Development and validation of a nomogram to predict survival in incurable cachectic cancer patients on home parenteral nutrition.

BACKGROUND: The use of home parenteral nutrition (HPN) in incurable cancer patients is extremely varied across different countries and institutions. In order to assess the clinical impact implied, we previously conducted a survey of incurable cancer patients receiving HPN, which shows that survival was markedly affected by Karnofsky performance status (KPS), tumor spread, Glasgow prognostic score (GPS) and tumor site. The aim of this study was to develop a nomogram incorporating the above factors for survival prediction. PATIENTS AND METHODS: We gathered a series of 579 patients, all receiving HPN, which was randomly split into a training and a testing sample. Using Cox proportional hazard regression modeling, a nomogram was built in the training sample, in order to estimate median survival or survival probability at 3 and 6 months according to individual patient characteristics. The nomogram performance was then verified in the testing sample. RESULTS: In the training sample, median survival was 3.2 (95% CI 3.0-3.7) months. GPS, KPS, tumor site and spread were confirmed to be significant prognostic factors. A significant interaction was also shown between the site and spread while weight loss (WL), adjusted for body mass index, failed to provide any substantial prognostic contribution. In the testing sample, nomogram performance was good in terms of calibration and discreet regarding discrimination. CONCLUSION: With the growing availability of new oncological treatments and their tendency to transform the trajectory of the advanced cancer into a chronic condition characterized by progressive WL and poor nutrients intake, an increasing number of patients are expected to receive HPN. In such a setting, tools for predicting the survival outcome may play a role toward personalized medicine and for investigating novel experimental therapies. Our proposed nomogram is a step forward in this direction but needs to be made stronger in order to definitely have clinical utility.

[Perforation of the small intestine]. / Le perforazioni dell'intestino tenue.

BACKGROUND: Small bowel perforation is a major problem in abdominal typhi disease, but is seldom observed in Italy, as Salmonella typhi infections are rare in this Nation. The cause of perforation varies greatly. The reported mortality is high and varies from 23 up to 42%. A retrospective study has been performed in order to find how to improve the outcome. METHODS: A series spanning 10 years is reviewed, from January 1, 1987 to December 31, 1997, comprising 60 patients with small bowel perforation, operated in a urgency setting in the Operating Room of the Emergency Department of the Molinette Hospital in Torino. Resection and primary anastomosis were utilized in 33 patients, 27 underwent oversewing. In 3 patients a colostomy was felt necessary because of a concomitant damage of the colon. RESULTS: No leakages occurred. Hospital stay varies from 1 day to 76 days (24 days mean). Mortality is consistent with literature: 20 patients (33%) but the cause is related to the primary diseases of the patients. Delay in diagnosis did not affect the patient's outcome. CONCLUSIONS: In conclusion, it is confirmed the one-time surgery as the choice treatment in small bowel perforations from causes other then S. typhi infection. Mortality is not directly related to the consequences of surgical repair.

[Treatment of traumatic injuries of the spleen. Retrospective analysis of 164 cases]. / Trattamento delle lesioni traumatiche della milza. Analisi retrospettiva su 164 casi.

Increased awareness of the spleen's immunologic function and the risk of overwhelming post-splenectomy sepsis has aroused interest in methods of splenic preservation in patients with abdominal trauma. During an 8-year period, 164 patients with documented blunt splenic injuries were treated in accordance with an evolving therapeutic program. Definitive treatment included nonoperative management in 19 patients (group I, 11.6%), repair in 50 (group II, 30.5%) and splenectomy in 95 (group III, 57.9%). Mortality and morbidity were higher in group III (6.3% and 34.3% respectively) according to the Injury Severity Score (ISS 33.3 +/- 13). In group II one patient died from severe head injuries. Only one patient failed nonoperative management and required laparotomy with resultant splenectomy on hospital day 10. Observation without surgery has proved to be safe and effective in children (failure incidence less than 10%); success rates in adults would not parallel the experience reported in children because of differences in anatomy and mechanism of injury. Selective criteria, including hemodynamic stability after initial fluid challenge, normal level of consciousness, lack of peritoneal signs, transfusion requirements of less than 4 units of blood, CT demonstration of minor splenic lesion and exclusion of associated abdominal injuries requiring surgery, make eligible for nonoperative management 12 to 18% of adults with anticipated success in over 75%. Operative repair or partial splenectomy can be employed in many patients, both adults and children, with a 1% incidence of rebleeding necessitating reoperation.

[Lesions of the spleen caused by blunt trauma. Proposal of a classification based on CT and correlation with prognosis and treatment]. / Lesioni della milza da trauma chiuso. Proposta di una classificazione basata sulla TAC e correlazione con prognosi e trattamento.

The use of CT scan has had a profound influence on the evaluation and treatment of closed abdominal injuries, enabling a progressive reduction to be achieved in the total number of emergency laparotomies. The authors review CT performed over the past two years in adult hemodynamically stable patients with traumatic splenic lesions. In 19 cases it was possible to commence non-surgical treatment which was successful in 18/19 cases. A simple and precise scoring system was elaborated on the basis of data obtained from CT by evaluating 4 parameters: extent of free intraperitoneal effusion, concomitant lesions to other abdominal organs, severity and site of splenic lesion. This classification gives a high degree of prognostic accuracy and provides a useful guideline in the choice of the most appropriate treatment.

[A modified Hill's procedure in the surgical treatment of hiatal hernia]. / L'intervento di Hill modificato nel trattamento chirurgico dell'ernia jatale.

After an introduction on the problems regarding indications and surgical management of gastro-oesophageal reflux disease, the Authors describe the technique they use, which is a modification of Hill's posterior gastropexy, involving the placement of suture through the median arcuate ligament, without exposing the celiac axis. The preliminary results of a prospective randomized clinical trial, conducted at the Surgical Clinic Department of Catholic University, Rome, are described. The trial evaluated early and late results of Hill's modified technique versus a control group, in which a Dor technique has been used. Intraoperative oesophageal manometry has been performed in both groups, to set the cardioplasty more properly. Ninety-one patients out of 132 have been studied; 65 had a good response to medical therapy and 26 have been operated upon. In 9 cases (6 Dor and 3 Hill) intraoperative manometry was performed. All patients have been studied pre-operatively with upper g.i. series, endoscopy with biopsies, oesophageal manometry and 24-h pH monitoring; this protocol has been repeated after 3 to 6 months postoperatively, to evaluate the results more accurately. The preliminary data, although statistically non significant because of the small study group, seem to favour the Hill modified technique, both for complication and reflux control. Further data are needed to confirm them.

Kininase I, kininase II and aminopeptidase levels in patients with gastrointestinal tumors.

Some indices of the kallikrein kinin system, namely kininase I (KI), kininase II or angiotensin converting enzyme (KII-ACE) and phenylalanine-arginine aminopeptidase (AP) were analyzed, to detect their levels in ten selected normal subjects and in 20 selected patients with colonic (n = 8) and gastric adenocarcinoma (n = 12). While AP and KI levels did not show differences in the groups under analysis, KII values showed a significant difference (P +/- 0.01), present since the early stages of the diseases and unrelated to the normal laboratory indices.