Primary re-excision: the Italian experience in patients with localized soft-tissue sarcomas

Primary re-excision (PRE) is a wide, non-mutilating procedure carried out in patients with soft-tissue sarcomas (STS) when microscopic residuals are left after initial excision or when there are insufficient data on its completeness. The aim of this study was to evaluate the role of PRE in patients enrolled in two consecutive Italian studies between January 1988 and September 1999. Of 126 patients with grade IIa tumors, 53 underwent PRE (23 rhabdomyosarcomas [RMS] and 30 non-RMS STS [NRSTS]). The primary sites were the extremities in 20, paratesticular 15, trunk 9, head-neck-non-parameningeal (HNnPM) 6, bladder 1, other sites in 2; the tumor (T) status was T1a in 30, T1b in 10, T2a in 9, and T2b in 4; the median interval between primary surgery and PRE was 36 days. Of the 53 patients, 45 had complete histologic excision of the tumor (residuals were found in 21/45 specimens) and subsequently received chemotherapy (CT) alone: 39/45 are in their first complete remission (CR) with a median follow-up of 53 months; 6/45 (3 RMS, 3 NRSTS) relapsed, 4 locally (2 extremities, 2 trunk), and 1 of these died of progressive disease, and 2 with metastatic spread died of their disease. In 8/53 cases (HNnPM 4, extremities 2, bladder 1, trunk 1) PRE did not achieve complete removal of the residuals (3 T1a, 2 Tlb, 2 T2a, 1 T2b); these patients were treated with CT and/or radiotherapy (RT); 1 also underwent further surgery. PRE was able to achieve or confirm complete excision in 45/53 patients, and 39 maintained the first CR without RT. The histologic types and the presence of residuals at PRE did not predict the failures; PRE was effective especially in extremity, trunk, and paratesticular sites, whereas its role was uncertain in large sarcomas over 5 cm in size. Accepted: 16 November 2000     

Comparison of perioperative blood salvage and postoperative reinfusion of drained blood during surgical correction of craniosynostosis in infants

BACKGROUND: The surgical correction of craniosynostosis may be associated with extensive blood loss and transfusion. The aim of this study was to compare the efficacy of the perioperative use of the continuous autotransfusion system (CATS group) and of the postoperative use of the CBCII ConstaVac(R) system (CV group) to reduce homologous transfusion in infants during repair of craniosynostosis. METHODS: Two groups of consecutive infants, weighing <10 kg, and scheduled for the surgical correction of craniosynostosis, were compared retrospectively according to the blood salvaging system used: CATS group and CV group. The primary endpoint was the comparison of the total volume of homologous blood transfused. RESULTS: There was no significant difference between the CV (n = 69) and the CATS (n = 135) groups with regard to physical, preoperative and postoperative data, except for the type of craniosysnostosis with more scaphocephaly in the CV group (P = 0.03). No significant difference in blood loss and homologous transfusion was observed between the two groups during the perioperative period. Two subgroups of patients were also compared: a subgroup including patients operated on with a linear craniectomy for scaphocephaly, and a subgroup including all other patients. There was also no significant difference in blood loss and homologous transfusion between the CV and the CATS groups for these two subgroups of patients. CONCLUSION: Our results suggest that the postoperative use of the CBCII ConstaVac(R) system is as efficient as the perioperative use of the CATS(R) system for reducing homologous blood transfusion during repair of craniosynostosis in infants weighing <10 kg.     

Spinal 5-HT(2) and 5-HT(3) receptors mediate low, but not high, frequency TENS-induced antihyperalgesia in rats

Transcutaneous electrical nerve stimulation (TENS) is a form of non-pharmacological treatment for pain. Involvement of descending inhibitory systems is implicated in TENS-induced analgesia. In the present study, the roles of spinal 5-HT and alpha(2)-adrenoceptors in TENS analgesia were investigated in rats. Hyperalgesia was induced by inflaming the knee joint with 3% kaolin-carrageenan mixture and assessed by measuring paw withdrawal latency (PWL) to heat before and 4 h after injection. The (1). alpha(2)-adrenergic antagonist yohimbine (30 microg), (2). 5-HT antagonist methysergide (5-HT(1). and 5-HT(2). 30 microg), one of the 5-HT receptor subtype antagonists, (3). NAN-190 (5-HT(1A), 15 microg), (4). ketanserin (5-HT(2A), 30 microg), (5). MDL-72222 (5-HT(3), 12 microg), or (6). vehicle was administered intrathecally prior to TENS treatment. Low (4 Hz) or high (100 Hz) frequency TENS at sensory intensity was then applied to the inflamed knee for 20 min and PWL was determined. Selectivity of the antagonists used was confirmed using respective agonists administered intrathecally. Yohimbine had no effect on the antihyperalgesia produced by low or high frequency TENS. Methysergide and MDL-72222 prevented the antihyperalgesia produced by low, but not high, frequency TENS. Ketanserin attenuated the antihyperalgesic effects of low frequency TENS whereas NAN-190 had no effect. The results from the present study show that spinal 5-HT receptors mediate low, but not high, frequency TENS-induced antihyperalgesia through activation of 5-HT(2A) and 5-HT(3) receptors in rats. Furthermore, spinal noradrenergic receptors are not involved in either low or high frequency TENS antihyperalgesia.     

Perioperative medicine. Are the anesthesiologists ready?

Perioperative medicine starts with preoperative assessment and preparation of patients undergoing various procedures. It includes intraoperative care and continues postproceudral management, from recovery room to intensive care and step-down facilities. Acute pain management must be optimized in order to enhance rehabilitation and restoration of functions. Perioperative medicine also includes management of acute and chronic pain. Potential areas of anesthesia involvement, still unclear, include preoperative and postoperative ward management and complete preparation such as cardiology or pulmonary testing. Further steps to take in the direction of perioperative medicine are the development of a different model of resident training, and the improvement of information technology and medical record.     

Pulmonary embolism in sclerotherapy for a venous malformation in a child under general anesthesia

We report a case of pulmonary embolism associated with percutaneous sclerotherapy (absolute ethanol: 0.5 mL.kg-1) of a venous angioma, performed under general anaesthesia in a 13 year-old child. The diagnosis of pulmonary embolism, suspected on the clinical setting and symptoms, was supported by the pulmonary scintigraphy obtained 4 hours later, showing 3 minimal pulmonary defects. The outcome was rapidly favourable without sequelae under heparin administration and the pulmonary scintigraphy, performed on day 7, was normal. The role of absolute ethanol, for explaining the apparent contrast between the severity of the symptoms and the minimal obstruction noted on pulmonary scintigraphy is discussed. Also discussed are the prophylactic and curative therapeutic issues of this severe complication.     

Use of recombinant activated factor VII in intractable bleeding during pediatric neurosurgical procedures.

OBJECTIVE: To report the use of recombinant activated factor VII (NovoSeven; Novo Nordisk A/S, Bagsvaerd, Denmark) in children undergoing major neurosurgical procedures and experiencing massive uncontrolled hemorrhagic shock. DESIGN: Retrospective review of patients and analysis of clinical and biological effects of an intravenous administration of recombinant activated factor VII. SETTING: Neurosurgical anesthesia and critical care unit of a pediatric university hospital. PATIENTS/SUBJECTS: Four children, <12-kg body weight, experiencing life-threatening perioperative hemorrhage required conventional treatment (massive red blood cells, fresh frozen plasma, platelet transfusion, and surgical hemostatic maneuvers) that failed to obtain definite hemostasis. INTERVENTIONS: Intravenous administration of recombinant activated factor VII (100 microg/kg). RESULTS: Intravenous administration resulted in a significant decrease in blood loss within minutes (preventing further need of transfusion), normalization of biological hemostasis markers, and improved surgical hemostasis. No side effects of recombinant activated factor VII were noted, and all patients, except one, had a good recovery. CONCLUSIONS: These four patients support the use of recombinant activated factor VII as a useful adjunct to control massive life-threatening bleeding during pediatric neurosurgical procedures when other means failed. However, the data are still limited in children, and more extensive research is needed to define the indications of recombinant activated factor VII in massive surgical hemorrhage in low-weight children.     

Neo-adjuvant chemotherapy and bladder preservation in locally advanced transitional cell carcinoma of the bladder

Background: The possibility of bladder preservation as well as the utility of neo-adjuvant chemotherapy for invasive bladder cancer are controversial issues. The purpose of this study was the evaluation of neo-adjuvant M-VAC chemotherapy and bladder preservation in patients with locally advanced transitional cell carcinoma of the bladder.Patients and methods: Eighty-seven consecutive evaluable patients with T₂–T_4aN_xM₀ TCC of the bladder were treated with three cycles of neo-adjuvant M-VAC chemotherapy. After three cycles of M-VAC, 42 patients had TURB alone, 13 patients underwent partial cystectomy, and 32 patients were to undergo radical cystectomy.Results: Forty (51%) patients were T₀ at the TURB following M-VAC. Thirty (71%) patients who had chemotherapy and TURB alone are alive; at a median follow-up of 54+ months (8+–109+). Twenty-four (57%) have maintained an intact bladder. Of 13 responding patients with monofocal lesions who underwent partial cystectomy, 8 patients (62%) are alive with a functioning bladder, at a median follow-up of 80+ months (16–107+ months). At a follow-up of 32 months (7–121+ months), 20 (63%) patients in the radical cystectomy group are alive. In patients who had downstaging to T₀ or superficial disease, median follow-up is 55 months (10–121+ months) and five-year survival is 71%. Patients who failed to respond (T₂ or greater after chemotherapy), at a median follow-up of 24 months (7–103+ months), had five-year survival of only 29%.Conclusions: Bladder sparing in selected patients on the basis of response to neo-adjuvant chemotherapy is a feasible approach which must be confirmed in prospective randomized trials.     

Health-related quality of life in asymptomatic patients with HIV. Evaluation of the SF-36 health survey in Italian patients

OBJECTIVE: To investigate the psychometric performance and clinical validity of the 36-Item Short Form (SF-36) health survey when completed by asymptomatic HIV-positive Italian patients and to compare their health profile with a representative sample of 2031 Italian citizens (the Italian norm). PATIENTS AND METHODS: This was an observational, multicentre, cross-sectional survey. Microbiologists throughout Italy recruited asymptomatic HIV-positive individuals who were aged at least 18 years and aware of their infection. Investigators collected demographic, social, clinical and treatment data. Patients, classified into 2 clinical categories (A1 and A2) according to explicit pre-defined criteria, completed the SF-36 health survey in the context of a medical visit. RESULTS: Between April and July 1996, 46 microbiologists recruited 214 patients (201 evaluable). No inconsistent responses were observed in 96% of the sample. The usually recommended psychometric standards were satisfied, and the internal consistency reliability indices were always greater than 0.70. Weak to moderate associations were found between SF-36 health survey scores and physicians' estimates of patients' physical performance, while no significant associations were found with CD4+ counts. On average, HIV-positive patients reported lower scores than the Italian norm, and patients in category A2 showed lower scores than patients in A1. These differences were more relevant in scales describing role limitations, general health perception, and psychological well-being. CONCLUSION: Our study showed that the SF-36 health survey maintained its psychometric properties in a sample of Italian asymptomatic HIV-positive patients and produced data that showed its validity and robustness in such a setting.