Squamous cell carcinoma of the renal pelvis with stones and inferior vena cava infiltration. Case report.

We report a rare case of a 50 year old man with renal squamous cell carcinoma (SCC) who first came to our attention with renal colic and fever not responding to antibiotic or analgesic treatment. He had a long history of kidney stones, but had not undergone any imaging in the last 5 years. Physical examination revealed tenderness and a palpable mass in the right flank and lumbar region. A whole body CT scan was performed, revealing an 11 cm mass in the right kidney infiltrating the inferior vena cava. There were areas of calcification within the mass and multiple stones within the renal pelvis. The tumor was considered unsuitable for resection according to radiological and clinical criteria. The mass was biopsied percutaneously under CT guidance and histological examination revealed squamous cell carcinoma of the renal pelvis. The patient was treated with neoadjuvant chemotherapy and embolization of the renal artery. He died one month after diagnosis. To our knowledge this is the second reported case in the world of renal SCC infiltrating the inferior vena cava and with kidney stones.

Subfascial endoscopic perforator surgery (SEPS) in chronic venous insufficiency. A 14 years experience.

INTRODUCTION: Subfascial Endoscopic Perforator Surgery (SEPS) enables the direct visualization and section of perforating veins. Morbidity and duration of hospitalization are both less than with conventional open surgery (Linton's or Felder's techniques). PATIENTS AND METHODS: A total of 322 legs from 285 patients with a mean age of 56 years (range 23-90) were treated at our Department from May 1996 to January 2010. In 309 cases, an endoscope (ETM Endoskopische Technik GmbH, Berlin, Germany) was introduced through a transverse incision approximately 1.5 cm in length and 10 cm from the tibial tuberosity, as with Linton's technique. A spacemaker balloon dissector for SEPS, involving a second incision 6 cm from the first, was used in only 13 cases. RESULTS: The procedure used in each case was decided on the basis of preoperative evaluation. SEPS and stripping were performed in 238 limbs (73.91%), SEPS and short stripping in 7 limbs (2.17%), SEPS and crossectomy in 51 limbs (15.84%), and SEPS alone in 26 limbs (8.07%). 103 patients presented a total of 158 trophic ulcers; the healing time was between 1 and 3 months, with a healing rate of 82.91% after 1 month and 98.73% after 3 months. CONCLUSION: Subfascial ligature of perforating veins is superior to sclerotherapy and minimally invasive suprafascial treatment for the treatment of CVI. It is easy to execute, minimally invasive and has few complications.

Uterine blood flow in pregnant patients with polycystic ovary syndrome: relationships with clinical outcomes.

OBJECTIVE: To study the impedance to blood flow through the uterine artery in pregnant women with polycystic ovary syndrome (PCOS), and to evaluate its predictive value for adverse pregnancy and perinatal outcomes in this population. DESIGN: Prospective case-control study. SETTING: Academic Departments of Obstetrics and Gynaecology in Italy. POPULATION: Seventy-three pregnant women with ovulatory PCOS (PCOS group) and 73 age- and body mass index-matched healthy pregnant controls (control group). METHODS: Serial Doppler velocimetry measurements of the uterine artery. MAIN OUTCOME MEASURES: Blood flow impedance indices and pregnancy/perinatal outcomes. RESULTS: A significantly (P < 0.05) higher rate of subjects with abnormal velocimetry findings was observed in the PCOS group than in the control group. In the PCOS group, the pulsatility index (PI) at first (P = 0.042) and mid-second (P = 0.039) trimesters of pregnancy, and bilateral notch at first (P = 0.025) and mid-second (P = 0.007) trimesters of pregnancy, were the strongest independent predictors of adverse outcomes. Conversely, in the control group, PI at the first trimester of pregnancy was a predictor of adverse outcomes only when combined with bilateral notch (P = 0.042), whereas at mid-second trimester of pregnancy PI (P = 0.033) and bilateral notch (P = 0.048) were independent predictors of adverse outcomes. CONCLUSIONS: Uterine artery Doppler indices are more commonly altered in pregnant patients with PCOS than in controls, showing a high predictive value for abnormal pregnancy/perinatal outcomes.

Severe obstructive sleep apnoea exacerbates the microvascular impairment in very mild hypertensives.

BACKGROUND: Different studies have shown that obstructive sleep apnoea syndrome (OSAS), frequently associated with hypertension, represents a harmful and independent risk for cardiovascular diseases. The aim of our study was to ascertain whether the occurrence of OSAS could worsen microcirculatory impairment in very mild hypertensives. MATERIALS AND METHODS: One hundred untreated very mild hypertensives underwent polysomnography and subdivided into 32 non-OSAS, 33 mild OSAS and 35 severe OSAS patients on standardized criteria. They underwent routine blood chemistry, ambulatory blood pressure monitoring and anthropometric analysis. Skin capillary density (n mm(-2)) of forearm (FAC) and periungueal (PUC) fields was obtained through videocapillaroscopy. By a venous congestion manoeuvre, PUC was maximized (CVC) and secondary capillary recruitment (GAIN) was calculated. These measurements served as indices of structural and functional capillary rarefaction, respectively. RESULTS: Severe OSAS hypertensives showed reduced FAC (P < 0.001) and PUC (P < 0.001) as compared to those with mild OSAS and non-OSAS, but a greater CVC (P < 0.01) and GAIN (P < 0.001). Multiple regression analysis showed that PUC was inversely related to total sleep time with oxyhaemoglobin saturation at < 90% (TST90) (P < 0.001) and FAC to the apnoea-hypopnoea index (AHI) (P < 0.001) and to the sleep propensity (P < 0.01). CVC was positively associated to AHI (P < 0.001) and GAIN to TST90 (P < 0.05). CONCLUSIONS: The findings suggest that OSAS, by means of reduced basal and functional capillarity rarefaction, might pose an additional risk of impaired peripheral perfusion in very mild hypertensives. A microcirculation study therefore should be a part of the clinical approach in patients at high cerebro-cardiovascular risk such as hypertensives and patients with OSAS.

[Two cases of synchronous papillary and medullary thyroid carcinoma]. / Due casi di carcinomi tiroidei sincroni di tipo midollare e papillifero.

The Authors describe two cases of simultaneous association of papillary and medullary thyroid carcinoma. They emphasize the treatment of these cases stressing the correlation between the therapeutic criteria and the malignancy of medullary carcinoma.

A new system for continuous and remote monitoring of patients receiving home mechanical ventilation.

Home mechanical ventilation is the treatment of patients with respiratory failure or insufficiency by means of a mechanical ventilator at a patient's home. In order to allow remote patient monitoring, several tele-monitoring systems have been introduced in the last few years. However, most of them usually do not allow real-time services, as they have their own proprietary communication protocol implemented and some ventilation parameters are not always measured. Moreover, they monitor only some breaths during the whole day, despite the fact that a patient's respiratory state may change continuously during the day. In order to reduce the above drawbacks, this work reports the development of a novel remote monitoring system for long-term, home-based ventilation therapy; the proposed system allows for continuous monitoring of the main physical quantities involved during home-care ventilation (e.g., differential pressure, volume, and air flow rate) and is developed in order to allow observations of different remote therapy units located in different places of a city, region, or country. The developed remote patient monitoring system is able to detect various clinical events (e.g., events of tube disconnection and sleep apnea events) and has been successfully tested by means of experimental tests carried out with pulmonary ventilators typically used to support sick patients.

Diastolic mitral regurgitation: a borderline case in cardiovascular physiology.

BACKGROUND: Mitral regurgitation during diastole in 5 subjects, of whom 4 affected by cardiovascular disease and 1 healthy competitive athlete, was the aim of this work. The 4 patients are respectively affected by: 1st case: arterial hypertension, dyslipidemia and III degree AV block in NYHA class II heart failure (HF); 2nd case: NYHA III HF, prosthetic biologic aortic valve dysfunction; 3th case: NYHA III HF, ischemic dilated cardiomyopathy; 4th case: ischemic dilated cardiomyopathy waiting for heart transplantation. METHODS AND RESULTS: The above 4 patients showed, on transthoracic echocardiogram, mitral diastolic regurgitation. The authors deem as caused, in agreement with the literature, both by an atrio-ventricular pressure gradient inversion during long-lasting diastoles (III degree atrioventricular block, blocked atrial systole, aortic valve regurgitation), and by an inadequate ventricular remodelling/distensibility. The 5th case deals with a healthy highly trained competitive athlete who, at the fitness checkup, showed mitral diastolic regurgitation. The study was also extended to two healthy groups of subjects, in order to rule out mitral regurgitation during the diastolic interval of the cardiac cycle. CONCLUSIONS: Such finding, after an accurate and critical analysis, led the authors to assume it may deal with a borderline physiological condition.

[Monitoring of antithrombin III in general surgery]. / Monitoraggio dell'antitrombina III in chirurgia generale.

The authors studied the effects of surgery on hemocoagulation parameters (PT, PTT, PLT, Fibrinogen, AT III). 30 patients, undergoing extrahepatic surgery were observed. Measurements were performed before, during and immediately after procedure, and 24 hs and 48 hs later. Results showed a significant drop of AT III activity (p < 0.05) throughout the surgical procedure with a prompt reversal to normal values right after the end of it. Fibrinogen values continuously increased from the end of surgery (compared to intra-op values) (p < 0.05) up to 48 hs (p < 0.01). PTT values decreased at the end of surgery (p < 0.05) and returned to normal during the following 24 hs. No thromboembolic and hemorrhagic complications were observed during the postoperative phase, with all patients being discharged after surgical resolution of pathologies. In conclusion accurate monitoring of hemocoagulation parameters (especially AT III) seems to be useful in order to prevent thromboembolic and/or hemorrhagic complications during and after surgery.

Design and development of a rheometer for biological fluids of limited availability.

From studies on the dynamic characterization of human bones, it is noticed that reference data on the viscous behavior of the bone marrow are quite poor. Dependently from marrow limited availability and its opacity, we have not been able to retrieve a tool of appropriate characteristics able to measure bone marrow viscosity. Therefore, principal techniques for the viscosity measurement have been preliminarily examined, and a device suitable for viscosity measurements of biological fluids has been realized. In particular, a rotational rheometer has been developed: it is a coaxial cylinders system, where the fluid flows dragged by the inner cylinder. The device is an absolute rheometer, that is, particularly useful as nowadays it is not known the classification of the bone as far as it concerns its viscous behavior. In this work a preliminary evaluation of the metrological characteristics of the measurement system has been carried out and its main metrological performances have been evaluated.

Active accumulation of very diluted biomolecules by nano-dispensing for easy detection below the femtomolar range.

Highly sensitive detection of biomolecules is of paramount interest in many fields including biomedicine, safety and eco-pollution. Conventional analyses use well-established techniques with detection limits ~1 pM. Here we propose a pyro-concentrator able to accumulate biomolecules directly onto a conventional binding surface. The operation principle is relatively simple but very effective. Tiny droplets are drawn pyro-electro-dynamically and released onto a specific site, thus increasing the sensitivity. The reliability of the technique is demonstrated in case of labelled oligonucleotides diluted serially. The results show the possibility to detect very diluted oligonucleotides, down to a few hundreds of attomoles. Excellent results are shown also in case of a sample of clinical interest, the gliadin, where a 60-fold improved detection limit is reached, compared with standard ELISA. This method could open the way to a mass-based technology for sensing molecules at very low concentrations, in environmental as well as in diagnostics applications.

An air flow sensor for neonatal mechanical ventilation applications based on a novel fiber-optic sensing technique.

In this work, a simple and low-cost air flow sensor, based on a novel fiber-optic sensing technique has been developed for monitoring air flows rates supplied by a neonatal ventilator to support infants in intensive care units. The device is based on a fiber optic sensing technique allowing (a) the immunity to light intensity variations independent by measurand and (b) the reduction of typical shortcomings affecting all biomedical fields (electromagnetic interference and patient electrical safety). The sensing principle is based on the measurement of transversal displacement of an emitting fiber-optic cantilever due to action of air flow acting on it; the fiber tip displacement is measured by means of a photodiode linear array, placed in front of the entrance face of the emitting optical fiber in order to detect its light intensity profile. As the measurement system is based on a detection of the illumination pattern, and not on an intensity modulation technique, it results less sensitive to light intensity fluctuation independent by measurand than intensity-based sensors. The considered technique is here adopted in order to develop two different configurations for an air flow sensor suitable for the measurement of air flow rates typically occurring during mechanical ventilation of newborns: a mono-directional and a bi-directional transducer have been proposed. A mathematical model for the air flow sensor is here proposed and a static calibration of two different arrangements has been performed: a measurement range up to 3.00 × 10(-4) m(3)∕s (18.0 l∕min) for the mono-directional sensor and a measurement range of ±3.00 × 10(-4) m(3)∕s (±18.0 l∕min) for the bi-directional sensor are experimentally evaluated, according to the air flow rates normally encountered during tidal breathing of infants with a mass lower than 10 kg. Experimental data of static calibration result in accordance with the proposed theoretical model: for the mono-directional configuration, the coefficient of determination r(2) is equal to 0.997; for the bi-directional configuration, the coefficient of determination r(2) is equal to 0.990 for positive flows (inspiration) and 0.988 for negative flows (expiration). Measurement uncertainty δQ of air flow rate has been evaluated by means of the propagation of distributions and the percentage error in the arrangement of bi-directional sensor ranges from a minimum of about 0.5% at -18.0 l∕min to a maximum of about 9% at -12.0 l∕min.

Pre-pregnancy weight and excess weight gain are risk factors for macrosomia in women with gestational diabetes.

OBJECTIVE: To determine whether women with gestational diabetes mellitus (GDM) whose weight gain exceeded the 2009 Institute of Medicine (IOM) recommendations were more likely to have macrosomia. STUDY DESIGN: Retrospective cohort study of the association of weight gain in women with Class A1 GDM, with term (≥37 weeks) singleton liveborns and macrosomia (birthweight ≥4000 g). Multivariate logistic regression models were used to adjust for covariates and test for interactions. RESULT: Of 1502 women studied, pre-pregnancy body mass index (BMI) categories were: normal (39.6%), overweight (28.5%) and obese (31.9%). The mean (±standard deviation ) weight gain (lbs) for these groups was: 27.6±10.9, 24.2±13.0 and 18.8±16.3 (P<0.0001), whereas the occurrence of macrosomia was 7.4, 11.4 and 19.0%, respectively. Women with an obese BMI were twice as likely to have a macrosomic infant compared with women in the normal BMI group (odds ratio, OR 2.0; 95% CI 1.4-3.0; P=0.0005). Independently, women who exceeded the IOM guidelines were three times more likely to have a macrosomic infant (OR 3.0, 95% CI 2.2-4.2, P<0.0001). CONCLUSION: Maternal pre-pregnancy weight and weight gain during pregnancy appear to be significant and independent risk factors for macrosomia in women with GDM.

Recurrent syncope in elderly patients and tilt test table outcome: the role of comorbidities.

Syncope is a common disorder that can lead to serious consequences in the elderly. Tilt-test is a safe, useful specific tool to investigate recurrent syncope also in the elderly. Comorbidities and medication use, widely present in elderly patients, affecting the hemodynamic response, can influence the tilt-test outcome. The aim of this study was to evaluate the influence of these confounding factors on tilt-test results in elderly patients with recurrent syncope. We included in this study a consecutive group of 87 patients>75 years (82.1+/-4.3 years) with unexplained syncope. They underwent passive upright tilt-test. Heart rate an blood pressure were recorded using non-invasive devices. The patients were classified according to the modified Vasovagal Syncope International Study (VASIS). Comorbidities were measured with the geriatric index of comorbidities (GIC), which is a composite score taking into account both the number of diseases and their severity as measured by Greenfield's IDS. The tilt-test was positive in 22 patients. There were no significant differences in clinical characteristics, and medication use between the tilt-test negative and positive patients, except for the GIC score (1.12+/-0.5 vs. 2.42+/-0.48; p=0.001) and for a reduced number of medications in the former group (5.7+/-3.1 vs. 8.2+/-2.4; p=0.001). This study suggests that comorbidities and the number of medications could influence tilt test outcome.

Long-term effectiveness of pulmonary rehabilitation in patients with chronic airway obstruction.

The aim of this study was to evaluate the long-term outcome of an outpatient pulmonary rehabilitation programme (PRP) in patients with chronic airway obstruction (CAO). In 61 CAO patients (35 asthmatics and 26 chronic obstructive pulmonary disease (COPD)) lung and respiratory muscle function, exercise tolerance (by symptom limited cycloergometer and walking tests), dyspnoea (Borg scale, visual analogue scale (VAS), baseline and transitional dyspnoea index (BDI and TDI, respectively)) and quality of life (St George's Respiratory Questionnaire (SGRQ)) were assessed at baseline (to), at discharge (t1) and 12 months postdischarge (t2). Preprogramme and post-programme hospital admissions and exacerbations of disease were also recorded. In comparison with baseline, no significant change was observed in lung function tests in either diagnostic group, either at t1 or at t2. In both groups improvements in respiratory muscle strength, exercise tolerance, Borg scale and VAS reported at t1 were partially reduced at t2. Analysis of variance showed that these changes over time were similar in the two groups. Mean values of SGRQ and BDI/TDI improved at t1, and, unlike exercise tolerance, did not worsen at t2. However, a clinically relevant difference in SGRQ between t2 and to was reported only in 56% of asthmatics and 52% of COPD patients. Compared with the preceding 2 yrs, in the year following PRP, hospital admissions and disease exacerbations decreased significantly in both diagnostic groups. Regardless of diagnosis, patients with chronic airway obstruction who underwent an outpatient pulmonary rehabilitation programme maintained an improved quality of life 12 months postdischarge despite a partial loss of the improvement in exercise tolerance.