patients treated for solid pancreatic and periampullary neoplasms is unknown despite the known risk of recurrence associated with these tumors. We hypothesized that fear of cancer recurrence (FCR) represents a common source of psychosocial distress in this population and sought to characterize subgroups for whom FCR might represent a target for intervention to improve quality of life.

Methods

We conducted a cross-sectional study of FCR in patients who were disease-free after potentially curative pancreatectomy for ductal or periampullary adenocarcinoma or pancreatic neuroendocrine tumor. We assessed seven discrete dimensions of FCR using the Fear of Recurrence Inventory and evaluated quality of life and psychosocial distress using the Functional Assessment of Cancer Therapy-Hepatobiliary Questionnaire and the Hospital Anxiety and Depression Scale.

Results

Of 354 eligible patients, 240 (68?%) participated in the study a median of 48?months after potentially curative pancreatectomy. An FCR severity score indicative of frequent fearful thoughts, emotional disturbance and functional impairment was identified in 37, 28, and 35?% of patients with pancreatic adenocarcinoma, nonpancreatic periampullary adenocarcinoma, and pancreatic neuroendocrine tumor, respectively. Anxiety (P?<?0.001) and low quality of life (P?=?0.028) were independently associated with a clinically significant level of FCR, but histopathologic diagnosis and clinicopathologic markers of prognosis were not.

Conclusions

FCR represents a significant concern for one-third of patients after curative surgery for a pancreatic or periampullary tumor, regardless of their actual likelihood of recurrence or disease-related death.     

When the government actively faces the burden of osteoporosis: the Italian experience

Epidemiology and costs of fragility fractures in Italy

The problem of osteoporosis is emerging as growing phenomenon, with an enormous impact on quality of life and on health expenses. As a consequence, a reduction in the social and health impact of bone fragility would be associated with an improved quality of life of all elderly citizens and with valuable cost savings at the health system level.

Osteoporosis: evolution of the concept in Italy

In the last 20?years, there have been enormous advances in the knowledge of diagnostic and therapeutic options and thus we would be in the position of starting effective therapies in at risk populations. However, this not always happens.

New approaches to the fragility fractures by the Italian government

In this paper we offer to the reader the possibility to know the history of osteoporosis, its diagnosis and its therapy in Italy, a country where life expectancy is one of the highest in the world.

The future of osteoporosis in Italy

We hope that the example of Italy would serve as an inspiration to those countries where the history of osteoporosis only recently began.     

Bilateral Buccal Bifurcation Cyst: Case Report and Literature Review

Buccal bifurcation cyst (BBC) is a rare inflammatory odontogenic cyst that typically occurs at the buccal region of the first or second mandibular molars of children. In the current case, a 9-year-old boy complained of an extraoral soft tissue painful swelling. Intraoral examination revealed a partial eruption of the right permanent mandibular first molar with drainage of purulent material and clinical absence of the left mandibular first molar. Panoramic radiographic and computed tomography showed two well-defined areas surrounding the mandibular first molars consistent with cystic lesions. Surgical enucleations were performed and histopathologic analysis revealed inflammatory cysts. Based on the clinical, microscopic, radiographic, and CT images, the diagnosis of bilateral BBC was established. Patient has been under follow-up for about 1 year showing normal bone repair and eruption of the involved teeth. Although BBC is uncommon, it is important to recognize this entity.