Resource utilization and direct costs of pediatric HIV in Italy.

This multicenter, prospective, observational study assessed the global economic impact of HIV care in a large cohort of HIV-infected children and adolescents in Italy. Three pediatric departments of reference participated on a voluntary basis. Centers were asked to enroll all their children during the period April 2010-March 2011. At enrollment, a pediatrician completed a questionnaire for each patient, including the type of service at access (outpatient consultation or day hospital), laboratory tests, instrumental examinations, specialists' consultations, antiretroviral therapy and opportunistic illness prophylaxis. Eligible patients had a confirmed diagnosis of HIV infection caused by direct vertical maternal-fetal transmission, their age ranging from 0 to 24 years. Since patients routinely have quarterly check-ups in all three centers, we adopted a three-month time horizon. Health-care services were priced using outpatient and inpatient tariffs. Drug costs were calculated by multiplying the daily dose by the public price for each active ingredient. A total of 142 patients were enrolled. More than half the patients were female and the mean age was 14 years, with no significant differences by center. There were substantial differences in health-care management among the three centers, particularly as regards the type of access. One center enrolled the majority of its patients in day-hospital and prescribed a large number of clinical tests, while children accessed another center almost exclusively through outpatient consultation. Drug therapy was the main cost component and was very similar in all three centers. The day-hospital was the second highest cost component, much higher than outpatient consultation (including examinations), leading to significant differences between total costs per center. These findings suggest that a recommendation to the Italian National Health Service would be to use more outpatient consultation for patients' access in order to increase their efficiency in treating pediatric HIV infection.

MDCT in diagnosing acute aortic syndromes: reviewing common and less common CT findings.

Nontraumatic acute thoracic aortic syndromes (AAS) describe a spectrum of life-threatening aortic pathologies with significant implications on diagnosis, therapy and management. In this context, multidetector computed tomography (MDCT) is the gold standard due to its intrinsic diagnostic value; its performance approaches 100% sensitivity and specificity, and it is accepted as a first-line modality for suspected acute aortic disease. MDCT allows early recognition and characterisation of acute aortic syndromes as well as the presence of any associated complications - findings that are essential for optimising treatment and improving clinical outcomes. Although classic CT findings have long been known, other unusual signs are continually reported in the medical literature. We reviewed the classic and less common CT findings, correlating them with pathophysiology, timing and management options, to achieve a definite and timely diagnostic and therapeutic definition.

H1N1 pneumonia: our experience in 50 patients with a severe clinical course of novel swine-origin influenza A (H1N1) virus (S-OIV).

PURPOSE: The authors reviewed chest radiographs (CXR) and thin-section computed tomography (CT) findings of pulmonary complications in a selected population of 50 consecutive patients with severe novel swine-origin influenza A (H1N1) virus (S-OIV) pneumonia who were seen at the Subintensive Respiratory Unit (UTSIR) and at the Intensive Care Unit (ICU) at Monaldi Hospital, Naples, Italy. MATERIALS AND METHODS: CXR and CT findings of 50 patients who fulfilled the World Health Organisation (WHO) criteria for S-OIV infection were reviewed by four radiologists. The final study group of 50 patients was divided into two subgroups on the basis of clinical course: group 1 consisted of 42 patients requiring noninvasive mechanical ventilation and admitted to the UTSIR; group 2 consisted of eight patients who required ICU admission and extracorporeal membrane oxygenation or advanced mechanical ventilation from October 2009 to December 2009. All patients underwent CXR and thin-section multidetector CT (MDCT) scan; the initial and follow-up radiographs and CT scans were evaluated for the presentation and follow-up pattern (consolidation, ground-glass opacities, nodules, reticulation), distribution and extent of abnormality. RESULTS: All patients had radiological signs of pulmonary involvement. Ground-glass opacity and consolidation, which was mainly peripheral, was the most frequent finding. In three patients, we report for the first time in viral pneumonia the reversed halo sign. Lesion extent was related to aggressiveness of the illness. More often, both lungs were involved (82%). Thoracic comorbidity was present in 18% of patients; 22% of patients was obese, and in this group, the clinical course was more aggressive than in the others with the same lesion extent at imaging. Furthermore, superinfection led to worsening of the clinical conditions. CONCLUSIONS: The most common CXR and CT findings in patients with S-OIV infection were unilateral or bilateral ground-glass opacities with or without associated focal or multifocal areas of consolidation. On MDCT, ground-glass opacities and areas of consolidation had a predominant peribronchovascular and subpleural distribution, resembling organising pneumonia; they progressed to bilateral extensive airspace disease in severely ill patients.

Unusual complications of endovascular repair of the thoracic aorta: MDCT findings.

With the development of minimally invasive surgical techniques, endovascular stent-graft placement has become an accepted and widely used alternative to the traditional surgical repair of aortic disease and is gaining acceptance as the treatment of choice. Many studies show that endovascular stent-graft therapy is safe and effective, although complications related to this treatment are also recognised. Although the incidence of major complication is low, neurological sequelae remain the major concern of endovascular repair. With growing experience, however, the spectrum of mid- and long-term complications has broadened to include potentially disastrous events, other than paraplegia or stroke, that require diligent surveillance. Three-dimensional data sets acquired quickly by multidetector computed tomography (MDCT) allow multiplanar reformations and 3D viewing, as well as quantitative assessment of vessel lumens, walls and surroundings. Although a large portion of radiologists will not be involved in the actual endograft deployment, many will be involved in the interpretation of postprocedural surveillance studies. Accordingly, the goal of this report is to summarise our experience with the presentation, diagnostic approach, management and outcomes of these unusual, but potentially catastrophic, postendovascular aortic repair complications to highlight their significance and increase familiarity with them among the imaging community. Increasing awareness of these complications may facilitate rapid diagnosis and/or triage and treatment.

Adult-onset pulmonary involvement in Niemann-Pick disease type B.

Niemann-Pick disease type B is caused by a deficiency in acid sphingomyelinase activity; among the six variants of Niemann-Pick disease known to date, it is the most frequently associated with lung involvement, a major cause of morbidity and mortality in this subtype in patients of all ages. Nevertheless, the vast majority of reports in the literature concern infantile forms, while less reported is, for several reasons, the onset in adults being consequently still poorly understood and characterized its clinical, radiographic and functional manifestations. We report a case of a 37 years-old female patient affected by subtype B since she was an infant, operated for aortic valve replacement two years before and came to our attention for the onset of a worsening exertional dyspnoea which proved, through a series of functional tests and radiological exams, to be a consequence of the diffuse lung involvement by the metabolic disorder; we performed a review on this topic through a Medline search of all the available "adult-onset" case reports published since the first description in 1964, also considering the possible association between NPDB and, more generally lysosomal storage disorders, and the valvular disease, already suggested by several Authors in previous works.

Primary pleural haemangioendothelioma in an Italian female patient: a case report and review of the literature.

Primary epithelioid haemangioendothelioma (EHE) of the pleura is a rare vascular tumour that occurs mainly in men. Pleural effusion and thickening are the most common clinical presentations. A 58 year old female, nonsmoking patient presented to us with dry cough, dyspnoea and left chest pain for several weeks (no asbestos exposure). Standard chest X-ray and contrast enhanced multislice computed tomography revealed a large-size lobulated mass originating from the pleura which was diagnosed as primary pleural haemangioendothelioma (PHE) by histology and immunohistochemistry (reactivity for vimentin, CD31, CD34, Factor VIII and ulex europeaus). No metastases were detected. The patient refused treatment and died three months later due to the onset of acute and progressive respiratory failure. Despite the lack of high-grade malignancy, primary PHE displays a poor prognosis while curative therapies are actually not available. To our knowledge, this is the first case of primary PHE in a female patient occurring in Italy and the third one to have been reported in English literature. Difficulties in diagnosis and treatment management are discussed below.

Nonbronchoscopic lung lavage for diagnosis of opportunistic infection in AIDS.

Thirty patients known to have or suspected of having acquired immunodeficiency syndrome (AIDS) were evaluated for opportunistic pulmonary infection using a double lumen lavage catheter (DLL). Lavage specimens obtained were cytocentrifuged and initially stained by the Papanicolaou technique as a means of rapid evaluation for Pneumocystis carinii. If no opportunistic organism was identified, the patient underwent further diagnostic investigations. In 18 patients receiving mechanical ventilatory support, the procedure was performed via the endotracheal tube. Twelve patients who were less severely ill underwent the procedure via the transnasal route. In 43 percent (13/30), opportunistic infections were diagnosed by DLL. Twelve had P carinii, one of whom had cytomegalovirus and another of whom had Herpes simplex viruses, and one with Toxoplasma gondii. Thus, the sensitivity for all opportunistic infections was 86 percent (12/14). The volume of fluid recovered averaged 93 percent of that instilled. There was no significant difference between prelavage and postlavage PaO2. In this group of patients, double lumen lavage obviated the need for more invasive and expensive procedures.

Retraction brain ischaemia: cerebral blood flow, evoked potentials, hypotension and hyperventilation in a new animal model.

Undue intraoperative brain retraction can cause significant neurosurgical morbidity. By combining brain retractor blade pressure measurement with monitoring of brain electrical activity, one can determine the limits of safe brain retraction and then test systematically various therapeutic interventions. Cortical evoked potential (EP) mapping and laser-Doppler cerebral blood flow (CBF) measurement were undertaken during brain retraction in the miniature swine (Sus scrofa). Forelimb somatosensory EP recording during subtemporal retraction simulated the pterional and subtemporal approaches, respectively. Retraction pressure of 30 mmHg usually resulted in a 50% decrement in EP amplitude after 10 to 20 minutes in normotensive, normocapnic adult animals. Recovery of EP occurred within 5 to 10 minutes of retraction release. The effects of animal age, induced hypotension (nitroprusside, MAP approximately 40), and induced hypocapnia (hyperventilation, PaCO2 approximately 28) on EP preservation during retraction were then investigated, with data reported here from 23 animals (8 to 35 kg). By Spearman rank correlation coefficients, early loss of EP was associated with the following: lower MAP (p approximately 0.0001), lower CBF (p approximately 0.0005), lower PaCO2 (p less than 0.001), and older age (p approximately 0.01). These results indicate (1) retractors should be relaxed every 10-15 minutes whenever possible (for at least 5 minutes), and (2) hypotension, in particular, but also hypocapnia (hyperventilation) should not be used indiscriminately. Details of this new model of retraction ischaemia are presented.

Retraction brain ischaemia: mannitol plus nimodipine preserves both cerebral blood flow and evoked potentials during normoventilation and hyperventilation.

In our miniature swine model simulating operating room brain retraction, we investigated the effects of mannitol plus nimodipine on cerebral blood flow (CBF) and evoked potentials (EP) ipsilateral and contralateral to retraction, in comparison with either agent alone, during both normoventilation and hyperventilation. We here report results in 27 animals with intravenous mannitol (2 g kg-1 over 15 min) and/or nimodipine (1 microgram kg-1 min-1 constant infusion). Mannitol plus nimodipine was superior both to controls and to either mannitol alone or nimodipine alone in preserving EP amplitude ipsilateral to retraction during both normoventilation and hyperventilation. Mannitol alone was effective in normoventilation at preserving EP, while nimodipine alone was effective in hyperventilation. No significant asymmetries in CBF or EP were seen with mannitol plus nimodipine in either normoventilation or hyperventilation. By five minutes postretraction CBF had returned to preretraction values for all groups, and EP amplitude had returned also except for hyperventilated controls. In this model of brain retraction, mannitol plus nimodipine is superior to either agent alone in maintaining both CBF and EP when normoventilation and hyperventilation are employed. The results are discussed in terms of the possible mechanisms for the different and complementary effects of mannitol and nimodipine.

Total or partial percutaneous renal ablation in the treatment of renovascular hypertension: radiological and clinical aspects.

In 15 patients with renovascular hypertension, considered unsuitable for angioplasty or surgery, percutaneous renal ablation was performed by injection of ethanol into the renal vasculature. Partial or complete renal ablation was confirmed by follow-up intravenous pyelography or arteriography. Patients were followed-up for a mean of 24.8 months after therapy and blood pressure was improved in all patients with five being cured. This study shows that percutaneous renal ablation is a useful and successful method of therapy for renal hypertension, and that it should be considered in patients unsuitable for surgery or angioplasty.

Effects of mannitol on cerebral blood flow, blood pressure, blood viscosity, hematocrit, sodium, and potassium.

In our miniature swine model of brain retraction ischemia under conditions simulating the neurosurgical operating room, we studied the effects of bolus mannitol (2 g/kg) administration on cerebral blood flow, blood pressure, blood viscosity, hematocrit, sodium, and potassium serially for 4 hours following administration, at which time a second bolus was administered. Both viscosity and hematocrit were significantly decreased transiently following both the first and second boluses. Sodium was decreased for 30 minutes following the first bolus, 15 minutes following the second bolus, and increased at 150 minutes and later following the second bolus. There was a mild decrease in blood pressure and a mild increase in cerebral blood flow following mannitol, but little difference between the first hour following a bolus (when the viscosity and hematocrit were decreased) and hours 2-4 (when they were near baseline). Mannitol's effects on blood pressure and cerebral blood flow probably depend on factors in addition to its effects on blood viscosity and hematocrit. The results are discussed in light of previous findings that bolus mannitol administration may improve cerebral blood flow in ischemia, but does not appear to benefit the preservation of brain electrical activity.

Diagnostic and therapeutic approach to minimal breast cancer.

The term "Minimal Breast Cancer" includes different neoplastic changes, the common characteristic of which is an high survival rate (90% of cases) when the treatment is early started. In all patients with palpable nodules and in patients "at risk", thermography, mammography, xerography, echography and cytological examination by suction-needle, must be performed to rule out the existence of a "Minimal Breast Cancer". The methods of treatment preferred by the Authors, according to the different types of pathological changes, are the following: a) through follow-up or, alternatively, subcutaneous mastectomy when a "lobular carcinoma in situ"; b) subcutaneous mastectomy and axillary emptying when the diagnosis is found in "intraductal carcinoma"; c) mastectomy, performed according to Patey's technique, or removal of all the involved breast quadrant, axillary emptying and radiotherapy of the residual glandular parenchyma in case of ductal carcinoma or invasive lobular carcinoma less than 0.5 cm in diameter.

[Preoperative evaluation of bronchogenic cancer by traditional and computerized tomography]. / Valutazione preoperatoria del cancro broncogeno mediante tomografia tradizionale e tomografia computerizzata.

The Authors verified the diagnostic incremental data furnished by computerized tomography in respect to traditional tomography in assessing and staging lung cancer. This comparative study was based on eight diagnostic parameters, analysed in 150 strongly suspected patients. It is concluded that computerized tomography allows to give a very accurate judgement about the stage of the cancer, reducing the need of diagnostic thoracotomies.

The biological activity of ABA-1-like protein from Ascaris lumbricoides.

The elevation of non-specific IgE (total IgE) in Ascaris infection can be seen one week after infection, and reaches a peak after approximately two weeks. It has been reported that ABA-1 protein is the main constituent in the pseudocoelomic fluid of Ascaris suum. To investigate the effect of the ABA-1-like protein from Ascaris lumbricoides (ALB), the cDNA was cloned by reverse transcriptase polymerase chain reaction, using original primers based on the consensus sequences of ABA-1 and TBA-1, that is an ABA-1-like protein from Toxocara canis. The clone was sequenced, we constructed the recombinant polyprotein of ALB (rALB14 and rALB7) based on the ALB sequence, and rALB was administrated to BALB/c mice. Fourteen days after inoculation with rALB14 which is the full length of ALB, the elevation of total IgE which we supposed to contain non-specific IgE was observed, and the results were as we expected. Furthermore, in an in-vitro experiment, we confirmed that the spleen cells proliferated when stimulated by rALB14 and concanavalin A. Therefore, the whole conformation of ALB is considered to be involved in the elevation of non-specific IgE, and is involved in the activation of T cells.

[The chemical structure of new substance as the metabolite of baicalin and time profiles for the plasma concentration after oral administration of sho-saiko-to in human].

Baicalin (BG) is one of the major components of Sho-Saiko-To. We found a new substance as the metabolite of BG in human plasma after oral administration of Sho-Saiko-To. The metabolite was identified as baicalein 6-O-sulfate (BS) by comparing its retention time in HPLC and electrospray ionization mass spectra (ESI-MS)/MS methods with that of an authentic sample. Time profiles for the plasma concentrations of BS and BG after oral administration of Sho-Saiko-To (EK-9) at a daily dose (6 g), were investigated in 14 healthy male volunteers. The determination for the concentrations of BS and BG in human plasma was developed by the HPLC method using electrochemical detector (ECD). Each 1 ml of the plasma specimen was used for the solid phase extraction. The calibration curves of BS and BG showed a good linearity between 5 and 300 ng/ml. The quantitative limits of BS and BG in human plasma were 5 ng/ml. Using this method, BS was detected after 1 h, reached a maximum level at 5 h and then decreased to the level less than the quantitative limit after 36 h, and the plasma level of BS showed a slight peak at 24 h. BG was detected after 1 h, reached a maximum level at 5 h and then decreased to the level less than the quantitative limit after 36 h, and the plasma level of BG showed two peaks at 12 h and 24 h.

[A case of nephrotic syndrome after bone marrow transplantation].

We reported a 27-year-old man who developed nephrotic syndrome 12 months after a bone marrow transplantation from his HLA-identical sister for chronic myelocytic leukemia. Anti-nuclear antibodies had been serially investigated after the bone marrow transplantation. They were detected in his serum 5 months before the appearance of proteinuria, but he tested negative at the onset of nephrotic syndrome. Histological analysis of the renal biopsy revealed subepithelial and subendothelial immune deposits in the glomerular basement membrane with increased mesangial matrix and cells. These findings suggested immune complex glomerulonephritis due to chronic graft-versus-host disease (GVHD) after bone marrow transplantation. In murine experimental chronic GVHD, anti-nuclear antibodies, which generate immune complexes that deposit or form in the kidney have been detected.