POS0789 APPLICATION OF THE NEW ACR/EULAR 2019 CLASSIFICATION CRITERIA OF SYSTEMIC LUPUS ERYTHEMATOSUS TO A INCEPTION, MONOCENTRIC COHORT OF UNDIFFERENTIATED CONNECTIVE TISSUE DISEASES POPULATION AT ONSET OF THE DISEASE

Background:

undifferentiated connective tissue diseases (UCTDs) are a group of systemic autoimmune diseases that share clinical and serological manifestations with definite connective tissue diseases (CTDs), but do not satisfy existing classification criteria1. Within this group, it is possible to identify very heterogeneous conditions: transitory and self-limiting forms, stable conditions over time and forms that will evolve towards definite CTDs, in particular Systemic Lupus Erythematosus (SLE). The availability of new classification criteria for CTDs could be useful in identifying major CTDs from their onset and help in the differentiation from stable UCTDs, which will maintain their undifferentiated profile over time.

Objectives:

the aim of this study was to apply the new ACR/EULAR 2019 classification criteria of SLE2 to patients included, at the onset of UCTD, to evaluate how many patients could be re-classified as SLE.

Methods:

this is a retrospective observational study that enrolls patients who received the diagnosis of UCTD at the Rheumatology Unit of Pisa, according to the classification criteria proposed by Mosca et al1, and were then regularly followed in the same clinic (inception cohort). For each patient, demographics, comorbidities, treatment, clinical and serological data were collected, at baseline and during follow-up. The new ACR/EULAR 2019 classification criteria of SLE were applied to the inception cohort at the onset of the disease. The characteristics of patients re-classified as SLE according to the new classification criteria and those of patients who “remained” classified as UCTD were compared.

Results:

we enrolled 202 patients with a diagnosis of UCTD, mainly female (F:M 193:9) and of Caucasian ethnicity (97.5%), mean age at the diagnosis 38,5 ± 13,2 years and a median follow-up of 5 years (IQR 2-10).

During the follow-up, 10 patients (4.9%) in our cohort developed clinical and serological characteristics that led to a diagnosis of a definite CTD, in particular: 7 SLE, 2 Mixed Connective Tissue Disease (MCTD) and 1 Sjogren’s syndrome.

Applying the ACR/EULAR 2019 classification criteria of SLE to patients enrolled at the onset of the disease, 38/202 (18.8%) would have been classified as SLE (with a median score of 12 (IQR 11-15)) on the basis of the presenting clinical and serological manifestations. Interestingly, 6/7 patients who received a diagnosis of SLE during the follow-up were among these 38 patients.

Among the items of the new classification criteria of SLE, the most frequently satisfied by patients “re-classified” were arthritis (63.2%), hematological (44.7%) and skin (23.7%) manifestations; as for the “immunological” items, hypocomplementemia (71%), SLE-specific (52.6%) and antiphospholipid (35.1%) autoantibodies.

Comparing the subgroup of patients “re-classified” as SLE with that of patients who “remained” UCTD, we found that the first group presented more frequently hematological manifestations, hypocomplementemia and anti-dsDNA, anti-Sm, anti-RNP, anti-beta2GPI positivity at the onset of the disease (p<0.01). Moreover, during the follow-up, the subgroup of patients “re-classified” as SLE developed more frequently malar (p<0.05) and discoid rash and arthritis (p<0.01) compared to patients who “remained” UCTD.

Conclusion:

The development of increasingly sensible and specific classification criteria for definite CTDs may guide in the identification of stable UCTDs since their early stages and consequently in better definition of these conditions that can be considered as a distinct clinical entity.

The early identification of stable UCTD is of great importance not only for clinical management (follow-up schedules as well as therapeutic protocols) but also for scientific implications.

References:

[1]Mosca M. et al., Clin Exp Rheumatol. Sep-Oct 1999;17(5):615-20; 2. Fanouriakis A. et al., Ann Rheum Dis. 2020 Jun;79(6):713-723.

Disclosure of Interests:

None declared

THU0254 ARTICULAR INVOLVEMENT, STEROID TREATMENT AND FIBROMYALGIA ARE THE MAIN DETERMINANTS OF PATIENT-PHYSICIAN DISCORDANCE IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Remission or the lowest possible disease activity are the main targets in the management of Systemic Lupus Erythematosus (SLE). Anyway, conflicting data are present in the literature regarding the correlation between physician-driven definitions and patient perception of the disease. The discordance between patient and physician perspectives may have a negative impact on disease outcomes.

Objectives:

The aim of this study was to identify the main determinants of patient-physician discordance in the evaluation of SLE and health status.

Methods:

This is a cross-sectional study that enrolls patients with a diagnosis of SLE (ACR 1997 criteria). For each patient, demographics, comorbidities, treatment, clinical and laboratory data were collected. Disease activity was evaluated with the SELENA-SLEDAI score and organ damage with the SLICC/DI. Patients included have been categorized according to the following categories: remission, on or off treatment1, low disease activity (LLDAS)2and active disease status. At enrollment, each patient completed the following PROs: SF-36, FACIT-Fatigue, LIT and SLAQ. We defined a SLAQ score<6, corresponding to the 25° percentile of our cohort, as the cut-off value to define a low disease activity state according to the patient self-evaluation.

Results:

We enrolled 259 consecutive adult SLE patients (93.05% female, 97.2% Caucasian, mean age 45.33±13.14 years, median disease duration 14 years (IQR 6-21)). 208/259 patients satisfied the definition of LLDAS and among them 171 were in remission; 51/259 patients were active. No significant differences emerged as for the results of PROs between groups. Considering the subgroup of 208 patients in LLDAS, we identified 56 patients with a subjective condition of low disease activity (SLAQ<6) and we defined them as “concordant”; the remaining 152 patients in LLDAS presented a subjective active disease (SLAQ≥6) and we defined them as “discordant”. Comparing these two groups, we found that “discordant” patients had more frequently ongoing and past joint involvement (p<0.05) and a concomitant diagnosis of fibromyalgia (p<0.01); finally, they were more frequently on glucocorticoid therapy (p<0.01). “Discordant” patients showed a significantly worse quality of life, evaluated by all PROs (p<0.0001) (Tab 1).

Table 1.

Determinants of patient-physician discordance

Discordant patients(152/208)Concordant patients(56/208)p-valueAge at enrollment(years)47.7±13.144.3±10.8nsDisease duration(years)15.5±10.213.8±9.2nsSLICC-DI1.3±1.70.9±1.7nsOngoing joint involvement(% of patients)10.5%0p<0.05Past joint involvement(% of patients)70.9%55.3%p<0.05GC therapy(% of patients)50%28.6%p<0.01GC daily dose(mg of prednisone)1.6±1.91.1±1.9p=0.06Fibromyalgia(% of patients)15.8%1.8%p<0.01PCS54.7±14.165.8±20.4p<0.0001MCS54±14.564.3±17.7p<0.0001LIT28.4±20.414±16.8p<0.0001FACIT35.3±10.147.3±3.6p<0.0001

Conclusion:

Articular involvement, fibromyalgia and ongoing glucocorticoid treatment, even at low dose, are the major determinants of patient-physician discordance in SLE, determining a negative patient perception of health status.

References:

[1]van Vollenhoven R, et al. Ann Rheum Dis 2017 - Review. PMID 27884822;

[2]Franklyn K, et al. Ann Rheum Dis 2016. PMID 26458737

Disclosure of Interests:

None declared

FRI0155 Α MULTICENTER “AT-RISK” COHORT FOR THE DISCOVERY OF ENVIRONMENTAL, CLINICAL AND MOLECULAR PREDICTORS FOR THE TRANSITION INTO SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Background:

SLE onset is preceded by a preclinical phase evidenced by the presence of anti-nuclear and other autoantibodies (autoAbs), which however, have low predictive value for development of clinical SLE.

Objectives:

To define the subgroup of autoAbs-positive individuals who are at high risk for progression into SLE by integrating environmental, clinical/serological, genetic and transcriptome data.

Methods:

A multicenter, across five European countries, inception cohort of autoAbs-positive individuals or first-degree relatives (FDRs) of SLE patients who are monitored prospectively over five years for possible transition to SLE according to the classification criteria. Structured data collection on demographics, family and medical history, clinical (criteria and selected non-criteria manifestations) and serological parameters, use of medications, hydroxyvitamin D levels and lifestyle (tobacco, alcohol use, physical activity, adherence to Mediterranean diet). Blood samples are stored for RNA-sequencing and genotyping.

Results:

A total 254 at-risk individuals (93% women, 99% Caucasians, aged [mean ± standard deviation] 36 ± 12 years) have been included and enrolment/monitoring is still ongoing. Forty individuals (16%) have FDR with SLE and 88 individuals (35%) have FDR with another autoimmune disorder. The frequency of active and past use of tobacco was 28% and 20%, respectively. Sedentary lifestyle (moving only for necessary chores or outdoor activity 1-2 times/week) was reported by 54% and adherence to the Mediterranean diet was low (3.4 ± 2.3, maximum score: 9). At enrolment, individuals had 1.9 ± 1.1 ACR-1997 classification criteria, with anti-nuclear antibodies (ANA) being the most frequent (88%), followed by synovitis (39%), photosensitivity (33%) and immunologic disorder (30%) (Table 1). During follow-up of 15.2 ± 7.2 months, a total 15 individuals (5.9%) have progressed into classified SLE, including cases with severe hematological and neurological disease.

Table 1.

Baseline characteristics of the at-risk for SLE cohort

N (%) or mean ± SDACR 1997 classification criteria1.9 ± 1.1 Malar rash68 (27%) Discoid rash29 (11%) Photosensitivity83 (33%) Mucosal ulcers49 (19%) Synovitis100 (39%) Serositis30 (12%) Renal disorder28 (11%) Neurologic disorder31 (12%) Hematologic disorder58 (23%) Immunologic disorder77 (30%) ANA222 (88%)SLICC 2012 classification criteria Clinical criteria1.0 ± 0.9 Immunological criteria1.3 ± 0.9

Conclusion:

Among individuals with positive autoAbs or FDRs with SLE, the short-term risk for transition into clinical SLE is low. Following the study completion, clinical and lifestyle data will be combined with blood transcriptome to define a high-risk subgroup of individuals for progression into SLE.

Acknowledgments:

The study is supported by the Foundation for Research in Rheumatology (FOREUM; preclin016)

Disclosure of Interests:

Christina Adamichou: None declared, Dionysis Nikolopoulos: None declared, Myrto Nikoloudaki: None declared, Zahra Rahme: None declared, Micaela Fredi: None declared, Antigoni Pieta: None declared, ARGYRO REPA: None declared, Alice Parma: None declared, Eleni Kalogiannaki: None declared, Nestor Avgustidis: None declared, Nikolaos Kougkas: None declared, Aggelos Banos: None declared, Anastasios Eskitzis: None declared, Alessandra Bortoluzzi: None declared, Søren Jacobsen: None declared, Prodromos Sidiropoulos: None declared, Emmanouil Dermitzakis: None declared, Marta Mosca: None declared, Luís Inês: None declared, Laura Andreoli: None declared, Angela Tincani: None declared, Antonis Fanouriakis Paid instructor for: Paid instructor for Enorasis, Amgen, Speakers bureau: Paid speaker for Roche, Genesis Pharma, Mylan, George Bertsias Grant/research support from: GSK, Consultant of: Novartis

AB0532 CORRELATION WITH THE FREQUENCY OF DISEASE RELAPSES DURING THE FIRST 3 YEARS FROM THE DIAGNOSIS AND DISEASE OUTCOMES IN BEHCET’S SYNDROME

Background:

Beside the organ involvement, a number of demographic factors could considerably influence the long-term and short-term outcomes of Behçet’s syndrome (BS): age at disease onset, duration of disease, gender and sex. Younger men patients are more suitable to have a more severe disease, due to an increased frequency both of morbidity and mortality, related to ocular,vascular and neurological involvement

Objectives:

The primary aims of the study were to evaluate disease activity in a cohort of BS patients consecutively followed in a BS clinic of a tertiary centre and to explore whether there is a correlation between frequency of relapses in the first 3 years of diseases and disease outcomes.

Methods:

One-hundred and sixty-five patients (91 males and 74 females; mean age 39±9 years, mean disease duration 9±5) with a diagnosis of BS according to the ISG criteria were studied. Disease activity has been evaluated by BDCAF and patients were also categorized in major or minor involvement of BS according or not to the presence of ocular, neurological and vascular involvement in the course of disease The numbers of relapses in the first 3 years from diagnosis were correlated with disease outcome and damage.

Results:

At time of the evaluation, 47% of BS patients presented an active disease; 69 patients presented muco-cutaneous involvement, 39 ocular disease, 21 joint involvement, 12 neurological impairment and 9 gastro-enteric involvement. Seventy-nine percent of patients presented in the course of the disease a severe BS involvement and the majority was represented by patients characterised by a more frequent relapse in the first 3 years of disease (M/F: 65/48, mean age 43±3 years). Those patients who experienced a more higher number of relapse in the first 3 years compared to the others were also characterised by poor disease outcomes and worse prognosis over time and this correlation was independent by the therapies taken.

Conclusion:

The high frequency of relapses during the first three years from diagnosis may be considered an important prognostic factor for disease outcome in BS patients, therefore could be taken into account as a useful element to tailor the management, not only according to the type and severity of symptoms and epidemiological factors.

Acknowledgments:

none

Disclosure of Interests:

None declared

Pheohyphomycotic soft tissue disease caused by Alternaria alternata in a kidney transplant patient: a case report and literature review

A 61-year-old Italian man, who underwent a renal transplantation 8 years ago, receiving azathioprine, prednisone, and cyclosporine for immunosuppressive therapy, presented with a large reddish indurated plaque with a central ulcer, which was slowly enlarged, on the right knee. From the diseased tissue biopsy, a dematiaceous fungus matching Alternaria alternata in all essential characters was isolated in pure culture. This is an uncommon fungal complication in a kidney transplant patient. A detailed morphological description of the isolate is provided as well as review of the literature.

[Isolation and characterization of Shiga-toxin-producing Escherichia coli from frozen hamburgers and soft cheeses]

Shiga toxin producing-Escherichia coli (STEC), an important emerging foodborne pathogen, has been associated with bloody and non-bloody diarrhea, hemorrhagic colitis, hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenic purpura. The cattle have been shown to be a major reservoir of STEC and raw foods such as ground beef and milk are the most common vehicles of infection. In the present study, the prevalence of STEC in 95 samples of frozen hamburgers and in 114 samples of soft cheese was established in 8.4% and 0.9%, respectively. The genotypic and phenotypic characteristics of the strains were determined. The virulence genes stx1, stx2, eaeA and EHEC-hlyA were identified by PCR and by colony blot hybridization assays. Serotyping, antimicrobial susceptibility and production of Stx using specific cytotoxicity assays on Vero cells were also determined. All STEC strains were characterized as eaeA-/EHEC-hlyA+. The stx2 genotype was prevalent (77.8%), and four different O:H serotypes were found, comprising: O8:H19 (5 strains), O113:H21 (1), O8:H16 (1), and O39:H49 (1). One STEC strain was nontypable. Although soft cheese complimented the microbiological quality controls for the coliform counts, the detection of STEC in one sample raises doubts concerning the effectiveness of the current quality controls. These data contribute to the implementation of strategies for the prevention and control of HUS.

[Chest pain and acute myocardial infarction at the emergency department: diagnostic and therapeutic approaches. Experience of the San Camillo Hospital in Rome]

BACKGROUND

Identification and treatment of patients with acute chest pain due to acute coronary syndrome is a common and difficult challenge for emergency physicians. The aim of this study was to establish: a) the reliability of diagnosis of acute myocardial infarction met in the emergency ward, b) the length of the patient's hospital stay with acute myocardial infarction discovered and treated in the emergency ward either with primary angioplasty or with thrombolysis.

METHODS

We analyzed the data collected in the emergency ward of the San Camillo Hospital in Rome from January 1 to June 30, 2000, with patients suffering from chest pain and diagnosis after hospitalization. The reliability of diagnosis of acute myocardial infarction was calculated from the comparison of the diagnosis in the emergency ward and the diagnosis at hospital discharge.

RESULTS

From January 1 to June 30, 2000, 45,810 patients have asked for help at the emergency ward; 2334 (5.1%) of these were suffering from chest pain. The diagnosis of acute myocardial infarction was done in the emergency ward in 147 cases (141 hospitalized, 4 deceased, and 2 transferred to other hospitals), equal to 65% of all those discharged with the same diagnosis in the period under examination. In 66 out of the 141 cases hospitalized (46.8%) primary angioplasty was successfully performed; in 14 (9.9%) only coronary angiography was performed (primary angioplasty unfeasible); in 22 (15.6%) thrombolysis was administered whereas in 38 cases (27.0%) other treatments were used. The average stay for the different groups turned out to be 9.8 +/- 4 days for primary angioplasty and 12.9 +/- 4 days for thrombolysis: the difference was relevant.

CONCLUSIONS

The accuracy value of the diagnosis of acute myocardial infarction made in the emergency ward of our Hospital is the same as that published in the international literature and demonstrates the high level of treatment of chest pain. Furthermore, the shorter hospital stay obtained by primary angioplasty in comparison with thrombolysis seems to strengthen the already favorable cost-benefit ratio of primary angioplasty in comparison with thrombolysis.

Imported and autochthonous histoplasmosis in Bergamo province, Northern Italy

This paper reviews the Italian literature and illustrates the results of a survey on Histoplasma capsulatum var. capsulatum infection carried out in the Bergamo area of Italy over the last 10 y. During the period January 1989-July 1999, 7 patients were diagnosed as being affected by the H. capsulatum var. capsulatum infection. Until 1999 41 cases have been described in the Italian literature (9 before the 1980s, 6 in the 1980s and 26 in the 1990s). The epidemiological profile of histoplasmosis is well-defined: risk factors are activities such as visiting caves or building sites, travelling and immigration, and it affects both immunocompetent and patients with AIDS. However, in the past, the Italian soil was considered as a low-endemic pabulum for H. capsulatum var. capsulatum and only a few autochthonous cases of histoplasmosis have been reported in Italy, specifically in the Po valley. In the present series, the identification of new cases in the Po valley in Lombardy suggests the possible autochthonous presence of histoplasmosis in Italy.

Neurophysiological consequences of three tracheostomy techniques: a randomized study in neurosurgical patients

We describe the effects of different tracheostomy techniques on intracranial pressure (ICP), cerebral perfusion pressure (CPP), and cerebral extraction of oxygen. We attempted to identify the main mechanisms affecting intracranial pressure during tracheostomy. To do so we conducted a prospective, block-randomized, clinical study which took place in a neurosurgical intensive care unit in a teaching hospital. The patients studied consisted of thirty comatose patients admitted to the intensive care unit because of head injury, subarachnoid hemorrhage, or brain tumor. Ten patients per group were submitted to standard surgical tracheostomy, percutaneous dilatational tracheostomy or translaryngeal tracheostomy. In every technique a significant increase of ICP (P < .05) was observed at the time of cannula placement. Intracranial hypertension (ICP > 20 mm Hg) was more frequent in the percutaneous dilatational tracheostomy group (P < .05). Cerebral perfusion pressure dropped below 60 mm Hg in eleven cases, more frequently during surgical tracheostomy. Arterial tension of CO2 significantly increased in all three groups during cannula placement. No other major complications were recorded during the procedures. At follow-up no severe anatomic or functional damage was detected. We conclude that the three tracheostomy techniques, performed in selected patients where the risk of intracranial hypertension was reduced to the minimum, were reasonably tolerated but caused an intracranial pressure rise and cerebral perfusion pressure reduction in some cases.

Early translaryngeal tracheostomy in patients with severe brain damage

OBJECTIVES

To describe the effects of early translaryngeal tracheostomy on intracranial pressure (ICP), cerebral perfusion pressure (CPP), and jugular bulb saturation (SjO2); to identify the main mechanisms affecting ICP during tracheostomy; and to evaluate the long-term effects of tracheostomy on tracheal anatomy and function.

DESIGN

Prospective, observational, clinical study.

SETTING

Neurosurgical intensive care unit in a teaching hospital.

PATIENTS

20 patients admitted to the ICU because of head injury, subarachnoid hemorrhage, or brain tumor with a Glasgow Coma Scale less than 8.

INTERVENTIONS

Patients underwent translaryngeal tracheostomy under strict neuromonitoring.

MEASUREMENTS AND RESULTS

ICP rose significantly (p < 0.05) at the critical time of cannula placement while all other parameters remained stable. At this time five patients suffered intracranial hypertension (ICP > 20 mmHg). In one of them CPP dropped below 60 mmHg. Arterial CO2 tension (PaCO2) did not rise significantly. No other major complications were recorded during the procedures. Three months after tracheostomy normal findings were detected by tracheoscopy in all cases (11 patients could be examined).

CONCLUSIONS

Translaryngeal tracheostomy, performed in selected patients when the risk of intracranial hypertension was reduced to the minimum, was well tolerated in the majority of cases and did not induce persistent intracranial disorders. However, ICP is affected by tracheostomy, and careful monitoring and patient selection is necessary. At follow-up no severe anatomical or functional damage was detected.

Propofol 1% and propofol 2% are equally effective and well tolerated during anaesthesia of patients undergoing elective craniotomy for neurosurgical procedures

BACKGROUND

The 2% formulation of the intravenous anaesthetic agent, propofol (Diprivan), delivers half the amount of lipid compared with the original 1% formulation. This may provide an acceptable alternative for patients who have an impaired ability to metabolise lipids.

METHODS

This study was a multicentre, randomised, open comparison of parallel groups. Seventy-three adult patients undergoing elective craniotomy in neurosurgery were randomised to receive either propofol 1% (10 mg/ml) or propofol 2% (20 mg/ml) for induction and maintenance of anaesthesia.

RESULTS

Analysis of induction time (199 s, 1%; 202 s, 2%; p > 0.05) and induction dose (1.13 mg/kg, 1.12 mg/kg; p > 0.05) shows that propofol 1% and propofol 2% are pharmacodynamically equivalent. Both formulations were similar regarding overall administration rates, recovery times, haemodynamic variables and tolerability. Plasma triglyceride levels, were lower in the propofol 2% group compared with the propofol 1% group, and significantly lower (p < 0.05) from 1 to 4 hours after induction.

CONCLUSIONS

We conclude that propofol 2% is as effective and as well-tolerated as propofol 1% for anaesthesia and is an acceptable alternative to propofol 1% in patients undergoing elective craniotomy in neurosurgery. The lower lipid load suggests it may be of particular benefit to patients with disorders of lipid metabolism.

[Interstitial cystitis: epidemiology]

The epidemiological assessment of intestitial cystitis (IC) is not definitive as no diagnostic criteria, such as endoscopy or biochemical and anatomopathological examination, exist. The diagnosis is solely based on symptoms like urgency, frequency and pelvic pain. The first studies on the population date back from 20 years ago and show a percentage of 10 cases every 100 thousand inhabitants. There is weak link between genetic factors, immunological diseases, previous cystitis or eating habits and intestitial cystitis. Epidemiological studies have highlight the frequency of this disease, and stressed the importance of stricted behavioural rules for the first stages of intestitial cystitis.

[Interstitial cystitis: surgical treatment]

Surgical therapy of interstitial cystitis must never be considered a first option but must be reserved for cases, less than 10%, in which conservative therapy has proven ineffectual. Surgical therapy includes a variety that started at the turn of the century. Neurosurgical denervation and perivesical denervation like cysto-cystoplasty and cystolysis, manipulate the innervation to reduce the bladder's hypersensitivity. This surgical approach may be considered in patients in whom bladder capacity is normal. The results are uncertain and the complications like neurogenic bladder relevant. Enterocystoplasty is much more widespread because interstitial cystitis is a benign disease that rarely required radical surgery. Augmentation cystoplasty and substitution cystoplasty are two variants but only the later has a rationale as it involves the resection of the detrusor which is the source of the pain. Detubularization drastically reduced urinary incontinence. The resection of the detrusor can be supratrigonal, subtrigonal or at the proximal urethra like in the orthotopic neobladder. If urinary diversion is chosen, the bladder must be removed. Before recommending surgical therapy each patient should undergo tests for the localization of the pain; moreover psychological and gynaecological evaluations should be made. If the bladder capacity exceeds 400 cc surgical operation is not advisable. If, on the other hand, the bladder capacity is lower than 400 cc substitution cystoplasty is first choice. If the patient suffers from trigonal cystitis or urethral hypersensitivity, urinary diversion is a better therapy. According to the questionnaires send to the Urologic Departments in Lombardy in 1998, the most widespread type of operation seems to be supratrigonal cystectomy + enterocystoplasty and augmentation cystoplasty. Subtrigonal cystectomy or urinary diversion are only occasionally chosen; continent pouch is the least frequent therapy at all.

In-stent neointimal proliferation correlates with the amount of residual plaque burden outside the stent: an intravascular ultrasound study

BACKGROUND

The aim of this study was to evaluate the relationship between residual plaque burden after coronary stent implantation and the development of late in-stent neointimal proliferation.

METHODS AND RESULTS

Between January 1996 and May 1997, 50 patients underwent intravascular ultrasound (IVUS) interrogation at 6+/-1.2 months after coronary stent implantation in native coronary arteries. IVUS images were acquired with a motorized pullback, and cross-sectional measurements were performed within the stents at 1-mm intervals. The following measurements were obtained: (1) lumen area (LA), (2) stent area (SA), (3) area delimited by the external elastic membrane (EEMA), (4) percent neointimal area calculated as (SA-LA/SA)x100, and (5) percent residual plaque area calculated as (EEMA-SA)/EEMAx100. Volume measurements within the stented segments were calculated by applying Simpson's rule. In the pooled data analysis of 876 cross sections, linear regression showed a significant positive correlation between percent residual plaque area and percent neointimal area (r=0.50, y= 45.03+0.29x, P<0.01). There was significant incremental increase in mean percent neointimal area for stepwise increase in percent residual plaque area. Mean percent neointimal area was 16.3+/-10.3% for lesions with a percent residual plaque area of <50% and 27.7+/-11% for lesions with a percent residual plaque area of >/=50% (P<0.001). The volumetric analysis showed that the percent residual plaque volume was significantly greater in restenotic lesions compared with nonrestenotic lesions (58.7+/-4.3% versus 51.4+/-5.7%, respectively; P<0.01).

CONCLUSIONS

Late in-stent neointimal proliferation has a direct correlation with the amount of residual plaque burden after coronary stent implantation, supporting the hypothesis that plaque removal before stent implantation may reduce restenosis.

[The clinical, angiographic and procedural predictors of thrombosis and restenosis in Micro stent II (AVE) coronary stents]

The aim of the study was to assess the incidence and the predictors of thrombosis and restenosis in Micro stent II AVE. In a sample of 197 stents successfully implanted in 181 consecutive patients, the incidence of thrombosis was 4.1%. The multivariate analysis showed the minimum lumen diameter post-stenting to be the only independent predictor of overall thrombosis. In fact, we found that the risk of thrombosis increases as the minimal lumen diameter decreases. Angiographic follow-up was available in 74% of the stents at 6.8 +/- 4.1 months and stent restenosis occurred in 26.2% of cases. Independent predictors of restenosis (multivariate linear discriminant analysis) were: 1) nominal stent diameter (the risk of restenosis decreases as the stent diameter increases); 2) the ratio between the diameter of the balloon carrying the stent measured at the maximum pressure/nominal stent diameter (the risk increases as the ratio decreases); 3) stented vessel (the risk increases in the following order: right coronary < circumflex < left anterior descending); 4) the American Heart Association classification of lesion morphology (the risk increases in the order A < B < C); 5) a lower risk was found in the absence of diabetes mellitus.

Incidence of compensatory enlargement and paradoxical shrinkage of coronary arteries in presence of atherosclerotic lesions: an intracoronary ultrasound study based on multiple cross-section analysis per artery

BACKGROUND

The aim of the study was to evaluate with intravascular ultrasound (IVUS) the incidence of compensatory enlargement and paradoxical shrinkage in 50 de novo coronary lesions, using two different approaches: 1) a single cross-section analysis and 2) a multiple cross-section analysis per artery. A 3-D IVUS system based on contour detection of lumen and plaque was applied (image acquisition speed: 0.5 mm/s, digitization rate: 5 images/s). In each cross section, we determined: 1) the lumen area (LA), 2) the external elastic membrane area (EEMA), 3) the plaque+media complex (p+m), 4) the relative EEMA = cross section EEMA/reference EEMA, 5) the relative p+m area = cross-section p+m area/reference p+m area, 6) the lumen area stenosis: 1-(cross-section LA/reference LA). In the single cross-section analysis, compensatory vessel enlargement was defined as narrowest EEMA > reference EEMA, and paradoxical vessel constriction as narrowest EEMA < reference EEMA. In the multiple cross-section analysis, compensatory vessel enlargement was defined as the presence of a significant positive correlation between relative EEMA and relative p+m area and paradoxical vessel constriction as a significant negative correlation between relative EEMA and lumen area stenosis.

RESULTS

In the single cross-section analysis, compensatory vessel enlargement and paradoxical constriction occurred in 58 and 42% of cases respectively. The multiple cross-section per artery analysis showed compensatory vessel enlargement in 80% of cases and paradoxical constriction in 36% of cases and revealed the combination of compensatory enlargement with paradoxical constriction in 22% of the analyzed segments.

CONCLUSIONS

Compensatory enlargement of coronary arteries was underestimated by the single cross-section analysis and was observed in 80% of cases when a multiple cross-section per artery analysis was applied. Paradoxical shrinkage was less common and often occurred in combination with compensatory enlargement within the same analyzed segment.

The prognostic value of soluble interleukin-6 receptor in patients with multiple myeloma

BACKGROUND

The effect of interleukin-6 (IL-6), the major growth factor for myeloma cells, may be enhanced by soluble IL-6 receptor (sIL-6R). Therefore, the current study investigated the clinical significance of serum sIL-6R in patients with multiple myeloma (MM).

METHODS

Serum levels of sIL-6R were determined by enzyme-linked immunoassay in 55 normal controls, 81 individuals with monoclonal gammopathy of undetermined significance (MGUS), and 164 patients with MM in various phases of the disease.

RESULTS

sIL-6R concentrations were higher in MM patients (162.0 +/- 134.6 ng/mL) than in individuals with MGUS (58.9 +/- 36.7 ng/mL) or in controls (45.6 +/- 22.3 ng/mL) (P = 0.0000). sIL-6R was not found to have a significant linear correlation with any other parameter, including IL-6, beta2-microglobulin (beta2-m), and neopterin, either in newly diagnosed cases or during the course of the disease. In addition, there were no statistically significant differences in sIL-6R concentrations between the clinical stages at the time of diagnosis. In univariate logistic regression analysis sIL-6R was a significant but weak prognostic indicator (P = 0.000000). Kaplan-Meier analysis showed that elevated levels of sIL-6R were associated with shorter survival (P = 0.00282). Patients also were stratified according to their serum beta2-m and sIL-6R levels. Patients with low levels of both parameters had a clear survival benefit over the other groups (P = 0.000000).

CONCLUSIONS

The correlation between sIL-6R levels and survival is significant but weak, making it unlikely to be of much value in predicting the outcome of patients with MM alone. The results of the current study support the role of sIL-6R levels in improving the prognostic value of beta2-m and in discriminating patients with MM from individuals with MGUS.

Intravesical electromotive administration of drugs for treatment of superficial bladder cancer: a comparative Phase II study

OBJECTIVES

To evaluate the efficacy of electromotive administration (EMDA) of intravesical mitomycin-C (MMC) in patients with superficial bladder tumors and to evaluate the toxicity of the treatment.

METHODS

Thirteen patients with multifocal Stages Ta-T1 and G1-G2 transitional cell carcinoma (TCC) of the bladder, primary or recurrent (group A), received MMC 40 mg (retained in the bladder for 2 hours) once a week for 8 weeks. Fifteen patients with the same characteristics (group B) were treated with EMDA/MMC at a current of 15 mA for 20 minutes once a week for 8 weeks. All lesions in the bladder except one (marker) were resected in each patient.

RESULTS

In group A, 5 of 12 patients (41.6%) demonstrated complete macroscopic and histologic disappearance of the marker lesion (complete response [CR]). In group B, 6 of 15 patients (40%) had a similar CR. Recurrence rate in responders was 60% in group A versus 33% in group B after 7.6 and 6 months, respectively. Disease-free interval was 14.5 months in the EMDA/MMC group compared to 10.5 months in the MMC group. Side effects were few.

CONCLUSIONS

In intermediate risk patients with TCC of the bladder, EMDA/MMC was not superior to MMC alone with a CR rate of 41% versus 41.6%. In responders, a lower recurrence rate and a longer disease-free interval were observed in the EMDA/MMC group.

Shock Wave Treatment of Peyronie'S Disease: Our Experience

From September 1997 to April 1998, 40 patients with induratio penis plastica were treated with extracorporeal shock waves (ESWT). This work compares our results with those of the main Italian centres that first used this method. The aim of this study is to assess the efficiency of the treatment in the period before the main guidelines were laid down: guidelines which from now on should standardise indications and methods of application whilst optimising results.

Acetylcholine-induced vasodilatation in the human peripheral circulation is independent of ATP-sensitive K+ channels and prostacyclin

BACKGROUND

Both experimental and clinical studies have shown that the increase in regional blood flow induced by acetylcholine is not completely prevented by inhibitors of the synthesis of endothelium-derived nitric oxide. To establish the role of ATP-sensitive potassium (KATP) channels and prostacyclin in mediating acetylcholine-induced increase in peripheral blood flow in humans, we assessed the effects of acetylcholine on the iliac artery blood flow velocity before and after glibenclamide, an antagonist of KATP channels, or before and after acetylsalicylic acid, an inhibitor of prostacyclin production.

MATERIAL AND METHODS

Seventeen patients without evidence of peripheral vascular disease and normal coronary arteries at angiography received intra-iliac incremental bolus injections of acetylcholine (0.2, 2, 20 and 50 micrograms) via a 5F femoral sheath, at the end of routine cardiac catheterization. All injections were repeated 90 minutes after oral administration of glibenclamide (10 mg) in 10 patients of 15 minutes after i.v. infusion of acetylsalicylic acid (1000 mg) in the remaining 7 patients. Right iliac artery blood flow velocity was measured by using an intravascular 0.014-in Doppler guidewire.

RESULTS

Before glibenclamide or acetylsalicylic acid administration, acetylcholine infusion increased average peak velocity by 128% (p < 0.001) and by 121% (p < 0.001), respectively. After glibenclamide or acetylsalicylic acid the increases of average peak velocity during acetylcholine infusion (by 121%, p < 0.001, and by 121%, p < 0.001, respectively) were similar (p = ns) to those observed during the control infusion.

CONCLUSIONS

In man acetylcholine-induced vasodilatation in the territory supplied by the iliac artery is not prevented by glibenclamide or acetylsalicylic acid, thus suggesting that it is independent of activation of KATP channels and prostacyclin release.

Intravenous pamidronate treatment in osteogenesis imperfecta

Three children with osteogenesis imperfecta, severe osteopenia, and repeated fractures were treated with cyclic infusions of aminohydroxypropylidene bisphosphonate (pamidronate) for a period ranging from 22 to 29 months. A clear clinical response was shown, with a striking reduction of new fracture episodes and a marked improvement in the quality of the patients' lives. Bone mineral density increased significantly in two patients, and linear growth continued along the percentile at the start of treatment. There were no adverse effects of note during treatment, and further studies are warranted.

Serum levels of tumour necrosis factor-alpha predict response to recombinant human erythropoietin in patients with myelodysplastic syndrome

We measured pretreatment serum levels of tumour necrosis factor-alpha (TNF-alpha) and interleukin-1 beta (IL-1 beta) in 25 patients with myelodysplastic syndrome receiving recombinant human erythropoietin (rhEPO) at dosages up to 300 U/kg thrice weekly for 12 weeks. Both TNF-alpha and IL-1 beta levels were measured using commercially available enzyme-linked immunoassays. A complete response (CR) was defined as a rise in untransfused haemoglobin concentrations of at least 2 g/dl or a 100% decrease in RBC transfusion requirements over the treatment period; a partial response (PR) was an increase in untransfused haemoglobin values of 1-2 g/dl or a decrease in RBC transfusion requirements equal to or greater than 50%; no response (NR) was defined as a response less than a PR. After 12 weeks of rhEPO treatment, four patients showed a CR, five patients a PR, and 16 patients NR. Serum levels of both TNF-alpha (80.5 %/- 64.8 vs 8.1 +/- 4.2 ng/l, P < 0.001) and IL-1 beta (60.4 +/- 49.9 vs 8.9 +/- 4.7 ng/l, P < 0.001) were higher in MDS patients than in a group of 28 normal controls. Responders (CR + PR) showed significantly lower serum levels of TNF-alpha than non-responders (21.6 +/- 26.2 vs 106.3 +/- 60.8 ng/l, P < 0.001), whereas IL-1 beta concentrations between those who benefited from therapy and unresponsive cases were not significantly different (39.8 +/- 48.9 vs 73.4 +/- 48.2 ng/l, P = 0.120). It is noteworthy that TNF-alpha levels were within the normal range in all responsive patients but one, whereas all non-responders presented elevated cytokine concentrations. No relationship was found between TNF-alpha or IL-1 beta values and haemoglobin levels, transfusion requirement, serum EPO or ferritin concentrations. We conclude that pre-treatment TNF-alpha levels might help to select those MDS patients who are most likely to benefit from rhEPO treatment.

Uretero-lithotripsy with the Swiss Lithoclast

Technological developments in ureteroscopy and extracorporeal shock wave lithotripsy (ESWL) have changed the treatment of ureteral stones over the last decade. “In situ” ESWL is now the treatment of choice in the management of ureteral calculi. Ureterolithotripsy should be preferred in certain cases, however, especially when the stone cannot be perfectly sighted or when the urinary tract needs to be drained due to obstruction and/or sepsis, with a saving of one ESWL session in 50% of patients. Current options that can be applied with lithotripsy are: electrohydraulic, laser, ultrasound and ballistic tripsy. The authors describe their experience with the Lithoclast in 82 patients. This technique has proved to be simple, safe, effective and particularly economic.

Uretroplastica a lembo libero dorsale

The Authors report their experience in the new urethroplasty technique by Barbagli for penile and bulbar urethral strictures. This procedure involves a free skin graft sutured to the corpora cavernosa. With this dorsal approach mechanical weakening is virtually impossible, so pseudo-diverticulum or urethrocele cannot develop. We adopted this technique in 5 patients during the last 12 months. The strictures of the urethra were 2.5 to 8 cm long. The follow-up, even thought short, show that this technique is safe and quite simple.

Amiloidosi polidistrettuale. Implicazioni urologiche

Amyloidosis covers a group of morbid processes which have the common characteristic of amyloid being deposited in an extracellular site of one or more organs. The mechanisms causing amyloidogenesis are still unknown. Involvement of the urinary apparatus is more frequent with primary amyloidosis and myeloma (AL form) as well as inflammatory or neoplastic diseases (AA form). The disease in the kidney is characterised by proteinuria progressing to the nephrotic syndrome and renal failure, while frank hematuria is typical of the disease in the bladder. In our case emergency cystectomy was performed because of severe anemia consequent to hematuria. Prodromal symptoms were asthenia, loss of weight, purpura and subsequent to involvement of the urinary tract, also gastroenteric, cardiac, neurovegetative, articular and thyroid disorders typical of multi-district involvement. Diagnosis is confirmed only after the histological examination and average survival rate is 20 months. There is no fully effective therapy.

Adenocarcinoma ureterale primitivo di tipo intestinale. Caso clinico

Intestinal type primitive ureteral adenocarcinoma is an uncommon neoplasm of the upper urinary tract, where the normal urothelium is replaced by an intestinal type glandular metaplastic epithelium. Our case concerns a 55-year-old man who 10 years ago had his left kidney and ureteral stump removed up to the junction with the iliac vessels due to a lumbar ureter filling defect. The ureter presented a 2 cm oedematous area with papillary vegetation. Histology revealed T1 adenocarcinoma with safe resection margin. Transurethral prostatectomy was performed and resectioning of a tumefaction of the left ostium, which proved to be an intestinal type of adenocarcinoma infiltrating the prostate. The patient underwent radical cystoprostatectomy with urinary diversion. The onset of primitive adenocarcinoma of the ureter may pass unnoticed in a chronically irritated urothelium. This case may be considered a multicentric, probably metachronous tumour and maximum surgical radicality is indicated as therapy.

[Replacement neobladders in men and women: our experience]

We present our clinical and metabolic follow-up data of 74 patients submitted to total bladder substitution using an ileal orthotopic neobladder in one group of 64 patients and a continent stomal pouch in another group of 10 patients. In the first group the mean follow-up was 41.5 months. The daytime continence was early achieved in 89% (57/64) and was maintained with time; at 12 month follow-up nocturnal continence was reached in 71% (45/64). Post voiding residual was significant only in 4 patients (2 men and 2 women). No clinical signs of pyelonephritis nor renal scars at IVP was evidenced in all but 7 patients in which a silent uretero-ileal stenosis developed. No severe metabolic acidosis or B 12 deficiency occurred. In the second group (Continent Pouch) the long term 3-Year follow-up shows a complete continence in all patients with an average capacity of 600 cc. No late complications occurred in all patients but one in which self intermittent catheterization was uncomfortable and now he prefer permanent catheter and in another patient with a stone in the Pouch treated with Lithoclast. In conclusion, total bladder substitution after radical cystectomy is now represented by orthotopic neobladder or continent Pouch in men and women. Early and late complication rate is relatively low and continence generally good.

Spirometric prediction equations for male Italians 7-18 years of age

The purpose of this study was to develop spirometric predictive equations (SPE) for forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and maximum midexpiratory flow (MMF25-75) derived from a large sample of healthy italian boys and male adolescents. We used the univariate and multiple linear regression models and considered as independent variables age and the following anthropometric measurements: height, weight, chest circumference. The predictive power of multivariate models was slightly higher than that of the univariate model using height as independent variable for FVC, FEV1 and MMF25-75.

[Adequacy of admission in neurosurgical intensive care]

OBJECTIVE

The Intensive Care Units of Milano metropolitan area are characterized by difficulties of hospitalization for acutely injured patients due to the low bed availability. We evaluated the problem trying to find out possible solutions.

DESIGN

On the day of achieved neurological and neurosurgical stability-defined as the day when the intracranial pressure and jugular venous oxygen saturation monitoring, hyperventilation, osmotic therapy were considered no longer needed--the monitoring procedures and instrumental and/or pharmacological treatments that the patients received were recorded and classified as follows: 1) intensive, 2) intermediate, 3) non-intensive.

PATIENTS

All the acutely injured patients admitted at five Neurosurgical ICUs during June-July and October-November 1994 have been studied. Only one of these ICUs had a "sub-intensive unit".

MEASUREMENTS AND MAIN RESULTS

391 patients (29.9%) aneurysms and arteriovenous malformations, 25.1% tumours, 2.8% head injuries, 8.7% spontaneous intracranial haematomas, 13.5% various pathologies) were studied. Out of them 358 had an acute brain failure. 16.5% died during brain failure and 83.5% reached neurological stability within 3 days. When neurological stability was reached 32.1% of patients could be classified as "intensive", 63.6% as "intermediate" and 4.3% as "unintensive". In the four ICUs, without sub-intensive ward facilities, 361 patients were admitted with a total amount of 2292 days of hospitalization. Among them 61.9% were spent for a) patients with no brain injury (32 pts/113 days), b) postoperative patients (113 pts/167 days), c) patients in stable neurological conditions (159 pts/1139 days). Therefore, only 38% of the days recorded were given to patients that needed neurointensive care.

CONCLUSION

Out data suggest that the receptivity for acute injured patients could be increased creating recovery room units and intermediate post-intensive units together with a better interchange between general and neurosurgical ICUs.

[Respiratory failure caused by myopathy in severe sepsis]

OBJECTIVE

To describe a generalized myopathic disorder occurred in the convalescence phase of illness of a critically ill patient.

SETTING

Neurological Intensive Care Unit.

PATIENT

A 43-year-old man with acute leukoencephalopathy and severe sepsis complicated by sustained and prolonged cardiovascular, respiratory and renal failure. After 15 days of complete respiratory autonomy, the patient presented an acute ventilatory failure associated with generalized muscle weakness. Neither a relapse of sepsis nor neurological worsening were detected.

MEASUREMENTS AND RESULTS

Electromyogram resulted in normal conduction velocity in both motor and sensitive nervous fibers. Muscular biopsy showed marked fiber size variability with several hypotrophic fibers type II fiber grouping, several areas of degeneration-necrosis with macrophage invasion, dishomogeneous oxidative enzymatic activity, no increase in glycogen or lipid content.

CONCLUSIONS

These results excluded critical illness polyneuropathy and all the other known myopathies. Prolonged period of sepsis with multiple organ failure can result in a direct generalized myopathy. This possibility should be kept in mind while treating long term critically ill survivors.

[T1G3 bladder tumors: 5 years later]

We have evaluated 79 patients affected by bladder cancer T1G3: 31 underwent just endoscopy, 11 radiotherapy, 10 cystectomy and 27 topical chemotherapy. At five years 44 patients were alive and disease free, 7 were alive but recurrent in TA, 3 were alive but in metastatic progression, 17 were died because of the tumor, 3 died because of the therapy, and 5 died disease free. The authors believe that this patients could be treated with BCG as first treatment choice performing cystectomy when relapse or progression occuring.

Desmoplastic small round cell tumor of the pleura

Three cases of desmoplastic small round cell tumor (DSRCT) with multiphenotypic differentiation, primary in the pleura, are presented. This is a previously unrecognized site for this tumor type. Two patients were male and one female aged 29, 24, and 17 years. All presented with chest pain and were found to have pleural-based tumors associated with pleural effusion. Abdominal involvement was not present in any of the cases. Histologically, the tumor showed the characteristic features of intra-abdominal DSRCT, including angulated nests of small cells embedded in a vascular fibroblastic stroma, focal rhabdoid phenotype, and areas of central necrosis. The neoplastic cells showed evidence of epithelial, mesenchymal, and neural differentiation with characteristic dot-like positivity for vimentin and desmin topographically corresponding to perinuclear aggregates of intermediate filaments identified on electron microscopy in one case. Two patients died of disease 2 years and 15 months after presentation, respectively, and one patient is alive with disease 18 months after presentation. The histogenesis of DSRCT is unknown. Most previously reported cases involved the peritoneum or tunica vaginalis, suggesting a histogenetic relationship to the mesothelium. The occurrence of these tumors in the pleura lends further support to this theory.

[Turbo TURP]

Transurethral resection of the prostate (TURP) is just one of the numerous options available in the modern treatment of benign prostatic hyperplasia (BPH), but it's still now the "gold standard". Absorption of irrigating fluid is the greatest complication and results in clinical manifestations in 2% of the TURPs performed. There is a statistically significant relationship between gland size and the total volume of irrigant absorbed. To reduce this absorption Reuter introduced suprapubic trocar drainage to obtain the same results from both the small and the large prostates. Operating time, in fact, is reduced because, also at the same time, this large tube drains both irrigation fluid and prostatic chips.

Ectopic “blind ureterocele”: Report of 2 cases

— Ureterocele without corresponding renal tissue has been called blind ureterocele. We observed this rare malformation in two cases: a 17-year-old youth with the ureteral orifice located at the seminal vesicle and a 25-year-old woman with the orifice at the bladder neck. In both cases the proximal ureter ended in the lumbar fossa without renal parenchyma. The etiology of this ureterocele is unclear. Functioning renal tissue is supposed to be necessary for the development of a ureterocele: in blind ureterocele the renal parenchyma could subsequently disappear.

Quality of micturition after prostatectomy for pT3 carcinoma

— The purpose of radical prostatectomy for neoplasia is to cure the patient and maintain a good micturition. The first aim is achieved only in patients with localized prostatic cancer. With cancer not confined to an organ, we cannot be sure of radicality. These patients run the risk of local recurrence and worsening of micturition. The quality of micturition is determined by both surgical procedure (sphintecal weakness, stenosis of the urethro-vesical anastomosis) and local staging of the neoplasia (whether local recurrence is present or not). We studied 56 pT3 patients with uroflowmetry and symptom score. The flowmetry was always good even when local relapse occurred, but worsened when stenosis started. Urgency was the most frequent symptom in patients with local relapse.

[Effects of inhalation anesthetics on intracranial pressure and cerebral blood flow velocity]

Inhalation anesthetics diminish cerebrovascular resistance, augmenting cerebral blood flow (CBF) and hematic volume. This may lead to a dangerous increase in intracranial pressure (ICP). It has been observed that isoflurane used in hypocapnia does not appear to cause an increase in ICP equal to that caused by other inhalation anesthetics. The authors aimed to evaluate the effects of isoflurane on ICP and on intracranial vessel reactivity to changes in CO2 using a pulsed intracranial Doppler technique which measures cerebral flow velocity (CFV). A prospective study was performed at the Neurosurgery Clinic of the University of Milan in 10 in-patients due to undergo surgical removal of supratentorial intracranial expansion. Patients were anesthetised with isoflurane 1 MAC in air and O2. The following parameters were monitored: ICP at a spinal subarachnoid level; mean arterial pressure (MAP); cerebral perfusion pressure (CPP); ECG; CFV; EtCO2. The study was subdivided into 5 stages: basal (before induction); hypocapnia lasting 30 min; registration of data for 10 min; stabilisation phase in normocapnia; registration in normocapnia. The results show that during hypocapnia isoflurane causes significant reductions in MAP and CCP whereas ICP and CFV tend to diminish but not significantly. On the contrary, isoflurane in normocapnia causes an increase in ICP and a further and more marked reduction in CPP with a corresponding but not significant increase in CFV. In conclusion, in the light of these results the increase in ICP and the contemporary reduction of MAP would appear to restrict the use of isoflurane in normocapnia in patients with intracranial pathologies.(ABSTRACT TRUNCATED AT 250 WORDS)

Combined Clark's nevus

We report five cases of combined Clark's nevi. Like all melanocytic nevi, Clark's nevus can combine with other nevi to produce lesions that are hard to interpret clinically and histologically. The morphology of combined Clark's nevus can resemble that of a melanoma associated with a nevus.

[Our experience with impotence following radical pelvic surgery]

The etiology of impotence after radical prostatectomy and radical cystoprostatectomy is unclear, although a variety of potential factors have been cited: neurogenic, psychogenic and vascular. Injury to the pelvic nerve plexus and the branches that innervate the corpora cavernosa (cavernous nerves), seems to be the most important iatrogenic factor. The Authors selected 14 patients candidate to radical prostatectomy or radical cystoprostatectomy and studied their potency pre and post operatively by anamnesis and/or Rigiscan test. The sacral-evoked potential was determined in all these patients in order to detect a neurological etiologies. The average latency of the bulbo cavernous reflex was similar in the patients that lost their potency after surgery and in the patients that didn't lose their potency after surgery. The sacral-evoked response seems not to be a diagnostic test in the study of the impotence after pelvic radical surgery.

Impalamento e lesioni retto-vescicali

Impalement with associated bladder injuries was observed in 4 patients. The treatment should be individualised but careful debridement of all necrotic tissue, urinary and fecal diversion, separation of the injured sites with wall-vascularised tissue such as peritoneum or omentum should reduce the high incidence of fistulae or bladder stones. Endoscopic or surgical exploration of the bladder is mandatory because foreign bodies risk creating calculi, like in our 2 cases.

Lo studio dell'impotenza nel paziente diabetico

In our Andrologic Unit a diagnostic trial for studying impotence in diabetic men has been assessed in co-operation with the Metabolic Diseases Center and Neurologic Division of this Hospital. By metabolic, hormonal, vascular and peripherical neurological examinations it has been possible to find in a short time diseases where impotence was only the first sign.

[Heparin and lipoprotein(a). Observations during hemodialysis]

The effect of heparin (bolus e.v. 5.000 I.U.) on blood levels of Lp(a) and other lipids (triglycerides, -HDL, -LDL and total cholesterol, apo A1, apo B100 and apo A1/apo B100) was studied in 15 patients (8 M and 7 F) with chronic renal failure during hemodialysis. Statistically significant reductions of the basal values were found for Lp(a) and the other lipids in the blood taken before the beginning of dialysis, 30 min' after the heparin bolus. The analysis of third blood sample (at the end of the hemodialysis, one hour after the end of the heparin maintenance infusion) showed a rise of HDL and LDL-lipoproteins over the basal values clearly in relation to reduced heparin and plasmatic fraction of the blood. The values of Lp(a) had not so high increase as consequence of more elevated affinity with heparin and of a possible enhanced metabolic rate via lipoprotein lipase. The authors, in agreement with similar changes of Lp(a) and other lipids previously observed in patients with coronary diseases during bypass surgery in extracorporeal circulation or angioplasty, (interventions requiring generous heparin treatment), believe to have now sufficient data for attributing heparin a causal role for the above mentioned effects. The authors stress the needing of other studies better understand the action to mechanisms of heparin and to evaluate possible future clinical applications of this new interesting Lp(a)-clearing effect.

[Transrectal echography in the diagnosis of cervico-urethral obstruction in the young]

The authors present a case of severe cervico-urethral obstruction by Von Brunn cysts. These cysts are often found even in macroscopically healthy bladders, but only rarely reach such a size as to be revealed by ultrasound. They can be asymptomatic or cause obstruction if large. They are no longer considered preneoplastic lesions and are therefore treated according to symptoms. When these cysts cause dysuria they are removed, preferably by transurethral resection, as it is the only method (unlike needle aspiration) which prevents recurrence.