[Efficient prevention of overweight and obesity in the experience of family practitioners and "nutrition units" of the public health system in Lombardy]

General practitioners (GP's) presence is homogeneously distributed in the Lombardy territory. GP's are easy accessible by people so they could play a key role in the prevention of overweight and obesity. In this study GP's included in everyday medical activity a primary prevention strategy regarding nutrition and lifestyle. The goal was to maintain a constant BMI for one and a half year for at least 50% of the patients (stable means without progression within BMI's range). During the same time another endpoint was to decrease from 1 to 3 units the BMI in overweight patients in half of the observed population. Subjects were randomly recruited during routinely ambulatory activity, without a specific BMI based selection. Diet quality was assessed with a food frequency questionnaire regarding "protective foods" as vegetables, fruits and legumes. Some "basic" information about nutrition and lifestyle where then provided through explanation of issues printed on A4 page brochure. Percentage BMI's range variation before and after the intervention show a stability in the observed population, with an increase 0,3% for normal weight males and 0,9% for females. BMI was constant in 72,2% of the subjects considering a 1 unit variation and in 92,2% considering 3 units variation. Within subjects who varied 1 unit (27,7%) more subjects decreased rather than gained weight (16% vs 11,7%); within subjects who varied 3 units (7.8%), 4,5% decreased and 3,3 increased their BMI. GP's demonstrate to have an efficient role in weight gain control with a simple and regular prevention strategy towards healthy lifestyles and simple nutritional tips. It is important for patients to comprehend the importance the doctor give to the overweight and obesity problem, apart from the medical issue considered during the visit. GP's have a key role for healthy life-style change programs among their patients. These results provide new arguments about the opportunity to invest public resources towards population (managed in collaboration with GP's coordinated by a public health department such as NU), rather than towards a single patient. The project management was supervised by the Nutrition Unit (NU) of the public heath system SIAN (ASL di Brescia).

Recovery of sexual function after nerve-sparing radical retropubic prostatectomy: is cavernous nitric oxide level a prognostic index?

The preservation of NANC nerve fibers (producing nitric oxide, NO) is necessary for erection recovery after retropubic radical prostatectomy (RRP). Yet, it is impossible to establish when and if a patient will recover erections; therefore, we investigate the prognostic value of cavernous blood NO levels on this parameter. Nerve-sparing RRP was performed on 14 patients for localized prostate cancer. We evaluated all patients 3 months after surgery by IIEF score: no patients had erections. A cavernous blood sample was also taken to determine NO levels (as nitrite). Patients were evaluated again 18 months after surgery. In six cases, erectile function was compromised, whereas in seven cases, potency was restored. Statistical analysis showed a relationship between nitrite levels in cavernous blood 3 months after surgery and the recovery or erectile function at 18 months. We propose that cavernous NO blood levels are a prognostic index of erection recovery.

Uterine Preservation or Hysterectomy for the Uterovaginal Prolapse

For many years uterine prolapse has been an indication for hysterectomy, quite apart from the presence or the absence of any uterine disease and independently of the patients’ desire. Many studies on pelvic statics showed the central role of uterus on the pelvic static itself. Aim of the study is to prospectively compare sacropexy with and without hysterectomy in patients with uterovaginal prolapse. Surgical techniques, efficacy and overall results are described.

Material and Methods

Fifty-six consecutive patients affected by grade III-IV uterovaginal prolapse underwent colposacropexy: hysterectomy followed by sacropexy (SP) in 29 and hysterocolposacropexy (ISP) in 27. Before surgery all patients provided a detailed case history and replied to a questionnaire on urinary symptoms (Urogenital distress inventory). Patients underwent a clinical urogynaecological examination (HSW), a pelvic ultrasound scan and urodynamic test. Check-ups were scheduled at 3, 6, 12 months and then annually.

Results

No significant differences emerged in demographic and clinical characteristic in the SP and ISP groups. Mean operating times, intraoperative blood loss and hospital stay are significantly less after ISP (p<0.001). No patient required surgery for recurrent prolapse. Urodynamic results showed the pressure/flow parameters improved significantly (p< 0.001). 24/27 patients (88.9%) in the ISP group and 25/29 (86.2%) in the SP are satisfied and would repeat surgery again. 5/7 patients who would not repeat surgery were incontinent.

Conclusions

Sacrocolpopexy provides a secure anchorage restoring an anatomical vaginal axis and a good vaginal length. ISP can be safely offered to women who request uterine preservation. Long-term results in terms of prolapse resolution, urodynamic outcomes, improvements in voiding and sexual dysfunctions are excellent.

New therapeutic options for refractory neurogenic detrusor overactivity

AIM

Current pharmacologic treatment of detrusor overactivity relies on anticholinergic drugs. However, they often have untolerable side effects so that they are administered in doses insufficient to restore urinary continence. Recently, intravesical instillations and injections into the detrusor muscle of new pharmacological agents have been developed. The present study report our own experience in the treatment of detrusor overactivity with intravesical administrations of vanilloid agents and with botulinum-A toxin injections into the detrusor muscle in a group of spinal cord injured patients. In particular, we compared the clinical and urodynamic effects of the 2 drugs in an attempt to find a new and valid therapeutic option in those cases unresponsive to conventional treatment.

METHODS

Seventy-five patients with spinal cord injury and refractory detrusor overactivity were included in the study: 35 patients received repeated intravesical instillations of resiniferatoxin (RTX) dissolved in normal saline; 40 patients received repeated injections of 300 units botulinum A-toxin diluted in 30 ml normal saline. Clinical assessment and urodynamics were performed at baseline and 6, 12 and 24 months after treatment.

RESULTS

With both treatments there was a significant reduction in mean catheterization and episodes of incontinence and a significant increase in mean first involuntary detrusor contraction and in mean maximum bladder capacity at 6, 12 and 24 months after therapy. We did not detect any local side effects with either treatment. Botulinum-A toxin significantly reduced also the maximum pressure of uninhibited detrusor contractions more than RTX at all follow-up time points.

CONCLUSION

In patients with spinal cord injury and refractory detrusor overactivity intravesical RTX and botulinum-A toxin injections into the detrusor muscle provided beneficial clinical and urodynamic results with reduction of detrusor overactivity and restoration of urinary continence in most patients. Botulinum-A toxin injection provided better clinical and urodynamic benefits than intravesical RTX.

First Italian report of onychomycosis caused by Onychocola canadensis

Onychocola canadensis is a non-dermatophytic mould that has been associated with onychomycosis particularly in temperate climates. Until now, O. canadensis has been isolated from patients in Canada (14 cases), New Zealand (three), France (nine), UK (four) and Spain (two). We describe the first Italian case of onychomycosis caused by this fungus.

Stage pT1 renal cell carcinoma: review of the prognostic significance of size

INTRODUCTION

The last TNM classification (before 1997) defined T1 kidney tumour as a tumour <2.5 cm, limited to the kidney: this cut-off point was changed in 1997 and T1 neoplasm was defined as <7 cm. This new cut-off now includes past T1 and T2 diseases, without any differences in terms of prognoses. We performed a retrospective analysis of our cases and specifically investigated if there were any differences in terms of prognosis in a group of patients, currently identifiable as pT1, if they were divided into two subgroups based on tumour pathological sizes.

MATERIALS AND METHODS

Our analysis involved 128 patients (mean age 57.6 years) who underwent radical nephrectomy or nephron-sparing surgery in the period between 1990 and 2000. All these patients were pT1 according to the new TNM classification and were divided into two groups according to different cut-off point sizes (from 2.5 to 5 cm). We analysed the surgical approach, overall survival and cancer-specific mortality in the two subgroups, renamed as pT1a and pT1b, and performed a statistical analysis of the results using the Kaplan-Meier method to prove if this substaging identified changes in survival outcome.

RESULTS

We obtained more interesting results for a 5-cm cut-off: the two groups showed a similar follow-up and overall survival rate but different cancer-specific mortality rate (6 vs. 12.1%). The statistical analysis showed that the two survival curves (pT1a vs. pT1b disease) had a similar trend up to about 60 months; after this period the two curves diversify with a drop in survival rate among patients with larger tumours (pT1b patients).

CONCLUSIONS

It would seem reasonable to reassess the TNM classification of stage pT1 in order to better define prognosis in this group of patients.

Four-corner colposuspension: clinical and functional results

We report our experience with four-corner colposuspension and the long-term functional and objective results. Thirty-seven women aged 42-74 affected by cystocele, associated with stress incontinence in 27, underwent four-corner colposuspension, combined with posterior colpoperineoplasty in 5 and vaginal wall sling in 5. Preoperative work-up included clinical examination, a symptoms questionnaire, transrectal dynamic ultrasonography and a urodynamic test. The mean follow-up to date is 62 months (range 36-83). Check-ups included a clinical examination, responses to a questionnaire on symptoms, uroflowmetry, transrectal ultrasound, and a urodynamic test in 25. All patients underwent four-corner colposuspension, together with vaginal wall sling in 5 with severe incontinence and colpoperineoplasty in another 5 with symptomatic rectoceles. There were no major complications. The urethrocele was stably corrected in all. No relapses occurred in 19 patients with grades I-II cystocele preoperatively. Various forms of prolapse recurred in 12/18 patients with grade III cystocele. Incontinence was successfully resolved in 23/27 patients (85%). Instability persisted in 8/14 patients. Obstruction persisted in 6 patients with prolapse recurrence. The ideal candidate for four-corner suspension is a patient with moderate cystocele and no signs of uterine prolapse who may, or may not, be incontinent.

In vitro and in vivo study of 5-methoxypsoralen skin concentration after topical application

The aim of this work was to study the skin distribution of 5-methoxypsoralen (5-MOP) after application of topical gels, in vitro and in vivo, in both healthy and psoriatic skin sites of 6 psoriatic patients. Drug skin distribution was determined using the thin slicing technique and subsequent HPLC analysis. In the presence of dermatological disease, i.e. psoriasis, the permeability of the tissue changed considerably, leading to an important increase in the cumulative amount of 5-MOP recovered in the skin after topical application. The amount of 5-MOP found in vitro in the human skin was intermediate between those cumulated in healthy and psoriatic skin sites during an in vivo experiment. The gel formulation is an efficacious carrier for the topical photochemotherapy of psoriasis with 5-MOP, since it allows drug penetration in psoriatic skin.

Renal cell carcinoma: histological findings on surgical margins after nephron sparing surgery

PURPOSE

We evaluated the incidence of peritumoral satellite lesions in nephron sparing surgery and examined whether these findings have a negative effect on cancer specific survival and on the percent of local recurrence.

MATERIALS AND METHODS

We performed nephron sparing surgery in 63 patients with kidney cancer, including 53 elective (group 1) and 10 imperative (group 2) operations. In all cases we removed 10 mm. of apparently healthy peritumoral parenchyma with the tumor. This tissue was subsequently examined by an anatomical pathologist to identify any satellite lesions.

RESULTS

Four satellite lesions were identified, including 3 in group 1 and 1 in group 2, at a mean of 5.3 mm. from the primary lesion. None of the patients in either group had local recurrence at followup. Cancer specific survival was 96.3% in group 1 (mean followup 61 months) and 58% in group 2 (mean followup 39 months). It was not influenced by the presence of satellite micro-lesions.

CONCLUSIONS

Despite common perplexities concerning the risk of multifocality in renal cell carcinoma we believe that the nephron sparing procedure in select patients is as effective as radical surgery. Based on our experience the surgical safety margin must be at least 10 mm. of macroscopically healthy, peritumoral tissue.

Differing expression of enzymes of the glyoxalase system in superficial and invasive bladder carcinomas

This work aimed to study the activities of the glyoxalase system enzymes (glyoxalase I (GI) and glyoxalase II (GII) and their gene expression in human bladder carcinomas compared with the corresponding normal mucosa. Samples of these tissues were collected from 26 patients with superficial (SBC) or invasive bladder cancer (IBC) and used to evaluate enzyme activity and gene expression by northern blot analysis. In keeping with the electrophoretic pattern and the expression level of the respective genes, GI activity significantly increased in SBC samples, while it remained unchanged in IBC samples compared with the normal mucosa. In contrast, GII showed a higher activity in the tumour (either SBC or IBC samples) versus normal tissues. These results confirm the role of the glyoxalases in detoxifying cytotoxic methylglyoxal (MG) in bladder cancer. The differing levels of GI activity level and gene expression of GI between the SBC and IBC samples could help in their differential diagnosis.

Peyronie's disease: corporoplasty using saphenous vein patch graft

OBJECTIVE

To establish who the best candidates for corporoplasty are. The standard guidelines include patients with partial erections, and/or recurvature preventing normal and satisfying intercourse. In our unit we prefer to implant prostheses even in patients with slight erectile dysfunction, therefore patients with full erections routinely undergo corporoplasty.

MATERIALS AND METHODS

We report our experience with corporoplasty using a vein patch graft after plaque incision or excision in 12 patients affected by Peyronie's disease.

RESULTS

The operation is easy to perform. Recovery of normal spontaneous erectile activity was observed in 10/12 (83%) patients at a mean of 1 month postoperatively. The results of checkups with Rigiscan and EchocolorDoppler have confirmed the stability of the graft and recovery of potency.

DISCUSSION

Autologous material is easy to harvest and it is elastic enough to support traction during erection. The patch can be modelled to fashion patches in any shape required. The risk of scar shrinkage, with the consequent onset of recurvature, is lower than with other materials such as Gore-tex or Derma. Corporoplasty ensured rapid rehabilitation of sexual functions in all patients. We do not usually perform the Nesbit procedure as shortening of the penis (which is characteristic of Peyronie's disease) would, in most patients, be accentuated by albuginea plication.

[When and why to use penile prostheses: seven years of experience]

During the last years important changes in the management of the patients with erectile dysfunction have been verified. Psychologist, neuro-physiologist and bioengineers have given a valuable help in this field. Implant surgery represents, to our notice, the curative more acceptable choice for patient and the partner, since the results are excellent and the materials used extremely manageable. In each case the degree of satisfaction of the patient remains the only legitimate indicator currently for establish the effectiveness of the therapy.

Plasma and skin concentration of 5-methoxypsoralen in psoriatic patients after oral administration

The aim of this work was to investigate the distribution of 5-methoxypsoralen in the skin after oral administration of the drug and to examine the correlation between skin and plasma concentrations. 5-Methoxypsoralen skin concentration was measured in both healthy and psoriatic sites of 10 psoriatic patients after single and multiple oral doses. The results obtained show that 5-methoxypsoralen accumulates at higher levels in the more external layers of the skin after oral administration. The high affinity of drug for the stratum corneum was confirmed by in vitro skin affinity measurements. The concentration of 5-methoxypsoralen in the skin was similar in both psoriatic and healthy sites, indicating that the pathology does not influence drug distribution in the skin. After single dose administration, a linear correlation was found between skin and plasma drug concentration. After multiple dose administration, drug concentration in the skin was fairly constant despite the variable plasma concentrations in different subjects.

Ureterointestinal anastomosis in orthotopic neobladders

OBJECTIVE

This study reports our experience with a ureteroileal reimplantation technique based on the Leadbetter-Clarke method, which is used for orthotopic neo-bladders, constructed preferably with the Camey II technique.

METHODS

We carried out 114 ureteroileal reimplantations using this technique in 58 patients undergoing radical cystectomy and orthotopic neobladder reconstruction. The incidence of neobladder-ureteral stenosis and reflux were analyzed during the follow-up.

RESULTS

During the mean follow-up of 31 months, the incidence of stenosis was 2.6% (3 ureteroileal implants, including 1 case of neoplastic stenosis). The incidence of slight-to-moderate reflux was 9.6% but did not cause any deterioration in renal function or an increased incidence of reflux-related pyelonephritis.

CONCLUSION

This technique provided good functional results and a low incidence of complications, and may be recommended as a valid alternative to standard methods of creating ureterovesical anastomosis.

Penile prosthesis implantation and couple's satisfaction

OBJECTIVE

Implant surgery is the most acceptable curative choice for patients with erectile dysfunction and their partners, since the results are excellent with regard to the couple's pleasure and the materials used are extremely manageable.

MATERIALS AND METHODS

We performed 46 prosthesis implantations in patients with erectile dysfunction: in 22 patients we implanted soft prostheses; in 20 malleable prostheses; in 1 a mono-component prosthesis, and in 3 patients a tri-component model. All patients and partners were evaluated using a questionnaire.

RESULTS

We obtained a degree of satisfaction equal to 82% against 18% dissatisfaction due to a sensation of 'unnaturalness' report by the partner, with low perioperative and postoperative complications.

CONCLUSION

In our opinion the degree of satisfaction of the patient is currently the only legitimate indicator to establish the effectiveness of therapy.

Detubularized rectosigmoid neobladder in women after cystectomy for bladder cancer

BACKGROUND AND OBJECTIVES

We present the long-term functional results of a new technique for bladder substitution after cystectomy for bladder cancer in women.

METHODS

Between 1991 and 1995, 10 women underwent radical cystectomy for bladder cancer with a new technique. We created a detubularized rectosigmoid neobladder associated with either a terminal colostomy or intrasphincteric perineal colostomy section (Heitz-Boyer-Hovelacque). We evaluated neobladder functioning over almost 5 years by means of urodynamic studies, ultrasound scans, urograms and pouchgrams, and renal function tests.

RESULTS

Neobladder function was excellent in all patients, with good diurnal and nocturnal urinary continence, voiding patterns, and preservation of the upper urinary tract.

CONCLUSIONS

This new technique, which is a modification of the standard rectal or rectosigmoid neobladder technique, is a valid alternative to the ortothopic neobladder in women, with good functional results.

Immunohistochemical and quantitative study of mast cells in La Peyronie's disease

OBJECTIVE

In order to investigate the possible association between mast cells (MCs) and the fibrous plaque of La Peyronie's disease, the number of MCs in normal penile tissue and in the fibrous plaque was determined.

METHODS

The control group consisted of 5 total and 3 partial penectomies with no fibrotic lesions, while the study group consisted of 23 excisional biopsies from cases of La Peyronie's disease dating back to at least 2 years earlier and with no signs of activity. The biopsies included tissues from the tunica albuginea (TA), the areolar tissue (Br) between the tunica and the erectile tissue (CC) and from the latter. The number of MCs was counted with the aid of an image analysis program following staining the antibody antitryptase.

RESULTS

In the cases of La Peyronie's disease the number of MCs/mm(2) was significantly higher in the TA and Br but lower in the CC. The MCs were related to fibroblasts and vasculonervous channels in the TA, and were concentrated around the fibrous plaques and granulation tissue between the TA and BR and between the latter and the CC.

CONCLUSION

Our data indicate that MCs have a role in the genesis of the fibrous plaque in the TA and in the persistent inflammation in the Br. Medical treatment aimed at repressing MC activation and proliferation locally might be useful in La Peyronie's disease.

No-mortality liver resection for hepatocellular carcinoma in cirrhotic and noncirrhotic patients: is there a way? A prospective analysis of our approach

BACKGROUND

Low resectability rates and significant morbidity and mortality rates often make surgery for hepatocellular carcinomas (HCCs) unfeasible.

HYPOTHESIS

Our policy for surgical treatment of cirrhotic and noncirrhotic patients with HCC is adequate and safe.

DESIGN

Prospective validation cohort study.

SETTING

University hospital.

PATIENTS

One hundred seven consecutive patients with HCCs. Associated cirrhosis was present in 64 (59.8%), and only 7 (6.5%) had normal livers.

INTERVENTIONS

The presence of ascites, serum bilirubin level, and indocyanine green retention rate at 15 minutes were considered when selecting patients for surgery. Preoperative recovery of liver function was achieved with portal venous branch embolization, liver volumetry, bed rest, and control of serum aminotransferase levels. The surgical techniques mainly involved bloodless dissection using intraoperative ultrasonography and intermittent warm ischemia. The main perioperative care regimen was fresh frozen plasma infusion and strict limitation of blood transfusion.

MAIN OUTCOME MEASURES

The 30-day postoperative mortality and morbidity rates.

RESULTS

All the patients underwent surgery (37 major resections, 45 segmentectomies, and 25 limited resections), with no 30-day postoperative mortality, overall morbidity of 26.2%, and no major complications. Multiple logistic regression analysis revealed that only the type of operation was associated with a significantly higher morbidity risk (P = .05).

CONCLUSION

With high resectability, low morbidity, and no mortality, our policy represents a solution to the drawbacks of surgical resection for treatment of HCCs, especially in patients with associated liver cirrhosis.