Inventory of landslides triggered by an extreme rainfall event in Marche-Umbria, Italy, on 15 September 2022

Systematic and timely documentation of triggered (i.e. event) landslides is fundamental to build extensive datasets worldwide that may help define and/or validate trends in response to climate change. More in general, preparation of landslide inventories is a crucial activity since it provides the basic data for any subsequent analysis. In this work we present an event landslide inventory map (E-LIM) that was prepared through a systematic reconnaissance field survey in about 1 month after an extreme rainfall event hit an area of about 5000 km² in the Marche-Umbria regions (central Italy). The inventory reports evidence of 1687 triggered landslides in an area of ~550 km². All slope failures were classified according to type of movement and involved material, and documented with field pictures, wherever possible. The database of the inventory described in this paper as well as the collection of selected field pictures associated with each feature is publicly available at figshare.

Breast conservation following neoadjuvant therapy for breast cancer in the modern era: Are we losing the opportunity?

The main rationale for neoadjuvant therapy for breast cancer is to provide effective systemic treatment while surgically down-staging the cancer. This down-staging was initially to convert inoperable patients to operable and later to increase rates of breast conservation in patients initially deemed mastectomy only candidates. Unexpectedly, in recent neoadjuvant trials lower rates of breast conservation have been observed than in past decades, despite remarkable advances in systemic therapies, which have increased pathologic complete response rates. These results point to factors aside from response and eligibility for breast conservation that may lead surgeons and/or patients to recommend and choose mastectomy. Here, we aim to examine the surgical benefits offered by the modern era neoadjuvant therapy and explore factors that have contributed to this decrease in breast conservation rates. If the main benefit of neoadjuvant therapy is to increase the opportunity for breast conservation, then our review suggests that to optimize less invasive surgical approaches, we will need to address both surgeon and patient-level variables and biases that may be limiting our ability to identify patients appropriate for less aggressive options. As an oncology community, we must be aware of the surgical overtreatment of breast cancer, especially in a time where systemic therapies have remarkably improved outcomes and responses.

Complicated diverticulitis in kidney transplanted patients: analysis of 717 cases

INTRODUCTION

This study aims to investigate possible risk factors for diverticulitis in kidney transplant recipients affected by colonic diverticulosis.

METHODS AND RESULTS

We investigated 717 patients transplanted between 2000 and 2010. Diverticular disease was endoscopically diagnosed in 17 of 717 examined patients. Eight patients were diagnosed with autosomal dominant polycystic kidney disease (ADPKD); 9 of 17 patients underwent emergency surgery. We performed Hartmann's procedure on all patients, with a second stage performed at least 6 months later.

DISCUSSION

Although the incidence of colonic diverticular perforation in kidney transplanted patients is similar to that observed in the general population, perforation in immunosuppressed patients is associated with a higher morbidity/mortality rate. In our study, the incidence of perforation is 1.25% (9 of 717), with almost half of the cases observed in patients with ADPKD (4 of 9). Such an observation is consistent with published data, in which patients with ADPKD are reported to more frequently develop colonic diverticulosis and its complications. One possible explanation might be related to a belated diagnosis of diverticulitis, which could initially simulate an inflammatory disease as a consequence of renal cysts. Also, steroids seem to be a predisposing factor for colonic perforation in these patients.

CONCLUSIONS

A timely surgery can significantly reduce mortality. In cases of elective surgery, mortality and morbidity are similar to those of immunocompetent patients; accordingly, this is the goal to be pursued. Early signs and symptoms are often masked by immunosuppressive therapy. In these patients, surgeons should always perform (1) abdominal computed tomography scanning and, in the presence of diverticulitis, reduce or withdraw immunosuppressive therapy; and (2) early surgery, with Hartmann's procedure being, in our opinion, the best choice. Before transplantation, elective surgery for colonic resection should be considered in patients with ADPKD or with a history of 1 or more episodes of acute diverticulitis who then regressed with medical therapy.

Wound complications after kidney transplantation in nondiabetic patients

INTRODUCTION

Impaired wound healing represents a common operative complication after kidney transplantation. This problem seems to be affected by factors related to surgical technique, drugs, and patient/graft peculiarities.

PATIENTS AND METHODS

From January 2000 to December 2007, 350 consecutive kidney transplantations were performed in a population of nondiabetic patients. We evaluated the influence of various factors on impaired wound healing.

RESULTS

Among 350 kidney transplantation patients, we observed 54 cases (15.43%) of impaired healing of the surgical incision: 36 (10.29%) with first level and 18 (5.14%) with second level wound complications. Factors related to complications were overweight and delayed graft function. Cyclosporine and tacrolimus had similar effects. However, all patients developing second level complications showed more risk factors. In our experience, postoperative lymphocele did not occur as an unique factor but became a significant risk factor when associated with another one. Patients who did not have reconstruction of the muscle layers showed a greater incidence of incisional complications.

CONCLUSION

Impaired healing of the surgical incision more or less seriously influenced outcomes of transplanted patients. This complication was common and usually related to the presence of more than one risk factor.

Cerebrospinal fluid amounts of HLA-G in dimeric form are strongly associated to patients with MRI inactive multiple sclerosis

Background:

The relevance of human leukocyte antigen (HLA)-G in dimeric form in multiple sclerosis (MS) is still unknown.

Objective:

To investigate the contribution of cerebrospinal fluid (CSF) HLA-G dimers in MS pathogenesis.

Methods:

CSF amounts of 78-kDa HLA-G dimers were measured by western blot analysis in 80 MS relapsing–remitting MS (RRMS) patients and in 81 inflammatory and 70 non-inflammatory controls.

Results:

CSF amounts of 78kDa HLA-G dimers were more frequent in RRMS than in inflammatory ( p<0.01) and non-inflammatory controls ( p<0.001) and in magnetic resonance imaging (MRI) inactive than in MRI active RRMS ( p<0.00001).

Conclusion:

Our findings suggest that HLA-G dimers may be implicated in termination of inflammatory response occurring in MS.

Effect of the disclosure of MS diagnosis on anxiety, mood and quality of life of patients: a prospective study

BACKGROUND

In the light of the new diagnostic criteria for multiple sclerosis (MS) and currently available early treatment, this study aimed to explore whether, and to what extent, disclosure of the diagnosis of MS or clinically isolated syndrome (CIS) affects patients' anxiety, mood and quality of life (QoL).

METHODS

Eligible participants were all patients referred for the first time to the Neurological Unit who had manifested symptoms suggestive of MS for no more than 6 months. All patients were evaluated for (i) QoL (SEIQoL and MS-QoL54), (ii) Anxiety (STAI) and Depression (CMDI) on study inclusion (T0), 30 days after diagnosis disclosure (T30), and after 1 (T1y) and 2 (T2y) years' follow-up.

RESULTS

Two hundred and twenty-nine patients were enrolled; 93 of these were unaware of their diagnosis. Patients who already knew their diagnosis (100 with CIS and 22 with MS) were excluded from the main analyses and used to perform control analyses. At the end of the screening, an MS diagnosis was disclosed to 18 of the 93 patients, whereas a CIS diagnosis was disclosed to 62 patients (12 patients received a diagnosis other than MS or CIS). Thirty days after diagnosis disclosure, irrespective of the diagnosis disclosed, both QoL and Anxiety and Depression were significantly rated as better compared to the start of screening, (p(s) < 0.03), and this improvement remained stable over the two annual follow-ups. However, as suggested by a significant 'Time' × 'Diagnosis' interaction with regard to both QoL and Anxiety and Depression (p(s) < 0.02), the effect of the disclosure in the short term differed depending on CIS or MS diagnosis. Specifically, on MSQoL, which is a health-related QoL scale, we found a statically significant improvement, immediately after the diagnosis disclosure, in both the MS and CIS groups (p(s) < 0.01). Differently, on SEIQoL, which is a non health-related QoL measure, and on the anxiety scale, we observed a statistically significant improvement only in the group which received a MS diagnosis (p(s) < 0.03).

CONCLUSIONS

This first prospective study provides objective data showing that early disclosure of MS diagnosis improves both the patient's QoL and psychological well-being. In addition, the results seem to suggest that CIS disclosure does not lead to the same favourable effects.

Incidence and predictors of acute symptomatic seizures after stroke

OBJECTIVE

To assess incidence and predictors of acute symptomatic seizures in a prospective cohort of patients with first stroke.

METHODS

Patients with first stroke hospitalized in 31 Italian centers were recruited. Relevant demographic data, disease characteristics, and risk factors were collected. Acute symptomatic seizures (≤7 days) were recorded and correlated to age, gender, family history of epilepsy, and vascular risk factors.

RESULTS

A total of 714 patients (315 women, 399 men; age 27-97 years) were enrolled. A total of 609 (85.3%) had cerebral infarction (32 cerebral infarction with hemorrhagic transformation [CIHT]) and 105 (14.7%) primary intracerebral hemorrhage (PIH). A total of 141 (19.7%) had a large lesion (>3 cm) and 296 (41.5%) cortical involvement. Twelve patients reported family history of seizures. Forty-five patients (6.3%) presented acute symptomatic seizures, 24 with cerebral infarction (4.2%), 4 with CIHT (12.5%), and 17 (16.2%) with PIH. In multivariate analysis, compared to cerebral infarction, PIH carried the highest risk (odds ratio [OR] 7.2; 95% confidence interval [CI] 3.5-14.9) followed by CIHT (OR 2.7; 95% CI 0.8-9.6). Cortical involvement was a risk factor for PIH (OR 6.0; 95% CI 1.8-20.8) and for CI (OR 3.1; 95% CI 1.3-7.8). Hyperlipidemia (OR 0.2; 95% CI 0.03-0.8) was a protective factor for IPH.

CONCLUSION

The incidence of acute symptomatic seizures is the highest reported in patients with first stroke with prospective follow-up. Hemorrhagic stroke and cortical lesion were independent predictors of acute symptomatic seizures. Hyperlipidemia was a protective factor for hemorrhagic stroke.

Hemoperitoneum as severe and unusual complication in the stapler recto-anopexy for hemorrhoidal prolapse. Case report

We report unusual but severe complication after Longo recto-anopexy for hemorrhoidal prolapse, i.e. large intramural hematoma of the rectum and subsequent hemoperitoneum. We make some assessment about the technique.

Effects of voriconazole on tacrolimus metabolism in a kidney transplant recipient

Infection occurs frequently in the organ transplant recipients during the post-transplant period because of immunosuppression. Therefore, prophylactic antimicrobial agents are often used. The azole antifungals, widely prescribed prophylactically, are known to have many drug-drug interactions. This report presents a case of drug-drug interaction between voriconazole and tacrolimus in a kidney transplant recipient. Voriconazole treatment led to a dramatic increase in tacrolimus concentration that required its discontinuation in spite of the manufacturer's guidelines that recommend a reduction of tacrolimus dosage by one-third. The present drug-drug interaction can be attributed to a strong inhibitory effect on cytochrome P450-3A4 activity by voriconazole. When voriconazole and tacrolimus are coadministered, close monitoring of tacrolimus blood levels is recommended as the rule-of-thumb reduction of tacrolimus dose by one-third may not be satisfactory.

Extrapleural solitary fibrous tumor: a clinicopathologic study of 19 cases

This study reports a series of 19 extrapleural solitary fibrous tumors. The patients included 6 men and 13 women with age ranging from 27 to 86 years. Three patients showed local recurrence. In 2 tumors, a diagnosis of malignancy was made. All of the tumors were strongly positive for CD34, and 3 of them expressed high levels of progesterone receptor. Solitary fibrous tumors are fairly rare, occurring in many parts of the body, and their behavior is unpredictable.

Spontaneous cervical extradural hematoma in a cutaneo-meningospinal angiomatosis (Cobb syndrome): case report

Spontaneous spinal extradural hematoma is a rare clinical entity, commonly associated with coagulopathies, tumours or vascular malformations. They are often a neurosurgical emergency, therefore prompt diagnosis and early treatment are necessary. The Cobb syndrome is a neurocutaneous syndrome in which there are metameric vascular skin nevus and spinal arteriovenous malformation. The authors report the case of a 52-year-old woman with acute cervical myelopathy and a cervical cutaneous hemangioma on clinical examination. It is stressed the importance of clinical suspicion of cutaneo-meningospinal angiomatosis based on a spinal cord syndrome in the presence of a vascular skin nevus of the same metameric level.

Idiopathic myenteric ganglionitis underlying acute 'dramatic' intestinal pseudoobstruction: report of an exceptional case

Inflammation of the myenteric plexus of the gastrointestinal tract is a very rare pathological condition, with few reports in the medical literature. This pathological condition causes atonic gut motor dysfunction and is principally secondary to other diseases, being reported nearly solely as a paraneoplastic phenomenon in neuroendocrine lung tumors, including small cell carcinomas or neuroblastomas. In addition it can also be associated with disorders of the central nervous system, although it has rarely been described in Chagas disease. It has been named ‘idiopathic myenteric ganglionitis’ because no apparent causes can be demonstrated. We report the clinicopathologic findings of an exceptional case of a young woman affected by severe chronic constipation suddenly changing into acute intestinal pseudoobstruction with dramatic evolution. Relationships between ganglionitis, idiopathic constipation and acute intestinal pseudoobstruction as well as therapeutic implications are discussed.

The finding of vascular and urinary anomalies in the harvested kidney for transplantation

INTRODUCTION

In kidney transplantation, anatomical vascular and excretory anomalies may represent causes of failure. Today's surgical techniques have made the most of the organs with anatomic anomalies and iatrogenic injury successfully used for transplantation.

MATERIALS AND METHODS

From January 2000 to June 2006, we harvested 230 kidneys, of including 88 kidneys (20%) with vascular, urinary, or vascular-urinary anomalies; 64 kidneys were implanted and 15 were sent to other transplantation centers. Only 9 kidneys were not appropriate for transplantation.

RESULTS

All patients who received kidneys with the above-mentioned anomalies were carefully examined after the transplantation and short-term and long-term complications were evaluated with respect to controls without anomalies.

DISCUSSION

Renal anatomic anomalies are frequently observed during kidney transplantation and may produce postsurgical complications. However, the presence of these anomalies does not necessarily imply the impossibility of using the kidney for a transplant, especially because of improved surgical techniques. Our experience in transplantation procedures showed that even if kidneys present the above-mentioned anomalies they can still be considered appropriate for transplantation when we perform a correct harvesting/back-table transplant surgery. So vascular and urinary anomalies have to be considered always an incentive to research new surgical solutions and to perform a careful surgical technique.

Older kidneys donor transplantation: five years' experience without biopsy and using clinical laboratory and macroscopic anatomy evaluation

INTRODUCTION

The exponential increase in organ demand is not associated with a similar increase of available kidneys. This emergency led to expanded criteria to consider a kidney transplantable. The aim of this retrospective study was to explain our use of older donor kidneys without biopsy.

MATERIALS AND METHODS

Between 2000 and 2005, 58 older kidneys were harvested: 27 were transplanted in our center; 13 were discarded; and 18 were transplanted in other centers. We considered 3 factors to define kidney quality: macroscopic anatomy, multiple factors linked to the donor, and clinical-laboratory data. After transplantation, we observed the patients for at least 1 year and up to 6 years.

DISCUSSION

At 1 year, 24/27 (89%) patients had a functional kidney, 2 patients showed an initial renal failure and 1 patient lost the kidney. At maximum follow-up, 19 patients (70%) had functional kidneys, 4 with initial renal failure. These results compared with the kidneys harvested using Standard Donor Kidney Criteria are acceptable. Obviously we need long-term follow-up to increase, the amount of data and obtain a definitive outcome.

CONCLUSION

Biopsy is the gold standard for the definition of an older kidney's quality. When a biopsy is not feasible, the study of the macroscopic anatomy the kidney's donor and of some donor's parameters represent an acceptable biopsy alternative, being able to rescue some organs that would be otherwise lost.

Healing of surgical incision in kidney transplantation: a single transplant center's experience

INTRODUCTION

Impaired healing of the surgical incision represents a common complication after kidney transplantation. We led a retrospective study seeking to understand the factors linked to these complications and reasons for their reduction during the last year.

PATIENTS AND METHODS

From January 2000 to April 2004, 170 consecutive kidney transplantations were performed in a homogenous patient population. We evaluated the influence of following factors to determine impaired healing of the incision: antirejection drugs, overweight/obesity, age, delayed graft function (DGF), diabetes, and abdominal wall reconstruction technique.

RESULTS

Among 165 patients we observed 26 (15.76%) cases of impaired healing of the surgical incision: 17 (65,38%) with first-level and nine with second-level wound complications.

CONCLUSIONS

Impaired healing of the surgical incision influences the outcome of kidney transplant patients. In our study we observed that cyclosporine and tacrolimus similary affected the incision's healing. It was not possible to evaluate the role of basiliximab. A univariate analysis of the factors related to complications revealed overweight and DGF. However, all patients developing second-level complications showed more risk factors. Patients who had not had reconstruction of the muscle layers showed a greater incidence of surgical complications, whereas patients who had skin sutured with an intradermic technique did not show an increased risk.

Difficult vascular conditions in kidney transplantation

The new dialytic and medical therapies have improved the survival of uremic patients and their preservation of a efficacious clinical condition so as to warrant suitability for transplantation, even after a long period of dialysis. In addition, today the use of a "marginal donor" and "marginal kidney" are often used to increase the pool of available organs, so that the surgeon must face more technical difficulties than in the past; anomalies of the donor kidney, harvesting and bench surgery damages, as well as vascular pathologies in the recipient. A review of our 151 renal transplantations from January 1999 to May 2003 showed that it was often possible to overcome these technical difficulties yielding good results. This work sought to demonstrate that neither "marginal donor"/"marginal kidney" used to expand donor pool nor recipient vascular pathologies should be considered transplant contraindications. Knowledge of various technical options and the ability to put them rapidly into practice are necessary to use any organ.

Transplantation and young surgeons in Italy

The relation between young surgeons and transplantation has always been a "love and hate" one. Until a few years ago this branch of surgery was seen as pioneering, with extreme and and extensive training, and was reserved to few elected members. Nowadays things are different. In this article we try to understand the true reasons that young Italian surgeons avoid transplantation surgery.

Cataract surgical coverage and outcome in the Tibet Autonomous Region of China

BACKGROUND

A recently published, population based survey of the Tibet Autonomous Region (TAR) of China reported on low vision, blindness, and blinding conditions. This paper presents detailed findings from that survey regarding cataract, including prevalence, cataract surgical coverage, surgical outcome, and barriers to use of services.

METHODS

The Tibet Eye Care Assessment (TECA) was a prevalence survey of people from randomly selected households from three of the seven provinces of the TAR (Lhoka, Nakchu, and Lingzhr), representing its three main environmental regions. The survey, conducted in 1999 and 2000, assessed visual acuity, cause of vision loss, and eye care services.

RESULTS

Among the 15,900 people enumerated, 12,644 were examined (79.6%). Cataract prevalence was 5.2% and 13.8%, for the total population, and those over age 50, respectively. Cataract surgical coverage (vision <6/60) for people age 50 and older (85-90% of cataract blind) was 56% overall, 70% for men and 47% for women. The most common barriers to use of cataract surgical services were distance and cost. In the 216 eyes with cataract surgery, 60% were aphakic and 40% were pseudophakic. Pseudophakic surgery left 19% of eyes blind (<6/60) and an additional 20% of eyes with poor vision (6/24-6/60). Aphakic surgery left 24% of eyes blind and an additional 21% of eyes with poor vision. Even though more women remained blind than men, 28% versus 18% respectively, the different was not statistically significant (p = 0.25).

CONCLUSIONS

Cataract surgical coverage was remarkably high despite the difficulty of providing services to such an isolated and sparse population. Cataract surgical outcome was poor for both aphakic and pseudophakic surgery. Two main priorities are improving cataract surgical quality and cataract surgical coverage, particularly for women.

Stop-flow technique for loco-regional delivery of high dose chemotherapy in the treatment of advanced pelvic cancers

AIM

To verify the rationale of a pelvic stop-flow technique for the perfusion of high-doses of mitomycin C and anthacyclines in patients with inoperable, recurrent pelvic cancer.

METHODS

The stop-flow technique was realized by using percutaneous double-balloon arterial-venous catheters that selectively isolate the pelvic vascular section and a perfusion provided by an extracorporeal pump for 20 min. Ten patients (pts) with unresectable pelvic recurrence from colon-rectal cancer were treated with a combination of Mitomycin C (MMC, 20 mg/sqm) plus doxorubicin (DOXO, 75 mg/sqm; 8pts) or epirubicin (EPI, 75 mg/sqm; 2pts) infused into the isolated pelvic compartment. Blood samples were collected from the extracorporeal vascular flow and from peripheral plasma, and analysed for drug quantitation.

RESULTS

During the procedure, there were no technical or hemodynamic complications, and no deaths occurred during surgery or in the postoperative period. MMC and DOXO peak levels measured in the extracorporeal system which irrotates the tumor area, were on average 21.6 (range: 4.3-44.3, MMC) and 17.2 (range: 1.8-48.4, DOXO) times higher than those observed in the peripheral blood. Similarly; the area under concentration (AUC) versus time curves measured in the pelvic compartment during stop-flow perfusion were 19.9 (range: 3.8-45.0, MMC) and 13.4 (range: 1.2-26.6, DOXO) times higher than the corresponding value in peripheral circulation. The drug percentage eliminated in the ultra filtrate was only 7.7% (MMC) and 0.9% (DOXO), and the plasmatic AUC(0-24) were similar to those observed with iv bolus of equivalent drug doses. Minimal systemic and local toxicities were observed. One complete pathological and 2 partial responses were observed; pain remission in 8/10 patients. median survival was 12 months (8-31).

CONCLUSION

The endo-arterial administration into the local vasculature produces high pelvic-systemic concentration gradients during the stop-flow perfusion with limited local and systemic toxicity. The encouraging clinical results suggest further evaluation.

Lymphoplasmacyte rich meningioma. A case report and review of the literature

A peculiar type of meningioma with conspicious plasma-cell components is described. In accordance with the World Health Organization's Histological Typing of Tumours of the Central Nervous System, this rare clinical entity is recently designed as lymphoplasmacyte rich (LPR) meningioma. This type of meningioma is usually accompanied by prominent peripheral blood abnormalities, anemia and/or policlonal gammophaty, that disappear after surgical removal of the tumor. Actually, the origin (neoplastic or inflammatory) of this tumor is unclear; its biological behavior and clinical course are anomalous so it is considered closer to intracranial inflammatory masses rather than typical meningioma. In this paper, a new case of intracranial LPR meningioma occurring in a woman, is reported and a review the literature is made.

[Non derivated surgery indications and limits in bile duct iatrogenic injuries treatment]

Recently the incidence of iatrogenic bile duct injuries has increased proportionally to development of the laparoscopic surgery. The objective of this study is to determine the possible application of non derivated surgical repairs in iatrogenic bile duct injuries treatment of the above procedures. These surgical approaches range from simply placing a surgical drainage to liver transplantation. With reference to Strasberg's classification non derivated treatments are listed, furthermore are discussed and analysed their indications and limits. Owing to their experience and specific literature, the authors came to the following conclusions: 1) These surgical options represent an ideal reconstruction technique because they restore bile ducts continuity without altering physiological mechanisms to which these anatomical structures are appointed. 2) The indications of applying these methods are rare and usually limited to those cases in which the lesion has been recognized during operation and in the immediate post operative period.

Body composition, fat distribution and metabolic characteristics in lean and obese women with polycystic ovary syndrome

The polycystic ovary syndrome (PCOS), characterized by chronic anovulation and hyperandrogenism, has many features of metabolic syndrome and can be considered a metabolic disease. Approximately 50% of patients with PCOS are overweight or obese with abdominal fat accumulation. Some metabolic alterations and abdominal fat distribution have also been reported in lean women with PCOS. The aim of this study was to evaluate the effect, if any, of obesity on metabolic features, body composition and fat distribution in patients with PCOS. Body composition and abdominal fat distribution (evaluated by DEXA), waist circumference, blood pressure, lipid profile, glucose tolerance and homeostasis model assessment index were determined in 23 lean [mean age 23 +/- 5 yr, mean body mass index (BMI) 22 +/- 2 kg/m2] and 27 overweight-obese (mean age 21 +/- 5 yr, mean BMI 32 +/- 5 kg/m2) patients with PCOS and in 20 age- and weight-matched eumenorrhoic women. Patients exhibited slight but non-significant differences in metabolic parameters, waist circumference, blood pressure and total and abdominal fat content compared with weight-matched controls. None of the lean subjects suffered from metabolic syndrome according to the National Cholesterol Education Program--Adult Treatment Panel III (NCEP-ATPIII) criteria as opposed to 10 overweight-obese patients and three overweight-obese control subjects (37% and 33.3% of each subgroup, respectively). Our data do not show significant metabolic alterations in lean PCOS women. Results indicate that obesity seems to underpin the metabolic alterations exhibited by the overweight-obese patients. However, since women with PCOS are at increased cardiovascular risk, further studies are needed to evaluate metabolic alterations and body composition in these patients.

Suboptimal kidney: the experience of a single transplant unit

Not all kidneys are suitable for transplantation. In 2001 in Italy, only 1530 of 1748 organs were transplanted. This difference (-12.5%) not only represents organs harvested from marginal donors considered not suitable, but also kidneys that, although collected from standard donors, had a vascular, parenchymal, or urologic anomaly that made them unsuitable for transplantation. In our center, we established a procedure that defined the characteristics of suboptimal kidneys and allowed us to specifically select the appropriate recipient. We considered as suboptimal all organs with complex arterial anomalies (more than 2 arteries although on a single patch or separated such as to need a double anastomosis or a bench reconstruction); organs with noticeable parenchymal damage (macroscopic sclerosis areas or sutured polar branches accidentally damaged during removal), and organs with complex anomalies of the excretory tract (complete double district). The organs were not considered as suboptimal if they had venous anomalies revised on the bench or if they had a double artery with a single patch <2.5 cm. Such organs were transplanted to recipients who were between 55 and 60 years of age with a body weight of at least 20% less than the donor, and female.

Blindness and eye diseases in Tibet: findings from a randomised, population based survey

BACKGROUND

Public health officials of the Tibet Autonomous Region (TAR) of China requested a survey of blindness, eye diseases, and eye care service utilisation to assist the development of a 10 year blindness prevention and treatment plan. The objective of the survey was to determine the prevalence of blindness and visual impairment, as well as cataract surgical coverage and surgical outcome in the TAR.

METHODS

The Tibet Eye Care Assessment was a cross sectional prevalence study of three of the seven prefectures (provinces) of the TAR (Lhoka, Nakchu, and Lingzhr) selected to represent its three main environmental regions. The survey sample was selected using a random multistage cluster method. Two teams conducted the survey in a standardised fashion in each prefecture, Lhoka during May and Nakchu during June 1999, and Lingzhr during May 2000. Visual acuity, cause of vision loss, trachoma, and vitamin A deficiency were included in the clinical examination.

RESULTS

Among the 15,900 people enumerated, 12,644 were examined for an overall response rate of 79.6%. The crude prevalence of blindness (presenting better eye visual acuity of less than 6/60) was 2.3%; age and sex adjusted blindness prevalence was 1.4% (95% CI 1.3 to 1.5). Visual impairment (better eye presenting visual acuity of 6/24 to 6/60) was found in 10.9% (95% CI 10.5 to 11.2) of the population (age and sex adjusted). Cataract was the primary cause of blindness (50.7%), followed by macular degeneration (12.7%) and corneal opacity (9.7%).

CONCLUSION

Blindness is a serious public health problem in Tibet, with prevalence higher than in similar studies in eastern China. As elsewhere in the world, women have an excess burden of blindness compared to men. About 75% of blindness in Tibet can be either prevented or treated. Eye care planning for Tibet must focus on cataract, particularly among women.

Bilateral chronic subdural hematoma associated with meningioma. Case report and review of the literature

Gross intracranial hemorrhage associated with brain tumor has been reported to range from 3.6-10%. Brain metastases and malignant glioma are the most frequent underlying pathologies. Intracranial hemorrhage related to meningioma is a rare condition. Subarachnoid hemorrhage, acute subdural hematoma, intratumoral and intraparenchymal hematomas are the most common forms of bleeding associated with meningioma. By contrast, chronic subdural hematoma (cSDH) and intraventricular hemorrhage are seen less frequently. The authors report a very rare case of left fronto-parietal convexity meningioma associated with bilateral cSDH in a patient with history of recent minor head trauma and review the literature on hemorrhage associated with meningiomas.

[Our experience with treatment of varicocele in a day-surgery protocol]

In the last few years the increasing interest for non-invasive operating techniques has allowed to reevaluate the sublinguinal varicocelectomy surgical technique for idiopathic varicocele surgical treatment. During the years 1998-2001, 29 patients have been operated on sub-inguinal varicocelectomy (14 patients were suffering from idiopathic varicocele of third grade, 11 of second grade, 3 of first grade, and 1 subclinical). Out of the 29 patients, only 10 were unable to procreate. All patients were operated under local anesthesia and discharged the same day (day-surgery). Owing to Authors' experience, the sublinguinal varicocelectomy by optical magnifying devices represents the "gold standard" in the idiopathic varicocele treatment because it allows to minimize relapsing rates, to limit post-operation complications, to improve the reproductive faculty of seminal fluid both qualitatively and quantitatively, to cut patient's operating costs significantly, to keep the operation time within acceptable limits, and to be easily learned and carried out.

Endoscopic release in carpal tunnel syndrome: analysis of clinical results in 200 cases

Carpal tunnel syndrome is the most common peripheral neuropathy. Conventional carpal tunnel surgery has been performed as a primary procedure for the decompression of the median nerve at the wrist in patients who have idiopathic carpal tunnel syndrome. While the results have been excellent, this surgical procedure has been reported to be related to high postoperative morbidity and extended length of recovery time. Over the past decade, endoscopic release of the transverse carpal ligament has been developed as a new, alternative method to the open procedures. Endoscopic carpal tunnel release has been reported to ensure less postoperative morbidity, more rapid recovery of strength, with earlier return to work, reduced disability time and a better cosmetic result. The authors present a surgical series of 200 hands in 164 patients (36 bilaterals) with idiopathic carpal tunnel syndrome, who underwent a single-portal endoscopic carpal tunnel release (Agee technique), with regards to the clinical outcome and complications occurred after 4-months follow-up.

Paravertebral retropleuric microsurgery approach to the treatment of thoracic disc herniation. Personal experience and consideration of unsatisfactory results

AIM

The authors report their experience on the paravertebral retropleuric microsurgery approach to the treatment of thoracic disc herniation. The paper describes both the approach and its result and it further expands on the reason behind the few cases of unsatisfactory results.

METHODS

Twenty-three patients were operated upon for thoracic disc herniation between 1994 and 2000. The paravertebral retropleuric microsurgery approach was used in each.

RESULTS

The results were very satisfactory in 20 cases, with all symptoms completely disappearing. In only 3 cases we had unsatisfactory results.

CONCLUSION

We think that the postero-lateral retropleuric approach is a correct method for the treatment of thoracic disc herniation because it did not cause any significant bone intervention.

Human herpesvirus 8 DNA in the cerebrospinal fluid of a patient with sensory impairment

This note reports the finding of human herpes virus 8 DNA in the cerebrospinal fluid of a woman with sensory impairment correlated with a basal disease suspected to be multiple sclerosis.

[Functional results of colorectal and coloanal anastomosis with and without pouch]

In the last two decades one of the main targets of anorectocolonic surgery has been to develop sphincter saving procedure able to achieve good results with acceptable five-years survivals, optimal local control of the diseases and low rate of local cancer recurrence. Partially the development of new operative techniques such as low colorectal and coloanal anastomoses with or without pouch, the TME operation and the nerve sparing procedure have reach this target. In fact, often after these operations we can observe a functional syndrome called "Post Anterior Resection Syndrome". The basis of this syndrome have to researched in anatomical and physiological alterations that followed a reconstructive operation. It is characterized by frequency and fragmentation of the stool, feeling of incomplete evacuation, tenesmus and urgency. Fecal continence may be compromised to different levels: usually with alteration limited to soiling and impaired control of flatus, occasionally with loss of liquid stool, rarely with loss of solid stools. The anorectal function will be altered for long time following the surgical procedure and the stabilization of functional results may require 1-3 years. On the basis of these considerations, the authors examine the etiopathogenesis and clinical presentation of the "Post Anterior Resection Syndrome", suggesting some expedients to prevent the functional problems. Analysing our experience and a wide specific bibliography, they also underline the indispensable point to achieve a good functional results after a reconstructive procedure. The author conclude asserting that the absence of these points have to be carefully valued because, in these situations, a simply colostomy is able to guarantee a better quality of life that a colorectal/coloanal anastomoses with or without pouch but associated to functional problems.

Phase I dose escalation study of gemcitabine and paclitaxel plus colony-stimulating factors in previously treated patients with advanced breast and ovarian cancer

Gemcitabine and paclitaxel (PTX) are among the most active new drugs in advanced breast and ovarian cancer. In this Phase I study, we used fixed doses of gemcitabine administered on days 1 and 8 and escalating doses of paclitaxel on day 1 of a 21-day cycle in patients with pretreated metastatic breast or ovarian cancer. The dose of gemcitabine was fixed at 1,000 mg/m2; PTX was commenced in the first small patient group at a dose of 90 mg/m2, which was then escalated in subsequent groups by 30 mg/m2 per step. From the third dose level onwards, all patients received granulocyte colony-stimulating factor 300 microg by subcutaneous injection on days 5 and 6, and granulocyte macrophage colony-stimulating factor on days 15-18. Cohorts of at least 3 patients were treated at each dose level. Dose escalation was stopped if at least a third of the patients in a given cohort had dose-limiting toxicity (DLT), which was defined as grade 4 neutropenia or thrombocytopenia, or grade 3-4 non-haematological toxicity. The maximum tolerated dose (MTD) was defined as the dose level immediately below that causing DLT in one-third of the patients or more. Evaluation of the tumour response was performed every three cycles. Forty-five patients (31 with breast cancer, 14 with ovarian cancer) were treated at seven different dose levels. Only at the seventh PTX dose level was DLT observed after the first course of therapy: three grade 4 neutropenia, one grade 4 thrombocytopenia, and one grade 4 anaemia. DLT occurred in 5/6 patients at at PTX dose of 270 mg/m2; therefore dose escalation was stopped at that level and the dose immediately before it (PTX 240 mg/m2) was considered as the MTD and recommended for further studies. No toxic deaths occurred. Grade 3-4 uncomplicated neutropenia was observed in four patients. Three had uncomplicated grade 3-4 thrombocytopenia. One patient had grade 3 and one grade 4 anaemia. Nonhaematological side effects were generally mild. Among 30 evaluable patients with metastatic breast cancer, four complete responses (CR) (13%) and 12 partial responses (PR) (40%) were observed, for an overall response rate of 53% (95% confidence interval (CI) 34-72). The median duration of response was 31 weeks. Among 13 evaluable patients with advanced ovarian cancer, one CR (8%) and five PRs (38%) were observed, for an overall response rate of 46% (95% CI 19-78). The median duration of response was 32 weeks. Our study shows that gemcitabine and PTX can be administered in combination in patients with breast and ovarian cancer without unexpected toxicities and with encouraging therapeutic results.

[Extended total gastrectomy: indications in the 3rd millennium]

BACKGROUND

Total extended gastrectomy (TEG) is indicated in the treatment of gastric cancer for necessity or to achieve an oncologic radicality. By this surgical treatment the stomach and other organs or a part of them involved by primitive tumor are removed.

METHODS

The authors report a study about 15 patients, out of 116 cases of gastric cancer, operated by TEG between 1990-1998. The middle-age of this patients was 63 years (range 45-76) and their general conditions were good in 9 cases and not-good in 6. The postoperative total parenteral nutrition (TPN) was carried out in all the patients, while preoperatively only in the most compromised patients. The surgical treatments were: 2 TG (total gastrectomy)+splenecomy; 3 TG+splenectomy+pancreatic resection; 4 TG+splenectomy+pancreatic resection+distal esophageal resection; 1 TG+distal esophageal resection; 2 TG+atypic hepatic resection; 1 TG+ atypic hepatic resection+duodenum resection; 2 TG+large intestine resection. While 10 patients were operated on to obtain radicality, 5 patients had a palliative treatment.

RESULTS

There was not perioperative mortality, but we have observed: one dehiscence of the duodenal stump and one pancreatic fistula treated with conservative therapy; one left subfrenic abscess treated with surgical therapy. The survival has been higher in the patients treated with radicality. On the basis of these cases, the authors consider: 1) the possibility to obtain radicality by TEG; 2) the gastric localizations more often associated to extravisceral neoplastic localization; 3) the role of extensive lymph node resection (III and IV level) to obtain oncological radicality or neoplastic reduction. CONCLUSIONS. On the basis of their personal experience and related literature, the authors conclude that TEG is indicated to: 1) obtain a better lymphadenectomy; 2) obtain an oncologic radicality; 3) reduce the neoplastic mass in order to facilitate adjuvant therapy; 4) avoid or treat neoplastic complications; 5) improve the quality of life.

[Benign unclassified tumor of the gonadal stroma: importance of alpha-inhibin expression]

We present a begin unclassified gonadal stroma tumor in a 62 year-old menopausal woman. We discuss the differential diagnosis with the most frequent fibromas and thecomas and with the rarer sclerosing stromal tumor of the ovary. The immunohistochemical staining for alpha-inhibin was important to confirm the origin of the spindle-cell proliferation from undifferentiated (unclassified) ovarian gonadal stroma.

Effects of chronic levodopa and pergolide treatment on cortical excitability in patients with Parkinson's disease: a transcranial magnetic stimulation study

OBJECTIVES

Transcranial magnetic stimulation was used to assess the effects of chronic levodopa and pergolide treatment on motor cortex excitability in Parkinson disease (PD).

METHODS

Motor thresholds, intracortical inhibition and facilitation were studied at baseline and after 6 and 12 months of therapy in 10 PD patients and compared to 7 age-matched controls.

RESULTS

At baseline, there was significantly less intracortical inhibition with only a slight reduction of intracortical facilitation in PD as compared to controls. Relative to pretreatment condition, levodopa restored intracortical inhibition for 12 months while pergolide did not. Intracortical facilitation was always within the normal range. Motor thresholds were unchanged in both groups of patients over 12 months. Clinically, levodopa and pergolide improved motor Unified Parkinson's disease rating scale (UPDRS) scores at 6 months but only levodopa maintained benefit at 12 months as compared to baseline.

CONCLUSIONS

Levodopa and pergolide differentially affected cortical inhibitory circuits at 12 months. The progressive deterioration of restored intracortical inhibition with pergolide may be due to the development of tolerance and down-regulation of dopamine receptors.

[Morgagni-Larrey diaphragmatic hernia: report of a case]

The Authors presents a Morgagni-Larrey's diaphragmatic hernia case, observed during subocclusive manifestation. They emphasize the utility to perform always the surgical intervention, also in the asintomatic cases.

[Meigs' syndrome: its clinical picture and treatment]

Meigs' syndrome is a rare clinical entity characterised with ovarian benign tumour, ascites and hydrothorax. Between January '94-September '98 we observed three patients with: ovarian neoformation, light (1 patient), moderate (2 patients) monolateral pleural effusion, moderate (2 patients) and considerable (1 patient) ascites. In all patients the preoperative evaluation (sero-haematologic routine, Ca 125 and other oncologic markers, chest X-ray, abdominal and pelvic ultrasonography, total-body Tc, cytological analysis of pleural and abdominal effusion) was suggestive for malignancy but not confirmed it. So an explorative laparotomy with histological extemporary analysis was performed. The results were: 1 fibrothecomas, 1 fibroma, 1 ovarian inflammation with cystic luteinization areas and fibromatosis uterine. All three patients had a good postoperative course. The symptomatology and the effusions disappeared 7-10 days after operation. The first two cases were diagnosed as classic Meigs' syndrome, the third one, instead, as a pseudo-Meigs's syndrome. In conclusion the A.A., according to literature and their experiences, underline: 1) an ovarian mass with pleural and abdominal effusion not always represents an advanced malignancy; 2) even if elevated Ca 125 value is usually associated to a ovarian malignancy, there are some benign lesions in which we observed elevated level of this marker 3) the removal of the ovarian mass is the only resolutive treatment for these patients.