Field demonstration for the solvent-based sampling method to perform compound-specific isotope analysis on gas-phase VOC

The solvent-based sampling method for collecting gas-phase volatile organic compounds (VOCs) and conducting compound-specific isotope analysis (CSIA) was deployed during a controlled field study. The solvent-based method used methanol as a sink to accumulate petroleum hydrocarbons during the sampling of soil air and effluent gas. For each gaseous sample collected, carbon isotope analysis (δ13C) was conducted for a selection of five VOCs (benzene, toluene, o-xylene, cyclopentane and octane) emitted by a synthetic hydrocarbon source emplaced in the subsurface. The δ13C values obtained for gaseous VOCs (collected from soil gas and effluent gas) were compared to measurements obtained for the same VOCs present in the source material (none aqueous phase liquid - NAPL) and dissolved in groundwater to evaluate the reliability of the solvent-based sampling method in providing accurate isotope measurements. Since the NAPL source was composed of only 12 VOCs, potential bias related to the analytical procedure (such as co-elution) were avoided, hence emphasizing on field-related bias. This field evaluation demonstrated the capacity of the solvent-based method to produce precise and accurate δ13C measurements. The isotopic discrepancies between the gaseous and the NAPL values were < 1 ‰ for 39 out of the 41 comparison points, thus deemed not statistically different based on a common isotopic uncertainty error of ±0.5 ‰. Moreover, the current field study is the first field study to report δ13C measurements for up to five gas-phase VOCs obtained from the same sample, which appears to be of interest for VOC fate or forensic studies. The possibility to use several VOC isotopic measurements enabled by the sampling method would contribute to strengthen the connection assessment between gaseous VOCs and the suspected emitting source. Accordingly, the field results presented herein support the application of this sampling methodology to conduct CSIA assessment in the frame of VOC vapor studies.

Unravelling long-term source removal effects and chlorinated methanes natural attenuation processes by C and Cl stable isotopic patterns at a complex field site

The effects of contaminant sources removal in 2005 (i.e. barrels, tank, pit and wastewater pipe sources) on carbon tetrachloride (CT) and chloroform (CF) concentration in groundwater were assessed at several areas of a fractured multi-contaminant aquifer (Òdena, Spain) over a long-term period (2010-2014). Changes in redox conditions, in these chlorinated methanes (CMs) concentration and in their carbon isotopic compositions (δ¹³C) were monitored in multilevel wells. δ¹³C values from these wells were compared to those obtained from sources (barrels, tank and pit before their removal, 2002-2005) and to commercial solvents values in literature. Additionally, CMs natural attenuation processes were identified by C-Cl isotope slopes (Λ). Analyses revealed the downstream migration of the pollutant focus and an efficient removal of DNAPLs in the pit source's influence area. However, the removal of the contaminated soil from former tank and wastewater pipe was incomplete as leaching from unsaturated zone was proved, evidencing these areas are still active sources. Nevertheless, significant CMs degradation was detected close to all sources and Λ values pointed to different reactions. For CT in the tank area, Λ value fitted with hydrogenolysis pathway although other possible reduction processes were also uncovered. Near the wastewater pipe area, CT thiolytic reduction combined with hydrogenolysis was derived. The highest CT degradation extent accounted for these areas was 72 ± 11% and 84 ± 6%, respectively. For CF, the Λ value in the pit source's area was consistent with oxidation and/or with transport of CF affected by alkaline hydrolysis from upstream interception trenches. In contrast, isotope data evidenced CF reduction in the tank and wastewater pipe influence areas, although the observed Λ slightly deviates from the reference values, likely due to the continuous leaching of CF degraded in the non-saturated zone by a mechanism different from reduction.

37Cl-compound specific isotope analysis and assessment of functional genes for monitoring monochlorobenzene (MCB) biodegradation under aerobic conditions

A laboratory approach was adopted in this study to explore the potential of ³⁷Cl-CSIA in combination with ¹³C-CSIA and Biological Molecular Tools (BMTs) to estimate the occurrence of monochloroenzene (MCB) aerobic biodegradation. A new analytical method for ³⁷Cl-CSIA of MCB was developed in this study. This methodology using a GC-IRMS allowed to determine δ³⁷Cl values within an internal error of ±0.3‰. Samples from a heavily MCB contaminated site were collected and MCB aerobic biodegradation microcosms with indigenous cultures in natural and enhanced conditions were set up. The microcosms data show a negligible fractionation for ¹³C associated to MCB mass decrease of >95% over the incubation time. Conversely, an enrichment factor of -0.6±0.1‰ was estimated for ³⁷Cl, which is a reflection of a secondary isotope effect. Moreover, the dual isotope approach showed a pattern for aerobic degradation which differ from the theoretical trend for reductive dehalogenation. Quantitative Polymerase Chain Reaction (qPCR) results showed a significant increase in todC gene copy number with respect to its initial levels for both natural attenuation and biostimulated microcosms, suggesting its involvement in the MCB aerobic degradation, whereas phe gene copy number increased only in the biostimulated ones. Indeed, ³⁷Cl fractionation in combination with the dual carbon‑chlorine isotope approach and the todC gene copy number represent valuable indicators for a qualitative assessment of MCB aerobic biodegradation in the field.

A sneaky surgical emergency: Acute compartment syndrome. Retrospective analysis of 66 closed claims, medico-legal pitfalls and damages evaluation

BACKGROUND

Acute compartment syndrome (ACS) is a clinical condition with potentially dramatic consequences, therefore, it is important to recognise and treat it early. Good management of ACS minimises or avoids the sequelae associated with a late diagnosis, and may also reduce the risk of malpractice claims. The aim of this article was to evaluate different errors ascribed to the surgeon and to identify how the damage was evaluated.

MATERIALS AND METHODS

A total of 66 completed and closed ACS cases were selected. The following were analysed for each case: clinical management before and after diagnosis of ACS, imputed errors, professional fault, damage evaluation and quantification. Particular attention was paid to distinguishing between impairment because of primary injury and iatrogenic impairment. Statistical analyses were performed using Fisher's exact test and Pearson's correlation.

RESULTS

The most common presenting symptom was pain. Delay in the diagnosis, and hence delay in decompression, was common in the study. A total of 48 out of 66 cases resolved with the verdict of iatrogenic damage, which varied from 12% to 75% of global capability of the person. A total of $394,780 out of $574,680 (average payment) derived from a medical error.

CONCLUSIONS

ACS is a clinical emergency that requires continuous clinical surveillance from both medical and nursing staff. The related damage should be evaluated in two parts: damage deriving from the trauma, so that it is considered inevitable and independent from the surgeon's conduct, and damage deriving from a surgeon's error, which is eligible for an indemnity payment.

Multi-isotope (carbon and chlorine) analysis for fingerprinting and site characterization at a fractured bedrock aquifer contaminated by chlorinated ethenes

The use of compound specific multi-isotope approach (C and Cl) in the characterization of a chlorinated ethenes contaminated fractured aquifer allows the identification of several sources and contaminant plumes, as well as the occurrence of biodegradation and mixing processes. The study site is located in Spain with contamination resulting in groundwater concentrations of up to 50mg/L of trichloroethene (TCE), the most abundant chlorinated ethene, and 7 mg/L of tetrachloroethene (PCE). The potential sources of contamination including abandoned barrels, an underground tank, and a disposal lagoon, showed a wide range in δ(13)C values from -15.6 to -40.5‰ for TCE and from -18.5 to -32.4‰ for PCE, allowing the use of isotope fingerprinting for tracing of the origin and migration of these contaminants in the aquifer. In contrast, there is no difference between the δ(37)Cl values for TCE in the contaminant sources, ranging from +0.53 to +0.66‰. Variations of δ(37)Cl and δ(13)C in the different contaminant plumes were used to investigate the role of biodegradation in groundwater. Moreover, the isotopic data were incorporated into a reactive transport model for determination of whether the isotope pattern observed downstream from the tank's source could be explained by the simultaneous effect of mixing and biodegradation. The results demonstrate that a multi-isotope approach is a valuable tool for characterization of complex sites such as fractured bedrock aquifer contaminated by multiple sources, providing important information which can be used by consultants and site managers to prioritize and design more successful remediation strategies.

The use of alkaline hydrolysis as a novel strategy for chloroform remediation: the feasibility of using construction wastes and evaluation of carbon isotopic fractionation

Laboratory and field-scale pilot experiments were performed to evaluate the feasibility of chloroform degradation by alkaline hydrolysis and the potential of δ(13)C values to assess this induced reaction process at contaminated sites. In batch experiments, alkaline conditions were induced by adding crushed concrete (pH 12.33 ± 0.07), a filtered concrete solution (pH 12.27 ± 0.04), a filtered cement solution (pH 12.66 ± 0.02) and a pH 12 buffer solution (pH 11.92 ± 0.11). The resulting chloroform degradation after 28 days was 94, 96, 99, and 72%, respectively. The experimental data were described using a pseudo-first-order kinetic model, resulting in pseudo-first-order rate constant values of 0.10, 0.12, 0.20, and 0.05 d(-1), respectively. Furthermore, the significant chloroform carbon isotopic fractionation associated with alkaline hydrolysis of chloroform (-53 ± 3‰) and its independence from pH in the admittedly limited tested pH range imply a great potential for the use of δ(13)C values for in situ monitoring of the efficacy of remediation approaches based on alkaline hydrolysis. The carbon isotopic fractionation obtained at the lab scale allowed the calculation of the percentage of chloroform degradation in field-scale pilot experiments where alkaline conditions were induced in two recharge water interception trenches filled with concrete-based construction wastes. A maximum of approximately 30-40% of chloroform degradation was achieved during the two studied recharge periods. Although further research is required, the treatment of chloroform in groundwater through the use of concrete-based construction wastes is proposed. This strategy would also imply the recycling of construction and demolition wastes for use in value-added applications to increase economic and environmental benefits.

Carbon isotope fractionation of 1,1,1-trichloroethane during base-catalyzed persulfate treatment

The extent of carbon isotope fractionation during degradation of 1,1,1-trichloroethane (1,1,1-TCA) by a base-catalyzed persulfate (S₂O₈(2-)) treatment system was investigated. Significant destruction of 1,1,1-TCA was observed at a pH of ∼12. An increase in the NaOH:S₂O₈(2-) molar ratio from 0.2:1 to 8:1 enhanced the reaction rate of 1,1,1-TCA by a factor of ∼5 to yield complete (>99.9%) destruction. An average carbon isotope enrichment fractionation factor which was independent of the NaOH:S₂O₈(2-) molar ratio of -7.0 ± 0.2‰ was obtained. This significant carbon isotope fractionation and the lack of dependence on changes in the NaOH:S₂O₈(2-) molar ratio demonstrates that carbon isotope analysis can potentially be used in situ as a performance assessment tool to estimate the degradation effectiveness of 1,1,1-TCA by a base-catalyzed persulfate system.

Carbon isotope fractionation of chlorinated ethenes during oxidation by Fe2+ activated persulfate

The increased use of persulfate (S(2)O(8)(2-)) for in situ chemical oxidation to treat groundwater and soils contaminated by chlorinated hydrocarbon compounds (CHCs) requires unbiased methods to assess treatment performance. Stable carbon isotope analysis offers a potential tool for assessing the in situ treatment performance of persulfate at sites contaminated with CHCs. This study investigated the extent of C isotope fractionation during oxidation of tetrachloroethene (PCE), trichloroethene (TCE) and cis-dichloroethene (cis-DCE) by persulfate activated by ferrous ion (Fe(2+)). An average carbon isotope enrichment factor ε(bulk) of -4.9‰ for PCE, -3.6‰ for TCE and -7.6‰ for cis-DCE were obtained in batch experiments. Variations in the initial S(2)O(8)(2-)/Fe(2+)/CHC molar ratios did not result in any significant differences in carbon isotope fractionation. The occurrence of carbon isotope fractionation during oxidation and the lack of dependence of enrichment factors upon the S(2)O(8)(2-)/Fe(2+)/CHC molar ratio demonstrate that carbon isotope analysis can potentially be used at contaminated sites as an additional technique to estimate treatment efficacy during oxidation of CHCs by Fe(2+) activated persulfate.

Mammaplasties and medicolegal issues: 50 cases of litigation in aesthetic surgery of the breast

BACKGROUND

Aesthetic surgery procedures are increasing all over the world, and so are related medicolegal questions and litigation cases. Aesthetic mammaplasties represent a very important part of this field and consequently many cases of error appear. Most of these errors lead to litigation from which plastic surgeons rarely can be exonerated. The aim of this article was to evaluate different errors ascribed to the plastic surgeon, the rate of cases in which professional responsibility has been identified, and the type of guilt imputed.

METHODS

Each case is based on the evaluation of both documentation used by the judge and the relationships of two specialists involved in the assessment of the presumed error. In every case, problems complained about by the patient and the eventually related error of the surgeon were analyzed. Moreover, the eventual identification of professional responsibility, the quantified damage, and its possible reduction by another corrective operation were considered.

RESULTS

The cases studied (N=50) were divided into 34 cases of augmentation mammaplasty, 11 cases of reduction mammaplasty, and 5 cases of mastopexy. Most of the problems complained about by patients were in the preoperative and intraoperative phases. In only 10% of the cases was the informed consent contested and an expected reduction of the damage was individuated in less than half of cases.

CONCLUSIONS

The evaluation of aesthetic damage is a tricky question due to different aspects such as the psychological component or the frequent lack of adequate photographic documentation of the patient before the operation. Moreover, whenever possible reduction of the damage is proposed, the patient's willingness to undergo another operation, with all its related costs and benefits, must be considered.

Blue-dye sentinel node mapping in thyroid carcinoma: debatable results of feasibility

The present study aims to investigate the feasibility and influence of the lymphatic mapping and sentinel node biopsy on determination of the nodal status in thyroid carcinoma using blue-dye method. Nine consecutive patients with cytological diagnosis of papillary carcinoma were included in this study. To detect the sentinel lymphnode, intra- or perinodular injection of an average quantity of 0.5 ml (range : 0.1-1.2) of Ble Patenté V was performed intraoperatively in 8 cases only, as in one case a solitary cystic nodule occupied the entire lobe and thus any injection was impossible. After an average time of 16 minutes (range : 5-25) before dissection of the thyroid , no lymphnodes and no lymphatic afferent thereto visibly coloured were evidenced, except for spread of the vital dye into adjacent tissue and disrupted blood and lymphatic vessels at the injection site. Our results evidence that : intranodular injection, does not allow proper diffusion of the dye in the adjacent parenchyma, and in nodules smaller than 1 cm it may be difficult ; and that it is hazardous in cystic nodule because of the rupture risk; perinodular injection, at the four cardinal points, is impossible when the nodule occupies the entire lobe or the isthmus; multinodular goiter complicates the identification by palpation of the neoplastic nodule in which the dye should be injected or, if perinodular injection is given, to detect the parenchyma surrounding the nodule.

Courtship displays and mounting calls are honest, condition-dependent signals that influence mounting success in Hermann's tortoises

Like other terrestrial tortoises, the courtship behaviour of Hermann's tortoises (Testudo hermanni Gmelin, 1789) is based on a multiple signalling system that involves visual, olfactory, tactile, and acoustic signals. In this study, we analysed relationships between male morphology, hematological profile, courtship intensity, vocalizations, and mounting success in Hermann's tortoises breeding in semi-natural enclosures to investigate the effects of male condition on signals exhibited during courtship and on their mounting success. Results showed that mounting success of Hermann's tortoise males was positively affected by the number of sexual interactions/h, number of bites given to the female during interactions, and by call rate and frequency-modulation range. Call rate, frequency-modulation range, and number of sexual interaction/h increased with hematocrit value, while number of bites given to females decreased with leukocyte concentration. In conclusion, courtship signals exhibited by Hermann's tortoise males, including vocalizations, reliably reveal different components of male condition, and females may use these multiple traits to choose high-quality partners. This is the first study documenting the condition-dependent nature of tortoise courting signals and their effect on male mounting success.

[Evaluation of the higher brain functions in 1st and 7th grade schoolchildren belonging to two different socioeconomic groups]

INTRODUCTION

The higher brain functions, together with the devices that sustain them, are essential assets belonging to human beings which are used to situate themselves in the world. They can be studied by conducting neuropsychological tests, the results of which vary according to demographic factors, such as age, sex, hand dominance, culture and level of schooling. The socioeconomic level (SEL) is another factor to be taken into account and must also be evaluated.

AIMS

Our objective was to evaluate and analyse the influence of SEL on the results obtained from neuropsychological tests carried out in normal school-age children.

SUBJECTS AND METHODS

We studied 401 normal children, of both sexes, taken at random, at the beginning (1st grade, 6 years old) and at the end (7th grade, 12 years old) of elementary school and belonging to two different SEL: high and low. Schools belonging to different categories were selected: public, private, urban and suburban. A battery of tests that is commonly used in Neuropsychology was utilised to evaluate laterality, spatial orientation, integration (Bender's test and the Rey figure test), attention, memory and the areas of language, gnosis and praxis.

RESULTS

Significant differences were found in relation to the SEL in the 1st and 7th grade tests: 20/27 (74%) and 17/27 (62%), respectively. These always meant lower results in the low SEL, except body scheme, ideomotor praxis and phonological coding, which in the 7th grade run in the opposite direction. Results were not related to the type of school (urban-suburban, public-private), sex, laterality or teachers' characteristics. Differences were more striking in the area of language, basic devices (attention, memory) and in the tests that integrate several different functions (Bender's test, Rey figure test).

CONCLUSIONS

SEL is linked to the results obtained in neuropsychological evaluation tests. There is a direct relationship with low results in the low level. There is also a correlation between certain family characteristics associated to the SEL and the scores in the cognitive evaluation tests.

Evaluation of a soft atherosclerotic lesion in the rabbit aorta by an invasive IVUS method versus a non-invasive MRI technology

The intravascular ultrasound (IVUS) modality has rapidly gained acceptance for the measurement of arterial plaque thickness and for anatomical characterization. In view, however, of the growing interest in the direct assessment of plaque size after therapeutic modalities directly reducing plaque burden, a non-invasive method such as magnetic resonance imaging (MRI) may be of help for repeated evaluations. The two methods were compared directly on a focal plaque developed at the abdominal aortic level by a combination of local electric lesion followed by a hypercholesterolemic diet. The plaque was fully characterized histopathologically at intervals up to 120 days from lesion induction, and maximal plaque formation was detected at 90 days from electrical injury. Plaques could be well assessed by IVUS at each time point analyzed and data correlated very well to histopathologic findings (r = 0.969, P = 0.0014). The MRI technology provided reliable determinations only at 90 days after lesion induction, i.e. at maximal plaque formation, with excellent correspondence to IVUS determinations (r = 0.989, P = 0.0111). Altogether these findings indicate that the non-invasive MRI technology, when applied to the analysis of arterial plaques of adequate size, can be used successfully for plaque determination, with results comparable to the invasive IVUS technique.

[Synchronous colorectal and renal tumors: two case reports]

The simultaneous presence of more than one primary malignant tumour in the same patient is a relatively rare event, with values going from 2.7% to 6.8%. In this paper two synchronous colorectal-renal cases surgically treated are described; in the first case with only one resolutive operation for the two tumours, in the second with two consecutive operations. In both cases, the patients had no familiarity for colorectal or renal malignant tumours. Both cases have paradigmatic peculiarities: in the first the discovery of the renal neoplasm has been possible in election during the normal execution of the diagnostic protocol for sigmoido-rectal neoplasm. The second case shows the other possible modality of the outset of the two tumours: the occlusive urgency which never allows to discover immediately the renal tumour (unless a laparotomic exploration makes it perceptible).

[Peripheral arterial disease in a population of type 2 diabetic patients: its correlation with diabetic microangiopathy and laboratory parameters]

BACKGROUND

The aim of this study was to evaluate the incidence of peripheral arterial disease (PAD) in a population of type 2 diabetic patients (NIDDM) and its possible correlation with diabetic nephropathy (DN), diabetic retinopathy (DR) and also with some biochemical parameters of glomerular and tubular renal function.

METHODS

The study included a total of 150 NIDDM patients, randomly selected, who have been followed-up at the Metabolic Center of our Division. All patients underwent assessment of the ankle/brachial pressure index (ABI) and Doppler ultrasound of the lower extremities. They were then divided into 2 groups: Group 0 without PAD and Group 1 with PAD. They also underwent a echo color-Doppler study of the renal interlobar arteries in order to evaluate the resistive index (RI), while the retinal vessels were assessed by biomicroscopy and fluorangiography.

RESULTS

The incidence of PAD in this study was 30.6%, occurring on average 14 years from the onset of diabetes, and affecting particularly patients with nephropathy. The presence of both albuminuria and retinopathy in the same patient increases by 8.9 times the risk of cardiovascular disease.

CONCLUSIONS

The RI, measured at the level of the intrarenal arteries, is of great interest as a marker not only of renal vascular damage in NIDDM patients, but also of a generalized vascular involvement.

The role of Bayesian Networks in the diagnosis of pulmonary embolism

Pulmonary embolism (PE) is a life-threatening condition and, despite advances in diagnostic technology, it remains an elusive diagnosis. The rich variety of possible clinical presentations make it particularly difficult to represent the diagnostic process as a 'decision tree'. However, Bayesian networks offer the opportunity of a compact representation of the domain underlying the decision process: once the network portrays the natural history of the disease, the utility of investigations can be quantitatively evaluated. We developed a network for the diagnosis of PE, including 72 variables to represent both the risk factors and the pathophysiological consequences of the disease. Its structure has been specified by discussing which causal relationships explain the manifestations of the disease. The quantitative measures of associations were retrieved from the medical literature, through a critical review of available studies and agreement on the assumptions made to cope with the lack of published information. Six examples are presented to illustrate the appropriateness of 'entropy reduction' as a measure of the utility of investigation, once the set of examinations to be evaluated is bounded on the grounds of their cost and the patient's current risk. The network, which has been given the acronym 'BayPAD' (Bayesian network for Pulmonary embolism Assisted Diagnosis), appears to be able to detect which observations make others irrelevant, so that decisions can be tailored to single cases.

Efficacy, tolerability and influence on "quality of life" of nifedipine GITS versus amlodipine in elderly patients with mild-moderate hypertension

OBJECTIVE

The main purpose of this study was to compare efficacy, tolerability and influence on quality of life (QOL) of nifedipine gastrointestinal therapeutic system (NI) 30-60 mg once a day vs amlodipine (AM) 5-10 mg once a day in elderly patients with mild-moderate hypertension.

DESIGN

This was a randomized, double-blind, parallel-group, multicenter study. After a 2-week single-blind placebo run-in, patients were randomized to either NI 30 mg or AM 5 mg. Responders continued on the same dosage for 16 additional weeks, while non-responders were titrated to 60 mg NI or 10 mg AM.

METHODS

Blood pressure was measured by mercury sphygmomanometer and efficacy equivalence of NI and AM tested by covariance analysis. Diastolic blood pressure (DBP) was the primary efficacy parameter, its baseline value being taken as covariate while centers effect and treatment interaction were included as fixed effects in the analysis model. The secondary efficacy variables systolic blood pressure (SBP) and scores for QOL were analyzed according to the same model.

RESULTS

At the end of the study, overall mean DBPs, calculated as least-square means (LSMEANS), in the "by protocol" population were 87.5 mmHg for NI and 86.7 for AM (difference 0.8 mmHg with 90% CI -1.2 to 2.8 mmHg). In the "by intention to treat" (ITT) population LSMEANS were 87.6 mmHg for NI and 86.4 mmHg for AM (difference 1.2 mmHg with 90% CI -0.6 to 3.1 mmHg). SBP LSMEANS in the "by protocol" population were 147.7 mmHg for NI and 147.3 mmHg for AM (difference 0.3 mmHg, with 90% CI -3.7 to 4.3); corresponding values in the "by ITT" population were 148.0 mmHg for NI and 147.2 for AM (difference 0.8 mmHg, with 90% CI -2.8 to 4.6). Mean values for QOL parameters were not significantly different. A total of 173 episodes of adverse events were documented in 54 patients (26 NI and 28 AM), dropouts were 15 (20% of group) on NI and 21 (28%) on AM.

CONCLUSIONS

NI 30-60 mg was shown to be as efficacious and safe as AM 5-10 mg in elderly patients with mild-moderate hypertension. QOL improved compared to baseline with no significant difference between the two drugs, thus confirming a positive class effect for calcium antagonists.

Incidental parathyroid adenomas with normocalcemia discovered during thyroid operations: report of three cases

We report three cases of parathyroid adenoma incidentally discovered during a total thyroidectomy. No patients showed any clinical or chemical features that led us to suspect a hyperparathyroidism condition before operation, but a macroscopically enlarged parathyroid was discovered during the dissection and it was removed in all three cases. All patients had a single adenoma confirmed by a histological analysis. Calcemia decreased after operation in every case but only one patient needed temporary adjunctive therapy. No permanent hypoparathyroidism or recurrent hyperparathyroidism was observed. We recommend that any enlarged parathyroid discovered during neck surgery should thus be removed in order to avoid the risks of future surgical procedures due to successive bouts of clinical hyperparathyroidism.

[Surgical treatment of varicocele in day surgery]

Aim of this study is the comparison between spermatic vein ligature (Ivanissevich technique) and low intrafunicular ligature in the surgical treatment of varicocele. The Authors present two groups of patients (total 61) operated between 1995 and 1999 with the above-mentioned surgical techniques. Apart from the utilized method, they didn't ascertain any improvements in the spermiograms of the patients older than 30 years. The low ligature of the spermatic veins demonstrated the advantages of surgery treatment and lower percentage of relapses.

Development of a lipid-rich, soft plaque in rabbits, monitored by histology and intravascular ultrasound

Lipid rich, soft plaques in the clinic are a common forerunner to occlusive thrombus formation, even with modest arterial stenosis. Animal models of atherosclerosis, obtained by various methods, do not generally allow direct in vivo evaluation of the lesion and, furthermore, cannot be examined more than once. The aim of the study was the generation of a rabbit model of atherosclerosis, with morphological characteristics similar to human lipid-rich, soft atheromatous plaques, and the evaluation of the reliability of intravascular ultrasound (IVUS) technology in the study of the development of atherosclerotic lesions in this model. Briefly, New Zealand white rabbits undergo perivascular electrical injury at both common carotid arteries, together with a 1.5% cholesterol diet for up to 90 days. The lesioned arterial segments show progressive changes, from diffuse cellular mortality, to macrophage infiltration in the media, up to the final migration of macrophages to the neointima, resulting in bulky, eccentric, macrophage and lipid-rich lesions. At IVUS, the produced lesions clearly resemble those described as 'soft plaques' in the clinical setting, with minimal calcification and reduced echo-reflectivity versus the adventitial layer. Quantitative and morphometric analysis of plaques shows a significant correlation between histological and IVUS measurements at each time point. In conclusion, vascular injury in the common carotids of rabbits generates atherosclerotic lipid-rich, soft plaques, that can be properly assessed by the IVUS methodology. The easy accessibility of the arterial lesion allows serial IVUS investigations and the direct evaluation of a number of locally or generally delivered therapeutic agents.

[Familial papillary carcinoma of the thyroid: biogenetic identification and clinical assessment of 4 families]

The Authors report 9 patients who were affected by familial papillary carcinoma of thyroid These patients were members of 4 families and they were selected in a general group of 97 patients affected by papillary cancer of the thyroid who underwent surgery from 1991 to 1998. The 9 patients were 1st degree relatives: two sisters, two sisters, two sisters and three brothers. The clinical course was similar in patients whether familiar or sporadic group, but average age in first was 10 yrs lower than in the latter group. Functional cervical dissection was needed only one time by lymphatic metastasis. Observed survival was 100% (follow up 92-16 months) and no specific complication was reported. Thyreoglobulin value was less than normal in every patients. Ret linkage analysis was always performed and no rearrangement was found; in 4 patients APC gene was detected but it was never seen. Case studies are consistent with an autosomal dominant trait that shows an high penetrance if associated with a permissive codominant trait. The authors believe that are necessary further studies on this occurrence. In papillary thyroid cancer familiarity was observed in 9.6%, than authors propose that relatives of thyroid papillary cancer should be underwent to screening.

Familial papillary carcinoma of the thyroid: a report of nine first-degree relatives of four families

The authors report the occurrence of papillary carcinoma of the thyroid in nine first-degree relatives of four families among a consecutive series of 97 patients with papillary carcinoma of the thyroid who were operated on from 1991 to 1998. Total thyroidectomy was performed in all cases. All patients are alive without evidence of disease after a mean follow-up period of 43 months. Since in our series familial papillary carcinoma of the thyroid was found in 9.3% of patients, we suggest an adequate screening among first-degree relatives of all patients with papillary thyroid carcinoma. Because of reported aggressive behaviour of familial papillary carcinoma of the thyroid, aggressive surgical treatment plus post-operative thyroid remnant ablation with radio-iodine should be warranted in all patients.

[Renal Doppler color ultrasonography in the study of diabetic nephropathy]

The traditional ultrasound approach in the field of diabetic nephropathy provides only partial clinical information; moreover, the data obtained are merely descriptive, in particular regarding the involvement of the intrarenal arteries, which is however the area mainly involved. The aim of our study was to assess the data provided by Doppler ultrasound and in particular the role of the Resistive Index (RI) in a population of 160 type 2 diabetics (NIDDM), divided into 4 groups according to the severity of diabetic nephropathy. The assessment of RI has enabled us to detect among patients in the early stages of diabetic nephropathy (64 patients of group 1), a subgroup of 28 subjects (43.8%) showing RI values equal to or above the threshold value of 0.7. The determination of renal size and of renal parenchyma echogenicity proved to be of little value. The most relevant clinical information is provided by the RI, a parameter that will allow the early detection of patients affected by NIDDM, who show renal vascular involvement without however any other alterations of the traditional ultrasound parameters.

[Monomorphic adenomas of the parotid gland: description of 3 clinical cases]

Three cases of monomorphic adenomas (two oncocytic adenomas and one basal cell adenoma) of the parotid gland are reported. The diagnosis is based on echography with fine needle biopsy and cervical computerized tomography. Because of the high percentages of multicentricity, the therapy of choice is superficial parotidectomy when the lesion is in the pre-neural lobe of the gland, or total parotidectomy in case of a deep mass.

[The inferior nonrecurrent laryngeal nerve: a report of 7 cases observed since 1987]

The non-recurrent inferior laryngeal nerve is a rare anomaly (0.34% on th right side, extremely rare on the left side) that increases the risk of damage to the nerve during thyroid and parathyroid surgery. Seven cases of non-recurrent laryngeal nerve are reported, emphasizing the diagnostic accuracy of angio-MR for the anatomical identification of the vascular anomaly that invariably occurs with the nerve malformation.

Hepatocyte growth factor (HGF) stimulates tumour invasiveness in papillary carcinoma of the thyroid

The present study has investigated the functional role of the Met receptor in primary cultures of 20 papillary carcinomas and of normal thyroid cells obtained from the same patients. Normal and tumour cells grew as adherent cells, formed a confluent monolayer after 10-20 days, had epithelial morphology, and were immunoreactive for cytokeratin, vimentin, and thyroglobulin. The potential effect of hepatocyte growth factor (HGF) on cell invasiveness was investigated in Boyden chambers, using a nucleopore filter coated with Matrigel as the barrier and HGF as the chemoattractant. Tumour cells of five out of seven cases of papillary carcinoma were more responsive to HGF than the corresponding normal cells in terms of the number of migrated cells per mm(2). Involvement of the Met receptor in the HGF-induced migratory response was suggested by the observation that the agonistic anti-Met monoclonal antibody (MAb) DO-24 was equally effective. HGF did not affect the proliferative activity of thyroid cells. Under the same experimental conditions, 10 per cent fetal bovine serum (FBS) induced a two-fold increase in [(3)H]thymidine incorporation into normal cells and tumour cells. These findings are consistent with the possibility that HGF plays a crucial role in determining the invasiveness of tumour cells in papillary carcinoma of the thyroid.

Surgical treatment of paragangliomas of the carotid body and other rare localisations

BACKGROUND

Cervical paragangliomas are uncommon benign or malignant neoplasms, deriving from stem cells of the neural crest. Compared to all the tumors of the head and neck, they occur less frequently. They can be found in any part of the body where there are sympathetic ganglia including chemoreceptors, suprarenal medulla, retroperitoneal ganglia and the extreme branches of the vagus nerves. It is not easy nowadays to define properly their biological behaviour, the possible multicentric location and the association with Multiple Endocrine Neoplasms; this is considered particularly important and occurs in 42 per cent of the cases of familial neoplasms of the paraganglion system.

METHODS

After a review of recent diagnostic, pathological and clinical findings, the authors report their experience, between 1970-1995, of 10 patients affected by sporadic paraganglioma and 1 by familial multicentric neoplasm localised in the carotid bodies of both sides, left vagus nerve and left hypoglossus nerve. All patients but one were treated by a curative resection of the neoplasm. In one case only an explorative laparatomy was possible because of visceral and vascular involvement.

RESULTS

There is no mortality. There are no modifications in arterial blood pressure and catecholamine values in all patients. The complications were a recurrential palsy in a patient operated on for vagal paraganglioma; a recurrential palsy and temporary dysarthria in the patient affected by multiple familial paraganglioma; another patient operated on for carotid body paraganglioma showed a cerebral ischemic lesion which caused a slightly transitory facial-brachial motor deficit on the right side and speech impairment.

CONCLUSIONS

We can venture to say that any type of cervical, mediastinal or retroperitoneal swelling in persons belonging to a genetically prone family must be first of all considered a possible paraganglioma. For this reason the patient with more than one growth of this type, whether synchronous or not, must undergo genetic investigation, along with the rest of his family.

Insular carcinoma of the thyroid. A report of 8 cases

Insular carcinoma of the thyroid (ICT) is an uncommon malignancy with intermediate morphology and behaviour between well-differentiated and anaplastic thyroid carcinoma. Eight patients with ICT underwent total thyroidectomy. A modified neck dissection was carried out in six of them. Cervical lymph nodes metastases were detected during surgery in six patients or at scintigraphy in two patients who did not undergo neck dissection. Postoperatively, a patient developed diffuse metastases not detected by 131I whole-body scintigraphy and she died of disease 6 months later despite radio- and chemotherapy. Another patient had distant metastases detected by 131I whole-body scintigraphy and successfully treated by radioiodine ablative therapy. Unfortunately, she developed other distant metastases with no 131I uptake and died of disease 23 months later despite chemotherapy. After a mean follow-up of 5.5 years, 6 patients (75%) were alive without evidence of disease. These observations confirmed the aggressiveness of ICTs that sometimes are not responsive to current available therapies. The frequent occurrence of metastases to the regional lymph node calls on for a modified neck dissection in all patients with ICT.

[Recurrences after thyroid lobectomy for benign thyroid diseases: analysis of a clinical-instrumental follow up]

The authors propose to verify the therapeutical role of lobectomy in confronting monolobar nodular thyroid disease. In a period of 4 years (1990-1993), forty-four patients (30 women, 14 men) underwent thyroid lobectomy for a benign disease and follow-up treatment for 3 years on a semestral basis. All patient were studied both before the operation and during the follow-up using US and measuring the levels of T3, T4 and TSH; 34 patients (77.2%) had undergone a scintigraphy before surgery. The indication towards surgical intervention was, in 16 patients, consequent to the diagnosis of monolobar uninodular goiter and in 28 patients to monolobar plurinodular goiter. The operation involves thyroidal extracapsular lobectomy with isthmectomy. There were no temporary and/or permanent recurrential lesions, nor there were any significant hypocalcaemic alterations. The US description of the follow-up has been classified in four groups: normal, non-homogeneity (presence of simple parenchymal non-homogeneity), recurrence/non-homogeneity (presence of both pseudonodular forms and parenchymal non-homogeneity), recurrence (presence of recurrence with nodule(s) whose diameter is greater than 5 mm.). From the US follow-up examination, it was shown that 14 out of 44 patients (31.8%) presented alterations in the residual lobe wich were not identifiable in the pre-operative US examination (3 recurrences = 6.81%; recurrence/non-homogeneity = 2.27%; 10 non-homogeneity = 22.7%). Thirteen out of 14 patients are treated with substitutive ormonal therapy Out of these 30 patients whose residual lobe shows no alterations using US, 23 (70.6%) are treated with substitutive ormonal therapy. The authors have underlined a substantial percentage difference between the incidence of normality of the residual lobe during follow-up to lobectomy due to adenoma (normality 88.8%) and to lobectomy due to goiter-related lesions (normality 60%). During US follow-up examinations, abnormality percentages equal or superior to 30%--as those noticed after lobectomy due to goiter-related lesions underline the doubts wich characterize any form of partial thyroidal asportation (4 recurrence in 35 cases of monolobar uni- or plurinodular goiter = 11.4%); also, in the authors' experience, substitutive ormonal therapy has seemingly no effect on the recurrence incidence. According to the authors, the lobectomy can occupy a therapeutical role in thyroid diseases with monolobar expression, but to avoid an elevated number of recurrences, a rigorous evaluation of the real extension of the nodular disease is indispensable.

Total versus subtotal thyroidectomy in the management of multinodular goiter

BACKGROUND

The choice between subtotal and total thyroidectomy for multinodular goiter is controversial.

MATERIAL AND METHODS

Subtotal and total thyroidectomy have been respectively performed in 108 and 451 euthyroid patients with multinodular goiter.

RESULTS

After subtotal and total thyroidectomy, transient recurrent laryngeal nerve (RLN) palsy occurred in 1 patient (0.9%) and 3 (0.6%), transient asymptomatic hypoparathyroidism in 27 (25%) and 131 (29%), and transient symptomatic hypoparathyroidism in 2 (1.8%) and 13 (2.9%), respectively (P = NS). After subtotal thyroidectomy, recurrence occurred in 27 patients (26%) Re-operation in 14 patients resulted in transient RLN palsy in 2 patients (14%), transient asymptomatic hypoparathyroidism in 6 (43 %) and transient symptomatic hypoparathyroidism in 2 (14%).

CONCLUSIONS

The failure to demonstrate any 'hormonal advantage' in preserving thyroid tissue by subtotal thyroidectomy, and the low morbidity rate and no need for re-operation after primary total thyroidectomy, make the latter the procedure of choice for the management of non-toxic multinodular goiter.

[2 cases of a true splenic cyst]

The nonparasitic cysts of the spleen are uncommon and their pathogenesis has not been precisely determined. Often asymptomatic, the cysts are recognised during an investigation of the abdomen for other pathological conditions; if present, the symptoms are not specific and mild. The authors report two cases of non parasitic cysts of the spleen: in the first case the onset of the disease was insidious, with dyspeptic symptoms and epigastric pain; in the second case, the cyst was initially interpreted like a metastatic localisation of a an abdominal melanoma.

Paragangliomas of the carotid body and other rare localisation

Cervical paragangliomas are uncommon benign or malignant neoplasms, originated by stem cells of neural crest. It is not easy nowadays to define properly their biological behaviour, the possible multiple location and the association with Multiple Endocrine Neoplasms. After a wide review about recent diagnostic, pathological and clinical acquisition, authors report their caseload of 10 patients affected by sporadic paragangliomas and 1 by familial multiple neoplasm localised in carotid bodies of both sides, left vagus nerve and left hypoglossus nerve. All patients but one were treated by a curative resection of the neoplasm. In one case only an explorative laparatomy was possible because of the visceral and vascular involvement.

[Riedel's thyroiditis: a case report and review of the literature]

Riedel's thyroiditis is a very rare disease of unknown aetiology, occasionally associated with retroperitoneal and mediastinal fibrosis. It is a benign condition, but may be confused with an anaplastic carcinoma of the thyroid. The differential diagnosis with anaplastic carcinoma is assured only by intraoperative biopsy. The Authors report a clinical case: symptoms were a progressive enlargement of the thyroid gland, left recurrential palsy, dyspnoea and dysphagia. The surgical treatment was total thyroidectomy, performed with bilateral neurolysis of recurrent nerves. The patient was also under adjuvant corticosteroid treatment.

[Submandibulectomy in the treatment of pathology of the submandibular gland: our experience 1970-1995]

Submandibular gland excision is proposed in the treatment of neoplastic and non neoplastic diseases; this surgical procedure can be performed by transoral or transcervical approach. The aim of the study is to demonstrate that cervical approach must be preferred because it is safer and allows a wider exposition of the surgical field. From 1970 to June 1995, 54 patients (47 with chronic sialadenitis, 7 with benign tumors and 7 with malignant tumors) were submitted to excision of the submaxillary gland. Of the 54 resections performed, 2 were completed with "functional" cervical lymphadenectomy and 1 with Radical Neck Dissection in pts. with malignant neoplasms. There were no postoperative deaths; complications occurred in 1 patient (1/54 = 1.8%) as a iatrogenic permanent lesion of the maxillary branch of the facial nerve (in detail 0/47 patients with benign disease and 1/7 (14.7%) patients with malignant disease). The cervical approach for the resection of the submaxillary gland is preferred to the transoral approach for the lower risk of iatrogenic lesions of the lingual and hypoglossal nerves and the possibility of curative resections in case of malignant neoplasms. A regulated and experimented technique through the cervical approach also lowers the risk of a lesion of the maxillary branch of the facial nerve.

Surgical treatment of paragangliomas of the neck

Of a total of 5,700 surgical procedures on the neck performed at our Institution between 1984 and 1995, 13 operations (0.22%) have been done on 11 patients with 16 cervical paragangliomas. A woman underwent resection of synchronous bilateral carotid body tumours and of an intravagal paraganglioma. Ten years later, after preoperative angiographic embolization, she underwent resection of a paraganglioma of the left hypoglossal nerve. Her sister, at age 21, underwent resection of a carotid body tumour and, respectively 19 and 20 years later, of a right and left intravagal paraganglioma. An interposition graft for replacement of the carotid bifurcation was necessary in one patient only. During resection of a left carotid body tumour, acute hypotension occurred resulting in an ischemic lesion of the right temporal lobe. Postoperatively, she also complained of respiratory distress that responded to medical therapy with difficulty. The related neurologic symptoms completely resolved three months after surgery. The operation for a paraganglioma of the left hypoglossal nerve resulted in a temporary motor deficit of the tongue and in permanent considerable difficulty in swallowing. Unilateral recurrent nerve palsy occurred in two patients. No patients during the postoperative follow-up showed signs of local recurrence or metastatic disease. In conclusion, surgery is an effective treatment for cervical paraganglioma, but because of the high surgical complication rate, an experienced and skilled surgeon is called on to optimize outcome. An adequate perioperative care is advisable.

[Surgical treatment of Basedow's disease: total thyroidectomy]

The Authors report their experience in the treatment of Graves disease. After a short review of the literature, the Authors stress the medical trait of such disease with possible spontaneous resolution. Therefore the number of cases surgically treated is necessarily low. Thirty patients, all with specific antibodies, were treated with total thyroidectomy. The therapy chosen and the results obtained are herein shown. No definitive hypoparathyroidism and inferior laryngeal nerve injuries were registered.

[Paraganglioma in the case records of the III Surgical Clinical Institute]

Cervical paragangliomas are uncommon benign or malignant neoplasms, originated from the stem cells of the neural crest. Up to date it is still not easy to define properly their biological behaviour, the possible multicentric location and the association with Multiple Endocrine Neoplasias. After a wide review of recent diagnostic, pathological and clinical notions, the Authors report their experience, from 1970 to 1995, of 10 patients affected by sporadic paraganglioma and 1 by familial multicentric neoplasm localized on carotid bodies of both sides, left vagus nerve and left hypoglossus nerve. All patients but one were treated by a curative resection of the neoplasm; in one case only an explorative laparotomy was possible because of the visceral and vascular involvement.

[Small cell carcinoma of the esophagus: a case report]

The authors present the case of a primitive small cell esophageal carcinoma. It is a rare and biologically aggressive neoplasm which occurs mainly in the elder male. The case observed concerns a 69 year old female treated with surgical therapy consisting in esophagectomy and intrathoracic esophagealgastrictype plasty. Diagnostic problems either histological or immunohistochemical and the choice of the following treatment are discussed. The cases of patients treated in other Surgical or Oncological centers are reported. Therapeutic orientation adopted by our group is stressed. In this case we have chosen surgical therapy because a sure diagnosis come be given only on the base of the attent histological examination of the entire specimen (endoscopic biopsies are not sufficient); survival data reported are in favour of surgical treatment where secondary metastases are not evident in the respect of antiblastic therapy and/or radiotherapy. Neoplastic recurrence occurred ten months after and a metallic endoscopic esophageal prothesis was positioned. The patient died 1 year after surgery by mediastinal syndrome.

[Total thyroidectomy technique: suggestions and proposals of surgical practice]

Total thyroidectomy at present depicts a diffuse surgical procedure in the management of benign and malignant disease of thyroid gland. It is followed by a low incidence of iatrogenic damages (nervous lesions or permanent hypoparathyroidism), just like subtotal thyroidectomy and lower than surgery for nodular recurrences. Authors present the surgical technique they follow to perform total thyroidectomy, used in over 400 cases of benign thyroid diseases operated since 1986. The most important points of this surgical procedures are represented by exposure and sparing of inferior laryngeal nerve and by preservation of parathyroid function. Parathyroid glands can be exposed to direct surgical trauma but, more often, they are injured by damage of their vascular supply. To avoid this complication, vascular ligations of inferior thyroid artery have to be done never on the trunk of the artery, but on its branches just near the glandular capsula. Sparing of inferior laryngeal nerves comports the exposure of this structure for all its cervical course especially in the terminal edge, when the nerve is nearest to the gland. Systematical application of illustrated procedure has produced no operative mortality, no inferior laryngeal nerve permanent palsy, transient hoarseness in 0.5%, and transient symptomatic hypocalcemia in 2.7%.