Analisi dei fattori di rischio dell'ipoparatiroidismo transitorio e definitivo nei pazienti sottoposti a tiroidectomia

Obiettivi. Con questa revisione della letteratura ci proponiamo di valutare quali sono i fattori che possono essere valutati nei pazienti da sottoporre a tiroidectomia ai fini di una migliore gestione preoperatoria e post-operatoria dell\u2019ipoparatiroidismo transitorio e definitivo. Discussione. L\u2019ipoparatiroidismo transitorio \ue8 una complicanza potenzialmente grave che include una vasta gamma di segni e sintomi che permane solo per poche settimane dopo l\u2019intervento chirurgico. L\u2019ipoparatiroidismo definitivo si verifica quando \ue8 necessario un trattamento medico per un periodo maggiore di 12 mesi. I fattori di rischio che ne possono influenzare l\u2019insorgenza in seguito ad interventi di tiroidectomia sono molteplici: biochimici preoperatori e post opera- tori, il sesso femminile, la malattia di Graves e le malattie neoplastiche della tiroide, l\u2019abilit\ue0 del chirurgo e la tecnica chirurgica utilizzata. Il trattamento medico prevede la somministrazione di calcio, vitamina D e talvolta magnesio. Conclusioni: Anche se i fattori biologici e biochimici legati al paziente ricoprono una certa importanza nella correlazione con l\u2019ipoparatiroidismo, riteniamo che i fattori causali pi\uf9 importanti sono da correlare alle variabili intraoperatorie come l\u2019esperienza del chirurgo e la tecnica utilizzata che deve mirare alla visualizzazione e al rispetto in situ delle paratiroidi.Aims. This review evaluates those main risk factors that can affect patients undergoing thyroidectomy, to reach a better pre- and post-operative management of transient and permanent hypoparathyroidism. Discussion. The transient hypoparathyroidism is a potentially severe complication of thyroidectomy, including a wide range of signs and symptoms that persists for a few weeks. The definitive hypoparathyroidism occurs when a medical treatment is necessary over 12 months. Risk factors that may influence the onset of this condition after thyroidectomy include: pre- and post-operative biochemical factors, such as serum calcium levels, vitamin D blood concentrations and intact PTH. Other involved factors could be summarized as follow: female sex, Graves' or thyroid neoplastic diseases, surgeon's dexterity and surgical technique. The medical treatment includes the administration of calcium, vitamin D and magnesium sometimes. Conclusions. Although biological and biochemical factors could be related to iatrogenic hypoparathyroidism, the surgeon's experience and the used surgical technique still maintain a crucial role in the aetiology of this important complication

Colour doppler-guided haemorrhoidal artery ligation: A possible evolution of transanal haemorrhoidal dearterialisation

Introduction. Haemorrhoids are a very common disease, with a great economic burden. Many treatments have been developed for trying to solve the problem, being the standard not yet found. In 1995, Doppler-guided haemorrhoidal artery ligation was introduced, aiming to reduce postoperative pain and complications. In this work, an evolution of the aforementioned surgical technique was described. Materials and Methods.183 patients treated with standard Doppler-Guided Haemorrhoidal Artery Ligation were statistically compared with 225 patients dealt with Colour Doppler-Guided Haemorrhoidal Artery Ligation. The procedures were performed under local anaesthesia with patients in lithotomy position. A special proctoscope and a dedicated Colourdoppler US probe were employed in the second group. Superior haemorrhoidal artery terminal branches were consecutively ligated according to provided technique in the first group and under vision in the second. In all cases, each ligation was followed by mucopexy. Results. No significant differences between the two groups, in terms of post-operative pain, early complications (bleeding, urinary retention, incontinence) or patient satisfaction, were demonstrated. Recurrence rate was significantly higher in patients treated with standard DG-HAL. No late complications (after one-year follow-up) were registered in both groups. Conclusions. Colour Doppler-Guided Haemorrhoidal Artery Ligation represents an ideal management for 1-day surgery, and fulfils the requirements of minimally invasive surgery in patients with III-IV grade haemorrhoids. The absence of complications and the evidence of significant wellness of patients are the best advantages. Colour Doppler-Guided Haemorrhoidal Artery Ligation is a safe and easy procedure with good results and a very short-time training. It could be considered an easy and reliable method to treat symptomatic haemorrhoids

Intraoperative cholangiography during cholecystectomy using a biliary-nose tube: Routinely used in patients with main bile duct stones

Background: Nowadays, the \u201cgold standard\u201d treatment for gallbladder stones is laparoscopic cholecystectomy but the risk of iatrogenic biliary duct injuries is increased compared to \u201copen\u201d surgery. Intraoperative cholangiography (IOC) can be useful to avoid biliary injuries but it can also be a no-safe procedure in center in which it is not routinely performed. Aim and objective: The aim of our study is to trust the efficacy of IOC in a patient with common bile duct (CBD) and gallbladder stones using a biliary-nose tube. Materials and methods: 135 patients with gallbladder and CBD stones were treated with sequential therapy and randomly divided into two groups. Laparoscopic cholecystectomy was performed within 24/48 h. During endoscopic retrograde cholangiopancreatography, a biliary-nose catheter was left to perform cholangiography during the following surgical procedure. Group A had also a cholangiography at the beginning of the surgical procedure in order to evidence biliary duct structure. Results: Cholangiography avoided a lesion of the biliary ducts in nine patients. Only a patient had a residual stone in the CBD. The dissection at Calot\u2019s triangle was faster in group A patients without differences between the surgeons involved. Conclusion: The biliary-nose tube can be useful in patients with gallbladder and CBD who underwent cholecystectomy for different reasons: it lets the surgeon performing IOC faster and without risk linked to the technique used; it reduces the risk of biliary injuries; and surgeons feel more safe and calm during the surgical procedure

The Mediterranean diet could be an exceptional support for patients with chronic renal disease

Chronic renal disease (CKD) is a social problem affecting millions of patients characterized by loss of renal function and related to metabolic diseases. The approach from the dietary point of view to this problem could be a perfect strategy to slow down the progression of the disease and at the same time the problems of malnutrition typical of CKD. Several studies show that the Mediterranean diet (MD) may play a key role in the control of the early stages of the disease. Even if the MD showed to be the best diet for the control of metabolic diseases and for the general well-being, in the case of the patient with CKD, should be adapted in what is called the DASH diet, characterized by the typical roles of the MD but with a controlled intake of minerals and proteins

Clinical efficacy and management of monoclonal antibodies targeting CD38 and SLAMF7 in multiple myeloma

Immunotherapeutic strategies are emerging as promising therapeutic approaches in multiple myeloma (MM), with several monoclonal antibodies in advanced stages of clinical development. Of these agents, CD38-targeting antibodies have marked single agent activity in extensively pre-treated MM, and preliminary results from studies with relapsed/refractory patients have shown enhanced therapeutic efficacy when daratumumab and isatuximab are combined with other agents. Furthermore, although elotuzumab (anti-SLAMF7) has no single agent activity in advanced MM, randomized trials in relapsed/refractory MM have demonstrated significantly improved progression-free survival when elotuzumab is added to lenalidomide-dexamethasone or bortezomib-dexamethasone. Importantly, there has been no significant additive toxicity when these monoclonal antibodies are combined with other anti-MM agents, other than infusion-related reactions specific to the therapeutic antibody. Prevention and management of infusion reactions is important to avoid drug discontinuation, which may in turn lead to reduced efficacy of anti-MM therapy. Therapeutic antibodies interfere with several laboratory tests. First, interference of therapeutic antibodies with immunofixation and serum protein electrophoresis assays may lead to underestimation of complete response. Strategies to mitigate interference, based on shifting the therapeutic antibody band, are in development. Furthermore, daratumumab, and probably also other CD38-targeting antibodies, interfere with blood compatibility testing and thereby complicate the safe release of blood products. Neutralization of the therapeutic CD38 antibody or CD38 denaturation on reagent red blood cells mitigates daratumumab interference with transfusion laboratory serologic tests. Finally, therapeutic antibodies may complicate flow cytometric evaluation of normal and neoplastic plasma cells, since the therapeutic antibody can affect the availability of the epitope for binding of commercially available diagnostic antibodies

Treatment of relapsed and refractory multiple myeloma in the era of novel agents

The introduction of the Immunomodulatory drugs (IMiDs) and proteasome inhibitors, used either as a single-agent or combined with classic anti-myeloma therapies, has improved the outcome for patients with relapsed myeloma. However, there is currently no generally accepted standard treatment for relapsed/refractory myeloma patients, partly because of the absence of trials comparing the efficacy of the novel agents in relapsed/refractory myeloma. Choice of a new treatment regimen depends on both patient and disease-specific characteristics. A lenalidomide-based regimen is the first choice in patients with neuropathy, while bortezomib has the highest efficacy in patients with renal insufficiency and is not associated with increased risk of thromboembolism. A second autologous stem cell transplantation (auto-SCT) can be applied in patients with a progression-free period of >= 18-24 months after the first auto-SCT. In high-risk relapse such as occurring early after auto-SCT consolidation with allogeneic SCT can be considered. In this review we provide an overview of the various salvage regimens and give recommendations for treatment of patients with relapsed/refractory myeloma in different clinical settings. (C) 2010 Elsevier Ltd. All rights reserved

Treatment of multiple myeloma with high-risk cytogenetics: a consensus of the International Myeloma Working Group

The International Myeloma Working Group consensus updates the definition for high-risk (HR) multiple myeloma based on cytogenetics Several cytogenetic abnormalities such as t(4; 14), del(17/17p), t(14; 16), t(14; 20), nonhyperdiploidy, and gain(1q) were identified that confer poor prognosis. The prognosis of patients showing these abnormalities may vary with the choice of therapy. Treatment strategies have shown promise for HR cytogenetic diseases, such as proteasome inhibition in combination with lenalidomide/pomalidomide, double autologous stem cell transplant plus bortezomib, or combination of immunotherapy with lenalidomide or pomalidomide. Careful analysis of cytogenetic subgroups in trials comparing different treatments remains an important goal. Cross-trial comparisons may provide insight into the effect of new drugs in patients with cytogenetic abnormalities. However, to achieve this, consensus on definitions of analytical techniques, proportion of abnormal cells, and treatment regimens is needed. Based on data available today, bortezomib and carfilzomib treatment appear to improve complete response, progression-free survival, and overall survival in t(4; 14) and del(17/17p), whereas lenalidomide may be associated with improved progression-free survival in t(4; 14) and del(17/17p). Patients with multiple adverse cytogenetic abnormalities do not benefit from these agents. FISH data are implemented in the revised International Staging System for risk stratification