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Impact of analgesia modality on postoperative recovery after laparoscopic distal pancreatectomy
No full textIn the context of enhanced recovery pathways (ERP) for colorectal surgery, thoracic epidural analgesia (TEA) delays recovery compared to opioid-based patient-controlled intravenous analgesia (PCA). Limited evidence is available for laparoscopic pancreatic surgery. The objective of this study was to evaluate the impact of different analgesic modalities on the time to functional recovery (TFR) following laparoscopic distal pancreatectomy (LDP). Clinical data for consecutive patients undergoing LDP were reviewed. All patients were treated within an ERP including a multimodal analgesia protocol. The main analgesic techniques used were TEA, intravenous morphine PCA, and patient-controlled sublingual sufentanil tablet system (SSTS). TFR was defined as postoperative days (PODs) needed to achieve adequate mobilization, return of gastrointestinal function, sufficient oral intake with no need for intravenous infusion, and adequate pain control with oral analgesia. Overall, 336 patients were included; 109 (32%) patients received TEA, 124 (37%) PCA, and 103 (31%) SSTS. TFR was significantly shorter for the SSTS group with median of 4 [IQR 3-5] days compared to 5 [4-6] days in both the TEA and PCA groups (p < 0.001). This difference was due to faster time to sufficient oral intake and adequate pain control with oral analgesia. On POD1, patients treated with TEA had better pain control compared to other modalities; the median NRS pain score at rest was 0 [0-3] compared to 2 [0-4] for both PCA and SSTS groups (p = 0.003). Multivariate regression showed that SSTS was associated with a 17% reduction (95% CI - 29 to - 5; p = 0.005) of TFR compared to TEA. Patients treated with SSTS had a significantly shorter TFR after LDP compared with other analgesic modalities with no difference in adverse events
Serum Lipids Alterations in Patients Under Systemic JAK Inhibitors Treatments in Dermatology: Clinical Aspects and Management
Get PDFBackground and Objectives: Janus kinase inhibitors (JAKi) have significantly advanced the treatment of various dermatological conditions by modulating the JAK-STAT signalling pathway. While these inhibitors have proven effective, they also pose challenges due to associated increase in serum lipid levels and relative potential cardiovascular risks. This perspective work aims to discuss the implications of these lipid alterations proposing management strategies for patients with dermatological disorders under JAKi treatments. Materials and Methods: This manuscript reviews existing and recent literature on the metabolic effects of JAKi, particularly focusing on their impact on lipid profiles in patients treated for dermatological diseases. Results: JAK inhibitors are consistently associated with an increase in both LDL and HDL levels shortly after treatment initiation, which tend to stabilise over time. Despite these changes, there is no clear evidence linking these alterations to an increased risk of major adverse cardiovascular events (MACE), indicating a complex interaction between lipid metabolism and JAK-STAT signalling. Conclusions: Although JAKi may induce lipid changes in patients, raising concerns, especially in ones with existing cardiovascular risks, currently there is no proven link to increased MACE in this population. Monitoring lipid levels, alongside lifestyle modifications and possible statin use, can manage these effects without the need to stopping treatment
Toward a Unified Definition of Progression Independent of Relapse Activity in Multiple Sclerosis
Get PDFOBJECTIVES: Progression independent of relapse activity (PIRA) is the main driver of disability accumulation in relapsing multiple sclerosis (MS). We tested various PIRA definitions against the risk of long-term disability. METHODS: Patients with relapsing MS, first visit ≥January 1, 2000, ≥3 visits with Expanded Disability Status Scale (EDSS), and ≥5-year follow-up were extracted from the Italian MS and Related Disorders Register on September 29, 2023. Eighteen PIRA definitions were obtained combining fixed or roving baseline, 24-week, 48-week confirmed or sustained disability accrual, no relapses ≤90 days before/≤30 days after the event (90d), ≤180 days before/≤30 days after the event, or absence of relapses from baseline to confirmation score (ABS). Predictive performance against the reaching of EDSS = 6.0 was calculated. RESULTS: A total of 30,203 patients were included. After a follow-up of 11.3 ± 4.3 years, PIRA ranged from 38.8% to 74.1%. EDSS = 6.0 was detected in 4,401 (15%) patients. Sensitivity of PIRA definitions against EDSS = 6.0 was higher using the 90d criterion (66.7%-69.4%), while the ABS criterion increased specificity (55.3%-62.2%). DISCUSSION: The definition of PIRA combining roving baseline, no relapses 90 days before and 30 days after the event and 24-week confirmation achieved the best predictive value and feasibility, supporting its use in routine practice and research
Changes in circulating pro-inflammatory lymphocytes and cortical excitability with extended-interval natalizumab dosing in multiple sclerosis
No full textBackground: Natalizumab is a potent treatment for multiple sclerosis (MS). By inhibiting immune cell trafficking to the CNS it increases the risk of progressive multifocal leukoencephalopathy (PML). Extended interval dosing (EID) aims to mitigate PML risk by partly restoring immune surveillance. End-of-dose symptoms, frequently reported by people on EID, may reflect an increased inflammatory cell trafficking. Methods: Twenty-five clinically and radiographically stable individuals on EID underwent neuropsychological (processing speed - PASAT and SDMT; self-reported fatigue - FSS), neurophysiological (SICI - Short Intracortical Inhibition, ICF– Intracortical facilitation, and CSP– cortical silent period), immunological assessments (circulating lymphocytes subpopulations and cytokines production), and plasma neurofilament quantification at the 2nd-4th and 6th-8th week after infusion. Results: 24/25 participants subjectively reported increased fatigue at the end-of-dose; no change in processing speed or self-reported fatigue was detected. At the end-of-dose, a selective drop in IFNγ-producing lymphocytes (CD4+: -57.7%, p = 0.01; CD8+: -41.45%, p = 0.014; NK: -54.23%, p = 0.033) and other pro-inflammatory lymphocyte subsets was observed compared with the intermediate visit. Furthermore, we observed changes in GABAergic cortical excitability, with an increased GABA-A dependent inhibition of the primary motor cortex at the end-of-dose (SICI, + 46.9%, p = 0.026) and a similar trend for GABA-B depended inhibition (CSP). Plasma neurofilament fluctuations were below the study’s detection power. Discussion: Pro-inflammatory lymphocytes escape peripheral circulation at the end-of-dose, in the absence of clinical or radiographic disease activity. The observed change in GABA-dependent cortical inhibition may reflect this increased CNS lymphocyte trafficking. No association with end-of-dose symptoms was found
Perioperative outcomes in open versus minimally invasive gastrectomy for gastric cancer: a European multicenter study based on the GASTRODATA registry
No full textMinimally invasive subtotal gastrectomy was associated with fewer perioperative complications than OG, while this association was not observed for total gastrectomy. Minimally invasive subtotal gastrectomy should be considered a viable option in specialized European centers
Amino Acid Infusion and Renal Protection: Beyond Hemodynamic Optimization in Cardiac Surgery
No full textDermoscopy and reflectance confocal microscopy of solitary flat pink lesions: A new combined score to diagnose amelanotic melanoma
Get PDFBackground: Differential diagnosis of amelanotic/hypomelanotic melanoma among solitary flat pink lesions is challenging, due to limited clinical and dermoscopic clues. Dermoscopy and reflectance confocal microscopy assessments improve diagnostic accuracy, but their combined capacity among solitary flat pink lesions is yet to be defined. Objectives: To determine (i) whether diagnostic accuracy is improved with combined dermoscopy and reflectance confocal microscopy, (ii) a model to estimate probability of flat amelanotic/hypomelanotic melanoma among solitary flat pink lesions. Methods: A retrospective single-centre study of solitary flat pink lesions, excised for suspected malignancy between 2011 and 2022 was performed. Images were independently evaluated by two dermatologists, blinded to histopathological diagnosis. Diagnostic performance was evaluated on the receiver operating characteristic curve and the area under the curve. Predictive features were identified by univariate and multivariate logistic regression analyses. A final predictive nomogram of independent risk factors was calculated by backward likelihood ratio. Hypothesis being tested was formulated before data collection. Results: A total of 184 patients (87 females, 47.3%) were included; mean age was 57.6 years (19–95). Combined dermoscopy and reflectance confocal microscopy was more sensitive (83%, CI 69.2–92.4 and 91.5%, CI 79.6–97.6) than dermoscopy alone (76.6%, CI 62.0–87.7 and 85.1%, CI 71.7–93.8). Predictive features defined the new model, including linear irregular vessels (4.26-folds, CI 1.5–12.1), peripheral pigment network (6.07-folds, CI 1.83–20.15), remnants of pigmentation (4.3-folds, CI 1.27–14.55) at dermoscopy and atypical honeycomb (9.98-folds, CI 1.91–51.96), disarranged epidermal pattern (15.22-folds, CI 2.18–106.23), dendritic pagetoid cells in the epidermis (3.77-folds, CI 1.25–11.26), hypopigmented pagetoid cells (27.05-folds, CI 1.57–465.5), and dense and sparse nests (3.68-folds, CI 1.24–10.96) in reflectance confocal microscopy. Diagnostic accuracy of the model was high (AUC 0.91). Conclusions: Adjunctive reflectance confocal microscopy increases diagnostic sensitivity of flat amelanotic/hypomelanotic melanoma differential diagnosis. The proposed model requires validation.Background: Differential diagnosis of amelanotic/hypomelanotic melanoma among solitary flat pink lesions is challenging, due to limited clinical and dermoscopic clues. Dermoscopy and reflectance confocal microscopy assessments improve diagnostic accuracy, but their combined capacity among solitary flat pink lesions is yet to be defined. Objectives: To determine (i) whether diagnostic accuracy is improved with combined dermoscopy and reflectance confocal microscopy, (ii) a model to estimate probability of flat amelanotic/hypomelanotic melanoma among solitary flat pink lesions. Methods: A retrospective single-centre study of solitary flat pink lesions, excised for suspected malignancy between 2011 and 2022 was performed. Images were independently evaluated by two dermatologists, blinded to histopathological diagnosis. Diagnostic performance was evaluated on the receiver operating characteristic curve and the area under the curve. Predictive features were identified by univariate and multivariate logistic regression analyses. A final predictive nomogram of independent risk factors was calculated by backward likelihood ratio. Hypothesis being tested was formulated before data collection. Results: A total of 184 patients (87 females, 47.3%) were included; mean age was 57.6 years (19–95). Combined dermoscopy and reflectance confocal microscopy was more sensitive (83%, CI 69.2–92.4 and 91.5%, CI 79.6–97.6) than dermoscopy alone (76.6%, CI 62.0–87.7 and 85.1%, CI 71.7–93.8). Predictive features defined the new model, including linear irregular vessels (4.26-folds, CI 1.5–12.1), peripheral pigment network (6.07-folds, CI 1.83–20.15), remnants of pigmentation (4.3-folds, CI 1.27–14.55) at dermoscopy and atypical honeycomb (9.98-folds, CI 1.91–51.96), disarranged epidermal pattern (15.22-folds, CI 2.18–106.23), dendritic pagetoid cells in the epidermis (3.77-folds, CI 1.25–11.26), hypopigmented pagetoid cells (27.05-folds, CI 1.57–465.5), and dense and sparse nests (3.68-folds, CI 1.24–10.96) in reflectance confocal microscopy. Diagnostic accuracy of the model was high (AUC 0.91). Conclusions: Adjunctive reflectance confocal microscopy increases diagnostic sensitivity of flat amelanotic/hypomelanotic melanoma differential diagnosis. The proposed model requires validation
2024 MAGNIMS–CMSC–NAIMS consensus recommendations on the use of MRI for the diagnosis of multiple sclerosis
No full textLeft Main Spontaneous Coronary Artery Dissection: Clinical Features, Management, and Outcomes
No full textBackground: Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute myocardial infarction (MI) and is associated with substantial adverse events. SCAD involving the left main coronary artery (LM) is a rare but potentially life-threatening condition. Currently, minimal data on LM SCAD have been reported. Objectives: The aim of this study was to investigate clinical features, contemporary management, and clinical outcomes of patients with LM SCAD. Methods: A systematic review and pooled analysis of published case reports was conducted using “left main” and “dissection” as keywords. The authors screened 1,106 papers in MEDLINE and Embase published between 1990 and 2023. Results: The final analysis included 132 patients (mean age 40 ± 11 years, 80% women) diagnosed with LM SCAD. Remarkably, 36% of cases occurred during pregnancy, and 95% presented with acute coronary syndrome, 22% with cardiogenic shock, and 8% with ventricular arrhythmias. At 120-day median follow-up, all-cause death occurred in 9%, left ventricular assist device implantation or heart transplantation in 4%, recurrent MI in 13%, and urgent myocardial revascularization (MR) in 21%. Compared with conservative management, early revascularization by percutaneous coronary intervention or coronary artery bypass grafting significantly reduced the composite endpoint of all-cause death, left ventricular assist device implantation or heart transplantation, recurrent MI, and urgent MR (adjusted HR: 0.37; 95% CI: 0.20-0.69; P < 0.001). Conclusions: LM SCAD carried significant acute morbidity and mortality. Early revascularization (percutaneous coronary intervention or coronary artery bypass graft) was associated with a lower incidence of early adverse outcomes compared with conservative management, driven largely by reduction in recurrent MI and urgent MR. These hypothesis-generating data should be confirmed in future prospective registries and clinical trials
