Prevalence and prevention and treatment modalities for pressure sores. Study of the Emilia-Romagna region

This audit initiative aimed at assessing the prevalence of pressure sores in the public hospitals of Emilia-Romagna, and at monitoring the rate of use of specific modalities of prevention and cure. The design was cross-sectional, with information collected on three index days during 2000 by trained personnel. Overall, the prevalence of pressure sores at the regional level was 7.1%, with remarkable variation across hospitals (from 2.9% to 9.7%), also after adjustment for case mix. As for patterns of prevention and cure, 74% of patients at risk (according to the Braden scale) of developing a pressure sores received only standard low technology devices, and 50% of those in need were included in a systematic programme of postural change. Adequate (according to the available evidence) medications were used in 45% of patients with a pressure sore. The overall prevalence of pressure sore is close (or even inferior) to that observed in similar studies. However, variation between hospitals indicates that the current health services ability to deal with pressure sore is variable and often suboptimal. This evaluation is also supported by the limited adoption of adequate preventive and curative modalities.     

Immunohistological evaluation of basal cell carcinoma immunoinfiltrate during intralesional treatment with alpha2-interferon

Summary We investigated the peritumoral and intratumoral immune infiltrate in 6 basal cell carcinomas (BCCs) treated with recombinant alpha_2b-interferon. Each BCC was injected intralesionally three times a week for 3 weeks with 1.5×10⁶ IU of interferon per injection (total dose 13.5×10⁶ IU). The immunohistological study was done before the start of interferon therapy and 15 days afterwards, using a series of monoclonal antibodies and an immunocytochemical technique. Before therapy the infiltrate consisted mainly of CD3+ (T) cells, with prevalence of CD4+ (helper/inducer) T cells. The percentage of T cells expressing interleukin-2 receptor (CD25+ cells) was higher in the tumor nests than in the peritumoral infiltrate (20% and 11% respectively). CD1+ (Langerhans) cells and CD14b+ cells (monocytes/macrophages) were present in the peritumoral infiltrate in all cases (9%±5% and 14%±7% respectively). Very few CD56+ (natural killer), CD15+ (granulocytes) and CD20+ (B) cells were observed in the peritumoral infiltrate and none at all in tumor nests. After 15 days of interferon therapy, we observed an increase in peritumoral and intratumoral CD4+ cells. There was a decrease in the number of CD25+ cells and of CD1+ cells in the peritumoral infiltrate. The number of intratumoral CD25+ increased. No variations were seen in CD14b, CD15, CD20, and CD56 positive cells. Eight weeks after completion of therapy, two BCCs were cleared and the remaining four showed clinical and histological improvement. These results may indicate a direct effect of interferon against BCC; in addition the immunohistological findings suggest that intralesional interferon enhances T cell mediated immune response, especially in tumor nests. Interferon may therefore act against BCC as a cytotoxic agent and as an immunomodulator.     

Reflux parameters as modified by EsophyX or laparoscopic fundoplication in refractory GERD

Aliment Pharmacol Ther 2011; 34: 67–75

Summary

Background EsophyX is a novel transoral incisionless fundoplication device developed to mimic surgical fundoplication. EsophyX fundoplication improves acid reflux parameters in proton pump inhibitor (PPI)‐responsive GERD patients but its efficacy in refractory GERD has been scarcely studied. Aim To assess reflux parameters before and after EsophyX or laparoscopic fundoplication and their relationship with symptoms in refractory GERD. Methods In an open‐label study, we enrolled prospectively patients with heartburn/regurgitation persisting despite high‐dose PPI therapy. Impedance‐pH monitoring was performed on PPI therapy before intervention and off PPI therapy 3 months after intervention. Results Ten patients chose to undergo EsophyX (EndoGastric Solutions, Redmond, WA, USA) fundoplication while ten chose laparoscopic fundoplication, and the baseline characteristics were comparable. Distal and proximal refluxes were significantly reduced post‐operatively in the surgical but not in the endoscopic group and the median values were significantly lower in the former than in the latter. The oesophageal acid exposure time was normal in 50% of cases after EsophyX and in 100% of cases after surgery (P = 0.033); the number of distal refluxes was normal in 20% and 90% of cases (P = 0.005) and the number of proximal refluxes was normal in 40% and 100% of cases (P = 0.011), respectively. A positive persisting symptom‐reflux association was found post‐operatively in 6/10 patients in the EsophyX group and in 0/10 patients in the surgical group (P = 0.011). Conclusions In patients with refractory GERD, EsophyX fundoplication is significantly less effective than laparoscopic fundoplication in improving reflux parameters and accordingly, in inducing symptom remission.     

Laparoscopic treatment of colonoscopic perforation: a case report

Infrequent but severe complications may occur during both diagnostic and therapeutic colonoscopy, including bleeding, perforation and sepsis. The most dangerous complication is perforation. Some iatrogenic perforations may be effectively managed by non-operative measures, but immediate surgery is most definitely indicated in order to minimise the morbidity and mortality associated with the complication. We report a case of colonoscopic perforation secondary to a therapeutic procedure, a snare polypectomy, successfully managed by laparoscopic repair using passing sutures and omentum fixation. The laparoscopic approach enables the surgeon to avoid an unnecessary laparotomy for an endoscopic complication.     

Venetoclax ramp-up strategies for chronic lymphocytic leukaemia in the United Kingdom: a real world multicentre retrospective study

This retrospective, observational study evaluated patterns of inpatient versus outpatient tumour lysis syndrome (TLS) monitoring during venetoclax ramp-up in 170 patients with chronic lymphocytic leukaemia. The primary outcome was clinical/biochemical TLS. Two clinical and four biochemical TLS occurred (4.1%). Five of the six events occurred in high-risk patients, four occurred at 20 mg dose and three at the 6-h time-point. Inpatient versus outpatient TLS rates within the high-risk subgroup were 15% and 8%. Risk category was the only predictor of TLS events in multivariate analysis. Outpatient escalation did not associate with clinically meaningful TLS events, suggesting outpatient escalation has manageable associated TLS risks, including in high-risk cohorts. These observations require confirmation in larger studies.     

Laparoscopic Distal Pancreatectomy in Children: Case Report and Review of the Literature

Background Laparoscopic resection of benign tumors of the pancreas has been reported in adults, but only four cases of partial laparoscopic pancreatectomy in children have been described in the English-language literature. Methods We describe the case of an 11-year-old girl with a solid pseudopapillary tumor who was treated with a laparoscopic, spleen-preserving, distal pancreatectomy. The specimen was extracted in an endoscopic bag retrieval system through a Pfannenstiel incision. Operative time was 120 minutes, and minimal blood loss occurred. The literature is reviewed. Results The postoperative course was uneventful. Twenty-two months after the operation, clinical follow-up (including assessment of exocrine and endocrine pancreatic function) revealed nothing abnormal. The functional and aesthetic results were satisfactory. Conclusions The technique used for our case is simple and reproducible, was completed safely within a reasonable operative time, and yielded a good result.     

CMV gB genotypes and outcome of vertical transmission: study on dried blood spots of congenitally infected babies.

BACKGROUND: The role of the virulence of the infecting cytomegalovirus (CMV) strain in the transmission of the virus from mother to fetus and the outcome of the fetal infection has not received much attention yet. Molecular analysis of the gene coding for the surface glycoprotein B (gB) has been used to investigate the relationship between genotype and virulence in groups of immunosuppressed patients. OBJECTIVES: (1) to assess the prevalence of different gB genotypes in babies with congenital CMV infection; (2) to investigate the possible relationship between genotype and severity of congenital CMV disease; (3) to evaluate the possibility of using dried blood on Guthrie cards (DBS) for genotyping. STUDY DESIGN: CMV DNA was extracted from DBS and from urine/saliva samples collected in the first two weeks of life of 98 congenitally infected babies, half of which were symptomatic at birth. Genotyping was performed through RFLP analysis of the region corresponding to the cleavage site of the gB protein. RESULTS: The most prevalent genotype was gB1 (42%) followed by gB3 (26%), gB2 (19%) and gB4 (13%). Rates of disease and CNS damages were higher among children infected by gB1 (35%, 17%) and gB3 (31%, 28%) than in those infected by gB2 and gB4 (20%, 17% and 13%, 15%, respectively). These differences however did not reach the statistical significance. The parallel typing of DBS and urine/saliva strains gave a full concordance of results. CONCLUSIONS: All four major CMV gB genotypes (gB1-4) can cause a congenital infection but none seems to be associated to the development and the severity of disease. The possibility of using the neonatal DBS for genotyping opens a way to the examination of large numbers of cases of congenital CMV infection.     

Video laparoscopic surgery: is out-of-hospital thromboprophylaxis necessary?

Despite widespread use of laparoscopic procedures, no adequate data are available to support specific recommendations for venous thromboprophylaxis in patients undergoing laparoscopic surgery. This prospective, randomized trial is the first to be designed to evaluate a regimen of out-of-hospital thromboprophylaxis after laparoscopic surgery. Consecutive patients admitted for laparoscopic surgery were considered for the study. The thromboprophylaxis regimen used for each patient was based on a risk score. Possible thromboprophylactic measures included elastic stockings and pre- and postoperative Dalteparin or early ambulation. At discharge, patients were randomly allocated either to continue Dalteparin for 1 week, or to receive no further prophylaxis. Patients judged to be at low risk were not randomized. Compression ultrasound of the leg veins was performed in all patients 4 weeks after hospital discharge. Fifty-three patients, all with acute appendicitis, were judged to be at low risk of deep vein thrombosis and were not included in the randomized study. The remaining 209 patients fell into two groups: 104 patients received postdischarge Dalteparin and 105 patients did not. The incidence of deep vein thrombosis was 0% (0 of 104) vs. 0.95% (one of 105), respectively (P = 1.00). The risk of postdischarge venous thromboembolism is low in patients undergoing laparoscopic surgery who receive in-hospital thromboprophylaxis. Given this low risk, a clinical trial powered to determine if extending prophylaxis in such patients reduces the risk of clinically apparent deep vein thrombosis would be unfeasibly large.     

Clinical and pathologic prognostic indicators in colorectal cancer. A population-based study.

The institution of a colorectal Cancer Register in a health care district of Northern Italy gave the authors the opportunity to evaluate the prognostic relevance of several morphologic and clinical variables by univariate and multivariate analyses. Of the 134 patients registered in 1984, 132 were followed up until the end of 1989. Overall 5-year survival was 37%, but the figure increased to 43% when only colorectal cancer-related deaths were considered. Univariate analysis for clinical variables showed that TNM staging and age at diagnosis were significantly related to prognosis, whereas none of the other parameters were indicative of the clinical outcome. With a similar analysis, among the various morphologic variables, pattern of growth (infiltrating versus expanding) and extent of fibrosis (extensive versus little or absent) appeared to be indicators of prognosis. When the variables that were significant (stage, age, pattern of growth, and fibrosis) in the univariate analysis were entered into the Cox model of multivariate analysis, TNM staging was the only parameter that maintained an independent prognostic importance. The authors state that their results confirm the importance of stage in predicting survival for cancer of the large bowel and suggest that the possible prognostic value of clinical and morphologic variables should be investigated within each of the major TNM or Dukes' classes.