Pheohyphomycotic soft tissue disease caused by Alternaria alternata in a kidney transplant patient: a case report and literature review.

A 61-year-old Italian man, who underwent a renal transplantation 8 years ago, receiving azathioprine, prednisone, and cyclosporine for immunosuppressive therapy, presented with a large reddish indurated plaque with a central ulcer, which was slowly enlarged, on the right knee. From the diseased tissue biopsy, a dematiaceous fungus matching Alternaria alternata in all essential characters was isolated in pure culture. This is an uncommon fungal complication in a kidney transplant patient. A detailed morphological description of the isolate is provided as well as review of the literature.

Early translaryngeal tracheostomy in patients with severe brain damage.

OBJECTIVES: To describe the effects of early translaryngeal tracheostomy on intracranial pressure (ICP), cerebral perfusion pressure (CPP), and jugular bulb saturation (SjO2); to identify the main mechanisms affecting ICP during tracheostomy; and to evaluate the long-term effects of tracheostomy on tracheal anatomy and function. DESIGN: Prospective, observational, clinical study. SETTING: Neurosurgical intensive care unit in a teaching hospital. PATIENTS: 20 patients admitted to the ICU because of head injury, subarachnoid hemorrhage, or brain tumor with a Glasgow Coma Scale less than 8. INTERVENTIONS: Patients underwent translaryngeal tracheostomy under strict neuromonitoring. MEASUREMENTS AND RESULTS: ICP rose significantly (p < 0.05) at the critical time of cannula placement while all other parameters remained stable. At this time five patients suffered intracranial hypertension (ICP > 20 mmHg). In one of them CPP dropped below 60 mmHg. Arterial CO2 tension (PaCO2) did not rise significantly. No other major complications were recorded during the procedures. Three months after tracheostomy normal findings were detected by tracheoscopy in all cases (11 patients could be examined). CONCLUSIONS: Translaryngeal tracheostomy, performed in selected patients when the risk of intracranial hypertension was reduced to the minimum, was well tolerated in the majority of cases and did not induce persistent intracranial disorders. However, ICP is affected by tracheostomy, and careful monitoring and patient selection is necessary. At follow-up no severe anatomical or functional damage was detected.

Neurophysiological consequences of three tracheostomy techniques: a randomized study in neurosurgical patients.

We describe the effects of different tracheostomy techniques on intracranial pressure (ICP), cerebral perfusion pressure (CPP), and cerebral extraction of oxygen. We attempted to identify the main mechanisms affecting intracranial pressure during tracheostomy. To do so we conducted a prospective, block-randomized, clinical study which took place in a neurosurgical intensive care unit in a teaching hospital. The patients studied consisted of thirty comatose patients admitted to the intensive care unit because of head injury, subarachnoid hemorrhage, or brain tumor. Ten patients per group were submitted to standard surgical tracheostomy, percutaneous dilatational tracheostomy or translaryngeal tracheostomy. In every technique a significant increase of ICP (P < .05) was observed at the time of cannula placement. Intracranial hypertension (ICP > 20 mm Hg) was more frequent in the percutaneous dilatational tracheostomy group (P < .05). Cerebral perfusion pressure dropped below 60 mm Hg in eleven cases, more frequently during surgical tracheostomy. Arterial tension of CO2 significantly increased in all three groups during cannula placement. No other major complications were recorded during the procedures. At follow-up no severe anatomic or functional damage was detected. We conclude that the three tracheostomy techniques, performed in selected patients where the risk of intracranial hypertension was reduced to the minimum, were reasonably tolerated but caused an intracranial pressure rise and cerebral perfusion pressure reduction in some cases.

[Interstitial cystitis: epidemiology]. / La cistite interstiziale: epidemiologia.

The epidemiological assessment of intestitial cystitis (IC) is not definitive as no diagnostic criteria, such as endoscopy or biochemical and anatomopathological examination, exist. The diagnosis is solely based on symptoms like urgency, frequency and pelvic pain. The first studies on the population date back from 20 years ago and show a percentage of 10 cases every 100 thousand inhabitants. There is weak link between genetic factors, immunological diseases, previous cystitis or eating habits and intestitial cystitis. Epidemiological studies have highlight the frequency of this disease, and stressed the importance of stricted behavioural rules for the first stages of intestitial cystitis.

[Interstitial cystitis: surgical treatment]. / Cistite interstiziale: terapia chirurgica.

Surgical therapy of interstitial cystitis must never be considered a first option but must be reserved for cases, less than 10%, in which conservative therapy has proven ineffectual. Surgical therapy includes a variety that started at the turn of the century. Neurosurgical denervation and perivesical denervation like cysto-cystoplasty and cystolysis, manipulate the innervation to reduce the bladder's hypersensitivity. This surgical approach may be considered in patients in whom bladder capacity is normal. The results are uncertain and the complications like neurogenic bladder relevant. Enterocystoplasty is much more widespread because interstitial cystitis is a benign disease that rarely required radical surgery. Augmentation cystoplasty and substitution cystoplasty are two variants but only the later has a rationale as it involves the resection of the detrusor which is the source of the pain. Detubularization drastically reduced urinary incontinence. The resection of the detrusor can be supratrigonal, subtrigonal or at the proximal urethra like in the orthotopic neobladder. If urinary diversion is chosen, the bladder must be removed. Before recommending surgical therapy each patient should undergo tests for the localization of the pain; moreover psychological and gynaecological evaluations should be made. If the bladder capacity exceeds 400 cc surgical operation is not advisable. If, on the other hand, the bladder capacity is lower than 400 cc substitution cystoplasty is first choice. If the patient suffers from trigonal cystitis or urethral hypersensitivity, urinary diversion is a better therapy. According to the questionnaires send to the Urologic Departments in Lombardy in 1998, the most widespread type of operation seems to be supratrigonal cystectomy + enterocystoplasty and augmentation cystoplasty. Subtrigonal cystectomy or urinary diversion are only occasionally chosen; continent pouch is the least frequent therapy at all.

The prognostic value of soluble interleukin-6 receptor in patients with multiple myeloma.

BACKGROUND: The effect of interleukin-6 (IL-6), the major growth factor for myeloma cells, may be enhanced by soluble IL-6 receptor (sIL-6R). Therefore, the current study investigated the clinical significance of serum sIL-6R in patients with multiple myeloma (MM). METHODS: Serum levels of sIL-6R were determined by enzyme-linked immunoassay in 55 normal controls, 81 individuals with monoclonal gammopathy of undetermined significance (MGUS), and 164 patients with MM in various phases of the disease. RESULTS: sIL-6R concentrations were higher in MM patients (162.0 +/- 134.6 ng/mL) than in individuals with MGUS (58.9 +/- 36.7 ng/mL) or in controls (45.6 +/- 22.3 ng/mL) (P = 0.0000). sIL-6R was not found to have a significant linear correlation with any other parameter, including IL-6, beta2-microglobulin (beta2-m), and neopterin, either in newly diagnosed cases or during the course of the disease. In addition, there were no statistically significant differences in sIL-6R concentrations between the clinical stages at the time of diagnosis. In univariate logistic regression analysis sIL-6R was a significant but weak prognostic indicator (P = 0.000000). Kaplan-Meier analysis showed that elevated levels of sIL-6R were associated with shorter survival (P = 0.00282). Patients also were stratified according to their serum beta2-m and sIL-6R levels. Patients with low levels of both parameters had a clear survival benefit over the other groups (P = 0.000000). CONCLUSIONS: The correlation between sIL-6R levels and survival is significant but weak, making it unlikely to be of much value in predicting the outcome of patients with MM alone. The results of the current study support the role of sIL-6R levels in improving the prognostic value of beta2-m and in discriminating patients with MM from individuals with MGUS.

Intravesical electromotive administration of drugs for treatment of superficial bladder cancer: a comparative Phase II study.

OBJECTIVES: To evaluate the efficacy of electromotive administration (EMDA) of intravesical mitomycin-C (MMC) in patients with superficial bladder tumors and to evaluate the toxicity of the treatment. METHODS: Thirteen patients with multifocal Stages Ta-T1 and G1-G2 transitional cell carcinoma (TCC) of the bladder, primary or recurrent (group A), received MMC 40 mg (retained in the bladder for 2 hours) once a week for 8 weeks. Fifteen patients with the same characteristics (group B) were treated with EMDA/MMC at a current of 15 mA for 20 minutes once a week for 8 weeks. All lesions in the bladder except one (marker) were resected in each patient. RESULTS: In group A, 5 of 12 patients (41.6%) demonstrated complete macroscopic and histologic disappearance of the marker lesion (complete response [CR]). In group B, 6 of 15 patients (40%) had a similar CR. Recurrence rate in responders was 60% in group A versus 33% in group B after 7.6 and 6 months, respectively. Disease-free interval was 14.5 months in the EMDA/MMC group compared to 10.5 months in the MMC group. Side effects were few. CONCLUSIONS: In intermediate risk patients with TCC of the bladder, EMDA/MMC was not superior to MMC alone with a CR rate of 41% versus 41.6%. In responders, a lower recurrence rate and a longer disease-free interval were observed in the EMDA/MMC group.

Serum levels of tumour necrosis factor-alpha predict response to recombinant human erythropoietin in patients with myelodysplastic syndrome.

We measured pretreatment serum levels of tumour necrosis factor-alpha (TNF-alpha) and interleukin-1 beta (IL-1 beta) in 25 patients with myelodysplastic syndrome receiving recombinant human erythropoietin (rhEPO) at dosages up to 300 U/kg thrice weekly for 12 weeks. Both TNF-alpha and IL-1 beta levels were measured using commercially available enzyme-linked immunoassays. A complete response (CR) was defined as a rise in untransfused haemoglobin concentrations of at least 2 g/dl or a 100% decrease in RBC transfusion requirements over the treatment period; a partial response (PR) was an increase in untransfused haemoglobin values of 1-2 g/dl or a decrease in RBC transfusion requirements equal to or greater than 50%; no response (NR) was defined as a response less than a PR. After 12 weeks of rhEPO treatment, four patients showed a CR, five patients a PR, and 16 patients NR. Serum levels of both TNF-alpha (80.5 %/- 64.8 vs 8.1 +/- 4.2 ng/l, P < 0.001) and IL-1 beta (60.4 +/- 49.9 vs 8.9 +/- 4.7 ng/l, P < 0.001) were higher in MDS patients than in a group of 28 normal controls. Responders (CR + PR) showed significantly lower serum levels of TNF-alpha than non-responders (21.6 +/- 26.2 vs 106.3 +/- 60.8 ng/l, P < 0.001), whereas IL-1 beta concentrations between those who benefited from therapy and unresponsive cases were not significantly different (39.8 +/- 48.9 vs 73.4 +/- 48.2 ng/l, P = 0.120). It is noteworthy that TNF-alpha levels were within the normal range in all responsive patients but one, whereas all non-responders presented elevated cytokine concentrations. No relationship was found between TNF-alpha or IL-1 beta values and haemoglobin levels, transfusion requirement, serum EPO or ferritin concentrations. We conclude that pre-treatment TNF-alpha levels might help to select those MDS patients who are most likely to benefit from rhEPO treatment.

Acetylcholine-induced vasodilatation in the human peripheral circulation is independent of ATP-sensitive K+ channels and prostacyclin.

BACKGROUND: Both experimental and clinical studies have shown that the increase in regional blood flow induced by acetylcholine is not completely prevented by inhibitors of the synthesis of endothelium-derived nitric oxide. To establish the role of ATP-sensitive potassium (KATP) channels and prostacyclin in mediating acetylcholine-induced increase in peripheral blood flow in humans, we assessed the effects of acetylcholine on the iliac artery blood flow velocity before and after glibenclamide, an antagonist of KATP channels, or before and after acetylsalicylic acid, an inhibitor of prostacyclin production. MATERIAL AND METHODS: Seventeen patients without evidence of peripheral vascular disease and normal coronary arteries at angiography received intra-iliac incremental bolus injections of acetylcholine (0.2, 2, 20 and 50 micrograms) via a 5F femoral sheath, at the end of routine cardiac catheterization. All injections were repeated 90 minutes after oral administration of glibenclamide (10 mg) in 10 patients of 15 minutes after i.v. infusion of acetylsalicylic acid (1000 mg) in the remaining 7 patients. Right iliac artery blood flow velocity was measured by using an intravascular 0.014-in Doppler guidewire. RESULTS: Before glibenclamide or acetylsalicylic acid administration, acetylcholine infusion increased average peak velocity by 128% (p < 0.001) and by 121% (p < 0.001), respectively. After glibenclamide or acetylsalicylic acid the increases of average peak velocity during acetylcholine infusion (by 121%, p < 0.001, and by 121%, p < 0.001, respectively) were similar (p = ns) to those observed during the control infusion. CONCLUSIONS: In man acetylcholine-induced vasodilatation in the territory supplied by the iliac artery is not prevented by glibenclamide or acetylsalicylic acid, thus suggesting that it is independent of activation of KATP channels and prostacyclin release.

[Replacement neobladders in men and women: our experience]. / Le neovesciche di sostituzione nell'uomo e nella donna: nostra esperienza.

We present our clinical and metabolic follow-up data of 74 patients submitted to total bladder substitution using an ileal orthotopic neobladder in one group of 64 patients and a continent stomal pouch in another group of 10 patients. In the first group the mean follow-up was 41.5 months. The daytime continence was early achieved in 89% (57/64) and was maintained with time; at 12 month follow-up nocturnal continence was reached in 71% (45/64). Post voiding residual was significant only in 4 patients (2 men and 2 women). No clinical signs of pyelonephritis nor renal scars at IVP was evidenced in all but 7 patients in which a silent uretero-ileal stenosis developed. No severe metabolic acidosis or B 12 deficiency occurred. In the second group (Continent Pouch) the long term 3-Year follow-up shows a complete continence in all patients with an average capacity of 600 cc. No late complications occurred in all patients but one in which self intermittent catheterization was uncomfortable and now he prefer permanent catheter and in another patient with a stone in the Pouch treated with Lithoclast. In conclusion, total bladder substitution after radical cystectomy is now represented by orthotopic neobladder or continent Pouch in men and women. Early and late complication rate is relatively low and continence generally good.

[Adequacy of admission in neurosurgical intensive care]. / Appropriatezza dei ricoveri in terapia intensiva neurochirurgica.

OBJECTIVE: The Intensive Care Units of Milano metropolitan area are characterized by difficulties of hospitalization for acutely injured patients due to the low bed availability. We evaluated the problem trying to find out possible solutions. DESIGN: On the day of achieved neurological and neurosurgical stability-defined as the day when the intracranial pressure and jugular venous oxygen saturation monitoring, hyperventilation, osmotic therapy were considered no longer needed--the monitoring procedures and instrumental and/or pharmacological treatments that the patients received were recorded and classified as follows: 1) intensive, 2) intermediate, 3) non-intensive. PATIENTS: All the acutely injured patients admitted at five Neurosurgical ICUs during June-July and October-November 1994 have been studied. Only one of these ICUs had a "sub-intensive unit". MEASUREMENTS AND MAIN RESULTS: 391 patients (29.9%) aneurysms and arteriovenous malformations, 25.1% tumours, 2.8% head injuries, 8.7% spontaneous intracranial haematomas, 13.5% various pathologies) were studied. Out of them 358 had an acute brain failure. 16.5% died during brain failure and 83.5% reached neurological stability within 3 days. When neurological stability was reached 32.1% of patients could be classified as "intensive", 63.6% as "intermediate" and 4.3% as "unintensive". In the four ICUs, without sub-intensive ward facilities, 361 patients were admitted with a total amount of 2292 days of hospitalization. Among them 61.9% were spent for a) patients with no brain injury (32 pts/113 days), b) postoperative patients (113 pts/167 days), c) patients in stable neurological conditions (159 pts/1139 days). Therefore, only 38% of the days recorded were given to patients that needed neurointensive care. CONCLUSION: Out data suggest that the receptivity for acute injured patients could be increased creating recovery room units and intermediate post-intensive units together with a better interchange between general and neurosurgical ICUs.

[Respiratory failure caused by myopathy in severe sepsis]. / Insufficienza ventilatoria da miopatia in corso di sepsi severa.

OBJECTIVE: To describe a generalized myopathic disorder occurred in the convalescence phase of illness of a critically ill patient. SETTING: Neurological Intensive Care Unit. PATIENT: A 43-year-old man with acute leukoencephalopathy and severe sepsis complicated by sustained and prolonged cardiovascular, respiratory and renal failure. After 15 days of complete respiratory autonomy, the patient presented an acute ventilatory failure associated with generalized muscle weakness. Neither a relapse of sepsis nor neurological worsening were detected. MEASUREMENTS AND RESULTS: Electromyogram resulted in normal conduction velocity in both motor and sensitive nervous fibers. Muscular biopsy showed marked fiber size variability with several hypotrophic fibers type II fiber grouping, several areas of degeneration-necrosis with macrophage invasion, dishomogeneous oxidative enzymatic activity, no increase in glycogen or lipid content. CONCLUSIONS: These results excluded critical illness polyneuropathy and all the other known myopathies. Prolonged period of sepsis with multiple organ failure can result in a direct generalized myopathy. This possibility should be kept in mind while treating long term critically ill survivors.

[T1G3 bladder tumors: 5 years later]. / Neoplasie vescicali T1G3: 5 anni dopo.

We have evaluated 79 patients affected by bladder cancer T1G3: 31 underwent just endoscopy, 11 radiotherapy, 10 cystectomy and 27 topical chemotherapy. At five years 44 patients were alive and disease free, 7 were alive but recurrent in TA, 3 were alive but in metastatic progression, 17 were died because of the tumor, 3 died because of the therapy, and 5 died disease free. The authors believe that this patients could be treated with BCG as first treatment choice performing cystectomy when relapse or progression occuring.

Desmoplastic small round cell tumor of the pleura.

Three cases of desmoplastic small round cell tumor (DSRCT) with multiphenotypic differentiation, primary in the pleura, are presented. This is a previously unrecognized site for this tumor type. Two patients were male and one female aged 29, 24, and 17 years. All presented with chest pain and were found to have pleural-based tumors associated with pleural effusion. Abdominal involvement was not present in any of the cases. Histologically, the tumor showed the characteristic features of intra-abdominal DSRCT, including angulated nests of small cells embedded in a vascular fibroblastic stroma, focal rhabdoid phenotype, and areas of central necrosis. The neoplastic cells showed evidence of epithelial, mesenchymal, and neural differentiation with characteristic dot-like positivity for vimentin and desmin topographically corresponding to perinuclear aggregates of intermediate filaments identified on electron microscopy in one case. Two patients died of disease 2 years and 15 months after presentation, respectively, and one patient is alive with disease 18 months after presentation. The histogenesis of DSRCT is unknown. Most previously reported cases involved the peritoneum or tunica vaginalis, suggesting a histogenetic relationship to the mesothelium. The occurrence of these tumors in the pleura lends further support to this theory.

[Turbo TURP]. / Turbo TURP.

Transurethral resection of the prostate (TURP) is just one of the numerous options available in the modern treatment of benign prostatic hyperplasia (BPH), but it's still now the "gold standard". Absorption of irrigating fluid is the greatest complication and results in clinical manifestations in 2% of the TURPs performed. There is a statistically significant relationship between gland size and the total volume of irrigant absorbed. To reduce this absorption Reuter introduced suprapubic trocar drainage to obtain the same results from both the small and the large prostates. Operating time, in fact, is reduced because, also at the same time, this large tube drains both irrigation fluid and prostatic chips.

Combined Clark's nevus.

We report five cases of combined Clark's nevi. Like all melanocytic nevi, Clark's nevus can combine with other nevi to produce lesions that are hard to interpret clinically and histologically. The morphology of combined Clark's nevus can resemble that of a melanoma associated with a nevus.

[Our experience with impotence following radical pelvic surgery]. / La nostra esperienza sulla impotenza dopo chirurgia radiacale pelvica.

The etiology of impotence after radical prostatectomy and radical cystoprostatectomy is unclear, although a variety of potential factors have been cited: neurogenic, psychogenic and vascular. Injury to the pelvic nerve plexus and the branches that innervate the corpora cavernosa (cavernous nerves), seems to be the most important iatrogenic factor. The Authors selected 14 patients candidate to radical prostatectomy or radical cystoprostatectomy and studied their potency pre and post operatively by anamnesis and/or Rigiscan test. The sacral-evoked potential was determined in all these patients in order to detect a neurological etiologies. The average latency of the bulbo cavernous reflex was similar in the patients that lost their potency after surgery and in the patients that didn't lose their potency after surgery. The sacral-evoked response seems not to be a diagnostic test in the study of the impotence after pelvic radical surgery.

[Heparin and lipoprotein(a). Observations during hemodialysis]. / Eparina e lipoproteina(a). Osservazioni in corso di emodialisi.

The effect of heparin (bolus e.v. 5.000 I.U.) on blood levels of Lp(a) and other lipids (triglycerides, -HDL, -LDL and total cholesterol, apo A1, apo B100 and apo A1/apo B100) was studied in 15 patients (8 M and 7 F) with chronic renal failure during hemodialysis. Statistically significant reductions of the basal values were found for Lp(a) and the other lipids in the blood taken before the beginning of dialysis, 30 min' after the heparin bolus. The analysis of third blood sample (at the end of the hemodialysis, one hour after the end of the heparin maintenance infusion) showed a rise of HDL and LDL-lipoproteins over the basal values clearly in relation to reduced heparin and plasmatic fraction of the blood. The values of Lp(a) had not so high increase as consequence of more elevated affinity with heparin and of a possible enhanced metabolic rate via lipoprotein lipase. The authors, in agreement with similar changes of Lp(a) and other lipids previously observed in patients with coronary diseases during bypass surgery in extracorporeal circulation or angioplasty, (interventions requiring generous heparin treatment), believe to have now sufficient data for attributing heparin a causal role for the above mentioned effects. The authors stress the needing of other studies better understand the action to mechanisms of heparin and to evaluate possible future clinical applications of this new interesting Lp(a)-clearing effect.

[Transrectal echography in the diagnosis of cervico-urethral obstruction in the young]. / L'ecografia transrettale nella diagnostica dell'ostruzione cervico-uretrale giovanile.

The authors present a case of severe cervico-urethral obstruction by Von Brunn cysts. These cysts are often found even in macroscopically healthy bladders, but only rarely reach such a size as to be revealed by ultrasound. They can be asymptomatic or cause obstruction if large. They are no longer considered preneoplastic lesions and are therefore treated according to symptoms. When these cysts cause dysuria they are removed, preferably by transurethral resection, as it is the only method (unlike needle aspiration) which prevents recurrence.