Loss of nephrin expression in glomeruli of kidney-transplanted patients under m-TOR inhibitor therapy

The development of proteinuria has been observed in kidney-transplanted patients on m-TOR inhibitor (m-TORi) treatment. Recent studies suggest that m-TORi(s) may alter the behavior and integrity of glomerular podocytes. We analyzed renal biopsies from kidney-transplanted patients and evaluated the expression of nephrin, a critical component of the glomerular slit-diaphragm. In a group of patients on 'de novo' m-TORi-treatment, the expression of nephrin within glomeruli was significantly reduced in all cases compared to pretransplant donor biopsies. Biopsies from control transplant patients not treated with m-TORi(s) failed to present a loss of nephrin. In a group of patients subsequently converted to m-TORi-treatment, a protocol biopsy performed before introduction of m-TORi was also available. The expression of nephrin in the pre-m-TORi biopsies was similar to that observed in the pretransplant donor biopsies but was significantly reduced after introduction of m-TORi(s). Proteinuria increased after the m-TORi inititiation in this group. However, in some cases proteinuria remained normal despite reduction of nephrin. In vitro, sirolimus downregulated nephrin expression by human podocytes. Our results suggest that m-TORi(s) may affect nephrin expression in kidney-transplanted patients, consistently with the observation in vitro on cultured podocytes.

Bilateral Congenital Absence of Internal Carotid Arteries in a Woman with Dementia

Dysgenesis of THE internal carotid artery is considered a rare condition, present in about 0.01% of subjects. This anomaly is generally asymptomatic and often represents an incidental finding in radiological examinations of the head performed for other reasons. A 75-year-old woman with symptoms of dementia was admitted to our hospital. Computed tomography and magnetic resonance examinations were performed. They showed the absence of both internal carotid arteries and the congenital nature of this abnormality. The usefulness of CT and MRI examinations in patients with this vascular abnormality is discussed.

Transient Bilateral Basal Ganglia Lesions in Rotavirus Encephalopathy

Rotavirus gastroenteritis may be associated with the onset of an acute reversible encephalitis. We describe a case of transient bilateral basal ganglia lesions after a prodromal gastroenteritis which completely resolved four months later. Diffusion weighted images were determinant to depict the basal ganglia abnormalities and were helpful to evaluate the prognosis. A review of the literature indicates that many diseases may be accompanied by signal abnormalities within the basal ganglia and that differential diagnosis is possible only through the simultaneous evaluation of imaging, clinical and laboratory findings.

Effects of phyto-oestrogens on tissues

Recent investigations on the effects of phyto-oestrogens on various tissues have revealed that these diverse molecules may improve human health, particularly by protecting against certain chronic diseases. After a brief examination of the food sources, structures, and general cellular actions of the major phyto-oestrogens, current research findings on cardiovascular disease, skeletal tissues, and reproductive cancers are reviewed. Phyto-oestrogen concentrations in blood may be maintained at high levels in those consuming soyabean (Glycine max)-based food daily at several meals and exert their effects on target cells through either genomic effects via the classical oestrogen receptors or non-genomic effects mediated by membrane-bound oestrogen receptors or other cellular proteins. The expression of oestrogen receptor (OR) subtypes alpha (a) and beta (beta) varies across tissues, and cells that preferentially express OR-beta, which may include bone cells, are more likely to respond to phyto-oestrogens. Conversely, reproductive tissues contain relatively more OR-a and may, thus, be differently affected by phyto-oestrogens. Soyabean phyto-oestrogens appear to prevent the progression of atherosclerosis through multiple interactions, including lowering of plasma lipids and lipoproteins, increased vasodilatation and, possibly, decreased activation of blood platelets and vascular smooth muscle cells. However, a favourable impact on cardiovascular disease morbidity and mortality by a soyabean-enriched western-type diet remains to be shown, and unresolved questions remain regarding dose and form of the phyto-oestrogens in relation to risks and benefits. The isoflavones of soyabean have been shown consistently to have bone-retentive effects in animal studies by several investigators using rodent models, although intakes must be above a relatively high threshold level for a lengthy period of time, and little or no extra benefit is observed with intakes above this threshold level. The reports of modest or no effects on prevention of bone loss in human and non-human primate studies respectively, may be due to the limited doses tested so far. The relationship between soyabean-food intake and cancer risk has been more extensively investigated than for any other disease, but with less certainty about the benefits of long-term consumption of phyto-oestrogen-containing foods on prevention of cancer. The observations that breast and prostate cancer rates are lower in Asian countries, where soyabean foods are consumed at high levels, and the high isoflavone content of soyabeans have led to examination of the potential protective effects of phyto-oestrogens. Establishing diet-cancer relationships has proved difficult, in part because of the conflicting data from various studies of effects of soyabean-diets on cancer. Epidemiological evidence, though not impressive, does suggest that soyabean intake reduces breast cancer risk. The isoflavone genistein has a potent effect on breast cancer cells in vitro, and early exposure of animals to genistein has been effective in reducing later development of mammary cancer. Thus, continuous consumption of soyabean foods in early life and adulthood may help explain the low breast cancer mortality rates in Asian countries. Although the evidence for a protective effect against prostate cancer may be slightly more supportive, more research is needed before any firm conclusions can be made about the phyto-oestrogen-cancer linkages.

Head and neck mycobacterial infections in pediatric patients

OBJECTIVE

Lymph nodal disease is one of the most common manifestations of head and neck tuberculosis and is particularly frequent in paediatric patients with an increasing incidence in the last decade. It may represent the manifestation of a systemic tuberculous disease or a clinical entity specific of the neck. Aim of this paper is to retrospectively analyse mycobacterial cervical adenopathies observed in two Paediatric European Centers between 1986 and 2004 and the outcomes of medical or surgical treatment.

METHODS

353 children were examined for mycobacterial cervical lymphadenopaties since January 1986 to December 2004. Demografic data about the sample are showed. The retrospective evaluation of the sample underlined distribution according to etiologic patterns, head and neck adenopathies localization. Previous or simultaneous medical or surgical treatment were analyzed. Statistical analysis with Chi Square test was performed.

RESULTS

281 (79.60%) cases showed a higher localization and 72 (20.40%) a lower localization. In relation to the etiological agent, 8 (2.27%) Mycobacterium tuberculosis (MTB) and 222 (62.89%) mycobacteria other than tuberculosis (MOTT) lymphadenopaties were observed in the upper localization as opposed to 21 (5.95%) MTB and 39 (11.05%) MOTT in the lower plane. Two (0.56%) were detected as upper lymph nodal tumefaction in the median line. In 86 (24.36%) cases at the MRI the so-called "iceberg effect" was noted. 163 (62.45%) patients underwent primary excisional biopsy whereas 74 (28.35%) underwent exeresis after other unsuccessfull therapies, 9 underwent only drainage, and 15 drainage with subsequent antibiotic therapy. Number of relapses after surgery was 16 (6.13%).

CONCLUSIONS

A not homogeneous therapeutic approach to the mycobacterial cervical adenitis arises from literature and WHO guidelines does not give indications for the treatment of the cervical pattern. A therapeutic strategy based on the etiology is mandatory. In case of MBT adenopathy the therapy of choice includes the association, in variable way, of different chemotherapic drugs; surgery is reserved to advanced cases. Conversely, in cases of MOTT adenopathy, surgery is the treatment of choice.

A comparison of epidural vs. paravertebral blockade in thoracic surgery

AIM

Epidural analgesia is considered to be the best method of pain relief after major surgery despite its side-effects, which include hypotension, respiratory depression, urinary retention, incomplete or failed block, and, in rare cases, paraplegia. Paravertebral block is an alternative technique that may offer a comparable analgesic effect and a better side-effect profile. This study measured postoperative pain and respiratory function in patients randomized to receive either paravertebral block or epidural analgesia for pain control after thoracic surgery.

METHODS

Twenty-four adult patients undergoing thoracic surgery were enrolled in a prospective and randomized clinical study. Patients were randomly allocated to receive either postoperative continuous paravertebral analgesia (N=12) or epidural analgesia (N=12) starting at pleura closure. Postoperative use of morphine, visual analogue scores, and spirometer data were collected for 72 hours after surgery as markers of pain relief.

RESULTS

There was a statistically significant (P=0.003) increase in median (25th-75th percentiles) patient-controlled use of morphine, with values of 36 (22-42) mg in the paravertebral group vs. 9 (2-22) mg in the epidural group. This increase in morphine usage in the paravertebral group was statistically significant at 6, 24, 48, and 72 hours after surgery. Postoperative pain measured with the visual analogue score was not significantly different in the two groups. Spirometer values at 72 h were better in the epidural group than in the paravertebral group (P=0.03).

CONCLUSIONS

Epidural analgesia is more efficient than paravertebral continuous block at reducing pain after thoracic surgery.

An Interpretation of Optic Nerve Tortuosity

Magnetic resonance imaging disclosed both optic nerve tortuosity and kinking in a 64-year-old man with orbital pain and monolateral abducens nerve palsy. The association between optic nerve tortuosity and abducens nerve palsy is often described in literature reports of idiopathic intracranial hypertension. However the diagnosis of idiopathic intracranial hypertension was excluded in our patient because of the absence of other signs such as papilledema (universally present in the cases of idiopathic intracranial hypertension), visual loss, headache and flattening of the posterior sclera. Other possible diagnoses to be considered when looking at a case of optic nerve tortuosity are neurofibromatosis and/or optic nerve glioma. Tortuosity of both optic nerves seems to be isolated in our patient and not associated with other diseases or disorders. We suggest that in some patients optic nerve tortuosity could be correlated with an aberrant anatomical development of the optic nerve. Further studies are necessary to confirm this hypothesis which currently remains conjectural.

Idiopathic spontaneous intestinal perforation: a distinct pathological entity in the preterm infant

AIM

Necrotizing enterocolitis (NEC) is the most common cause of intestinal perforation in newborn children. A novel condition of idiopathic spontaneous intestinal perforation (SIPI) was recently described, which does not show clinical and diagnostic features of NEC. The aim of the present study was to define clinical peculiarities and potential risk factors in newborns by comparing SIPI and NEC patients.

METHODS

In the last six years, 85 preterm infants have necessitated surgical counseling for acute abdominal conditions. Among them, 13 underwent emergency surgery, 6 for SIPI and 7 for NEC respectively. Patients were then subdivided into three groups: group 0: 72 infants who did not need surgery; group I: 6 patients with SIPI; group II: 7 patients with NEC. Some variables were retrospectively analyzed and were compared by means of chi(2) test with a significant value of P<0.05.

RESULTS

No association emerged between patient's sex gender (P=0.691), membrane ruptures (P=0.400) and maternal infection (P=0.415). A correlation was observed between pneumoperitoneum and SIPI/NEC (P=0.000). The study on group I and II showed a lower gestational age (27.3 as compared to 30.28 weeks) and a higher number of membrane ruptures (4/6 as compared to 3/7) and of maternal infections (4/6 as compared to 3/7).

CONCLUSIONS

This study showed that a determining factor for the etiopathogenesis of SIPI may be neonatal stress consequent to preterm birth. Infants under 28 weeks of gestational age, with low birth weight, show a particular predisposition to SIPI, with a risk accounting to 96% of the present case series.

Voluminous perinatal pelvic mass: a case of congenital hydrometrocolpos

Imperforate hymen is the most frequent congenital malformation of the female genital tract; it usually does not show symptoms until puberty. Only rarely, imperforate hymen manifests itself as an abdominal mass detectable in the prenatal period. We describe a rare case of voluminous hydrometrocolpos, antenatally diagnosed and successfully treated immediately after birth.

[Neonatal neuroblastoma and prenatal diagnosis]

The improvement of the imaging has considerably increased the number of cases of neuoroblastoma, diagnosed in preborn age. The authors present a case of neonatal neuroblastoma diagnosed in prenatal age and managed with a multidisciplinary approach. The authors report the case of R.T., born from a scheduled Caesarean delivery. The echographic morphological prenatal diagnosis showed an abdominal mass of 3x2 cm located on the upper side of the kidney, which was not apparently involved. Postnatal ultrasound evaluations confirmed that diagnosis. The diagnostic programme included nuclear magnetic resonance and a renogramm with metaiodobenzylguanidine. These exams confirmed the presence of a mass, probably due to a neuroblastoma. Due to the increasing of the mass, the patient underwent surgical excision of the neoplastic mass. The histological examination confirmed the diagnosis of neuroblastoma Stage I without medullary involvement. During the operation, a medullary biopsy was performed. The FISH exam did not show the amplification of N-myc or a delection of p36 chromosome. For patients younger than 18 months there is no therapeutic gold standard for the treatment of suprarenal masses of neoplastic origin, and the approach is still controversial. The complete excision of the mass should be taken in consideration in presence of an increasing neoformation, and should not include any chemotherapeutical or radiation therapy for stage I, II, IVs (INSS) or L1, MS (INGRSS) neoformations. In conclusion, the effectiveness of a multidisciplinary approach of neonatal neuroblastoma is higher in the early diagnosis and in an accurate staging of the disease, which is fundamental for the favourable prognosis.

IKZF1 (IKAROS) deletions as a prognostic marker in BCR-ABL1 positive acute lymphoblastic leukemia patients: A GIMEMA ALL WP Report

11005

Expression of BCR-ABL1 in hematopoietic stem cells can alone induce a chronic myeloid leukemia (CML) but cooperating oncogenic lesions are required for the generation of a blastic leukemia. To identify oncogenic sub-microscopic lesions that cooperate with BCR-ABL1 to induce ALL, by high resolution single nucleotide polymorphism (SNP) arrays (250K NspI and SNP 6.0, Affymetrix) we studied 106 patients (pts) with de novo adult BCR-ABL1-positive ALL. The most frequent somatic copy number alteration was deletion on 7p12 of IKZF1 (68/106, 64%), which encodes the transcription factor Ikaros required for the earliest stages of lymphoid lineage commitment. We characterized and mapped all breakpoints in IKZF1 gene to recognize that two major deletions occur: the first one characterized by loss of exons 4–7 (44%) and due to breakpoints in introns 3 and 7; the second one characterized by removal of exons 2–7 (19%) and due to a variable pattern of breakpoints in introns 1 and 7. In two pts we had both Δ2–7 and Δ4–7 deletions and in one we identified a deletion of all IKZF1 gene and part of GRB10. A variable number of nucleotides (patient-specific) were inserted at the conjunction and maintained with fidelity at the time of relapse. Gene expression profiling analysis of pts with IKZF1 deletion vs wild-type pts identified a unique signature characterized by a down-regulation of genes involved in pre-B-cell differentiation (e.g. VPREB1, VPREB3, IGLL3, BLK), demonstrating that genomic IKZF1 alterations have a strong impact on trascriptoma and contribute to an impaired B-cell differentiation. Univariate analysis showed that the IKZF1 deletion is a negative prognostic marker influencing the cumulative incidence of relapse (10.1 months for pts with deletion vs 56.1 months for wild-type pts, p=0.0103) and disease-free survival (DFS) (10.1 months vs 32.1 months, respectively, p=0.0229). The negative prognostic impact of the IKZF1 deletion on DFS was also confirmed by multivariate analysis (p=0.0445). In conclusion, deletion of IKZF1 is an important event in the development of BCR-ABL1 B-progenitor ALL which significantly influences clinical outcome. Supported by European LeukemiaNet, AIL, AIRC, FIRB 2006, Strategico di Ateneo, GIMEMA Onlus.

No significant financial relationships to disclose.

Expression of different isoforms of the B-cell mutator activation-induced cytidine deaminase (AID) in BCR-ABL1-positive acute lymphoblastic leukemia (ALL) patients

7049

Since the activation-induced cytidine deaminase (AID) enzyme can target non-immunoglobulin (Ig) genes and may even act as a genome-wide mutator, we investigated AID expression in BCR-ABL1-positive ALL and in chronic myeloid leukemia (CML) at the time of progression to blast crisis. On the 61 de novo adult BCR-ABL1-positive ALL patients (pts), AID mRNA and protein were detected in 36 (59%); their expression correlated with BCR-ABL1 transcript levels and disappeared after treatment with tyrosine kinase inhibitors at the time of remission. AID expression was also found in lymphoid blast crisis CML (50%), but not in myeloid lineage or in chronic phase CML. Different isoforms of AID were identified: 13/61 (21%) pts expressed the full-length isoform; 19/61 (31%) co-expressed the wild-type and different AID splice variants with deaminase activity (AIDΔE4a, with a 30 bp deletion of exon 4; AIDΔE4, with the exon 4 deletion; AIDins3, with the retention of intron 3–4); 4/61 (7%) expressed the AIDΔE3-E4 isoform without deaminase activity (deletion of exons 2 and 3). To investigate whether AID introduces DNA-single strand breaks, we performed a genome wide analysis by 250K NspI single nucleotide polymorphism (SNP) array. Patients who expressed wild-type AID had a higher number of alterations compared to AID-negative (median copy number alteration of 14 versus 4. respectively, p < 0.03). Recurring copy number abnormalities were identified in genes with an established role in leukemogenesis, such as IKZF1, CDKN2A, CDKN2B, PAX5, MELK, BTG1, and MDS1. Our findings show that BCR-ABL1-positive ALL cells aberrantly express different isoforms of AID that can act as mutator outside the Ig gene loci in promoting genetic instability in leukemia cells. Supported by: European LeukemiaNet, AIL, AIRC, FIRB 2006, Fondazione del Monte di Bologna e Ravenna, Strategico di Ateneo, GIMEMA Onlus.

No significant financial relationships to disclose.

[Kidney retransplantation: indications and limits]

Whether or not to consider a uremic patient for retransplantation remains a matter of debate. Donor shortage and putative poor outcomes are the main cons, improved results in the last decade and a better survival (HR 0.50) with retransplantation than dialysis stand as pros. The percentage of patients waitlisted for retransplantation or already having been retransplanted is increasing (up to 20-30%) and the absolute contraindications are limited to rare conditions (loss of previous transplant due to anti-glomerular basement antibodies in Alport's syndrome, early recurrence of GNF or hemolytic uremic syndrome). When retransplantation is considered, however, careful screening for risk factors is mandatory, whether they are related to the previous graft or to the recipient's clinical features or the donor's demographics and immunological status. In the last decade the clinical outcomes of retransplantation have significantly improved. No difference in patient survival at the fifth year has been reported between first, second and third grafts. The kidney survival at the same interval is above 70% for the second graft and 65% for the third graft. Nephrectomy of a previous graft is not necessary if not for clinical reasons. As far as the maximum number of retransplants is concerned, most transplant centers (69%) set no clear-cut limit. In conclusion, also taking into account that many patients after graft failure ask for readmission to the waiting list (75% in our experience), we think the retransplantation option should always be evaluated.

Prospective randomized, blind comparison of ropivacaine and levobupivacaine for superficial plexus anesthesia in carotid endoarterectomy

BACKGROUND

The authors performed a study to evaluate if the onset time, duration of sensory block, and quality of postoperative analgesia in superficial cervical plexus anesthesia with 0.5% levobupivacaine (1 mg/kg) was greater than 0.75% ropivacaine (1.5 mg/kg).

DESIGN

randomized, double-blind study.

SETTING

University teaching hospital.

PARTICIPANTS

28 consecutive patients undergoing elective carotid thromboendoarterectomy were randomized into two groups.

INTERVENTIONS

patients received either 1 mg/kg of 0.5% levobupivacaine (N.=15), or 1.5 mg/kg of 0.75% ropivacaine (N.=13). We assessed the onset time (pinprick test), duration of sensory block, and postoperative analgesia with the two drugs.

RESULTS

Onset time of sensory block was 20+/-6 min with ropivacaine and 29+/-8 min with levobupivacaine (P=0.003). Intraoperatively we used different total doses of lidocaine, with the median (interquartile range) dose of 50 (40-100) mg for ropivacaine and 130 (60-180) mg for levobupivacaine (P=0.05). The first pain medication was requested after 12+/-0.4 h by ropivacaine patients and after 11+/-1.6 h by levobupivacaine patients (P=0.5).

CONCLUSION

No beneficial effect was noted in the quality of nerve block or patient's satisfaction for 0.5% levobupivacaine when compared to 0.75% ropivacaine.

Stable isotope ratio analysis as a tool to discriminate between rainbow trout (O. mykiss) fed diets based on plant or fish-meal proteins

The use of stable isotope ratio analysis (SIRA) as a rapid analytical tool to characterize and discriminate farmed fish on the basis of the feedstuffs included in the diet formulation is discussed. Two isoproteic (44.8%) and isolipidic (19.6%) extruded diets were formulated: a fish-meal-based diet (FM diet), containing fish meal as the sole protein source; a plant-protein-based diet (PP diet), where pea protein concentrate and wheat gluten meal replaced 80% of fish meal protein. The diets were fed to eight groups of rainbow trout (initial body weight: 106.6g) for 103 days in two daily meals under controlled rearing conditions. Growth performance (final body weight: 318.5 g; specific growth rate: 1.06%) and feed-to-gain ratio (0.79) were not affected by the dietary treatment. The differences in isotopic values of the two diets were clearly reflected in the different carbon and nitrogen isotopic values in rainbow trout fillets. The delta(13)C and delta(15)N values of muscle of farmed rainbow trout showed differences between farmed fish fed a fish-protein-based diet (-20.47 +/- 0.34 and 12.38 +/- 0.57 for delta(13)C and delta(15)N, respectively) and those fed a plant-protein-based diet (-23.96 +/- 0.38 and 7.15 +/- 0.51 for delta(13)C and delta(15)N, respectively). The results suggest that SIRA provides a robust and verifiable analytical tool to discriminate between fish fed on a plant or a fish protein diet.

A Double-Blind, Vehicle-Controlled Clinical Study to Evaluate the Efficacy of MAS065D (XClair™), a Hyaluronic Acid-Based Formulation, in the Management of Radiation-Induced Dermatitis

This study was designed to assess the efficacy and tolerability of MAS065D (Xclair) compared to a vehicle control in the management of radiation dermatitis in patients receiving radiotherapy for breast cancer. Twenty patients were randomized blindly to use the two study substances, three times daily, on separate sections of irradiated skin throughout the duration of radiotherapy and for two weeks afterwards. Patients were monitored before therapy, weekly during therapy, and for 2 weeks after radiotherapy was completed. Skin appearance according to National Cancer Institute (NCI) toxicity criteria, erythema rating, transepidermal water loss (TEWL), skin hydration, patients' view of itch, pain, acceptance, and view of each cream and adverse events, were monitored; at the final visit patients and investigators expressed their preference for one of the creams. MAS065D showed statistically significant superiority in the outcomes of NCI grading for radiation dermatitis and erythema. Patients' and investigators' preferences for one of the study substances were statistically in favor of MAS065D. Very few patients recorded nonzero itch and pain scales, so no significant differences emerged between the two groups. It was concluded that MAS065D can provide an effective option for managing radiation dermatitis although further studies are needed to assess its effect on pain and itch.

Stenting of transplant renal artery stenosis: outcome in a single center study

AIM

Transplant renal artery stenosis (TRAS) is the most frequent vascular complication following transplantation and is a potential curable cause of resistant hypertension, allograft dysfunction, and graft loss. Percutaneous angioplasty (PTA) is the treatment of choice, but the incidence of restenosis may be as high as 35%. Alternative treatment option combines the angioplastic procedure with the placement of a stent. The aim of this study was to evaluate retrospectively the clinical outcome of 30 patients with TRAS or post-PTA recurrent TRAS between 1991 and 2006 treated by endoluminal stenting. Primary outcomes of this study were survival rate, percentage of restenosis and lost of the graft. Secondary outcomes were: reduction of blood pressure, creatinine levels and number of antihypertensive medications.

METHODS

From May 1991 to May 2006 a retrospective review of stent placement procedures for TRAS was performed. Reviewed parameters included: technical success, arterial blood pressure and number of antihypertension medications, serum creatinine level before and after intervention. Thirty-two interventions in 30 allografts were carried out. Allograft survival rate was estimated using the Kaplan-Meier

RESULTS

The technical success rate of stenting was 100% with a single major complication event (a puncture site pseudoaneurysm). Mean follow-up time was 7.1 years; of the 30 allograft that underwent stent placement, all were patent at the last follow-up, with five restenosis (15.6%) of which only one needed to be retreated endoluminally. A reduction of the mean serum creatinine levels and of the number of blood pressure medications was observed. There was no difference in the survival curve of the grafts without TRAS compared to those with stenting treated TRAS.

CONCLUSION

The treatment of the TRAS with selective or primary stenting is safe with a long-term patency rate. The efficacy of the stenting in this retrospective study is suggested by a decrease in mean systolic and diastolic blood pressure, serum creatinine levels and number of blood pressure medications.

Long-term follow-up of patients with hyperthyroidism due to Graves' disease treated with methimazole. Comparison of usual treatment schedule with drug discontinuation vs continuous treatment with low methimazole doses: a retrospective study

Antithyroid drugs may be proposed as the firstline therapy for hyperthyroidism due to Graves' disease since some patients undergo prolonged remission after drug withdrawal. On the other hand, some studies, though controversial, indicated that methimazole (MMI) has some immunomodulating activity. We retrospectively analyzed 384 consecutive patients newly diagnosed with Graves' disease in the years 1990-2002 to ascertain whether long-term therapy with low doses of MMI may prevent relapse of thyrotoxicosis. Two hundred and forty-nine patients were included in our study. The date of reduction of MMI dose to 5 mg/day was considered time 0 for survival analysis. In 121 MMI was discontinued in less than 15 months after time 0 (group D), while in the remaining 128 a daily MMI 2.5-5 mg dose was maintained (group M). One hundred and thirty-five patients were excluded for inadequate response to MMI, relapse of thyrotoxicosis that could be related to an improper withdrawal or reduction of MMI, inadequate or too short followup, iodide contamination, steroid or interferon therapy, pregnancy or post-partum. D and M groups did not differ for clinical and hormonal parameters except age, which was lower in D (p=0.019). Age > vs < 35 yr was relevant in survival analysis; therefore patients were divided in 2 groups according to this age cut-off. In younger patients relapse of thyrotoxicosis occurred in 15 patients of group D 2.4-39.6 months (median 19.0) after time 0, and 8 M after 5.9-40.0 (21.3) months, while 14 D and 5 M maintained euthyroidism until the end of the observation after 31.8-95.3 (56.6) months and 30.4-62.1 (46.5) months, respectively. Survival analysis indicated that the risk of relapse was similar in group D and M. In older patients relapse of thyrotoxicosis occurred in 40 patients of group D after 8.2-65.8 (25.4) months and 29 M after 5.8-62.5 (22.4) months, while 52 D and 86 M maintained euthyroidism until the end of the observation, 20.1-168.0 (46.7) months and 24.1-117.4 (53.4) months respectively. Survival analysis indicated that the risk of relapse was increased in group D. Therefore long-term treatment with low doses of MMI seems to prevent relapse in Graves' disease in patients above 35 yr of age. This should be confirmed in a prospective study.

Rapidly progressive organising pneumonia associated with cytomegalovirus infection in a patient with psoriasis

A 63-year-old woman experienced progressive respiratory distress and psoriatic plaques. The radiographic images showed diffuse interstitial infiltrates. The surgical open lung biopsy revealed an obliteration of the alveolar spaces by plugs of connective tissue distributed within the terminal bronchioles, alveolar ducts and spaces. No relevant cause was determined, and she was diagnosed with idiopathic organising pneumonia. The patient was discharged with oral glucocorticosteroid and supplemental oxygen therapy. One month later, the patient's pulmonary status had progressively worsened, and she was re-admitted. She required higher oxygen concentrations and mechanical ventilation. Pharmacological therapy included high-dose steroids and cyclophosphamide. Serological assays revealed high antibodies titers (both IgM and IgG) to cytomegalovirus. Therefore, ganciclovir was added to the regimen. Despite the therapy, she died as a result of the disease. The review of the current literature on the topic is also presented.