Microsurgical versus endoscopic trans-sphenoidal approaches for clivus chordoma: a pooled and meta-analysis

Neurosurgical Review - Chordoma is a rare slow-growing neoplastic bone lesion. However, they show an invasive local growth and high recurrence rate, leading to an overall survival rate of 65% at 5...     

Do all antihypertensive drugs improve carotid intima‐media thickness?A network meta‐analysis of randomized controlled trials

The many clinical trials investigating the effect of various antihypertensive drugs on carotid intima‐media thickness (CIMT) produced conflicting results. We used meta‐analysis to evaluate CIMT changes and network meta‐analysis to rank drugs according to the magnitude of these changes. We identified 31 randomized controlled trials listed in three databases as of January 2008. Using a random‐effects model, we found a significant CIMT decrease with antihypertensive drugs compared to placebo (?0.10 [?0.16; ?0.04]). Overall effect sizes vs. placebo were significant for angiotensin‐converting enzyme (ACE) inhibitors (?0.08 [?0.14; ?0.02]), and a trend was found for beta‐blockers (?0.09 [?0.19; 0.01]). The data did not allow other direct comparisons vs. placebo. Significant benefits were found for calcium‐channel blockers (CCBs) compared to both ACE inhibitors (0.37 [0.20; 0.54]), as well as for angiotensin II receptor blockers (ARBs) compared to beta‐blockers (0.42 [0.29; 0.55]). Diuretics were less efficient than CCBs (?0.09 [?0.16; ?0.02]). Indirect comparisons with network meta‐analysis showed significant effects of CCBs and ARBs vs. placebo (both P < 0.05) and vs. diuretics (both P < 0.001). The CIMT decrease with ACE inhibitors and beta‐blockers was greater than with diuretics (both P < 0.05) but was not different from the placebo effect. In subgroup analyses, significant benefits occurred with lower baseline CIMT values and shorter treatment durations but were unrelated to the size of the blood pressure decrease. In conclusion, among antihypertensive drugs, CCBs and ARBs have the greatest effect on CIMT.     

Fertility of male workers of the italian mint

Fertility among workers exposed to metal fumes and solvents in the Italian mint (stampers, founders, and other technical workers) was compared to the reproductive experience of the administrative staff. Data on the reproductive history and time to pregnancy were collected by interview. For workers with children, data on the time to pregnancy (TTP) for the first pregnancy was assessed in relation to occupational risk factors. The groups with the highest prevalence of pregnancy delay beyond 6 months were stampers (21%) and those exposed to solvents (21.5%). Logistic regression did not show a significant association of these job exposures with pregnancy delay, but the power of the study to show an important difference was low. The data are not inconsistent with the hypothesis that male exposure to solvents and metal fumes is associated with an increase in the TTP.     

Angiotensinogen gene M235T polymorphism and reduction in wall thickness in response to antihypertensive treatment

The angiotensinogen M235T polymorphism has been linked to hypertension and cardiovascular disease. Carotid intima-media thickness (IMT) is an early marker of atherosclerosis. The objectives of the present study were to determine in previously untreated essential hypertensive patients whether carotid IMT was associated with the M235T polymorphism, and to determine whether the M235T polymorphism could influence the reduction of carotid IMT by antihypertensive treatment. Common carotid artery IMT was determined with a high-definition echotracking system in 98 previously untreated hypertensive patients in a cross-sectional study. A subgroup of 56 patients was included in a randomized double-blind parallel group study comparing the effect of the angiotensin-converting-enzyme-inhibitor enalapril with that of the beta-blocker celiprolol during a 5 month period. In the cross-sectional study, a multivariate analysis showed that the M235T genotype was a significant independent determinant of carotid IMT, explaining 7% of the variance. Carotid IMT was higher in patients homozygous for the T allele than in MM patients. In the longitudinal study, the reduction in carotid IMT after antihypertensive treatment was significantly ( P <0.01) higher in patients carrying the TT genotype than in patients carrying the MM genotype, despite similar reductions in blood pressure and independently of drug type. In conclusion, these data suggest that the angiotensinogen TT genotype at position 235 is a genetic marker for early carotid atherosclerosis in a hypertensive population and its regression under antihypertensive treatment.     

Statin treatment before percutaneous cononary intervention

Treatment with 3-hydroxy-3-methyl glutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) improves short-and-long term prognosis in high-risk patients with stable coronary artery disease and in those with acute coronary syndrome and their use is strongly recommended for secondary prevention.Moreover, recent data suggest that statin pre-treatment is associated with a better short- and long-term outcome in patients undergoing percutaneous coronary intervention. Current guidelines for coronary revascularization recommend the use of high-dose of statins before percutaneous coronary intervention to reduce the risk of periprocedural myocardial infarction in statin naïve patients (class IIa A) and in those on chronic statin therapy (class IIa B). However, the beneficial clinical effects elicited by statins in patients undergoing coronary angioplasty may arise not only from a cardiac protection against periprocedural myocardial injury but also from a renal protection against acute kidney injury caused by iodinated contrast media. Actually, statins exert multiple non-lipid lowering (pleiotropic) effects, including improved endothelial function, reduced inflammatory and immuno-modulatory processes, oxidative stress and platelet adhesion, that may contribute to both cardio- and nephro-protection even in the short-term.KEY WORDS : Statins, percutaneous coronary intervention, myocardial infarction, kidneyThe prognostic benefits of 3-hydroxy-3-methyl glutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) in high-risk patients with stable coronary artery disease (CAD) and in those with acute coronary syndromes (ACS) are well established and their use is strongly recommended for secondary prevention (1-4). Two concepts arise from these studies about statin administration: earlier is better considering the time and higher is better considering the dose. In a cohort of 1,159 patients with acute myocardial infarction (MI), the statin treatment initiated within 48 hours after admission was associated with significantly lower major adverse cardiac events at one-year (17.8% vs. 24.6%; P=0.016) compared to statin treatment started after 48 hours; the early statin therapy was an independent predictor of one-year outcome [Odds Ratio (OR): 1.49; 95% Confidence Interval (CI): 1.0 to 2.21; P=0.045] (5). In patients with ACS, statin therapy may reduce one-month mortality (OR: 0.63; 95% CI: 0.41 to 0.99; P=0.047) when treatment is started very early, within 24 hours of hospitalization (6). The favourable effect of high-dose statin treatment is more evident in patients undergoing percutaneous coronary intervention (PCI). In the PROVE-IT TIMI 22 (Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis In Myocardial Infarction) study, early intensive compared to moderate statin treatment, significantly reduced the composite end point of cardiovascular death, non fatal MI, recurrent ischemia or rehospitalisation for unstable angina in patients undergoing PCI [Hazar Ratio (HR): 0.73; 95% CI: 0.61 to 0.87; P=0.001] but not in those medically treated (HR: 0.84; 95% CI: 0.65 to 1.09; P=0.183), without a significant interaction between the dose of statin (intensive vs. moderate) and the treatment strategy (PCI vs. non PCI) (7). Few randomized studies have compared the prognostic impact of statin treatment when administered before PCI. However, available data suggest that pre-PCI statin administration may further improve prognosis. A recent meta-analysis of randomized trials that included stable CAD or ACS patients, showed a better 30-day outcome in the 1,649 patients randomized to short-term (from 12 hours to 2 weeks) high-dose statin compared to that of 1,649 patients randomized to low-dose or no statin therapy before PCI (8); in this meta-analysis, the rate of death, spontaneous non fatal MI or target vessel revascularization at 30-day was lower in patients pre-treated with statins (0.6% vs. 1.4%; OR: 44; 95% CI: 0.19 to 1.01; P=0.05). Moreover, non-ST elevation (NSTE) ACS statin-naïve patients (n=225) treated with high dose rosuvastatin (40 mg) 7-25 hours before PCI presented a better long-term outcome than patients (n=220) treated with rosuvastatin after intervention (Figure 1) (9). At 12 months, the composite primary end point of death, non-fatal MI, non-fatal stroke, or revascularization was significantly lower in the pre-PCI statin group (20.5% vs. 9.8%; P=0.002); similarly the risk of death and non-fatal MI at 12-month was significantly lower in patient who started rosuvastatin before PCI (HR: 3.71; 95% CI: 1.22 to 11.27; P=0.021) (9). Even a chronic statin therapy seems to improve long-term prognosis after PCI. Among 8,041 patients with stable CAD treated with PCI, 5,939 of these were on statin therapy (≥1 month) and 2,102 statin-naïve at the time of admission; statin therapy before PCI was associated with a significant reduction of one-year mortality (HR: 0.56; 95% CI: 0.42 to 0.75; P<0.001) with a benefit observed within the first month following PCI (10).Open in a separate windowFigure 1Clinical outcome during the follow-up. Incidence of death, non-fatal myocardial infarction, non-fatal stroke or revascularization at 1-month and at the end of 12-month follow-up in patients treated with high-dose rosuvastatin before percutaneous coronary intervention (statin) and in patients who received statin treatment after the procedure (control). From reference 9, modified.The beneficial clinical effects of statin pre-treatment may be related to their possible protective effects against both myocardial damage following PCI and kidney damage following contrast media administration. This review is focused on the relationship between the administration of statin therapy before PCI and the occurrence of periprocedural myocardial infarction (pMI) and contrast-induced acute kidney injury (CI-AKI).     

The sonographic prediction of invasive carcinoma in unilocular-solid ovarian cysts in premenopausal patients: a pilot study

BACKGROUND Unilocular-solid ovarian cysts are a rare but challenging pathology in young women, with a desire to spare their fertility. In these cases, the risks of borderline and invasive disease are around 10 and 20%, respectively. No ultrasound rule has yet demonstrated the ability to discriminate with high accuracy, a borderline tumor from a benign tumor or 'invasive tumor'. The aim of this study was to assess the predictive performance of different ultrasound parameters in differentiating benign and borderline tumors versus invasive malignant tumors in premenopausal patients with unilocular-solid ovarian masses. METHODS Women aged ≤50 years with unilocular-solid adnexal masses with a maximum diameter ≤10 cm, undergoing surgery in our department within 3 months from ultrasound examination, were included in this retrospective study. A standardized ultrasound examination technique and predefined definitions of ultrasound characteristics were used. The results of ultrasound examination using gray scale and color Doppler were compared with the histological examination of the respective surgical specimens. RESULTS The study included 51 patients. On histological examination, 36 (70%) lesions were classified as benign, 10 (20%) as borderline ovarian tumors and 5 (10%) as invasively malignant tumors. In receiver-operating characteristic curve analysis, the best cut-off for the largest solid component with regard to discriminating non-invasive (benign or borderline) from invasive tumors was 14 mm. A largest solid component >14 mm, the presence of papillation blood flow and the combination of the two parameters provided a sensitivity of 100% and a specificity of 63, 63 and 80%, respectively. CONCLUSIONS Transvaginal ultrasound examination seems to be able to discriminate between invasive and non-invasive tumors in the premenopausal patients with unilocular-solid adnexal masses. Because of the retrospective nature of the study, further prospective clinical trials are needed to confirm the accuracy of the selected sonographic parameters in discriminating the invasive and non-invasive adnexal tumors.