Gender-related differences of diabetic patients undergoing percutaneous coronary intervention with drug-eluting stents: A real-life multicenter experience

Background

Gender-based differences in diabetic patients are understudied in the field of percutaneous coronary intervention (PCI) with drug-eluting stents.

Methods

Data were obtained from a multicenter registry of 2420 consecutive patients with diabetes mellitus (DM) who underwent PCI with paclitaxel- or sirolimus-eluting stents between 2003 and 2009. Among them, 679 (28.1%) women were compared to 1741 (71.9%) men in terms of clinical aspects and major adverse cardiac events (MACE), including all-cause death, myocardial infarction (MI) and target lesion revascularization (TLR). Target vessel revascularization (TVR) and any revascularization were also reported.

Results

Women were less numerous, older, used more insulin and showed more tortuous coronary arteries, while men were more frequently smokers and received larger stents. At the median follow-up of 24.3 months (interquartile range 12.3–39.7), MACE, TVR and any revascularization did not significantly differ between females and males (19.9% vs 18.7%, 12.2% vs 13.4%, 14.1% vs 15.1%, respectively). At multivariable analysis of the overall cohort, female gender was not a predictor of MACE (hazard ratio [HR] 1.02, 95% confidence interval [CI] 0.92–2.36, p = 0.11), death (HR 1.04, 95% CI 0.84–1.24, p = 0.86), MI (HR 1.48, 95% CI 0.92–2.36, p = 0.11), and TLR (HR 1.14, 95% CI 0.85–1.52, p = 0.38).

Conclusion

In this registry of diabetic patients treated by drug-eluting stents, women were less represented, older and needed more insulin compared to men who, on the other hand, received larger stents. Gender-related outcomes were similar and female sex did not predict MACE.     

Interaction between Helicobacter pylori infection and untreated coeliac disease on gastric histological pattern

Objective. Helicobacter pylori infection is the major agent of gastric damage. Coeliac disease may affect the morphology and function of the entire gastrointestinal tract from the stomach to the colon. The aim of this study was to assess the gastric histological pattern in patients with H. pylori and untreated coeliac disease.

Material and methods. We retrospectively enrolled 183 H. pylori-positive patients with (85, group A) and without (98, group B) untreated coeliac disease. The groups were similar for age, gender and smoking habit, and all the patients came from the same geographical area. Histological evaluation of gastric pattern was performed on 4 biopsies (2 in the antrum, 2 in the corpus). Gastric damage was classified according to the modified Sydney System. Diagnosis of H. pylori infection was based on positivity to histology. The chi-square test was used to assess differences between groups. A p-value <0.05 was considered significant.

Results. Group A showed a significantly higher prevalence of follicular gastritis than group B (23.5% versus 12.2%, p=0.045). A significantly lower prevalence of atrophic gastritis was observed in group A compared with that in group B (6% versus 22.5%, p=0.002). The prevalence of chronic superficial gastritis, activity degree and intestinal metaplasia was similar between the two groups.

Conclusions. In patients with H. pylori infection, untreated coeliac disease could represent a risk factor for follicular gastritis and is associated with a lower prevalence of atrophic gastritis. The complex interaction between H. pylori and untreated coeliac disease on Th-1/Th-2 balance in the gastric mucosa could explain these results.     

Curative colorectal resections in patients aged 80 years and older: clinical characteristics, morbidity, mortality and risk factors

Background

The management of colorectal cancer in the elderly presents unique challenges. The objective of this study was to determine outcomes following curative colorectal resection in patients aged 80 years and older.

Patients and methods

Study design is retrospective. Data were extracted from the university hospital database and medical records of patients aged 80 years and older operated between April 2004 and December 2009. Intervention was curative colorectal resection. Main outcome measures include postoperative morbidity, mortality and individual risk factors associated with them.

Results

Three hundred fifty-eight patients (43.8 % males, age?=?84?±?3 years) were included; 72.6 % received elective surgery. A significantly higher complication rate and 30 day, 1 year and 4 year mortality were present for emergency operations compared to elective (p?<?0.001). One-year survival was 65.0 % for elective resections and 55.1 % for emergency. At 4 years of follow-up, survival was 49.2 % for the elective vs. 27.6 % for emergency. The American Society of Anesthesiologists (ASA) score is the only factor associated with the 30-day mortality at the multivariate analysis (p?<?0.01), Dukes staging with overall mortality (p?<?0.005), sex and mode of the operation with major complications (p?<?0.05). A limitation of the study is that is retrospective.

Conclusions

The highest mortality rates following colorectal surgery in the elderly are in the early postoperative period, especially for emergency operations and patients with significant comorbidities. However, the 1-year survival following elective curative resection for colorectal cancer approaches 65 %. ASA score and modality of the operation (elective vs. emergency) impacted on postoperative mortality and morbidity and could be used to select patients with more favourable outcomes.     

An open-label pilot study comparing rivastigmine and low-dose aspirin for the treatment of symptoms specific to patients with subcortical vascular dementia

Background: Patients with vascular dementia (VaD) show cholinergic deficits that may result in characteristic clinical syndromes for different subtypes of the condition. In addition to executive function, subcortical VaD is characterized by behavioral and emotional problems, reflecting deterioration of the frontal lobe.Objective: The purpose of this study was to determine the effect of rivastigmine on the specific symptoms of subcortical VaD.Methods: Patients received rivastigmine 3 to 6 mg/d (n = 8) or low-dose aspirin (cardioaspirin) 100 mg/d (n = 8) for 22 months in an open-label study design. Rivastigmine-treated patients began therapy with the lower dosage of rivastigmine 3 mg/d, which was increased to the higher dosage of 6 mg/d after 4 weeks. Disease severity was assessed using the Clinical Insight Rating Scale. Behavior was assessed using the NeuroPsychiatric Inventory (NPI), the Behavioral Pathology in Alzheimer's Disease (BEHAVE-AD) rating scale, and the Cornell Scale for Depression in Dementia (CSDD). The main results of this study, including executive function, NPI, and caregiver stress scores, have been presented elsewhere.Results: Sixteen patients were enrolled. Patients receiving rivastigmine showed statistically significant improvements in their BEHAVE-AD and CSDD scores (P = 0.001 and P = 0.02, respectively, versus cardioaspirin). Comparison of individual items on the BEHAVE-AD scores of the rivastigmine group with the cardioaspirin group indicated statistically significant improvements in activity disturbance, affective disturbance, aggressiveness, anxiety/phobia, hallucinations, and paranoia/delusions (P = 0.007, P = 0.035, P = 0.008, P = 0.003, P = 0.006, and P = 0.001, respectively). Similarly, comparison of the NPI scores of the 2 groups showed that the rivastigmine group experienced significantly greater improvements in anxiety, hallucinations, and wandering (P = 0.001, P = 0.005, and P = 0.014, respectively). Side effects in both groups were tolerable and there were no study withdrawals.Conclusions: In this preliminary study, rivastigmine treatment was well tolerated and effective. Improvements in the symptoms that characterize subcortical VaD were observed, suggesting that rivastigmine may have provided targeted treatment in areas of the brain that are particularly affected in this patient population. A large, double-blind, placebo-controlled study of rivastigmine in patients with VaD is warranted.     

Radioguided sentinel lymph node biopsy in patients with malignant cutaneous melanoma: the nuclear medicine contribution

As for other solid tumors, malignant cutaneous melanoma drains in a logical way through the lymphatic system, from the first to subsequent levels. Therefore, the first lymph node encountered (the sentinel node) will most likely be the first to be affected by metastasis, and a negative sentinel node makes it highly unlikely that other nodes in the same lymphatic basin are affected. Sentinel lymph node biopsy distinguishes patients without nodal metastases, who can avoid nodal basin dissection with its associated risk of lymphedema, and those with metastatic involvement who might benefit from additional therapy. This procedure represents a significant advantage as a minimally invasive procedure, considering that only an average 20% of melanoma patients with Breslow thickness between 1.5 and 4 mm harbour metastasis in their sentinel node(s) and are therefore candidates to elective lymph node dissection procedures. The cells that originate cutaneous melanomas are located between dermis and epidermis, a zone that drains to the inner lymphatic network in the reticular dermis, in turn to larger collecting lymphatics in subcutis. Therefore, the optimal modality of interstitial administration of radiocolloids for lymphoscintigraphy and subsequent radioguided sentinel lymph node biopsy is through intradermal/subdermal injection. (99m)Tc-labeled colloids in various size ranges are equally adequate for radioguided sentinel lymph node biopsy in patients with cutaneous melanoma, depending on local experience and availability. For melanomas located in the midline area of the head, neck, and trunk, particular consideration should be given to ambiguous lymphatic drainage, which frequently requires interstitial administration virtually all around the tumor or surgical scar from prior excision of the melanoma. Lymphoscintigraphy is an essential part of radioguided sentinel lymph node biopsy because images are used to direct the surgeon to the sites of the node(s). The sentinel lymph node should have a significantly higher count than that of background (at least 10:1 intraoperatively). After removal of the sentinel node, the surgical bed must be reexamined to ensure that all radioactive sites are identified and removed for analysis. The success rate of radioguidance in localizing the sentinel lymph node in melanoma patients is about 98% in institutions where a high number of procedures are performed, approaching 99% when combined with the vital blue dye technique. The procedure is becoming the standard of care for patients with cutaneous melanoma because of its high prognostic value that has led to include the procedure in the most recent version of the TNM staging system.     

The shell technique: bilateral fronto-orbital reshaping in trigonocephaly

The shell technique, used in the Pediatric Neurosurgical Department at the Catholic University, Rome, since the 1990s for the correction of trigonocephaly, is associated to a significant reduction in surgical time and intraoperative blood loss as compared to other procedures, while allowing an adequate remodelling of the bifrontal bone by means of multiple radial osteotomies. The technique does not necessitate the creation of a supraorbital bar, as the supraorbital ridges are modified in situ, further reducing the operative blood loss. In spite of reduced surgical time and manipulation, this procedure ensures aesthetic and functional results comparable to more extensive and complex cranial vault reshaping procedures. The main limitation of this technique is related to the surgical timing, as better results are obtained between 3 and 9 months of age, when the skull bone is still ductile to work with, thus allowing it to be remodelled by greenstick fractures. Moreover, in this age group, the cranial defects that result from the enlargement of the frontal bone flap by means of radial cuts and from the anterior displacement of its lateral portions may benefit from the more effective bone regeneration which characterizes younger children as compared to their older counterparts. A small number of cases showing either persistent hypotelorism or temporal depression have been observed in the post-operative period, although these residual deformities probably depend on a more extensive involvement of the cranial base in the synostotic process in these patients than on the procedure itself.     

A longitudinal study of brain atrophy and cognitive disturbances in the early phase of relapsing-remitting multiple sclerosis

OBJECTIVE: (a) To establish whether the cognitive decline of the early phase of relapsing-remitting multiple sclerosis depends on the progression of the burden of disease, or on the loss of brain parenchyma, or is influenced by both; (b) to monitor the loss of brain parenchyma in the early phase of the disease; and (c) to examine its possible relation with the progression of physical disability. METHODS: For 2 years 53 patients with clinically definite relapsing-remitting multiple sclerosis with disease duration 1-5 years and expanded disability status scale < or =5.0 at baseline were monitored. The neuropsychological performances, the psychological functioning, the neurological impairment, and the disability have been assessed at baseline and after 2 years. Patients also underwent PD/T2 and T1 weighted brain MRI. T2 and T1 lesion volumes were measured by a semiautomatic technique. Quantification of brain parenchymal volumes was obtained using a highly reproducible computerised interactive program. The relation between cognitive impairment and MRI findings has been investigated by partial correlation and stepwise multiple regression analyses excluding the effects of age, education, anxiety, depression, and total days of steroid use. RESULTS: In the 2 years of the study the mean change for T2 and T1 lesion volumes and brain parenchymal volumes were +1.7 ml (95% confidence interval (95% CI) 1.3-2.2, p=0.005, (29.8%); +0.2 ml, 95% CI 0.15-0.26, p=0.004, (25%); and -32.3 ml, 95% CI 24.2-42.3, p<0.0001, (2.7%), respectively. Overall, 14 patients (26.4%) were judged to be cognitively impaired at baseline and 28 (52.8%) at the end of the follow up. Of the 18 neuropsychological tests and subtests employed in the study, patients with multiple sclerosis failed 5.8 (SD 2.3) tests at the baseline and 8.4 (SD 2.9) (p<0.0001) tests at the end of the study. When the cognitive changes were examined in individual patients, five (9.4%) of them were considered cognitively improved, 33 (62.3%) remained stable, and 15 (28.3%) worsened over 2 years. T2 and T1 volume changes in improved, stable, and worsened patients did not show any significant difference, whereas brain parenchymal volume decrease in cognitively worsened patients was significantly greater (-66 ml (5.4%), 95% CI 37-108.9, p=0.0031). The cognitive impairment was independently predicted over 2 years only by the change of brain parenchymal volumes (R=0.51, p=0.0003). Ten patients (18.9%), who worsened by one or more points in the EDSS during the follow up period had significant decreases in brain parenchymal volumes (-99 ml (8%), 95% CI 47.6-182.3, p=0.005). At the end of the study the loss of brain parenchyma correlated significantly with change in EDSS (r= 0.59, p<0.0001). CONCLUSIONS: In the early phase of relapsing-remitting multiple sclerosis the cognitive deterioration relies more on the development of brain parenchymal volume atrophy than on the extent of burden of disease in the brain. The loss of brain parenchymal volume underlies the progressive accumulation of physical disability from the initial phase of the disease, which becomes more demonstrable only if studied with longer observation periods. Probably, the main pathological substrate of brain atrophy in the early stage of the disease is early axonal loss, which causes the progression of neurological deficits and the development of cognitive impairment. These data support the debated opinion that disease modifying therapy should be initiated as early as possible.     

Prevention of corticosteroid-induced osteoporosis with salmon calcitonin in sarcoid patients

Summary The aim of this study was to evaluate the usefulness of salmon calcitonin (sCT) in preventing corticosteroid-induced osteoporosis. Three groups of patients with sarcoidosis requiring long-term steroid therapy were followed for 2 years with yearly evaluations of vertebral cancellous mineral content (VCMC) by quantitative computed tomography. The first group (n=18) was treated with intramuscular (i.m.) sCT for the 2-year study period; the second (n=11) with i.m. sCT for the first 4 months and then with sCT nasal spray for 20 months; the third (n=35) received no sCT. We observed a large mineral loss in the third group but a very slight drop of VCMC in the two groups receiving sCT. SCT nasal spray was better tolerated and as effective as i.m. injections. The action of sCT appeared extremely useful, especially in the first year of steroid therapy when corticosteroid-induced mineral loss was maximal. We conclude that sCT nasal spray is a good tool for preventing corticosteroid-induced osteoporosis.     

Radiation-induced brain tumours after central nervous system irradiation in childhood: a review

OBJECTS: Radiation-induced cerebral tumours constitute a significant risk for subjects undergoing radiotherapy for the management of cerebral neoplasms. Age-related cerebral vulnerability could be a specific factor in the genesis of these complications. METHODS: The pertinent literature of both paediatric and adult series has been reviewed. Three personal cases were added. RESULTS: One hundred forty-two paediatric second brain tumours were evaluated. Out of them, 69 were malignant gliomas, 33 meningiomas, 8 sarcomatous lesions and 13 low-grade astrocytomas. The average latency period for the appearance of the second tumour was 8 years. Among the second tumours occurring in adults, meningioma is the most common. In this subgroup, the latency period ranged between 16 and 30 years. CONCLUSION: Paediatric radiation-induced brain tumours differ from the adult counterpart for both the histological subtypes. These figures indicate a specific vulnerability of the infantile brain demonstrated by the most frequent occurrence of highly malignant lesions.