Impact of highly active antiretroviral therapy on outcome of cholecystectomy in patients with human immunodeficiency virus infection.

BACKGROUND: Highly active antiretroviral therapy (HAART) reduces virus proliferation and significantly decreases the rate of septic and opportunistic complications in patients infected with human immunodeficiency virus (HIV). Although surgery is performed routinely on patients receiving HAART, the effect of this treatment on surgical outcome has not been examined in detail. METHODS: This retrospective study reviewed 54 consecutive patients with HIV infection who underwent surgical cholecystectomy: 31 patients were on HAART, 13 on nucleoside analogue reverse transcriptase inhibitors (NRTIs) and ten were receiving no specific therapy. Characteristics of HIV-1 infection, laboratory investigations, characteristics of the gallbladder disease, type of operation, postoperative course, morbidity and mortality were recorded. Univariable analysis and unconditional logistic regression were performed to determine factors related to postoperative complications and death. RESULTS: The three groups were similar in terms of HIV-1 infection characteristics. In univariable analysis HAART and laparoscopic cholecystectomy were associated with a significantly lower complication rate, whereas only HAART was shown to be protective by logistic regression analysis. A low HIV RNA load and a high CD4(+) cell count were significant predictors of uncomplicated surgical outcomes. CONCLUSION: HAART significantly reduces the risk of complications after cholecystectomy in patients with HIV infection or acquired immune deficiency syndrome.

The mechanisms of blood vessel closure in humans by the application of ultrasonic energy.

BACKGROUND: The use of the ultrasonically activated scalpel (UAS) for vessel closure has attained widespread acceptance in many surgical fields. The aim of our study was to investigate the electron microscopic changes to the blood vessels after the application of UAS. METHODS: We collected 10 arterial and 10 venous segments from vessels that had previously been closed by UAS during abdominal operations. The samples were then prepared for ultramicroscopic analysis. Pathological changes in the lumen and the three wall layers of the blood vessel were examined under scanning and transmission electron microscopy. RESULTS: All of the vessel segments showed similar changes: the presence of a blood clot, endothelial cell condensation, coagulative necrosis of the wall, and charring of the vessel at its tip. The edge of the cut vessel were closed by the coagulation bond, which was tied up by collagen fibrils escaped from denaturation. CONCLUSION: When ultrasonic energy is applied to tissues, it changes their structure so as to make a new extracellular matrix.

Angiogenic effects of suture biomaterials. An experimental study in rats.

Angiogenesis is a limiting step of inflammation and wound healing. Although laboratory tests for the evaluation of the angiogenetic effects of biomaterials are available, no investigations have been performed. In this study we examine the angiogenetic effect of suture biomaterials in the rat mesenteric window model. Absolute controls had laparotomy only, controls had mesenteric window wounding, test groups had the insertion of either a thread of collagen, polyglactin 910, polyglycolic acid salt, silk or of a titanium clip. We considered the percentage area of the mesenteric window covered by neovessels. After 7 days, negligible angiogenesis was found in absolute controls, significant angiogenesis in controls, collagen, polyglactin 910 and polyglycolic acid salt treated rats, without differences between treatments. A significant increase of angiogenesis in comparison to the control group was found in rats treated with silk and titanium. Ultramicroscopy of the neovessels showed specific changes of their architecture in titanium-treated rats. In conclusion, angiogenesis during wound healing is differently influenced by the suture material used. Silk and titanium stimulated angiogenesis in a different way.

Metastatic melanoma of the gallbladder.

A 38-year-old man arrived at our clinic with symptoms and investigation results (U.S. scan and MR) suggestive of acute calculous cholecystitis. He gave a past history of excision of a stage I melanoma of the shoulder. Metastatic disease was suspected following measurement of CA 19.9 levels and the CT scan. The patient underwent laparotomy and cholecystectomy; pathological examination confirmed the presence of a malignant melanoma metastatic lesion of the gallbladder.

[The Verona Medical Interview Classification System/Patient (VR-MICS/P): the tool and its reliability]. / Il Verona-Medical Interview Classification System/Patient (VR-MICS/P). Presentazione dello strumento e studio di attendibilità.

OBJECTIVE: To assess the reliability and to describe the categories and the procedure to apply the VR-MICS/P (Verona-Medical Interview Classification System/Patient). SETTING: The interviews used for the reliability study were audiotaped. Five general practitioners (GPs) working in two general practices in South-Verona recorded their consultations. SAMPLE: 50 interviews selected randomly from 120, 10 for each GP. The selection criterion for the participating patients was a GHQ-12 score of 3 and the consultation for a new illness episode. MAIN OUTCOME MEASURES: The VR-MICS/P classifies patients' verbal behaviours into 21 categories, 15 of them are defined by form (cue or statement) and content. PROCEDURE: Two trained raters classified 50 interviews. Before applying the classification system each interview is divided into units which are numbered to define doctor's and patient's sequence of speech. RESULTS: The reliability of VR-MICS/P was satisfactory (Kappa 0.85). Similarity Index (Dice, 1945) for categories varied between 0.71 and 0.94. Reliability for form and content classification was satisfactory too (Similarity Index between 0.81 and 0.89 and between 0.84 and 0.94, respectively). CONCLUSIONS: The VR-MICS/P is a reliable measure for describing patients' verbal behaviours during medical interviews. It can be used together with the VR-MICS/D (Verona-Medical Interview Classification System/Doctor; Saltini et al., 1998) to describe the medical interview, the quality of doctor-patient interview and can be used as a measure of patient centredness.

Late rejection of the mesh after laparoscopic hernia repair.

We report the first case of late rejection of a mesh after laparoscopic hernia repair. It occurred in a 48-year-old man who had had a laparoscopic hernia repair by transabdominal preperitoneal approach 3 years earlier. The most characteristic finding was the slow development of a firm mass in the right groin, without pain or fistula. At admission 3 months later, US and CT scans demonstrated a necrotic mass extending into both iliac fossa. The mass was approached through a midline incision. Pus was taken for microscopic examination (negative), and the mesh was removed, along with several staples. Ultramicroscopic examination of the mesh showed breakdown of the fibers, collagen reduction, and no chronic inflammatory cells. No infectious cause of inflammation was identified.

[An instrument for evaluating th medical interview in general practice: VR-MICS/D (Verona-Medical Interview Classification System/Doctor)]. / Uno strumento per la valutazione dell'intervista medica nel contesto della medicina generale: il VR-MICS/D (Verona-Medical Interview Classification System/Doctor).

OBJECTIVE: To assess the reliability of the VR-MICS/D (Verona-Medical Interview Classification System/Doctor) and to identify the verbal behaviour by general practitioners in interviews conducted with primary care attenders with medical complaints and emotional distress. SETTING: Two general practices in South-Verona. SAMPLE: 100 primary care patients attending for a new illness episode with a GHQ-12 score > or = 3. The five participating GPs contributed each with 20 audiotaped interviews of 10 patients judged by GP as emotionally distressed and of 10 judged without emotional distress. MAIN OUTCOME MEASURES: The VR-MICS/D classifies GPs' verbal behaviour during the medical interview into 16 categories in terms of form (question or statement) and content and allows to assess their interview skills. PROCEDURE: Two raters classified 30 interviews (15 with patients judged by their GP as emotionally distressed and 15 with patients judged without emotional distress). Having established satisfactory reliability, the overall verbal performance, based on 100 interviews, was assessed and GPs' verbal behaviours with patients judged as emotionally distressed was compared with that adopted with patients judged without emotional distress. RESULTS: The reliability was satisfactory (Kappa 0.93). Percentage agreements for categories varied between 78.2% and 96.4%. The most frequent verbal behaviours were closed ended questions and information giving (58% of a total of 5522 classified verbal units). Interviews with patients judged as emotional distressed contained a greater number of psychological and psychosocial contents, facilitating comments and clarifications. These differences, however, were small, despite their statistical significance. CONCLUSIONS: The VR-MICS/D is a reliable measure for describing GPs' verbal behaviour during the interview with emotional distressed patients. The interview style of the GPs in this study was similar to that reported in the literature for GPs without formal training in communication skills and was characterised by a prevalently doctor-centred approach. This approach, particularly with emotional distressed patients, has severe limitations and underlines the necessity of the introduction of communication skills training.

Paradoxical effects of intra-arterial administration of basic fibroblast growth factor on inflammatory angiogenesis in rats.

The authors studied the effects of basic fibroblast growth factor (b-FGF) on inflammatory angiogenesis in rats. In the corneal cauterization model b-FGF was given intra-arterially (i.a.) (carotid) and in the mesenteric window angiogenesis model, topically (i.e., intraperitoneally (i.p.)). The corneal cauterization was done under anaesthesia by topical application of silver nitrate. Mesenteric window angiogenesis was induced by injection of saline or b-FGF for four days. There were the same two groups of treatment in both models b-FGF 2.5 micrograms/kg/day or saline 1.2-5 ml/kg/day. The area of neovessels and the number of polymorphonuclear cells/field were considered for the corneal angiogenesis, the total length of neovessels was measured for the mesenteric window angiogenesis. The results were expressed as mean values (s.d.). When given i.a., b-FGF significantly reduced the number of polymorphonuclear cells three days after corneal cauterization (from 107 +/- 27 to 41.8 +/- 26, p < 0.01) and inhibited the area covered by neovessels (30 +/- 7.7% vs 51 +/- 20%, p < 0.01) after five days. In contrast, given through the extracellular space, it significantly stimulated the length of mesenteric window microvessels (169 +/- 60 mm vs 90 +/- 31 mm, p < 0.05). These results suggest that b-FGF stimulates inflammatory angiogenesis through interaction with extracellular matrix components, but inhibits it directly when given intra-arterially.

[Clinical improvement induced by chemotherapy and social rehabilitation in a preterminal case of brain stem neoplasm: the objective and instrumental aspects]. / Miglioramento clinico indotto dalla chemioterapia e riabilitazione sociale in un caso preterminale di neoplasia tronco-encefalica: aspetti obiettivi e strumentali.

A sixteen-years-old boy with a brain-stem neoplasia inducing coma was treated with chemotherapeutic agents. It resulted in dramatic clinical and instrumental improvement; radiologic findings were evaluated, showing decreasing dimension of intracranial mass. Brain-stem auditory evoked potentials were highly sensitive. We think that chemotherapy can be considered among the options a physician can offer to such a patient explaining informed consensus.