Preoperative Chemotherapy and Resection Margin Status in Colorectal Liver Metastasis Patients: A Propensity Score-Matched Analysis.

In this article, we compared the early and long-term outcomes of patients with metastatic colorectal cancer treated with chemotherapy followed by resection with those of patients undergoing surgery first, focusing our analysis on resection margin status. Patients who underwent liver resection with curative intent for colorectal liver metastases from July 2001 to January 2018 were included in the analysis. Propensity score matching was used to reduce treatment allocation bias. The cohort comprised 164 patients; 117 (71.3%) underwent liver resection first, whereas the remaining 47 (28.7%) had preoperative chemotherapy. After a 1:1 ratio of propensity score matching, 47 patients per group were evaluated. A positive resection margin was found in 13 patients in the surgery-first group (25.5%) versus 4 (8.5%) in the preoperative chemotherapy group (P = 0.029). Postmatched logistic regression analysis showed that only preoperative chemotherapy was significantly associated with the rate of positive resection margin (odds ratio 0.24, 95% confidence interval 0.07-0.81; P = 0.022). Median follow-up was 41 months (interquartile range 8-69). Cox proportional hazard regression analysis revealed that only positive resection margin was a significant negative prognostic factor (hazard ratio 2.2, 95% CI 1.18-4.11; P = 0.014). Within the preoperative chemotherapy group, median overall survival was 40 months in R0 patients and 10 months in R1 patients (P = 0.016). Although preoperative chemotherapy in colorectal liver metastasis patients may affect the rate of positive resection margin, its impact on survival seems to be limited. In the present study, the most important prognostic factor was the resection margin status.

Neural correlates of anxiety sensitivity in panic disorder: A functional magnetic resonance imaging study.

Panic disorder has been associated with dysfunctional neuropsychological dimensions, including anxiety sensitivity. Brain-imaging studies of the neural correlates of emotional processing have identified a network of structures that constitute the neural circuitry for emotions. The anterior cingulate cortex (ACC), medial prefrontal cortex (mPFC) and insula, which are part of this network, are also involved in the processing of threat-related stimuli. The aim of the study was to investigate if neural activity in response to emotional stimuli in the cortico-limbic network is associated to anxiety sensitivity in panic disorder. In a sample of 18 outpatients with panic disorder, we studied neural correlates of implicit emotional processing of facial affect expressions with a face-matching paradigm; correlational analyses were performed between brain activations and anxiety sensitivity. The correlational analyses performed showed a positive correlation between anxiety sensitivity and brain activity during emotional processing in regions encompassing the PFC, ACC and insula. Our data seem to confirm that anxiety sensitivity is an important component of panic disorder. Accordingly, the neural underpinnings of anxiety sensitivity could be an interesting focus for treatment and further research.

Extensive cytoreductive surgery in a Jehovah's Witness patient. A case report.

Jehovah's Witnesses are a well-known patient demographic in medicine because of their religious-based refusal of blood transfusion. This case report outlines the treatment of a Jehovah's Witness patient in need of an extensive cytoreductive surgery due to a peritoneal carcinomatosis of ovarian origin. The surgeons carried out all the recommended surgical and anaesthetic measures concluding that extensive cytoreductive surgery on a Jehovah's Witness is possible and that a complete cytoreduction can be safely performed.

The HAC trial (harmonic for acute cholecystitis): a randomized, double-blind, controlled trial comparing the use of harmonic scalpel to monopolar diathermy for laparoscopic cholecystectomy in cases of acute cholecystitis.

BACKGROUND: The HARMONIC SCALPEL (H) is an advanced ultrasonic cutting and coagulating surgical device with important clinical advantages, such as: reduced ligature demand; greater precision due to minimal lateral thermal tissue damage; minimal smoke production; absence of electric corrents running through the patient. However, there are no prospective RCTs demonstrating the advantages of H compared to the conventional monopolar diathermy (MD) during laparoscopic cholecystectomy (LC) in cases of acute cholecystitis (AC). METHODS: This study was a prospective, single-center, randomized trial (Trial Registration Number: NCT00746850) designed to investigate whether the use of H can reduce the incidence of intra-operative conversion during LC in cases of AC, compared to the use of MD. Patients were divided into two groups: both groups underwent early LC, within 72 hours of diagnosis, using H and MD respectively (H = experimental/study group, MD = control group). The study was designed and conducted in accordance with the regulations of Good Clinical Practice. RESULTS: 42 patients were randomly assigned the use of H (21 patients) or MD (21 patients) during LC. The two groups were comparable in terms of basic patient characteristics. Mean operating time in the H group was 101.3 minutes compared to 106.4 minutes in the control group (p=ns); overall blood loss was significantly lower in the H group. Conversion rate was 4.7% for the H group, which was significantly lower than the 33% conversion rate for the control group (p<0.05). Post-operative morbidity rates differed slightly: 19% and 23% in the H and control groups, respectively (p=ns). Average post-operative hospitalization lasted 5.2 days in the H group compared to 5.4 days in the control group (p=ns). CONCLUSIONS: The use of H appears to correlate with reduced rates of laparoscopic-open conversion. Given this evidence, H may be more suitable than MD for technically demanding cases of AC.

T.E.A. Study: three-day ertapenem versus three-day Ampicillin-Sulbactam.

BACKGROUND: Intra-abdominal infections are one of the most common infections encountered by a general surgeon. However, despite this prevalence, standardized guidelines outlining the proper use of antibiotic therapy are poorly defined due to a lack of clinical trials investigating the ideal duration of antibiotic treatment. The aim of this study is to compare the efficacy and safety of a three-day treatment regimen of Ampicillin-Sulbactam to that of a three-day regimen of Ertapenem in patients with localized peritonitis ranging from mild to moderate severity. METHODS: This study is a prospective, multi-center, randomized investigation performed in the Department of General, Emergency, and Transplant Surgery of St. Orsola-Malpighi University Hospital in Bologna, Italy. Discrete data were analyzed using the Chi-squared and Fisher exact tests. Differences between the two study groups were considered statistically significant for p-values less than 0.05. RESULTS: 71 patients were treated with Ertapenem and 71 patients were treated with Ampicillin-Sulbactam. The two groups were comparable in terms of age and gender as well as the site of abdominal infection. Post-operative infection was identified in 12 patients: 10 with wound infections and 2 with intra-abdominal infections. In the Ertapenem group, 69 of the 71 patients (97%) were treated successfully, while the therapy failed in 2 cases (3%). Therapy failures were more frequent in the Unasyn group, amounting to 10 of 71 cases (p = 0.03). CONCLUSION: According to these preliminary findings, the authors conclude that a three-day Ertapenem treatment regimen is the most effective antibiotic therapy for patients with localized intra-abdominal infections ranging from mild to moderate severity. TRIAL REGISTRATION: Trial registration: ClinicalTrials.gov: NCT00630513.

Peritoneal adhesion index (PAI): proposal of a score for the "ignored iceberg" of medicine and surgery.

Peritoneal adhesions describe a condition in which pathological bonds form between the omentum, the small and large bowels, the abdominal wall, and other intra-abdominal organs. Different classification systems have been proposed, but they do not resolve the underlying problem of ambiguity in the quantification and definition of adhesions. We therefore propose a standardized classification system of adhesions to universalize their definition based on the macroscopic appearance of adhesions and their diffusion to different regions of the abdomen. By scoring with these criteria, the peritoneal adhesion index (PAI) can range from 0 to 30, unambiguously specifying precise adhesion scenarios. The standardized classification and quantification of adhesions would enable different studies to more meaningfully integrate their results, thereby facilitating a more comprehensive approach to the treatment and management of this pathology.

The development of the Metacognition Assessment interview: instrument description, factor structure and reliability in a non-clinical sample.

BACKGROUND: Metacognition is a multi-facet psychological construct; deficits in metacognitive abilities are associated to low social functioning, low quality of life, psychopathology, and symptoms. The aim of this study was to describe and develop a valid and reliable interview for assessing metacognition. METHODS: The semi-structured interview, based on the author's theory model of the metacognition construct, is described. The Metacognition Assessment Interview (MAI) is an adaptation of the Metacognition Assessment Scale (MAS) and evaluates how the subject is interviewed used metacognition during his own real life experiences elicited by the interviewer. A user manual was developed to assist the interview and scoring procedure. RESULTS: Exploratory factor analysis and confirmatory factor analysis revealed preliminary evidence of a two factor-hierarchical structure, with two lower-order scales, representing the two main theoretical domains of the metacognitive function, "the Self" and "the Other", and one single higher-order scale that we labelled metacognition. Contrary to the authors' prediction the existence of the four distinct dimensions under the two domains was not confirmed. The MAI and its two domains demonstrated acceptable levels of inter-rater reliability and internal consistency. CONCLUSIONS: The MAI appears to be a promising instrument for assessing metacognition. Future psychometric validation steps and clinical directions are discussed.

Alexithymia and anxiety sensitivity in populations at high risk for panic disorder.

OBJECTIVE: Populations at high risk for panic disorder (PD) probably share with subjects with PD an underlying vulnerability involving features like anxiety sensitivity (AS) and alexithymia. The present study would verify if PD relatives (R) and subjects who have experienced 1 or more panic attacks (PAs) show different levels of AS and alexithymia with respect to healthy controls (HC). METHODS: One hundred fifty-seven HCs, 30 subjects with PA, 64 R subjects, and 139 outpatients with PD were evaluated and compared on AS, alexithymia, and control variables. RESULTS: Subjects with PD show higher alexithymia and AS levels compared with HCs; R subjects do not differ on ASI total score; and R females show more alexithymic features. Subjects with PA are comparable with HCs both on AS and alexithymia. CONCLUSIONS: Results confirm an impairment in emotional and bodily sensations information processing in subjects with PD but partially disconfirm the expectation of a difference between R subjects and subjects with PA with respect to HCs on AS and alexithymia. Emotional and bodily sensation competencies could be protective factors for PD in high-risk populations.

An explorative study on metacognition in obsessive-compulsive disorder and panic disorder.

OBJECTIVE: To test the hypothesis that dysfunctional metacognitions might be a general vulnerability factor for anxiety disorder, metacognitive beliefs among patients with obsessive-compulsive disorder (OCD), patients with panic disorder (PD), and healthy subjects (HS) were studied. Correlations between metacognitive beliefs, OCD, and PD symptoms were also investigated. METHODS: Patients with OCD (n = 114), patients with PD (n = 119), and HS (n = 101) were assessed with the Metacognition Questionnaire (MCQ). RESULTS: Patients with OCD and those with PD scored significantly higher than HS on the MCQ in 2 dimensions: negative beliefs about worry concerning uncontrollability and danger as well as beliefs about the need to control thoughts dimensions. No difference in MCQ scores was observed between the OCD and PD groups. The former 2 MCQ dimensions were positively correlated with the degree of indecisiveness in patients with OCD, whereas the MCQ negative beliefs about worry positively correlated with the average intensity of anticipatory anxiety in patients with PD. CONCLUSIONS: The presence of dysfunctional metacognitions in both patients with OCD and those with PD suggests that such beliefs can represent not only generic vulnerability factors for anxiety disorders but also elements that contribute to maintaining the disorder, as evidenced by their associations with aspects of OCD and PD symptoms.

Language of dyspnea in panic disorder.

Dyspnea is a key symptom in panic attacks. This study investigated different types of dyspnea induced by the 35% CO2 challenge test given to patients with panic disorder (PD). The types of dyspnea provide room for possible conjectures on neurophysiological pathways involved in the experience of breathing discomfort in PD and in the panic-respiration connection. Factor analysis applied to the Dyspnea Questionnaire identified three main factors: breathing effort, sense of suffocation, and rapid breath. Factor scores for breathing effort and sense of suffocation significantly discriminated between patients who did and those who did not report CO2-induced panic attacks. Factor scores for breathing effort significantly discriminated between patients whose reaction resembled their unexpected panic attacks and those whose reaction did not. A dissociation between an increased central respiratory command and a decreased mechanical efficiency of the respiratory response in patients with PD may underlie the breathing effort factor during the CO2 challenge. The sense of suffocation factor was found to be linked to chemosensitivity. Although involved in CO2 reactivity, it may not be a central factor in unexpected panic attacks.

Lack of relationship between CO2 reactivity and serotonin transporter gene regulatory region polymorphism in panic disorder.

Changes in the function of the serotonergic system influence both panic phobic symptoms and carbon dioxide (CO2) reactivity in patients with panic disorder. Schmidt et al. [2000: J Abnorm Psychol 109(2):308-320] recently reported a predictive role of the genetic variants of the 5-HTTLPR on the fearful response to CO2 in healthy controls. We tested the hypothesis that the heterogeneity of CO2 reactivity in patients with panic disorder could be related to the allelic variation of the 5-HTT promoter. Ninety-five patients with panic disorder were challenged with 35% CO2. 5-HTTLPR allelic variation in each subject was determined using a PCR-based method. There were no differences for all the measures of CO2 reactivity among the genotype groups. CO2 reactivity of patients with panic disorder seems not to be influenced by the genetic variants of the 5-HTTLPR; this finding does not support a role for the serotonin transporter in the etiopathogenesis of CO2 reactivity in panic disorder.

Anxiety sensitivity and modulation of the serotonergic system in patients with PD.

Anxiety sensitivity, i.e., the fear of anxiety-related bodily sensations, is one of the most studied cognitive variables in panic disorder (PD). However, the effects of selective serotonergic antipanic agents on this variable have not yet been investigated. The present study examines the effects of 6 weeks of treatment with citalopram on anxiety sensitivity in patients with PD. Twenty patients entered the study. On day 0, before starting drug treatment, after 1 week and after 6 weeks of treatment, each patient was evaluated with the Anxiety Sensitivity Index (ASI); the severity of clinical symptomatology was assessed with standardized psychometric scales. Results showed a significant reduction of anxiety sensitivity after 6 weeks of treatment. There was a significant correlation between decrease of anxiety sensitivity and anticipatory anxiety, while no correlations were found between panic attacks and agoraphobic avoidance. These results suggest that antipanic drug treatment decreases anxiety sensitivity.

Comparison of 35% carbon dioxide reactivity between panic disorder and eating disorder.

Patients with panic disorder (PD) are hyperreactive to carbon dioxide (CO(2)), but the specificity of this characteristic to PD is controversial. Anxiety and phobic symptomatology are common to both panic and eating disorders (ED). To investigate the specificity of CO(2) hyperreactivity to PD, the responses to inhalation of a 35% CO(2) and 65% oxygen (O(2)) gas mixture were assessed. Reactions to 35% CO(2) challenge were compared among three groups of age- and sex-matched subjects: 14 patients with ED, 14 patients with PD, and 14 healthy controls (HC). A double-blind, randomized, crossover design was used. Only patients with PD showed a strong reaction to 35% CO(2), while patients with ED and HC did not react significantly. The results support the specificity of CO(2) hyperreactivity to PD.

Vulnerability to 35% CO2 of panic disorder patients with a history of respiratory disorders.

Patients with panic disorder often report a history of respiratory pathology. Furthermore, panic disorder patients are vulnerable to CO2 challenges. The increased CO2 vulnerability displayed by panic disorder patients may be related to lifetime respiratory pathology. We examined whether panic disorder patients with a history of respiratory disorders are more vulnerable to a 35% CO2 challenge than those without such a history. Ninety-six patients with panic disorder were interviewed about their lifetime respiratory status (asthma, bronchitis and various other respiratory conditions) and underwent the challenge. Immediately before and after the CO2 inhalation, the patients filled out the Visual Analogue Scale for Anxiety (VAS-A) and the Panic Symptom List (PSL). We found no differences between the two panic disorder groups on anxiety (VAS-A), panic symptoms (PSL) or panic attacks after the CO2 challenge. Our results suggest that having a PD is an important factor in CO2 vulnerability independent of a history of respiratory disorders.

Anxiety sensitivity and 35% CO2 reactivity in patients with panic disorder.

OBJECTIVE: The present study examines the possible relationships between anxiety sensitivity (AS) and reactivity to the 35% carbon dioxide (CO(2)) challenge in panic disorder (PD). METHODS: One-hundred eight patients with PD underwent the 35% CO(2) challenge and completed the Anxiety Sensitivity Index (ASI). Multiple regression analyses were applied to evaluate the role of AS as a predictor of CO(2)-induced anxiety. RESULTS: Fifty-six patients with PD showed high AS scores, whereas 48 showed medium scores and 4 low scores. ASI scores significantly predicted symptomatological reaction to CO(2) but not subjective induced anxiety. CONCLUSION: These findings suggest that the fear of anxiety-related bodily sensations was related to the symptomatological reactivity to CO(2) but did not seem to play a crucial role in the modulation of the subjective anxiogenic/panicogenic response to hypercapnia in patients with PD.