Ultra-short antibiotic prophylaxis guided by preoperative microbiological nasal swabs in endoscopic endonasal skull base surgery.

PURPOSE: Endoscopic endonasal skull base surgery (EESBS) is a clean-contaminated procedure. Guidelines regarding the antibiotic prophylaxis in EESBS have not been developed yet, and today, there are no universally accepted protocols. In this article, we investigated the efficacy of our new ultra-short antibiotic prophylaxis protocol for EESBS guided by the cultural results of preoperative microbiological nasal swabs. METHODS: We defined as "nasal swab-related antibiotic protocol" the administration of a first-generation cephalosporin (cefazolin 2 g) in patients whose nasal swabs revealed the presence of normal nasal flora or methicillin-sensitive Staphylococcus aureus (MSSA), and the administration of vancomycin 1 g intravenously in patients whose nasal swabs revealed the presence of methicillin-resistant Staphylococcus aureus (MRSA) or with reported cephalosporin/penicillin allergy. This case-control study included 120 patients who underwent EESBS. The case group included 60 cases who received the "nasal swab-related antibiotic protocol," while the control group included 60 cases who received the "standard hospital antibiotic protocol" used in neurosurgery (cefazolin 2 g plus metronidazole 500 mg at induction, and 2 g of cefazolin repeated after 180 min). RESULTS: The preoperative microbiological nasal swabs showed normal nasal flora in 42 patients (70%), MSSA in 17 patients (28.3%), and MRSA in 1 patient (1.6%). During the study period, no cases of meningitis or sinusitis occurred in the case group ("nasal swab-related antibiotic protocol"), while two infections (3.3%, 1 sinusitis and 1 meningitis) were reported in the control group ("standard hospital antibiotic protocol"). Mean length of hospitalization was 6.5 days for the case group and 8.5 days in the control group. "Standard hospital antibiotic protocol" is less expensive (range, 2.88-5.42 euros) compared with our new "nasal swab-related antibiotic protocol" (range, 10.02-32.56 euros), but in line with other antibiotic prophylaxis protocols reported in literature. DISCUSSION: The low complication rates of our case series (0%) is comparable to complication rates reported in literature (1.6% for meningitis and 8% for sinusitis). Compared with other perioperative antibiotic regimens reported in literature, the "nasal swab-related antibiotic protocol" is cheap and at least equally effective. We discuss the rationale on which we based the choice of chemoprophylaxis, the timing, and the length of our regimen. CONCLUSIONS: Our study confirmed the safety and efficacy of our easily applicable and low-cost antibiotic prophylaxis protocol.

Endoneural abscess of common popliteal nerve as first clinical manifestation of leprosy: the first reported case in history in a low-incidence country.

A migrant from Palestine came to our attention for weakness of dorsiflexion of the left foot and hypoesthesia of the homolateral common peroneal nerve territory. Skin biopsies from skin lesions in the hypoesthetic area were not diagnostic. Radiological investigation showed focal nerve enlargement with a possible focal lesion. At this time, and given the uncertainty of the diagnosis, we had to choose between medical therapy with steroid and a surgical exploration of the nerve. We decided for the latter option. Intraoperatively, we found a focal round enlargement of the nerve. Epineurotomy was performed at that level, revealing a round caseous granulomatous mass that was excised. Microbiological examination revealed presence of Mycobacterium Leprae allowing diagnosis of leprosy. Medical therapy was then started, leading to resolution of clinical symptoms. Endoneural lepromatous abscesses are uncommon lesions that should be suspected in patients presenting with peripheral nerve dysfunction with anamnesis of travel in leprosy endemic regions or contacts with people from endemic regions with or even without skin lesions. Detection of endoneural abscesses is of critical importance because prompt surgical excision in conjunction with medical therapy leads to improvement of symptoms and permits correct diagnosis. In times of large human migrations from leprosy endemic areas, knowledge of this uncommon presentation of leprosy and its management will help lead to the best management of these patients.

To give or to receive? Opinions of teenagers on kidney donation.

BACKGROUND: The attitude toward living donation varies widely in the world, for economic and cultural reasons. In Italy, as in other Mediterranean settings, the role of living kidney donation is minor. AIM: To analyze the reasons for this attitude, we gathered data in a general population sample of high school students in a large northern Italian industrial city (Torino, about 900,000 inhabitants). METHODS: Semistructured questionnaires (n = 1676), gathered in 2001 to 2002 in 14 high schools, in the context of an educational program on dialysis, renal transplantation, and organ donation, were analyzed presumably reflecting opinions gathered before the educational intervention. RESULTS: Most students, in the case of a close relative or partner needing dialysis, answer that they would donate a kidney (yes: 78.2%, no: 2.9%, uncertain-blank: 18.9%); receiving a living donor kidney is felt as disturbing: only 57.5% of the students would accept it (no: 5.9%, uncertain-blank: 36.6%), mainly because of fear of long-term problems for the donor. Donation from an older to a younger person is seen more positively than vice versa. CONCLUSION: In our settings, the attitude of the teenagers on living donation is positive; however, while "giving" is positively seen, the presence of unresolved fears is witnessed by the lower acceptance of the idea of "taking." These data suggest to focus on the risks of kidney donation in educational campaigns and in patient-physician information. The positive attitude shared by the teenagers supports the working hypothesis that lack of information is one of the determinants of the low living donor transplantation rate in our area.

Preparation of candidates for renal transplantation: cost analysis.

While the costs of renal transplantation are lower than those of dialysis, little is known about the costs of managing the waiting list. We performed a cost analysis of admission and clinical management of a waiting list for renal and pancreas-kidney transplantation. Admission to the waiting list included (1) renal graft from cadaver: minimum cost Euros () 1784.56 for men < 55 years, maximum 2127.85 for women >/= 55 years; (2) pancreas-kidney transplantation: minimum 2475.50 for men, maximum 2540.10 for women >/= 35 years. Check of suitability state on waiting list after 2 and 5 years: minimum 1400.15 for men >/= 55 years (check every 2 years), maximum 1467.07 for women >/=40, <55 years (every 5 years). The differences are related to the imaging techniques: from 43.90 (Doppler ultrasonography) to 283.28 (coronary angiography). Maintenance of the waiting list: minimum cost 1885.21 in the first year and 3187.02 in the (fifth year) for men < 55 years; maximum 2228.50 (first year) and 5116.70 (fifth year) for women >/= 55 years. These results show different costs for recipients on the basis of sex and age ranges, due to the different requirements for imaging tests such as cardiac scintiscan at age >/= 55 years) and economic charges that increase with age. Reduced waiting times allow lowered total costs. This evaluation allowed us to calculate for our region (Piemonte, Northern Italy), the management costs of the patients presently on our waiting list (369 patients at December 31, 2002) from preparation to transplantation as 959,179.18.

Patient knowledge and interest on dialysis efficiency: a survey.

BACKGROUND: Therapeutic compliance is fundamental on dialysis; however following a therapy requires a prior understanding of it. Aim of the study was to assess the need and interest for information on dialysis efficiency and to prepare a dedicated teaching tool. METHODS: 72 patients, on hemodialysis in two limited-care satellite units, were given a questionnaire testing knowledge and interest on dialysis efficiency. In a subsequent second phase, following patients' suggestions, a cartoon book was prepared and opinions recorded. RESULTS: 63 patients' returned the questionnaire. 79.4% had basic knowledge on routine blood tests, 30.1% were aware of their specific meaning. All patients asked for further information, preferring books to other media. The book "Kt/V as cartoon" was distributed; 71.2% read it, 93% scored it as good-very good. In the Unit employing flexible dialysis schedules, 22/42 patients increased dialysis time. CONCLUSIONS: Despite insufficient knowledge on dialysis efficiency, patient interest is high. An educational program is feasible and may also give practical results, such as self-increase in dialysis time.

[Daily dialysis: evaluation of the first year of experience at home and in a limited care center]. / La dialisi quotidiana: valutazione del primo anno di esperienza a domicilio ed in un centro ad assistenza limitata.

BACKGROUND: Among self dialysis treatments, daily dialysis is encountering a growing interest. Aim of this study was to evaluate results of the first year of daily dialysis in our Center. METHODS: Since November 1998, twelve patients started daily dialysis. One patient started RRT on daily dialysis; one patient was in training; 8 were on home dialysis, 3 in the limited care center. Selection of patients was performed according to wide acceptance criteria as for age (range 33-61 years), dialysis follow-up (range 1-23 years), comorbidity (=/>1 comorbid factor present in 8). Dialysis schedule consisted of 6 sessions per week (2-3 hours), blood flow 250-320 ml/min, individualized dialysate. Occasional shift to 3-4 times per week were allowed for logistic or working reasons. RESULTS: Results were analyzed taking into account patient satisfaction and main clinical parameters. In 9/12 the choice of treatment resulted from both clinical reasons and patient preferences, while in 3 was due to clinical indications (1/3 dropped out). The main reasons of choice were logistic or research of the best treatment. The most common fears regarded fistula and needle puncturing. Despite the time unconvenience, the rapidly regained well being was the reason for choosing this treatment. Also in this relatively short follow-up the favorable results reported as for weight gain, blood pressure control and metabolic pattern are confirmed. The few side effects were multifactorial (fistula thrombosis after blood pressure normalization, 2 recurrences of atrial fibrillation). CONCLUSIONS: In conclusion, daily dialysis resulted also in our centre as a promising alternative even in difficult patients.

Daily dialysis Kt/V and flexible schedules: is it possible to control efficiency, when and how?

BACKGROUND: Daily hemodialysis is a promising treatment schedule but uniform criteria for defining efficiency are lacking. METHODS: On our daily dialysis (DD) schedule, duration is flexible (2-3 hours, patients are free to add up to 30 min/session), Qb 250-350 mL/min; dialyser 1.6-1.8 m2. Study was performed on 12 pts on DD for > or = 2 months, with > or = 4 Kt/V on subsequent days, tested in the same laboratory. GOAL: To evaluate variability and identify a simple method for weekly calculation, Kt/V was assessed for 133 sessions. RESULTS: On flexible DD, variability of Kt/V-session is high (relative error 4.9%-22%). On flexible schedules, within the time range chosen (2-3 hours) variability of average hourly Kt/V is lower (standard deviation: min (0.014; max (0.052 hour, relative error 4.9%-10%) allowing calculation of weekly Kt/V (averaging 3 sessions: relative error < 6%) suitable for clinical practice. CONCLUSIONS: Flexible schedules, allowing patients to increase treatment time, are an interesting clinical option, but a challenge for Kt/V assessment.

Henoch-Schönlein purpura after 20 years of renal replacement therapy.

While the clinical impact of the impaired immune response, commonly described in chronic dialysis patients, is still a matter of discussion, it is usually considered that immunological diseases tend to become progressively less active after the start of regular renal replacement therapy (RRT). We reported a case of Henoch-Schonlein Purpura in a 51-year-old male, on RRT for 20 years, 8 on dialysis and 12 with renal graft, because of ESRD of unknown origin (chronic glomerulonephritis?). The acute onset of the syndrome, presenting purpuric rash, abdominal discomfort and asymmetric joint pain with edema and local signs of acute inflammation, was followed by several relapses over a 2 years period. This biopsy proven diagnosis offered an explanation for his chronic renal failure; furthermore, we conclude that, possibly because of the usually good correction of uremic immunodepression by efficient dialysis (this patient's Kt/V ranged from 1.1 to 1.3 according to Lowrie's formula), the possibility of immune diseases should be carefully considered even in long long-term RRT patients.

Modelling the "ideal" self care--limited care dialysis center.

Limited care dialysis is an interesting option, which has gained attention in several settings because of the aging of the uremic cohort. The aim of this study was to assess its potential in the Piedmont region in northern Italy, evaluating patients' and care-givers' preferences and testing them in a mathematical model of organisation. The study was conducted in the satellite unit of a university hospital (200-210 dialysis patients), following 35 patients (15 at home, 20 in the center, 10 on daily dialysis). Opinions were collected with a questionnaire and features identified were empirically tested through a simulation model. Most patients (34/35) preferred a small unit, with a stable caring team. Further options were flexibility of dialysis schedule, multiple treatment options, integrated center/home care. These needs could be met by a flexible organization including conventional dialysis (3/week) and daily dialysis (6/week). We employed a simulation model (ARENA software) to calculate the nurses required for each shift and the opening hours and best schedule for the unit. Addition of daily dialysis (2-3 hours) to two conventional 4-5 hour sessions to increased the number of patients followed or "spared" beds, ensuring flexibility. According to patients' best choice (7 dialysis stations), and to the recorded calls, the needs are for two nurses per shift, two shifts per day and six nurses for up to 30 patients in limited care. In conclusion, small centers with flexible schedules can tailor dialysis to patients' needs. A managerial approach is valuable for testing cost/benefit ratios in specific contexts.

[The status of peritoneal dialysis in Piedmont by 12/31/1997]. / La situazione della dialisi peritoneale in Piemonte al 31/12/1997.

BACKGROUND: The aim of the study is to examine the situation of chronic uremia substitutive treatment by means of peritoneal dialysis in Piedmont on December 31, 1997 using data from the Piedmont regional dialysis and transplant register. METHODS: Starting from the year 1981, data are reported (absolute, per million population, and according to different patient's anagraphic ages) about peritoneal dialysis prevalence and incidence; about basic nephropathies; drop-out from treatment; patient's rehabilitation; complications incidence, particularly peritonitis; patient's survival compared with survival of patients treated, during the same years with extracorporeal techniques. RESULTS: The data demonstrate, during these years, an increase of peritoneal dialysis incidence and prevalence; patients' survival curves, compared with those of patients treated with extracorporeal techniques, are very similar during the first years of treatment and worse afterwards, but never reaching statistical significance. CONCLUSIONS: They support Peritoneal Dialysis as a very good kind of substitutive treatment for some years, but this opinion deserves further examination and investigation on a longer period of time.

Education as a clinical tool for self-dialysis.

Therapeutic compliance and patient education are presently considered crucial parts of end-stage renal disease (ESRD) therapy. In the center where Italian home and self-care dialysis treatment started, an education program was designed as multi-step pathway--following patients from chronic renal failure to dialysis and eventual graft--employing lessons, booklets, and books. Each step was validated in various subsets of patients. Lessons involved two hours of informal discussion on the main aspects of ESRD and renal replacement therapy (RRT); booklets were created from tape recordings of the lessons. Patient participation was good, with 28 of 33 patients on charge in the center for 6 months or more taking part in more than one lesson in 1999. In 16 of 16 patients who answered a questionnaire after two lessons, expressed opinion was "good" to "fair." All asked for further material. With regard to books, 500 copies of the book What does dialysis mean? were given out in the region; this book was validated in 22 patients on peritoneal dialysis (PD) and 18 on hemodialysis (HD). It helped patients to accept dialysis in 65% of cases and to comprehend it in 90%. Four thousand copies of the book Stories, containing 18 interviews on transplantation, were printed, and this book was validated in 21 patients on self-care and 35 on hospital dialysis (potential candidates for graft). Of 56 patients, 53 asked for further material; 19 changed their initial opinion (10 choose transplantation, despite initial skepticism; 9 put off transplantation, despite initial acceptance). On a local scale, the program led 12 of 18 new patients, who followed at least part of the program, to choose self-dialysis (PD, home, and self-care dialysis).

[Research potential of a regional registry]. / Potenzialità di ricerca di un registro regionale.

BACKGROUND: The need for data bank gathering information in dialysis patients is as old as dialysis. Dialysis Registries presently active are characterized by different policies of data gathering (large vs small number of information) and of use (research vs economical or clinical purposes). Aim of the work was a discussion on the use of a Regional Registry (RPDT, Regional Registry of Dialysis and Transplantation of Piedmont, Italy), gathering since 1981 a wide set of information (about 80 items) on all patients treated in a relatively small area (about 4,300,000 inhabitants). METHODS: Two researches were selected: the first includes patients treated for > or = 20 years by RRT. Cases were identified on the basis of RPDT data and an inquiry regarding all patients was performed, with specific interest on comorbidity. The second includes diabetic patients on regular RRT, a sample of which was further analyzed in high detail. RESULTS AND CONCLUSIONS: While a Regional Registry, even gathering a wide set of data is unable to answer to the most qualitative questions, such as quality of life, its archives are a powerful tool to identify cases. Furthermore, ad hoc inquiries may represent a way to control quality of data or to test new fields to be studied. In the case of patients with long RRT follow-up, comorbidity questions were tested before being included on RPDT. In the case of a sample of diabetic patients, type of diabetes and cause of ESRD were controlled. This biunivocal relationship between clinical work-up and epidemiological archives may often interest future perspectives.

[Epidemiologic analysis of the incidence of new diabetic patients on dialysis as a basis for a clinical study]. / Analisi epidemiologica dell'incidenza dei nuovi ingressi diabetici in dialisi come base per uno studio clinico mirato.

BACKGROUND: Aim of this study is to analyse the incidence of diabetic patients starting dialysis in Piedmont (Italy) during the period 1981-1996 and to evaluate, in a subgroup of patients, the causes of uremia (diabetic nephropathy or other), and the type and seriousness of comorbid factors, in order to define the clinical conditions and try to explain the causes incidence increase. METHODS: Data are taken from the RPDT (Regional Registry of Dialysis and Transplantation of Piedmont). RESULTS: Total incidence of new patients starting dialysis in this Region increased from 65 pmp in 1981-1982 to 116 pmp in 1995-1996 and the mean age increased from 55.4 +/- 15.5 years in 1981-1982 to 61.5 +/- 15.6 in 1995-1996; 49% of patients had at least one of the 13 conditions of comorbidity considered by the Registry (including severe vascular, cardiac, systemic diseases and diabetes). In the same period the incidence of diabetic patients increased from 6 pmp (1981-1982) to 19 for males and 12 pmp for females (1995-1996); this increase is higher for males and limited to patients with age > or = 60 years (for example: group 70-79 years from 7 to 56 pmp). A study performed in a group of 64 patients (52 type 2 and 12 type 1) showed the incidence of multiple comorbid factors: the most important in type 2 are vascular diseases (44/52) and heart diseases (20/52); blindness and amputations are relatively rare (2 each). An important comorbid factor in type 1 diabetes is blindness (3/12) and in this group the most frequent cause of uremia is diabetic nephropathy (DN) (9/12); in the group of type 2 patients nephroangiosclerosis and a clinical picture of progressive renal failure, without nephrotic syndrome, represents 48% of all diagnoses. CONCLUSIONS: These results underline the necessity of a strict collaboration with diabetologists and of an improvement of dedicated structures in order to meet the increase of this critical population.

[Social rehabilitation, state of the disease and quality of life. What are the parameters to evaluate rehabilitation of the patient under dialysis in the '90s?]. / Riabilitazione sociolavorativa, stato di malattia e qualità di vita. Quali indicatori per il paziente in dialisi negli anni '90?

The parameters used at present by the Piedmont Dialysis and Transplant Register to evaluate rehabilitation and quality of life of the dialyzed patients have been useful in the past, but they will no longer be so in the future, as the typology of the dialyzed patient is changing: the mean age is increasing, patients with high-risk conditions as vasculopathy and diabetes are widely accepted to the treatment. Thus, rehabilitation has to be evaluated not only from a social and professional viewpoint, but also as "illness situation" and "quality of life" and this can be done using the Karnofsky scale and the test of Spitzer: our Register needs to be implemented in the future by such evaluations, to go on giving us useful information about rehabilitation of the dialyzed patients.

[Patients with neoplastic disease or older than 80 years of age: dialysis survival]. / Pazienti con patologia neoplastica o di età superiore ad 80 anni: destino dialitico.

In several European countries, including Italy, the resident population is ageing. This process is at the basis of the progressive increase in incidence of new elderly patients starting dialysis and, to a lesser degree, of patients affected by severe comorbid conditions, such a neoplasia. The aim of the study was an analysis of the situation in Piedmont (Northern Italy, 4,400,000 inhabitants): out of 4483 new entries in 1981-1993, 192 were aged 80 years and 87 were affected by renal neoplasia or by multiple myeloma. Incidence of patients aged 80 increased throughout the period; use of high tolerance techniques increased in the meantime allowing an improvement in survival results. The high incidence of vasculopathic patients and the high rates of death from cachexia pinpoint how much still has to be done in the field of prevention, even before dialysis starts.

[Clinical and epidemiologic characteristics of selected long-term survivors undergoing dialysis]. / Caratteristiche cliniche ed epidemiologiche di pazienti selezionati da una lunga sopravvivenza in dialisi.

At the end of December, 1993, 389 patients treated by means of dialysis for more than 15 years were registered in the Piedmont Dialysis and Transplantation Register; among them, 183 were alive. Characteristics of these patients as age at the beginning of dialytic treatment, casual nephropathies, causes of death, high risk conditions, dialytic schedules, vascular access, hospitalization requirements, rehabilitation, dialysis efficacy, gross mortality, were compared with those of patients treated for a shorter time, concluding that a very long dialytic survival can be achieved with a good clinical and social rehabilitation.

[Diabetes mellitus is currently one of the most frequent causes or associated causes of uremia. Data from the Piedmont registry of dialysis and transplantation (update, December 1993)]. / Il diabete mellito rappresenta attualmente una delle cause-concause più frequenti di uremia. Dati del registro piemontese di dialisi e trapianto (aggiornamento al dicembre 1993).

A regular dialytic treatment of diabetic patients is until accepted from about twenty years in many areas. Aim of this work was a retrospective analysis of main clinical and survival data of diabetic patients (diabetic nephropathy or diabetes as comorbidous factor = 659 cases) admitted for dialysis in Piedmont (Northern Italy Region about 4,400,000 inhabitants) in the period 1981-1993 (functional recovery and follow-up < 1 month excluded). A progressive increment in incidence of diabetic patients was seen mostly in the aged. At 12/31/1993, 263 of 2404 patients admitted for dialysis were diabetics (10.9%); the majority of them was treated in Hospital Centers with bicarbonate haemodialysis (54.4%), while a small group was treated with CAPD (12.9%). During the years ¿80 was seen a progressive leaving of CAPD as first choice method in this population and in the last period the orienteering is the utilization of mixed methods (diffusive-convective as first choice). As regards the survival are not prominent significant differences between this cohort and the cohort affected by vasculopathy as comorbidous factor (86.2 and 54.2% in diabetics vs 78.6 and 55.2% in patients affected by vasculopathy at 1 and 3 years--p = 0.3481; patients aged 45-64 years). In conclusion the cohort of diabetic patients represent a good marker of the clinical problems of the elder population with high clinic risk, in progressive increasing in our Region.