[Day surgery in breast reconstructive surgery: our experience]

Breast cancer is the most common tumour in Italy in the female population, counting for about 40000 new cases every year. The psychological aspects of breast mutilation and the social and economic implications are receiving increasing attention. Despite of the diffusion of screening programs to detect pre-clinical breast cancers, 30% of patients still undergo radical interventions. Therefore, many women present serious limitations of their social-life that can lead to severe depression since, in occidental countries, the biological function of the breast is less considered than its primary role of femininity and sexuality. The gold-standard is to conceal oncological radicality and aesthetic preservation. The Authors present their experience analysing the techniques employed.

[Posterior mediastinum neoplasms: a case of schwannoma]

The Authors report the case of a 33-year-old male affected with an asymptomatic schwannoma of the posterior mediastinum, and review the relevant Literature, discussing the difficulties in making the differential diagnosis of the posterior mediastinum lesions, particularly in the pre-clinical phase. Neurogenic tumors represent about 75 percent of all tumors of mediastinum and about one third of all tumors of the mediastinum. They can originate from the peripheral nervous system group, from the sympathetic nervous system group or, in rare cases, from the vagus nerve. In adult patients, they are usually found by chance during radiographic examination of the thorax, and they are usually asymptomatic and benign. During preoperative evaluation, a magnetic resonance examination of rachis should be done to exclude the possibility of intraspinal involvement. If there are no contraindications, the treatment of choice should be surgical resection by means of thoracoscopy or thoracotomy, when size and location of the tumors allow it in order to prevent malignant evolution.

[Therapeutic strategies in neoplasms of the distal bile duct and the Vater's ampulla]

Malignant periampullary and ampullary tumors represent an anatomic and clinical entity of complex surgical approach due to the difficulty in setting out an early diagnosis, for the back of symptoms at early stages. The Authors at the Department of Surgery and Medical Technology Applications "F. Durante", University of Rome "La Sapienza", since 1990 to 2001 observed 19 cases. The results of surgical treatment of these tumors are here reported. By the analysis of the cases it is evident that long-term survival if mainly conditioned by prompt diagnosis stage of the tumor, and patient status before the operation.

[Atrial fibrillation and hyperthyroidism: results after thyroidectomy]

Hyperthyroidism patients can develop atrial fibrillation (AF) with a frequency range between 10 and 25%. The Authors consider 256 hyperthyroid patients operated in their Department, from 1985 to 2001. Before and after surgery, thyroid examination, routine blood tests and common diagnostic evaluations were performed. The follow-up has been 12 months and during this period a L-Thyroxine (50-200 mg/die) therapy has been arranged. Before surgery 59 patients (23%) showed an AF associated with palpitations (76%), asthenia (66%), tremors (54%) and dyspnea (43%). The onset of AF was less than 1 months in 18% of cases, less than 3 months in 30% and chronic in remaining 52%. The 87% of patients was already pharmacologically treated. All the patients were treated with anticoagulants, with a INR value between 2 and 3. After the surgery, 47% of patients presented a restoration of the sinusal rhythm, while the 53% showed a stronger therapeutic responsiveness to specific antiarrhythmic therapy. Treatment of FA hyperthyroid patients with FA tends to normalize the function of the thyroid gland (euthyroidism). In our experience the restoring of sinusal rhythm usually develops in patients with 50 years of age (45 +/- 5 years), while in older patients AF tends to be resistant to treatment.

[Neurinoma of the brachial plexus: 2 case reports]

Neurinomas, also referred to as neurilemmomas and schwannomas, are rare benign tumours of the peripheral nerves. A small percentage of these lesions arise from the brachial plexus. The Authors report two cases of schwannoma arising from the brachial plexus. Such lesions, usually asymptomatic, may cause sensitivity alterations or, less frequently, motor deficits in the involved arm. Tumour enucleation, avoiding damage to any of the nervous fascicles, is the treatment of choice.

Effects of a nonforage diet on milk production, energy, and nitrogen metabolism in dairy goats throughout lactation

The objective of the experiment was to compare a silage-based control diet (C) with a nonforage diet (NF) in dairy goats throughout lactation in terms of animal performance and energy utilization. Eight Saanen goats were divided into two groups and fed C or NF, a commercial blend that included sunflower meal, cassava, coconut meal, and whole cottonseeds as the main ingredients that was characterized by a small particle size and a high crude protein content. In early, mid, and late lactation (44, 100, and 219 days in milk) the goats were individually tested for dry matter intake (DMI), digestibility, milk yield and composition, milk renneting properties, rumen and plasma parameters, and nitrogen and energy utilization (open circuit respiration chambers). During early and mid lactation, the NF fed goats had a very high DMI: 2946 and 2915 g/d, respectively. Nevertheless, milk yield was similar for the two treatments: 4369 vs. 4342 and 3882 vs. 3841 g/d for goats fed diets C and NF during the first and second periods, respectively. Milk fat content was not statistically different between the two diets. The protein content and rheological parameters of milk were similar for the two diets. Nonprotein nitrogen and urea levels in milk of goats fed NF were significantly higher than goats fed C. Ruminal ammonia and plasma urea nitrogen were also significantly increased by diet NF, due to its high protein content. Plasma glucose, beta-hydroxybutyrate, and nonesterified fatty acids and ruminal volatile fatty acids were not influenced by dietary treatment. Dietary NF significantly decreased energy digestibility (74.5 vs. 65.8%, on average for the lactation, for C and NF, respectively) and had a significantly lower metabolizability (metabolizable energy/intake energy; 66.6 vs 58.0%, on average); however, the efficiency of utilization of metabolizable energy was unaffected by the diet. In conclusion, goats were fed a nonforage diet during the entire lactation without detrimental effect on their health and productive performance.

In vitro reconstructed dermis implanted in human wounds: degradation studies of the HA-based supporting scaffold

The objective of the present study was to demonstrate the safety and efficacy of a dermal replacement for cutaneous wounds of diverse origin. Autologous fibroblasts were cultured in fleece scaffolds made from benzyl esters of hyaluronic acid and applied onto cutaneous lesions. The cases presented are (1) skin removal for multiple epithelioma and (2) chronic deep decubitus ulcer. Dermal-like tissue applied by the surgeon elicited no adverse reactions, and was fully integrated and well-vascularized by 1-3 weeks. In Case 1, the material was fully integrated after 1 week, and after 3 weeks an epidermal autograft was overlaid which showed good take with excellent integration observed after 4 weeks. At 12 months, skin demonstrated visual normo-elastic properties and no signs of excessive scarring. In Case 2, 2-3 weeks after the dermal implant was applied, the wound was invaded with granulation tissue and healing occurred by secondary intention. The ulcer was healed by 8 weeks, with the biomaterial completely resorbed and a complete re-epithelialization over the dermal-like tissue. These results suggest that autologous fibroblast culture in hyaluronan-derived scaffolds may be successfully grafted in diverse cutaneous pathologies and constitute a suitable bed for further epidermal implantation.

Use of dermal-like tissue in the management of chronic and acute full-thickness cutaneous wounds

This paper presents a dermal replacement technique for cutaneous wounds of diverse origin. An autologous tissue-engineered dermal-like structure was implanted in one patient with an acute surgical excision of a nevus and in another patient with a chronic post-traumatic ulcer. The dermal constructs were well integrated with the wound area, and, at 3 weeks, an epidermal covering was implanted. In both cases, 3 to 8 weeks after autografting, good integration of the transplanted epidermis with the surrounding native skin and a good take over the dermal-like tissue occurred. The use of this technology, despite its high cost, is increasing. Clinicians choose it because it helps heal critical wounds for which current therapies have failed.

Motor neuron disease and HIV-1 infection in a 30-year-old HIV-positive heroin abuser: a causal relationship?

Although human retroviruses seem plausible agents of motor neuron diseases, there are only few reports of patients infected by the human immunodeficiency virus, with documented motor neuron disorder. That retroviral infections may cause motor neuron pathology by various mechanisms in animals and humans is known. Neurological symptoms potentially attributed to damage of lower motor neurons are often described during the course of HIV-1 infection and AIDS, however, it is often difficult to establish whether the disorder is primarily affecting the perikarya of lower motor neurons, or whether it is due to a focal proximal axonopathy, or to a dying-back process. We report a 30-year-old heroin abuser, HIV-1 positive, who presented a rapidly progressive limb weakness, muscle wasting, and bulbar signs, in absence of sensory loss of cerebellar and pyramidal signs. Imaging studies were negative. CSF showed increased protein content, negative cytology, and no oligoclonal bands. Serum protein electrophoresis, urinary heavy metal, and viral researches were negative. CD4 cells were counted 340 mm3 with a CD4-CD8 ratio equal to 0.4. Electrophysiology showed acute and chronic neurogenic changes, confirmed by muscle biopsy. Conduction studies along motor and sensory nerves fell within normal range. Biopsy of sural nerve revealed mild myelinated and unmyelinated fiber loss, occasional degeneration and regeneration, unremarkable inflammation. Despite treatment with AZT, zalcitabine, and steroids, the patient died after 3-month illness. Neuropathology showed normal cortical cell Betz's, and hemispheric white matter. Brain stem motor nuclei (inferior olival, dorsal motor of the vagus, hypoglossal) showed atrophy and intracytoplasmatic lipofuscin accumulation. Vacuolization, central chromatolysis, and neuronophagia were rarely seen. As associated pathology, in the fourth ventricle there were two small subependymal foci of demyelination, with reactive astrocytes and vascular proliferation. A possible crucial role of the HIV-1 infection in the development and progression of our patient's illness is considered in view of the known altered immunity proved in MND and ALS cases.

Leptomeningeal carcinomatosis presenting as progressive multineuritis: clinical, pathologic, and MRI study

Two patients developed a persistent illness characterized clinically and electrophysiologically by asymmetric involvement of spinal roots, of cranial and peripheral nerves. In the first case the disease was not discovered clinically but only after autopsy. The primary neoplasm remained undetected at autopsy. There was profound infiltration of the leptomeninges by tumor cells with features of metastatic adenocarcinoma. In the second patient onset of neurological symptoms occurred 16 years after surgery for breast cancer, which may be reasonably considered the primary malignancy-CSF cytology was positive only in the second patient in whom Gd-DTPA MRI supported the diagnosis. Our cases demonstrate that diagnosis in leptomeningeal carcinomatosis may be a challenging clinical problem.