Caffeine as an indicator of estrogenic activity in source water

Caffeine has already been used as an indicator of anthropogenic impacts, especially the ones related to the disposal of sewage in water bodies. In this work, the presence of caffeine has been correlated with the estrogenic activity of water samples measured using the BLYES assay. After testing 96 surface water samples, it was concluded that caffeine can be used to prioritize samples to be tested for estrogenic activity in water quality programs evaluating emerging contaminants with endocrine disruptor activity.

Severe pneumonia after intravesical BCG instillation in a patient with invasive bladder cancer: case report and literature review

We present here the case of a 66 year old man with a severe bilateral community acquired pneumonia secondary to dissemination after an intravesical instillation of bacilllus Calmette-Guerin (BCG). Diagnosis was based on positive polymerase chain reaction (PCR) for mycobacterium tuberculosis complex in bronchoalveolar lavage and on the finding on transbronchial biopsy of non necrotising granulomas histopathologically similar to the granulomas found in bladder biopsies. These findings were confirmed using a validated real time PCR assay demonstrating the presence of the BCG genome in transbronchial and bladder biopsies.

Bronchial glomus tumor mimicking a COPD exacerbation

We report the case of a glomus tumor originating in the left main bronchus diagnosed in a 79 year old Caucasian man. A glomus tumor is an extremely rare neoplasm in the bronchi with nonspecific clinical features. Bronchoscopy allows the diagnosis through biopsy and subsequent histopathological examination of the tissue and in selected cases may represent a valid alternative to surgery permitting a radical tumor excision.

Foot bone mass and analysis of calcium metabolism in diabetic patients affected by severe neuropathy

AIM

Charcot neuro osteoarthropathy (NAC) is a devastating foot complication which is associated to peripheral neuropathy. The aim of this study was to investigate the changes in foot bone mass in patients with peripheral neuropathy and to correlate this with calcium metabolism in diabetes.

METHODS

The study included three groups of patients enrolled consecutively: group 1 consisted of 28 diabetic patients, affected by both peripheral neuropathy and autonomic neuropathy as well as monolateral foot ulcer; group 2 consisted of 10 diabetic patients without neuropathy and without foot ulcerations; group 3 consisted of 10 healthy people. In all patients we studied calcium and bone metabolism and quantitative ultrasonography (QUS) of calcaneal bone was performed in both feet in each subject. Calcium and bone metabolism were assessed by the assay of serum parathyroid hormone (PTH), serum calcium, serum phosphorus, serum magnesium, serum bone alkaline phosphatase isoenzyme and urinary excretion of deoxypyridinoline DPD.

RESULTS

In patients with neuropathic ulceration, QUS showed a decrease in bone density in the affected foot: mean T score in the normal foot was -0.54+/-0,26 (mean+/-ESM) while mean T score in the foot with the ulcer was -1.23+/-0.31 (mean+/-ESM) (P=0.004). In diabetic patients without neuropathy the authors did not find any difference in T score between the two feet. Moreover, the T score in the feet in these patients didn't show any differences in comparison to the T score of the healthy foot in neuropathic patients. The T-score in the feet of normal subjects didn't show any difference in respect to the healthy feet in diabetic patients. No difference of serum parameters of calcium metabolism was seen among the groups, while, among the parameters of bone metabolism, B-ALP was elevated in patients with foot ulcer.

CONCLUSION

These data suggest that bone demineralization is associated to peripheral neuropathy with foot ulceration. MOC can represent a way to personalized therapy of patients who are prone to fractures and to the development of NAC.

Ectopic thymoma simulating a pericardial cyst

We present a case of a 53 year old man with a thymoma near the pericardium, a rare ectopic localisation of thymoma. A round radiodensity found at the right cardiophrenic angle was initially suspected at the echocardiography to be a pericardial cyst. The diagnosis of thymoma was made only after histopathological examination of the surgically re-sected lesion.

Thyroid papillary cancers: microcarcinoma and carcinoma, incidental cancers and non-incidental cancers - are they different diseases?

OBJECTIVE

Tumour size represents a much-debated prognostic factor in papillary cancer, and the necessity to perform a fine-needle aspiration (FNA) on small nodules is a frequent matter of discussion. We compared some prognostic histological features for various sizes of papillary cancers (PCs) and, with regard to these prognostic features, we compared non-incidental with incidental PCs. We also considered the possibility that ultrasonography could detect nodules harbouring the most aggressive cancers.

DESIGN AND PATIENTS

We have studied patients with a histological diagnosis of PC from 1999 to 2003. FNA was performed on all nodules > 1.0 cm and on hypoechoic nodules with irregular margins or microcalcification when the size was < 1.0 cm (3321 FNAs in total). We were able to consider several different types of patients: those with PC diagnosed by FNA before surgery; those with large goitre and PC of small size diagnosed after histological examination and in whom a careful examination of the presurgical ultrasonography could show a distinct highly suspicious nodule that was not subjected to FNA, and patients with real incidental PC (that is, those with nodular goitre who correctly underwent FNA on suspicious nodules but in whom thyroid cancer was discovered only at histological examination). We considered two groups of patients with PC. Group 1 PCs were diagnosed before surgery with FNA (128 cases); in this group we also considered the two cases that were not correctly diagnosed before surgery. Group 2 real incidental PCs (12 cases) were found in goitres at histological examination after thyroidectomy for goitre (282 thyroidectomies). Group 1 was divided into three subgroups according to the maximum size of the PC at histological examination: (a) 44 PCs with maximum size < 10 mm, (b) 47 PCs with maximum size between 10 mm and 20 mm, and (c) 39 PCs with maximum size 20 mm. In all subgroups 1 as well as in group 2, the following four histological features were considered separately: multifocality, extracapsular extension, lymph-node involvement and its extent, and special aggressive features (dedifferentiation and/or insular aspects, tall and columnar variants).

RESULTS

In subgroups 1a, 1b and 1c the results were, respectively: multifocality 56.8, 57.4 and 51.2%; extracapsular extension 27.2, 23.4 and 46.3% (P = 0.01, subgroups 1a and 1b vs. subgroup 1c); lymph-node metastasis 13.5, 23.3 and 46.1% (P = 0.003 subgroup 1a vs. 1c; P = 0.04, subgroup 1b vs. 1c); special aggressive features 11.3, 25.5 and 28.2% (P = ns). Group 2 showed one case of multifocality (8.3%) in a patient with prior exposure to radiotherapy in childhood, while no case was found of extracapsular invasion or lymph-node involvement, and only one patient had a PC with features of dedifferentiation.

CONCLUSIONS

Non-incidental cancer, apart from multifocality, showed a classical progression for all prognostic factors from microcarcinoma to larger cancers. However, real incidental PC seemed to be different from non-incidental PC microcarcinoma regarding the main prognostic features. We conclude that ultrasonography is useful not only in terms of revealing the presence of cancer but also in identifying the most aggressive cancers.

Right ventricular failure: physiology and assessment

Right ventricular function can be altered in several disease states involving lungs and heart. Severe right ventricular dysfunction is a major determinant of outcome in such situations, and may strongly influence clinical management. The complex geometry of the right ventricle and the different physiology with respect to the left ventricle make the right ventricular failure difficult to define and assess. The response to increased afterload is the main determinant of right ventricle physiology in pathologic conditions. This consists of right ventricular hypertrophy and enlargement, with reduced coronary blood flow to the right ventricular wall, dilation of tricuspid annulus and displacement of interventricular septum. This latter change involves the left ventricular diastolic function, which is reduced by leftward septal shifting. In right ventricle myocardial ischemia and infarction the primum movens of altered right ventricular function is not an increase in afterload, but the ischemic involvement of the right ventricle, more often in the setting of an inferior acute myocardial infarction. The assessment of right ventricular failure is based on thermodilution by pulmonary artery catheter, contrast and radionuclide ventriculography, echocardiography, and magnetic resonance. Among these techniques, thermodilution and echocardiography play a relevant role in clinical scenarios, being readily available and feasible bedside.

Pancreas transplantation: problems and prospects in intensive care units

AIM

The aim of this study is to describe personal experience in the intensive management of patients with severe diabetes undergoing pancreas transplantation.

METHODS

Clinical records of subjects consecutively undergoing an isolated or combined pancreas transplant have been examinated.

RESULTS

During the considered period, 10 patients received an isolated pancreas transplant and 43 a simultaneous kidney-pancreas transplantation (SPKT), including 6 using a kidney from a living donor. The mean stay in the Intensive Care Unit (ICU) was 4.7 days: 52 patients (98.2%) were transferred to the Surgical Department, whereas one (1.8%) belonging to the SPKT group died with a non-functioning graft. Ten patients (18.6%) were re-admitted because of the onset of late complications, including one SPKT who died of sudden cardiac death with functioning grafts. Arterial hypertension appeared in 51% of the recipients, and 5.6% experienced at least one hypotensive episode. Cardiac rhythm alterations were diagnosed in 5 subjects (9.4%), and myocardial ischemia in 9 (17%).

CONCLUSIONS

Pancreas transplantation is a therapeutic option that can improve patients' quality of life by also slowing down the evolution of diabetes; however, it is important to bear in mind the associated risks. The best results are obtained in patients in whom the disease has not already seriously impaired the function of the various target organs.

Perioperative anesthetic management for laparoscopic kidney donation

OBJECTIVES

To report a single-center experience about the perioperative and anesthetic management of laparoscopic living kidney donation.

PATIENTS AND INTERVENTIONS

Subjects undergoing laparoscopic (n = 39) (performed between April 2000 and August 2002) and traditional "open" kidney donation (n = 27) received a standard balanced anesthetic technique. However to counterbalance the reported abdominal insufflation-related kidney dysfunction, laparoscopic donors were administered an extra intravascular volume loading with colloid and crystalloid starting on the night before surgery.

RESULTS

Laparoscopic donors underwent longer procedures with lower estimated blood losses (P =.0001), were intraoperatively administered higher amounts of intravenous fluids (P <.01), showed less postoperative analgesic requirement (P <.0001), shorter intensive care unit and overall hospitalization (P <.001), quicker resumption of solid oral intake (P <.01), and full return to work (P <.001) with no difference in the postoperative complication rate. Diuresis resumed intraoperatively in all recipients and early graft function did not differ between the two groups, although the serum creatinine declined earlier, but not significantly, in those receiving kidneys procured by the traditional method. No difference was seen in graft rejection rates.

DISCUSSION AND CONCLUSIONS

Laparoscopic kidney donation does not require a particularly complex or expensive anesthetic management or approach; as it has been suggested that intra-abdominal hypertension coming from CO(2) insufflation inside the donor's peritoneal cavity may threaten graft function, during laparoscopic kidney donation it is advisable to adopt a strategy for "renal protection." Thus, when a laparoscopic kidney donation is performed at our center, a multidisciplinary approach is commonly adopted based on three key points: perioperative positive volemic balance in donors; intraoperative urinary output of at least 100 mL/h; inflation with an abdominal pressure not exceeding 12 mm Hg.

Perioperative management for laparoscopic kidney donation

AIM

To report a single centre's experience in the perioperative management of live kidney laparoscopic donations. METHODS.

DESIGN

comparative analysis of all laparoscopic kidney donations performed between April 2000 and August 2002 and a corresponding number of "traditional surgery" donors from a historical series.

SETTING

kidney transplant centre of a teaching hospital.

INTERVENTIONS

39 and 27 subjects undergoing respectively laparoscopic and traditional "open" kidney donation were studied. A standard balanced anesthesiological technique was used in both groups but, to counterbalance the reported abdominal insufflation-related kidney dysfunction, laparoscopic donors were administered an extra intravascular volume loading with colloids and crystalloids starting from the night before surgery.

RESULTS

Laparoscopic donors underwent a longer procedure with a lower estimated blood loss (p=0.0001) and were intraoperatively administered with a higher amount of intravenous fluids (p<0.01); they showed less postoperative analgesic requirement (p<0.0001), a shorter ICU stay and overall hospitalisation (p<0.001), a quicker resumption of solid oral intakes (p<0.01) and full return to work (p<0.001) with no difference in the rate of postoperative complications. Diuresis resumed intraoperatively in all recipients and early graft function did not differ in the 2 groups although serum creatinine declined earlier, but not significantly, in those receiving kidneys by the traditional method.

CONCLUSION

Kidney laparoscopic donation does not require a particularly complex or expensive anaesthetic management or approach; it is advisable to adopt strategies to counterbalance laparoscopy-associated abdominal hypertension.

Pulmonary blastoma: case report in an adult

We present a case of biphasic pulmonary blastoma, a rare primary malignant lung neoplasm, in a 48 year old man. Despite its resection followed by postoperative chemotherapy, the neoplasm recurred and the patient survived only 41 months after the diagnosis.

Identification of counterfeit drugs using near-infrared spectroscopy

This work was aimed at the investigation of the use of near-infrared spectroscopy (NIRS) for the identification of counterfeit drugs. The identification is based on the comparison of the NIR spectrum of a sample with typical spectra of the authentic drug using multivariate modelling and classification algorithms (PCA/SIMCA). Initially, NIRS was evaluated for spectrum acquisition of various drugs, selected in order to observe the diversity of physico-chemical characteristics found among commercial products. The parameters which could affect the spectra of a given drug (especially if presented in solid form) were investigated and the results showed that the first derivative can minimise spectral changes associated with tablet geometry, physical differences in their faces and position in relation to the probe beam. The power of NIRS in distinguishing among similar pharmaceuticals was demonstrated and a protocol is proposed to construct a multivariate model and to include it in a library allowing testing for drug authenticity. The methodology was evaluated with real samples of counterfeit drugs and was able to recognise all those presenting changes in composition as false. The results show unequivocally the potential of NIRS for rapid, on-site and non-destructive identification of counterfeit pharmaceuticals.

Thyroid nodules with microfollicular findings reported on fine-needle aspiration: invariably surgical treatment?

OBJECTIVE

To assess whether fine-needle aspiration (FNA) can be a diagnostic procedure for identification of malignant thyroid nodules when the smear reveals the cytologic (microfollicular) finding of "follicular neoplasm" (FN).

METHODS

We reviewed a group of 79 patients with FN who underwent surgical treatment and evaluated the possible significance of the cytologic features of anisokaryosis, amount of colloid, and nuclear overlapping (NO). We excluded from the study those patients with FN who had other highly suspicious cytologic features, such as sporadic grooves and sporadic pseudonucleoli.

RESULTS

In our series of 79 patients with FN at FNA, we found anisokaryosis in 49.4%, scant or no colloid in 31.6%, and NO in 5.1%. Thyroid cancer (TC)--follicular cancer or follicular variant of papillary cancer--was found in six patients (7.6%): four patients (10.2%) with anisokaryosis and two patients (5.0%) without anisokaryosis (P<0.5; chi2 test). All the patients with malignant lesions had scant or no colloid in the smears, and four of them were those with NO. Therefore, TC was found in 24.0% of nodules with scant or no colloid versus 0.0% of nodules with abundant colloid (P<0.001; chi2 test), and TC was found in 100% of nodules with NO versus 2.6% of nodules without NO (P<0.001; chi2 test).

CONCLUSION

Because of the high prevalence of thyroid nodules and the frequency of FN at FNA, the number of unnecessary interventions may be very high. FNA cannot be diagnostic in FN because invasion of the tumor capsule and blood vessels can be evidenced only at histologic examination. Although it is common opinion that microfollicular nodules should be surgically treated, simple cytologic features can help select patients at low risk who can be monitored and reassessed clinically and by FNA. Patients with high-risk cytologic features such as NO should be advised that a total thyroidectomy may be necessary.

Congenital diaphragmatic hernia in an adult simulating a pleural liposarcoma

We report the case of a 32-year-old man with the onset of exercise-related dyspnea, chest pain and chest radiography simulating a pleural effusion. The computed tomography of the chest showed signs suggesting pleural liposarcoma. Because of these findings, a videothoracoscopy was performed which surprisingly showed the presence in the left pleural space of intrapleural omentum and spleen. This report underlines that the clinical manifestations of Bochdalek hernia in adults are variegate and in most cases preoperative diagnosis is not possible.

Automated monosegmented flow analyser. Determination of glucose, creatinine and urea

An automated monosegmented flow analyser containing a sampling valve and a reagent addition module and employing a laboratory-made photodiode array spectrophotometer as detection system is described. The instrument was controlled by a 386SX IBM compatible microcomputer through an IC8255 parallel port that communicates with the interface which controls the sampling valve and reagent addition module. The spectrophotometer was controlled by the same microcomputer through an RS232 serial standard interface. The software for the instrument was written in QuickBasic 4.5. Opto-switches were employed to detect the air bubbles limiting the monosegment, allowing precise sample localisation for reagent addition and signal reading. The main characteristics of the analyser are low reagent consumption and high sensitivity which is independent of the sample volume. The instrument was designed to determine glucose, creatinine or urea in blood plasma and serum without hardware modification. The results were compared against those obtained by the Clinical Hospital of UNICAMP using commercial analysers. Correlation coefficients among the methods were 0.997, 0.982 and 0.996 for glucose, creatinine and urea, respectively.

Determination of urea in serum by using naturally immobilized urease in a flow injection conductimetric system

A flow injection method was developed, aimed at the determination of urea in human serum. The system makes use of the naturally immobilized urease present in Canavalia ensiformis DC (jack bean). A column is filled with small pieces of this bean, and the sample (50 microliters) containing urea passes through it carried by a 1% NaCl solution. On leaving the column the stream is merged with an alkaline reagent (0.5 mol dm-3 NaOH; 0.5% disodium dihydrogen ethylenediaminetetraacetate). The ammonium ions, arising from the enzymatic reaction that occurs inside the column, are changed into the molecular form, which permeates a polytetrafluoroethylene membrane and is received in a de-ionized water acceptor stream. The ammonia ionizes causing an increase in the conductance, which is proportional to the urea content of the sample. About 40 samples can be processed in 1 h with negligible carry-over and with a relative standard deviation of 1% or less. The results are in agreement with those obtained by a standard spectrophotometric method.

[Predictive significance of reticulocyte count (interpretative methodologic approach)]

This study concerns the comparison of two methodologies for reticulocyte count on two groups of 100 subjects. The evaluation of the results achieved with the two colorants (brilliant cresyl blue and pre-colored glasses with crystal acetate violet and methylene blue) suggests the application of more reliable parameters (reticulocyte index, reticulocyte production index) for the interpretation of reticulocyte counting. It seems desirable to correct the absolute reticulocyte number with the degree of anemia of the patient and to calculate the medullary production index to identify the effective reticulocytosis.