Optimizing Efficacy of Quick Parathyroid Hormone Determination in the Operating Theater

The usefulness of intraoperative parathyroid hormone (PTH) monitoring has been extensively documented in primary hyperparathyroidism (HPT), whereas few data have been published on its use in reoperations or in secondary and tertiary HPT. We report our initial experience with a rapid (12 min response) PTH immunochemiluminometric assay performed in the operating room during surgery in 12 patients with primary HPT, 16 end-stage renal disease patients with secondary HPT and five kidney transplanted subjects with tertiary HPT. Blood samples were taken at baseline, within 10 min after resection and subsequently at various intervals whenever needed. The mean PTH levels before and after parathyroidectomy were 230.5 pg/mL (range 69–842) and 47.3 pg/mL (range 5–184), respectively, in primary HPT, 855.0 pg/mL (416–1655) and 202.2 pg/mL (53–440) in secondary HPT, and 205.6 pg/mL (116–301) and 45.4 pg/mL (18–97) in tertiary HPT. All patients but one had a significant percentage decline from pre-excision values (mean 76.9%, 76.0%, and 76.1% in primary, secondary and tertiary HPT, respectively). While a reduction of more than 50% was observed in 30 out of 33 patients after the first intraoperative sampling, additional measurements were performed in 10 cases. On-site PTH monitoring with this user-friendly and reliable system has proved helpful in targeting PTH tests to give the surgeon a rapid and accurate assessment of the intervention. The development of optimal PTH sequence strategies with decision-focused analytical and clinical limits will improve the efficacy of “point-of-care” PTH assay and resource utilization.

Assessment of pN-GAL as a marker of renal function in elite cyclists during professional competitions

Glomerular filtration rate (GFR) has been shown to be lower than physiological values during exercise with a strong negative correlation with exercise intensity. Among new markers of renal function, neutrophil gelatinase-associated lipocalin (NGAL) seems to be very promising. It is an early, sensitive and specific marker of acute kidney injury (AKI) with two isoforms: plasma NGAL (pNGAL) and urinary NGAL (uNGAL). The aim of the present study was to assess acute variations in NGAL plasma levels after performing high endurance physical exercise in a group of professional cyclists during the two major European professional cycling competitions (Giro D’Italia and Tour de France). Eighteen professional cyclistis were recruited for the study. A blood sample was collected during rest (after 8 hours fasting) and immediately after the competition (mountain stages) in order to assess the effect of very intense exercise on kidney function by measuring the variations of pNGAL. We also assessed plasma levels of creatinine, creatine-kinase (CK), LDH, transaminases and electrolytes. The results showed that Creatinine, CK and electrolytes levels remained almost stable between rest and post-competition. The levels of transaminases and NGAL showed a mild increase between rest and post-competition, with a significant difference between the two values only for transaminases (p=0.005). However, post-competition values of all investigated variables remained within the physiological range. The results of the present study suggest that even if NGAL values mildly rose after competition, no kidney injury occurred in these highly trained athletes during mountain stages of professional competitions. Other studies in literature confirmed that high endurance physical exercise seems not to cause renal injury in elite athletes. This is probably due to adaptive mechanisms of renal function and to the adaptation to physical stress gained with training.

Addition of bevacizumab (beva) to xeliri/xelox chemoradiotherapy in neoadjuvant setting for patients (pts) with locally advanced rectal cancer (LARC): A feasibility study

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Background: Preoperative chemo-radiotherapy in pts with LARC has been extensively evaluated, although no standard treatment has been defined. We planned to add the new anti-VEGF monoclonal antibody bevacizumab in the neoadjuvant setting, in order to evaluate whether the modifications induced in normal and tumor microcirculation and vascularity could increase the treatment toxicity profile and induce relevant complications during the surgery. Methods: From Jul 05 to Sept 06, pts with histologically proven uT3–4 N± or uT2 N+ rectal cancer were treated with capecitabine 1,000 mg/m2 bid on days 1–14 before chemoradiation phase and then 825 mg/m2 bid on days 22–55 plus irinotecan 180 mg/m2 (XELIRI) or oxaliplatin 130 mg/m2 (XELOX) on days 1, 22, 43 in combination with BEVA 5 mg/kg q2w starting on day 1 until the completion of the treatment. Radiotherapy was administered according to our previous study (45 Gy to the whole pelvis, plus 9 Gy as conc. boost to the CTV during the last six fractions). Surgery was carried out 8 weeks after the completion of chemoradiation. Results: Eleven pts (7 male/4 female), ECOG PS 0–1, were enrolled in this study. No patient showed systemic disease at the time of diagnosis. Six pts received XELIRI chemotherapy, 5 pts XELOX. Ten pts completed the planned chemotherapy schedule, one patient discontinued chemotherapy administration after the second irinotecan infusion due to GI grade III toxicity. All eleven pts completed the planned radiation treatment, with a total dose of 54 Gy. Three pts reported moderate hypertension, treated with standard anti-hypertensive drugs, and one had epistaxis, but no one required discontinuation of BEVA Conclusions: The use of BEVA in the neoadjuvant setting of pts with LARC is feasible and safe. In combination with XELIRI/XELOX chemoradiation, BEVA does not increase the treatment toxicity profile, nor provoke any surgical delay or modifications. BEVA in this setting should be further evaluated in larger phase II studies, in order to estimate the rates of clinical and pathologic complete and partial response, compared to XELIRI/XELOX chemoradiation schedules.

No significant financial relationships to disclose.

Liver cancer is induced by a subnecrogenic dose of DENA when associated with fasting/refeeding: role of glutathione-transferase and lipid peroxidation

In previous studies, we reported that fasting/refeeding has a role in sustaining the initiation of liver cancer by a subnecrogenic (noninitiating) dose of diethylnitrosamine (DENA). This research investigated whether the metabolic alterations imposed by fasting/refeeding provide an imbalance between the generation of carcinogenic molecules and the scavenger defense mechanisms in rat liver. Metabolism of DENA, levels of reduced glutathione (GSH) and GSH transferase (GST) activity, as well as basal and stimulated malondialdehyde (MDA) production, were examined. Rats fasted for 4 days showed a decrease in the liver levels of GSH, GST activity, monounsaturated fatty acids and % of labeled nuclei. After 1 day of refeeding, at which point DENA was administered, the levels of GSH recovered, GST activity remained below control values, basal and stimulated MDA production and content of total polyunsaturated fatty acids in liver phospholipids decreased. One day after DENA treatment, MDA production further decreased, although the % of labeled nuclei increased. No significant changes in the content of arachidonic acid, the main target of peroxidation, were observed at any time. The results indicated that the induction of the hepatocellular carcinoma was associated with a depression of GST activity and lipid peroxidation when rats were given 20 mg/kg of DENA after 1 day of refeeding after 4-day fasting.

[Hemangioendothelioma of the liver in the newborn: description of 2 cases]

The infantile hemangioendothelioma of the liver is a rare benign vascular tumor that accounts for some 10% of all primary hepatic masses. Two cases were seen at the Department of Pediatric Surgery of Vicenza's Hospital in the last ten years. Both of patients were females and presented in neonatal period asymptomatic. The first patient was found to have hepatomegaly by pediatrician at six weeks of age, the second was an incidental finding following ultrasound neonatal screening. The Authors outline some difficulties met with differential diagnosis between benign versus malignant hepatic tumors. Explorative laparotomy was considered necessary in both the patients. Liver biopsy was the only surgical procedure performed in the nonresectable tumor. Treatment with corticosteroids finally proved to be successful to determine progressive involution of the tumor. In the resectable form, left hepatic lobectomy was successfully performed because of the progressive size increase of the tumor.

Mitochondrial DNA variants observed in Alzheimer disease and Parkinson disease patients

Mitochondrial DNA (mtDNA) variants associated with Alzheimer disease (AD) and Parkinson disease (PD) were sought by restriction endonuclease analysis in a cohort of 71 late-onset Caucasian patients. A tRNA(Gln) gene variant at nucleotide pair (np) 4336 that altered a moderately conserved nucleotide was present in 9/173 (5.2%) of the patients surveyed but in only 0.7% of the general Caucasian controls. One of these patients harbored an additional novel 12S rRNA 5-nucleotide insertion at np 956-965, while a second had a missense variant at np 3397 that converted a highly conserved methionine to a valine. This latter mutation was also found in an independent AD + PD patient, as was a heteroplasmic 16S rRNA variant at np 3196. Additional studies will be required to determine the significance, if any, of these mutations.

Tumor necrosis factor induces genes involved in inflammation, cellular and tissue repair, and metabolism in murine fibroblasts

TNF-alpha is a primary mediator of the inflammatory response and has been ascribed a wide range of biologic activities including the cytolysis of some but not all transformed cell lines in vitro. Since most cells, normal and transformed, will also be lysed if they are concurrently treated with inhibitors of transcription or translation, the ability to resist TNF lysis depends on the de novo induction of specific gene products. To identify genes that might be involved in the ability to resist TNF-mediated cytolysis, cDNA libraries enriched for TNF-induced genes were constructed and screened. Twenty-one genes that are induced by TNF were isolated. Ten of the cDNA clones were identified by DNA sequence analysis and function in inflammatory responses, tissue or cellular repair, or cellular metabolism. Seven genes were not identified and are novel. The remaining four genes are encoded in the mitochondrial genome. Interestingly, not all the mitochondrial transcripts are induced. This may reflect a fine tuning of certain components of mitochondria that may be necessary for survival after TNF treatment.

Tumor necrosis factor induces genes involved in inflammation, cellular and tissue repair, and metabolism in murine fibroblasts

TNF-alpha is a primary mediator of the inflammatory response and has been ascribed a wide range of biologic activities including the cytolysis of some but not all transformed cell lines in vitro. Since most cells, normal and transformed, will also be lysed if they are concurrently treated with inhibitors of transcription or translation, the ability to resist TNF lysis depends on the de novo induction of specific gene products. To identify genes that might be involved in the ability to resist TNF-mediated cytolysis, cDNA libraries enriched for TNF-induced genes were constructed and screened. Twenty-one genes that are induced by TNF were isolated. Ten of the cDNA clones were identified by DNA sequence analysis and function in inflammatory responses, tissue or cellular repair, or cellular metabolism. Seven genes were not identified and are novel. The remaining four genes are encoded in the mitochondrial genome. Interestingly, not all the mitochondrial transcripts are induced. This may reflect a fine tuning of certain components of mitochondria that may be necessary for survival after TNF treatment.

The treatment of isovaleric acidemia with glycine supplement

Although dietary leucine restriction and supplemental glycine are used to treat patients with isovaleric acidemia [deficient isovaleryl-CoA-dehydrogenase (E.C.1.3.99.10)], little quantitative information is available regarding their optimum relationship. Herein we compare different glycine supplements and quantitate isovalerylglycine produced in two patients with clinically different forms of isovaleric acidemia during restricted leucine intake and during oral leucine loading. We found that under stable conditions of leucine restriction, 150 mg glycine/kg/day is an optimum glycine supplement and that glycine supplements of more than 250 mg/kg/day may result in reduced isovalerylglycine production; that when isovaleric acid accumulation is increased, glycine supplements to 600 mg/kg/day will increase isovalerylglycine production; and that the phenotype of isovaleric acidemia is related not only to the extent of impaired isovaleryl-CoA dehydrogenase, but also the ability to detoxify accumulated isovaleryl CoA to isovalerylglycine.

[Preventive pediatric medicine in schools. Statistical results obtained in the 1983-84 school-year in the community of Comiso (RG)]

The paediatric group of Comiso Hospital has carried out a research on 1086 children during the school year 1983-84 at Comiso nursery and elementary schools. The results obtained have shown the necessity of prevention sanitary education on the paediatric diseases, especially on auxologiche pathologies.

[Results of an investigation carried out in the 1983-1984 school-year in the nursery and elementary schools of the community of Comiso on the frequency of atopic diseases]

The authors have carried out a research at Comiso nursery and elementary schools. The conclude that it is necessary to examine more deeply the problems of the atopic diseases in paediatric field. The results obtained have shown a greater frequency of cutaneous pathologies at nursery schools and of respiratories pathologies at elementary ones.

Biochemical and neuropsychological effects of elevated plasma phenylalanine in patients with treated phenylketonuria. A model for the study of phenylalanine and brain function in man

Phenylketonuria provides a human model for the study of the effect of phenylalanine on brain function. Although irreversible mental retardation is preventable through newborn diagnosis and dietary phenylalanine restriction, controversy exists regarding the effects of increased concentrations of phenylalanine in older patients. We have studied ten older, treated, phenylketonuric patients using a triple-blind, multiple trials, crossover design. Each patient was tested at the end of each of three 1-wk periods of high or low phenylalanine intakes. Tests included a repeatable battery of neuropsychological tests, analysis of plasma amino acids, and measurement of urine amino acids, phenyl organic acids, dopamine, and serotonin. In all 10 patients plasma phenylalanine rose (900-4,000 microM). In 9 of 10 patients there was an inverse relationship between plasma phenylalanine and urine dopamine excretion. When blood phenylalanine was elevated, these patients had prolonged performance times on neuropsychological tests of higher but not lower integrative function. Urinary serotonin fell during phenylalanine loading in six patients. The concentration of phenylacids in the urine was not proportional to the plasma phenylalanine at concentrations below 1.5 mM. In one patient, neither performance time nor dopamine excretion varied as blood phenylalanine rose or fell. We interpret these data as follows: blood phenylalanine above 1.3 mM impairs performance on neuropsychological tests of higher integrative function, this effect is reversible, and one mechanism may involve impaired biogenic amine synthesis.

[Pseudocyst of the pancreas fistulized into the right pleural cavity]

The development of a pancreatic pseudocyst which fistulized into the right pleural cavity through a lesion in the diaphragm is described. The case is the 2nd in Italian literature and the 5th in the world. The relationships between pancreatic and thoracic pathology are examined, particularly the various ways in which pancreatic enzymes are spread and transferred to the abdomen and thorax. Such a fistulization phenomenon is the ultimate expression of an erosive process of the pancreatic juice and is considered quite exceptional with respect to the more frequent cases of pleural exudation with high amylase content which are often encountered in concomitance with verified pancreatic pathology.