[Mesh infection in inguinal hernioplasty by Streptococcus dysgalactiae subspecies equisimilis. Case report and review of the literature]. / Infezione da Streptococcus dysgalactiae subspecies equisimilis in ernioplastica inguinale. Caso clinico e revisione della letteratura.

INTRODUCTION: Mesh infection in inguinal herniography is usually caused by Staphilococcus aureus and Staphilcoccus epidermidis. Generally it obliges to prosthesis removal with hernia relapse and increase of social costs for the prolongation of hospitalization. CASE REPORT: A 60-year-old woman, obese, undergone 4 months before to left inguinal prosthetic herniorrhaphy complicated by infection of the surgical site which didn't require the explantation of the mesh, although determining an early hernia relapse. She is submitted by the authors to a surgical intervention for left groin hernia relapse with placement of a polypropylene monofilament fixed with prolene. Six hours after the operation she shows systemic symptoms and local signs of prosthesis infection. Cultural examination of the surgical wound secretion allows the identification of Streptococcus dysgalactiae subspecies equisimilis (SDSE). A therapy with Amoxicillin-Clavulanic Acid and Levofloxacine leads to resolution, in 10 weeks, of the infection. DISCUSSION: In our case the infection of the new mesh, appearing prematurely, has been probably favoured by obesity and operative time longer than 3 hours. Conservative treatment has been fulfilled by success for the elevated sensitivity of the SDSE bacterium to penicillin and fluoroquinolones. CONCLUSIONS: Recent epidemiologic studies have demonstrated an increase of infections caused by SDSE, which will probably gain clinical relevance in the next future relatively to surgical prosthetic hernioplasty. In all cases of infection the authors suggest cultural isolation of the casual germ and the execution of the antibiogram because the conservative medical treatment can avoid mesh removal with consequent elevated risk of hernia relapse.

[Gallbladder polypoid lesions. Three clinical cases with difficult diagnosis and literature review]. / Lesioni polipoidi della colecisti. Presentazione di tre casi clinici di "difficile" diagnosi e revisione della letteratura.

INTRODUCTION: Gallbladder polypoid lesions occur in 1.3%-6.9% of cases. The preoperative diagnosis between benign, malignant and potentially malignant lesions is difficult. Therefore it is not possible any. PATIENTS AND METHODS: The Authors describe three cases. The case 1 was a gallbladder diffuse adenomyomatosis; the ultrasound and the CT were of little help in defining preoperatively the nature and the gravity of the thickening. Case 2 was an adenomyomatosis of the fundus: the ultrasound examinations were not able to establish preoperatively lesion's nature, site and dimensions. In the case 3, ultrasounds showed polypoid lesions and calculi concrections not found in colecistectomy. DISCUSSION: The ultrasound is the most widely used diagnostic tool in the evaluation of gallbladder polypoid lesions; its accuracy is only 66%. CT, which has an accuracy level of 75%, must be carried out there is any possibility of malignant degeneration of the polyp. If doubts persist, a MR, 93% accuracy, is indicated. In selected cases, PET can be of further help. CONCLUSIONS: The preoperative diagnosis of the nature of gallbladder polypoid lesions is "difficult" and this justifies the lack of consensus on treatment. However, the adenoma-carcinoma sequence, widely discussed in literature, can justifies to the use of CT, MR, PET and surgical treatment after an ultrasound examination.

Endoscopic sphincterotomy of the major duodenal papilla in acute relapsing pancreatitis associated with pancreas divisum: a case report.

We report a case of acute relapsing pancreatitis associated with pancreas divisum, who underwent major papilla sphincterotomy after failed minor papilla cannulation. Long-term results were satisfactory. The possible explanations of the efficacy of major papilla endoscopic resection in this particular case are discussed.

[Umbilical primary endometrioma. Case report]. / Endometriosi primitiva ombelicale. Caso clinico.

Umbilical primary endometrioma is a rare extra-uterine localization of endometriosis with a documented neoplastic risk. It is often difficult to distinguish primary umbilical endometriosis from other benign and malignant tumors of the abdominal wall. The Authors report a case of umbilical endometriosis in a 36-year old female. Endometriosis was suspected because of the presence of the typical cyclic bleeding and swelling. Abdominal CT excluded the presence of other endometriotic localizations. The umbilical mass was widely excised together with umbilicus, fascia and peritoneum. The tissue defect was primary closed without prosthetic mesh. Histological examination of the specimen showed the presence of endometrial glands with stromal component, compatible with the diagnosis of endometriosis. The Authors suggest that surgery should be performed in the first 3-4 days of the follicular phase, to minimize the risk of diffusion of endometriotic cells. Moreover, the excision should be wide in order to prevent local recurrence.

[Massive haemoperitoneum due to traumatic rupture of multifocal hepatocarcinoma in the right hepatic lobe. Case report]. / Emoperitoneo massivo da rottura di epatocarcinoma multifocale del lobo destro. Case report.

UNLABELLED: Abdominal blunt trauma is the main cause of death in people younger than 40 years old. The liver injury still represents a challenging problem. Isolated hepatic injury is rare and it occurs more frequentely in polytraumatizated patients and causes massive haemoperitoneum. The Authors report a case of a 83 years-old woman admitted to Emergency Department for syncope due to an active bleeding arising from a rupture of a right hepatic lobe unsuspected tumor. The computer tomography (CT) scans showed a clear pattern of liver laceration of the VI segment with contrast enhancement spreading in the surrounding tissues, and detected a multifocal hepatocarcinoma located in the VI, VII and VIII segments. Patient's haemodinamically unstable conditions suggested an urgent laparotomy. An accurate perihepatic packing with sterile-drape were successfully employed to control liver hemorrage. Temporary abdominal closure, followed by hepatic arteriography and the right hepatic artery embolization, completed the damage control. Re-exploration laparotomy after 72 hours confirmed the definitive haemostasis and the pack removal was performed without complications. CONCLUSIONS: CT plays a leading role in the diagnosis of liver damage. The patient's haemodynamic status is the principal criterion determining conservative or operative therapy in blunt liver injury. The early perihepatic packing followed by artheriographic embolization to stop liver hemorrhage showed efficacy and safety for the patient. The packing performed with sterile-drape is able to avoid removal complications and 72 hours timing for the pack removal is effective to avoid re-bleeding.

Carcinosarcoma of the uterus: a case report and review of the literature.

Carcinosarcoma is a rare tumor of the uterus with a poor prognosis. We present a case of uterine carcinosarcoma in an 82-year-old woman who suffered from pervaginal bleeding for ten months duration with progressive anemia. Abdominopelvic nuclear magnetic resonance (NMR) imaging showed the presence of an intrauterine mass, infiltrating the myometrium and reaching the cervix. The patient was submitted to total abdominal hysterectomy with bilateral salpingo-oophorectomy. The carcinosarcoma, arising from the lumen of the uterus, infiltrated the inner one-third of the myometrial layer (pT1b, pNx, pMx; FIGO Stage 1B). A CT of the total body performed six months after surgery showed no signs of recurrent and/or metastatic tumor. The clinicopathological features, treatment options and prognosis of this aggressive neoplasm are reviewed.

[A case of uterine carcinosarcoma]. / Carcinosarcoma dell'utero: descrizione di un caso clinico.

Uterine carcinosarcoma is a highly aggressive neoplasm with tendency to early recurrence and/or metastasis. The neoplasia has both epithelial and stromal malignant components. Clinically, it is characterized by a postmenopausal metrorrhagia, associated sometimes with abdominal pain. The Authors describe a case of carcinosarcoma in a 82-year old woman with a vaginal bleeding since 10 months and an ingravescent hypochromic anemia. The RMN of the abdomen and pelvis showed a mass occupying the whole uterine lumen, without signs of pelvic diffusion. A bilateral hystero-oophorectomy was performed; the patient's critical conditions and a high anaesthesiological risk advised us not to perform a bilateral pelvic lymphadenectomy with aortic sampling. Six months after operation, a clinical follow-up with a total-body CT didn't show any sign of local recurrence and/or distant metastasis. From the analysis of this case report and from the data of the literature some important considerations can be done: a) gynecologic check up in post-menopausal women with associated risk factors (obesity and hypertension) can allow an early diagnosis also in asymptomatic patients; b) sovrapubic and transvaginal US, abdomino-pelvic CT and MRI are essential for a correct clinical staging; c) surgical excision followed by the histological examination of the specimen is mandatory to establish a correct diagnosis.

[A possible cause of misdiagnosis in tumors of the axilla: schwannoma of the brachial plexus]. / Una possibile causa di errore nella diagnosi differenziale delle formazioni ascellari: lo schwannoma asintomatico dei tronchi del plesso brachiale.

The Authors report a rare case of a 57 years old man affected by a left radial nerve schwannoma that occurred as an asymptomatic lesion of the axilla. At clinical examination the lump was undistinguishable from the most common axillary lymphadenopathy. A lymphoadenopathy was erroneously diagnosed with ultrasonography (US). This mistake was due to the low specificity of the instrumental methodology and to the rarity of an asymptomatic schwannoma of the infraclavicular brachial plexus. The neoplasia was excised without using the microscope. In the early post-operative follow up, a "falling" attitude of the wrist, the hand and the fingers appeared, peculiar for a lesion of the radial nerve. Furthermore a hypoaesthesia of the skin of first finger and of the first interosseus space was associated. The sensitive and motor electromyography showed a radial nerve suffering. The "stupor" of the nerve trunk was treated with steroid therapy for 7 days and the patient underwent to some series of neuro-rehabilitative physical therapy for 12 weeks. The postoperative total body CT, showed that the lesion was unique: therefore it was possible to exclude the diagnosis of neurofibromatosis. After 28 months electromyography and axillary US were performed showing the complete resolution of the motor and sensitive deficit and the absence of local recurrence.

[On-line haemodiafiltration with sorbent-regenerated ultrafiltrate as replacement fluid: Beta2-microglobulin removal versus filtration fraction]. / Emodiafiltrazione on-line con reinfusione endogena (HFR): rimozione di Beta2-microglobulina (Beta2-m) vs frazione di filtrazione (FF%).

PURPOSE: In order to encourage the removal of middle molecules in hemodiafiltration (HDF) techniques an attempt is made to maximize convective clearance by increasing the ultrafiltration rate. However, convective clearance is limited by the maximum filtration fraction (FF%) obtainable, by the pre- or post reinfusion method and by the convective surface and the capacity of the filter used. This study aimed to evaluate the effect of the FF% in the removal of Beta2-microglobulin (Beta2-m) during hemodiafiltration reinfusion (HFR) to identify the best ultrafiltration strategies; and therefore, a better removal of medium molecular weight solutes in this hemodiafiltrative technique recently introduced in clinical practice. METHODS: Ten chronic uremic patients (eight males, two females; age 66 +/- 18 yrs) already on renal dialysis therapy (RDT) for 80 +/- 36 months, were subjected to four HFR sessions, with Td=240 +/- 10 min, Qb=312 +/- 18 and Qd=500 mL/min; the reinfusion rates (Qr) used were 43.6 +/- 7.2 mL/min (25-58) with FF% rates varying from 20-34 (24.2 +/- 3.8) for hematocritic levels of 34.6 +/- 4.2% at the start of the dialysis session. For each session the intradialytic reduction rates (RR%) of urea, creatinine (Cr), phosphate, uric acid and Beta2-m and its average clearance (KBeta2-m mL/min) were evaluated. RESULTS: The results obtained gave a RR% for urea of 69.4 +/- 5 (Kt/Veq=1.23 +/- 0.2) and for Cr, phosphate and uric acid values of, respectively, 61.2 +/- 5.4, 47.5 +/- 10 and 75.8 +/- 6.7. The intradialytic reductions in Beta2-m were 49.3 +/- 10.3% with a variability range from 29-69% and with average KBeta2-m values of 63.8 +/- 13.5 mL/min. The RR% of ss2-m and KBeta2-m were inversely correlated (p<0.01) to the FF% rate applied during the treatment; 75% of the HRF sessions in which we observed a reduction in Beta2-m levels >40% were those where a FF% between 20 and 26% was applied. CONCLUSIONS. From our study, it appears that in HFR the best ultrafiltration strategy from the convective sector in removing Beta2-m has FF% values in the range 20-26%. The occurrence of lower intradialytic reductions of Beta2-m with increasing FF% can be interpreted as a consequence of phenomena related to high intradialytic hemoconcentrations, to the excessive increase in the TMP and/or the increase in the protein cake with a consequent reduction in permeability and mass transfer. Although using a limited convective surface with a limited possibility of increasing the FF%, nevertheless, HFR seems capable of ensuring a satisfactory uremic toxin removal of low and medium molecular weight, which combined with the high biocompatibility deriving from the use of reinfused endogen, can be considered an effective dialytic strategy for preventing or retarding the complications in dialytic patients.

Epidemiological profile of symptomatic osteoarthritis in older adults: a population based study in Dicomano, Italy.

OBJECTIVES: To assess the prevalence of hand, hip, and knee osteoarthritis (OA) in an older Italian community dwelling population and its association with disability. METHOD: A cross sectional survey of the whole community aged 65 years and over, was carried out in Dicomano, a small rural town in Tuscany, Italy. Subjects were screened by geriatricians for major chronic conditions, including hip, knee, and hand OA, using diagnostic algorithms based on the American College of Rheumatology (ACR) clinical criteria. A rheumatologist examined subjects who screened positive. Disability was assessed by a World Health Organisation questionnaire. RESULTS: 697 of 864 eligible subjects (81% of the eligible population) were screened. OA of the knee, hand, or hip was identified by clinical ACR criteria respectively in 159, 139, and 81 subjects, and was confirmed by the rheumatologist in 158/182 (87%), 75/101 (74%), and 63.2% of cases. The estimated prevalence was 29.8%, 14.9%, and 7.7%, respectively. Only hip OA was significantly associated with disability in basic activities of daily living. CONCLUSIONS: About one third of community dwelling older people are affected by symptomatic peripheral OA. Hip OA was strongly associated with disability.

Prevalence of symptomatic hand osteoarthritis in community-dwelling older persons: the ICARe Dicomano study. Insufficienza Cardiaca negli Anzizni Residenti a Dicomano.

OBJECTIVE: To assess whether the American College of Rheumatology (ACR) classification criteria for hand osteoarthritis (OA) may be used successfully to detect hand OA in population-based studies and to estimate the prevalence of hand OA in an elderly italian population. DESIGN: This study was part of a cross-sectional population-based survey on heart failure in the elderly (ICARe Dicomano study). All community-dwelling citizens aged >65 were considered eligible and screened by expert geriatricians for the presence of major chronic conditions, including hip, knee and hand OA, using custom-made algorithms based on standard criteria. Those subjects who screened positively were subsequently assessed by a rheumatologist. RESULTS: Six hundred and ninety-seven subjects (80% of the eligible population) underwent a general examination by a geriatrician. One hundred and thirty-nine of these met the ACR criteria for hand OA at screening: 22 subjects with isolated first carpometacarpal (CMC) joint OA and 117 with generalized nodal OA. 74.2% of the diagnoses were confirmed in the 101 participants re-examined in a second phase by a rheumatologist (19 subjects presented with isolated thumb-base OA and 56 with nodal OA). The estimated prevalence in the cohort was 14.9%. CONCLUSIONS: The ACR clinical criteria for hand OA may be used in population studies, especially when the burden of this disease is evaluated.

Ethylene-oxide and steam-sterilised polysulfone membrane in dialysis patients with eosinophilia.

Eosinophilia and some acute dialysis side-effects, such as itching, flushing and bronchospasm, are often associated with the presence of ethylene oxide (ETO) as dialyzer sterilizing agent. This study evaluated the effects of two different polysulfone (PS) hollow-fiber dialysers sterilized with ETO and steam in 31 chronic dialysis patients with eosinophilia. Clinical symptoms, metabolic and biochemical parameters, complement (C3a and C5a) activation and production were evaluated in each patient dialysed for two months at a time with Cuprophan dialyser, ETO-PS dialyser and steam-PS dialyser. The steam-sterilizer agent does not alter the purifying capacity of the PS membrane which maintains its superiority over Cuprophan in terms of biocompatibility. Using steam-PS, intradialytic eosinophil kinetics seems to improve. In some patients with high serum levels of ETO-specific IgE these levels tend to diminish. Generic intradialytic symptoms do not differ between the two sterilization methods, although some hypersensitivity symptoms during the first dialysis hour are considerably lower in some patients when steam-sterilized PS is used.

Longitudinal assessment of body composition in CAPD patients using bioelectric impedance analysis. A comparison with hemodialysis patients.

The utility of bioelectric impedance analysis was assessed for longitudinal evaluation of body composition in two groups of uremic patients, one on CAPD and one on hemodialysis treatment, with no clinical marks of hyperhydration or infection. Nineteen CAPD patients (11 men 8 women) and 21 HD patients (12 men 9 women) were studied with bioelectric impedance analysis for a period of 12 months; total body water, fat free mass, and fat mass were calculated from bioelectric impedance analysis data of resistance and reactance at time 0 and 12 months later. No significant differences in body composition were found in the two groups at time 0 and 12 months later, with a similar trend for total body water, fat free mass, and fat mass. In CAPD, a significant increase in body weight was observed due mainly to a rise in fat mass, particularly evident in women with uremia. Bioelectric impedance analysis appears to be an instrument easily repeatable and reliable in CAPD and HD patients, reflecting at the same time body composition, the dialytic adequacy of a technique, and the patient's well being.

Analysis of the factors influencing bicarbonate balance during acetate-free biofiltration.

In acetate-free biofiltration (AFB), the physical separation between the base losses and the gains could facilitate the modeling of intradialytic bicarbonate (HCO3) balance. In order to verify this hypothesis, we analyzed in a multicenter study, 126 AFB sessions in which differing parameters were evaluated (dialysis time, blood flow, ultrafiltration, infused HCO3, pre- and post-dialytic HCO3, hematocrit and body wt). Statistical analysis performed with multiple linear regression showed that the post-dialysis HCO3 was significantly dependent (F = 21.68, d.f. 5.95, P < 0.001) directly on the amount of infused HCO3, the level of pre-dialysis HCO3 and the final body weight, and inversely on the dialysis time and the blood flow. HCO3 values predicted by the statistical model correlated well with the observed ones (r = 0.788, P < 0.0001) with a mean absolute difference of 2.138 mEq/liter. This modeling approach allowed us to predict, with a computer-aided procedure, the quantities of HCO3 to be infused to obtain a desired and personalized acidosis correction.

Can teledialysis help in the clinical management of patients on remote hemodialysis?

This study investigated whether transmission of the parameters monitored from a remote center to the main center could improve the control of a dialysis session. The parameters of the computer connection module Monitral SC in remote and main centers, were transmitted by means of the Hospal data collection software (Demoplus) by modem, to the host computer. Each remote center can be temporarily disconnected, if necessary, from the telephone line and linked directly to a local computer. We checked 101 hemodialyses. The dialysis was monitored from filter washing to disconnection of the patients and the following parameters were selected: backfiltration during washing and hemodialysis: ultrafiltration, conductivity and temperature. From the sessions recorded (93%) we observed that backfiltration during the filter preparation phase was high (30%) in 28 sessions. Backfiltration during the preparatory phase is the major problem for correct management of dialysis sessions. The high percentage in which ultrafiltration had to be stopped shows that control of this parameter is still not ideal. Finally, the collection of monitor parameters and the comparative analysis of clinical data is useful for improving dialytic management.

Comparison of clinical and neurological status in elderly patients treated with two different hemodialysis techniques.

Five patients with a mean age of 63.4 years (range 62-67) who had frequent episodes of intradialytic intolerance during acetate hemodialysis (HDA) received biofiltration (BF). For each period of study (6 months on HDA and 6 months on BF), the patients underwent a complete clinical assessment, with evaluation of the electroencephalographic (EEG) pattern and acid-base status. During BF, we observed a reduction of hypotensive episodes (10% on BF vs. 26% on HDA) and EEG disturbances (18% on BF vs. 70% on HDA), with a more physiological correction of uremic acidosis. We conclude that BF improves clinical status and neurological tolerance with a better compensation of acidosis in the elderly.

The acid-base balance and the electroencephalographic pattern in patients on biofiltration treatment.

Electroencephalogram (EEG) monitoring and arterial blood gases was performed during biofiltration (BF) treatment and during conventional acetate hemodialysis (HDA). Biofiltration is an ultrashort hemodiafiltration with 3 liters of substitution fluid (Na+ 145 mEq/l, HCO-3 100 mEq/l). Our data show a better correction of acid-base balance during BF than during HDA. Moreover, we observe a lower incidence of EEG disturbancies on BF, that suggests a better neurological tolerance of this treatment.