Anterior approach to the spine. Role of the general surgeon, techniques and surgical complications. The 10-year experience of the Niguarda Hospitals.

AIM: The aim of the study was to present the incidence of early and late surgical complications in a group of patients treated with anterior approach for spine lesions. The study was also focused on technical aspects for lesions of D1-D2 and L5-S1 segments and results on a group of patients underwent adjunctive surgical procedures at the same time of spinal surgery. METHODS: This was a retrospective study based on our database from April 1998 to December 2008. The study enrolled 120 consecutive patients (M/F 73/47; mean age 43.1 years; range 15-70 years) who underwent spinal surgery for trauma (92 patients), primitive or metastatic cancer (12 patients), benign lesion (2 patients), degenerative disc disease (6 patients) and infection disease (8 patients). This work describes the anterior approach to the spine. RESULTS: No death was recorded. Thirty-two patients (26.6%) presented postoperative complications: persistent urinary tract infections in 19 (15.9%), pneumonia in 6 (5%), pleural effusion in 3 (2.5%), wound infection in 2 (1.6%), retro-peritoneal abscess in 1 (0.8%) and haemorrhage in 1 (0.8%). During the follow-up (mean 3.8 years; range 2 months-10 years) 1 patient (0.8%) required two further surgical procedures for tuberculosis abscess recurrences. CONCLUSION: Anterior approach to the spine is effective and safe. Surgical complications do not negatively affect patient survival and spine stabilization included patients with D1-D2 and L5-S1 lesion and patients who receive adjunctive surgery at the same time of spine procedure.

Protection levels in vaccinated heifers with experimental vaccines Brucella abortus M1-luc and INTA 2.

Brucella abortus M1-luc is a mutant strain derived from S19 vaccine strain in which most of bp26 sequence has been replaced by the luciferase coding gene. Strain I2 is a double mutant derived from M1-luc in which most of omp19 has been deleted without introduction of any genetic markers. In BALB/c mice, M1-luc presented equivalent performance to S19 regarding persistence, splenomegaly and protection against challenge. Interestingly, I2 was more attenuated than S19, with no reduction of protection against challenge. In order to evaluate the potential for vaccine use of these strains in the natural host, four groups of 15 heifers, 6-month old, were either non-vaccinated or vaccinated with S19, M1-luc or I2. To at reached 17-month old, heifers were synchronized with two doses of PGF2alpha and received natural service during 60 days with two bulls. Pregnant heifers were challenged at approximately six gestation months with virulent B. abortus S2308. Blood samples post-challenge of heifers were collected for serologic test as well as specimens of aborted fetuses and premature calves for bacterial isolation and histopathological analyses. Protection levels against abortion were 78.6% for S19, 81.8% for M1-luc and 45.5% for I2, compared to the 25% that did not abort from the non-vaccinated group. These results indicate that in bovines BP26 had no influence in protective capacity of S19, correlating with the results obtained in mice. However, contrarily to what was previously observed in mice, lack of expression of Omp19 rendered in less protection capacity of S19 in the natural host.

Renal grafts from elderly donors: histological studies and long-term results.

To satisfy the increasing requests for renal grafts, elderly donors are increasingly accepted for kidney transplant at many centers. The main unresolved question is the long-term effect on graft survival of potential histological lesions due to donor age. We present a prospective histological study performed from January 1997 to December 2001 on 184 consecutively transplanted renal grafts in which the only criterion for graft acceptance was a normal value of serum creatinine upon admission to the intensive care unit independent of donor age. At the end of the study, 57 recipients (31%) of mean age 55 years (range 39 to 67 years) received a renal graft from donors aged more than 60 years (mean age 66 years; range 60 to 75 years), this cohort denoted as older donor kidney transplant group (ODKTG) and 127 recipients (69%) with a mean age of 49 years (range 21 to 63 years) received a renal graft from donors whose age was lower than 60 years (mean age 49 years; range 16 to 59 years), a cohort denoted as the younger donor kidney transplant group (YDKTG). The two groups were comparable for time of dialysis, cold ischemia time, immunosuppression therapy, grading of histological damage. At the end of the study with a mean follow-up of 5.6 years (range 3.5 to 7.5 years), primary graft nonfunction and delayed graft function were significantly more represented in the ODKTG than the YDKTG. Cumulative patient and graft survival was 84.3% and 79.4% in the ODKTG, respectively, and 93.8% and 85.9% in the YDKTG, respectively (P = NS). Cumulative serum creatinine values were 1.98 mg/100 mL in ODKTG and 1.65 mg/100 mL in YDKTG (P = NS). In conclusion, renal grafts from older donors presented histological damage comparable to that seen among renal grafts from younger donors.

Pancreas retransplantation: ideal timing and early and late results.

Surgical complications are the leading cause of pancreatic graft loss among diabetic patients who undergo pancreas transplantation alone (PTA), or combined with kidney transplantations (PK) or after kidney transplantations (PAK). Therapeutic effects on secondary complications of diabetes justify pancreas retransplantation (re-PT) when the first graft is lost. However, the appropriate timing for retransplant and related problems is not known. We present our initial experience on re-PT performed on seven diabetic patients who lost their first pancreas grafts (PK) due to surgical complications (venous thrombosis in five and enteric fistula in two). Five re-PT were performed a few days after the first PT without a second course of induction therapy, while two patients received re-PT some months later with reinduction therapy. In the early re-PT group, one patient died some hours after the second surgical procedure due to pulmonary embolism, while four patients lost their second grafts due to accelerated rejection within 2 years from re-PT. In the late re-PT group, both patients have good graft function without signs of rejection. Our initial experience showed discouraging results in the group of early re-PT, due to accelerated rejection episodes leading to a high incidence of graft loss. Late re-PT accompanied by reinduction therapy seemed to have better results.

Early and late residual renal function and surgical complications in living donors: a 15-year experience at a single institution.

Living donation in the field of renal transplantation has increased over time as well as the use of laparoscopic nephrectomy. We present a 15-year experience on 162 living donors (105 women, 57 men; mean age, 46.7 years; range, 31-74 years) who underwent nephrectomy using different surgical approaches as open lombotomic nephrectomy (OLN), open transperitoneal nephrectomy (OTN), and laparoscopic hand-assisted nephrectomy (LHAN). We collected data on residual donor and recipient renal function, as well as early versus late medical and surgical complications. With a mean follow-up of about 8 years, we observed normal residual renal function in all donors and similar results of early and late graft function independent of the surgical procedure. Long-term incidence of hypertension and noninsulin-dependent diabetes in living donors was similar to the general population. OLN and OTN donors showed higher incidences of early and late complications, readmissions, and reoperations than LHAN donors. Our results confirmed that living donor nephrectomy is a safe procedure without serious side effects in terms of renal function and long-term quality of life. LHAN should be the preferred technique because of a lower incidence of early and late complications.

Dual Kidney Transplantation: Evaluation of Recipient Selection Criteria at Niguarda Hospital.

BACKGROUND: Dual kidney transplantation (DKT) is a largely accepted strategy to enlarge the donor pool. Niguarda Hospital started this program in December 2010, and 38 DKT have been performed. In our series, we included recipients older than those in the other series published in literature. The aim of this study was to know if our recipient selection criteria for DKT are safe. METHODS: We reviewed our data base of DKT and analyzed recipients' medical history, surgical technique, post-operative complications, graft survival, morbidity, and mortality. We then compared our results with the literature. RESULTS: From December 2010 to April 2015, 38 DKT were performed in Niguarda Hospital. Delayed graft function was present in 21 recipients. Explantation of both kidneys was performed in 1 patient and explantation of 1 kidney in 6 patients. Post-operative complications were present in 8 patients. Five patients returned to hemodialysis after DKT. One recipient died of medical post-operative sepsis. The mean follow-up was 24 months. Graft survival and patient survival were 86.84% and 97.93%, respectively. Compared with the literature, our series had similar mortality and morbidity rates, even if recipients' age was higher than in other series. CONCLUSIONS: The strategy of DKT allocation in elderly recipients is safe. Further studies have to be performed to optimized selection of the recipients for DKT not to disadvantage younger patients in the transplant waiting list and to improve the technique of organ evaluation and preservation to refine graft allocation.

Management of occult adrenocorticotropin-secreting bronchial carcinoids: limits of endocrine testing and imaging techniques.

The differential diagnosis and the identification of the source of ACTH in occult ectopic Cushing's syndrome due to a bronchial carcinoid still represents a challenge for the endocrinologist. We report our experience in six patients with occult bronchial carcinoid in whom extensive hormonal, imaging, and scintigraphic evaluation was performed. All patients presented with hypercortisolism associated with high plasma ACTH values. The CRH test and high dose dexamethasone suppression test suggested an ectopic source of ACTH in three of six patients. During bilateral inferior petrosal sinus sampling, none of the patients showed a central to peripheral ACTH gradient. At the time of diagnosis, none of the patients had radiological evidence of the ectopic source of ACTH, whereas pentetreotide scintigraphy identified the lesion in two of four patients. Finally, a chest computed tomography scan revealed the presence of a bronchial lesion in all patients, and pentetreotide scintigraphy identified four of six lesions. In all patients a bronchial carcinoid was found and removed. In one patient with scintigraphic evidence of residual disease after two operations, radioguided surgery, using a hand-held gamma probe after iv administration of radiolabeled pentetreotide, was performed; this allowed detection and removal of residual multiple mediastinal lymph node metastases. In conclusion, our data show that there is not a single endocrine test or imaging procedure accurate enough to diagnose and localize occult ectopic ACTH-secreting bronchial carcinoids. Radioguided surgery appears to be promising in the presence of multiple tumor foci and previous incomplete removal of the tumor.

Kinetics of Tn5 transposition.

The kinetics of Tn5 transposition and gene expression were studied. For about 2 h after infection with lambda Tn5, Tn5 transpositions accumulate, reaching a level of about 1.5% of the infected cells. After 2 h transposition is essentially turned off. In cells carrying a resident Tn5, transposition is undetectable after infection. The synthesis of the Tn5-specific proteins p58 and p54 and the kanamycin-resistance protein were studied in pre-irradiated cells infected with lambda Tn5. The synthesis of p58 and p54 peaked early after infection and was significantly reduced, relative to pneo, by 2 h after infection. Moreover, p54 appeared to reach a maximum later than p58. These kinetic data put new constraints on models for the regulation of Tn5 transposition.

Bile lipid output and composition in patients fitted with external biliary drainage: activity of cicloxilic acid.

In 7 patients with external biliary drainage for total occlusion of the extrahepatic bile ducts the bile output was measured in 3-day periods, with and without cicloxilic acid treatment (240 mg daily, per os). The output increased markedly during treatment in all cases. In the 3 patients in whom the bile lipid composition was analyzed also, the bile salt and phospholipid concentrations increased while the cholesterol concentration was unchanged--with an consequent lowering of the biliary cholesterol saturation index--during treatment with cicloxilic acid.

Is lymphocele in renal transplantation an avoidable complication?

BACKGROUND: This study evaluated the impact of surgery in the incidence of lymphocele after kidney transplantation (KTx). METHODS: A prospective randomized study was conducted during a 6-year period on a group of patients undergoing KTx and operated on by the same surgeon (CVS). A total of 280 patients undergoing KTx were randomly allocated into two groups: (1) group C (control group) was 140 patients who were submitted to KTx with standard technique: implantation of the kidney in the controlateral iliac fossa with vascular anastomoses on the external iliac vessels; and (2) group M (modified technique group) was 140 patients who underwent a modified technique with a cephalad implantation of the graft in the ipsilateral iliac fossa and vascular anastomoses in the common iliac vessels. Both groups were comparable for age, cold ischemia time, incidence of rejection episodes, presence of adult polycystic kidney disease, and source of donor graft. RESULTS: Group M showed an incidence of lymphocele production (3 patients, 2.1%) significantly lower than group C (12 patients, 8.5%). Eight patients (1 in group M and 7 in group C) required surgical treatment by peritoneal fenestration. No allograft or recipient was lost as a result of fluid collection but the hospitalization was shorter in group M than in group C. CONCLUSIONS: A cephalad implantation of the renal graft in the ipsilateral iliac fossa has been associated with a lower incidence of lymphocele, probably because vascular anastomoses on the common iliac vessels cause less lymphatic derangement than those performed on the external iliac vessels.

[Early stages in the replication of aphthous fever virus. Kinetics of partial degradation and sites for the establishment of penetrating residual virus]. / Etapas tempranas en la replicación del virus de la fiebre aftosa. (VFA). Cinética de la degradación parcial y sitios de estabilización del virus penetrante residual.

At input multiplicities between 5-10 UFP/cell FMDV O1 Caseros adsorb in BHK21 Clon 13 cells at a rate of 5-20% depending whether cells are in suspension or in monolayers. At least four washings with medium are required to eliminate non specifically adsorbed virions. The remaining attached virus appears to be in contact with "specific" receptors of the cytoplasmic membrane. After penetration, 80% of virus became degraded to slow molecular weight material which is detected at first in the subcellular fraction and is gradually excreted out of the cells. The degradation process occurs from 0 to 15 minutes and it is demonstrated by a parallel decrease in infectivity and stability of purified labelled FMDV O1 Caseros. The 20% remaining virus is found firmly attached to a subcellular fraction precipitable at 15,000 xg. Parental residual infectivity remains remarkably stable for 90 min at which time newly synthetized RNA appears. Fraction of 15,000 xg from infected cultures was obtained at 60 min PI and incubated in vitro at 37 C. The infectivity remains unaltered for a period of 120 min even if the preparation is treated with 0.2% of triton x 100. Fraction of 15,000 xg from infected and control cultures obtained at different time PI were seeded on a linear sucrose gradient. A sharp peak of acid phosphatase associated with the lower mobility bands indicates the presence of intact lysosome structures. A shoulder of the enzyme activity is detected between the two main protein bands. Associated with the region rich in unbroken lysosomes, a very sharp peak of infectivity and/or 3H uridine or 32P labelled incoming virus can be detected. A different pattern of the residual incoming infectivity is found associated with the more rapid sedimentation protein band. 3H uridine incorporation at the beginning of viral RNA synthesis initiation shows that an important amount of newly synthesized viral RNA is found in the lower mobility band of the 15,000 xg fraction. Some incorporation is also detected in the faster band. The results presented here suggest that some functional activity is associated with the residual virus present at the beginning of infection in the 15,000 xg fraction. It can also be accepted that this virus penetrates by pinocytosis of specific receptors at the cytoplasmic membrane.