Contralateral risk reducing mastectomy in patients with sporadic breast cancer. Benefits and hazards.

During the last years an improving outcome of breast conserving surgery was observed along with the availability of diagnostic procedures allowing early diagnosis. Nevertheless, women with breast cancer are more frequently requesting a radical approach comprising contralateral mastectomy even if they do not have a demonstrated increased genetic risk. In this paper we reviewed the main reasons patients ask for aggressive preventive surgery, the perceived and the real risks of developing contralateral breast cancer, and the potential, if any, survival benefits along with the hazards associated to contralateral risk reducing mastectomy. A respectful management should be given to these women within a multi-disciplinary team. Psychological support is highly encouraged cope fears and uncertainties but treating physicians should provide patients with comprehensive and unbiased data to take the best decision for the single person. Physicians should also give clear information on the benefits of adjuvant therapies which are reducing the incidence of contralateral breast cancer and also of the possible influences of healthy lifestyle (weight control, physical activity, diet) as effective preventive methods.

Physical function of the upper limb after breast cancer surgery. Results from the SOUND (Sentinel node vs. Observation after axillary Ultra-souND) trial.

BACKGROUND: The SOUND (Sentinel node vs. Observation after axillary Ultra-souND) trial is an ongoing prospective randomized study comparing sentinel node biopsy vs. no axillary surgical staging in patients with small breast cancer and negative pre-operative ultra-sound of the axilla. PATIENTS AND METHODS: The first 180 recruited patients were administered the QuickDASH (Disability Arm and Shoulder) questionnaire at different time points (before surgery, 1 week, 6 months and 1 year after surgery) to evaluate the physical function of the ipsilateral upper limb, The QuickDASH score ranges from 0 (no disability) to 100 (complete disability). RESULTS: 176 patients were available for analysis (94 in SNB arm and 82 in observation arm). The two groups were comparable with respect to age, tumor characteristics and treatments. Pre-surgery score values were 3.0% and 2.7% in the SNB arm and observation arm, respectively (P = 0.730). One week after surgery, the score increased to 24.0% in the SNB arm and 10.6% in the observation arm (P < 0.001). After 6 and 12 months, the score decreased in both arms to values similar to baseline values. The overall trend in time of the score was significantly different between the two arms (P < 0.001), even after the exclusion of five patients who received AD in the SNB arm (P < 0.001). CONCLUSIONS: Patients who underwent SNB had a significantly higher rate of disability in the early post-operative period compared to patients who did not. The avoidance of SNB might translate into a considerable reduction of physical and emotional distress.

[High digoxin serum levels in an elderly patient for the endogenous digoxin-like immunoreactive substances. A case report]. / Elevati livelli di digossinemia in una paziente anziana per ifattori endogeni immunoreattivi digossino-simili. Caso clinico.

UNLABELLED: Digoxin is typically prescribed in the treatment of heart failure. Its limited therapeutic range requires systematic monitoring of plasmatic concentration through immunoreactive tests. Laboratory results, however, can be altered by the presence of digoxin-like immunoreactive factors (DLIF) which are released in all clinical conditions involving volemic expansion. CASE REPORT: An 86-year-old woman arrived in emergency with severe dyspnoea, atrial flutter and a medical history of ischemic cardiopathy. The patient was treated with ACE inhibitor, furosemide, spironolactone and digoxin. The first lab test for digoxin showed levels of digoxin of 7.05 ng/ml. Although the patient did not show any clinical evidence of digital intoxication nor was she treated with drugs which might interfere with digoxin kinetics and even if she had markers of renal function within clinical limits, digoxin was suspended and a treatment was initiated with 0.9% NaCl solution and furosemide. The second lab test showed levels of digoxin of 8.38 ng/ml. A possible interference of DLIF with immunoreactive tests was therefore assumed. MATERIALS AND METHODS: The patient's serum was ultrafiltered and centrifugated to remove possible DLIF; subsequently, the measurement of digoxin levels was repeated. As a result, the digoxin level decreased to 0.25 ng/ml. CONCLUSIONS: DLIF increase in several diseases, including heart failure, end-stage renal disease, pre-eclampsy and acromegaly. High digoxin levels in a patient who does not show any symptoms of digital intoxication should lead to suspect the presence of these factors and to preventively determine DLIF in serum so as not to incur the risk of suspending an important treatment like digoxin in heart failure.

[The use of cardiac markers bed test in acute coronary syndrome in emergency department]. / Utilizzo dei biomarcatori cardiaci bed-test nella sindrome coronarica acuta nel Dipartimento di Emergenza.

AIMS: The evaluation of the patient with chest pain in the emergency department is one of the most common situations that the doctor has to face. The diagnostic procedure supposes an observation period of at least 6-12 hours, a well organized medical facilities and the identification of all SCA cases to reduce inappropriate admission. MATERIALS AND METHODS: In our study we have estimated the utility of the marker assay that is associated to the use of risk scores (TIMI and GRACE risk score) to obtain indication about the most appropriate assistance level. In particular, we used the assay of necrosis markers to highlight the damage along with the assay of natriuretic peptides for their role in the diagnosis and in the monitoring of the patients with cardiac damage. RESULTS: Also PCR has an important role such as marker of plaque stability and of inflammation. These markers associated to the necrosis markers could give important clinical information of independent nature. DISCUSSION: The sensibility of laboratory markers, without important necrosis, is low and it is not possible to exclude in a few time a SCA There is now an alternative strategy: a precocious risk stratification. Using clinical criteria it is possible to do a first evaluation of the probability of SCA and the complications.

[Management model of chest pain in Medical Emergency Room and Chest Pain Unit of Policlinico Umberto I of Rome]. / Modello di gestione del dolore toracico in Pronto Soccorso Medico e nella Chest Pain Unit dell'Azienda Policlinico Umberto I di Roma.

In Italy one of the most common cause of access to the Emergency Departments is not traumatic chest pain, representing from the 6% to 10% of all the diagnoses. Admissions to the Emergency Department (DEA) of Policlinico Umberto I of Rome for non-traumatic chest pain, occurred between 2000 and 2008, were analyzed in this study. Out of 26,8910 admissions to the medical emergency room (PS), 21,088 (7.84%) were due to non-traumatic or precordial chest pain. Of these, 2881 (14%) patients had a diagnosis of myocardial infarction STEMI, NSTEMI and IA and 18,207 (86%) had a diagnosis of atypical chest pain, representing respectively 1.07% and 6.77% of all admissions to PS. About 27.62% of patients with atypical chest pain were discharged from the PS, 33.27% were hospitalized, 36.73% refused hospitalization, 1.68% were transferred elsewhere, and 0.7% did not uptake the visit. 85% of patients with myocardial infarction STEMI, NSTEMI and IA were hospitalized, 3.75% refused hospitalization, 8.82% were transferred elsewhere, and 1.71% died in the PS. Hospitalizations resulted often in unjustified and protracted length of hospital stays for clinical investigations, with negative repercussions for patients and costs. In the last years, the number of inappropriate hospitalizations progressively increased, partly as consequence of recourse to the court aiming at defining legal responsibility of the health board.Since avoiding inappropriate hospital admissions is an essential requirement for containing healthcare costs and improving the health service, Chest Pain Unit has been established. Its responsibility is to recognize and promptly treat patients with chest pain and acute coronary syndrome. As well, it is responsible to quickly discharge patients with chest pain at low and intermediate risk of acute coronary insufficiency, after careful clinical assessment lasting 24-36 hours.

[Carcinoid tumors of the appendix: when right colectomy?]. / I tumori carcinoidi dell'appendice. Quando l'emicolectomia destra?

Three cases of carcinoid tumour of the appendix (about 0,3 % of all performed appendectomies) has induced the Authors to a review of the literature with the aim to underline the most important biological and pathological findings and the current clinic and therapeutic knowledges. The diagnosis before surgery is rarely made; it is formulated incidentally in most patients by the histological exam during the operation for an appendicitis or during other surgical procedures. The kind of surgical intervention, that is the entity of the surgical demolition, for the treatment of the carcinoid tumours of the appendix is still controversial: appendectomy or right colectomy? It is possible identify, also during the operation for an appendicitis or for other abdominal lesions, criteria that can orient toward a major surgery (size of the neoplasia, subserosal lymphatic invasion, infiltration of the serosa, diffusion in the meso-appendix, location in closeness of the base of the appendix, invasion of the the locoregional lymph nodes, presence of metastases, section ?margins, number of mitoses, cellular pleiomorfism).

[Excision of a schwannoma of the neck: surgical technique]. / Exeresi di uno schwannoma del collo: note di tecnica chirurgica

We present a case of schwannoma of the neck in 49 year old man, symptomatic (paresthesia, cervical mass and dysphagia). After ultrasonography and magnetic resonance of the neck, the patient was operated and excision of the lesion was completely performed. The operation was performed through a cervical approach: the nerves and the vascular and muscular structures were carefully isolated and preserved. The tumour arised from the cervical sympathetic chain. The diagnosis of schwannoma was possible only by histopathologic examen. After 48 months no local recurrence or postoperative complication related to intervention were found. These lesions are uncommon. The identification of the nerve is often difficult until the operation, which is the treatment of choice for the schwannoma.