Activated recombinant factor VII in orthotopic liver transplantation.

UNLABELLED: Orthotopic liver transplantation (OLT) is affected by important alterations of hemostasis. The aim of this study was to evaluate the efficacy of recombinant factor VII activated (rFVIIa) to reduce intraoperative bleeding during OLT. METHODS: Twenty OLT patients were assigned in double-blind way to a rFVIIa group or a control group. Inclusion criteria were hemoglobin > 8 g/dL: INR > 1,5 and fibrinogen > 100 mg/dL. We administered a single bouls of rFVIIa (40 microg/kg) or placebo. We determined INR, partial thromboplastin time, fibrinogen, ATIII, and blood cell counts. Blood products were administered as follows: 4 units of fresh frozen plasma when INR > 1.5, and 1 unit of RBC for Hb < 10 g/dL. The study ended 6 hours after the bolus. RESULTS: No thromboembolic events occurred. The INR was different between rFVIIa group and the controls at T0 (1.9 vs 1.6 P < .021) and during T1 (1.2 vs 1.6 P < .004). The total transfused red blood cells was 300 mL +/- 133 in rFVIIa group and 570 mL +/- 111 in control group (P < .017). The total fresh frozen plasma was 600 mL +/- 154 in rFVIIa group and 1400 mL +/- 187 in control group (P < .001). Total blood loss was greater in the control group than the rFVIIa group: 1140 mL +/- 112 vs 740 mL +/- 131 (P < .049). DISCUSSION: The use of rFVIIa during OLT can reduce the risk of bleeding during surgery. The literature has described cases who did not benefit from the treatment. An adequate cut-off of INR, allowed us to treat only patients at greater bleeding risk.

Fenoldopam and gastric tonometry during orthotopic liver transplantation.

UNLABELLED: The aim of this study was to evaluate the effects of continuous infusion of fenoldopam on splanchnic perfusion in orthotopic liver transplant (OLT) recipients. PATIENTS AND METHODS: We enrolled 40 patients of mean age 57+/-16 years who underwent (OLT). They were randomly divided into two double blinded groups; continuous fenoldopam (0.06 mcg/kg per minute) or placebo infusion. Hemodynamics, gastric tonometry, urine output, renal function parameters, and diuretics use were collected during selected phases of the surgery and postoperatively every 12 hours for 72 hours in the intensive care unit. RESULTS: No significant differences were observed between the two groups concerning hemodynamics, though in the fenoldopam group we observed increased splanchnic perfusion during the whole study period but particularly after arterial unclamping (pHi 7,31+/-0.04 vs 7.28+/-0.05; P < .05) and at 48 hours after surgery (pHi 7.49+/-0.15 vs 7.39+/-0.15; P < .05). Creatinine and blood urea nitrogen values were slightly higher in the placebo group, but this data did not reach statistical significance, while higher doses of furosemide were administered to the placebo group to maintain a urinary output over 200 mL/hour during the whole study. DISCUSSION: In this study we observed that continuous fenoldopam infusion (0.06 mg/kg per minute) improved splanchnic perfusion without affecting systemic pressure. CONCLUSION: Patients undergoing OLT have altered splanchnic perfusion related to cirrhosis, surgical manipulation, and fluid shifts during and after surgery. The use of a splanchnic vasodilator drug improved outcomes in these patients.

Modifications of intracranial pressure after molecular adsorbent recirculating system treatment in patients with acute liver failure: case reports.

UNLABELLED: Cerebral dysfunction may be fatal in patients with acute liver failure (ALF); intracranial pressure (ICP) monitoring may be mandatory to direct measures to prevent further cerebral edema. Recently the introduction of dialysis with the molecular adsorbent recirculating system (MARS) has improved the outcomes among patients with ALF. The aim of this study was to evaluate ICP changes after MARS treatment among patients with ALF. METHODS: Three patients -- 14, 18 and 16 years old -- were admitted to the ICU for acute liver failure induced by HBV in two cases and by acetaminophen in the other one. Because of Glasgow Coma Score (GCS) <8, they were intubated and ventilated to protect the airway and maintain moderate hypocapnia. Invasive monitoring of intracranial pressure MARS treatments were performed in all patients. RESULTS: The patients received MARS treatments every day after their admission to liver transplantation. After MARS therapy the ICP decreased on average from 21 to 7 mm Hg. Significant hemodynamic modifications were not observed and their neurological conditions improved. CONCLUSION: MARS treatment improved the clinical pictures of these patients increasing the available time to obtain an urgent liver graft.

Clinical effects of direct hemoperfusion using a polymyxin-B immobilized column in solid organ transplanted patients with signs of severe sepsis and septic shock. A pilot study.

BACKGROUND: Polymyxin B (PMX-B) is a polycationic antibiotic, known to bind the lipid A portion of endotoxin, a cell wall component found exclusively in gram negative bacteria (GNB). An extracorporeal hemoperfusion device (TORAYMYXIN) has been developed: PMX is covalently bound on the surface of an insoluble carrier material so that the endotoxin can be inactivated in the blood without exerting its toxicity on the brain and kidney. The aim of this study was to clarify the efficacy, safety and clinical effects of direct hemoperfusion with an immobilized polymyxin-B fiber column (DHP-PMX) in solid organ transplanted patients with severe sepsis or septic shock. METHODS: From June 2004 to May 2005, 15 patients (10 men and 5 women), mean age 55 years old (46-65 range), underwent kidney or liver transplantation and developed severe sepsis or septic shock, as defined by the Consensus Conference of American College Physicians/Society of Critical Care Medicine (ACCP/SCCM) criteria. GNB were detected in all the patients receiving conventional treatments including antibiotic therapy, vasopressive or inotropic agents, and ventilation support. The DHP-PMX treatment was performed three times in each patient. Hemodynamic and respiratory parameters, dosage of vasopressor/inotropic drugs were assessed at baseline and after each treatment. RESULTS: No adverse events occurred. From baseline to 3rd treatment, mean arterial pressure (MAP) was increased (from 63+/-5 to 83+/-4 mmHg), while the dosage of dobutamine (from 7.5+/-3 to 3+/-2 mcg/kg/min) and noradrenaline (from 1.3+/-0.45 to 0.05+/-0.02 mcg/kg/min) were reduced. The PaO2/FiO2 ratio increased (from 234+/-38.47 to 290+/-107.48 mmHg). CONCLUSION: The use of DHP-PMX in association with conventional therapy may be an important aid in patients with sepsis.

[Adenoid cystic carcinoma of the prostate. Clinical case]. / Carcinoma adenoido-cistico della prostata. Caso clinico.

The authors report an extremely rare case of adenoid cystic carcinoma of the prostate. No satisfactory clinical and pathological classification exists for this tumour, creating particular difficulties for therapeutic decisions and prognosis. Descriptions of cases with excellent survival rates are reported in the literature, to the extent that this is sometimes regarded as a low-malignancy tumour, but other reports also exist of massive diffusion of the pathology with fatal consequences. Advances in the knowledge of this tumour have enabled a number of earlier pathogenetic hypotheses to be ruled out, namely its possible derivation from ectopic salivary cells, ectopic periurethral glands or metaplastic urethral mucosa, but the origin of this carcinoma is still not certain. It is also difficult to differentiate this form from the typical adenocarcinoma and to make a prognosis for survival. In the case reported here, the final diagnosis was made on the lymph node biopsy obtained during surgery, given that a preoperative biopsy was not feasible owing to the scarcity of material available. The patient received standard hormonal therapy for prostate carcinoma.

[Unusual development of urothelioma of the upper urinary tract]. / Insolita evoluzione di urotelioma delle vie urinarie superiori.

A case of extrarenal spreading of transitional cell carcinoma caused by rupture of ureterohydronephrosis by ureteral transitional cell carcinoma is reported. Ultrasonography and CT revealed the presence of a severe right ureterohydronephrosis with large septa and a 2 cm diameter exophytic neoplasia of the middle ureter. Nephroureterectomy was performed with excision of a perirenal mass. Histologic examination revealed the presence of transitional cell carcinoma in the perirenal mass, caused by dissemination after renal rupture. CT and ultrasonography were not able to differentiate hydronephrosis from pericapsular spreading because of the extreme disruption of the renal parenchyma.

[Fibrous pseudotumors of the tunica vaginalis testis. A clinical case]. / Pseudotumore fibroso della tunica vaginale del testicolo. Caso clinico.

A case of multiple fibrous pseudotumors of the tunica vaginalis is reported. Ultrasonography led to diagnosis 10 years previously and the patient underwent surgical exploration when the lesions were up to 6 cm in diameter.

Correlation between Gleason score of needle biopsy and radical prostatectomy tissue.

Gleason score has been identified as an important variable to predict disease extent and biologic behaviour of prostate cancer. However, the correlation between Gleason score of needle biopsy and surgical specimen is often poor. We studied 72 patients who underwent needle biopsy and radical prostatectomy to correlate Gleason score with PSA, clinical and pathological tumour stage. Only 47.2% of Gleason scores were identical in the biopsy and specimens, 37.5% were undergraded and 15.2% were overgraded. Correlations between clinical and pathological stage were identical in 30.5% of patients, 61.1% of patients were understaged and 8.3% overstaged. In conclusion, accuracy of clinical staging and grading of prostate cancer is low. Although the Gleason score on needle biopsy might be useful to predict the final stage and grade, correlation with surgical specimen is poor.

[Fracture of the penis: description of a case]. / Frattura del pene: descrizione di due casi.

Fracture of the penis is not a frequent event and it consists of a rupture of the tunica albuginea of the corpora cavernosa and sometimes of the urethra; the lesion occurs when the penis is erect because during erection the tunica albuginea is very thin and not flexible and it can be easily damaged by a trauma; most lesions occur during intercourse for impact of the erect penis against the female perineum or the pubic synphisis, but lesions during masturbation, fightings or falling off the bed are also described [1-2-3]. Clinically there are pain, detumescence, hematoma and recurvatum of the penis toward the opposite side of the lesion and hematuria if also the urethra is damaged. Usually diagnosis is quite easy with a good anamnesis, clinical examination and echotomography which can reveal presence of hematoma and hypoechogenic areas along the tunica albuginea or the urethra that appears irregular. Nowadays, fractures of the penis need a surgical approach to obtain good results avoiding consequences such as recurvatum or fibrotic areas [3-4-7-8]. We describe two cases of fracture of the penis occurred in two young men during masturbation and treated surgically with excellent results: twelve and eighteen months respectively after surgery patients are well and can enjoy a normal sexual activity with no problems at all.

[Electrovaporization of the prostate]. / Elettrovaporizzazione della prostata.

Electrovaporization is a new and potentially useful modification of transurethral resection of the prostate which is rapidly becoming a treatment of choice for symptomatic benign prostatic hyperplasia. We report our experience with 22 patients treated using the Circon Acmi Grooved Vaportrode vaporization electrode. Procedures were carried out using the standard technique of electrovaporization with general or regional anaesthesia. Mean operative time was 40 minutes (range 25-65 minutes) and all patients were discharged without catheter after 1 or 2 days. Symptom score, peak uroflow and postvoid residual urine showed statistically significant improvement at 3 months (p < 0.01). There were no significant complications. Transurethral electrovaporization of the prostate seems to be a easy and safe procedure with significantly lower costs and excellent results. However, long-term efficacy and complications need to be evaluated in multicentre clinical trials.

[Prostatic endoprosthesis in the treatment of prostatic obstruction: preliminary experience with the new Trestle model]. / Le protesi endoprostatiche nel trattamento dell'ostruzione prostatica: esperienza preliminare con il nuovo modello Trestle.

The urethral stent is a relatively new treatment modality for benign prostatic hypertrophy ostruction. Although the ultimate prostatic endoprosthesis has yet to be developed, various stents have been produced and investigated with good results. We review the several currently available stents and we report the preliminary clinical experience with a new device (Trestle).

Mycoplasma pneumoniae infection complicated by paroxysmal cold hemoglobinuria with anti-P specificity of biphasic hemolysin.

A 7-year-old boy with Mycoplasma Pneumoniae infection complicated by transitory paroxysmal cold haemoglobinuria (PCH) is described. The Donath-Landsteiner-antibody exhibited anti-P specificity; hemolytic activity was partially inhibited against papainized erythrocytes at 0 degrees C incubation temperature and increased from 8 degrees C upwards. The association of Mycoplasma pneumoniae infection with PCH has been described 4 times only and in one instance where specificity was stated it was anti-I.

[Clarithromycin in pediatric age. Personal experience]. / La claritromicina nell'età pediatrica. Esperienza personale.

The authors report their experience on the use of oral suspension of Clarithromycin in respiratory infections in the pediatric age. Thirty-three patients affected by various infectious pathologies of the respiratory tract, treated with oral Clarithromycin at the dosage of 15 mg/kg/day, were studied. The therapeutic outcome was very encouraging, the drug well tolerated and without side effects.

[Clinical-therapeutic considerations in pertussis]. / Considerazioni clinico-terapeutiche sulla pertosse.

One-hundred and seventy-one cases of pertussis were observed at the Institute of Infections Diseases and at the 2nd Division of Infectious Diseases of the Policlinico Umberto I in Rome from January 1, 1987 to June 30, 1991. All subjects were treated according to a therapeutic protocol consisting of macrolides (erythromycin or myocamicin) at doses of 40-50 mg/die, betamethasone 0.1 mg/kg/die, specific immunoglobulin G at doses of 0.5 ml/kg repeated after 24 hours (new born babies and babies still unweaned) and oxygen therapy during the paroxystic fits. In 20 patients who were over the first year of life and who had serious asphyxiated fits, bronchodilators (trimetochinol or salbutamol) were added to the previous therapeutic scheme. Our data show both efficacy of therapeutic protocol and importance of early starting the treatment to shorten the length of disease, the strength of asphyxiated fits, and the risk of contagion.