Polyclonal and monoclonal B lymphocytes response in HCV-infected patients treated with direct-acting antiviral agents.

Hepatitis C virus (HCV) chronic infection can be associated with extrahepatic manifestations such as mixed cryoglobulinaemia and lymphoproliferative disorders that are endowed with increased rates of morbidity and all-cause mortality. In this study, we used flow cytometry to evaluate the effect of interferon-free antiviral treatment on peripheral blood lymphocytes in HCV-infected patients with or without associated lymphoproliferative disorders. Flow cytometry analysis of peripheral blood lymphocytes was performed at baseline and at the end of treatment. In HCV-infected patients with lymphoproliferative disorders, we evaluated immunoglobulin (Ig) light chain κ/λ ratio variations as a measure of monoclonal B-cell response to antiviral therapy. Healthy volunteers were enrolled as controls. A total of 29 patients were included, nine with and 20 without lymphoproliferative disorders. Sustained virological response was achieved in 29 of 29 patients. We observed a significant reduction in the B-cell compartment (39% global reduction) in eight of nine HCV-infected patients with lymphoproliferative disorders after viral clearance. We recognized the same trend, even if less pronounced, in HCV-infected patients without lymphoproliferative disorders (9% global reduction). Among HCV-infected patients with lymphoproliferative disorders, three showed an improvement/normalization of the immunoglobulin light chain ratio, whereas in the remaining six patients monoclonal B cells persisted to be clonally restricted even 1 year after the end of treatment. Our data show that DAAs treatment can be effective in reducing the frequency of pathological B cells in the peripheral blood of HCV-infected patients affected by HCV-associated lymphoproliferative disorders; however, monoclonal populations can persist after viral eradication.

Lymphocytes subsets reference values in childhood.

Immunophenotyping of blood lymphocyte subsets and activation markers is a basic tool in the diagnostic process of primary immunodeficiency diseases, its use becoming more and more widespread as the knowledge about these illnesses increases. However, the availability of reliable reference values, which need to be age-matched for the pediatric population, is a pre-requisite for the reliable interpretation of immunophenotyping data. Aim of this study is to analyze the lymphocyte subsets and activation markers distribution in children aged 0-18 years referring to the University Hospital of Padova and to create age-matched reference values expressed by percentiles, thus providing a valuable guideline for the interpretation of the immunophenotype.

First case of bronchiolar-pleural fistula repair with platelet-leukocyte rich gel.

Bronchiolar-pleural fistulas are a frequent complication of thoracic surgery. Current treatment strategies and their invasiveness are quiet different, but often surgeons decide for a new surgical intervention and definitive closure of the breach. We report the case of a bronchiolar-pleural fistula in a 75 years old man with important co-morbidities that we treated with instillation of platelet-leukocyte rich gel (PLR-G). We discuss actual indications for PLR-G as well as its possible role in thoracic surgery.

Non-fatal suicidal behaviour in Padua, Italy, in two different periods: 1992-1996 and 2002-2006.

PURPOSE: The WHO/EURO multicentre study on suicidal behaviour showed the lowest rates of suicide attempts in the Italian centre of Padua. Present study aims to discover changes in non-fatal suicidal behaviour rates and characteristics by comparing hospital-admitted subjects in two study periods (1992-1996 and 2002-2006). METHODS: Data were obtained from the University Hospital of Padua. The crude prevalence rates of events and persons by year per 100,000 (subjects aged 15+ years) were calculated. Rate ratios, Chi-square tests and t tests were calculated. RESULTS: The mean prevalence rate per year showed a significant increase during the second study period from 59.2 to 93.6 per 100,000 (RR = 1.58, 95%CI = 1.24-2.02). Changes were significant for both genders, but the increase was stronger in males. The proportion of subjects with non-fatal suicidal behaviour was highest in the youngest age group (15-29 years) in the first period and in adults (30-44 years) in the second period. The absolute number of subjects with non-fatal suicidal behaviour increased more than two times for adults aged 30-44 years. Changes in other age groups were minor. The absolute numbers of non-Italian-born subjects with non-fatal suicidal behaviour increased from 11 to 135 persons. The proportion of poisoning was significantly lower in the second period. CONCLUSIONS: When comparing the time periods 1992-1996 and 2002-2006, there was a significant increase in suicidal events in Padua. There have been remarkable changes in the characteristics of suicide attempt(er)s. The most remarkable change was in the number of non-Italian-born subjects, who should be specifically targeted by suicide prevention activities.

Barrett's esophagus after laparoscopic Nissen-Rossetti fundoplication: functional evaluation.

AIM: The aim of this study was to demonstrate the efficacy of laparoscopic antireflux surgery in controlling Barrett's esophagus progression, through functional study. METHODS: Between January 2008 and December 2009, 21 patients with a preoperative diagnosis of Barrett's esophagus underwent Nissen-Rossetti fundoplication. RESULTS: All patients underwent preoperatively a 24-hour pH-metry (100%). Twenty patients (95.2%) had postoperative pH monitoring at six months, 16 patients at 12 months (76.2%), eight at 24 months (57.14%). Median De Meester and Johnson score was preoperatively 18.55 (range 8.6-179.7), at six months 7.65 (range 6.4-13), at 12 months 7.5 (range 6.4-14.2), at 24 months 11.95 (range 6.4-20.6). CLE was still present in 18 patients (18/21, 85.7%), but no patient developed dysplasia or esophageal adenocarcinoma. Two patients with gastric- and one patient with intestinal metaplasia showed complete regression at 12 and 24 months after fundoplication (3/21, 14.3%). Symptom control alone does not manage acid reflux in patients with Barrett's esophagus after surgery, and postoperative 24-hour pH-metry confirms acid reflux abolition. A persistent reflux is more likely to develop cancer than in monitored patients. CONCLUSION: Only the presence of intact and effective anti-reflux wrap guarantees protection of the esophagus against CLE progression or its regression. Functional study after surgery identifies patients with Barrett's progression risk.

A three-year experience of the Referral Center for Surgical Treatment of Gastroesophageal Reflux Disease.

AIM: Gastro-esophageal reflux disease (GERD) rapresents the fastest growing disease affecting the alimentary and breathing apparatus. Incidence of esophageal adenocarcinoma with Barrett Esophagus (BE) imposes a decision about therapy management. METHODS: Between January 2006 to December 2009, 3 653 patients were subjected to our observation; 2 095 patients underwent endoscopy (57.4%), of these 598 underwent twenty-four hours pH-Metry (16.3%); 1 558 patients (42.6%) had clinical consult. RESULTS: A total of 1 255/2 095 referred typical symptoms (60%), 644 patients typical and atypical symptoms (30.7%), 96 patients atypical symptoms (4.6%); 4.7% had dysfagia and cramps; 1 897 patients (90.5%) had Los Angeles A esophagitis, 62 Los Angeles B (2.96%), 6 had Shatzki Ring (0.3%). NERD in 26 patients (1.24%); 3.4% had Hp Gastritis; 33 had BE (1.6%), 10 intestinalized type (30.3%), 23 gatric type (69.7%). Eighty-five/2 095 patients (4%, 36 M and 49 F, m.a. 42.5 years, range 20-72) underwent laparoscopic Nissen-Rossetti Fundoplication (4%), 69 with preoperative typical symptoms (81%), 11 typical and atypical symptoms (13%), 5 atypical symptoms (6%). Twenty-three had BE (27%, 9 intestinal metaplasia, 3 Long and 6 Short Barrett, 14 Gastric metaplasia); 61 with Los Angeles A esophagitis (98.3%), 1 with Shatzki Ring (1.7%). PH-Metries were positive. CONCLUSION: GERD requires specialistic and qualified centers.

Total fundoplication without division of the short gastric vessels: functional evaluation at one year and review of literature.

AIM: Gastro-esophageal reflux disease (GERD) has emerged as one of the most common diseases in modern civilization. We investigated functional evaluation after total fundoplication without division of short gastric vessels and review of literature. METHODS: From January 2007 to June 2008 43 patients with chronic gastroesophageal reflux underwent laparoscopic Nissen-Rossetti fundoplication, 7 were lost during the follow-up. Patients underwent endoscopy, 24 hours pH-Metry, preoperatively, 6 months and 12 months after surgery. Articles were sourced from PubMed and Medline, using the MeSH terms "gastroesophageal reflux disease" and "laparoscopic surgery" and "fundoplication technique". Selection of articles were based on peer review, journal, relevance and English language. RESULTS: Endoscopic findings revealed complete healing of esophagitis in all patients. Barrett esophagus was still present. Six patients reported persistence of symptoms but postoperative pH-metry and endoscopy showed the absence of reflux; two patients (5.5%) were still on PPI therapy at 12 months. Seven patients (19.4%) reported dysphagia for solid for at least three months. Re-admission for dysphagia was required for two (5.5%) and one patient underwent to endoscopic dilatation. At six and 12 months no dysphagia was reported. During the follow-up no gas-bloat syndrome was referred. The Johnsson and DeMeester's score reduction from six months to 12 months was statistically significant. Randomized and non-randomized studies seem to point out in a precise way that a division of short gastric vessels is unnecessary to perform a "short and floppy" placation. CONCLUSION: Nissen-Rossetti fundoplication is safe and effective for treatment of GERD, with minimal post-operative side effects.

Intravenous thrombolysis in the emergency department for the treatment of acute ischaemic stroke.

BACKGROUND AND AIMS: Thrombolytic therapy with intravenous recombinant tissue plasminogen activator (rt-PA) improves outcome in patients with ischaemic stroke treated within 3 h of symptom onset, but its extended implementation is limited. A pilot study was designed to verify whether evaluation of patients with acute ischaemic stroke and their treatment with intravenous rt-PA in the emergency department (ED), followed by transportation to a semi-intensive stroke care unit, offers a safe and effective organisational solution to provide intravenous thrombolysis to acute stroke patients when a stroke unit (SU) is not available. METHODS: After checking for inclusion and exclusion criteria, ED doctors contacted the stroke team with a single page, located family members and urgently obtained computed tomography scan and laboratory tests. A stroke team investigator clinically assessed the patient, obtained written informed consent and supervised intravenous rt-PA in the ED. After treatment, the patient was transferred to the SU for rehabilitation and treatment of complications, under supervision of the same stroke team investigator. RESULTS: 52 patients were treated with intravenous rt-PA within 3 h of symptom onset. 20 patients (38%) improved neurologically after 24 h, the number increased to 30 (58%) after one week. At 3 months 22 patients had a favourable outcome (43%). The 3-month mortality rate was 12%. Symptomatic cerebral haemorrhage was observed in two patients (4%). CONCLUSIONS: Intravenous rt-PA administration in the ED is an effective organisational solution for acute ischaemic stroke when an SU is not established.

[Laparoscopic combined Nissen-Rossetti fundoplication and cholecystectomy: our experience]. / Plastica Nissen-Rossetti e colecistectomia in un unico tempo laparoscopico: esperienza personale.

OBJECT: The aim of this study is to valuate the opportunity to associate both laparoscopic Nissen-Rossetti fundoplication and cholecystectomy in patients with gallbladder cholelithiasis and gastro-oesophageal acid reflux (endoscopically and pHmetrically assessed), considerating that the gallbladder removal makes duodenal-gastric reflux worse. PATIENTS AND METHODS: From 2005 until 2007 we associated laparoscopic Nissen-Rossetti fundoplication and cholecystectomy in 10 patiens, who presented surgical indications for gallbladder cholelithiasis and gastro-oesophageal reflux. Clinical data, surgical procedures and post-operative complications were compared to our esperiency on the singular procedure (laparoscopic Nissen-Rossetti fundoplication and cholecystectomy). Results were valuated at 3, 6 and 12 months after surgical interventions by clinical and instrumental follow up (24-pH-metry and oesophagus-gastro-duodenoscopy). RESULTS: The analysis of instrumental data of these associated procedures doesn't present significative differences between the singular surgical approach. In all the patients treated by combined procedure, the follow-up shows a normal pHmetric exam, a good control on the acid reflux by fundosplication, absence of distal oesophagitis and gastric reflux symptoms. CONCLUSIONS: The association of laparoscopic Nissen-Rossetti fundoplication and laparoscopic cholecystectomy is indicated in patients who present both pathologies and needs to be considerating in relations to the good results and the low postoperatoric morbidity.

Quality in emergency departments: a study on 3,285,440 admissions.

INTRODUCTION: A multi-centre study has been conducted, during 2005, by means of a questionnaire posted on the Italian Society of Emergency Medicine (SIMEU) web page. Our intention was to carry out an organisational and functional analysis of Italian Emergency Departments (ED) in order to pick out some macro-indicators of the activities performed. Participation was good, in that 69 ED (3,285,440 admissions to emergency services) responded to the questionnaire. METHODS: The study was based on 18 questions: 3 regarding the personnel of the ED, 2 regarding organisational and functional aspects, 5 on the activity of the ED, 7 on triage and 1 on the assessment of the quality perceived by the users of the ED. RESULTS AND CONCLUSION: The replies revealed that 91.30% of the ED were equipped with data-processing software, which, in 96.83% of cases, tracked the entire itinerary of the patient. About 48,000 patients/year used the ED: 76.72% were discharged and 18.31% were hospitalised. Observation Units were active in 81.16% of the ED examined. Triage programmes were in place in 92.75% of ED: in 75.81% of these, triage was performed throughout the entire itinerary of the patient; in 16.13% it was performed only symptom-based, and in 8.06% only on-call. Of the patients arriving at the ED, 24.19% were assigned a non-urgent triage code, 60.01% a urgent code, 14.30% a emergent code and 1.49% a life-threatening code. Waiting times were: 52.39 min for non-urgent patients, 40.26 min for urgent, 12.08 for emergent, and 1.19 for life-threatening patients.

[Retroperitoneal mass: a clinical case]. / Formazione retroperitonale: caso clinico.

The Authors discuss about a case of retroperitoneal mass, recently observed in their Institution. About the nature of the mass, by the imaging and clinical evolution, the Authors suppose a traumatic genesis: subcapsular renal hematoma, occurred 2 years before, broken and expanded in retroperitoneal space and then superficialized in the left lumbar region.

[Intragastric balloon in bariatric surgery]. / Ruolo del palloncino intragastrico in chirurgia bariatrica.

Intragastric balloon (BIB) is a mechanical restrictive device formed by a silicone wrapper inserted endoscopically in the stomach, filled with 500 cc of physiological blue methyl solution and kept in situ for 6 months. In two years 98 intragastric balloon have been set in 88 patients at the average age of 37.1 years, of 41.9 of BMI and 47.6 kg of weight. Complications were intolerance, gastro-oesophageal reflux, break and/or deflation and meteorism. BIB is an effective procedure in the temporary treatment of obesity leading to satisfactory weight loss and to short-term improvement of comorbidities.

Point-of-care testing of cardiac markers: results from an experience in an Emergency Department.

AIM: An experimental approach to the use of point-of-care testing for cardiac markers in the Emergency Department (ED) of our Institution has been carried out using two devices (SCS, Dade Behring and Triage Cardiac Panel, Biosite Diagnostics) for the measurement of cardiac markers. RESULTS: (1) From the analytical point of view, a fundamental tool for an efficient management of patients was the agreement between results from point-of-care testing and from the instruments located in STAT lab and/or central laboratory: in about 5% of patients, a lack of comparability of data, resulted in an inappropriate admission of patients (medical vs. intensive care unit). (2) The actual total turnaround time (TAT) in the management of samples sent to STAT lab was estimated to be equal to 82.5 min (50th percentile). (3) In the same organizational setting, the use of a point-of-care device produced a turnaround time equal to 17 min (50th percentile). (4) The reduction in turnaround time resulted in a faster discharge for five patients who had normal ECG findings and cardiac marker values, the Delta time (POCT-STAT lab) ranging from -10 to -70 min. CONCLUSIONS: The point-of-care option evaluated also in relation to personnel issues for staff working in the ED, brought some interesting questions about the characteristics of POCT devices (easy to use 100%, safety for operator 91%) and the obtained results (quantitative and correlated to STAT lab, 91%), as well as the need of other options such as the implementation of rapid tube sample delivery.

Total gastrectomy in the treatment of adenocarcinoma of the cardia. Review of the results in 73 resected patients.

Between January 1, 1971, and December 31, 1978, 73 patients with adenocarcinoma of the cardia were treated by total gastrectomy with distal esophagectomy. The continuity of the alimentary tract was restored by esophagojejunostomy using a Roux-Y procedure in 32 patients and jejunal loop interposition in 41 patients. The early postoperative mortality rate was 18 percent. The overall 5 year survival rate was 26.7 percent, and the 5 year survival rate for stage I and II disease was 91.6 percent and 25 percent, respectively, whereas none of the stage III and IV patients survived more than 4 years. Fifty-eight percent of the patients without nodal involvement lived more than 5 years. The 5 year survival rate was only 9.3 percent in the presence of nodal metastases. Our 5 year survival rates suggest the value of elective total gastrectomy for stage I or II adenocarcinoma of the cardia. Jejunal loop interposition is a time-consuming but functionally superior procedure in comparison to other reconstructive procedures after total gastrectomy.

[Development of polycythemia vera during chronic idiopathic myelofibrosis]. / Sviluppo di policitemia vera in corso di mielofibrosi idiopatica cronica.

A case of typical idiopathic myelofibrosis turning into polycythaemia vera 6 years after diagnosis is reported. This transformation occurred after treatment with busulphan. The present case is added to similar previous observations to give further support to the contention that the transition of chronic idiopathic myelofibrosis to polycythaemia vera may be a consequence, though rare, of therapy rather than a spontaneous event occurring during the course of the disease.

[Acute leukemia secondary to idiopathic myelofibrosis with homozygote pseudo-Pelger anomaly and complex chromosomal changes]. / Leucemia acuta secondaria a mielofibrosi idiopatica con pseudo-Pelger omozigote ed alterazioni cromosomiche complesse.

The Authors present a case of acute myeloblastic leukemia secondary to a busulfan and splenic radiotherapy treated idiopathic myelofibrosis. The presence of D group complex chromosomal abnormalities could be responsible for the simultaneous massive Pelger anomaly of granulocytes.

[B lymphoproliferative syndrome with characteristics common to chronic lymphatic leukemia, Waldenström disease and plasmacytic leukemia]. / Sindrome linfoproliferativa B con caratteri intermedi fra leucemia linfatica cronica, morbo di Waldenström e leucemia plasmacellulare.

A case of lymphoproliferative disorder presenting some features of chronic lymphocytic leukemia, Waldenström's disease and plasmacell leukemia without the full diagnostic criteria of any of these diseases is reported. It clearly demonstrates the affinity existing among the various neoplasms of the B-lymphocyte cell line.

[Chronic idiopathic neutropenia: a benign hematological disorder]. / Neutropenia cronica idiopatica: un disordine ematologico a carattere benigno.

Clinical data in 23 consecutive patients with chronic idiopathic neutropenia are reported. During a long-term follow-up (4 to 11 years), none had leukemia or autoimmune diseases. In particular, in no case did serious recurrent infections develop despite severe neutropenia. Immunological studies showed the presence of antibodies to neutrophils in a unique case and of the marker make-up of K lymphocytes in other two with chronic T8 lymphocytosis and associated neutropenia. The immunological features of this syndrome is briefly discussed. Chronic idiopathic neutropenia, even in the presence of an immunological imbalance, is a benign haematological disorder and does not need any treatment.

[Basic therapy of rheumatoid arthritis with thiopronine. Preliminary results]. / Terapia "di fondo" dell'artrite reumatoide con tiopronina. Risultati preliminari.

A long term open study of the use of thiopronine in the treatment of 38 patients with ARA classified "classic" or "definite" rheumatoid arthritis is reported. Doses of the drug were increased from an initial 250 mg per diem by the addition of 250 mg every 15 days to 1 g per diem. After 6 months testing, results were satisfactory (good and fair) in 65% of the cases in both biological and clinical terms. In 15% of the cases, treatment was interrupted mainly due to mucous and cutaneous side effects. These preliminary results confirm reports in the literature and encourage further experiment.

[Protocol of combined surgical and polychemico-immunoradiologic therapy of stage T2N2MO lung cancer]. / Protocollo di trattamento combinato, chirurgico e polichemio-immuno-radioterapico del carcinoma polmonare allo stadio T2N2M0.

Preliminary data on the use of a combined surgical-polychemical-immunoradiotherapy protocol in the treatment of 13 T2N2M0 lung cancer patients are reported. The results are compared with those obtained in a 13 patient control group, homogenous by histotype, stage and surgical treatment who were given no other therapy. At 24 months the average survival rate in the first group was 61.5% compared to 15.3% in the second. It was significant that survival at 24 months after pneumonectomy rose from 16.6% to 50% and even more significantly survival after lobectomy rose from 14.2% to 71.4%.