Preliminary classification criteria for the cryoglobulinaemic vasculitis.

BACKGROUND: To develop preliminary classification criteria for the cryoglobulinaemic syndrome or cryoglobulinaemic vasculitis (CV). METHODS: Study part I developed a questionnaire for CV to be included in the formal, second part (study part II). Positivity of serum cryoglobulins was defined by experts as an essential condition for CV classification. In study part II, a core set of classification items (questionnaire, clinical and laboratory items, as agreed) was tested in three groups of patients and controls-that is, group A (new patients with the CV), group B (controls with serum cryoglobulins but lacking CV) and group C (controls without serum cryoglobulins but with features which can be observed in CV). RESULTS: In study part I (188 cases, 284 controls), a positive response to at least two of three selected questions showed a sensitivity of 81.9% and a specificity of 83.5% for CV. This questionnaire was employed and validated in study part II, which included 272 patients in group A and 228 controls in group B. The final classification criteria for CV, by pooling data from group A and group B, required the positivity of questionnaire plus clinical, questionnaire plus laboratory, or clinical plus laboratory items, or all the three, providing a sensitivity of 88.5% and a specificity of 93.6% for CV. By comparing data in group A versus group C (425 controls), the same classification criteria showed a sensitivity 88.5% and a specificity 97.0% for CV. CONCLUSION: Classification criteria for CV were developed, and now need validation.

Hyperbaric oxygen therapy as salvage treatment for sudden sensorineural hearing loss: review of rationale and preliminary report.

BACKGROUND: The management of sudden sensorineural hearing loss has not yet been standardised. Hyperbaric oxygen therapy influences recovery from sudden sensorineural hearing loss, but the underlying mechanism is unknown and the appropriate indications and protocols undetermined. MATERIALS AND METHODS: Nineteen patients affected by sudden sensorineural hearing loss were treated after unsuccessful medical therapy, either in an acute or chronic setting. Pure oxygen inhalation at 2.5 atmospheres absolute pressure was administered for 90 minutes, for 30 sessions. Frequency-specific and average pure tone hearing thresholds were determined before and after hyperbaric oxygen therapy. The number of hyperbaric oxygen therapy sessions, the patient's age and any therapeutic delay were considered as quantitative variables possibly influencing outcome. Stepwise multivariate analysis was performed. RESULTS: Salvage hyperbaric oxygen therapy appeared to improve patients' pure tone hearing thresholds, particularly at low frequencies. Positive results were more likely with increased patient age and reduced delay in receiving hyperbaric oxygen therapy. CONCLUSION: Hyperbaric oxygen therapy has a strong scientific rationale, and improves pure tone hearing thresholds in cases of sudden sensorineural hearing loss unresponsive to medical therapy. Further research may be able to identify those patients with sudden sensorineural hearing loss for whom hyperbaric oxygen therapy would be most cost-effective.

Steatosis of the graft is a risk factor for posttransplantation biliary complications.

BACKGROUND: Despite recent advances in organ preservation, immunosuppression, and surgical techniques, the biliary tree is still considered the Achilles' heel of liver transplantation. The aim of this study was to retrospectively analyze the incidence of biliary complications and identify predisposing risk factors. METHODS: From January 2004 to December 2007, 117 consecutive deceased donor liver transplantations were retrospectively analyzed for the development of biliary complications by review of medical records. Patients were divided into group 1 with biliary complications (n = 43) and group 2 without biliary complications (n = 74). RESULTS: The overall biliary complication rate was 36.8%; leakage 6% and stricture 30.8%. Univariate analysis indicated that significant predictors of biliary complications were the time interval between portal and arterial reperfusion (P = .037) and macrovacuolar steatosis of the graft >25% (P = .004). A stepwise logistic regression model demonstrated that >25% macrosteatosis of the graft was the only independent risk factor predicting biliary complications after liver transplantation (odds ratio [OR] = 5.21; CI 95% [1.79-15.15]; P = .002). No differences were noted in patient or graft survival between the 2 groups. CONCLUSION: Transplantation of a liver with >25% steatosis was a risk factor for the development of a biliary complication.

Bone marrow B-cell clonal expansion in type II mixed cryoglobulinaemia: association with nephritis.

OBJECTIVES: To investigate the relationship between the pattern of bone marrow (BM) B-cell expansion and the clinical features of mixed cryoglobulinaemia (MC) syndrome. METHODS: Fifty-five patients with type II MC syndrome were analysed. Their median age was 64 yrs (range 24-82), the median disease duration was 6 yrs (range 1-26) and the mean follow-up after BM analysis was 2.65 yrs (s.d. = 1.33). Peripheral neuropathy was present in 33 patients (60%), nephritis in 14 (25.4%), skin ulcers in 14 (25.4%) and lymphoma or atypical lymphoproliferative disorder (LPD) in 17/55 (30.9%). Anti-HCV antibodies were found in 43/55 patients (78.2%). BM B-cell expansion was evaluated by a semi-nested PCR amplification of the V-D-J region of the IgH genes. RESULTS: A clonal B-cell expansion in the BM was found in 33/55 (60%) patients, while a polyclonal pattern in 22/55 (40%). A BM pattern of clonal B-cell expansion increased the risk of nephritis of about 10 times [odds ratio (OR) = 10.11, CI95%1.52-67.31], if compared to a polyclonal pattern. In contrast, the risk of skin ulcers was decreased in BM clonal cases (OR = 0.09, CI95%0.02-0.49). Overt lymphomas did not emerge from patients with BM monoclonal expansion (without clinical or histopathological features of lymphoproliferation; or with LPD) in a short-term, consistent with the finding that monoclonality was associated with nephritis and not with an underlying, not recognized lymphoma. CONCLUSION: BM clonal B-cell expansion is associated with nephritis in MC syndrome. Particular B-cell clones may be preferentially expanded and may play a pathogenic role in MC nephritis.

Diffusion-weighted MRI in evaluating liver fibrosis: a feasibility study in cirrhotic patients.

PURPOSE: This study was designed to establish whether the measurement of apparent diffusion coefficients (ADCs) is clinically accurate in diagnosing liver fibrosis in a selected series of cirrhotic patients. MATERIALS AND METHODS: Twenty-eight cirrhotic patients (mean age 58.1 years) with histologically proven liver fibrosis and 29 healthy controls (mean age 43.8 years) underwent liver diffusion-weighted magnetic resonance (MR) using a 1.5-Tesla (T) magnet equipped with a phased-array coil. Diffusion studies with parallel imaging [generalized autocalibrating partially parallel acquisitions (GRAPPA)] were performed within a single breath-hold using a single-shot spin-echo echo-planar sequence (TE 74 ms) using four b values: b=0, 150, 250 and 400 s/mm(2). A unidirectional diffusion gradient was applied. ADCs were measured on ADC maps. RESULTS: Mean ADC was significantly lower in cirrhotic livers than in controls (1.11+/-0.16 vs. 1.54+/-0.12.10(-3)mm(2)/s) (p<0.0001). Receiver operating characteristic (ROC) analysis showed an area under the curve (AUC) of 0.96 [confidence interval (CI) 95%:(0.87; 0.94)], demonstrating higher sensitivity and specificity (92.9% and 100%, respectively) for an ADC cutoff of 1.31.10(-3)mm(2)/s. Positive predictive value (PPV), negative predictive value (NPV) and overall accuracy were 100%, 99.9% and 96.4%, respectively. CONCLUSIONS: Diffusion-weighted MRI is an accurate tool in evaluating advanced liver fibrosis if an optimised single-shot spin-echo echo-planar sequence with maximum intermediate b value is used. The ADC threshold for liver fibrosis was 1.31.10(-3)mm(2)/s.

Sonographic criteria for differentiation of benign and malignant solid breast lesions: size is of value.

PURPOSE: The purpose of this study was to evaluate whether lesion size may influence the value of sonographic findings in the differential diagnosis between benign or malignant breast lesions. MATERIALS AND METHODS: Sonographic features of 256 histologically confirmed (148 benign, 108 malignant) breast lesions were retrospectively and independently reviewed by three radiologists unaware of mammographic findings and pathology results. Each lesion was assessed for several sonographic features and assigned a level of suspicion. Logistic modelling defined the predictive value of each sonographic feature per se and in relation to lesion size. The k statistic (k) evaluated interobserver agreement in lesion classification. The accuracy of breast sonography in characterising solid lesions was also evaluated. RESULTS: Analysis of the sonographic features predictive of malignant disease, taken as a whole, showed that only irregular margins and marked hypoechogenicity maintain their predictive value independent of lesion size. When lesion size is considered, the other features remain significant only for lesions larger than 7 mm. Interobserver agreement for sonographic suspicion, when calculated not taking into account lesion size, was good or excellent whereas it was reduced for lesions smaller than 7 mm. Accuracy of breast sonography improved when evaluating lesions larger than 7 mm. CONCLUSIONS: Lesion size influences the value of sonographic findings in distinguishing benign from malignant lesions. The usually adopted criteria in sonography have a significantly lower accuracy in characterisation of small lesions.

New tridimensional approach to the evaluation of the spine through surface measurement: the BACES system.

The aim was to test a new instrument, the BACES system, an articulated arm connected to a computer, to improve noninvasive examination of the spine and to reduce X-ray examinations. To this aim, four observers performed three series of eight measurements on a dummy and two healthy volunteers. Data on the projection of the spine, any curve detectable on the frontal and sagittal plane, and any rotation at each thoracolumbar level were collected and analysed. To detect the role of the observer, of the procedure and of the object in measurement variability, a two-factor analysis of variance was performed. The results showed measurement errors for kyphosis and scoliosis generally below 3 degrees, whereas the lordosis showed a major variability, especially in volunteers, because of the attitude role. Rotations showed a limited variability too, generally below 2 degrees. In the clinical setting, > 2 SD may reasonably be considered a clinical change because it has not a great chance of being a measurement error. Thus, the BACES system allowed us to identify with fairly good precision kyphosis, scoliosis and trunk rotations. Even though at the moment no surface measurement method can replace X-rays, the instrument can integrate and limit the use of radiographic evaluations.

Ultrasonographic appearance of tissue is a better indicator of CL function than CL diameter measurement in dairy cows.

In this study, the ovaries of 99 randomly selected Friesian cows were examined by ultrasonography measuring the diameter and evaluating the appearance of corpora lutea (CLs) in order to assess the most reliable method for their functional classification. Concurrently, blood samples were taken and analyzed for plasma progesterone (P4) concentration. On the basis of the ultrasonographic measurement of the diameter of the CL, three groups were established: (A) CL not detected (n = 30), (B) CL psi < 20 mm (n = 22), and (C) CL psi > or = 20mm (n = 47). On the basis of the ultrasonographic appearance, three different groups were established: (A) CL not detected (n = 30), (B) evolving CL (n = 25), and (C) mid-cycle CL (n = 44). On the basis of the P4 values, CLs were functionally classified in the following three groups: (A) CL not detected when plasma P4 was lower than 1 ng/ml (n = 27), (B) evolving CL when plasma P4 was between 1 and 4 ng/ml inclusive (n = 29), and (C) mid-cycle CL when plasma P4 was more than 4 ng/ml (n = 43). The degree of agreement between plasma P4 concentrations and either ultrasonographic classification (diameter or appearance) was highly significant (P < 0.001). However, the results of the present study suggest that for the evaluation of functional classification of the CL in cows ultrasonographic appearance is more reliable than the evaluation of the diameter.

A light and electron microscopic quantitative analysis of nerve-immune cell contacts in the gut-associated lymphoid tissue of the mouse colon.

Light microscopy (LM) histochemistry and transmission electron microscopy (EM) have been used to investigate the structural relationship between immunocompetent cells and enteric nerves in the gut-associated lymphoid tissue (GALT) of the mouse colon, i.e., a) the scattered immune cells in the lamina propria, b) the lymphoid follicles and c) the cryptopatches. Nerve-immune cell contacts have been quantified by LM, using the osmium-zinc iodide procedure for visualizing nerve fibers. Appositions of nerves to immune cells have been studied by EM when the distance between the immune cell plasma membrane and the neurilemma was 200 nm or less. In the diffuse GALT a), the LM incidence of nerve-lymph cell and nerve-plasma cell contacts has been calculated to be one and half and, respectively, three times greater than would be expected by chance alone (P < 0.0001 in both cases). EM showed close apposition of axonal varicosities, mostly containing 60 nm diameter dense-cored vesicles, to B lymphoblasts/immunoblasts or plasma cells. In isolated lymphoid follicles b), nerve-immune cell contacts were identified almost exclusively in the T-cell dependent parafollicular regions; the incidence of such contacts, calculated by LM, did not exceed expected theoretical values. By EM, apposition of nerve varicosities to small/middle-sized lymphocytes containing cytoplasmic lysosomal granules was seen sporadically. Examination of nerve-immune cell contacts in cryptopatches c), a recently identified extrathymic T-cell generating compartment, allowed recognition of a small proportion of nerve-lymph cell structural interactions, both at LM and EM. This study provides systematic quantitative data on the microanatomical relationship between enteric nerves and immune cells in the various GALT compartments. Findings suggest that such nerve-immune cell contacts might represent the structural foundation for communication between enteric nerves and the GALT.

Agreement between ultrasonographic classification of the CL and plasma progesterone concentration in dairy cows.

We evaluated the agreement between ultrasonographic characteristics of the corpus luteum (CL) and plasma progesterone (P4) concentration in dairy cows. In Phase I of the study, the ovaries of 8 cows were ultrasonographically examined, and P4 was analyzed daily from estrus (Day 0) to Day 4, then at Day 7 and Day 10, and again daily from Day 17 to the onset of next estrus. In Phase 2, the ovaries of 157 randomly selected Friesian cows were examined once by ultrasonography, and blood samples collected concurrently were analyzed for plasma P4. On the basis of the P4 values, the function of CLs was classified as follows: 1) non-secretory CL when plasma P4 was lower than 1 ng/mL (n=41); 2) evolving CL when plasma P4 was between 1 and 4 ng/mL (n=55); and 3) mid-cycle CL when plasma P4 was more than 4 ng/mL (n=61). On the basis of ultrasonographic examination, 3 additional groups were established (absence of CL, evolving CL, midcycle CL). Ultrasonographic characteristics and size of Day 3 to 4 CLs and their respective plasma P4 concentrations were not distinguishable from those of CLs observed 3 to 4 d before the subsequent estrus. The degree of agreement between the two classification was 72%. The data indicate that the functional classification of CLs is difficult to determine based on ultrasonography alone.

Apposition of enteric nerve fibers to plasma cells and immunoblasts in the mouse small bowel.

Light (LM) and electron microscopy (EM) were used to investigate the structural relationship between enteric nerves and the population of immune cells in the mouse small bowel. By LM, the osmium-zinc iodide procedure was used for visualizing nerve fibers; the incidence of nerve-plasma cell contacts in the mucosa and submucosa was calculated to be approximately 4 times and, respectively, 3 times greater than would be expected by chance alone (P < 0.0001). EM revealed close, synaptic-like contacts between axonal varicosities and plasma cells or B immunoblasts. The results presented here provide systematic quantitative evidence that a structural foundation for communication between nerve fibers and B cells exists in the mouse small bowel.

The use of oxytocin for the reduction of cow placental retention, and subsequent endometritis.

Oxytocin was administered to reduce incidence of retained placenta and uterine infections that could delay subsequent conception. Three hundred and fifty multiparous Friesian cows, each with spontaneous delivery of a single calf were divided randomly into two groups. Some (n = 175) were injected with 30 IU of oxytocin immediately after delivery and again 2-4 h later, while the remainder formed an untreated control group. The placental retention 24 h after parturition was 24.6% and 10.9% in control and treated animals respectively (P < 0.01). Endometritis occurred in 51.6% of the animals following placental retention as compared to 10.4% of those with normal expulsion of the fetal membranes (P < 0.001). A comparison of reproductive indices showed a statistically significant improvement of fertility in treated cows with the average interval from calving to conception being reduced from 124.4 d to 93.7 d (P < 0.0001).

Continuous wave Nd:YAG laser photocoagulation in proliferative diabetic retinopathy.

AIMS: The therapeutic efficacy of the continuous wave (CW) Nd:YAG laser (working in the free running mode) was investigated in proliferative diabetic retinopathy (PDR) comparing it with a conventional laser source such as the krypton laser. METHODS: Twenty four eyes of 12 patients affected with bilateral PDR were included and divided in two groups. The right eyes were treated with a red krypton laser and the left eyes with a CW Nd:YAG laser. RESULTS: Three months after krypton photocoagulation 10 eyes showed a reduction or a complete regression of PDR and two eyes were unchanged. In the CW Nd:YAG laser group no eyes showed any regression of new vessels, in seven eyes the angiographic features were unchanged, and in five eyes they worsened. All the eyes of the second group underwent retreatment with the krypton laser after 3 or 6 months. After a mean follow up of 13 months all eyes in the krypton group showed a reduction or complete regression of PDR; in the retreated group 10 eyes improved and two were unchanged. CONCLUSIONS: The statistical analysis showed a highly significant difference (p = 0.001) between krypton and CW Nd:YAG laser which indicated the lack of efficacy of the latter in the treatment of PDR. In the krypton laser group no significant difference (p = 0.05) after the retreatment was found confirming the efficacy of this treatment.

Efficacy of collagen shields after extracapsular cataract extraction.

The efficacy of presoaked porcine collagen shields was compared with subconjunctivally injected corticosteroids and antibiotics in reducing ocular inflammation after ECCE with IOL implantation, and signs of reduced oxygen delivery to the cornea were assessed. Fifty eyes of fifty patients were recruited. At the end of surgery 25 eyes (group 1) received a 24-h shield presoaked with 0.1% betamethasone disodium phosphate and 0.5% netilmycin. The other 25 eyes (group 2) received 1 mg betamethasone disodium phosphate and 250 mg piperacillin as a subconjunctival injection. The eyes were then taped closed. Inflammatory parameters (anterior chamber flare, fibrin, folds of Descemet's membrane, corneal edema) and tolerability of the delivery system (pain, itching) were evaluated 24 h after surgery. None of the patients lost the shield and the collagen devices were well tolerated. Groups 1 and 2 showed no significant differences in the parameters considered. There was, however, transient, slight diffuse superficial corneal edema in 24% of group 1 and 4% of group 2, raising the question of inadequate oxygen transmission through collagen shields under closed lids. The results suggest that collagen shields used with the right solution have no significant adverse effect and may be a less invasive alternative to subconjunctival injection.

Efficacy of oxytetracycline and tetracycline-benzydamine in the prevention of infection after placental retention in cattle.

The efficacy of intrauterine oxytetracycline and a combination of benzydamine and tetracycline in preventing uterine infections in 150 Italian Friesian cows with retained placentas were compared. The animals were divided into three equal groups. Sixteen per cent of the oxytetracycline-treated group, 12 per cent of the benzydamine-tetracycline-treated group and 76 per cent of the untreated group developed endometritis. The difference between the two treatment groups was not significant but both treatments were effective in preventing septic complications in cows with retained placentas.