Mirtazapine in an HIV-1 infected patient with progressive multifocal leukoencephalopathy.

We describe the clinical course of an HIV-infected patient with progressive multifocal leukoencephalopathy who took mirtazapine for his depression. After six months of therapy the clinical symptoms had not worsened and the neuroradiological image of the brain was unchanged. Further studies are necessary to determine the effect of serotonin receptor antagonist in treating PML associated to HIV.

Endothelin-A blockade attenuates systemic and renal hemodynamic effects of L-NAME in humans.

Eight Na-repleted volunteers underwent 3 separate 90-minute infusions of either N(G)-nitro-L-arginine methyl ester (L-NAME) 3.0 mg. kg(-1). min(-1) or endothelin-A receptor (ET-A) blocker BQ-123 (BQ) 0.125 nmol. kg(-1). min(-1) or both. Mean arterial pressure (MAP), glomerular filtration rate (GFR), renal blood flow (RBF), renal vascular resistances (RVR), and sodium excretion rate (UNaV) were measured at baseline (b) and from 0 to 45 minutes (period 1) and 45 to 90 minutes (period 2) of infusion. BQ alone had no effect. GFR declined by 4.9% (P<0.001 versus b) in period 1, to 9.9% (P<0. 001) in period 2 with L-NAME, and by 3.3% (P<0.01) to 6.6% (P<0.001) with L-NAME plus BQ (P=NS between L-NAME and L-NAME plus BQ). UNaV fell equally with L-NAME or L-NAME plus BQ. MAP rose significantly in period 2 with L-NAME (6.9%; P<0.001) but not with coinfused BQ (2. 1%; P=NA versus b, P=0.005 versus L-NAME alone). RBF declined by 12. 2% (P<0.001) to 18.3% (P<0.001) with L-NAME and by 4.6% (P<0.005) to 8.2% (P<0.001) with L-NAME plus BQ. These changes were smaller with L-NAME plus BQ (P<0.05 in period 1 and P<0.02 in period 2). Blunted changes were also seen for RVR (P<0.005 in period 1 and P<0.001 in period 2 between L-NAME alone and L-NAME plus BQ). These findings show that systemic and renal vasoconstriction due to L-NAME are attenuated by BQ, which suggests that an interaction between endogenous nitric oxide production and ET-A activity participates in the maintenance of baseline systemic and renal vascular tone in humans.

[Effect of iron depletion on long-term response to interferon in patients with chronic hepatitis C with increased plasma iron without accumulation of liver iron]. / Effetto della ferrodeplezione sulla risposta a lungo termine all'interferone in pazienti affetti da epatite cronica C con aumentato ferro plasmatico senza accumulo di ferro epatico.

We studied the effect of iron depletion on the response to subsequent interferon therapy in a population of 83 patients affected by chronic hepatitis C who had not previously undergone any specific therapy and who had laboratory confirmation of iron overload (serum ferritin > 400 ng/mL in the males and > 300 ng/mL in the females). The population was divided into two homogeneous groups. Group A consisted of 43 patients who underwent phlebotomy (300 mL every 10-15 days for an average total of 8 sessions) until serum ferritin levels of < 100 ng/mL were obtained. The 40 patients in Group B were treated with interferon without prior iron depletion. Iron depletion alone, induced in Group A, brought about a highly significant (p < 0.01) reduction of alanine aminotransferase serum values: from 165 U/L (range 60-370 U/L) to 67 U/L (range 27-158 U/L). Seventy-six patients completed therapy and follow-up: a complete and sustained response was obtained in 12/39 cases in Group A and in 6/37 cases in Group B (p < 0.05). Iron depletion carried out in patients with chronic hepatitis C, who have elevated base values of serum ferritin, induces a significant reduction in necro-inflammatory activity (notable decrease in average alanine aminotransferase values) and improves the response to subsequent treatment with interferon, although it does not modify the viral load.

[Current diagnosis of gastroesophageal reflux disease: learning experience]. / Diagnosi attuale della malattia da reflusso gastroesofageo: esperienza di scuola.

The authors report their study on gastro-esophageal reflux disease, a pathology that has become increasingly common over the past years reflecting both a real increase and the use of new and more sophisticated and reliable diagnostic methods and tests. It can be included in the group of pathologies absorbing the largest proportion of financial resources, even exceeding biliary lithiasic disease according to American studies. The authors start by analysing the symptoms of gastroesophageal reflux disease, drawing a distinction between typical (heartburn, epigastric pain and postprandial regurgitation) and atypical symptoms (laryngotracheal symptoms, bronchopulmonary symptoms and esophageal motor incoordination). They outline the diagnostic iter and tests most widely used today to achieve a correct diagnosis. Lastly, they report their experience of 160 patients attending their esophageal diagnostic unit since January 1999 who underwent a number of different instrumental tests, the results of which are compared. Three different aspects are compared: the presence of symptoms, 24-hour pH-metry and endoscopic tests. All these are necessary for a correct diagnosis of gastroesophageal reflux disease and to evaluate the possibility and efficacy of surgery. They emphasise the diagnostic importance of 24-hour pH-measurement as the only test that can directly reveal gastroesophageal reflux. Positive pH results represent a discriminating element in deciding whether the patient should undergo surgery.

[Gastroduodenal reflux after laparotomic or laparoscopic cholecystectomy]. / Il reflusso duodeno-gastrico dopo colecistectomia laparotomica o laparoscopica.

BACKGROUND: The authors analyse gastroduodenal reflux (GDR) in the light of the progress made over the past ten years. The good results achieved using mini-invasive techniques in cholecystectomy prompted the authors to compare laparotomic and laparoscopic cholecystectomy in order to evaluate the influence of both techniques in determining GDR and clinical symptoms. METHODS: Symptoms were evaluated before and after surgery in 30 patients operated using a laparotomic technique and in 30 patients operated using a laparoscopic technique. Two groups of 10 patients, operated respectively using laparotomic and laparoscopic techniques, were studied both clinically and endoscopically before and after surgery. RESULTS: The analysis of the results shows a lower incidence of GDR and typical symptoms of GDR in patients undergoing laparoscopic surgery. The rationale underlying the lower incidence of GDR and its symptoms in these patients compared to the more conventional group is not completely clear. CONCLUSIONS: These results may be influenced by reduced surgical trauma and the careful selection of case or the laparoscopic technique, hence the exclusion of cases complicated by severe cholecystitis.

[Duodeno-gastric reflux in gallbladder stones and after laparotomic cholecystectomy]. / Il reflusso duodeno-gastrico nella calcolosi della colecisti e doppo colecistectomia laparotomica.

BACKGROUND: Duodeno gastric reflux (DGR) is still a not well-defined condition, even though it has been the subject of different studies for many years. METHODS: The authors examine its relation with gallstones before and after the surgical removal of the gallbladder. After examining various study techniques, they present their experience of DRG. In this work the methodology used in a group of 40 patients suffering from gallstones and operated by laparotomic cholecystectomy is presented. All patients have been subjected to a clinical questionnaire in order to evaluate their symptoms, before and after cholecystectomy, and at the same time they have been subjected to an endoscopic exam. It s not easy to comment the RESULTS. RESULTS: Actually, of 32 patients (80%) showing DGR symptoms before surgical treatment, 20 showed their persistence, worsening, or the appearance of new symptoms after cholecystectomy, while 12 were completely asymptomatic. Of 8 patients with no symptoms before cholecystectomy, 3 developed a typical DGR symptomatology while 5 were asymptomatic. CONCLUSIONS: So 57% of patients were DGR symptomatic after surgical treatment. The compromised function of cholecystitis with calculi, antrum-pyloric-duodenal motility, continuous bile flux in the duodenum, surgical trauma all interact in determining DGR.

[Surgery of large ventral hernias. Personal experience in 1990-1997]. / La chirurgia dei grandi laparoceli. Esperienza di scuola 1990-1997.

BACKGROUND: The surgical treatment of large wall defects conventionally defined as an extension over 10 cm is discussed. The difficulty to contain the bowels that have lost law of domicile in the abdominal hollow, constitutes motive for notable increase of the endo-abdominal Pressure with serious consequences in the postoperative course and this leads to the use of prothesis meshes that allow the closing of the abdominal hollow with the Tension-Free technique. METHODS: Personal experience embraces 45 patients, with large wall defects, divided into 21 patients with overumbilical location, 14 with umbilical location, 10 with periumbelical location; a simple suture has been used in 7 cases, the reconstruction of the wall according to Stoppa in 36 cases and the apposition of Goretex net internally and Marlex net externally in 2 cases. RESULTS: There have been neither mortality, neither recidivists of illness, but only some complications: 9 cases of superficial infection, 1 case of intestinal occlusion and 2 of subcutaneous seroma. CONCLUSIONS: According to their experience and wide literature review, the authors draw some conclusions: an accurate toilet and a careful evaluation of the respiratory functionality are fundamental; it's necessary to postpone surgical intervention in presence of local inflammation and, where this is improrogable it's opportune to avoid the use of prothesis meshes or refold on readsorbible prothesis; special care must be taken to the hemostasis and an aspirative drain for 24-48 hrs preserves from the risk of postoperative hematomas and following local infections. The submuscular mesh permits a Tension-Free suture and for this reason it would have nowdays a more extensive use. Finally it's pointed out the choice of a PTFEe mesh in contact with the intestinal skein.

[Secondary costal myxoid chondrosarcoma. Presentation of a clinical case]. / Condrosarcoma mixoide costale secondario. Presentazione di un caso clinico.

A type of malignant neoplasm of not frequent observation is reported and the difficulties concerning the distinction from the benign counterpart are underlined, for which a detailed instrumental study is made necessary, integrated with pre and, above all, postoperative histologic analysis. A white male patient of 83, affected by plurirecidivant chondromyxoma of the rib, was admitted for local recurrence. The lesion objectively appeared not dissimilar from the preceding ones, as an ovalar mass fixed on the underlying plains. Radiologic and ultrasonographic examinations seemed to confirm the admission diagnosis; at the end the patient underwent a new intervention. Histologic examination of the lesion yielded a diagnosis of chondromyxosarcoma. The clinical case is made even more interesting by the finding, through the TC technique, preoperatively performed, of a metastatic repetition on the opposite side. The authors examine the problem of the early recognition of a malignant neoplasm developing, in a patient with a clinical history of recidival chondromyxoma. Physical examination and laboratory analysis are not useful in the assessment of the occurring transformation. At molecular level chondromyxosarcoma is characterized by several genomic rearrangements and mutations. Though primitive chondromyxosarcoma often involves the ribs, chondromyxoma's transformation into its malignant counterpart is not a common event. The development of distant metastasis characterizes long term cases. Given the lack of encouraging results about chemo and radio-therapy efficacy in influencing the natural course of the disease, a systematic approach will be made necessary in patient management.

[Simultaneous bilateral pneumothorax. Case report]. / Presentazione di un caso di pneumotorace a contemporanea insorgenza bilaterale.

A case report of a 44 year-old white man admitted to the surgical unit for a bilateral simultaneous pneumothorax is presented. The pneumothorax occurred on day one after a surgical operation for discal hernia; in the past the patient already presented a right spontaneous pneumothorax at 32 years of age and a left pneumothorax at 37 years of age, both treated with a pleural drainage. A thoracic drain was bilaterally positioned with a good result only in the right side. The persistence of the left pneumothorax induced the authors to perform a postero-lateral thoracotomy bullae excision and pleurectomy with a good postoperative course. After a few months a new right pneumothorax occurred and the patient was treated with a right postero-lateral thoracotomy, bullae resection and pleurectomy. On the basis of the case reported, the authors consider the different opportunities in the treatment of spontaneous pneumothorax in relation to the present knowledges and technologies. Surgical procedure is to be preferred in case of persistence of pneumothorax despite a pleural drain and in case of pneumothorax in high risk subjects. Even if thoracoscopy seems to give better results regarding postoperative pain, it is not always possible with such a method to perform a careful pleurectomy neither to obtain it in all cases (above all in secondary pneumothorax). Every case must then be carefully studied to choose the best treatment at present available.

[Predisposing factors for development of cardial adenocarcinoma]. / Fattori predisponenti l'adenocarcinoma del cardias.

After a careful revision of the various papers and on the basis of their personal experience, the persons responsible for this project analyse the factors that, today, influence the development of an adenocarcinoma in the region of the gastro-esophageal junction. They also study therapeutic strategies on the basis of new findings in anatomic-physiological matters of this region. From this analysis, specialists notice an increase in adenocarcinomas which affect the gastric region of the cardia, in comparison with carcinomas which affects the gastric region in toto. By considering Barrett, Hayward, Riedel and Ruol's studies, they maintain that the fundamental factor which causes the development of cardial adenocarcinoma is the gastroesophageal reflux. This reflux acts as a chronic irritative stimulus on the esophageal wall and therefore it provokes an increase in mucous secretion and the formation of metaplasia. This metaplasia is initially mucosecreting, acid-secreting and in the end it becomes intestinal. This also leads to the appearance of absorbent calciform cells; the absorption of toxic or mutagenic substance for the cell itself, will be the next step for the development of an adenocarcinoma. Nowadays the therapy of intestinal metaplasia provides for different therapeutic levels: from the endoscopic monitoring (which is used for the most serious cases of dysplasia), to the PPI medical treatment(today in disuse), to the surgical laparoscopic treatment with non-refluxing plasty (Nissen, Toupet). This last treatment is today associated with endoscopic esophageal mucosectomy in order to achieve a better effectiveness. This happens through the use of various methodologies, for example the multipolar electrocoagulation.

[Surgery of dysphagic diseases. Personal experience (349 surgical interventions)]. / Patologie disfagiche di competenza chirurgica. Esperienza di scuola (349 interventi chirurgici).

The authors report their surgical experience relating to dysphagic diseases of the esophagus (349 cases). In the light of these results, they describe the different surgical techniques used in the various pathologies: 1) Esophageal diverticula: The value of a careful evaluation of subdiverticular spasm is emphasised using preoperative manometry in cervical and epiphrenic diverticula, leading to subdiverticular myotomy when present. 2) esophageal achalasia and intermediate motor disorder: A clear difference must be drawn between these two diseases owing to the different motor behaviour of the esophagus. Dilatation of the LES is only useful in intermediate motor disorder and should be avoided in esophageal achalasia where a gastroesophageal reflux is produced if dilatation fails. Intraoperative manometry is very useful during the extramucosa myotomy phases as an indication of the complete removal of the sphincteric barrier, thus avoiding the risk of persisting disease. 3) Non-neoplastic stenosis. In primary stenosis (caused by caustic agents, primary GER or associated with JE) a conservative approach is advisable, whereas in iatrogenic stenosis (mainly linked to dilatation or cardiac surgery), owing to the anatomic complexity of the esophagogastric junction, a more radical approach is often required in the form of esophagogastric resection or even sub-total esophagectomy. 4) Neoplastic stenosis: Leiomyomas, although unusual, represent a clear indication for thoracoscopic access, provided that the dimensions allow it. Esophageal cancers represent a major surgical problem. A radical approach is represented by TE and the subsequent use of the stomach, or more rarely, the colon to reconstruct the alimentary tract. In spite of the very low resectability rate owing to locoregional spreading, until recently palliative surgery was essential to allow patients to eat. The introduction of autoexpanding prostheses, positioned using endoscopic methods, has provided a better solution to this problem.

[Assessment of plasma lipid profile in acute coronary syndromes. The use of fibrinolytics and heparin do not affect it significantly]. / Andamento del profilo lipidico plasmatico nelle sindromi coronariche acute. L'uso di fibrinolitici ed eparina non lo modificano significativamente.

BACKGROUND: Neurohormonal and metabolic responses to acute ischemic events associated with thrombolysis and heparin induce substantial changes in the lipid profile (acute phase response). The aim of this study was to assess changes in total cholesterol and triglycerides in patients with acute coronary syndrome, admitted to our Intensive Coronary Care Unit (ICCU). METHODS: The study included 1051 consecutive patients, 316 with unstable angina, 583 with Q wave acute myocardial infarction (AMI) and 152 with non-Q wave AMI. Total cholesterol and triglycerides were measured in all patients at time 0 (admission), at time 1 (the morning following admission), at time 2 (the morning after discontinuation of heparin treatment). RESULTS: The mean value of total cholesterol at admission was 235, 210 and 197 mg% at admission, time 1 and time 2, respectively. Triglyceride levels were 234, 178 and 189 mg%, respectively. In the subgroup of thrombolized AMI the reduction in total cholesterol at time 1 and time 2 resulted similar in comparison with non-thrombolized AMI (p = NS). The decrease in triglycerides showed a similar pattern in the different subgroups. Comparison was also done according to sex, age, and complications. CONCLUSIONS: These data confirm that mean total cholesterol and triglycerides at admission are sharply higher than values considered normal in the literature. Within 24 hours of admission there is a 10.7% drop in total cholesterol which increases to 16.2% after a few days (mean 3.4 days). Total cholesterol determination upon admission in patients with acute coronary syndromes is necessary in order to know the true concomitant lipid profile during the precipitating ischemic events. The decision of initiating early therapy with statins would then appear more justified.

[Effectiveness and side effects of the treatment with propafenone and flecainide for recent-onset atrial fibrillation]. / Efficacia ed effetti collaterali del trattamento con propafenone e flecainide della fibrillazione atriale di recente insorgenza.

BACKGROUND: The authors report their experience in recent-onset atrial fibrillation treated with intravenous flecainide and propafenone, in comparison with the placebo group. METHODS: We randomized 352 (138 in the flecainide group, 164 in the propafenone group and 50 in the control group) consecutive patients (167 males, 185 females, mean age 59 +/- 12 years) with recent-onset atrial fibrillation. The electrocardiogram of all patients was monitored for at least 24 hours. RESULTS: The restoration of sinus rhythm occurred in 72.5, 80.4, 86.2 and 89.8% of patients in the flecainide group; in 54.3, 68.3, 75 and 92.1% in the propafenone group; in 22.2, 27.8, 35.2 and 46.3% in the control group, at 1, 3, 6 and 24 hours respectively. The occurrence of side effects was the same in all treatment groups, and occurred in about 10% of patients in the flecainide and propafenone groups, and in 4% in the control group. In our study population the treatment of recent-onset atrial fibrillation with flecainide was faster in converting the arrhythmia to sinus rhythm (p < 0.005 at 1 hour, p < 0.05 at 3 hours, p = 0.05 at 6 hours). However within 24 hours the efficacy of either flecainide or propafenone was the same (p = NS at 24 hours). CONCLUSIONS: Side effects were similar in both treatment groups. In particular malignant arrhythmias did not occur in the treatment groups and in the control group.

[Ileal occlusion caused by enterolith migrated from Meckel's diverticulum]. / Occlusione ileale da enterolita migrato da diverticolo di Meckel.

The authors present a case report of an intestinal obstruction due to a relatively big coprolite migrated from a large Meckel's diverticulum to the distal Ileum. The patients apparently healthy and a vegetarian, complained on admission of the absence of emission of faeces and gas since four days before with noticeable abdominal distension. In the physical examination he presented intestinal meteorism, a hard abdomen, painful on deep palpation in the median quadrants, especially in the epigastric and mesogastric ones. The abdominal X-RAY in the standing position confirms: an occlusive state with numerous liquid levels in the Ileum. Because of a worsening of the symptomatology and the appearance of generalized comprimission, two days later an exploratory laparotomy was performed. The intervention showed the presence of a Meckel's diverticulum with approximately 10 cm in length, with an ample neck, the distal Ileum for approximately 15 cm in dilation returned rapidly to a normal calibre, after a pastous endoluminal formation borne in the Meckel's diverticulum (Meckel resection presented actually a large niche at the fundus level with a eroded wall) and migrated in the distal Ileum where it could cause the obstruction. In the present case it is probably useful to perform a preoperative CT scan in order to get a precise etiology and perform an ascending Colonscopy, so avoiding a surgical procedure. According to the authors a CT scan is indicated in all cases of intestinal occlusion of unknown case, in order to have a more precise definition of the physiopathology of the occlusion.

[Etio-pathogenesis of cystic fibrosis]. / Momenti eziopatogenetici della fibrosi cistica.

Recent researches confirm the recessive mendelian modality of hereditary transmission in Cystic Fibrosis. Two groups of factors contribute to the pathogenesis of respiratory disease: the secretive-obstructive and the infectious. It has also been ascertained that a large part of the respiratory complications are due to pseudomonas aeruginosa, above all to particular sub-groups which produce hexosepolisaccaridic masses. Even though immunological moments are present, it has been confirmed that the disease does not have a primary immunologic pathogenesis. Various recent acquisitions shed light on the fundamental alterations in pathophysiology of the disease. The most interesting developments regard: the glycoproteins of secretions and tissues; the activity of the enzymes involved in glycoproteins metabolism; the electrolytes regulation systems, in particular the intracellular calcium; the presence of abnormal proteins in plasma, urine, secretions and cells in culture; the characteristics of chemical mediator receptors. The modifications of the processes of glycosilation and hydrolysis of the glycoproteins are particularly significant. The most important and univocal observations regard the enzymes, sialyl-transferase and alpha-L-fucosidase, the former involved in the incorporation of sialic acid into the glycoproteins and the latter in the detachment of fucose from the glycoproteins. Polyamines, which participate in many phases of metabolism, as that of glycoproteins, have been found to present modifications of certain importance.(ABSTRACT TRUNCATED AT 250 WORDS)

[Serotonin distribution between plasma and platelets in clinically healthy children]. / Distribuzione della serotonina nel plasma e nelle piastrine di soggetti in età pediatrica clinicamente sani.

Serotonin distribution between plasma and platelets was examined in 34 clinically healthy children. We measured 5-HT with spectrofluorometric method. We obtained no correlation between plasma and platelets 5-HT. Serotonin is more concentrated in platelets than in plasma. In fact, platelets uptake 5-HT even at low plasma concentration, by an active transport mechanism and store it in granular substructures. 5-HT uptake occurs in similar way both in platelets and in 5-HT neurons. MOreover, the 5-HT receptors react to 5-HT agonist or antagonist drugs as the receptors of some SNC areas (not those with dense 5-HT innervation). Therefore, platelets might be used as indication for 5-HT neurons activity in those SNC regions whose receptors react to drugs as platelets receptors.

[Correlation between tryptophan, NEFA and albumins in the nephrotic syndrome]. / Studio delle correlazioni fra triptofano, NEFA e albumina nella sindrome nefrosica.

Many connections were considered between bound and free tryptophan and albumins, NEFA and other aminoacids in 18 proofs in ten subjects of paediatric age affected by nephrotic syndrome. A decrease of total tryptophan and a tendency to increase of free tryptophan were showed in our experience. NEFA, at normal concentrations, should not be responsible for this; and this could suggest that the binding sites on albumins for NEFA and tryptophan are different. Besides there is appearance of a positive correlation between albumins and bound tryptophan and a negative correlation between albumins and free tryptophan. These results can suggest that the reduction of the total tryptophan is due to the loss of the fractions bound to albumins, but urinary tryptophan is not increased in our studies. As the albumins get fewer, there is a lost in linked tryptophan and an increase of free tryptophan. A total reduction of other aromatic aminoacids can also explain, through a reduced intestinal absorption, the decrease of the tryptophan in the nephrotic syndrome.

[Plasma and platelet serotonin in children with essential headache]. / La serotonina plasmatica e piastrinica in bambini con cefalea essenziale.

We examined the haematic concentration of 5 HT in idiopathic headache in children. We observed plasma and platelet 5 HT concentration in 18 migrainous patients free from painful crisis, and we compared the results with a control group of 20 clinically healthy children. No significant variation was noted in plasma 5 HT concentration between the two groups. The data are more difficult to interpret on the platelet because of the slight statistical difference (0.1 greater than p greater than 0.05). However we think suggestive the possible existence of persisting platelet anomalies in migrainous children and this hypothesis can be verified in a larger number of children free from painful crisis.