The Pathophysiology of Collateral Circulation in Acute Ischemic Stroke

Cerebral collateral circulation is a network of blood vessels which stabilizes blood flow and maintains cerebral perfusion whenever the main arteries fail to provide an adequate blood supply, as happens in ischemic stroke. These arterial networks are able to divert blood flow to hypoperfused cerebral areas. The extent of the collateral circulation determines the volume of the salvageable tissue, the so-called "penumbra". Clinically, this is associated with greater efficacy of reperfusion therapies (thrombolysis and thrombectomy) in terms of better short- and long-term functional outcomes, lower incidence of hemorrhagic transformation and of malignant oedema, and smaller cerebral infarctions. Recent advancements in brain imaging techniques (CT and MRI) allow us to study these anastomotic networks in detail and increase the likelihood of making effective therapeutic choices. In this narrative review we will investigate the pathophysiology, the clinical aspects, and the possible diagnostic and therapeutic role of collateral circulation in acute ischemic stroke.

Comorbidity and in-hospital mortality in peritoneal dialysis patients: data of the Emilia Romagna region of Italy

OBJECTIVE

Kidney failure increases in-hospital mortality (IHM); however, comorbidity is crucial for predicting mortality in dialysis patients. Our aim was to evaluate the impact of comorbidity, assessed by modified Elixhauser index (mEI), Charlson Comorbidity Index (CCI), and age-adjusted CCI, on IHM in a cohort of peritoneal dialysis patients admitted to hospitals of the Emilia Romagna region (ERR) of Italy.

PATIENTS AND METHODS

All hospital admissions of peritoneal dialysis patients recorded between 2007 and 2021 in the ERR database were analyzed. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) was used for detecting diagnoses and procedures, and the inclusion criterion was code 5498. Comorbidity burden was evaluated by three different scores, and hemodialysis (HD) treatment need was considered. IHM was our outcome.

RESULTS

During the 15 years of the study, 3,242 hospitalized peritoneal dialysis patients (62.7% males) were evaluated. Mean age was 62.8±20.6 years, 9.6% underwent HD, and IHM was 5.9% (n=192). IHM mortality was stable throughout the study period. Deceased subjects were older, were hospitalized longer, had a higher comorbidity burden, and had a higher percentage of HD treatment needs than survivors. Age, male sex, comorbidity burden, and HD treatment were predictors of IHM. Receiver operating characteristics (ROC) analysis confirmed the impact of comorbidity burden on IHM, especially when age was considered.

CONCLUSIONS

We conclude that in male, elderly hospitalized peritoneal dialysis patients with failing dialysis technique, comorbidity burden should be considered being a predictor of IHM.

Osimertinib and anti-HER3 combination therapy engages immune dependent tumor toxicity via STING activation in trans

Over the past decade, immunotherapy delivered novel treatments for many cancer types. However, lung cancer still leads cancer mortality, and non-small-cell lung carcinoma patients with mutant EGFR cannot benefit from checkpoint inhibitors due to toxicity, relying only on palliative chemotherapy and the third-generation tyrosine kinase inhibitor (TKI) osimertinib. This new drug extends lifespan by 9-months vs. second-generation TKIs, but unfortunately, cancers relapse due to resistance mechanisms and the lack of antitumor immune responses. Here we explored the combination of osimertinib with anti-HER3 monoclonal antibodies and observed that the immune system contributed to eliminate tumor cells in mice and co-culture experiments using bone marrow-derived macrophages and human PBMCs. Osimertinib led to apoptosis of tumors but simultaneously, it triggered inositol-requiring-enzyme (IRE1α)-dependent HER3 upregulation, increased macrophage infiltration, and activated cGAS in cancer cells to produce cGAMP (detected by a lentivirally transduced STING activity biosensor), transactivating STING in macrophages. We sought to target osimertinib-induced HER3 upregulation with monoclonal antibodies, which engaged Fc receptor-dependent tumor elimination by macrophages, and STING agonists enhanced macrophage-mediated tumor elimination further. Thus, by engaging a tumor non-autonomous mechanism involving cGAS-STING and innate immunity, the combination of osimertinib and anti-HER3 antibodies could improve the limited therapeutic and stratification options for advanced stage lung cancer patients with mutant EGFR.

Rituximab in people living with HIV affected by immune-mediated renal diseases: a case-series

Over the last two decades, rituximab (RTX) has played an important role in the treatment of some lymphoproliferative malignancies and immune-mediated diseases. RTX administration is generally safe and well-tolerated, but side effects including late-onset neutropenia, hypogammaglobulinemia, hepatitis B reactivation and rare cases of progressive multifocal leukoencephalopathy have been observed after its administration. Although there are no absolute contraindications regarding its use in people living with HIV (PLWH), the prescription of this drug has been principally limited in patients with oncohematological diseases. In this report, we described the outcome of four PLWH who underwent RTX therapy after the diagnosis of immune-mediated renal disease. The main RTX-associated adverse effects were leukopenia, late-onset neutropenia and decline of CD4+ and CD8+ T-cell counts. In addition, two of the four patients experienced pneumonia requiring hospitalization within six months from the last RTX infusion. We suggest that RTX should be used with caution in PLWH until further evidence emerges on its safety profile in this vulnerable population.

AB0525 NATURAL HISTORY OF CRYOGLOBULINEMIA FROM 2000 TO 2018 FROM THE LABORATORY POINT OF VIEW: AN ANALYSIS OF CRYOGLOBULIN CHARACTERISTICS IN A SINGLE CENTER

Background:

Big data refers to large amounts of information. With today’s ever-improving technologies created by the automation and digitization, it becomes easier to convert data into relevant information, which can be used to provide better patient management, especially when it occurs a rare condition such as cryoglobulinemia (CRG).

CRG is due to an immunoglobulins (Ig) that precipitate at low temperatures. There are 3 types of CRG: type I: monoclonal Ig; type II: monoclonal Ig + polyclonal Ig; type III: 2 polyclonal Ig.

Objectives:

The aim of this study was to analyse the available data coming to the Department of Laboratory Medicine of Modena to describe the population of patients suffering of CRG.

Methods:

Data from the Modena Labs network were extracted by means of the software “Pagoda”, for statistical purposes, directly connected to the Laboratories Information System (LIS). Considered time period 2000-2018

Results:

The analysed samples were 28,847, 4901 (17%) of which positive to the cryoglobulins (CR) detection. The typing positive CR were 4190 (85%): type 1 7.8 %, type II 48.54% and type III 43.8% The positive samples belonged to 2528 patients. Patients were 1563 (62%) women, average age 66±16, and 965 (38%) men, average age 62±16. (female/male ratio = 1.62) No statistically significant difference regarding sex and age between the 3 types. The cryoglobulinemia phenomenon is quite complex and the typing of monoclonal, polyclonal components of the Ig classes and chains has made it possible to identify 41 possible combinationsOut of 115 patients with Type 1 cryoglobulin, 73% had a monoclonal IgM and 36% monoclonal IgG; 11.2% both monoclonal IgG and IgM. The к light chain was the most frequent: 55,6% IgM-k and 23,4% IgG-k vs 29% IgM-λ and 18.2% IgG-λ. Two patients had an IgA-k cryoglobulin.

Patients with Type 2 cryo were 781: monoclonal IgM-k 587 (75.1 %), 126 IgM-λ (16.1 %), 52 IgG-k (6.6 %), IgG-λ (5%), 1 IgA-λ; 2.8% had both IgG and IgM. Out of 1204 patients with Type 3 cryo, 74.8% had both polyclonal IgG and IgM, 13,8% had isolated IgM or IgG (9%); 4.8 % IgG-IgA-IgM together, both IgG and IgA in only 0,5% of patients. Almost the 50% (1255) of the patients had a diagnosis supporting the request of CR:

HCV, 604 (48%); chronic hepatitis, 177 (14%); rheumatologic disorder, 107 (9%); autoimmune diseases, 83 (7%), nephropathy, 80 (7%); others, 204 (15%).

Genotyped HCV+ patients were 290 (48%), with the following results: 1b, 136 (47%); 2a/2c, 65 (22%); 3a, 26 (9%); others 63 (22%).

Conclusion:

The data show that CRG is a pathology which affects the elderly and especially women, as in autoimmune and rheumatological diseases. The predominant CRG type is the III and the most frequently related pathology to the request for CR is HCV+ and chronic hepatitis. The most common HCV genotype are 1b and 2a/2c The cryoglobulinemia phenomenon is complex and laboratory typing is intriguing.

Starting from this preliminary descriptive study, it will be possible, with the available data, to perform elaborations that allow to relate CRG with the diagnosis and verify the effect of therapy.

Big Data methods’ application represents an undeniable resource for public institutions when carrying out strategic decision-making processes.

Disclosure of Interests:

None declared

A clinical improvement of a idiopathic cervical dystonia in a patient treated with transdermal Rotigotine: a case-report

Dystonia is the third most common movement disorder. Cervical dystonia is the most common form of dystonia, a subtype of Primary Focal Dystonia due to the phasic and/or tonic involuntary contractions of different combinations of neck muscles, generally treated with good clinical results with botulin toxin type A or B injection. The etiology of cervical dystonia is still unknown. It was recently proposed that the cervical dystonia is due to malfunctioning of the head neural integrator, that result of impairment in cerebellar, basal ganglia, or proprioceptive feedback. The hypothesis of the existence of an electrical circuit that connects the basal ganglia with the cerebellum and the proprioception feedback, participating in the neural integrator of the head, explains that the damage at any point of the network can lead to motor deficits. Although dystonia is often associated with abnormal dopamine neurotransmission, dopaminergic drugs are not currently used to treat dystonia because there is a general view that they are ineffective. The results from the clinical trials and tests in mice suggest that the coactivation of D1 and D2 dopamine receptors may be an effective therapeutic strategy in some patients. These results support the assumption that dopamine receptors could be considered as targets for treating dystonia. Furthermore, a dopamine agonist-response dystonia in patients with an autosomal recessive L-amino acid decarboxylase deficiency, has been described in the scientific literature. We report a case of focal cervical dystonia successful treated with a dopamine agonist (D3>D2>D1) Rotigotine, a transdermal drug that induces a continuous dopaminergic stimulation.

Rhodococcus equi Pneumonia in Kidney Transplant Recipient Affected by Acute Intermittent Porphyria: A Case Report

Rhodococcus equi is a gram-positive coccobacillus responsible for severe infections in patients with weakened immune systems. R equi generally causes pnumonia that may evolve into fatal systemic infection if left untreated. Here, we present a case of a 67-year-old woman affected by acute intermittent porphyria (AIP) who developed R equi pneumonia 7 months after kidney transplantation. Although clinical features at presentation were nonspecific, lung computed tomography showed right perihilar consolidation with a mass-like appearance causing bronchial obstruction. Appropriate antibiotic including intravenous meropenem and oral azithromycin that was then switched to oral levofloxacin and oral azithromycin along with reduction of immunosuppressive therapy resolved pneumonia without provoking an acute attack of porphyria. AIP limited the choice of antibiotics for the treatment of R equi infection because some potentially porphyrinogenic antibacterial agents were avoided. Based on this experience, azithromycin and meropenem can be safely administered for the treatment of R Equi infection in patients with AIP.

Knowledge and Attitudes Toward Organ Donation in Health Care Undergraduate Students in Italy

INTRODUCTION

The number of organ donors in Italy is increasing, but with still disappointing living donation activity and relatively frequent objection by potential deceased donors' relatives to organ recovery. Few studies have assessed health care students' knowledge and attitude on donation.

METHODS

We administered a questionnaire to medical (MS) and nursing students (NS) at University of Modena and Reggio Emilia, Italy, and 749 students (406 MS and 343 NS) completed the questionnaire.

RESULTS

Although 95% of students were in favor of donation, only 21.9% of NS and 24.9% of MS were registered as donors. One quarter of students reported family disagreement. MS appeared more confident with personnel involved in donation. Overall, 60% of students knew the term donation after brain death but only 40% were aware of the criteria used to define it. Barely 27.1% of NS and 15.3% of MS believed they had received sufficient information in lessons. Backward logistic regression demonstrated that students whose families agree with them and who knew the definition of donation after brain death were more likely to express the disposition of registering, and those who showed distrust in the declaration of brain death were half as likely to register as donors.

DISCUSSION

Students expressed a lack of knowledge, controversial attitudes on donation, and strong need for education; increased awareness may help increase donation rates. The majority of educational institutions in Italy do not directly address training on organ donation and transplantation for health care students; an integrated curriculum favoring interpersonal discussion including practical aspects is urgently required.

Gastric Mucormycosis in a Liver and Kidney Transplant Recipient: Case Report and Concise Review of Literature

Mucormycosis is an uncommonly encountered fungal infection in solid organ transplantation. The infection is severe and often results in a fatal outcome. The most common presentations are rhino-sino-orbital and pulmonary disease. We describe a rare case of gastric mucormycosis in a patient with a combined liver-kidney transplant affected by glycogen storage disease type Ia. A 42-year-old female patient presented with gastric pain and melena 26 days after transplantation. Evaluation with upper endoscopy showed two bleeding gastric ulcers. Histological examination of gastric specimens revealed fungal hyphae with evidence of Mucormycetes at subsequent molecular analysis. Immunosuppressive therapy was reduced and antifungal therapy consisting of liposomal amphotericin B and posaconazole was promptly introduced. Gastrointestinal side effects of posaconazole and acute T-cell rejection of renal graft complicated management of the case. A prolonged course of daily injections of amphotericin B together with a slight increase of immunosuppression favored successful treatment of mucormycosis as well as of graft rejection. At 2-year follow-up, the woman was found to have maintained normal renal and liver function. We conclude that judicious personalization of antimicrobial and antirejection therapy should be considered to resolve every life-threatening case of mucormycosis in solid organ transplantation.

Heart failure: molecular, genetic and epigenetic features of the disease

Factors that compete to establish heart failure (HF) are not completely known. In the last years the several technological improvements allowed us to deeply study the molecular and genetic aspects of this complex syndrome. This new approach to HF based on molecular biology new discoveries shows us more clearly the pathophysiological bases of this disease, and a future scenery where the genetics may be useful in the clinical practice, as screening of high risk populations, as well as in the diagnosis and therapy of underlying myocardial diseases. The purpose of this review was to analyse the molecular, genetic and epigenetic factors of HF. We described the molecular anatomy of the sarcomere and the pathogenesis of the heart muscle diseases, abandoning the previous monogenic theory for the concept of a polygenic disease. Different actors play a role to cause the illness by themselves, modifying the expression of the disease and, eventually, the prognosis of the patient.

Analgesia with paracetamol/tramadol vs. paracetamol/codeine in one day-surgery: a randomized open study

OBJECTIVES

The analgesic efficacy of two fixed combinations of tramadol/paracetamol (TP 37.5/325 mg) and codeine/paracetamol (CP 30/500 mg) was compared in 122 patients undergoing one-day surgical procedures (hallux valgus, haemorrhoidectomy, varicectomy and inguinal hernia repair), randomly treated with TP 37.5/325 mg or CP 30/500 mg one tablet after surgery ended, followed by one tablet four times daily for 48 hours.

METHODS

Pain was assessed by a Verbal Rating Scale (VRS). Whenever the VRS score was > or = 3, the patient was given a "rescue medication" (tramadol 50 mg s.c.). The quality of life (time to return to normal daily activities, nightly rest, appetite, mood, deambulation, and self-care) was assessed in the postoperative period. Patients were asked to give their judgment on the surgical procedure and postoperative outcome.

RESULTS

The results indicate that TP 37.5/325 mg was superior to CP 30/500 mg in terms of higher analgesic efficacy (VSR at 24 hours: CP 30/500, 2.52 +/- 0.86 vs. TP 37.5/325, 1.40 +/- 0.76; p < 0.001), less patients reporting adverse events (CP 30/500: 62% vs. TP 37.5/325: 36%; p < 0.01), less patients requiring rescue medications (CP 30/500: 18.2% vs. TP 37.5/325: 5.5%; p < 0.01), and more favorable judgment (scored "excellent" by 16% and 54.5% of CP 30/500 or TP 37.5/325-treated patients, respectively; p < 0.001).

CONCLUSIONS

We conclude that a fixed association of tramadol/paracetamol is a valuable and safe tool for pain management in day hospital surgery, especially whenever any effort is done to reduce the time for hospitalization.

Inactivation of wine spoilage yeasts Dekkera bruxellensis using low electric current treatment (LEC)

AIMS

The objective of this study was to investigate the inactivation of a selected yeast Dekkera bruxellensis strain 4481 in red wine by application of low electric current treatment (LEC).

METHODS AND RESULTS

LEC (200 mA) was applied for 60 days to a red wine, Montepulciano d'Abruzzo, in an alternative strategy to the SO(2) addition during wine storage. The LEC effect on both cell activity and microflora viability was assessed. LEC decreased significantly the survival viable cells and increased the death rate of D. bruxellensis strain 4481 yeast. A final comparison was made of the main physico-chemical parameters of the wine after the different treatments. The study suggests the importance of an appropriate LEC treatment which limits wine deterioration in terms of off-flavours synthesis.

CONCLUSIONS

The results demonstrate that the growth of undesirable Dekkera can be inhibited by low voltage treatment; LEC was shown to be useful to prevent wine spoilage and has the potential of being a concrete alternative method for controlling wine spoilage.

SIGNIFICANCE AND IMPACT OF THE STUDY

Wine spoilage can be avoided by preventing the growth of undesirable Dekkera yeasts, through the effective use of LEC in the winemaking process.

Infertility in women: combined sonohysterography and hysterosalpingography in the evaluation of the uterine cavity

PURPOSE

To evaluate the diagnostic effectiveness of combined hysterosalpingography (HSG) and sonohysterography (SHG) in the study of infertile women.

MATERIALS AND METHODS

208 women affected by primary (184) or secondary sterility (24) were divided in two random groups. Group 1 underwent only HSG and group 2 underwent simultaneous HSG and SHG. The results obtained in the two groups were correlated with the results of hysteroscopy or laparoscopy, considered Gold Standard. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and likelihood ratio (LR) of HSG alone and combined HSG/SHG were calculated. Results were evaluated with t-test, Pearson's Chi square or Fisher exact test when appropriate and ROC analysis.

RESULTS

In group 1, hysteroscopy revealed no pathology in the uterine cavity in 70/104 patients, but evidenced 47 abnormalities related to the uterine cavity in 34 women. HSG outcome was in accordance with hysteroscopy in 27/34 cases of abnormalities, and in 64/70 cases of normal outcome. Sensitivity 0.79, specificity 0.91, PPV 0.82, NPV 0.90, LR+ 9.26. In group 2, hysteroscopy revealed no pathology in the uterine cavity in 64/104 patients but 52 abnormalities related to the uterine cavity in 40 women. HSG and SHG outcomes were confirmed by hysteroscopy in 39/40 cases of abnormalities of the uterine cavity and in 60/64 cases of normal uterine cavity. Sensitivity 0.97, specificity 0.94, PPV 0.91, NPV 0.98, LR+ 15.60. Statistical analysis showed that combined HSG and SHG yielded elevated specificity and LR+ and therefore few cases of false positive outcome.

CONCLUSION

Combined performance of HSG and SHG can shorten diagnostic investigation time and reduce the discomfort to the patient as the injector is fed into the cervix only once. This may also reduce the patient's anxiety level as one of the causes of infertility.

Retrospective survey on laparoscopic cholecystectomy in the cirrhotic patient

Cholelitiasis is a common disease in patients with liver cirrhosis, mainly due to intravascular haemolysis and functional alterations of the gallbladder. In Child A and B cirrhotics laparoscopic cholecystectomy (LC) demonstrated the same advantages and safety as in the non cirrhotic patients. On the contrary, indications for surgery in Child C patients should be carefully evaluated. Nevertheless, the current number of patients with Child C cirrhosis submitted to LC is too low to extrapolate definitive data. Here we report our observations on a retrospective case series of LCs performed for symptomatic biliary disease in patients affected with liver cirrhosis. Both medical records and surgical registers were used to collect pre-operative, intra-operative and post-operative data from 40 cirrhotics out of 921 patients operated by laparoscopic cholecystectomy between November 1996 and November 2006. All patients underwent LC because of symptomatic disease. The average duration of the laparoscopic intervention was 111 minutes (60-220 minutes) distributed as follows according to the severity of liver disease: 66 minutes (48-87) in the Child A group, 108 minutes (91-119) in the Child B group and 138 minutes (110-160) as refers to Child C cirrhotics. Median blood loss was quantified as 80 ml (28-97) in Child A group, 155 ml (130-180) in Child B group and 300 ml (220-500) among Child C cirrhotics. The median length of hospital stay was 6 days (3-9 days) in the Child A group, 9 days (7-13 days) in the Child B group and 21 days (16-27 days) in Child C cirrhotics. Three cases out of 40 (7,5%) died: 2 Child C and 1 Child B. In conclusion, this study confirms that in patients affected with Child A and B cirrhosis LC may be safely performed either in emergency or in election whereas as refers to Child C cases we have observed a slightly higher mortality but a relevant higher impact of non lethal complications.

Pile composting of two-phase centrifuged olive husk residues: technical solutions and quality of cured compost

The present work proposed an economically sustainable solution for composting olive humid husks (OHH) and leaves (OL) at a small/medium sized olive oil mill. We planned and set up a composting plant, the prototype taking the form of a simplified low-cost turning machine, and evaluated the use of an inoculum of one year-old composted humid husks (CHH) and sheep manure (SM) to facilitate the starting phase of the process. Trials were carried out using four piles under different experimental conditions (turnover, static, and type of inoculum). The best results were achieved with turnover and an inoculum that induced fast start-up and a correct evolution of the composting process. The final product was a hygienically clean, cured compost.

Scaling-up in industrial winemaking using low electric current as an alternative to sulfur dioxide addition

AIMS

To better understand the outcome of employing low electric current (LEC) technology as a new preservation and alternative in wine technology, and to contribute to its development. It is used in industrial-scale winemaking with commercial yeast (Saccharomyces cerevisiae) during the grape must fermentation.

METHODS AND RESULTS

LEC (200 mA, time 16 days) was applied to fresh grape must as an alternative method to the usual sulfur dioxide addition used in the industrial process; two tanks, each 30,000 l, were employed for parallel fermentations. The results show that LEC decreased the survival time and increased the death rate of apiculate yeasts, whereas it did not affect the growth and survival of S. cerevisiae. A comparison was made of the main chemical and sensory parameters of the wines obtained.

CONCLUSIONS

The results have demonstrated that the low-voltage treatment had a positive effect on the grape juice fermentation (yeast microflora) during the early stages of winemaking. SIGINIFICANCE AND IMPACT OF THE STUDY: These results could be of significant importance in developing, for 'biological wine', new winemaking technologies for an innovative control process of yeast fermentation.

Systemic Modulation of Gene Expression in Tomato by Trichoderma hamatum 382

ABSTRACT A light sphagnum peat mix inoculated with Trichoderma hamatum 382 consistently provided a significant (P = 0.05) degree of protection against bacterial spot of tomato and its pathogen Xanthomonas euvesicatoria 110c compared with the control peat mix, even though this biocontrol agent did not colonize aboveground plant parts. To gain insight into the mechanism by which T. hamatum 382 induced resistance in tomato, high-density oligonucleotide microarrays were used to determine its effect on the expression pattern of 15,925 genes in leaves just before they were inoculated with the pathogen. T. hamatum 382 consistently modulated the expression of genes in tomato leaves. We identified 45 genes to be differentially expressed across the replicated treatments, and 41 of these genes could be assigned to at least one of seven functional categories. T. hamatum 382-induced genes have functions associated with biotic or abiotic stress, as well as RNA, DNA, and protein metabolism. Four extensin and extensin-like proteins were induced. However, besides pathogenesis-related protein 5, the main markers of systemic acquired resistance were not significantly induced. This work showed that T. hamatum 382 actively induces systemic changes in plant physiology and disease resistance through systemic modulation of the expression of stress and metabolism genes.

Is color-Doppler US a reliable method in the follow-up of transjugular intrahepatic portosystemic shunt (TIPS)?

Transjugular intrahepatic portosystemic shunt (TIPS) has become a widely accepted treatment for complications of portal hypertension. Shunt or hepatic vein stenoses or occlusions are common short- and mid-term complications of the procedure, with a one-year primary patency ranging from 25% to 66%. When promptly identified, shunt stenosis or occlusion may be treated before the recurrence of gastrointestinal bleeding or ascites. The revision is usually successful and the primary-assisted patency of TIPS is approximately 85% at one year.Doppler sonography is a widely accepted screening modality for TIPS patients, both as a routine follow-up in asymptomatic patients and in those cases with clinically suspected TIPS malfunction.In a routine US follow-up, a TIPS patient is scheduled for a control 24 h after the procedure, and then after one week, 1 month, 3 months, and at 3-month intervals thereafter. Venography is at present performed solely on the basis of a suspected shunt dysfunction during the sonographic examination.Color-Doppler sonography is the most reliable method for monitoring the shunt function after TIPS implantation. Several studies have shown that Doppler sonography is a sensitive and relatively specific way to detect shunt malfunction, particularly when multiple parameters are examined. Achieving high sensitivity is optimal so that malfunctioning shunts can be identified and shunt revision can be performed before symptomatic deterioration. Venous angiography is at present indicated only on the basis of US suspicion of shunt compromise. Power-Doppler US and US contrast media can be useful in particular conditions, but are not really fundamental.

Post-transplant hepatic complications: Imaging findings

Transplantation is considered definitive therapy for acute or chronic irreversible pathologies of the liver, and the increased survival rates are mainly due to improved immunosuppressive therapies and surgical techniques. However, early diagnosis of possible graft dysfunction is crucial to liver graft survival. Diagnostic imaging plays an important role in the evaluation of the liver before and after transplant and in the detection of complications such as vascular and biliary diseases, acute and chronic rejection and neoplastic recurrence. Integrated imaging using color-Doppler, CT, MRI and traditional x-ray reach a high level of sensitivity and specificity in the management of transplanted patients.

Biotechnology applied to cultural heritage: biorestoration of frescoes using viable bacterial cells and enzymes

AIMS

To set up and employ, for the biorestoration of cultural heritage (altered frescoes), an advanced and innovative biotechnology method based on the sequential use of whole viable bacterial cells and specific enzymes.

METHODS AND RESULTS

The bioremediation intervention consisted of the direct application onto an artwork surface of whole bacterial cells of the Pseudomonas stutzeri A29 strain (bioaugmentation), followed by, in a final step, a purified Protease enzyme. The bioremediation was performed on a Spinello Aretino fresco that had become altered by the animal glue residues of past restoration. For the reader's interest the fresco is the 14th century Conversione di S. Efisio e battaglia (Conversion of S. Efisio and battle), size 3.5 x 7.8 m at the Pisa Camposanto Monumentale, Italy. An assessment was made of the final costs of the biological tests (whole bacterial cells, enzymes) so as to compare them with other intervention techniques.

CONCLUSIONS

A successful innovative biological approach to recover valuable frescoes was set up, and the best conditions for treatment efficiency were identified. Furthermore the cost of the biological cleaning using viable bacterial cells and enzymes (P. stutzeri, Protease, Collagenase, 1 : 3 : 10, ratio respectively) was much lower than that of other conventional methods, making this biotechnology not only very interesting but also very competitive.

SIGNIFICANCE AND IMPACT OF THE STUDY

New biotechnologies with an innovative, soft approach to the 'biocleaning' and 'biorestoration' of cultural heritage are in constant demand, and our results are clear evidence that such an approach has been achieved; the technique could be of significant importance towards developing other goals.

[Criteria for assessing severely hot environments: from the WBGT index to the PHS (predicted heat strain) model]

BACKGROUND

The present study deals with the main methods for assessment of hot environments: i.e., WBGT, SWreq and PHS. It is stressed how the WBGT index, which is strictly empirical, although a very practical tool for the assessment of the hot environments, can only be used for a rough evaluation of heat stress, and especially for a not very high metabolic rate (M<175 W/m2). On the contrary, the SWreq method, which is based on both subject-environment heat exchange and the effect of clothing, allows a better assessment of the work situation with a general reduction of the exposure limits with respect to WBGT, especially in non-uniform environments (ta not equal to tr). However, it should be noted that application of SWreq is required by the ISO standard 7243 when the WBGT limit values are exceeded.

METHODS

In this study interest was extensively focused on the "Predicted Heat Strain" method, highlighting via a special software the differences in heat stress assessment related to this new approach, which will be adopted by the ISO in the next revision of standard 7933.

RESULTS

The PHS method, unlike SWreq, allows the prediction of the time-response of the main physiological variables of interest (i.e., skin temperature, core temperature and sweat rate). Moreover thanks to better modelling of heat exchanges, the PHS method allows account to be taken of both movement and clothing effects, resulting in even more reduced exposure.

A pure primary squamous cell breast carcinoma presenting as a breast abscess: case report and review of literature

We report the fourth worldwide case of pure primary squamous cell carcinoma of the breast presenting as an abscess. An inflammatory breast lesion in postmenopausal woman must be suspected as a malignant one and drainage of the abscess has to be followed by an accurate excision. The finding of a pure squamous cell carcinoma bears the necessity of an accurate diagnostic work up, to exclude a skin lesion or a metastasis from other district. Also histological criteria are discussed. More difficult to outline therapeutic options, due to the rarity of disease and great difference in outcome observed.

[Prolassomucosectomy according to Longo. Intermediate results]

We present results obtained in our first series of 25 patient treated by prolassomucosectomy for haemorrhoidal prolapse with a follow up of 18-36 months. Control of the disease and functional results proved to be optimal. After small early haemorrhages from the suture line, we started adding stitch sutures with haemostatic intent to all three vascular pedicles. Early or late additional complication were not observed.

Controlling grape must fermentation in early winemaking phases: the role of electrochemical treatment

AIMS

To contribute to an understanding of the phenomena related to the effect of low electric current (LEC) in grape must fermentation during laboratory and pilot plant scale winemaking, with selected co-culture yeasts (Saccharomyces cerevisiae strain 404 and Hanseniaspora guilliermodii strain 465).

METHODS AND RESULTS

LEC (10, 30, 50 and 100 mA) was applied to fresh grape must as an alternative method to the usual addition of SO2. Parameters such as polarity, treatment duration (24-96 h) and type of inoculum yeast were varied one at a time. LEC decreased the survival time and increased the death rate of H. guilliermondii strain 465 in co-cultures, whereas it did not affect the growth and survival of S. cerevisiae strain 40. A final comparison was made of the main physico-chemical parameters on wine obtained after the different tests.

CONCLUSIONS

The results have demonstrated that the low voltage treatment using a pair of graphite electrodes had a positive effect on grape juice fermentation (yeast microflora) during the early stages of winemaking, even with the potential of being an alternative method to the usual addition of SO2.

SIGNIFICANCE AND IMPACT OF THE STUDY

These results could be of significant importance in developing new winemaking technologies for an innovative yeast fermentation control process for 'biological wine'.

Assessment of the risk of heat disorders encountered during work in hot conditions

OBJECTIVE

To co-ordinate the work of the main European research teams in the field of thermal factors in order to develop and improve significantly the methods presently available for assessing the risks of heat disorders encountered during work in hot conditions.

METHOD

Each item from the required sweat rate model was reviewed on the basis of the most recent literature. A database with 1,113 laboratory and field experiments, covering the whole range of hot working conditions, was assembled and used for the validation.

RESULTS

Influence of clothing ensemble on heat exchange: methods and formulas were developed that take into account the dynamic effects associated with forced convection and the pumping effect associated with body movements and exercise. Prediction of the average skin temperature: the model used in the required sweat rate standard ISO 7933 was extended to cover more severe conditions with high radiation and high humidity and different clothing and take into account the rectal temperature for the prediction of the skin temperature. Criteria for estimating acceptable exposure times in hot work environments: criteria were reviewed and updated concerning the maximum increase in core temperature and the acceptable water loss, for acclimatised and nonacclimatised subjects. These limits are intended to protect 95% of the population. Measuring strategy: a strategy was developed to assess the risks in any working situation with varying conditions of climate, metabolic rate or clothing. A detailed methodology was developed in three stages: an "observation" method for the recognition of the conditions that might lead to thermal stress; an "analysis" method for evaluating the problem and optimising the solutions; and an "expert" method for in-depth analysis of the working situation when needed.

VALIDATION

the different results were used to prepare a revision of the interpretation procedure proposed in the ISO standard 7933. We validated the modified approaches using the database. This involved the whole range of conditions for which the model was extended, namely conditions with high and low radiation, humidity and air velocity as well as fluctuating conditions. Based on these results, the predicted heat strain model was developed: it is presently proposed as an ISO and CEN standard.

[Continence problems after radical prostatectomy: role of rehabilitation of the pelvic floor]

Continence mechanisms can be compromised after radical prostatectomy. Relatively low percentages of urinary incontinence are reported (2-15%). Perineal floor physiotherapy is considered an actual method of treatment of urinary incontinence in females. It is based on pelvic floor muscles exercises, biofeedback and functional electrical stimulation. The aim of physiotherapy is to improve pelvic floor muscles proprioception, to increase tone of levator ani and to favour automatization of these muscles in daily life. The reports in Literature on perineal floor physiotherapy in treating incontinence after radical prostatectomy are scarce. In this paper we present our experience about 9 patients with incontinence post radical prostatectomy (out of 74 patients operated on at our Institution). We obtained an improvement or a complete cure in 78% of the treated patients. We believed that pelvic floor physiotherapy can be considered a good and safe method of treatment of incontinence after radical prostatectomy, at least in less serious cases.

Development and validation of the predicted heat strain model

Eight laboratories participated in a concerted research project on the assessment of hot working conditions. The objectives were, among others, to co-ordinate the work of the main European research teams in the field of thermal factors and to improve the methods available to assess the risks of heat disorders at the workplace, and in particular the "Required Sweat Rate" model as presented in International Standard ISO 7933 Standard (1989). The scientific bases of this standard were thoroughly reviewed and a revised model, called "Predicted Heat Strain" (PHS), was developed. This model was then used to predict the minute by minute sweat rates and rectal temperatures during 909 laboratory and field experiments collected from the partners. The Pearson correlation coefficients between observed and predicted values were equal to 0.76 and 0.66 for laboratory experiments and 0.74 and 0.59 for field experiments, respectively, for the sweat rates and the rectal temperatures. The change in sweat rate with time was predicted more accurately by the PHS model than by the required sweat rate model. This suggests that the PHS model would provide an improved basis upon which to determine allowable exposure times from the predicted heat strain in terms of dehydration and increased core temperature.

[Changes in the organization of the extracellular matrix at the skin level during diabetes]

The ultrastructural study of cutaneous biopsies in diabetic patients highlighted in different phases of disease a progressive alteration of extracellular matrix (E.M.). In the initial phase of disease the morphologic aspect showed an increased accumulation of proteoglycan biglycan, laminin, fibronectin and type IV collagen. These components are responsible for the lamina lucida expansion and are induced by TGF-beta. In the last phase of the disease, an accumulation and a defective organization of E.M. component arises. Type V collagen, normally not present in the skin, is observed. In patients with over ten years of diabetic history, the morphological aspect is defined by a progressive disorganization of E.M. The formation of a vicious circle is responsible for the progressive remodeling of E.M. This process may be linked to the not enzymatic glycosylation of E.M., due to several episodes of hyperglycemia, and to autoinductive mechanisms of TGF-beta. These mechanisms are responsible for the cytokine synthesis and for the E.M. inhibition of degradation.

Intrapatient comparison of atrial and ventricular sensing, pacing threshold, and impedance: benefits with steroid-eluting leads

We compared the atrial and ventricular bio-electrical effects relating to pacing threshold, pacing impedance, and pacing energy in each of 58 patients to determine the importance of pacing impedance in safe low energy stimulations. The study was conducted during 4 years of follow-up. Of the 58 patients in our study, 31 were stimulated in both chambers with steroid-eluting leads (Capsure 4503 and 4003) and 27 with platinum electrode catheters (Target Tip 4511 and 4011). The two groups were homogeneous in sex, age, cardiopathy, and reason for implant. At 6 months, the mean impedance values for the Target Tip were: 358 +/- 72 omega for the atrium and 443 +/- 72 omega for the ventricle (P < 0.00002); after 1 year, atrium = 386 +/- 77 omega, ventricle = 439 +/- 42 omega (P < 0.04); at 2 years, atrium = 409 +/- 86 omega, ventricle = 510 +/- 94 omega (P < 0.0001); at 3 years, atrium = 428 +/- 81 omega, ventricle = 494 +/- 67 omega (P < 0.02); and at 4 years, atrium = 424 +/- 71 omega and ventricle = 501 +/- 69 omega (P < 0.003). The mean impedance value (for the Capsure) was: atrium = 351 +/- 43 omega, ventricle = 431 +/- 81 omega at 6 months (P < 0.03); at 1 year, atrium = 359 +/- 38 omega, ventricle = 446 +/- 83 omega (P < 0.01); at 2 years, atrium = 304 +/- 124 omega, ventricle = 459 +/- 108 omega (P < 0.0003); at 3 years, atrium = 359 +/- 108 omega, ventricle = 461 +/- 89 omega (P < 0.02); and at 4 years, atrium = 419 +/- 133 omega and ventricle = 515 +/- 75 omega (P < 0.01). In view of the chronic threshold, low energy stimulation was used at follow-up. The mean low energy stimulation values programmed for Target Tip were: atrium = 2.5 V/0.35 ms, ventricle = 2.5 V/0.30 ms; for Capsure, atrium = 2.5 V/0.25 ms, ventricle = 2.5 V/0.25 ms. The mean stimulation energy value was 31% higher in the atrium than in the ventricle with Capsure leads, and 39% higher with Target Tip. Pacing impedance was lower in the atrium than in the ventricle with both leads. Energy consumption in the atrium is significantly greater than in the ventricle with both leads, particularly with Target Tip.

[Physiopathology of vasovagal syncope: review of the most endorsed theories and recent findings]

Vasovagal syncope is associated with an abnormal reflex and the physiopathological mechanisms of the phenomenon overall are only partially known. Experimental and clinical studies suggest that the main factor which triggers the syncope is the brusque interruption of the alpha-adrenergic tone with marked, sudden peripheral vasodilation. Although documented, vagal hypertony, with consequent bradycardia and asystolia, is only occasional and is almost always a secondary phenomenon. The most commonly suggested cause of vasovagal syncope is a Bezold-Jarish reflex starting from the cardiac receptors in the walls of the ventricle, mediated by the paradoxical activation of afferent vagal fibres. However, recent studies are suggesting that there may be other pathogenetic mechanisms such as the paradoxical activation of the venous-atrial baroceptors and other "extracardiac" vascular receptors. The neuro-endocrine aspect of the vasovagal reaction is very complex and in spite of the many studies carried out on the catecholamine, renal-angiotensive system, arginine-vasopressin, and b-endorphine trends, there are still many points awaiting clarification. The response of the autonomous nervous system linked to age also require further research.

Apolipoprotein E polymorphism in Italy investigated in native plasma by a simple polyacrylamide gel isoelectric focusing technique. Comparison with frequency data of other European populations

A new polyacrylamide gel isoelectric focusing (PAGIEF) technique has been developed that allows rapid and reliable identification of Apolipoprotein E (APOE) phenotypes directly from plasma or serum without any prior treatment. This method was used to determine the APOE phenotypes in samples from Central and Southern Italy, Sicily, and Sardinia. The frequencies observed for the APOE*2, APOE*3, and APOE*4 alleles in Central and Southern Italy (Sicily included) were similar (0.066, 0.851, 0.083 and 0.056, 0.858, 0.085 respectively) though lower APOE*4 frequencies were found in the more southern regions. The Sardinian population showed APOE gene frequencies (APOE*2 = 0.050, APOE*3 = 0.898, APOE*4 = 0.052) to be significantly different from those of the rest of Italy owing to the low APOE*4 frequency, the lowest among Caucasian populations. The frequencies were compared with those found in other European populations. A clear cut North-South decreasing cline was found for APOE*4 allele frequencies and an opposite trend was found for APOE*3 frequencies. The overall dispersion of European populations as determined by the three APOE allele frequencies was graphically represented using coordinate analysis. The tendency of the APOE*4 frequency to decline with latitude both at the Italian and at the European level was discussed with reference to similar trends observed for dietary habits (saturated fat intake).

Hematological causes of venous thrombosis in young people: high incidence of myeloproliferative disorder as underlying disease in patients with splanchnic venous thrombosis

Thrombotic events occur frequently in myeloproliferative disorders, namely polycythaemia vera and essential thrombocythaemia. Standard diagnostic criteria are designed quite stringent, so that a number of patients could be underdiagnosed. Spontaneous erythroid colonies formation from bone marrow or peripheral blood in the absence of exogenous erythropoietin is considered a reliable index of myeloproliferative disorder even at early stages. Endogenous erythroid colonies (EECs) formation was assessed in 43 patients having recently suffered from venous thrombosis prior to 45 years and without a previous diagnosis of hematological disease favouring thrombosis. A screening for coagulative abnormalities associated with thrombophilia was also carried out: in 5 patients (11.6%) a plasmatic thrombogenic defect was found (quantitative deficiency of antithrombin III, 1 case, protein C, 2 cases, protein S, 1 case, and plasminogen, 1 case). In 10 patients (2 males and 8 females) (23.2%) EECs assay was positive, allowing diagnosis of myeloproliferative disease even though 7 of them did not fulfill standard diagnostic criteria. In the other 3 patients who met the criteria for diagnosis of overt myeloproliferative disease the thrombotic event was the inaugural manifestation. In all these EECs-positive patients thrombosis involved mesenteric and portal veins (n = 4), hepatic veins (n = 3), portal vein (n = 2), mesenteric vein (n = 1). One of them was simultaneously affected from congenital protein C deficiency. Thus latent or atypical forms of myeloproliferative disease as well as the overt stages were the most frequent recognized cause of splanchnic venous thrombosis, accounting for 55% of the cases of our series. On the contrary no EECs-positive subject was found among the 25 patients with other sites of thrombosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of the side effects of therapeutic cytapheresis and those of other types of hemapheresis

The side effects of a series of 2418 hemapheresis procedures performed in a total of 570 subjects (patients and donors) are described. Patients with various diseases were subjected to plasmapheresis (926 procedures in 181 patients) or cytapheresis (305 procedures in 89 patients). One hundred twelve plasmapheresis procedures and 1075 of cytaphereses were also performed in 300 blood donors. A total of 225 complications involving 107 patients (39.6%) occurred during 196 (15.9%) therapeutic procedures. Among the blood donors only 45 complications, involving 35 patients (11.6%) occurred during 45 procedures (4.2%). The complications seen with therapeutic plasmaphereses were circulatory disturbances (38% of all those observed), citrate reactions (27%), technical problems (20%), allergic reactions (9%) and miscellaneous complications (6%). Therapeutic cytaphereses were complicated by citrate reactions (44%), technical problems (25%), circulatory disturbances (14%), allergic reactions (11%) and miscellaneous complications (6%). Complications in the blood donor group included circulatory disturbances (51%), technical problems (36%) and various other problems (13%). No infectious complications or deaths were observed. The probability that adverse reactions will occur depends on the condition of the patient, the frequency of the sessions and the volume of fluid exchanged. Evaluation of the main risk factors, use of less intensive protocols and interruption of the session at the first sign of disturbances will help improve patient tolerance of these procedures.

Pharmacokinetics and tissue distribution of amoxicillin plus clavulanic acid after oral administration in man

Augmentin (875 amoxicillin and 125 mg potassium clavulanate) was administered orally to patients with chronic bronchitis. Concentrations of amoxicillin and clavulanic acid were measured in serum, sputum and urine. Peak serum levels for amoxicillin of 11.23 +/- 2.61 micrograms/ml were observed at 2 hours and for clavulanic acid of 2.55 +/- 0.54 micrograms/ml at 1 hour. After 9 hours, 50% of the amoxicillin and 39% of the clavulanic acid had been renally excreted. The peak sputum concentration of amoxicillin was 1.31 +/- 0.42 micrograms/ml at 4 hours and of clavulanate was 0.79 +/- 0.23 micrograms/ml at 2 hours. Patients awaiting surgery received an oral dose of augmentin as above. Samples of lung, tonsil, middle ear mucosa and prostate were obtained and tissue concentrations of both compounds measured. Peak levels of amoxicillin ranged from 0.87 micrograms/g (tonsil) to 2.56 micrograms/g (lung) and of clavulanic acid from 0.20 micrograms/g (prostate) to 0.56 micrograms/g (lung) between 3 and 4 hours after dosing.

[Antiemetic and antinauseant effect of alizapride in patients subjected to antiblastic infusion chemotherapy in a day-hospital regime]

A study about alizapride in out patients with nausea and vomiting during infusional antiblastic chemotherapy.

Combination of 6-mercaptopurine, vincristine, methotrexate, and prednisone in resistant or relapsed acute nonlymphoid leukemia

Twenty-six adults with acute nonlymphoid leukemia (ANLL) relapsed or resistant after first-choice chemotherapy including cytarabine and/or anthracyclines were treated with a modified POMP (6-mercaptopurine, vincristine, methotrexate, and prednisone) combination. Complete remission (CR) was achieved in five of eight resistant patients (62%) and in nine of 18 relapsed patients (50%). Intermittent cycles of chemotherapy including daunorubicin, cytarabine, 6-thioguanine, and etoposide were then administered. In the resistant group CR lasted from 11 to 126 weeks (median, 86), with two patients remaining in CR 126 and 108 weeks after remission induction; in relapsed patients, CR lasted from 9 to 50 weeks (median, 31).

White cells transfusion in recent onset type 1 diabetes

Two HLA-identical brothers developed Type 1 diabetes simultaneously. In the light of present knowledge of the pathogenesis of Type 1 diabetes, immunosuppression was adopted in one brother by means of white cell transfusion from the father. The other brother acted as a control. This immunosuppressive approach has been shown to be effective in kidney transplantation and, as far as Type 1 diabetes is concerned, in the BB Wistar rat. An immunological and metabolic follow-up study of 1 yr only revealed slight differences between the 2 brothers (who are both on insulin) but the pattern of lymphocyte activation appeared to become normalized earlier in the transfused brother.

Depletion lymphocytapheresis in chronic lymphocytic leukemias: criteria for predicting which patients will respond to treatment

Depletion lymphocytapheresis therapy using the continuous-flow separator was used in twenty-two cases of chronic lymphocytic leukemia. Applying the Montserrat scoring system, a prediction can be made, to a good approximation, whether the patient will be a "responder" or a "non-responder" to leukapheresis. Criteria have been formulated for decisions on when depletion lymphocytapheresis is absolutely or only relatively indicated, on the basis of total scores from 2 through 6 using the Montserrat criterion.

Sequential Therapy with Lithium in Chemotherapy-induced Vomiting

Having noticed psychotic traits in some patients showing incoercible vomiting due to antineoplastic drugs we have thought of establishing a therapy with lithium in the days preceding the therapeutic cycle in order to reduce the emetic events. The effectiveness of lithium carbonate (600 mg/mq p.o./day for one week) in the prevention or reduction of vomiting induced by antiblastic therapy has been checked in comparison with metoclopramide and domperidone in 40 patients. In the group pretreated with lithium, 80 % of the cases showed favorable results. In the control groups, on the contrary, the efficacy of the antiemetic therapy has shown to be of lesser importance (55 %). The undesirable side-effects of lithium appear to be irrelevant. We therefore think that pretreatment with lithium may become, in selected cases not affected by traditional antiemetics, of great importance in the control of emetic symptomatology.

[Primary angiosarcoma of the right atrium invading the pericardial cavity. Description of a case diagnosed by exploratory thoracotomy and surgically treated with success]

The AA. report the case of a 43-year-old woman with an angiosarcoma arising from the right atrial wall and growing into the pericardial cavity. The patient presented with recurrent pericardial effusion initially responsive to medical therapy. The diagnosis was made at the exploratory thoracotomy. Repeated 2D-Echocardiograms did not help for the diagnosis in this particular case. The patient underwent surgical resection of the tumor, chemo- and radiotherapy. After 30 months there are no signs of recurrence or metastasis. In our opinion the frequent recurrence of pericardial effusion in the same patient should be regarded with special suspicion.