R-loop landscapes in the developing human brain are linked to neural differentiation and cell-type specific transcription

Here, we construct genome-scale maps for R-loops, three-stranded nucleic acid structures comprised of a DNA/RNA hybrid and a displaced single strand of DNA, in the proliferative and differentiated zones of the human prenatal brain. We show that R-loops are abundant in the progenitor-rich germinal matrix, with preferential formation at promoters slated for upregulated expression at later stages of differentiation, including numerous neurodevelopmental risk genes. RNase H1-mediated contraction of the genomic R-loop space in neural progenitors shifted differentiation toward the neuronal lineage and was associated with transcriptomic alterations and defective functional and structural neuronal connectivity in vivo and in vitro. Therefore, R-loops are important for fine-tuning differentiation-sensitive gene expression programs of neural progenitor cells.

A Case Report on Treatment of Nonhealing Leg Ulcer: Do Not Forget the Underlying Disease

Prevalence of nonhealing ulcers of lower extremities has increased over years causing heavy health, social, and economic burdens. Chronic ulcers are difficult to treat since they require tailored multistep treatment and patient compliance. To treat chronic wounds successfully, clinicians must keep in mind the ulcer etiology as well as the underlying diseases. Several factors may be involved in the pathogenesis of chronic skin ulcers. Leukocytoclastic vasculitis belongs to the group of immune vascular diseases and may be an extrahepatic manifestation of hepatitis C virus (HCV) infection. We describe the case of a patient with a nonhealing vasculitic leg ulcer and chronic HCV infection successfully treated with the combination of advanced dermal substitute and direct-acting antiviral therapy. An 81-year-old female presented to our unit with a 6-month history of a leg ulcer that developed from an exudating skin nodule. At presentation, the lesion was large,caused a severe pain and was unresponsive to analgesics. Skin biopsy showed leukocytoclastic vasculitis. She had a history of old untreated HCV infection, hypertension, type 2 diabetes mellitus, chronic venous insufficiency and tibial arteriopathy. The application of porcine-derived dermal substitute achieved only initial improvement. Therefore, direct-acting antiviral therapy was started, and when HCV RNA became undetectable in blood, pain disappeared and skin ulcer improved up to healing. In conclusion vasculitic leg ulcers can be caused by HCV infection. In such cases, even the use of innovative skin therapy, may obtain only initial and partial improvement, and eradication of HCV viremiais essential to obtain wound healing.

Use of a flowable wound matrix to treat lower limb vascular ulcers

OBJECTIVES

This study is aimed at assessing the safety and effectiveness of an advanced flowable wound matrix (FWM) in the treatment of hard-to-heal vascular leg ulcers that often involve deep structures, are irregular and/or tunnelled or excavated.

METHODS

Records of patients seen at our Vascular Surgery Unit, at the University of Campania 'Luigi Vanvitelli', for hard-to-heal vascular leg ulcers between January 2018 and January 2020 were retrospectively reviewed. For each wound aetiology, area and complications were recorded and evaluated. Every patient received one or more applications of FWM and was followed up.

RESULTS

A total of 22 patients (18 female/four male), mean age 63±8.5 years, were treated. The initial wound area ranged from 4-58cm². After wound bed preparation, FWM was applied. Treatment was well tolerated and effective-rate of complications was low, graft take was very satisfactory, and no graft loss, rejection or superimposed infections were observed. Healing time was short: 85% of ulcers healed after 12 weeks. Most importantly, there was a decrease in the rate and level of amputations as compared with standard wound care.

CONCLUSIONS

The data presented indicate that FWM is an option for the treatment of hard-to-heal vascular leg ulcers, particularly for those with an irregular cavity.

DECLARATION OF INTEREST

The authors have no conflicts of interest.

The Impact of COVID-19 Pandemic on Vascular Leg Ulcers

The aim of this study was to evaluate the impact of 2 lockdown periods during coronavirus disease 2019 (COVID-19) on the course and management of nonhealing vascular ulcers of lower limbs. A total of 41 patients were included in the study. Before the pandemic began they had been seen at our unit at weekly intervals. During lockdown from March 9, 2020, to May 18, 2020 subjects were not allowed to enter the hospital unless they needed urgency or emergency surgery, or oncological management. During the second lockdown, from October 19, 2020, to December 11, 2020 patients could be followed up at distance by direct outreach including telephoning contacts. Data obtained early after each lockdown were compared with those obtained prior to the pandemic. Data for the first lockdown show that pain intensified and there was an increase in the recurrence rate of wounds, of their severity, and of superimposed infections as compared with the prelockdown period. The risk of lower-limb amputation was also considerably greater. During the second and less restrictive lockdown, patients were followed up by telemedicine and data indicate that skin lesions had not worsened any further. The management of vascular wounds was impacted by the pandemic unfavorably with health care failures in the hospital as well as in the primary care settings. In conclusion, the treatment of vascular leg ulcers is challenged by the COVID-19 pandemic as this spreads worldwide. This seems to be in keeping with what happens for other diseases. The data we obtained indicate that the pandemic-related lockdown has a deleterious effect on vascular skin wounds, with an increase of severity and mortality risk. The impact appears to be proportional to the number and the degree of limitations imposed on people.

Use of Porcine-Derived Dermal Substitutes for Treatment of Nonhealing Vascular Leg Ulcers: A Case Series

Nonhealing leg ulcers are a major health problem worldwide with a high economic burden since they require human and material resources. Moreover, nonhealing ulcers are a major nontraumatic cause of lower limb amputations. Dermal substitutes have emerged as an effective therapeutic option for treatment of skin lesions, but data on leg ulcers are scarce. We evaluated safety and efficacy of a porcine-derived dermal substitute in the treatment of chronic vascular leg ulcers. Records of patients with nonhealing ulcers seen at our unit from 2018 to 2019 were retrospectively reviewed. Wound etiology, wound area, and complications were evaluated. Each patient received one application of porcine-derived dermal substitute and was followed-up. Six patients (5 females and 1 male) with a mean age of 61.3 (52-81) years presented with nonhealing leg ulcers. After surgical debridement and wound bed preparation, porcine-derived dermal substitute was applied onto the ulcer. Granulation was satisfactory within 10 days. All wounds healed after an average time of 14 weeks. Graft take was good, and no graft loss, rejection, or associated infection were observed. In conclusion, the data presented indicate that dermal substitutes are safe and effective for treatment of chronic nonhealing vascular leg ulcers.

CGF Treatment of Leg Ulcers: a Randomized Controlled Trial

Background

Concentrated Growth Factors (CGF) is a concentration of second generation autologous growth factors compared to platelet rich plasma (PRP) and represents a multifactorial stimulation system that can be used for the management and treatment of chronic skin ulcers.

Aim

The aim of this work is to evaluate the additional benefits of the CGF compared to the standard of dressing and its effects on the dynamics of the healing process.

Methods

Autologous CGFs were obtained from 100 patients with chronic mixed ulcers (venous ulcers in patients with II stage claudication) of the lower limbs in a multicentric controlled randomized study.

Results

The results showed a significant advantage in the use of CGF in association with cleansing and selective compression in the healing time and stabilization of mixed ulcers of the lower extremities.

Conclusions

These results support the CGF’s clinical use for improving clinical outcomes in mixed ulcers of the legs.

Surgical Versus Sequential Hybrid Treatment of Carotid Body Tumors

Carotid body tumor (CBT) are slow-growing tumors that develop in the cervical region at the carotid bifurcation. . In a randomized study, 33 patients were treated for CBT excision: 10 patients performed preoperative embolization (PE) and 23 were treated only by isolated traditional surgery (N-PE). The first group includes patients undergoing preoperative embolization. The second group of patients (N-PE) included 11 males and 12 females. Intraoperative complications were lower in patients treated with a hybrid procedure (PE): sections of the cranial nerves were recorded in 7% of cases compared to 12% of the surgical procedure (P-value = 0.72); while the reversible nerve lesions (P value = 0.21) and the permanent ones (P value = 0.46), were instead similar in both procedures. The comparative blood loss during the operative procedure shows a P-value of 0.02. Operating times, reversible damage of the cranial nerves , incidence of stroke (0% vs1%, P value> 0.99) and post-operative hospital stay (4.1 vs. 4.2 days, P value = 0.91) did not show differences in the two groups of patients. The analysis of the results detects pre-operative embolization of CBT in reducing intraoperative blood loss and resection of the cranial nerves..

Decreased Antithrombin III Activity in Diabetes May Be Due to Non-Enzymatic Glycosylation – A Preliminary Report

Antithrombin III activity was moderately but significantly decreased in insulin dependent diabetics (p <0.005), while no difference has been found between the diabetic (n = 25) and control groups (n = 22) in antithrombin III plasma concentration.

Moreover, antithrombin III activity was inversely correlated with glycosylated plasma proteins (r = -0.57; p <0.01).

These data show that in diabetes there is a depressed biological activity of antithrombin III and suggest that this reflects nonenzymatic glycosylation of antithrombin III protein.

La neuroendoscopia nel trattamento delle cisti aracnoidee Indicazioni e limiti

Gli autori descrivono 15 casi di cisti aracnoidee operate con tecnica endoscopica. Si tratta di 10 maschi e 5 femmine di età compresa fra 2 mesi e 80 anni con le seguenti localizzazioni cistiche: 6 della valle silviana, 2 soprasellari, 5 in fossa cranica posteriore, 1 della convessità frontale e 1 parietale interemisferica.

I risultati sono stati soddisfacenti con risoluzione dei sintomi clinici in 11 casi (73%) mentre sul piano radiologico una riduzione di volume della cisti si è ottenuta in 7 casi (46%). Vengono discussi vantaggi e limiti della tecnica endoscopica e le indicazioni in riferimento alla localizzazione cistica ed in confronto ai trattamenti tradizionali (craniotomia e shunt).

Chronic hepatitis C virus infection and atherosclerosis: Clinical impact and mechanisms

Hepatitis C virus (HCV) infection represents a major health issue worldwide due to its burden of chronic liver disease and extrahepatic manifestations including cardiovascular diseases, which are associated with excess mortality. Analysis of published studies supports the view that HCV infection should be considered a risk factor for the development of carotid atherosclerosis, heart failure and stroke. In contrast, findings from studies addressing coronary artery disease and HCV have yielded conflicting results. Therefore, meta-analytic reviews and prospective studies are warranted. The pathogenic mechanisms connecting HCV infection, chronic liver disease, and atherogenesis are not completely understood. However, it has been hypothesized that HCV may promote atherogenesis and its complications through several direct and indirect biological mechanisms involving HCV colonization and replication within arterial walls, liver steatosis and fibrosis, enhanced and imbalanced secretion of inflammatory cytokines, oxidative stress, endotoxemia, mixed cryoglobulinemia, perturbed cellular and humoral immunity, hyperhomocysteinemia, hypo-adiponectinaemia, insulin resistance, type 2 diabetes and other components of the metabolic syndrome. Understanding these complex mechanisms is of fundamental importance for the development of novel therapeutic approaches to prevent and to treat vascular complications in patients with chronic HCV infection. Currently, it seems that HCV clearance by interferon and ribavirin treatment significantly reduces non-liver-related mortality; moreover, interferon-based treatment appears to decrease the risk of ischemic stroke.

Combined effect of beauvericin and T-2 toxin on antioxidant defence systems in cherry tomato shoots

During their life cycle, plants can undergo simultaneous attack by different pathogens that produce various toxins. It is well known that in some plant-fungal interactions, mycotoxins play an important role in pathogenesis and induce a reactive oxygen species increase. Plants counteract the overaccumulation of reactive oxygen species by reinforcing their defence systems. The mycotoxins T-2 toxin (T-2) and beauvericin (BEA) are produced by some Fusarium species and have different chemical structures, mechanisms of action and biological activities. In this study, the individual and combined effects of these two toxins on defence systems, such as the ascorbate-glutathione cycle and peroxidases, were evaluated in cherry tomato shoots. Hydrogen peroxide content as an index of oxidative stress was also measured. Inhibitory effects on ascorbate peroxidase, dehydroascorbate reductase and ascorbate, and stimulatory effects on glutathione reductase, monodehydroascorbate reductase and reduced glutathione were observed when tomato plants were simultaneously treated with BEA and T-2. The trend of these biochemical parameters highlight the presence of a range of defence mechanisms activated by plants in response to mycotoxins. The interaction between BEA and T-2 resulting in synergistic and/or antagonistic effects on the studied defence systems is also discussed. It is concluded that the effects of these mycotoxins alone are not predictive of their combined effects.

Chronic HCV infection is a risk of atherosclerosis. Role of HCV and HCV-related steatosis

OBJECTIVES

HCV and NAFLD are associated with atherosclerosis in general population. The prevalence of atherosclerosis in chronic hepatitis C (CHC) patients is unknown. We hypothesized that HCV per se and HCV-related steatosis could favour atherosclerosis. Thus, in CHC patients we assessed: (a) the prevalence of atherosclerosis; (b) the role of HCV, cardio-metabolic risk factors and hepatic histology.

METHODS

Overall, 803 subjects were enrolled: (A) 326 patients with liver biopsy-proven treatment naive CHC (175 with and 151 without steatosis); (B) 477 age and gender matched controls, including 292 healthy subjects without steatosis (B1) and 185 with NAFLD (B2). Carotid atherosclerosis (CA), assessed by high-resolution B-mode ultrasonography, was categorized as either intima-media thickness (IMT: >1mm) or plaques (≥ 1.5mm).

RESULTS

CHC patients had a higher prevalence of CA than controls (53.7% vs 34.3%; p<0.0001). Younger CHC (<50 years) had a higher prevalence of CA than controls (34.0% vs 16.0%; p<0.04). CHC patients without steatosis had a higher prevalence of CA than B1 controls (26.0% vs 14.8%; p<0.02). CHC with steatosis had a higher prevalence of CA than NAFLD patients (77.7% vs 57.8%, p<0.0001). Viral load was associated with serum CRP and fibrinogen levels; steatosis with metabolic syndrome, HOMA-IR, hyperhomocysteinemia and liver fibrosis. Viral load and steatosis were independently associated with CA. Diabetes and metabolic syndrome were associated with plaques.

CONCLUSION

HCV infection is a risk factor for earlier and facilitated occurrence of CA via viral load and steatosis which modulate atherogenic factors such as inflammation and dysmetabolic milieu.

Molecular epidemiology of high-level aminoglycoside-resistant enterococci isolated from patients in a university hospital in southern Italy

OBJECTIVES

We evaluated the genetic and molecular basis of high-level resistance to gentamicin and amikacin in 91 clinical isolates of Enterococcus faecalis and Enterococcus faecium in a university hospital in southern Italy from 1987 to 2003.

METHODS

Antibiotic susceptibility was evaluated by disc diffusion and microdilution methods. Genotyping was performed by PFGE and dendrogram analysis. Aminoglycoside resistance genes were analysed by multiplex PCR. Aminoglycoside resistance gene transfer was performed by filter mating.

RESULTS

In our strain collection, 44% of E. faecalis and 52% of E. faecium were high-level-resistant to gentamicin. Fifty-two PFGE profiles were identified for E. faecalis and 15 for E. faecium. Although the majority of PFGE patterns were single isolates, four patterns (two for E. faecalis and two for E. faecium) were isolated each in 8 and 4, and 6 and 4 different patients, respectively. The aac(6')-Ie-aph(2'')-Ia gene was responsible for high-level resistance to gentamicin and amikacin in E. faecalis and E. faecium; the aph(2'')-Id gene responsible for resistance to gentamicin was also isolated in E. faecium; the aph(3')-IIIa and ant(4')-Ia genes responsible for resistance to amikacin were also isolated in E. faecalis and E. faecium. High-level resistance to gentamicin, along with the aac(6')-Ie-aph(2'')-Ia gene, was transferred at a frequency of about 10(-5) to 10(-8) per recipient cell in 14 of 17 E. faecalis and 3 of 4 E. faecium different genotypes.

CONCLUSIONS

The spread of the aac(6')-Ie-aph(2'')-Ia gene was responsible for high-level resistance to gentamicin and amikacin among enterococci isolated from patients in our geographical area.

[Spinal cord electric stimulation. Treatment of serious chronic ischemic syndromes of the limbs]

BACKGROUND

Aim of this study is to estimate the effectiveness of epidural electric stimulation of spinal cord for the treatment of patients with severe peripheral chronic arteriopathy who can't be surgically treated or when surgical therapy failed.

METHODS

A retrospective study was carried out on 18 patients with peripheral chronic arteriopathy at clinical stage I of Fontaine classification; average age was of 60.08 years an they had rest pain and dystrophic lesions. Five patients couldn't be surgically treated. Stimulator catheter was placed in the epidural space and its action was evaluated studying lesion demarcation and pain resolution.

RESULTS

In 16 cases there was a good pain control and in 14 patients lesion demarcation, while in 4 cases there was cases no improvement and amputation was necessary.

CONCLUSIONS

Epidural electric stimulation of spinal cord is a valid treatment in selected patients for ischemia pain control and limb savage.

Possibilities at present for the application of lumbar sympathectomy in chronic occlusive arterial disease of the lower limbs

BACKGROUND

Research on the limitations of the validity of lumbar sympathectomy in surgical treatment of lower limb occlusive arterial disease is still of great interest today.

METHODS

Our study deals with 385 patients who underwent the surgical removal of a segment which includes the 2nd and the 3rd ganglion of the lumbar sympathetic chain in the period between the month of January 1989 and the month of December 1998.

RESULTS

Results were good in 63.6% of patients and stationary in 10.53% of cases; in 26% of cases lumbar sympathectomy was not valid.

CONCLUSIONS

Satisfactory results were recorded, as will be shown in this text, on patients experiencing a period of rest pain, patients with ischaemic dystrophic lesions and those with very advanced intermittent claudication equally favourable results were seen in diabetic patients.

[Present-day role of vena cava filters]

BACKGROUND

The purpose of the present is to assess the effectiveness of pulmonary embolism prevention using temporary or permanent vena cava filters in deep venous thromboses of the lower extremities with a discussion of indications and complications.

METHODS

In the period between 1989 and 1998 we observed 46 patients (33 m, 13 f) suffering from deep venous thrombosis of the lower extremities.

RESULTS

The cases treated with cava filter showed an improvement in clinical conditions in 15-19 cases with 4/19 cases of complications: filter ascent, lipothymia, one case of pneumothorax and one case of filter ascent with thrombosis of the contralateral venous axis. All complications were solved without further sequelae. After catheterisation of the femoral vein, the thrombosis of the contralateral venous axis in patients with caval filter was a frequently observed event (in 75% of cases). In the cases without filter, an evident improvement was observed in 22/27 cases, a slight improvement in 2/27 cases, with 3/27 cases of complications: two cases of cardiocirculatory arrest and one case of severe dyspnea with suspected pulmonary embolism which survived the event.

CONCLUSIONS

From our experience, the use of caval filters is unquestionably useful for the prevention of pulmonary embolism, but is not wholly free from complications.

Prosthetic infections

BACKGROUND

The authors report the up to date trends regarding the etiopathology, diagnosis and treatment of vascular-graft infections. This paper concerns the responsible micro-organisms; the reference to the formation of anastomotic pseudo-aneurysm for the infections involving the lines of suture and the reference to the aortoenteric fistula.

METHODS

A case study which refers to the period between 1990 and 1999 presents 19 cases of prosthetic infections out of 520 operations of implants of prosthetic materials.

RESULTS

11 successful, 7 amputations, 1 decrease.

CONCLUSIONS

In the past years the results of the treatment have improved thanks to a more refined and codified therapeutical conduct and to the employment of prosthetic materials which are more resistant to infection, or to a greater attention paid to asepsis, before, during and after surgery to antibiotic prophylaxis before, during and after the operation. But, nevertheless graft infection still remains a dreadful complication for vascular surgery operations. The therapeutical approach is substantially aggressive and the removal of the infected prosthesis is essential. Nevertheless we believe that we should not underestimate open local treatment, which in localized and superficial infections and infections not involving anastomosis allows us to preserve prosthesis and make it root.

[Popliteal aneurysms. Personal experience]

BACKGROUND

The 70% of peripheral aneurysms are localized at the popliteal artery; approximately one third of patients are asymptomatic, but the occurrence of complications (acute ischemia, rupture) endangers the survival of the leg. The purpose of this paper is to demonstrate the validity of elective surgery for popliteal aneurysms, also for asymptomatic lesions.

METHODS

Twenty-seven popliteal aneurysms were observed in 20 patients; only 7 of these were affected by a unilateral lesion, other 7 patients by a bilateral lesion and the remainder 6 patients by a polydistrict association; 3 patients refused the surgical therapy which was proposed. Prosthetic grafting with exclusion or resection of the aneurysm has been practiced in 16 cases; one time only a Dacron graft was employed, while the autologous saphenous vein was employed in 15 cases. A locoregional thrombolysis has been performed in 3 patients, in presence of an acute peripheral ischemia. In 5 cases a conservative approach has been chosen; these were asymptomatic aneurysms with a <2 cm diameter.

RESULTS

In 87,5% of patients operated (14/16) a good immediate result was obtained. In a mean 2 years follow-up the 75% of these patients maintained the clinical result. The fibrinolytic therapy was resolutive in 2 cases of acute peripheral ischemia; a lumbar sympathectomy was necessary in one case.

CONCLUSIONS

In consideration of the complications that the aneurysmatic disease can give, among which the acute peripheral ischemia is the most dreadful, a surgical approach is widely justified, also in the light of the good results described.

Management of chronic subdural hematoma in patients treated with anticoagulation

BACKGROUND

The diffusion of the surgical technique of cardiac valve replacement with metallic prostheses, as well as bypass graft in the arterial occlusive disease of the lower extremities, both requiring permanent oral anticoagulation, has increased the number of patients affected by chronic subdural hematoma that can be diagnosed at an earlier stage of this disease with the advent of the CT.

METHODS

The records of seven patients with mean GCS = 14.2 and mean clinical grade = 1.85 affected by chronic subdural hematoma and in treatment with anticoagulants were examined retrospectively. All the patients underwent subtemporal craniectomy plus closed drainage or burrhole(s) plus closed drainage after immediate correction of hypocoagulability by administration of vitamin K and fresh frozen plasma and normalization of PA by calcium heparin.

RESULTS

Outcome was good for all the patients except one who died because of cerebral herniation due to massive solid subdural hematoma during extracorporeal dialysis. Complications included: intracerebral hemorrhage, solid subdural hematoma, slow brain reexpansion, subdural collection reaccumulation and cerebral embolism. Three patients required re-operation. Mean duration of hospital stay was 18 days with range from 7 to 24 days.

CONCLUSIONS

Basing on this retrospective study and the proposed pathophysiology, the guidelines for optimal management of this subgroup of patients are proposed. Recommendations include the immediate correction of hypocoagulability, the appropriate surgical technique and the cautious conversion to oral anticoagulation as well as the appropriate timing of such conversion.

[Magnetic resonance angiography of the epiaortic vessels of the thorax]

INTRODUCTION

Magnetic Resonance angiography (MRA) is an accurate and non-invasive diagnostic method to evaluate vascular disease. On the basis of its technological advancements, this technique has gained an important role in the diagnostic protocol of cerebral and cervical vascular diseases. Nonetheless, MRA efficacy changes in different anatomic districts as a consequence of the specific anatomy and flow features. Cardiac and respiratory artifact and different coil sensitivity also affect MRA results. For these reasons, intrathoracic epiaortic vessels are a difficult applications for MRA.

MATERIAL AND METHODS

We examined 20 patients affected with epiaortic atherosclerosis with MRA, carried out with an 0.5 T MR unit (Vectra, GE). Examinations consisted of Phase Contrast (PC) 3D sequences (TR/TE/FA/Venc = 30/13/45/30-50), with 3 axes of flow encode, matrix 128 x 256, 2 mm partition thickness, and axial and/or coronal acquisition volume. The MRA was repeated after Gd-DTPA intravenous perfusion and a qualitative and quantitative evaluation of pre- and post-contrast results was performed. Specific parameters of evaluation were: angiographic contrast, contrast to noise ratio, saturation effect of longitudinal magnetization, contrast between arteries and veins. All patients were examined with Doppler US and angiography. MRA data were compared to angiography in order to establish MRA sensitivity and specificity.

RESULTS AND CONCLUSIONS

PC sequences showed high accuracy in the examination of the proximal tract of epiaortic vessels; Gd-DTPA administration substantially improved MRA results. The perspectives of technological improvement will probably candidate PC MRA to be a valid alternative to US-Doppler and, perhaps, to angiographic study.

[The Studer ileal bladder and the Paduan ileal bladder: comparison of 2 techniques]

Between January 1988 and December 1995 48 orthotopic detubularized and reconfigured ileal neobladder were carried out with two distinct surgical procedures in the same Hospital. 33 underwent lower urinary tract reconstruction using Studer's technique with an afferent ileal tubular isoperistaltic segment; in 15 patients the ileal substitution of the bladder was performed with Paduan ileal bladder (VIP). In any case an ileal low pressure reservoir was obtained with similar functional capacity (400 ml. at the urodynamic control), as using the same length of ileum (40 cm) for the reconstruction of the reservoir itself. In order to other functional aspects (e.g. diurnal and nocturnal continence) results were analogous if a correct rehabilitation program was observed. Significant post-voiding residual and late neobladder decompensation was prevented with adequate mictional training. Early and late complications (globally 19-24%) were evaluated: strictures of ureteroileal and ileo-urethral anastomoses were rare; an ileoureteral reflux was observed at a cystographic control in 50% of Studer group, but never clinically significant and only in 20% of VIPs. No clinically significant metabolic changes were found. Survival was satisfactory at a mean follow-up of 48 months.

Transurethral incision of prostate (TUIP) and retrograde ejaculation

OBJECTIVE

Men of any age with bladder outlet obstruction and without measurable enlargement of the prostate constitute ideal candidates for TUIP. Effectiveness of any technique with respect to flow rate improvement is firmly established, indifferently whether unilateral or bilateral. But there is a wide variation in the reported incidence of retrograde ejaculation with unilateral and bilateral incision.

MATERIAL AND METHODS

The retrospective analysis of our 45/57 available patients treated with this technique, between January 1993 and March 1995, does not show a major incidence of this complication for the bilateral incision, with an overall incidence of 6.6% (3/45 patients).

CONCLUSIONS

Although ejaculation may be preserved, it cannot be guaranteed.

Different susceptibility of coagulase-positive and coagulase-negative staphylococci to ciprofloxacin

Ciprofloxacin susceptibility was evaluated in 573 clinical staphylococcal isolates (Staphylococcus aureus 230, methicillin-resistant (MR) 36%; coagulase-negative strains 343, MR 66%) collected from 1989 to 1995. Resistance to ciprofloxacin for MR Staphylococcus aureus was 25% until 1991 when ciprofloxacin was introduced into the hospital formulary, and rose progressively to 90% in 1994-1995. MR Staphylococcus haemolyticus showed a ciprofloxacin resistance of 46% until 1991 and of 73% from 1992 to 1995. In contrast MR Staphylococcus epidermidis and other coagulase-negative strains showed a constant susceptibility to this agent (80%). Ciprofloxacin has limited usefulness against MR Staphylococcus aureus but can be still used to treat Staphylococcus epidermidis infections.

Unorthodox antibiotic combinations including ciprofloxacin against high-level gentamicin resistant enterococci

Development of high-level gentamicin resistance among enterococci represents a serious therapeutic problem as it precludes synergy between aminoglycosides and cell-wall active agents. As part of a search for active antibiotic combinations against enterococci with high-level gentamicin resistance, we tested by the time kill curve method the efficacy of ciprofloxacin combined with ampicillin, trimethoprim-sulphamethoxazole, vancomycin or teicoplanin against ten isolates of Enterococcus faecium, three of Enterococcus casseliflavus and 13 of Enterococcus faecalis that exhibited a MIC of gentamicin > or = 2000 mg/L. Most of the E. faecium were also resistant to ampicillin and to ciprofloxacin. The combination of ciprofloxacin with ampicillin was bactericidal against five of seven E. faecium strains that exhibited a ciprofloxacin MIC < or = 4 mg/L, but was inactive against the three E. faecium that were highly resistant to ciprofloxacin. This combination was also bactericidal against the E. casseliflavus and all the E. faecalis strains. The combination of ciprofloxacin with trimethoprim-sulphamethoxazole was bactericidal against five of the seven E. faecium and seven of the nine E. faecalis strains with a ciprofloxacin MIC < or = 4 mg/L. No bactericidal activity of this combination was seen against the enterococci that were highly resistant to either ciprofloxacin or to trimethoprim-sulphamethoxazole. The combination of ciprofloxacin with glycopeptides was inactive against E. faecium and E. casseliflavus and against E. faecalis, it was either ineffective or antagonistic; in only one case it was bactericidal. Five strains of E. faecium were resistant to all antibiotic combinations tested.

[Enterococcal endocarditis: clinical and microbiological features of our series]

Of 81 cases of infectious endocarditis seen at our institution from 1988 to 1995, 61 had positive culture (75%) and, of these, 10 (16%) were caused by enterococcal strains (9 by Enterococcus faecalis, 1 by Enterococcus faecium). The 10 cases consisted of 5 native valve endocarditis and 5 late prosthetic valve endocarditis. Median age of patients was 50 years (range 21-58); 6, were males. Diagnostic or surgical procedures on the abdomen, genito-urinary tract, or chest preceded the onset of fever in almost all cases. Nine enterococcal strains showed low-level resistance to aminoglycosides and one was highly resistant. Seven patients were treated with ampicillin and gentamicin and 2 with teicoplanin and gentamicin. The patient, whose infection was caused by an high gentamicin-resistant E. faecalis, was treated with the combination of ciprofloxacin and cotrimoxazole chosen on the basis of the in vitro susceptibility tests. Congestive heart failure occurred in 4 patients and major embolic events in 3. All patients were cured; 4, with medical therapy alone and 6, with antimicrobials associated with surgical substitution of the valve. The data indicate that enterococcal endocarditis, when treated with appropriate antimicrobial regimens, associated with surgical treatment when necessary, has a very low mortality rate. The conventional treatment, -lactams plus gentamicin is usually effective. However, for high-level gentamicin-resistant strains alternative treatments must be selected on the basis of the in vitro susceptibility tests.

Bacillus Calmette-Guerin in the treatment of stage T1 grade 3 transitional cell carcinoma of the bladder: long-term results

PURPOSE

We performed a retrospective long-term study to evaluate the results of immunotherapy in the treatment of high grade superficial bladder tumors.

MATERIALS AND METHODS

Between 1981 and 1993, 593 patients with superficial transitional cell carcinoma of the bladder underwent transurethral resection. Of 64 patients with stage T1 grade 3 disease 50 received intravesical bacillus Calmette-Guerin after transurethral resection of all visible tumor.

RESULTS

At a median followup of 42 months (range 12 to 112) 36 patients (72%) are disease-free and have not required further treatment. Superficial recurrence was noted in 8 patients (16%). Disease progressed in 6 patients (12%), including 5 with locally invasive and 1 with metastatic disease. Cystectomy was performed for progression in 4 patients and for recurrent stage T1 grade 3 disease in 1. There was 1 disease related death (2%). The overall survival rate is 94%.

CONCLUSIONS

Intravesical bacillus Calmette-Guerin appears to be the most effective conservative treatment for patients with stage T1 grade 3 bladder cancer.

Resistance to aminoglycosides and other antibiotics among clinical isolates of Enterococcus spp

We conducted a study on 81 clinical isolates of enterococci (65 Enterococcus faecalis and 16 Enterococcus faecium) collected consecutively over a one year period at our University Hospital. Of them, 10 (15%) Enterococcus faecalis and 6 (38%) Enterococcus faecium showed high level resistance to aminoglycosides, were all acquired in surgical units and in five cases they were responsible for invasive infections. Ampicillin and imipenem were active only against Enterococcus faecalis. Vancomycin and teicoplanin were bacteriostatic; however, teicoplanin MICs were lower and in 45% of cases its MBC values were within clinically achievable serum concentrations. Ciprofloxacin and cotrimoxazole were active in vitro.

Biologic characteristics of T1 papillary bladder cancer. Flow cytometric study of paraffin-embedded material

DNA ploidy, proliferative activity (evaluated in terms of the proliferative index [PI]) and epidermal growth factor receptors (EGF-R) expression in primary bladder cancer in 52 patients were studied by means of flow cytometry and immunohistochemistry. Forty of the 52 tumors yielded evaluable DNA histograms: 22 were diploid (55%) and 18 aneuploid (45%) (median DNA index = 1.5). Ninety-five percent of the tumors were positive for EGF-R expression. The median PI value of the entire case series, estimated with a mathematical model, was 5.4%, or 6.7% in diploid tumors and 12.1% in aneuploid ones. EGF-R expression was higher in aneuploid than diploid tumors. Most of the well-differentiated tumors were diploid, while aneuploid populations and positivity for EGF-R expression were more frequent in poorly and moderately differentiated tumors. No differences in proliferative activity were observed in relation to grade. Overexpression of EGF-R in aneuploid tumors and a relationship between it, proliferative activity and grading were observed. The disease-free survival rates were 72% and 91% for patients with aneuploid and diploid tumors, respectively.

Prevalence of antibiotic resistance among clinical isolates of methicillin-resistant staphylococci

The prevalence of methicillin-resistant and multiply antibiotic-resistant staphylococci causing infections in hospitalized patients was studied over a two-year period. Among 122 clinically significant staphylococci, the prevalence of methicillin resistance was 66%, with a higher prevalence of Staphylococcus haemolyticus (85%) and Staphylococcus epidermidis (83%) observed than of Staphylococcus aureus (49%). Multiple antibiotic resistance was observed more frequently among coagulase-negative staphylococcus (52 to 70%) than among Staphylococcus aureus (17%). All strains of methicillin-resistant Staphylococcus aureus were susceptible to glycopeptide antibiotics and to trimethoprim-sulfamethoxazole, whereas approximately 50% of coagulase-negative staphylococci exhibited either moderate susceptibility or resistance to teicoplanin. For these latter strains, vancomycin remains the agent of choice, whereas teicoplanin cannot be recommended unless its efficacy is established by MIC determination.

Transurethral resection of the prostate and metastatic prostate cancer

Demonstration of malignant cells in blood specimens collected during transurethral resection of the prostate (TURP) has implicated TURP in the dissemination of prostatic cancer. Of 153 patients who underwent radiation therapy for prostate cancer between January 1977 and June 1990 and were retrospectively analyzed, 93 were evaluable. Fifty-nine patients required TURP before radiation therapy for prostatic obstruction (BPH and/or cancer); the remaining 34 patients underwent radiation therapy after fine-needle aspiration biopsy. No statistically significant difference in failure rate could be detected between these groups, with a failure rate of 47% (28 of 59 patients) at a median follow-up time of 49 months (range, 8 to 146 months) in the TURP group versus a failure rate of 47% (16 of 34 patients) at a median follow-up time of 50 months (range, 3 to 122 months) in the group who underwent biopsy only (Fisher's exact test, P = 0.23). Within the confines of this retrospective study, it appeared that TURP did not enhance the development of metastatic disease.

[Angioplasty of the deep femoral artery using a semirigid PTFE prosthesis. Experimental studies]

Underlining the importance of Profundus Femoral Artery and its capacity to make up for lower limb's haemodynamics during obliterative arteriopathy, the Authors conceive a funnel-shaped intravascular prosthesis, Goretex constructed (PTFE), to introduce, in case of obstruction, in the artery lumen with a suitable instrument. The research is performed through ten oldster dogs whose average weight is twenty-four kilograms. Isolated the deep Femoral Artery and carried out an arteriotomy of about two centimetres on the Common Femoral Artery, we bring the prothesis in Profundis Femoral Artery and we fix it to the wall of the Common Femoral Artery with 8/O microsurgical dots. After thirty days, the arteriographic test shows the patency of the endoprosthesis with normal peripheral flow in nine animals out of ten. By virtue of this preliminary experiment, the Authors point out the semplicity of this intervention, also feasible in local anaesthesia, the good tolerability of the prosthesis and its perfect integration with the surrounding arterious wall, without shifts or dissecting laminar flows between the external prosthesis wall and the vessel lumen of the animal.

A kinetic thermodynamic phenomenological approach to genetic expression of heat-shock proteins

The approach of viewing complex biochemical phenomena as autocatalytic relaxation processes has been introduced previously (Liquori & Tripiciano, 1980; Liquori & Florio, 1985). In the present work this formalism is extended from its original framework regarding cell growth, to the problem of genetic expression. The case of the heat-shock response in organisms ranging from man to bacteria is discussed. Finally, we give some biochemical examples in which the new approach underlines evident temporal co-operativity.

Decreased antithrombin III activity in diabetes may be due to non-enzymatic glycosylation--a preliminary report

Antithrombin III activity was moderately but significantly decreased in insulin dependent diabetics (p less than 0.005), while no difference has been found between the diabetic (n = 25) and control groups (n = 22) in antithrombin III plasma concentration. Moreover, antithrombin III activity was inversely correlated with glycosylated plasma proteins (r = 0.57; p less than 0.01). These data show that in diabetes there is a depressed biological activity of antithrombin III and suggest that this reflects nonenzymatic glycosylation of antithrombin III protein.

[Lipid-metabolic and blood coagulation factors in chronic peripheral arteriopathies]

The authors have tested serum levels of cholesterol, triglycerides, HDL-cholesterol and LDL-cholesterol, with the plasmatic levels of Antithrombin III and other parameters (Quick time, PTT, fibrinogenaemia and platelets) in patients affected by chronic obstructive arterious diseases in various stages including a group of patients affected by diabetes mellitus. The results show that there is a correlation between the behaviour of the parameter tested and the follow-up of the diseases, particularly for HDL and LDL cholesterol and Antithrombin III. The authors suggest the use of these tests for monitoring this kind of vascular peripheral diseases.

Effect of anaesthesia on serum levels of LH and FSH in man with and without GnRH test

The effect of anaesthesia with atropine and pentobarbital (PB) in three groups of volunteers has been tested. The dose used for the anaesthesia was 20 mg/kg body weight of PB. The experiment was performed with and without stimulation test with GnRH. Anaesthesia was shown to increase serum levels of LH and to increase the response to stimulation with GnRH. Atropine and mental stress seem to have no effect on the hormones. No variation in serum levels of FSH in the anaesthesized volunteers was noted. The data obtained have been statistically controlled.

[Effect of pretreatment with metoclopramide on plasma prolactin response to methergoline]

The Authors examined 20 voluntary women without endocrine diseases. The women took 4 mg of metergoline orally and 30-60-90-120-180-240 minutes after the medicament was given the serum prolactin levels were tested. After 3 weeks, 14 among 20 subjects repeated the test assuming during the 3 days before 50 mg of metoclopramide orally once a day. The Authors found a remarkable decline of prolactin serum levels after metergoline administration in all subjects. After metoclopramide administration prolactin serum levels increased meaningly. Metergoline administration gave again considerable fall of prolactin serum levels in the 14 subjects. From the data the Authors affirm that metergoline inhibits prolactin secretion with an antiserotonine action

[Effect of metoclopramide on growth hormone (GH) release induced with ACTH]

We examined 10 volunteers subjects, sound and exempt from endocrine disease. The rapid injection of 0,25 mg of ACTH (Synacten) was followed by a distinct increase of plasma Growth Hormone (GH) within 30 or 60 min in 9 of 10 normal volunteers. The test were then repeated in the 12 "responders" after previous subministration of Metoclopramide and the GH response was totally abolished.