What to Do, and What Not to Do, When Diagnosing and Treating Breakthrough Cancer Pain (BTcP): Expert Opinion.

Clinical management of breakthrough cancer pain (BTcP) is still not satisfactory despite the availability of effective pharmacological agents. This is in part linked to the lack of clarity regarding certain essential aspects of BTcP, including terminology, definition, epidemiology and assessment. Other barriers to effective management include a widespread prejudice among doctors and patients concerning the use of opioids, and inadequate assessment of pain severity, resulting in the prescription of ineffective drugs or doses. This review presents an overview of the appropriate and inappropriate actions to take in the diagnosis and treatment of BTcP, as determined by a panel of experts in the field. The ultimate aim is to provide a practical contribution to the unresolved issues in the management of BTcP. Five 'things to do' and five 'things not to do' in the diagnosis and treatment of BTcP are proposed, and evidence supporting said recommendations are described. It is the duty of all healthcare workers involved in managing cancer patients to be mindful of the possibility of BTcP occurrence and not to underestimate its severity. It is vital that all the necessary steps are carried out to establish an accurate and timely diagnosis, principally by establishing effective communication with the patient, the main information source. It is crucial that BTcP is treated with an effective pharmacological regimen and drug(s), dose and administration route prescribed are designed to suit the particular type of pain and importantly the individual needs of the patient.

Polyp of the cecum. Laparoscopic-assisted polypectomy.

The Authors discuss on a laparoscopic-assisted approach for excision of a sessile villous adenomatous polyp of the cecum, unresectable by endoscopy. Because of the large implant of the polyp, endoscopic polypectomy was considered at high risk and a surgical laparoscopic procedure was scheduled for removal of the lesion. After right colon mobilization, an intraoperative endoscopy confirmed the location of th polyp in the posterior wall of the cecum, closed to the ileo-cecal valve. A small 10 cm laparotomy, through which the cecum was pulled out the abdominal cavity, was performed. Then, a minimal colotomy along the intestinal taenia was carried out to allow a safe and complete excision of the polyp. This laparoscopic approach differs from the other laparoscopic-assisted methods reported in the Literature since it provides at the same time the postoperative advantages associated with minimal access surgery and a safe oncological removal of the polyp with low risks of complications.

Laparoscopic treatment of mucinous adenocarcinoma of jejunum associated with celiac disease. Case report.

Mucinous adenocarcinoma of the small bowel is very rare, and only few cases have been described in the literature. Association of this tumor with celiac disease has never been published. The authors report a unique case of jejunal mucinous adenocarcinoma in which a concomitant celiac disease has been histologically recognized. The difficult diagnosis, the role of laparoscopic surgery and the relationship between small bowel tumors and celiac disease are discussed. A 49-year-old man presented with recurrent melena, nausea, vomiting and anemia. A stenosis of the jejunum was documented by means of CT scan and video capsule enteroscopy. A laparoscopy was scheduled. A tumor, found in the first jejunal loop, was removed by laparoscopic surgery. Histopathology revealed a rare mucinous adenocarcinoma associated with epithelial changes secondary to celiac disease. Although small bowel tumors are rare entity, in patients with celiac disease complaining of symptoms related to altered intestinal transit or occult bleeding, an appropriate work-up should be planned for diagnosis. Mucinous type intestinal adenocarcinoma, even if never published before, could be observed. Laparoscopic surgery is often essential for the diagnosis and treatment.

[Venous thromboembolism prophylaxis after general surgery: where are we now?]. / Profilassi antitrombotica nel paziente chirurgico: a che punto siamo?

Venous thromboembolism (VTE) is a frequent complication in patients undergoing major surgery, with the possibility of long-term disability or fatal outcome. The rationale of the thromboprophylaxis in all patients can be summarized in three points: 1) the VTE is common in some types of surgery; 2) the VTE can be fatal; 3) thromboprophylaxis is highly effective and safe and, besides these clinical benefits, leads to lower total costs of treatment without further diagnostic and a new shelter for treating venous thrombosis. The surgical patients may present at admission one or more risk factors for VTE, The effect of this risk is cumulative, it is important to stratify the risk and to established an adequate prophylactic strategy. Today there is a unanimous consensus that the low molecular weight heparins are both effective and safe in preventing VTE in surgical patients. Unanimously approved guidelines can help surgeons in making decisions regarding VTE prophylaxis.

Laparoscopic left colectomy: from the perfect knowledge of surgical anatomy to the proper surgical technique.

Laparoscopic colo-rectal surgery has been increasingly accepted and performed in several surgical centres. However, there are still concerns about the intra-operative risks and therefore on the safety of the procedure especially during the learning curve. As a matter of fact, in approximately one third of laparoscopic colo-rectal procedures, an intra-operative complication, mainly bleeding or iatrogenic injuries, may occur. In this paper, according to our experience, we analyse step by step the surgical technique of the laparoscopic left colectomy and evaluate the technical difficulties and complications in order to avoid them.

Kinetics of hepatitis B virus load and haemodialysis: a prospective study.

The control of the spread of hepatitis B virus (HBV) infection within dialysis units has been an important goal in the management of patients on regular dialysis but infected patients continue to enter the dialysis system. It is evident that HBV viraemia in hepatitis B surface antigen (HBsAg)-positive patients on dialysis is low but it remains unclear whether haemodialysis per se can contribute to viral load reduction in such patients. HBV DNA was determined in 40 HBsAg-positive patients on maintenance haemodialysis immediately before and at the end of a 4-h haemodialysis session. The same measurements were repeated 48 and 72 h later. Twenty (50%) of 40 HBsAg-positive patients had detectable HBV DNA in serum. Detectable HBV DNA in serum was not predicted by demographic, clinical or biochemical parameters. HBV load decreased in the majority of patients after haemodialysis, although the difference was not significant (29 390 +/- 48 820 vs 23 862.8 +/- 4 350 copies/mL, NS). There was a strong relationship between mean HBV DNA levels before dialysis and absolute reduction of HBV DNA during haemodialysis sessions (r = 0.75, P = 0.0001). No difference occurred in the magnitude of change in HBV DNA titre when comparing cellulosic to synthetic membranes. Haemodialysis per se leads to a reduction in HBV load in HBsAg-chronic carriers on maintenance dialysis. This phenomenon could explain the low viral loads in these patients. Prospective studies are in progress to identify the mechanisms responsible for reduction in HBV load during haemodialysis.

[Laparoscopic treatment of adrenal myelolipoma: case report and review of the literature]. / Trattamento laparoscopico del mielolipoma surrenalico: caso clinico e revisione della letteratura.

Adrenal myelolipoma is a rare benign, non-functioning tumor consisting of fat and hematopoietic tissues. In January 2005 we had observed an adrenal myelolipoma in 70 year old man. During the follow-up for bladder urothelioma, an abdominal CT revaled a well delineated 4x4 cm homogeneous fatty mass in the right suprarenal area with negative attenuation values. The functional study of adrenal gland was normal. The patient underwent videolaparoscopic right adrenalectomy (Gagner technique). Postoperative course was uneventful. The istological diagnosis showed adrenal myelolipoma. We conclude that videolaparoscopic adrenalectomy should be considered the gold standard treatment for benign adrenal lesions.

[Laparoscopic treatment of liver hydatid cyst: personal technique]. / Il trattamento chirurgico laparoscopico delle cisti idatidee epatiche: tecnica personale.

Treatment of liver hydatid cyst is still controversial. Besides medical treatment, interventional radiologic techniques and traditional surgery, recently the laparoscopic approach has been proposed. Laparoscopic treatment of liver hydatid cyst, however, has not been well defined so far and seems to be associated with a recurrence rate from 0 to 9%, in a 3-49 months follow-up. Disadvantages of the laparoscopic approach are difficult control of spillage, peritoneal dissemination of parasites and incomplete aspiration of high density fluid contents of the cyst. The authors have reviewed the literature and describe a personal technique to avoid this disadvantage and to reduce postoperative recurrence rate.

Influence of hepatitis B virus virema upon serum aminotransferase activity in dialysis population.

BACKGROUND: The control of the spread of hepatitis B virus (HBV) infection within dialysis units has been one of the major advances in the management of patients with end-stage renal disease (ESRD). However, clinical and biochemical expression of HBV in dialysis patients have not been adequately addressed. Elevated values of serum aminotransferase activity are a sensitive measure of hepatocellular injury, but the role of HBV infection in the development of liver disease among dialysis patients has not been adequately analysed. Also, the clinical impact related to the virological characteristics of HBV in dialysis has not been evaluated. METHODS: Demographic, biochemical and virological data from 727 patients undergoing chronic dialysis in seven dialysis units in northern Italy were collected in order to assess the biochemical consequences related to the presence of HBV infection in this population. We have measured by RT-PCR technology the titers of HBV viremia in HBsAg positive patients receiving dialysis. RESULTS: Univariate analysis showed that AST and ALT values were significantly higher in HBsAg positive/HBV DNA positive than HBsAg negative patients on dialysis; AST, 22.86+/-31.34 vs. 14.19+/-9.7 IU/L (P=0.00001); and ALT, 25.07+/-41.59 vs. 13.9+/-41.59 IU/L (P=0.00001). In the subgroup of HBsAg positive patients, the frequency of detectable HBeAg in serum was 14.9% (7/47). The median value of HBV DNA in patients with detectable HBV DNA in serum was 2.160 x 10(3) copies/mL (range, 2.5 x 10(2)-4 x 10(6) copies/mL). HBsAg positive/HCV positive patients had higher aminotransferase activity than other subgroups (P=0.0001). Multivariate analysis showed a significant and independent association between detectable HBsAg/HBV DNA in serum and AST (P=0.00001) and ALT (P=0.0001) activity AST and ALT levels were lower in dialysis than healthy individuals--this finding persisted in age- and gender-matched comparisons. CONCLUSIONS: The HBV viral load in HBsAg positive patients receiving maintenance dialysis is not high. HBsAg positivity with detectable HBV DNA in serum is a strong and independent predictor of raised aminotransferase activity among dialysis patients. HBsAg positive patients had greater aminotransferase activity than HBsAg negative individuals even if both the groups had mean aminotransferase levels within the normal range considered for healthy population. Clinical trials aimed at identifying the best cut-off value to enhance the diagnostic yield of AST/ALT for detecting HBV in dialysis population are under way.

[Hepatopathy and hepatitis B virus infection in dialysis patients: cross-sectional study]. / Epatopatia e infezione da virus dell'epatite B nei pazienti in dialisi: studio trasversale.

BACKGROUND: Control of spread of HBV infection in dialysis units in developed countries has been one of the major advances in managing end-stage renal disease (ESRD). Patients with chronic HBV, however, continue to enter the population pool of dialysis patients and transplant candidates. The clinical significance related to the presence of HBsAg in serum of dialysis patients has not been completely understood. AIM AND METHODS: We collected demographic, biochemical and virological data from a large (n=464) population of patients on maintenance dialysis. This was done to assess the influence of virological and host factors on hepatocellular damage, as shown by serum aminotransferase activity. RESULTS: The frequency of HBsAg positivity in our dialysis population was 8.2 % (38/464); the rate of HBsAg positive patients showing HBe antigen was 20.6% (7/34). Twenty-two (84.6%) of 26 HBsAg positive patients showed detectable HBV DNA in serum by Amplicor HBV MonitorTM Test. HBsAg positive patients had serum aminotransferase activity significantly higher than HBsAg negative individuals; GOT (AST) 25.1+/-29.9 vs. 16+/-21.5 UI/L (p=0.001), and GPT (ALT) 31.3+/-52.5 vs. 17.7+/-21.9 UIL (p=0.034). In the subset of HBsAg positive dialysis patients, those in the replicative phase HBeAg positive) had aminotransferase activity higher than HBeAg negative individuals, AST, 42.3+/-43.6 vs. 22.4+/-27.3 UI/L (p=0.097) and ALT, 49.41+/-54.7 vs. 29.17+/-55.76 UI/L (NS) respectively. We did a multivariate analysis by standard least square model on the entire patient group and we found independent and significant association between detectable HBsAg in serum and AST (p=0.0089)and ALT (p=0.0159) values. There was an independent and significant relationship between age and ALT (p=0.01). CONCLUSIONS: In our study group, HBsAg positive patients on dialysis had serum aminotransferase activity significantly higher than that measured in HBsAg negative individuals. However, mean transaminase levels in HBsAg positive patients on dialysis were below the upper limit of normal for the reference range of healthy controls. HBsAg positive dialysis patients with active viral replication showed the greatest liver damage. Studies are in progress to understand further HBV-related liver disease in dialysis population.

[HRT in post-menopausal women: endometrial histology and bleeding patterns]. / HRT sequenziale continua della donna in post-menopausa: istologia endometriale e modalità di sanguinamento.

BACKGROUND: In this open prospective study the correlation between bleeding patterns and endometrial histology has been evaluated in 101 postmenopausal women after 2 years of continuous sequential hormone replacement therapy (HRT). METHODS: All patients received continuous transdermal 17-b-estradiol supplementation, 0.05 mg/daily, with cyclic progestogen for 12 days every month. The progestogen was: dydrogesterone 10 mg/daily (56 cases); nomegestrol 5 mg/daily (15 cases); MAP 10 mg/daily (15 cases); norethisterone 0.25 mg/daily (15 cases). The changes in the characteristics of bleeding pattern and endometrial biopsy were performed in 90 of 101 patients, at the 10-12th of progestogen therapy. RESULTS: The endometrial pattern was secretory in 60 cases, proliferative in 5 and atrophic in 22. In 3 cases the endometrial histology showed a simple hyperplasia. The bleeding generally starts 2 days after the end of progestogen therapy (13th +/- 2.9 day), with a mean duration of 4 days (4 +/- 2.8); in 21 patients (~20%) the bleeding is reduced. The endometrial histological characteristics haven't any influence on the bleeding pattern. CONCLUSIONS: In this study there was a low incidence of simple hyperplasia (3%), but the characteristics of bleeding don't permit to suspect this hyperplasia.

[Postoperative pain in laparoscopic surgery]. / Il dolore post-operatorio in chirurgia laparoscopica.

The occurrence of post-operative pain, although less severe and frequent than in open surgery, may affect length of hospital stay and early return to normal activity in some patients operated on with laparoscopic surgery. Although several pathogenetic factors have been indicated in the literature, the mechanism responsible for post-operative pain after laparoscopy; still remains unclear. In this study the Authors evaluated post-operative pain in 90 patients submitted to laparoscopic cholecystectomy and correlated it to the length of operation, endoabdominal CO2 pressure maintained during surgery, and use of local anesthesia instilled din the liver bed and in the sites of introduction of trocars. Measuring post-operative pain by means of a modified Scott-Huskisson Visual Analogue Scale, no difference in the severity of the pain was noted in the two subgroups of patients with a length of operation inferior or superior to 60 minutes, respectively. Conversely, a statistical significant difference (p = 0.04 and p = 0.049 according to Fisher exact test and Pearson test, respectively) was observed evaluating the use of local anesthesia and the level of CO2 endoabdominal pressure, with less pain in patients whose pressure was maintained under 10 mmHg and in patients treated with instillation of local anesthetic drugs in the liver bed and in the sites of introduction of trocars.

[Development of anesthesiological techniques in the surgical treatment of inguinal hernia]. / Evoluzione del trattamento anestesiologico nella terapia chirurgica dell'ernia inguinale.

The Authors describe the evolution of their anesthesiological techniques in the surgical repair of inguinal hernia. In this study they compare indications, complications, costs, hospital stay, length of surgery, postoperative pain and return to work after operations performed under local, spinal and general anesthesia. In their experience inguinal hernia treatment with local anesthesia and a tension-free technique is the preferred method of surgical repair.

[Stenotic endometriosis of the sigmoid. Apropos a case]. / L'endometriosi stenosante del sigma. A proposito di un caso.

The authors report a rare case of stenotic sigmoid endometriosis which presented with constipation and dysmenorrhea in a 48-year-old woman without past gynecological history. There were no typical radiological and endoscopic findings and only pathological examination revealed endometriosis. The patient did well after sigmoid resection and bilateral salpingo-oophorectomy and has had no further complaints. The authors stress the rare location of the disease and review the literature about etiopathogenetic hypotheses and pathological features. The diagnostic value of clinical examination, barium enema and colonoscopy is low as endometriosis rarely involves the mucosa. This case led the authors to discuss about diagnostic difficulties, differential diagnosis and therapeutic options.

[Clinical-diagnostic and therapeutic considerations in a rare case of mesenteric cyst]. / Considerazioni clinico-diagnostiche e terapeutiche su un raro caso di cisti mesenterica.

The authors report a rare case of mesenteric cyst in a 36 years old woman. These cysts have a pathogenesis that primarily may be ectopic lymphatic tissue and their most common site is in the small bowel mesentery, especially of the ileum. In the case reported the cyst was located in the right mesocolon. Mesenteric cysts can appear as chronic abdominal pain, a painless abdominal mass, or acute abdomen. Diagnostic aids include abdominal computed tomography and sonography, that usually make diagnosis of mesenteric cyst. Treatment of choice is enucleation; resection of the adjacent bowel may occasionally be necessary.

[Local anesthesia in the treatment of inguinal hernia]. / L'anestesia locale nel trattamento dell'ernia inguinale.

Local anesthesia is the most common technique used in the surgical treatment of inguinal hernia. The introduction of synthetic prosthesis, which are resistant to infection, has to the development of surgical techniques used in local anesthesia, in a day hospital setting. These techniques permit a lowering of hospital costs and a reduction of the incidence of complications and recurrences. Over the last few years the authors have been performing a modified Lichtenstein repair or the Rives technique in local anesthesia. In this study they present their data on 52 patients surgically treated in the period 1997-1998, and discuss the advantages of their technique.

Efficacy and acceptability of transdermal estradiol in the treatment of postmenopausal bone loss.

In order to assess the effects and acceptability of transdermal estradiol on the prevention of the loss of bone mass, the Authors administered transdermal estradiol (ETTS 50 mcgr/day) for 3 weeks and, cyclically, medroxyprogesterone 10/mg/day from day 10 to day 21 of each cycle for 12 months, to 20 operated patients for bilateral ovariectomy. Primary markers of the bone turnover (hydroxyproline urinary, osteocalcin, PTH) were estimated before therapy and after 3, 6, 9, 12 months. The BMD was evaluated before therapy and after 6 and 12 months. Our study clearly shows that the transdermal administration of estradiol prevents the postmenopausal bone loss, also in postmenopausal women at higher risk of developing osteoporosis as those evaluated in our study.

Modifications of the bone turnover in operated patients of bilateral ovariectomy.

The most important factor responsible for osteoporosis postmenopausal is the loss of the oestrogen. For this reason we have estimated the modifications of the bone turnover in the operated patients for bilateral ovariectomy in fertile age by study of the BMD (bone mineral density) and of the various biohumoral parameters that are involved in the process of bone remodelling urinary hydroxyproline, osteocalcin). Our research consists of two phases. I phase: we have conducted a transverse study on a group of 43 patients subdivided in 3 subgroups on the basis of the years elapsed since they were operated. II phase: it is a longitudinal study. We have observed 6 women. We have estimated the turnover before the operation (T0) at (T1), at 30 (T2), at 90 (T3) and at 180 (T4) days from the operation. The results show that the sudden and rapid decrease of the oestrogenic rate determines a sudden increase of the bone turnover. The activity of the osteoblastic line is faster, the activity of osteoblastic line is slower. The beginning of the loss of the bone mass is about the 7% already at six months (longitudinal study), the loss of bone mass reaches the maximum within the first 2-3 years (about 16%) from the operation (transverse study).