Effects on renal function of obstructive and nonobstructive dilatation of the upper urinary tract in ileal neobladders with refluxing ureteroenteric anastomoses.

AIMS: To investigate the incidence and long-term effects on kidney function of obstructive and nonobstructive dilatation of the upper urinary tract in patients with ileal neobladder with refluxing ureterointestinal anastomoses. METHODS: We retrospectively analyzed a prospectively derived database of 110 patients with bladder cancer and who were treated with an ileal neobladder between 1996 and 2007 using refluxing end-to-side ureterointestinal anastomoses on a short afferent limb. The mean follow up was 65 months. At every follow up visit the patients had an analysis of serum creatinine, urine culture, abdominal CT or ultrasonography, and, if there was dilatation of the upper urinary tract, 99mTc-DTPA renal scintigraphy was requested. RESULTS: In all, 206 renoureteral units were included in the study. Overall, seven had anastomotic stricture and of those, three were symptomatic and were corrected; while four were asymptomatic and of those, only two, with preserved split GFR, were surgically treated, while the remaining two, with a poor split GFR, were followed up. The last 99mTc-DTPA showed a preserved split GFR in the reimplanted units and further split renal function decrease in untreated units. Nonobstructive dilatation of the upper urinary tract, caused by reflux, was diagnosed in 13 units. The dilatation was bilateral in three patients with recurrent UTIs and urosepsis, and the split GFR was bilaterally reduced at diagnosis with a further reduction at the last 99mTc-DTPA. The remaining seven units with sterile urine, showed a preserved split GFR during follow up. CONCLUSIONS: All strictures, regardless of their severity, should be immediately corrected. Reflux per se does not provoke renal impairment unless recurrent UTIs and urosepsis are present.

Glansectomy with split-thickness skin graft for the treatment of penile carcinoma.

Using our prospectively derived database, we identified 17 patients with squamous-cell carcinoma involving the glans penis, who were treated using organ-sparing surgery between March 2003 and January 2008. Of them, two were treated with partial glansectomy with primary glans closure, and 15 underwent total glans amputation and reconstruction of a new glans using a split-thickness skin graft (STSG). These 15 patients represent the subject of our study (mean age 51 years, range 42 to 59 years). Overall, two patients had early partial loss of the graft and of them, one required surgical regrafting. Two late complications occurred, consisting of one meatal stenosis and one postoperative phimosis. At a mean follow-up of 36 months, functional results were extremely satisfactory. All patients maintained their erectile function with good vaginal penetration starting from 3 months after surgery, with a range between 2 and 6 months. Orgasm and ejaculation were preserved in all patients, although reduced glans sensitivity was reported by all patients. No local recurrences were reported.

Core curriculum in emergency medicine integrated in the specialty of anaesthesiology.

Anaesthesiologists, for their knowledge, skills and expertise, have been playing a key role in the development of emergency medicine. In many countries, anaesthesiologists are today fully involved in teaching and practicing emergency medicine, and have leading roles in emergency departments. Proper education and effective interdisciplinary medical cooperation is essential for quality assurance in emergency medicine. This paper, produced by a working party of the European Board of Anaesthesiology of the European Union of Medical Specialists (EUMS/UEMS), gives directions for a core curriculum in emergency medicine integrated in the specialty of anaesthesiology.

Dislocation of central venous catheters in paediatric patients.

Children have limited venous access possibilities; therefore, when long-term therapy is necessary, it is better to place a catheter in a central vein. The Port catheter, totally implanted, is less exposed to the risk of infection and permits a normal life. However, there is the possibility of the displacement or fragmentation of the catheter that can be diagnosed initially only by clinical symptoms and later by a chest X-ray. We report a case of disconnection between the Port catheter and the reservoir resulting in catheter migration to the left pulmonary artery.

Dual effect of methylprednsolone pulses on apoptosis of peripheral leukocytes in patients with renal diseases.

It is well known that change in apoptosis may modulate the natural story of illness, and that many drugs may act through modulation of apoptosis, but the role of steroids in acting through apoptosis in different settings, including renal diseases, has still to be elucidated. We studied the in vivo effects of steroids by oral assumption (10 to 25 mg/deltacortene) or by intravenous pulses (300 to 1000 mg/dose) on apoptosis and cellular subsets of peripheral lymphocytes, by evaluating DNA-fragmentation and lymphocyte subsets in 79 subjects: 22 controls and 57 patients with various renal diseases (25 Lupus-GN, 19 membranous-GN (MGN), 6 rapidly progressive-GN (RPGN), 2 acute interstitial nephritis (AIN), 5 on chronic dialysis. Baseline apoptosis was present in 1/22 (4.5%) of controls, 3/25 (12%) SLE, 2/6 (33.3%) RPGN and 10/19 (52.6%) MGN. A significant decrease in CD3+CD8+ cell count and a significant increase of the CD3+CD4/CD3+CD8+ ratio were found in apoptosis-positive subjects. DNA fragmentation did not change after oral steroids, paralleling a 22 to 32% decrease in total lymphocytes. Following intravenous methylprednisolone pulses, a deeper drop of all lymphocyte subsets was observed, while DNA fragmentation turned from present to absent in 2 MGN, but not in 2 RPGN, and from absent to present in 1 ARF and 1 SLE, independently of the dosage. We demonstrated that the presence of apoptosis in renal diseases is associated with decreased CD3+CD8+ cell count. Furthermore, steroid intravenous pulses, besides inducing a profound decrease in lymphocyte subsets, do exert a dual effect on baseline leukocyte apoptosis, eventually leading to a reversal of baseline patterns, either turning from negative to positive or from positive to negative. Oral steroid therapy did not influence baseline apoptosis.

Linear and nonlinear circular dichroism of R-(+)-3-methylcyclopentanone.

Linear and nonlinear circular dichroism of R-(+)-3-methylcyclopentanone (R-3MCP) is reported in the gas and liquid phases. Measurements of (2+1) resonance-enhanced multiphoton ionization circular dichroism (REMPICD) for nozzle-jet expanded molecular beams of the equatorial conformer of R-3MCP are presented. Monitoring either mass-selected cations or photoelectrons produced via (2+1) REMPI through the n --> 3s Rydberg transition yielded a REMPICD of +1.5+/-0.5% [REMPICD identical with 2(I(L)-I(R))(I(L)+I(R))], where I(L/R) refers to the ion/electron signal for left/right circularly polarized light. A racemic mixture of 3-methylcyclopentanone showed no significant CD; however, the signal fluctuations were much larger than that observed for the resolved R-(+)-3-methylcyclopentanone as might be expected for the small number of ions produced from slightly unequal numbers of enantiomers in each laser shot. Gas phase, vibrationally resolved, one-photon CD for vapor phase R-(+)-3-methylcyclopentanone (i.e., admixture of five axial and equatorial forms) was measured to be approximately 0 and -0.004 at photon energies corresponding to the one- (nonresonant) and two-(3s resonance) photon energy levels. The one-photon CD (of the room temperature population of conformers) at an energy corresponding to the ionization step was measured previously to be approximately +0.0011 which is of the same sign as the REMPICD. The first step is also near a positive CD region. This suggests that the (2+1) REMPICD is determined primarily by both the initial and continuum steps. The one-photon CDs for the equatorial and axial forms of 3MCP are calculated, using GAUSSIAN03, to be approximately equal but having opposite sign for the transitions of interest. The CD for 3MCP in cyclohexane is found to be strongly temperature dependent as a result of the presence of both the axial and equatorial conformers. The energy difference between the two conformers is determined from a van't Hoff plot of these data to be 3.50+/-0.05 kJ/mole in cyclohexane and is approximately 1 kJ/mole smaller than measurements employing other methods.

Secondary migration of a central venous catheter: a rare complication.

The Authors describe a case of spontaneous migration in the right jugular vein of a central venous catheter tip, properly positioned in the right atrium through the right subclavian vein two days before.

Effect of beta radiation on the crystallization of sodium chlorate from water: a new type of asymmetric synthesis.

Sodium chlorate is an achiral molecule that crystallizes from water in the chiral space group P2(1)3. In the absence of chiral perturbations, a random distribution of (+) and (-) crystals is obtained. Kondepudi(2) has shown that constantly stirring an evaporating NaClO(3) solution gives mostly either (+) or (-) crystals. Repeating this experiment many times gives equal numbers of (+) and (-) sets of crystals. Herein we report that when evaporating aqueous NaClO(3) is subjected to beta particles from an Sr-90 source, an asymmetric distribution of (+) and (-) crystals favoring the (+) crystals is obtained. The beta particles are energetic polarized electrons that are approximately 80% of left-handed helicity. By a poorly understood mechanism, the spin polarized electrons produce chiral nucleating sites that favor formation of the (+)-NaClO(3) crystals. Exposure of the evaporating solution instead to energetic positrons from an Na-22 source yields mainly (-)-NaClO(3) crystals. Polarized positrons are of predominantly right-handed helicity. One may conclude that the chirality of the radiation is correlated with the chirality of the crystals being generated.

Explaining photodermatosis: cyclopentenone vs. alpha-methylene-gamma-lactone natural products.

The possible role of cyclopentenone-containing sesquiterpene lactones in the cause of photochemical chronic actinic dermatitis (CAD) is examined in light of recent reports that the alpha-methylene-gamma-lactone group of these natural products forms 2+2 photoadducts with the DNA base thymine. Neither cyclopentenone nor tenulin (a cyclopentenone-containing sesquiterpene lactone) form such photoadducts with thymine either with sunlight or a UV lamp (300 nm). In contrast, alpha-methylenebutyrolactone readily forms the 2+2 photoadduct with thymine in sunlight. Thus, the photochemical role of the alpha-methylene-gamma-lactone group (rather than cyclopentenone) is strongly implicated in the CAD disease.

Optimizing efficacy of quick parathyroid hormone determination in the operating theater.

The usefulness of intraoperative parathyroid hormone (PTH) monitoring has been extensively documented in primary hyperparathyroidism (HPT), whereas few data have been published on its use in reoperations or in secondary and tertiary HPT. We report our initial experience with a rapid (12 min response) PTH immunochemiluminometric assay performed in the operating room during surgery in 12 patients with primary HPT, 16 end-stage renal disease patients with secondary HPT and five kidney transplanted subjects with tertiary HPT. Blood samples were taken at baseline, within 10 min after resection and subsequently at various intervals whenever needed. The mean PTH levels before and after parathyroidectomy were 230.5 pg/mL (range 69-842) and 47.3 pg/mL (range 5-184), respectively, in primary HPT, 855.0 pg/mL (416-1655) and 202.2 pg/mL (53-440) in secondary HPT, and 205.6 pg/mL (116-301) and 45.4 pg/mL (18-97) in tertiary HPT. All patients but one had a significant percentage decline from pre-excision values (mean 76.9%, 76.0%, and 76.1% in primary, secondary and tertiary HPT, respectively). While a reduction of more than 50% was observed in 30 out of 33 patients after the first intraoperative sampling, additional measurements were performed in 10 cases. On-site PTH monitoring with this user-friendly and reliable system has proved helpful in targeting PTH tests to give the surgeon a rapid and accurate assessment of the intervention. The development of optimal PTH sequence strategies with decision-focused analytical and clinical limits will improve the efficacy of "point-of-care" PTH assay and resource utilization.

[HEPASCORE: a decision-support system for the identification, clinical staging and functional assessment of hepatopathies]. / HEPASCORE: un sistema di supporto alla decisione per l'identificazione, la stadiazione clinica e la valutazione funzionale delle epatopatie.

A decision support system (HEPASCORE) has been developed to optimize the application of objective criteria for qualitative and quantitative assessment of liver function; clinical and laboratory data are automatically processed, and conclusions are explained. Early recognition of abnormal liver states is performed according to a sequential approach, based at first on clinical rules utilizing data from history and physical examination, then confirming or denying the hypothesis by means of selected laboratory tests. Once an abnormal condition is defined, clinical severity can be evaluated by use of suitable scores, either prognostic or focused on major clinical complications. In addition, selected sets of biochemical tests can be used to score one or more functional aspects. Lastly, whenever quantitative estimates of residual liver function are requested, dynamic tests can be applied to measure meaningful parameters such as functioning liver mass and functional hepatic plasma flow. HEPASCORE has been successfully applied to exclude liver abnormalities in subjects at risk, to follow up liver patients, to predict the natural outcomes of severe liver diseases, to foresee the adverse effects of drugs undergoing first-pass liver extraction and the side effects of invasive procedures. While the proposals contained in the system could be further modified for specific needs, they reflect a satisfactory methodological approach, and the program serves as a useful support to decisions regarding the identification and functional evaluation of hepatopathies. The system was developed with Microsoft Access 7.0 and runs on a personal computer under Windows 95.

Autoimmune events during interferon beta-1b treatment for multiple sclerosis.

Autoimmune events, although rarely reported during interferon beta-1b (IFNB) treatment of relapsing-remitting (RR) multiple sclerosis (MS), may be more frequent than expected due to the many immunologic abnormalities associated with this disease. We report the prospective two-year follow-up of autoimmune events in 40 RR MS patients treated with IFNB and in 21 untreated MS controls. Thyroid and liver function and serum level of 12 autoantibodies (autoAbs) against organ- (thyroid, gastric, pancreatic) and non-organ-specific antigens were serially monitored. In contrast to control patients, autoAbs (anti-nuclear, -smooth muscle or -thyroid antigens) were detected in 13 IFNB-treated patients, and these were associated with thyroid or liver function alteration in many cases. Persistent autoimmune thyroid dysfunction occurred in three IFNB-treated patients, all of whom were women with a familial history of thyroid disease or baseline anti-thyroid autoAb positivity. For improvement of the MS relapse rate, thyroid dysfunction was adequately treated without stopping IFNB. Liver function alteration (17 IFNB-treated patients, associated with non-organ-specific autoAbs in four) was transient and did not require IFNB treatment to be stopped, with the exception of one patient who was already suffering from a drug-induced hepatopathy at baseline. During the IFNB treatment of MS, several autoimmune events may occur, indicating that thyroid and liver function and autoAbs must be carefully monitored.

Efficacy and efficiency of oral microemulsion cyclosporin versus intravenous and soft gelatin capsule cyclosporin in the treatment of severe steroid-refractory ulcerative colitis: an open-label retrospective trial.

We have used cyclosporin to treat patients with acute steroid-resistant ulcerative colitis since the beginning of 1991. Of the 55 patients so far elected for treatment, 40 received the drug intravenously at 2 mg/kg/day for 14 days, with the responders being maintained on traditional soft-gelatin-capsule cyclosporin at a dose of 6-8 mg/kg/day for 6 months; the remaining 15 received oral microemulsion cyclosporin, 5 mg/kg/day, for 3 months. The doses were titrated to ensure whole-blood drug concentrations of 60-240 ng/ml, with levels of approximately 200 ng/ml being attained by both regimens. One-hundred percent of the patients receiving oral microemulsion cyclosporin and 65% of those receiving the intravenous regimen achieved a short-term response (p = 0.011). Both the responder subsets received additional azathioprine and relapsed on treatment with the same frequency of 40%. However, 17% of the patients who received intravenous cyclosporin developed major toxicity (including one fatality), whereas no major toxicity was observed in the oral microemulsion cyclosporin group. The microemulsion formulation was therefore more effective than intravenous cyclosporin in achieving the short-term remission of steroid-unresponsive ulcerative colitis. As the maintenance drug, it led to the same frequency of disease relapse as traditional oral cyclosporin. However, because it did not involve invasive in-hospital procedures or cause major toxicity, it was more efficient than the combination of the intravenous and traditional oral drug.

Prognostic implications of detection of troponin I in patients with unstable angina pectoris.

In our study, troponin I was not a predictor of cardiac events and a negative troponin I test did not exclude the presence of severe coronary artery disease. A positive troponin I test in patients with unstable angina identified a subgroup with probable, more active coronary disease (with higher levels of C-reactive protein).

[Partial liquid ventilation (PLV) in the newborn and infants: initial experiences in Italy]. / Ventilazione liquida parziale (PLV) nel neonato e nel lattante: prime esperienze in Italia.

Partial liquid ventilation is a valid alternative ventilation strategy for the management of the respiratory distress in newborn and infant. Authors describe their first experiences in 11 children (7 newborns, 4 infants).

Modified and improved anti-acetylcholine receptor (AchR) antibody assay: comparison of analytical and clinical performance with conventional anti-AChR antibody assay.

We developed a modified anti-acetylcholine receptor (AChR) antibody (Ab) assay based on a radioreceptor assay and a calibration curve. We compared the analytical and clinical performances of this modified assay with those of the conventional anti-AChR Ab radioreceptor assay. Serum specimens were from patients with myasthenia gravis (MG) (n = 156) and from control subjects (n = 106). The modified assay demonstrated lower within-assay (4.0-6.6%) and between-assay (5.3-7.8%) CVs, greater linearity, lower cost, and shorter assay time than the conventional method. ROC curve analysis indicated almost identical specificity and sensitivity (> 0.92) for these two anti-AChR Ab assays. The modified and conventional assays were also equivalent for blocking anti-AChR Ab assay. Moreover, the modified anti-AChR Ab assay, differently from the conventional assay, allowed us to reveal anti-AChR Ab concentration differences among different clinical grades of MG.

Systemic high-dose recombinant-alpha-2a-interferon therapy modulates lymphokine production in multiple sclerosis.

Chronic systemic high-dose recombinant alpha 2a-interferon (rIFNA) therapy reduces exacerbation rate and MRI signs of disease activity in relapsing/remitting multiple sclerosis (RR MS) patients. In order to clarify the possible mechanisms underlying the clinical efficacy of rIFNA in MS, several immunologic studies were performed as a part of a pilot clinical trial. Twenty RR MS patients were treated with 9 x 10(6) IU of rIFNA (n = 12) or placebo (n = 8) intramuscularly every other day for 6 months. Cytokine production by cultured lymphocytes, major histocompatibility complex class II (MHC-II) antigen expression on cultured macrophages, peripheral blood (PB) and cerebrospinal fluid (CSF) lymphocyte phenotype, and IgG and beta 2 microglobulin levels were studied before therapy, after 6 months of therapy, and 6 months after stopping therapy. rIFNA therapy was associated with reduction of interferon-gamma and tumor necrosis factor-alpha production by PB lymphocytes (p < 0.04), and with slight, not significant, increase of transforming growth factor-beta 2 or interleukin (IL)-10 production. IL-4 was undetectable in the culture supernatants both before and after therapy. rIFNA therapy had no effect on macrophage MHC-II molecule expression. An increased percentage of CD8+, CD8+ high CD11b+ low, and CD3- CD16+ CD56+ cells, and of CD4+ absolute cell number was observed in CSF after rIFNA therapy. After rIFNA administration, IgG level significantly increased both systemically (p < 0.02) and intrathecally (p < 0.001). Serum beta 2 microglobulin level increased (p < 0.01), as well. Only 1 out of the 12 rIFNA treated patients developed neutralizing antibodies against rIFNA during therapy. Six months after stopping therapy all the immunologic changes returned to baseline. These data suggest that the beneficial effect of rIFNA therapy on MS disease activity is probably mediated by a downregulation of proinflammatory cytokine synthesis by PB lymphocytes rather than by macrophage MHC-II antigen expression. The immunologic effects of high-dose systemic rIFNA therapy are temporary and restricted to the period of drug administration.

Hepatitis G virus RNA in the serum of patients with elevated gamma glutamyl transpeptidase and alkaline phosphatase: a specific liver disease? [corrected].

We tested the sera of 67 consecutive patients for hepatitis G virus (HGV) RNA by reverse transcriptase-polymerase chain reaction (RT-PCR). These patients (42 males and 25 females, median age 35 years, range 13-64 years) had liver disease of unknown aetiology and were without markers of hepatitis (A-E) viruses or signs of genetically determined, autoimmune, alcoholic or drug-induced liver disease. The controls in this study were 110 patients (50 females and 60 males, median age 45 years, range 9-65 years) with chronic hepatitis B virus (HBV) infection (19 patients) or hepatitis C virus (HCV) infection (91 patients). Ten of 67 (14.9%) patients with cryptogenic disease were positive for HGV RNA by at least three separate tests; HGV RNA was also detected in one of 19 (5.3%) hepatitis B surface antigen (HBsAg) carriers and in nine of 91 (16.6%) patients with antibody to HCV. These data suggest that HGV occurs as frequently in HCV-infected patients as in those with cryptogenic disease. Elevated serum gamma glutamyl transpeptidase (gamma-GT) (higher than twice the normal value) and alkaline phosphatase levels were found in eight of 10 (80%) HGV RNA positive patients and in six of 57 (10.5%) HGV RNA negative patients (P < 0.0001). Five (50%) HGV RNA positive patients had non-specific inflammatory bile duct lesions. A statistically significant difference was observed between HGV RNA positive and negative patients with chronic HBV or HCV infections (P < 0.029). Therefore, the spectrum of liver disease associated with HGV is wide, but a characteristic lesion of the bile duct leading to elevation of cholestatic enzymes might be specific for this virus.

Spontaneous release of interleukin 1 beta from human blood monocytes in thyrotoxic osteodystrophy.

Hyperthyroidism is a well documented cause of impaired bone turnover characterized by increased osteoblastic and osteoclastic activity, resulting in predominance of bone resorption and in decreased bone mass. Thyroid hormones can carry out a direct effect on osteoblasts which express specific receptors on their surface membrane; differently effect on osteoclast seems to be mediated by local factors, cytokynes released by activated osteoblasts or by bone monocytes cells. Interleukin 1 beta is the first purified cytokyne shown to have bone resorbing activity. In ten thyrotoxic female patients IL 1 beta in the cellular medium of the monocytes blood cells culture has been measured, compared to PYD/cr urinary excretion, and FT3, BGP serum levels, before and after thyrostatic treatment. Ten normal females were studied as control group. The results before treatment showed osteopenia in 20% (DEXA densitometry), increased values of FT3, BGP, IL 1 beta and PYD/cr in patients versus controls (p < 0.001). The thyrostatic therapy obtained normalization of IL 1 beta, PYD/cr, BGP, and FT3 levels. Our data demonstrate that increased thyroid hormone levels in vivo are associated to increased secretion of monocytes cytokynes in vitro and suggest that alterations in local production of bone acting cytokyne may underlie to thyrotoxic osteodistrophy.