Early acute hemispheric stroke after carotid endarterectomy. Pathogenesis and management

Purpose  

A major stroke after carotid endareterectomy (CEA) is an event that should be managed according to a planned strategy. Literature data on this issue are not definitive. We reviewed our series in the attempt to define an algorithm of treatment if this complication occurs.     

Nasal cytology: Methodology with application to clinical practice and research

Nasal cytology is an easy, cheap, non‐invasive and point‐of‐care method to assess nasal inflammation and disease‐specific cellular features. By means of nasal cytology, it is possible to distinguish between different inflammatory patterns that are typically associated with specific diseases (ie, allergic and non‐allergic rhinitis). Its use is particularly relevant when other clinical information, such as signs, symptoms, time‐course and allergic sensitizations, is not enough to recognize which of the different rhinitis phenotypes is involved; for example, it is only by means of nasal cytology that it is possible to distinguish, among the non‐allergic rhinitis, those characterized by eosinophilic (NARES), mast cellular (NARMA), mixed eosinophilic‐mast cellular (NARESMA) or neutrophilic (NARNE) inflammation. Despite its clinical usefulness, cheapness, non‐invasiveness and easiness, nasal cytology is still underused and this is at least partially due to the fact that, as far as now, there is not a consensus or an official recommendation on its methodological issues. We here review the scientific literature about nasal cytology, giving recommendations on how to perform and interpret nasal cytology.     

Moving against frailty: does physical activity matter?

Frailty is a common condition in older persons and has been described as a geriatric syndrome resulting from age-related cumulative declines across multiple physiologic systems, with impaired homeostatic reserve and a reduced capacity of the organism to resist stress. Therefore, frailty is considered as a state of high vulnerability for adverse health outcomes, such as disability, falls, hospitalization, institutionalization, and mortality. Regular physical activity has been shown to protect against diverse components of the frailty syndrome in men and women of all ages and frailty is not a contra-indication to physical activity, rather it may be one of the most important reasons to prescribe physical exercise. It has been recognized that physical activity can have an impact on different components of the frailty syndrome. This review will address the role of physical activity on the most relevant components of frailty syndrome, with specific reference to: (i) sarcopenia, as a condition which frequently overlaps with frailty; (ii) functional impairment, considering the role of physical inactivity as one of the strongest predictors of physical disability in elders; (iii) cognitive performance, including evidence on how exercise and physical activity decrease the risk of early cognitive decline and poor cognition in late life; and (iv) depression by reviewing the effect of exercise on improving mood and increasing positive well-being.     

Oxidative and nonoxidative benzodiazepines and the risk of femur fracture. The Systematic Assessment of Geriatric Drug Use Via Epidemiology Study Group

Benzodiazepine use is a well-identified risk factor for falls and the resulting femur fractures in elderly adults. Benzodiazepines not requiring hepatic biotransformation may be safer than agents undergoing oxidation because oxidative activity has been shown to decline with age. The association between the use of either oxidative or nonoxidative benzodiazepines and the risk of femur fracture among elderly adults living in nursing homes was studied. A nested case-control study was conducted using the Systematic Assessment of Geriatric drug use via Epidemiology (SAGE) database; the records of 9,752 patients hospitalized for incident femur fracture during the period 1992 to 1996 were extracted, matching by age, gender, state, and index date to the records of 38,564 control patients. Conditional logistic regression models were conducted to estimate the odds ratios (ORs) for femur fracture with adjustment for potential confounders. The adjusted OR for the overall use of benzodiazepines was 1.10 (95% confidence interval [CI], 0.98-1.20); the risk seemed of only slightly greater magnitude for exposure to nonoxidative agents (1.18; 95% CI, 1.03-1.36) than to oxidative benzodiazepines (1.08; 95% CI, 0.95-1.23). Among the latter, the effect was mainly accounted for by the use of agents with a long elimination half-life. A dose relationship was observed exclusively among users of long half-life oxidative benzodiazepines. The risk associated with the use of nonoxidative benzodiazepines showed no relationship to the age of the patients. In contrast, patients aged 85 years or older receiving oxidative benzodiazepines at high dosages or as needed had a two- to three-fold increased risk of femur fracture than did patients in the younger age group. Among older individuals, the use of benzodiazepines slightly increased the risk of femur fracture, mainly irrespective of the metabolic fate of the drug. Our results suggest that the use of nonoxidative benzodiazepines does not carry a lower risk for femur fracture than does the use of oxidative benzodiazepines. However, the latter agents may be associated with a somewhat higher risk of side effects among the oldest old, especially at higher dosages.     

Helicobacter pylori and type 1 diabetes mellitus in children

BACKGROUND: Helicobacter pylori is a recognized gastroduodenal pathogen and H. pylori infection is one of the most common bacterial infections, usually acquired during childhood. However, diabetes mellitus is characterized by an increased susceptibility to infections. METHODS: We compared the prevalence of H. pylori infection as well as cytotoxin-associated gene A-CagA-and vacuolating cytotoxin gene A-VacA-positivity in 103 children and adolescents with type 1 diabetes mellitus and in 236 nondiabetic children. We used a novel Recombinant ImmunoBlot Assay-Strip (RIBA SIA) with individual band for whole H. pylori lysate and recombinant CagA and VacA. RESULTS: H. pylori-positive subjects, both diabetics and controls, were significantly older than negative subjects. In the whole group of diabetic patients the prevalence of each of the three reactivities was higher than in control subjects, reaching significance only for lysate. Only diabetic patients over 12 years of age, with a longer disease duration, had a higher prevalence of positive cases, although not significantly so. CONCLUSIONS: In the first few years of disease, diabetic children do not differ from the nondiabetic population. Subsequently they show an H. pylori seroprevalence tendentially higher than that of controls of the same age. Therefore, H. pylori infection acquired in childhood and lasting several years, could be one of the causes of chronic atrophic gastritis, which is more frequent in longstanding diabetes mellitus.     

Retroperitoneal tumors

The retroperitoneal tumors are seldom met in their several histological expressions. Authors totally considered 27 patients with retroperitoneal tumors and they were observed from 1975 to 1996: 21 of them were primitively cured in this Institute whereas 6 were affected with relapse or metastasis after a surgical approach which had been performed by other structures. Their operability resulted of 100% with an 87% resectability rate. The surgical mortality resulted nil while the morbidity rate was of 44%. The global survival resulted of 60% to 5 years while the disease-free interval was of 35%. The outliving to 5 years resulted of 65% with a 60% disease-free interval only in the patients who were treated in first instance. The surgical therapy represents the only treatment which can modify the clinical history of such neoplasms. Exeresis should be aggressive enough in order to obtain a total extirpation of the mass and grant a right margin of safety of sound tissue. Such radical proceeding should also be pursued in the treatment of relapses and metastases. The therapeutical efficacy is always linked to the precocity the diagnosis. A strict follow-up of the patients who underwent a surgical operation for retroperitoneal neoplasm is therefore necessary. A minority of the instances was only subjected to a complementary radio and/or chemotherapic treatment. Such protections did not significantly modify the outliving.     

Impact of the type and severity of dementia on hospitalization and survival of the elderly. The SAGE Study Group

We conducted a retrospective cohort study to examine whether patients with Alzheimer's disease (AD) or vascular dementia (VaD) differed in the number and type of associated comorbid conditions. In addition, we evaluated the impact of the severity of cognitive impairment on hospitalization and mortality of patients in each group. We studied 161,106 patients over age 65, with any degree of cognitive impairment, residing in any of 1,573 Medicare/Medicaid-certified nursing homes of 5 states of the USA between 1992 and 1995. Patients were assessed with the federally mandated Minimum Data Set (MDS). The MDS has been cross-linked to Medicare eligibility files and to the Medicare Provider Analysis and Review database. AD patients were younger, and more likely to be female and Caucasian than VaD patients. For comparable levels of cognitive impairment, AD patients appeared to have fewer comorbid conditions, including those that were not risk factors for VaD. In addition, patients with AD had decreased morbidity and mortality relative to patients with VaD. These findings support the hypothesis that AD patients are a healthier group of demented patients.     

Pretherapeutic endosonography in rectal adenocarcinoma

The advent of transrectal ultrasonography has contributed to improving therapeutic management of cancer of the rectum. The 7.5 MHz transrectal probe evidences five tissue layers in the rectal wall. The 10-12.5 MHz probe can visualize seven layers. Transrectal ultrasonography can also be used to explore the perirectal environment and detect possible nodes. Echographically, the tumor is seen as an hypoechogenic mass invading the rectal wall outwardly, disorganizing the wall structures. Parietal recurrence is seen as a hypoechogenic heterogeneous thickening. Ultrasonographic surveillance can be proposed for operable patients with a high risk of recurrence. Cautious interpretation is required due to the known limitations of transrectal ultrasonography. Truly invaded nodes may not be seen due to their small size (less than 2-3 mm) or their localization far from the probe (false negatives). Transrectal ultrasonography provides important information for therapeutic decision making in terms of surgical access and/or indications for possible adjuvant therapy. Transanal resection may also be ruled out if there are perirectal nodes. Patients may also be selected for preoperative radiotherapy, possibly associated with chemotherapy.     

Cytological screening of uterine cervical cancer by samples in liquid medium (CytoRich). Preliminary study of a series of 111 292 patients

We report on the preliminary results of a series of 111,292 patients who benefited from a liquid medium sample (CytoRich) for cervical cancer screening. The number of dubious or limited smears was reduced by 0.03% and 0.53% respectively. The junction zone was better explored, and metaplastic changes were observed in 35.71% of the cases. This method improved the identification of low-grade lesions by +56% (2751/111,292; 2.47%) and of high-grade lesions by +75% (860/111,292; 0.77%), with a reduction in the number of ASCUS/AGUS by -44% (2065/111,292; 1.85%). This preliminary study confirms the results already published. The results demonstrating cytohistological correlation should prove to be a decisive factor, enabling the testing of the sensitivity and specificity of this technique. It will then be possible to envisage a future 'new paradigm' for screening cervical cancer as the result of a liquid medium sample, computer-assisted screening and HPV viral identification by Hybrid capture II.