Surrenectomia bilaterale sincrona: quale è l'approccio migliore?

Lo scopo di questo studio è stato quello di comparare prospetticamente i risultati di due approcci, laparoscopico con paziente in flank position e retroperitoneale, alla surrenectomia bilaterale sincrona prendendo in considerazione i tempi operatori, le complicanze intra e post-operatorie, i tempi di recupero post-operatorio e la durata della degenza ospedaliera. Lo studio ha coinvolto due centri, il Dipartimento di Chirurgia dell'Università di Pisa, U.O. di Endocrinochirurgia per l'approccio laparoscopico in flank position, e il Dipartimento di Chirurgia dell'Università di Halle in Germania per l'approccio retroperitoneale. Tra il 1994 ed il 2008 34 pazienti consecutivi su un totale di 638 operati per patologia surrenalica nello stesso periodo sono stati sottoposti a surrenectomia bilaterale sincrona nei due centri di riferimento terziario per la chirurgia endocrina e mini-invasiva coinvolti nello studio. 20 pazienti sono stati sottoposti a surrenectomia bilaterale laparoscopica transperitoneale a Pisa (Gruppo A) e 14 pazienti a surrenectomia bilaterale retroperitoneale ad Halle (Gruppo B). Nel gruppo A le indicazioni all'intervento erano: Sindrome di Cushing in 4 casi e Morbo di Cushing in 9 casi. 3 pazienti presentavano una Sindrome di Cushing da secrezione di ACTH ectopica e 4 pazienti erano affetti da feocromocitoma bilaterale. Nel gruppo B le indicazioni all'intervento erano: Morbo di Cushing in 3 pazienti, Sindrome di Cushing in un paziente, feocromocitoma in 7 pazienti di cui 6 affetti da MEN 2, Sindrome di Conn in un paziente, iperplasia surrenalica congenita in un paziente e produzione di ACTH ectopico in un paziente Il gruppo A era costituito da 7 maschi e 13 femmine, il gruppo B da 6 maschi e 8 femmine. L'età media del gruppo A era 48,1 anni, quella del gruppo B 38,9 anni (p=0.06). Il BMI non era statisticamente differente tra i due gruppi (29,4 nel gruppo A contro 26,3 nel gruppo B p=0,08). Il diametro medio delle masse surrenaliche asportate era significativamente maggiore nel gruppo A rispetto al gruppo B (lato destro: 61,1mm contro 42,8mm con p=0,002; lato sinistro 64,1mm contro 37,4mm con p=0,003). Non sono state evidenziate differenze statisticamente significative tra i due gruppi in termini di tempi operatori globali, comprendendo quindi anche i tempi di intubazione, estubazione e cambiamento di posizione del paziente per l'approccio transperitoneale, e di tempi operatori propriamente detti, ossia dall'incisione alla sutura della cute. Non sono state registrate complicanze post-operatorie di rilievo nei due gruppi. In conclusione non è possibile determinare quale tra questi due approcci, transperitoneale e retroperitoneale, sia il migliore per la surrenectomia bilaterale sincrona. Entrambi si sono dimostrati fattibili, sicuri ed efficaci nel trattamento delle masse surrenaliche con un outcome per il paziente pressochè identico. Per questo motivo la scelta tra le due tecniche spetta al chirurgo, sulla base delle sue capacità e preferenze e delle caratteristiche del paziente. Ovviamente la cosa migliore e più auspicabile sarebbe che ci fosse la possibilità in ogni centro di poter eseguire entrambi gli approcci sulla base delle caratteristiche della patologia e del paziente, laparoscopica transperitoneale per masse superiori ai 60mm o in caso di concomitante patologia addominale, retroperitoneale per pazienti già sottoposti ad interventi addominali, con obesità di grado severo o con masse molto piccole così da ridurre al minimo l'invasività della procedura

On the importance of anandamide structural features for its interactions with DPPC bilayers: effects on PLA2 activity

The acylethanolamide anandamide (AEA) occurs in a variety of mammalian tissues and, as a result of its action on cannabinoid receptors, exhibits several cannabimimetic activities. Moreover, some of its effects are mediated through interaction with an ion channel-type vanilloid receptor. However, the chemical features of AEA suggest that some of its biological effects could be related to physical interactions with the lipidic part of the membrane. The present work studies the effect of AEA-induced structural modifications of the dipalmitoylphosphatidylcholine (DPPC) bilayer on phospholipase A2 (PLA2) activity, which is strictly dependent on lipid bilayer features. This study, performed by 2-dimethylamino-(6-lauroyl)-naphthalene fluorescence, demonstrates that the effect of AEA on PLA2 activity is concentration-dependent. In fact, at low AEA/DPPC molar ratios (from R = 0.001 to R = 0.04), there is an increase of the enzymatic activity, which is completely inhibited for R = 0.1. X-ray diffraction data indicate that the AEA affects DPPC membrane structural properties in a concentration-dependent manner. Because the biphasic effect of increasing AEA concentrations on PLA2 activity is related to the induced modifications of membrane bilayer structural properties, we suggest that AEA-phospholipid interactions may be important to produce, at least in part, some of the similarly biphasic responses of some physiological activities to increasing concentrations of AEA

Minimally invasive video-assisted thyroidectomy (MIVAT)

Minimally invasive video-assisted thyroidectomy (MIVAT) was first described in 1999 and it has become a widespread technique performed worldwide. Although initially limited to benign thyroid nodules, MIVAT was progressively adopted for all types of thyroid diseases, while remaining within the selection criteria. It is reported that, in selected cases, MIVAT is comparable to standard open thyroidectomy (SOT) in terms of oncologic radicality, time, costs and complications rate, with the advantage of a better cosmetic result and a lower post-operative pain

Firm mass in thyroid of an elderly patient: not always cancer

Summary In elderly patients presenting with a solid thyroid mass, the differential diagnosis between benign and malignant lesion is not always straightforward. We present the case of an 85-year-old woman with fever and an enlarged, firm and painful thyroid mass. Blood exams documented a mild thyrotoxicosis with a moderate inflammatory status. Thyroid scintiscan showed an absent uptake of 131I. Ultrasound and CT scan documented a 3 cm hypoechoic nodule with infiltration of the sternocleidomastoid muscle, very suspicious for neoplastic nature. Fine-needle aspiration and tru-cut biopsy were performed. During biopsy, the lesion was partially drained and a brownish fluid was extracted. The culture resulted positive for Klebsiella pneumoniae whereas the pathological analysis of the specimen was not conclusive due to the presence of an intense inflammatory response. A targeted oral antibiotic therapy was then initiated, obtaining only a partial response thus, in order to achieve a definite diagnosis, a minimally invasive hemithyroidectomy was performed. The pathological analysis documented acute suppurative thyroiditis and the clinical conditions of the patient significantly improved after surgical removal of thyroid abscess. In elderly patients with a solid thyroid mass, although neoplastic origin is quite frequent, acute suppurative thyroiditis should be considered as a differential diagnosis. Learning points: A solid and rapidly growing thyroid mass in elderly patients can hide a multifaceted variety of diseases, both benign and malign. A multidisciplinary team (endocrinologist, surgeon, radiologist and pathologist) could be necessary in order to perform a correct differential diagnosis and therapeutic approach. Surgery can be decisive not only to clarify a clinically uncertain diagnosis, but also to rapidly improve the clinical conditions of the patient

MUNDUS project : MUltimodal neuroprosthesis for daily upper limb support

Background: MUNDUS is an assistive framework for recovering direct interaction capability of severely motor impaired people based on arm reaching and hand functions. It aims at achieving personalization, modularity and maximization of the user’s direct involvement in assistive systems. To this, MUNDUS exploits any residual control of the end-user and can be adapted to the level of severity or to the progression of the disease allowing the user to voluntarily interact with the environment. MUNDUS target pathologies are high-level spinal cord injury (SCI) and neurodegenerative and genetic neuromuscular diseases, such as amyotrophic lateral sclerosis, Friedreich ataxia, and multiple sclerosis (MS). The system can be alternatively driven by residual voluntary muscular activation, head/eye motion, and brain signals. MUNDUS modularly combines an antigravity lightweight and non-cumbersome exoskeleton, closed-loop controlled Neuromuscular Electrical Stimulation for arm and hand motion, and potentially a motorized hand orthosis, for grasping interactive objects. Methods: The definition of the requirements and of the interaction tasks were designed by a focus group with experts and a questionnaire with 36 potential end-users. Five end-users (3 SCI and 2 MS) tested the system in the configuration suitable to their specific level of impairment. They performed two exemplary tasks: reaching different points in the working volume and drinking. Three experts evaluated over a 3-level score (from 0, unsuccessful, to 2, completely functional) the execution of each assisted sub-action. Results: The functionality of all modules has been successfully demonstrated. User’s intention was detected with a 100% success. Averaging all subjects and tasks, the minimum evaluation score obtained was 1.13 ± 0.99 for the release of the handle during the drinking task, whilst all the other sub-actions achieved a mean value above 1.6. All users, but one, subjectively perceived the usefulness of the assistance and could easily control the system. Donning time ranged from 6 to 65 minutes, scaled on the configuration complexity. Conclusions: The MUNDUS platform provides functional assistance to daily life activities; the modules integration depends on the user’s need, the functionality of the system have been demonstrated for all the possible configurations, and preliminary assessment of usability and acceptance is promising

Apoptosis Induced by Piroxicam plus Cisplatin Combined Treatment Is Triggered by p21 in Mesothelioma

BACKGROUND: Malignant mesothelioma (MM) is a rare, highly aggressive tumor, associated to asbestos exposure. To date no chemotherapy regimen for MM has proven to be definitively curative, and new therapies for MM treatment need to be developed. We have previously shown in vivo that piroxicam/cisplatin combined treatment in MM, specifically acts on cell cycle regulation triggering apoptosis, with survival increase. METHODOLOGY/PRINCIPAL FINDINGS: We analyzed, at molecular level, the apoptotic increase caused by piroxicam/cisplatin treatment in MM cell lines. By means of genome wide analyses, we analyzed transcriptional gene deregulation both after the single piroxicam or cisplatin and the combined treatment. Here we show that apoptotic increase following combined treatment is mediated by p21, since apoptotic increase in piroxicam/cisplatin combined treatment is abolished upon p21 silencing. CONCLUSIONS/SIGNIFICANCE: Piroxicam/cisplatin combined treatment determines an apoptosis increase in MM cells, which is dependent on the p21 expression. The results provided suggest that piroxicam/cisplatin combination might be tested in clinical settings in tumor specimens that express p21

Non stationary model of the heartbeat time series in atrial fibrillation

V. Capasso Edito

Video-assisted thyroidectomy: indications and results

Background and aims: Minimally invasive video-assisted thyroidectomy (MIVAT) was set up and introduced in our department in 1998. Its results, after an acceptable relapse, can now be evaluated, also speculating on new possible indications. Patients and methods: The procedure is based on a unique incision in the central neck, 2 cm above the sternal notch, using small conventional retractors and needlescopic (2 mm) reusable instruments. Haemostasis is achieved by a harmonic scalpel. Patients, 833, underwent MIVAT since June 1998. There were 715 females and 118 males (ratio 4:1). Lobectomy was carried out in 323 (38.7%) patients, total thyroidectomy in 510 (61.2%) patients. Results: Mean operative time of lobectomy was 36.2 min (range: 20-120); for total thyroidectomy, 46.1 min (30-130). Conversion to standard cervicotomy was required in 16 cases (1.9%); Operative complications were represented by transient monolateral recurrent nerve palsy in eight cases (0.9%), definitive monolateral recurrent nerve palsy in seven cases (0.8%). Twenty patients exhibited a hypoparathyroidism, which corresponds to 3.9% of total thyroidectomies performed, but only two showed permanent hypoparathyroidism (0.3%). Conclusion: MIVAT can be considered a safe operation offering significant cosmetic advantages with possible new promising indications such as prophylactic thyroidectomy in rearranged during transfection (RET) gene mutation carriers. It is still limited to a minority of patients, in particular, in endemic goitre countries. © Springer-Verlag 2006. Author keyword