FOLLOW-UP OF EPITHELIAL OVARIAN CANCER PATIENT AFTER PRIMARY TREATMENT (Controversies and actual guidelines)

SAŽETAK. Objavljene smjernice vezane za follow-up pacijentica primarno liječenih od karcinoma jajnika, ali i drugih ginekoloških malignoma, temelje se na podacima samo nekoliko studija koje nisu randomizirane i koje ne prikazuju učinkovitost i utrošak/dobrobit pretraga što su korištene za dijagnozu recidiva bolesti. Te studije/preporuke nisu usuglašene po vrsti pretraga i vremenskoga intervala pregleda. Uz to kod detekcije recidiva u pacijentica primarno liječenih od karcinoma jajnika, ostaje još terapijska dilema s obzirom na to da će gotovo svaka pacijentica s recidivom bolesti umrijeti. Follow-up asimptomatskih pacijentica najčešće obuhvaća uvid u povijest bolesti, serumski CA 125, ginekološki fizikalni pregled i često ultrazvučni pregled, a koriste se i druge radiološke pretrage kada simptomi i znakovi ukazuju na mogući recidiv bolesti. U literaturi nalazimo dvije oprečne tendencije. Prva koja vodi minimalističkome praćenju i druga koja, na osnovi novih procedura, lijekova i tehnologija, potiče kliničara da se koristi skupim pretragama koje još nisu znanstveno opravdane. Potrebna su velika prospektivna randominizirana ispitivanja koja uspoređuju minimalistički follow-up s intenzivnim skupim pristupom pretraga. Studije moraju voditi računa o ciljevima liječnika (dobri i učinkoviti rezultati koji jamče najbolju kliničku praksu), potrebama pacijentica (percepcija da je liječenje vođeno na odgovarajući način) i realnim mogućnostima zdravstvenoga sustava. Te studije trebale bi jasnije usporediti objektivni klinički ishod (sveukupno preživljenje, vremenski interval bez bolesti i komplikacije) te subjektivni ishod (kvalitetu života i očekivanja pacijentica).All the guidelines published regarding the follow up of patient primary treated for ovarian cancer and other gynecological cancer, are the results only of few studies not randomised and in absence of evidence of effectiveness and cost/benefit of the procedure used for diagnosis of recurrent disease. Few formal guidelines exist regarding the surveillance of these patients, and there is no agreement in the literature about the type and timing of examinations to perform. Moreover, the objective of follow-up is unclear as recurrent epithelial ovarian cancer continues to be a therapeutic dilemma and quite all the relapsed patients will eventually die of their ¬disease. The follow-up of asymptomatic patients generally include complete clinical history, serum cancer antigen (CA 125) assay, physical examination, and often ultrasound examination, whereas additional radiologic imaging techniques are usually performed when symptoms or signs appear. Currently, there exist two opposite tendencies suggesting different follow-up modalities. On one side »minimalistic« follow-up and on the other side, the introduction of new drugs and new technologies induce the physician to prescribe expensive examinations without proved utility. Prospective randomised clinical trials have to be planned in order to ¬compare minimalistic and intensive follow-up policies. These trials have to evaluate the relationship between the gynecological oncologist’s needs (good quality scentific data available, which leads the best clinical practice), patient’s need (according to the satisfaction degree they feel about the treatments and follow-up) and possibility of health care system. New clinical trials also are needed in order to evaluate the relationship between the objective clinical outcome (overall survival, disease-free interval, and complications) and the subjective outcome (quality of life and expentacies of the patient)

Surgical Stress Reduction in Elderly Patients Undergoing Elective Colorectal Laparoscopic Surgery within an ERAS Protocol

n/

Transperitoneal laparoscopic retrievement of a migrated prosthetic head after total hip arthroplasty: a case report

The migration of a prosthetic head during total hip arthroplasty (THA) is a rare complication. Few cases are described in the literature, offering different solutions and surgical approaches for prosthetic head retrievement. Here, we present a case of successful laparoscopic transperitoneal retrieval of a prosthetic head migrated above the right iliac vein after THA with a posterolateral approach

The medico-legal assessment of asylum seeker victims in Italy

Introduction: Changing patterns of migration hasrequired states andgovernments to respond to the specific medical and legal needs of asylum seekers. Based on medical assessments undertaken at the University Institute of Legal Medicine, the present study aims to describe the cases of asylum applicants who have suffered from physical violence, including torture, and the variables involved. Methods: Over a 10-year period, 225 survivors were examined by clinical forensic professionals from the University Institute of Legal Medicine. Results:85% of asylum applicants came from Africa, 87% were male, and the most common age group was 26-40 years old. 46% of applicants fled their country for political reasons. Blunt force injuries were reported in 45% of cases, the trunk was the most affected area of the body (40%), and applicants presented with an average of two different mechanisms of lesions and an average of four lesions each. Discussion/conclusion:Assessment of physical violence on asylum seekers requires the cooperation of professionals with different skillsets and training

Long-term outcomes and predictive ability of non-invasive scoring systems in patients with non-alcoholic fatty liver disease

[Background & Aims] Non-invasive scoring systems (NSS) are used to identify patients with non-alcoholic fatty liver disease (NAFLD) who are at risk of advanced fibrosis, but their reliability in predicting long-term outcomes for hepatic/extrahepatic complications or death and their concordance in cross-sectional and longitudinal risk stratification remain uncertain.[Methods] The most common NSS (NFS, FIB-4, BARD, APRI) and the Hepamet fibrosis score (HFS) were assessed in 1,173 European patients with NAFLD from tertiary centres. Performance for fibrosis risk stratification and for the prediction of long-term hepatic/extrahepatic events, hepatocarcinoma (HCC) and overall mortality were evaluated in terms of AUC and Harrell’s c-index. For longitudinal data, NSS-based Cox proportional hazard models were trained on the whole cohort with repeated 5-fold cross-validation, sampling for testing from the 607 patients with all NSS available.[Results] Cross-sectional analysis revealed HFS as the best performer for the identification of significant (F0-1 vs. F2-4, AUC = 0.758) and advanced (F0-2 vs. F3-4, AUC = 0.805) fibrosis, while NFS and FIB-4 showed the best performance for detecting histological cirrhosis (range AUCs 0.85-0.88). Considering longitudinal data (follow-up between 62 and 110 months), NFS and FIB-4 were the best at predicting liver-related events (c-indices>0.7), NFS for HCC (c-index = 0.9 on average), and FIB-4 and HFS for overall mortality (c-indices >0.8). All NSS showed limited performance (c-indices <0.7) for extrahepatic events.[Conclusions] Overall, NFS, HFS and FIB-4 outperformed APRI and BARD for both cross-sectional identification of fibrosis and prediction of long-term outcomes, confirming that they are useful tools for the clinical management of patients with NAFLD at increased risk of fibrosis and liver-related complications or death.[Lay summary] Non-invasive scoring systems are increasingly being used in patients with non-alcoholic fatty liver disease to identify those at risk of advanced fibrosis and hence clinical complications. Herein, we compared various non-invasive scoring systems and identified those that were best at identifying risk, as well as those that were best for the prediction of long-term outcomes, such as liver-related events, liver cancer and death.This study has been supported by the EPoS (Elucidating Pathways of Steatohepatitis) consortium funded by the Horizon 2020 Framework Program of the European Union under Grant Agreement 634413 and the Newcastle NIHR Biomedical Research Centre. The authors are contributing members of The European NAFLD Registry. The study was also supported by the Italian Ministry of Health, grant RF-2016-02364358 (Ricerca Finalizzata, Ministero della Salute), and the Italian Ministry for Education, University and Research (Ministero dell’Istruzione, dell’Università e della Ricerca - MIUR) under the programme “Dipartimenti di Eccellenza 2018 – 2022” Project code D15D18000410001.Peer reviewe

Effect of aliskiren on post-discharge outcomes among diabetic and non-diabetic patients hospitalized for heart failure: insights from the ASTRONAUT trial

Aims The objective of the Aliskiren Trial on Acute Heart Failure Outcomes (ASTRONAUT) was to determine whether aliskiren, a direct renin inhibitor, would improve post-discharge outcomes in patients with hospitalization for heart failure (HHF) with reduced ejection fraction. Pre-specified subgroup analyses suggested potential heterogeneity in post-discharge outcomes with aliskiren in patients with and without baseline diabetes mellitus (DM). Methods and results ASTRONAUT included 953 patients without DM (aliskiren 489; placebo 464) and 662 patients with DM (aliskiren 319; placebo 343) (as reported by study investigators). Study endpoints included the first occurrence of cardiovascular death or HHF within 6 and 12 months, all-cause death within 6 and 12 months, and change from baseline in N-terminal pro-B-type natriuretic peptide (NT-proBNP) at 1, 6, and 12 months. Data regarding risk of hyperkalaemia, renal impairment, and hypotension, and changes in additional serum biomarkers were collected. The effect of aliskiren on cardiovascular death or HHF within 6 months (primary endpoint) did not significantly differ by baseline DM status (P = 0.08 for interaction), but reached statistical significance at 12 months (non-DM: HR: 0.80, 95% CI: 0.64-0.99; DM: HR: 1.16, 95% CI: 0.91-1.47; P = 0.03 for interaction). Risk of 12-month all-cause death with aliskiren significantly differed by the presence of baseline DM (non-DM: HR: 0.69, 95% CI: 0.50-0.94; DM: HR: 1.64, 95% CI: 1.15-2.33; P < 0.01 for interaction). Among non-diabetics, aliskiren significantly reduced NT-proBNP through 6 months and plasma troponin I and aldosterone through 12 months, as compared to placebo. Among diabetic patients, aliskiren reduced plasma troponin I and aldosterone relative to placebo through 1 month only. There was a trend towards differing risk of post-baseline potassium ≥6 mmol/L with aliskiren by underlying DM status (non-DM: HR: 1.17, 95% CI: 0.71-1.93; DM: HR: 2.39, 95% CI: 1.30-4.42; P = 0.07 for interaction). Conclusion This pre-specified subgroup analysis from the ASTRONAUT trial generates the hypothesis that the addition of aliskiren to standard HHF therapy in non-diabetic patients is generally well-tolerated and improves post-discharge outcomes and biomarker profiles. In contrast, diabetic patients receiving aliskiren appear to have worse post-discharge outcomes. Future prospective investigations are needed to confirm potential benefits of renin inhibition in a large cohort of HHF patients without D