Refractory IgA Nephropathy: A Challenge for Future Nephrologists

IgA nephropathy (IgAN) represents the most prevalent form of primary glomerulonephritis, and, on a global scale, it ranks among the leading culprits behind end-stage kidney disease (ESKD). Presently, the primary strategy for managing IgAN revolves around optimizing blood pressure and mitigating proteinuria. This is achieved through the utilization of renin-angiotensin system (RAS) inhibitors, namely, angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs). As outlined by the KDIGO guidelines, individuals who continue to show a persistent high risk of progressive ESKD, even with comprehensive supportive care, are candidates for glucocorticoid therapy. Despite these therapies, some patients have a disease refractory to treatment, defined as individuals that present a 24 h urinary protein persistently >1 g after at least two rounds of regular steroids (methylprednisolone or prednisone) and/or immunosuppressant therapy (e.g., mycophenolate mofetil), or who do not tolerate regular steroids and/or immunosuppressant therapy. The aim of this Systematic Review is to revise the current literature, using the biomedical database PubMed, to investigate possible therapeutic strategies, including SGLT2 inhibitors, endothelin receptor blockers, targeted-release budesonide, B cell proliferation and differentiation inhibitors, fecal microbiota transplantation, as well as blockade of complement components.

Home infusion program with enzyme replacement therapy for Fabry disease: The experience of a large Italian collaborative group

Fabry disease (FD) [OMIM 301500] is an X-linked lysosomal storage disorder caused by a deficiency of the lysosomal enzyme alpha-galactosidase A, resulting in progressive multisystem accumulation of globotriaosylceramide (Gb3). Although the introduction of Enzyme Replacement Therapy (ERT) resulted in a variety of clinical benefits, life-long intravenous (IV) treatment with ERT with an every other week schedule, may interfere with daily life activities and impact on QoL. We report here a multicentric, observational, longitudinal data analysis on a large cohort of 85 Italian FD patients (45 males, 40 females) from 11 out of 20 Italian regions, who received a cumulative number of 4269 home infusions of agalsidase alfa. For the whole cohort, the average duration of home therapy was 1 year and 11 months (range 3 months–4 years and 6 months), and during this period, compliance to treatment (number of infusions performed vs scheduled) reached 100%. The EQ-5 VAS scale was administered to patients to evaluate the self-reported QoL, 58% of patients showing an increase of EQ-5 VAS score at follow up compared to baseline (home treatment start) or remaining stable. A mild increase of average disease severity, measured through Mainz Severity Score Index (MSSI), was found during hospital treatment (p < 0,007), while it remained stable between the first home therapy infusion and last follow up. Interestingly, 4 out of 7 (57%) patients, showing an improvement in FD-related clinical status after starting home therapy, had previously a sub-optimal compliance to treatment during the period of hospital treatment management. Only 4 adverse non serious reactions (0,093%) were reported totally in 2 patients during home treatment.

We conclude that home infusions in eligible patients with FD are safe, contribute to improve treatment compliance and therapeutic clinical outcomes, and may have a positive impact on self-perceived QoL.

Impaired bone remodeling in children with osteogenesis imperfecta treated and untreated with bisphosphonates: the role of DKK1, RANKL, and TNF-α

In this study, we investigated the bone cell activity in patients with osteogenesis imperfecta (OI) treated and untreated with neridronate. We demonstrated the key role of Dickkopf-1 (DKK1), receptor activator of nuclear factor-κB ligand (RANKL), and tumor necrosis factor alpha (TNF-α) in regulating bone cell of untreated and treated OI subjects. These cytokines could represent new pharmacological targets for OI.

INTRODUCTION

Bisphosphonates are widely used in the treatment of children with osteogenesis imperfecta (OI) with the objective of reducing the risk of fractures. Although bisphosphonates increase bone mineral density in OI subjects, the effects on fracture incidence are conflicting. The aim of this study was to investigate the mechanisms underlying bone cell activity in subjects with mild untreated forms of OI and in a group of subjects with severe OI treated with cycles of intravenous neridronate.

METHODS

Sclerostin, DKK1, TNF-α, RANKL, osteoprotegerin (OPG), and bone turnover markers were quantified in serum of 18 OI patients (12 females, mean age 8.86 ± 3.90), 8 of which were receiving cyclic intravenous neridronate, and 21 sex- and age-matched controls. The effects on osteoblastogenesis and OPG expression of media conditioned by the serum of OI patients and anti-DKK1 neutralizing antibody were evaluated. Osteoclastogenesis was assessed in cultures from patients and controls.

RESULTS

DKK1 and RANKL levels were significantly increased both in untreated and in treated OI subjects with respect to controls. The serum from patients with high DKK1 levels inhibited both osteoblast differentiation and OPG expression in vitro. High RANKL and low OPG messenger RNA (mRNA) levels were found in lymphomonocytes from patients. High amounts of TNF-α were expressed by monocytes, and an elevated percentage of circulating CD11b-CD51/CD61+ osteoclast precursors was observed in patients.

CONCLUSIONS

Our study demonstrated the key role of DKK1, RANKL, and TNF-α in regulating bone cell activity of subjects with OI untreated and treated with bisphosphonates. These cytokines could represent new pharmacological targets for OI patients.

Contribution of germline mutations in the BRCA and PALB2 genes to pancreatic cancer in Italy

Pancreatic adenocarcinoma (PC) is the third most common cancer associated with BRCA mutations. Most notice has been given to BRCA2, while the association between BRCA1 and PC is less widely reported. Recently, PALB2 has been implicated in both PC and breast cancer (BC) susceptibility. We selected 29 Italian PC patients from a case-control study of PC according to their personal and family history of both PC and breast/ovarian cancer (BC/OC) and tested them for presence of germline mutations in BRCA1, BRCA2 and PALB2. We identified no germline mutations or deletions in PALB2, but detected 7 BRCA mutations (4 in BRCA1 and 3 in BRCA2). These findings suggest that PALB2 does not play a major role in PC susceptibility in our population. As we found an almost equal frequency of germline mutations in BRCA1 and BRCA2, germline alterations in either of these genes may explain a subset of Italian families presenting both PC and BC/OC. Moreover, as we began the observation of these families from probands who are affected by PC, we provide here a direct assessment of the role of PALB2 and BRCA mutations in PC susceptibility.

Morquio A syndrome due to maternal uniparental isodisomy of the telomeric end of chromosome 16

Morquio A syndrome (MPS IVA) is a recessive lysosomal storage disorder (LSD) caused by mutations in the GALNS gene leading to the deficiency of lysosomal enzyme N-acetylgalactosamine-6-sulfate sulfatase (GALNS). Patients show a broad spectrum of phenotypes ranging from classical severe type to mild forms. Classical forms are characterized by severe bone dysplasia and usually normal intelligence. So far, more than 170 unique mutations have been identified in the GALNS gene of MPS IVA patients. We report on a Morquio A patient with a classical phenotype who was found to be homozygous for a missense mutation (c.236 G>A; p.Cys79Tyr) in the GALNS gene. This alteration affects the highly conserved p.Cys79 that is transformed into formylglycine, the catalytic residue of the active site. The mutation was present in the proband's mother, but not in the father, whose paternity was confirmed by microsatellite analysis. In order to test the hypothesis of maternal uniparental disomy (UPD), we investigated the segregation of sixteen microsatellite markers from chromosome 16. The results showed a condition of maternal UPD due to an error in meiosis I. Maternal isodisomy of the 16q24 region led to homozygosity for the GALNS mutant allele, causing the patient's disease. These findings allow to add for the first time the LSD Morquio A syndrome to the list of conditions that can be caused by UPD. The possibility of UPD is relevant when giving genetic counseling to couples since the recurrent risk in future pregnancies is dramatically reduced.

A novel microdeletion syndrome at 3q13.31 characterised by developmental delay, postnatal overgrowth, hypoplastic male genitals, and characteristic facial features

BACKGROUND

Congenital deletions affecting 3q11q23 have rarely been reported and only five cases have been molecularly characterised. Genotype-phenotype correlation has been hampered by the variable sizes and breakpoints of the deletions. In this study, 14 novel patients with deletions in 3q11q23 were investigated and compared with 13 previously reported patients.

METHODS

Clinical data were collected from 14 novel patients that had been investigated by high resolution microarray techniques. Molecular investigation and updated clinical information of one cytogenetically previously reported patient were also included.

RESULTS

The molecular investigation identified deletions in the region 3q12.3q21.3 with different boundaries and variable sizes. The smallest studied deletion was 580 kb, located in 3q13.31. Genotype-phenotype comparison in 24 patients sharing this shortest region of overlapping deletion revealed several common major characteristics including significant developmental delay, muscular hypotonia, a high arched palate, and recognisable facial features including a short philtrum and protruding lips. Abnormal genitalia were found in the majority of males, several having micropenis. Finally, a postnatal growth pattern above the mean was apparent. The 580 kb deleted region includes five RefSeq genes and two of them are strong candidate genes for the developmental delay: DRD3 and ZBTB20.

CONCLUSION

A newly recognised 3q13.31 microdeletion syndrome is delineated which is of diagnostic and prognostic value. Furthermore, two genes are suggested to be responsible for the main phenotype.

Long-term enzyme replacement therapy in a severe case of mucopolysaccharidosis type II (Hunter syndrome)

Hunter syndrome or mucopolysaccharidosis II (MPS II) is a rare X-linked disease caused by a deficiency of the iduronate-2-sulphatase (12S) lysosomal enzyme, resulting in a progressive accumulation of glycosaminoglycans (GAGs). Enzyme replacement therapy (ERT) with recombinant human 12S idursulfase has been used infrequently in children < 5 years. We present the case of a 7 years and 10 months-old child, who was diagnosed with a severe form of MPS II at the age of 3 years, and who began a 36 months' treatment with idursulfase at 4 years 10 months. After 10 months, GAG urinary excretion was normal, but after just 4 months the liver and spleen had decreased in size, returning to normal limits by 36 months. Significant bone remodeling was noted after 16 months. Cardiac and neurological development, however, progressively deteriorated. The only adverse reactions were episodic inflammations of the upper and/or lower respiratory tract, but there was no otitis. Early use of ERT, presuming good treatment adherence, can significantly improve bone abnormalities.

Efficacy of ACE-inhibitor therapy on renal disease in glycogen storage disease type 1: a multicentre retrospective study

BACKGROUND

The efficacy of ACE-inhibitors in decreasing microalbuminuria and proteinuria has been reported in a few patients with glycogen storage disease type 1 (GSD1); however, no case-control study has ever been published.

AIM

The aim of the current study was to evaluate the efficacy of ACE-inhibitors in reducing glomerular hyperfiltration, microalbuminuria and proteinuria, and in delaying the progression of renal damage.

PATIENTS AND METHODS

Ninety-five patients (median age at the time of the study: 14.5 years) were enrolled from nine Italian referral centres for metabolic diseases. A retrospective study of a 10-year follow-up was conducted in order to compare the evolution of these parameters in treated patients with those who were not treated with ACE-inhibitors.

RESULTS

A significant and progressive decrease of glomerular filtration rate was observed in treated patients vs. those who were not treated with ACE-inhibitors (P < 0.05). No difference was observed for microalbuminuria and proteinuria between the two groups of patients. Moreover, the ACE-inhibitors significantly delayed the progression from glomerular hyperfiltration to microalbuminuria, but not that from microalbuminuria to proteinuria.

CONCLUSIONS

The results of the present study underline the importance of a strict follow-up of renal function in GSD1 patients. The detection of glomerular hyperfiltration suggests precocious initiation of ACE-inhibitor treatment to delay the progression of renal damage. A randomized prospective study is needed to establish for certain the real effectiveness of this treatment in GSD1 patients.

Satiety after vertical banded gastroplasty

Early satiety following gastroplasty is due to the new anatomic conditions created by the operation and refers to a distressing or painful epigastric sensation after food consumption. Early satiation may act as an aversive stimulus, shaping eating habits and behaviour in such a way as to promote satisfactory weight loss and maintenance. This hypothesis was tested in patients who had undergone vertical banded gastroplasty (VBG). The duration of the sensation of early satiety was associated with the scores of questionnaires assessing eating behaviour, but seemed to be completely unrelated to the radiologically measured proximal pouch volume, energy intake and weight loss data. These findings suggest that cognitive factors play a substantial role in determining food intake and therefore in achieving weight goals following gastric restriction.

Genetic analysis in nine unrelated Italian patients affected by OTC deficiency: detection of novel mutations in the OTC gene

Ornithine transcarbamylase deficiency (OTCD) is an X-linked urea cycle disorder due to a defect of the mithocondrial enzyme ornithine transcarbamylase (OTC). Genetic analysis in nine unrelated Italian patients affected by OTCD (one male patient and eight female manifesting carriers) led to the detection of three novel mutations and six previously reported mutations in the OTC gene. The analysis was performed by direct sequencing of OTC cDNA, OTC exons, and intron-exon boundaries and enzymatic restriction analysis on the patients' genomic DNA and total RNA isolated from peripheral blood lymphocytes. In the male patient the new mutation S132P due to the nucleotide change c.394T>C was identified. In a manifesting carrier the nucleotide change c.292G>A that leads to the novel amino acid substitution E98K was identified; this mutation is close to the OTC protein's carbamyl phospate binding site. In another manifesting carrier the OTC cDNA analysis revealed the normally spliced transcript and an aberrant transcript with an insertion of two nucleotides (c.77-78insAG). In the patient's genomic DNA we identified a new transvertion IVS1-3C>G at the heterozygous state; this nucleotide change generates a new splice acceptor site in intron 1 that induces an RNA splicing defect. This insertion causes a frame shift in OTC cDNA ORF and leads to a premature stop codon. The previously described mutations N161S, R141Q, T178M, R92X, A208T, M268T were identified in the other six manifesting carriers.

D1 versus D2 pancreatoduodenectomy in surgical therapy of pancreatic head cancer

BACKGROUND/AIMS

The aim of this study was to evaluate the influence of standard pancreatoduodenectomy versus pancreatoduodenectomy with extended lymphadenectomy and the role of adjuvant therapy on survival in patients with ductal adenocarcinoma of the pancreatic head. In addition the problems related to resection are discussed.

METHODOLOGY

A total number of 124 pts operated on between 1985 and 1999 were divided into three groups according to our different strategies. Standard resection (D1) was performed on 48 patients (group A), extended resection (D2) on 45 patients (group B) and combined treatment (extended resection plus adjuvant therapy) on 31 patients. The outcome of these three groups was compared with regard to postoperative morbidity and survival.

RESULTS

There was no significant difference in terms of survival between group A and B, while adjuvant therapy (group C), achieved statistical significance as factor influencing survival, together with tumor stage.

CONCLUSIONS

Our data suggest that no further improvement can be obtained on long-term survival by extended retroperitoneal dissection while chemoradiotherapy showed a doubling of median survival.

Outcome of biliopancreatic diversion in subjects with Prader-Willi Syndrome

BACKGROUND

In Prader-Willi Syndrome (PWS), mental retardation and compulsive hyperphagia cause early obesity, the co-morbidities of which lead to short life-expectancy, with death usually occurring in their 20s. Long-term weight loss is mandatory to lengthen the survival; therefore, the lack of compliance in voluntary food restriction requires a surgical malabsorptive approach.

METHODS

15 PWS subjects were submitted to biliopancreatic diversion (BPD) and followed (100%) for a mean period of 8.5 (4-13) years. BPD consists of a distal gastrectomy with a long Roux-en-Y reconstruction which, by delaying the meeting between food and biliopancreatic juices, causes an intestinal malabsorption. Indication for BPD was BMI > 40 or > 35 with metabolic complications. Preoperative mean age was 21 +/- 5 years, mean weight 127 +/- 26 kg, and mean Body Mass Index (BMI, kg/m2) 53 +/- 10. According to Holm's criteria, all of the subjects had a total score > or = 8. IQ assessment was performed in each subject, with a mean score of 72 +/- 10. An arbitrary lifestyle score was given to each subject.

RESULTS

No perioperative complications were observed. Percent excess weight loss (%EWL) was 59 +/- 15 at 2 years and 56 +/- 16 at 3 years, and then progressive regain occurred; at 5 years %EWL was 46 +/- 22 and at 10 years 40 +/- 27. Spearman rank test failed to demonstrate any correlation between weight loss at 5 years and patient data, except with lifestyle score (Spearman r = 0.8548, p < .0001). Current mean age is 31 +/- 7 years.

CONCLUSION

BPD has to be considered for its value in prolonging and qualitatively improving the PWS patient's life.

Alteration of excitation-contraction coupling mechanism in extensor digitorum longus muscle fibres of dystrophic mdx mouse and potential efficacy of taurine

No clear data is available about functional alterations in the calcium-dependent excitation-contraction (e-c) coupling mechanism of dystrophin-deficient muscle of mdx mice. By means of the intracellular microelectrode "point" voltage clamp method, we measured the voltage threshold for contraction (mechanical threshold; MT) in intact extensor digitorum longus (EDL) muscle fibres of dystrophic mdx mouse of two different ages: 8 - 12 weeks, during the active regeneration of hind limb muscles, and 6 - 8 months, when regeneration is complete. The EDL muscle fibres of 8 - 12-week-old wildtype animals had a more negative rheobase voltage (potential of equilibrium for contraction- and relaxation-related calcium movements) with respect to control mice of 6 - 8 months. However, at both ages, the EDL muscle fibres of mdx mice contracted at more negative potentials with respect to age-matched controls and had markedly slower time constants to reach the rheobase. The in vitro application of 60 mM taurine, whose normally high intracellular muscle levels play a role in e-c coupling, was without effect on 6 - 8-month-old wildtype EDL muscle, while it significantly ameliorated the MT of mdx mouse. HPLC determination of taurine content at 6 - 8 months showed a significant 140% rise of plasma taurine levels and a clear trend toward a decrease in amino acid levels in hind limb muscles, brain and heart, suggesting a tissue difficulty in retaining appropriate levels of the amino acid. The data is consistent with a permanent alteration of e-c coupling in mdx EDL muscle fibres. The alteration could be related to the proposed increase in intracellular calcium, and can be ameliorated by taurine, suggesting a potential therapeutic role of the amino acid.

Energy and nitrogen absorption after biliopancreatic diversion

BACKGROUND

The strict long-term weight maintenance in good nutritional conditions observed after biliopancreatic diversion (BPD) needs to be explained.

MATERIALS AND METHODS

15 operated subjects were maintained at an isoenergetic and isonitrogenic diet as similar as possible to their usual diet. Apparent absorption (AA) of energy, fat, nitrogen and calcium was calculated subtracting the fecal content, measured directly, from the oral intake, derived from tables. The alimentary protein absorption was directly determined by I125 albumin oral administration.

RESULTS

Mean AA for energy and fat was 57% and 32%, respectively; AAs were unrelated as absolute value and negatively associated as percent of the intake with the energy and fat intake. I125 intestinal absorption was 73%, while nitrogen percent AA was 57%, indicating higher than normal loss of endogenous nitrogen. Calcium AA was 551 mEq/day, 26% of the intake. A positive correlation between nitrogen and calcium AA as absolute values and alimentary intake was observed, while there was no correlation when AA were considered as per cent of the intake.

CONCLUSIONS

For energy and fat, an increase in intake corresponds to an increase in percent malabsorption, so that the absolute amount absorbed tends to remain constant, accounting for the excellent weight maintenance observed following BPD. This was confirmed by a long-term hypernutrition study after BPD. On the contrary, for nitrogen and calcium, the percent absorption tends to remain constant when intake varies, so that an increase in alimentary intake results in an increased absolute amount absorbed.

Reverse fasciosubcutaneous flap versus distally pedicled sural island flap: two elective methods for distal-third leg reconstruction

In case of soft-tissue injury to the distal third of the leg, a safe and effective repair technique should be adopted. The use of complex procedures such as free flaps and cross-leg flaps is not always advisable. The authors present two methods that have proved to be both reliable and effective in obtaining long-lasting satisfactory results: the reverse fasciosubcutaneous sural flap and the reverse fasciocutaneous island sural flap. Since 1992 the authors have operated on 25 patients affected by traumatic tissue loss of the distal third of the leg and the calcaneal region. They used the fasciosubcutaneous flap in 14 patients and the sural flap in 11. Both of these flaps are technically simple, safe, and effective, and cause minimal injury to the donor site. The sural flaps are more useful for moderate-size wounds, especially in the calcaneal region, whereas the fasciosubcutaneous flap is better for repairing larger lesions of the leg and the ankle.

Alteration of mitochondrial DNA and RNA level in human fibroblasts with impaired vitamin B12 coenzyme synthesis

Alterations of mitochondrial (mt) nucleic acid metabolism in methylmalonic aciduria (MMA) were studied in two cell lines from skin fibroblasts of patients with mitochondrial (GM00595) or cytosolic (GM10011) defects in the biosynthesis pathways of cobalamin coenzymes. The mtDNA level increased two-fold in GM00595 cells, which carry a mt defect in the adenosylcobalamin synthesis, whereas no appreciable change was found in GM10011 cells. The content of the two rRNAs 16S and 12S mtRNAs, normalized for the mtDNA copy number, decreased by 70% and 50% in GM00595 and GM10011, respectively. The normalized content of ND1, ND2 and CO I mRNAs decreased in GM00595, but was unchanged in GM10011. Respiratory chain complex activities measured in these two cell lines were not different from control activities. These data suggest that the maintenance of the mt function is due to doubling of mtDNA and that this compensatory response takes place only in those cells in which the greater reduction of the level of rRNA might have brought the content of these transcripts below the threshold value for optimal expression of the mt genome.

Increased burn patient survival with once-a-day high dose teicoplanin and netilmicin. An Italian multicenter study

This is the final report of a large, controlled, multicenter Italian study on immuno- and chemotherapy in adult patients with burns affecting 20 to 95% of total body surface area (mean 35%). The antibiotic treatment of burn patients consisted of topical silver sulfadiazine, short-term antimicrobial chemoprophylaxis with pefloxacin (800 mg i.v. qd) for the first 4 days and polychemotherapy with teicoplanin (800 mg i.v. qd) together with netilmicin (300 mg i.m. qd) in one or more cycles of 5-12 days. At random, half of the patients received thymostimulin, 70 mg i.m. qd for the first month and every other day thereafter. The analysis at completion of 634 valid cases showed that when the results are stratified by means of the Roi risk index, 396 of the 530 patients who contracted wound infection (84%) after chemoprophylaxis were in the first three categories and a mean of 95% survived. Of the remaining 134 patients (Roi index 4-5) only 50% survived. There was no difference in survival of the immunotherapy group in comparison with the parallel group without thymostimulin. The short-term antimicrobial prophylaxis prevented wound infection in only 104 of 634 patients (16%) and they were at low risk (84% Roi index 1). Of the bacterial pathogens involved in septic complications Staphylococcus aureus and Pseudomonas aeruginosa were prevalent (86%): eradication was achieved in 43% of patients and clinical cure or improvement were seen with combination chemotherapy in 64% of all patients, mainly with only one treatment cycle. This value increased to 79% for the 395 protocol-complying patients and went down to 20% in the 135 non-compliers. The total survival of complier and non-complier patients was 447 of the 530 valid patients (84%). The overall mortality of the 634 evaluable patients was 13.1%, ranging from less than 2% to 68%. Burn mortality was directly proportional to the percentage of burned body surface area, to increasing age and other variables of the Roi index, a 50% mortality being associated with a 72.5% total body surface area burned. Normoergic burn patients had a mortality rate of 9.1% versus 35.7% in anergic patients.

Pseudodiastrophic dysplasia type Burgio in a newborn

Pseudodiastrophic dysplasia is a distinct disorder that differs from diastrophic dysplasia on the basis of elbow and proximal interphalangeal joint dislocations, platyspondyly, and scoliosis. We report on a new patient with this rare skeletal dysplasia and two previously undescribed major malformations: omphalocele and complex heart defect.

Biliary malformation with renal tubular insufficiency in two male infants: third family report

We report two male sibs, born to non-consanguineous healthy parents, who showed arthrogryposis, cholestatic jaundice and tubular renal insufficiency. The liver biopsy of the first case showed scanty hypoplastic biliary ducts. This association, first reported by Lutz and Richner in 1973, is a distinct syndrome, characterized by intra-extrahepatic biliary hypoplasia, and described in McKusick's catalogue under the number 210550. All reported cases were males and consanguinity was found in two families. For these reasons, the possibility of an autosomal recessive or of an X-linked transmission should be considered. A similar association, in reports by Nezelof, Di Rocco, and Saraiva, without intra-extrahepatic atresia but with a cholestatic pigmentary liver disease was considered as another condition (no. 301820) by McKusick in 1992.

Surgical treatment of hypospadias at different ages. Part 2: Adolescents and adults

— The Authors describe their diagnostic and therapeutic protocol for hypospadic patients in adolescent and adult age. Patients can be divided into: those who have received unsatisfactory treatment, those who have not yet been treated and patients with Penile curvature without hypospadia.

Il trattamento chirurgico delle ipospadie nelle differenti età evolutive. Parte 1a: Età infantile:Hypospadias treatment in different ages of development. Part 1: Infancy

The Authors describe their diagnostic protocol for hypospadias in childhood, including the evaluation of associated malformations and degree of intersexuality. Treatment usually consists of a single-stage operation, except for perineo-scrotal hypospadias, and must be performed before the child is two years old.

[Pilomatrixoma of the parotid region]

Pilomatrixoma, or calcifying epithelioma of Malherbe, is an uncommon, benign, epithelial tumor of the skin that often arises in head and neck regions, in the first 2 decades of life. The report of two cases of pilomatrixoma in the parotid area permits to clarify the clinical features and the problems in the differential diagnosis of these tumors.

Chronic leg ulcerations resembling vasculitis in two siblings with prolidase deficiency

Two cases of prolidase deficiency in two siblings are presented. The patients complained of the typical clinical symptoms of the disease, including chronic leg ulcerations resembling vasculitis. They were mentally retarded, had typical facial characteristics, splenomegaly, and haematologic anomalies. Biochemical and morphological investigations confirmed the diagnosis. In these cases, alterations of the peripheral nervous system and decreased IgA levels were demonstrated for the first time.

Reconstruction of the heel by a medial plantar flap

Reconstruction of the heel is a complex problem for which many methods have been proposed. The authors describe a method of applying a medial plantar flap with particular reference to special clinical situations of a vascular nature. Based on their clinical experience, they recommended the medial plantar flap as the method of choice in the reconstruction of the heel, particularly in view of the trophic, mechanical and sensory features of the transposed skin and the absence of a significant morphological or functional deficit in the donor site. Moreover, the method involves a single surgical stage and a brief period of hospitalisation.

Expanded tubed flap in scalp reconstruction: a modern option in an old technique

Reconstruction of extensive scalp defects represents a difficult problem for the plastic surgeon. In this case report, a successful result was obtained by stretching a dorsal tubed flap with an inflatable balloon placed between the tube and the underlying donor site. This modified tissue expansion has permitted us to transfer an adequate amount of tissue and resurface an extensive area hardly reached by other reparative methods.

Tissue expansion in the leg: limits and complications in trauma pathology

Subcutaneous tissue expansion in the treatment of skin loss was first introduced by Neuman (1957) and subsequently developed by Radovan (1982) as a means of increasing the amount of tissue available for reconstruction. It takes advantage of the elasticity of the skin and its ability to expand when submitted to traction, thereby increasing its surface area. This is achieved by the temporary subcutaneous insertion of prostheses which are gradually expanded with physiological saline injected percutaneously through a valve. Once the required increase in skin surface has been achieved, the prosthesis is removed. Indications and modalities for the use of expanders in the head and neck (Argenta et al., 1983; Manders et al., 1984) and the breast (Radovan, 1982; Argenta et al., 1983) are now well established, but severe skin loss in the distal part of the leg, particularly if due to trauma and accompanied by exposure of the neural structure, may create serious problems of reconstruction. We therefore found it useful to apply this new technique in this situation, having previously adopted it in other parts of the body and obtained good results which would have been difficult to achieve with traditional techniques.

Progressive form of multiple pterygium syndrome in association with nemalin-myopathy: report of a female followed for twelve years

We report on a girl with progressive multiple pterygium syndrome in association with gluteal muscle fibrosis and nemalin-myopathy. This girl has been followed for 12 years. Clinical findings, natural history, and the presence of nemalin myopathy suggest the possibility of a distinct form of multiple pterygium syndrome in this patient.

The Bartsocas-Papas syndrome: autosomal recessive form of popliteal pterygium syndrome in a male infant

We report on an additional patient with the severe autosomal recessive form of the popliteal pterygium syndrome. The patient was diagnosed at birth and had all of the phenotypic manifestations of this rare syndrome. Clinical findings and natural history suggest this is a distinct genetic entity.

[Long-term results of prolonged dicoumarol anticoagulant therapy in 327 peipheral arteriopathic subjects]

327 patients with peripheral arteriopathy were treated solely with protracted dicoumarol anticoagulant therapy. The indication for such therapy was applied not only in patients in whom the high risk and poor run-off contraindicated revascularisation operations, but also in those in good general conditions at the 2nd or 3rd stage with iliac and femoral thromboses. Two-thirds of the arteriopathics observed were given the anticoagulant treatment for more than two years, with a maximum of eight years. Clinical evolution of the disease is discussed in relation to the treated patients' age and stage, while emphasis is given to the very low incidence of complications and contraindications, despite the long period of treatment.

[Revascularization of the aorto-femoral axis by means of a by-pass. Remote results]

The Authors report their experience in 73 patients wit aorto-iliaco-femoral chronic obliteration, subjected to revascularisation. In 49 cases a bilateral by-pass was performed, in 22 a monolateral by-pass, and in two a thromboendarterioectomy. The results obtained were classified as successes or failures according to the perviousness or otherwise of the substituted or disobliterated arterial segments, and as immediate or longterm according to whether they were evaluated at the time of the patient's discharge or during a period lying betwee six months and seven years from the operation. Immediate successes were obtained in 95.9% of cases with bilateral by-pass, and in 90.9% of the monolateral by-passes. Aggregate mortality was 2.7%. In the long-term chick-ups, the previousness of the bilateral by-passes was 82.9%, that of the monolateral by-passes 72.2%. On the basis of the results obtained the Authors therfore reiterate their preference for by-passes, and for bilateral by-passes in particular (70% of cases). Monolateral bridging were in fact performed only in those cases where the contralateral vascular district was unharmed, in patients with serious ganrenous lesions and those with a high operative risk.