Sensitization to cockroach allergens in the urban atopic populations living in Campania district (southern Italy). A multicenter study.

BACKGROUND: Although cockroach (CR) is an important cause of allergic sensitization worldwide, only a few data are available in Italy and in a previous study we have observed, in Naples area, a low prevalence of CR sensitization. OBJECTIVES: We sought to perform a prospective study for assessing the prevalence of allergic sensitization to CR in a sample of atopic population living in Campania district area (Southern Italy). METHODS: Ten Allergy Units or Centres of Campania district participated in this cross-sectional study. Each centre was required to collect the results of at least 100 allergy consultations in consecutive outpatients referred for actual or suspected respiratory allergy. We registered demographic data, type and duration of respiratory symptoms, pets ownership, possible exposure to CR allergens, results of the skin prick tests (SPTs). RESULTS: A total of 1477 patients were examined, 985 (66.68%) had a SPTs positivity to at least one allergen. In this context, ninety were sensitized to CR, thus the overall sensitization prevalence in subjects with respiratory allergy was 6.09% ranging between 0-11% and only five patients were mono-sensitized. Thirteen patients reported rhinitis (R) + bronchial asthma (A), twenty-one R + A + conjunctivitis (C), thirty-seven R + C, five only A and eleven individuals only R. Sixty-seven patients exhibited persistent and twenty-three intermittent symptoms. Dust mite constituted the first cause of associated sensitization to CR. CONCLUSIONS: The prevalence of allergic sensitization to CR is not negligible in population living in Campania district and shows a higher trend in comparison to that found recently and some years ago in Naples area. Finally, we suggest atopic individuals and especially those highly sensitized to mite allergens or those living in low-income areas to be tested by SPTs / evaluation of serum specific IgE to CR allergens to exclude the occurrence of CR allergic sensitization.

Radioiodine therapy of hyperfunctioning thyroid nodules: usefulness of an implemented dose calculation algorithm allowing reduction of radioiodine amount.

AIM: Radioiodine is a common option for treatment of hyperfunctioning thyroid nodules. Due to the expected selective radioiodine uptake by adenoma, relatively high "fixed" activities are often used. Alternatively, the activity is individually calculated upon the prescription of a fixed value of target absorbed dose. We evaluated the use of an algorithm for personalized radioiodine activity calculation, which allows as a rule the administration of lower radioiodine activities. METHODS: Seventy-five patients with single hyperfunctioning thyroid nodule eligible for 131I treatment were studied. The activities of 131I to be administered were estimated by the method described by Traino et al. and developed for Graves'disease, assuming selective and homogeneous 131I uptake by adenoma. The method takes into account 131I uptake and its effective half-life, target (adenoma) volume and its expected volume reduction during treatment. A comparison with the activities calculated by other dosimetric protocols, and the "fixed" activity method was performed. 131I uptake was measured by external counting, thyroid nodule volume by ultrasonography, thyroid hormones and TSH by ELISA. RESULTS: Remission of hyperthyroidism was observed in all but one patient; volume reduction of adenoma was closely similar to that assumed by our model. Effective half-life was highly variable in different patients, and critically affected dose calculation. The administered activities were clearly lower with respect to "fixed" activities and other protocols' prescription. CONCLUSION: The proposed algorithm proved to be effective also for single hyperfunctioning thyroid nodule treatment and allowed a significant reduction of administered 131I activities, without loss of clinical efficacy.

Sensitization to horse allergens in Italy: a multicentre study in urban atopic subjects without occupational exposure.

BACKGROUND: Horses play a significant role in people's leisure time in Italy and other countries, but few data are available on IgE-mediated sensitization to horse allergens in patients without occupational exposure. We assessed, in a multicentric survey, the prevalence of horse sensitization in atopic subjects and its clinical characteristics. METHODS: Allergists from the whole Italian territory were required to collect the results of skin prick tests from at least 100 consecutive subjects. Those patients with a positive skin test to horse dander underwent a detailed interview concerning clinical history, pet ownership and possible exposure. RESULTS: Data from 3,235 outpatients were collected and 2,097 had at least 1 skin positivity. Among them, 113 (5.38%) were sensitized to horse dander (9 monosensitized). Thirty patients reported direct horse contact (4 owners and 26 for riding or occasional contact), 23 patients were sometimes in contact with horse owners and 60 subjects denied any direct or indirect exposure. Among 9 horse monosensitized patients, 6 had intermittent and mild rhinitis and 3 persistent moderate/severe rhinitis plus asthma. Three of them were horse owners or riders and the remaining had no contact with the animal. CONCLUSIONS: Our data evidence that the rate of sensitization to horse dander is not negligible and probably underestimated. In susceptible, not occupationally exposed individuals, horse contact, but also indirect or no apparent exposure, may induce sensitization. We recommend inclusion of horse allergen in the routine panel for the diagnosis of respiratory allergy.

A study of the efficacy of radioiodine therapy with individualized dosimetry in Graves' disease: need to retarget the radiation committed dose to the thyroid.

Although Iodine-131 (131I) therapy is fully validated for Graves' disease (GD), there is debate about radioiodine amount to be administered (prescribed activity), as well as the use of individualized dosimetry vs fixed 131I activity. The clinical outcome of 119 GD patients treated with 131I from 2003 to 2008 has been evaluated. The prescribed activity was calculated according to a dosimetric protocol taking into account several variables, including thyroid volume reduction during treatment. In addition, we performed a simulation according to other dosimetric protocols, by calculating the corresponding prescribed activities. The patients were followed up for at least 12 months after treatment. In the first period of observation (2003), a 120-200 Gray (Gy) radiation dose to the thyroid was prescribed, according to the guidelines published by the Italian Societies of Endocrinology, Nuclear Medicine and Medical Physics: hyperthyroidism cure with a single radioiodine administration was obtained in 53% of patients. This outcome raised up to 89% when a higher radiation dose to the target (200- 250 Gy) was prescribed, although the administered activities were still lower, as a rule, than the most commonly employed fixed activities (400-600 Mega-Becquerel--MBq). Our method showed a high level of individual dose optimisation, particularly when compared to simplified methods. In conclusion, the protocol adopted in this study ensures a satisfactory rate of hyperthyroidism cure, while administering quite low 131I activities, provided that an adequate committed radiation dose to the thyroid is prescribed. In this context, the dose indication given by the aforementioned guidelines should probably be revised.

Thyrotropin receptor autoantibody measurement following radiometabolic treatment of hyperthyroidism: comparison between different methods.

BACKGROUND: TSH receptor antibodies (TRAb) play a crucial role in the pathogenesis of Graves' disease (GD). The use of human recombinant TSH-receptor far improved the analytical performance of TRAb assays (2nd-generation assays). The 3rd-generation assay is based on the inhibition of binding of a human biotin-labeled monoclonal thyroid- stimulating antibody (M22) to TSH-receptor by the autoantibodies present in the serum. AIM: We aimed to assess the ability of the 2nd- and 3rd-generation assays to detect serum TRAb following radioiodine therapy for hyperthyroidism. METHODS: Sera from 47 hyperthyroid (25 autoimmune, 22 non-autoimmune) patients were tested using the two different assays before and at different time intervals after radioiodine therapy. The modifications of TRAb were evaluated, as well as the correlation between the two methods. RESULTS: The results obtained by the two methods proved to be closely correlated. A rise in TRAb was invariably observed in GD patients following radioiodine, with a median peak at 6 months, irrespective of their initial clinical status, presence of ophthalmopathy, smoking habits or other variables. Such a rise was nearly superimposable using both methods. No TRAb appearance was observed in patients with non-autoimmune hyperthyroidism. CONCLUSIONS: The use of methods of higher sensitivity with respect to that formerly used indicate that nearly all GD patients develop TRAb following radioiodine, and that this phenomenon is transient and not related to baseline conditions and clinical outcome/efficacy of treatment.

[Long-term results of laparoscopic retroperitoneal lymph node dissection (RPLND) in low-stage nonseminomatous germ-cell testicular tumors (NSGCTT) performed by a senior surgeon: 1999-2003]. / Risultati a lungo termine della linfadenectomia retroperitoneale laparoscopica nei tumori germinali non seminomatosi del testicolo; esperienza di un chirurgo anziano: 1999-2003.

BACKGROUND: Laparoscopic RPLND for low-stages NSGCTT is controversial: it is performed and recommended by excellent laparoscopic surgeons, but it is not widely used. The aim of this paper is to evaluate the results achieved by a senior surgeon, expert in open RPLND, who was introduced to laparoscopic surgery by excellent laparoscopists (LN, CU, GJ). PATIENTS AND METHODS: of the 48 operated patients, 36 had primary RPLND for clinical stage I disease (22 TIN0, 7 TxN0, 5 T2-3 N0 and 2 TIS1 N0) and 12 had post-chemotherapy surgery for IIA and IIB retroperitoneal nodes with normalized AFP and HCG. L-RPLND was performed with 4 ports and the en bloc removal of unilateral retroperitoneal nodes with the spermatic vessels. No post-operative adjuvant chemotherapy was planned for patients with documented nodal metastases as for open RPLND since 1985. RESULTS: Average operative time was 3.30' for the 36 clinical stage I patients and 4 hours for post-chemotherapy surgery. Blood loss was minimal in all cases, because of early conversion to open surgery in all patients with no immediate hemostasis at L-RPLND. Metastases were found in 6 (17%) out of the 36 clinical stage I patients: none in the 22 pTI, 1 in the 7 Tx, 3 in the 5 pT2-3 and in 2 of the 2 pT1S1 patients. Residual teratoma was found in 6 of the 12 patients who received neo-adjuvant chemotherapy for clinical stage IIA or IIB disease. The other 6 had fibrosis-necrosis. Further metastases developed in 2 of the 30 patients with negative nodes: 1 in the lung in a pT1, and 1 in a pT2 patient with increasing markers. Surprisingly, the first two pT2-3 patients with positive nodes developed liver metastases in a few months after L-RPLND. Consequently, all following patients with active metastases at L-RPLND received 2 courses of adjuvant PEB. All 4 patients who relapsed were cured, are alive and disease-free. CONCLUSIONS: L-RPLND is a very demanding operation, which appears to be more a staging procedure than a curative operation. It is ideal for pT1 clinical stage I and for post-chemotherapy stages IIA& B with residual teratoma and normalized markers, but wait & see in good risk and open RPLND in high risk patients are very competing. Only few reports compared laparoscopic versus open RPLND, but not in a randomized study.

Ultrasonography thyroid volume estimation in hyperthyroid patients treated with individual radioiodine dose.

Radioiodine (RAI) therapy is a safe and effective treatment for hyperthyroidism and individual doses are frequently administered. Initial thyroid volume (TV) is an important parameter for RAI therapy. Ultrasonography (US) is considered the most reliable method of determining TV. The aim of this study was to evaluate TV by means of US in a cohort of 75 hyperthyroid patients before and after RAI therapy. According to clinical examination, thyroid US and technetium-99m (99mTc)-pernechnetate scintiscan, the diagnosis of hyperthyroidism was multinodular goiter (MNG) in 27, diffuse goiter (DG) in 32 and uninodular goiter (UNG) in 16 patients. The RAI dose to be administered was calculated according to TV and RAI uptake, up to a maximum of 600 MBq. TV was further evaluated 1, 3 and 6-12 months after RAI therapy. The initial TV was 42.3+/-4.0 ml for MNG, 29.7+/-2.8 ml for DG and 34.5+/-3.7 ml for UNG. After 6-12 months a non-significant TV reduction was observed in the MNG group even though the fraction of initial TV was 53.3+/-6.5%. Moreover, a significant TV reduction was noticed in the DG group (8.8+/-2.3 ml; p<0.001). In this group the fraction of initial TV was 28.6+/-3.2% at 6-12 month evaluation. A less marked, though still significant (p=0.04) TV reduction (19.6+/-3.2 ml) was also observed in the UNG group, the fraction of initial TV being 57.8+/-5.3% 6-12 months after RAI. In the whole patient population there was no significant correlation between TV reduction or TV at the last examination and initial TV, RAI dosage, baseline free T4 and TSH levels. No correlation was found between clinical condition at the last examination and TV reduction. In conclusion, these data justify TV estimation by means of US in the protocol of individual RAI dose for the therapy of hyperthyroidism. Our follow-up documents a poorly predictable TV reduction in all clinical conditions, but this is more pronounced and predictable in patients with diffuse toxic goiter.

Occurrence of overt celiac disease in the elderly following total thyroidectomy.

We report the case of a female patient in whom gluten-induced entheropathy was revealed at the age of 71 yr by resistance to treatment with levothyroxine (L-T4), calcium carbonate and alfacalcidol. Hypothyroidism and hypoparathyroidism were the consequence of a total thyroidectomy performed at the age of 65 yr for a large multinodular goiter. Six months after thyroid ablation the patient started to complain of abdominal pain, diarrhea and weight loss. Following, anemia and osteopenia were documented. A progressive increase of replacement therapy for hypothyroidism and hypoparathyroidism was necessary. The clinical presentation suggested a malabsorption syndrome: celiac disease (CD) was diagnosed by serological markers and duodenal biopsy. Following gluten-free diet a normalization of clinical and serological findings was observed, bone mass density improved and a reduction of L-T4, calcium and vitamin D requirements was observed.

Amyand's hernia: case report and review of the literature.

The authors report a case of gangrenous acute appendicitis in the sac of an inguinal hernia (Amyand's hernia). After a review of the literature, they emphasise the extreme rarity of the case reported, they underline how the clinical picture is highly similar to that of a strangulated inguinal hernia. They affirm that appendicectomy and hernioplasty may be performed at the same time, since the repair of the hernia should be performed without prosthesis implantation due to the contamination of the operating field.

[Surgery of inguinal hernia in the elderly]. / La chirurgia dell'ernia inguinale nel paziente geriatrico.

The authors report their 14 years experiences with inguinal hernia repair in elderly. The result were compared with young (< 75 years old), and confirmed that there were no significant differences between the 2 groups. The study confirmed the safety and effectiveness of the "tension-free" technique under local anaesthesia, which is proposed as the treatment of choice in elderly.

[Indications for preventive tracheostomy in the surgical treatment of non-neoplastic thyroid disease]. / Indicazioni alla tracheostomia precauzionale nella chirurgia delle tireopatie non neoplastiche.

In thyroid surgery, an emergency tracheostomy is mandatory, as is well known, in acute pre- and postoperative asphyxia due to obstruction of the upper airways, especially in cases of malignant tumours. In particular conditions, in the presence of benign thyroid disease and when there is no reduction in the laryngo-tracheal lumen, tracheostomy has an important precautionary function following total thyroidectomy. The authors describe their experience with 6 patients treated by precautionary tracheostomy after total thyroidectomy for benign thyroid disease, analysing the indications and the advantages of this method.

Complete regression of primary gastric MALT-lymphoma after double eradication Helicobacter pylori therapy: role and importance of endoscopic ultrasonography.

The authors report on a case of complete regression of primary gastric Mucosa Associated Lymphoid Tissue MALT-lymphoma after double eradication Helicobacter pylori therapy. They analyze the diagnostic role of endoscopic ultrasonography and the therapeutic aspects, on the grounds of literature data and personal experience are analyzed.

Preoperative endoscopic ultrasonography in patients with gastric cancer.

AIMS AND BACKGROUND: There is a need to assess the accuracy of endoscopic ultrasonography (EUS) in the diagnosis and staging of gastric cancer, especially in the early and very advanced stages of the disease when the therapeutic approach is still controversial. METHODS: A retrospective study was performed on 79 patients with gastric cancer in order to compare the stage defined by preoperative EUS with that assessed histopathologically. All patients underwent laparotomy for final diagnosis, staging, and eventually treatment. The results of EUS were correlated with the histologic findings of the resected specimens. RESULTS: In the uT1 group, which corresponds to early gastric cancer, the diagnosis was histologically confirmed in 85.7% of the cases. In patients with advanced tumors defined as uT3-uT4, i.e., tumors infiltrating the serosa or neighboring structures, the diagnostic concordance was 91.1%. In contrast, concordance for less advanced lesions confined to the muscular layer was only 31.2%. As regards the lymph nodes, they were defined metastatic in 31 patients and confirmed to be histologically involved in 77.4%. In contrast, when the lymph nodes were assessed as negative at EUS, they proved to be metastatic in more than half the cases. CONCLUSIONS: From the data it appears that EUS has proven to be valuable in correctly staging most of the patients. EUS shows not only tumor depth and local spread but also the passage from a pathologic to a normal wall and lymph node metastasis. EUS appears to represent an important advance in the staging and follow-up of patients with gastric cancer. Instruments and techniques will continue to evolve, but the next level of research should be designed to show that the improved staging provided by EUS has clinical utility and can affect patient outcome. It is noteworthy that the highest accuracy of EUS has been shown in those conditions (uT1 and uT3-4) which currently are under consideration for a therapeutic approach that differs from the standard one.

Hypocalcemia and hypoparathyroidism after total thyroidectomy: a clinical biological study and surgical considerations.

BACKGROUND: Post-operative hypocalcemia is a common and most often transient event afterextensive thyroid surgery. It may be due to iatrogenic injury to the parathyroid glands. AIMS: We carried out a study aimed to evaluate the incidence of hypocalcemia and hypoparathyroidism following extracapsular total thyroidectomy. METHODS: The study was carried out in 312 patients (273 females and 39 males, whose age was between 23 and 76 years, median age 48.61 +/- 14.1) who had undergone total thyroidectomy (TT) in our department from 1995 to 1998 and in 100 patients (72 females and 28 males, whose age was between 24 and 75 years, median age 51.66 +/- 13.4) who had undergone other (non-thyroid) surgery. RESULTS: Post-operative hypocalcemia was observed in 62 patients of the control group (62%) and the decrease of the serum calcium level lasted about 3 days, and went back to normal within the 5th day. In 2 patients undergoing total thyroidectomy, hypocalcemia was considered severe (confirmed for more than 7 days, symptomatic), these had been operated for large multinodular goitre with mediastinal extension. In these patients the symptoms arose acutely about 5 h after the operation. In both cases the clinical and biological aspects went back to normal within 10 days, after a treatment with calcium and vitamin D. Transient asymptomatic hypocalcemia was observed in 234 thyroidectomized patients (75%) and thus did not need any treatment for it. CONCLUSION: The results obtained confirm that transient hypocalcemia can be observed after any operation; and particularly responsible is the decrease of the calcium concerning the proteins. We found that post-operative hypoparathyroidism is due to injury to the parathyroid glands (parathyroid ischaemia or surgical ablation of one or more glands). Here we see the delayed serum calcium level < or = 7.5 mg/dl or the delayed serum phosphorous level > 7.4 mg/dl. The results of our study, with 2 patients presenting transient post-operative hypoparathyroidism, contribute in confirming that the extracapsular total thyroidectomy aimed to reduce any injury to the parathyroid and to the recurrent nerves, represent the better operation also for the extended benignant thyroidopathies.

[Xanthogranulomatous pyelonephritis. Our experience and review of the literature]. / Pielonefrite xantogranulomatosa. Nostra esperienza e review della letteratura.

BACKGROUND: Ten cases of xanthogranulomatous pyelonephritis (XGP) with diagnostic and therapeutic observation are described and other experiences reported in the literature are analyzed. METHODS: The clinical, laboratory and radiological features of 10 patients who had undergone nephrectomy in our Istitute, between October 1993 and March 2000, with a postoperative pathological diagnosis of XGP have been retrospectively re-evaluated. RESULTS: The most frequent symptom was flank pain. All the patients presented leucocytosis. Urine culture was positive for Proteus Mirabilis in four patients (40%) and for E. Coli in three (30%). In all the patients an ultrasound scan and urography were performed, six patients (60%) had undergone a CT scan and two of them (20%) a MRI. In six patients (60%) urinary lithiasis was associated and it was ramified in four of them (40%). The disease was always unilateral, affecting the right kidney in six cases and the left one in the other four. In three cases (30%) it presented in the focal form. The treatment was always surgical and it consisted of nephrectomy; a conservative surgical approach was used in two cases (20%). At the follow-up 4 patients (40%) showed recurrent urinary tract infections. None presented relapse. CONCLUSIONS: XGP is an uncommon chronic inflammatory disease, often associated with urinary tract infections and/or urolithiasis. The clinical presentation is nonspecific so that differential diagnosis with other kidney diseases becomes difficult. A CT scan can be helpful in formulating diagnosis. The treatment is surgical and it consists of a nephrectomy, while a conservative approach can be reserved in some cases for the focal form. Cases treated with antibotics have been described.