Purpura fulminans in meningococcal septicaemia in an adult: a case report

Purpura fulminans is a rare and severe complication of meningococcal septicaemia. It presents as a petechial rash spreading rapidly in extent and depth, evolving into full-thickness skin necrosis. The condition is extremely uncommon in the adult population. We report the case of a 28-yr-old man with extensive meningococcal-related skin necrosis. The initial diagnosis was made and first treatment given in the emergency department of a local hospital, from where after 12 days he was transferred to our hospital. Our approach was based on the continuation of intensive treatment and on staged aggressive debridement. Temporary alloplastic skin grafts were used to prepare the wound bed and the wounds were closed with autologous skin grafts. The patient survived but subsequently, owing to chronic skin ulceration and scar instability, he underwent late bilateral below-the-knee amputation.The patient returned to normal deambulation with an orthopaedic prosthesis 18 months after the onset of meningococcal septicaemia.

Elevated thrombopoietin in plasma of burned patients without and with sepsis enhances platelet activation

BACKGROUND

Thrombopoietin (TPO) is a humoral growth factor that does not induce platelet aggregation per se, but enhances platelet activation in response to several agonists. Circulating levels of TPO are increased in patients with sepsis and are mainly related to sepsis severity.

OBJECTIVES

To investigate the potential contribution of elevated TPO levels in platelet activation during burn injury complicated or not by sepsis.

METHODS

We studied 22 burned patients, 10 without and 12 with sepsis, and 10 healthy subjects. We measured plasma levels of TPO, as well as leukocyte-platelet binding and P-selectin expression. The priming activity of plasma from burned patients or healthy subjects on platelet aggregation and leukocyte-platelet binding, and the role of TPO in these effects were also studied in vitro.

RESULTS

Burned patients without and with sepsis showed higher circulating TPO levels and increased monocyte-platelet binding compared with healthy subjects. Moreover, TPO levels, monocyte-platelet binding and P-selectin expression were significantly higher in burned patients with sepsis than in burned patients without sepsis. In vitro, plasma from burned patients without and with sepsis, but not from healthy subjects, primed platelet aggregation, monocyte-platelet binding and platelet P-selectin expression. The effect of plasma from burned patients with sepsis was significantly higher than that of plasma from burned patients without sepsis. An inhibitor of TPO prevented the priming effect of plasma from burned patients.

CONCLUSIONS

Increased TPO levels may enhance platelet activation during burn injury and sepsis, potentially participating in the pathogenesis of multi-organ failure in these diseases.

Postburn Scars: An Update

Burn wounds give rise to the largest scars we can find in human pathology, influencing patients' quality of life. Despite the improved knowledge on pathophysiology, efficacy of the various treatments remains unsatisfactory. In this short review recent literature is examined with a focus on recent data on postburn pathological scars epidemiology and risk factors, which underline the high prevalence and the long evolution, pointing to identify this illness as a systemic inflammatory one, more frequent in women and in those of younger age, regulated by local factors relevant in wound healing.

Epidemiology and risk factors for pathologic scarring after burn wounds

OBJECTIVE

To describe the clinical characteristics of postburn scars and determine the independent risk factors specific to these patients. While burns may generate widespread and disfiguring scars and have a dramatic influence on patient quality of life, the prevalence of postburn pathologic scarring is not well documented, and the impact of certain risk factors is poorly understood.

METHODS

A retrospective analysis was conducted of the clinical records of 703 patients (2440 anatomic burn sites) treated at the Turin Burn Outpatient Clinic between January 1994 and May 15, 2006. Prevalence and evolution time of postburn pathologic scarring were analyzed with univariate and multivariate risk factor analysis by sex, age, burn surface and full-thickness area, cause of the burn, wound healing time, type of burn treatment, number of surgical procedures, type of surgery, type of skin graft, and excision and graft timing.

RESULTS

Pathologic scarring was diagnosed in 540 patients (77%): 310 had hypertrophic scars (44%); 34, contractures (5%); and 196, hypertrophic-contracted scars (28%). The hypertrophic induction was assessed at a median of 23 days after reepithelialization and lasted 15 months (median). A nomogram, based on the multivariate regression model, showed that female sex, young age, burn sites on the neck and/or upper limbs, multiple surgical procedures, and meshed skin grafts were independent risk factors for postburn pathologic scarring (Dxy 0.30).

CONCLUSION

The identification of the principal risk factors for postburn pathologic scarring not only would be a valuable aid in early risk stratification but also might help in assessing outcomes adjusted for patient risk.

Circulating plasma factors induce tubular and glomerular alterations in septic burns patients

Background

Severe burn is a systemic illness often complicated by sepsis. Kidney is one of the organs invariably affected, and proteinuria is a constant clinical finding. We studied the relationships between proteinuria and patient outcome, severity of renal dysfunction and systemic inflammatory state in burns patients who developed sepsis-associated acute renal failure (ARF). We then tested the hypothesis that plasma in these patients induces apoptosis and functional alterations that could account for proteinuria and severity of renal dysfunction in tubular cells and podocytes.

Methods

We studied the correlation between proteinuria and indexes of systemic inflammation or renal function prospectively in 19 severe burns patients with septic shock and ARF, and we evaluated the effect of plasma on apoptosis, polarity and functional alterations in cultured human tubular cells and podocytes. As controls, we collected plasma from 10 burns patients with septic shock but without ARF, 10 burns patients with septic shock and ARF, 10 non-burns patients with septic shock without ARF, 10 chronic uremic patients and 10 healthy volunteers.

Results

Septic burns patients with ARF presented a severe proteinuria that correlated to outcome, glomerular (creatinine/urea clearance) and tubular (fractional excretion of sodium and potassium) functional impairment and systemic inflammation (white blood cell (WBC) and platelet counts). Plasma from these patients induced a pro-apoptotic effect in tubular cells and podocytes that correlated with the extent of proteinuria. Plasma-induced apoptosis was significantly higher in septic severe burns patients with ARF with respect to those without ARF or with septic shock without burns. Moreover, plasma from septic burns patients induced an alteration of polarity in tubular cells, as well as reduced expression of the tight junction protein ZO-1 and of the endocytic receptor megalin. In podocytes, plasma from septic burns patients increased permeability to albumin and decreased the expression of the slit diaphragm protein nephrin.

Conclusion

Plasma from burns patients with sepsis-associated ARF contains factors that affect the function and survival of tubular cells and podocytes. These factors are likely to be involved in the pathogenesis of acute tubular injury and proteinuria, which is a negative prognostic factor and an index of renal involvement in the systemic inflammatory reaction.

BRAF(V600E) mutation and the biology of papillary thyroid cancer

BRAF((V600E)) mutation is the most frequent genetic alteration in papillary thyroid carcinomas (PTCs) that are 80-90% of all thyroid cancers. We evaluated the relationship between BRAF((V600E)) and tumor, host, and environmental factors in PTCs from all geographical areas of Sicily. By PCR, BRAF((V600E)) was investigated in a series of 323 PTCs diagnosed in 2002-2005. The correlation between clinicopathological tumor, host, and environmental characteristics and the presence of BRAF((V600E)) were evaluated by both univariate and multivariate analyses. BRAF((V600E)) was found in 38.6% PTCs, with a 52% frequency in the classical PTCs and 26.4% in the tall cell variant. Univariate analysis indicated that BRAF((V600E)) was associated with greater tumor size (P=0.0048), extra-thyroid invasion (P<0.0001), and cervical lymph nodal metastases (P=0.0001). Multivariate logistic regression analysis confirmed that BRAF((V600E)) was an independent predictor of extra-thyroid invasion (P=0.0001) and cervical lymph nodal metastasis (P=0.0005). The association between BRAF((V600E)) and extra-thyroid invasion was also found in micro-PTCs (P=0.006). In 60 classical PTCs, BRAF((V600E)) was positively correlated with matrix metalloproteinase-9 expression (P=0.0047), suggesting a possible mechanism for BRAF((V600E)) effect on PTC invasiveness. No association was found between BRAF((V600E)) and patient age, gender, or iodine intake. In contrast, a strong association was found with residency in Eastern Sicily (P<0.0001 compared with Western Sicily). These results indicate that BRAF((V600E)) mutation is a marker of aggressive disease in both micro- and macro-PTCs. Moreover, for the first time, a possible link between BRAF((V600E)) mutation and environmental carcinogens is suggested.

Low triiodothyronine serum levels as a predictor of poor prognosis in burn patients

OBJECTIVE

Euthyroid sick syndrome is a common finding in critically ill patients with nonthyroidal illness, characterized by low serum levels of free triiodothyronine (fT3) with a peculiar increase in reverse T3 (rT3) and normal-to-low free thyroxine (fT4) as well as thyroid-stimulating hormone (TSH) levels. This condition has been proposed as a prognostic factor of worse outcome in critically ill patients, while no conclusive data are available in burns.

METHODS

Since thyroid function testing is contained in our baseline laboratory tests at admission, we retrospectively evaluated fT3, fT4 and TSH in 295 consecutive burn patients admitted to the Burn Center of Turin from January 2002 to December 2006, comparing hormone levels in survivors and non-survivors.

RESULTS

fT3 and TSH levels were significantly lower (p<or=0.0002) in non-survivors compared to survivors, while no significant difference between the two populations was found in fT4 concentrations. Excluding from the study 20 patients who received dopamine administration for more than 21h, serum fT3 levels fell further still (p=0.0003). In addition, fT3 concentrations showed a significant correlation with burn severity expressed by the Roi score (Spearman's correlation coefficient -0.37 with p<0.00001).

CONCLUSION

Low fT3 levels are associated with poor outcome in burn patients. Hence, fT3 measurement could be proposed as a strong and cost-effective tool of poor prognosis.

Imbalance between activin A and follistatin drives postburn hypertrophic scar formation in human skin

Hypertrophic scarring is a skin disorder characterized by persistent inflammation and fibrosis that may occur after wounding or thermal injury. Altered production of cytokines and growth factors, such as TGF-beta, play an important role in this process. Activin A, a member of the TGF-beta family, shares the same intra-cellular Smad signalling pathway with TGF-beta, but binds to its own specific transmembrane receptors and to follistatin, a secreted protein that inhibits activin by sequestration. Recent studies provide evidences of a novel role of activin A in inflammatory and repair processes. The aim of this study was to evaluate the importance of activin A and follistatin expression in the different phases of scar evolution. Immunostaining of sections obtained from active phase hypertrophic scars (AHS) revealed the presence of a high number of alpha-SMA(+) myofibroblasts and DC-SIGN(+) dendritic cells coexpressing activin A. Ex-vivo AHS fibroblasts produced more activin and less follistatin than normal skin or remission phase hypertrophic scar (HS) fibroblasts, both in basal conditions and upon TGF-betas stimulation. We demonstrate that fibroblasts do express activin receptors, and that this expression is not affected by TGF-betas. Treatment of HS fibroblasts with activin A induced Akt phosphorylation, promoted cell proliferation, and enhanced alpha-SMA and type I collagen expression. Follistatin reduced proliferation and suppressed activin-induced collagen expression. These results indicate that the activin/follistatin interplay has a role in HS formation and evolution. The impact of these observations on the understanding of wound healing and on the identification of new therapeutic targets is discussed.

Acute complex traumas of the lower limbs: a modern reconstructive approach with negative pressure therapy

Acute traumas of the lower limbs cause complex functional damage for the association of skin loss with exposed tendons, bones, and/or vessels, requiring a multidisciplinary approach. Once bone fixation and vascular repair have been carried out, the surgical treatment for skin damage is usually based on early coverage with conventional or microsurgical flaps. Negative pressure therapy can play a primary role in the management of the elderly or intensive care patients, where wounds are secondary to life-threatening problems. A total of 35 patients with 37 acute traumatic wounds of the lower limbs were treated with vacuum-assisted closure (VAC) therapy for an average of 22 days (range 3-46 days). The sponge was applied the day after bone fixation, vascular repair, and surgical debridement of nonviable tissues, so as to obtain a better control of bleeding. After VAC treatment, all patients quickly developed healthy granulation tissue and a significant reduction in both extent and depth of wounds. Split-thickness skin grafts were used to cover granulation tissue in most of the cases (66% -- 24 cases), and then local flaps (13% -- five cases) or direct sutures (8% -- three cases). The wounds healed spontaneously without surgical management in four patients. One patient died during the treatment period for concomitant diseases. No relevant complications directly related to VAC therapy were observed other than one case of severe pain in an amputated stump. The average follow-up duration was 265 days (range 33-874 days). No further tegumentary reconstruction was required. VAC therapy may represent a valid alternative to immediate reconstruction in selected cases of acute complex traumas of the lower limb and allows for a stable functional result, using a minimally invasive approach.

Prolonged survival in poor-risk diffuse large B-cell lymphoma following front-line treatment with rituximab-supplemented, early-intensified chemotherapy with multiple autologous hematopoietic stem cell support: a multicenter study by GITIL (Gruppo Italiano Terapie Innovative nei Linfomi)

A prospective multicenter program was performed to evaluate the combination of rituximab and high-dose (hd) sequential chemotherapy delivered with multiple autologous peripheral blood progenitor cell (PBPC) support (R-HDS-maps regimen) in previously untreated patients with diffuse large B-cell lymphoma (DLB-CL) and age-adjusted International Prognostic Score (aaIPI) score 2-3. R-HDS-maps includes: (i) three APO courses; (ii) sequential administration of hd-cyclophosphamide (CY), hd-Ara-C, both supplemented with rituximab, hd-etoposide/cisplatin, PBPC harvests, following hd-CY and hd-Ara-C; (iii) hd-mitoxantrone (hd-Mito)/L-Pam + 2 further rituximab doses; (iv) involved-field radiotherapy. PBPC rescue was scheduled following Ara-C, etoposide/cisplatin and Mito/L-Pam. Between 1999 and 2004, 112 consecutive patients aged <65 years (74 score 2, 38 score 3) entered the study protocol. There were five early and two late toxic deaths. Overall 90 patients (80%) reached clinical remission (CR); at a median 48 months follow-up, 87 (78%) patients are alive, 82 (73%) in continuous CR, with 4 year overall survival (OS) and event-free survival (EFS) projections of 76% (CI 68-85%) and 73% (CI 64-81%), respectively. There were no significant differences in OS and EFS between subgroups with Germinal-Center and Activated B-cell phenotype. Thus, life expectancy of younger patients with aaIPI 2-3 DLB-CL is improved with the early administration of rituximab-supplemented intensive chemotherapy compared with the poor outcome following conventional chemotherapy.

Henoch-Schönlein purpura associated with acetaminophen and codeine

We report a case of a relapse of Henoch-Schönlein Purpura (HSP) associated with intake of paracetamol (also known as acetaminophene) and codeine. A 69-year-old man presented with fever, gross hematuria, acute renal failure, palpable purpuric skin rash over the legs, feet and arms, arthralgias and abdominal discomfort. 1 week before he had started therapy with co-efferalgan (association of paracetamol and codeine) for cervical arthrosis. Blood test revealed increase in serum creatinine levels (2.6 mg/dl), CRP (375 mg/dl), with no thrombocytopenia or hypocomplementemia. Co-efferalgan was discontinued. Gross hematuria resolved in 2 days, purpuric rash disappeared in 10 days, renal function returned to normal after 2 weeks and abdominal pain and arthralgias improved on the following 2 - 3 weeks. An objective causality assessment in accordance with the Naranjo algorithm, revealed that the adverse drug reaction was probable between paracetamol/codeine and Henoch-Schönlein purpura. To our knowledge, and based on a medline search (up to 2005), we believe that this could be considered the first case of Henoch-Schönlein purpura, associated with intake of paracetamol and codein. Although this event could be considered rare, clinicians should to be aware of possible associations between HUS and the intake of paracetamol and/or codeine to provide an early therapeutic intervention and a close monitoring.

[Acute renal failure secondary to retroperitoneal fibrosis as first manifestation of lupus nephritis]

Retroperitoneal fibrotic is a fibrous process of the retroperitoneum and can result in ureteral obstruction. Although the pathogenesis is unknown, it is suggested that an immunological mechanism plays a role. It can occur as an isolated finding or be associated with several conditions such as malignancies, infections, connective tissue disease and the action of drugs. However, a few cases of retroperitoneal fibrosis, associated with systemic lupus erythematosus (SLE) have been reported. We describe a case of a 23-year-old female with lupus nephritis who presented with bilateral obstructive nephropathy due to retroperitoneal fibrosis. Treatment with steroids improved both conditions. Our case and previously reported cases of SLE and retroperitoneal fibrosis support the hypothesis that this association is not fortuitous, but reflects a common immunological mechanism.

Effect of in vitro mechanical compression on Epilysin (matrix metalloproteinase-28) expression in hypertrophic scars

Epilysin, designated matrix metalloproteinase (MMP)-28, is the newest member of this family of proteases expressed by keratinocytes in response to an injury. MMP-28's physiological role and specific substrates are unknown, but its expression pattern suggests that it may serve a role in both tissue homeostasis and wound healing. The aim of this preliminary study was to observe the presence of MMP-28 protein in normotrophic and hypertrophic scars and to evaluate the effect of in vitro mechanical compression on its expression. Biopsies from normotrophic and hypertrophic scars resulting from burns were divided into two samples, one to be used as control (uncompressed) and the other to be compressed in an oxygenated organ chamber for 24 hours in the presence of a serum-free medium, using an electromechanical load transducer (stable pressure = 35 mmHg). Analysis of MMP-28 protein secretion, assessed by Western blot and beta-casein zymography in scar conditioned media, revealed that normotrophic scar did not release MMP-28 in any condition while hypertrophic scar released active MMP-28 both in control conditions and after compression. MMP-28 immunohistochemistry revealed a light protein presence in normotrophic scar keratinocytes and a strong MMP-28 positivity in hypertrophic scar keratinocytes in control conditions, while compression increased MMP-28 staining in normotrophic scar and induced a significant reduction of the protein presence in hypertrophic scar keratinocytes. As it has been suggested that MMP-28 may restructure the skin basal membrane (Saarialho-Kere et al., 2002), our data indicate that mechanical compression directly acts to modulate the remodeling phase of wound healing, altering release and activity of MMP-28 in hypertrophic scars.

Combined endoscopic treatment for cholelithiasis associated with choledocholithiasis

BACKGROUND

The advent of endoscopic techniques changed surgery in many ways. For the management of cholelithiasis, laparoscopic cholecystectomy (LC) is the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of option exist, including endoscopic sphinterotomy (ES) before LC in patients with suspected common bile duct (CBD) stones, laparoscopic bile duct exploration, open CBD exploration, and postoperative endoscopic retrograde cholangiopancreatography (ERCP). Also, the alternative technique of peroperative ES is emerging.

METHODS

We report our experience of routine intraoperative cholangiography followed either by peroperative ERCP in one step or by transcystic drain and postoperative ERCP. In our technique, to facilitate Vater papilla cannulation we inserted a 450-cm transcystic guidewire that was caught by a duodenoscope. Papillotome was then inserted over the guidewire to ensure cannulation of the CBD.

RESULTS

Twenty-eight patients were treated successfully in one step and 24 in two steps. The mean operative time was 181 +/- 41 min for patients treated in one step and 131 +/- 30 min for patients treated in two steps. The mean hospital stay was 4.8 +/- 3.3 days for patients treated in one step and 9.6 +/- 4.0 days for patients treated in two steps. Five patients (18%) with positive intraoperative cholangiography for stones for whom peroperative ERCP was not available showed a normal postoperative transcystic cholangiogram and therefore ERCP was canceled. Fourteen of 25 patients treated in one step and none of 17 treated in two steps had raised serum amylase, which resolved spontaneously with no symptoms. No patient developed postoperative pancreatitis. Three (10%) ERCP complications were observed, consisting of mild bleeding of the papilla. All cases were managed by endoscopic adrenaline injection. There was no mortality.

CONCLUSION

We believe peroperative ERCP with the technique described should be considered as the treatment of choice for choledocholithiasis associated with cholelithiasis. When single-stage treatment is not possible, a two-step rendezvous technique should be preferred.

[Cryosurgery with transpleurodiaphragmatic approach in the treatment of non-resectable and recurrent hepatic metastasis from the colorectum]

Cryotherapy allows the destruction of unresectable liver malignancies. The abdominal approach is uneasy for recurrent colorectal metastases located in the upper part of the liver and close to the inferior vena cava, the hepatic veins and the diaphragm. A transpleurodiaphragmatic access was employed. From 1999 to 2003, ten patients with recurrent colorectal liver metastases underwent transdiaphragmatic cryotherapy via a right thoracotomy. Median diameter was 30 mm. One to 4 cryoprobes were used, depending on the size and location of the metastasis. There were no operative deaths, and only 3 patients developed minor complications. Computerized tomography examination of the liver performed one week, three months after cryotherapy, assessed treatment completeness in all patients. At 14 months, 9 patients were alive and 6 were disease-free. Two patients had liver recurrences outside the cryolesion. A transthoracic access may represent the safest and easiest surgical approach for liver tumor cryoablation in selected patients with non resectable recurrent metastases of the upper liver.

[Surgical resection of gastrointestinal stromal tumor after treatment with imatinib: clinical case]

The stromal tumor is the most common mesenchymal tumor of the gastrointestinal tract. Surgical resection is the first-line therapy for operable lesions, however for inoperable imatinib is an effective therapy. In this setting a patient has been operated after a remarkable response to imatinib, used as both neoadjuvant and adjuvant. This approach led to a disease-free condition without toxicity and complications.

Regional citrate anticoagulation in critically ill patients treated with plasma filtration and adsorption

BACKGROUND

In high-risk bleeding conditions conventional systemic anticoagulation with heparin is a contraindication to renal replacement therapy. We evaluate the feasibility and safety of regional citrate anticoagulation in high-risk bleeding conditions during coupled plasma filtration adsorption (CPFA).

METHODS

Thirteen critically ill patients (9 severely burned, 4 polytraumas) with septic shock and acute renal failure treated with CPFA-CVVHD by using bicarbonate-based solutions (heparin-CPFA group, 58 sessions) or with CPFA-CVVHF using citrate (citrate-CPFA group, 36 sessions).

RESULTS

Plasma flow and used cartridges showed no differences between the citrate-CPFA and heparin-CPFA groups, while lost clotted cartridges were significantly lower in the citrate-CPFA group. Blood ionized calcium (iCa2+), Ca2+ infusion, pH and bicarbonates remained constant during citrate-CPFA, with no difference between pre- and post-cartridge plasma citrate. A significant positive correlation between iCa2+ in blood and ultrafiltrate was present.

CONCLUSIONS

These suits demonstrate the feasibility and safety of regional citrate anticoagulation in severely burned and polytrauma septic patients treated by CPFA.

One-year surveillance of legionellosis in burned patients and Legionella environmental monitoring

Burned patients have a theoretically high risk of Legionella infection because burns produce a compromised immune system. Cutaneous surfaces are without protective barriers, and bathing tank water is frequently used for washing and caring. A one-year surveillance study was performed on 65 burned patients by antibody determination and by culture of bronchial aspirates. Environmental culturing for Legionella was done in the patients' care areas every four months during the same period. Low titers ranging from 8 to 32 were found in 30 (46.1%) subjects against 18 antigens including several Legionella species. No increase in antibody titers was shown in 193 patients' sera. Cultures of respiratory samples were negative. L. pneumophila serogroups 4, 5, 6 and 8 and L. rubrilucens were isolated from 55.5% of water samples. Despite no evidence of Legionella infection among patients included in this study, the authors believe it to be advisable to improve control measures in hospital water supplies, used by burned patients, to minimise the risk of legionellosis.

[Severe renal failure in a child]

A four-year-old male child was admitted with severe renal failure, apparently recent in onset and he was treated with peritoneal dialysis (PD). A renal biopsy showed interstitial cellular infiltration with crystals within the tubules and sclerotic glomeruli. Type I hyperoxaluria was diagnosed and the child received a liver and kidney transplant after 10 months of dialysis. Two years later, he has normal renal function, and blood and urine oxalate levels are within normal ranges.

Radiofrequency thermal ablation of hepatocellular carcinoma: our five year experience

PURPOSE

We describe our experience in the multimodal treatment of HCC patients both using the PRFTA and IRFTA treatment associated or not with hepatic resection, valuating the feasibility, the complication, length of hospital stay and survival rate of selected HCC patients.

MATERIALS AND METHODS

Between March 1998 and January 2004, 53 HCC patients undergoing PRFTA and IRFTA treatment. We describe 41 patients with monofocal disease and 12 patients with multifocal disease: in this last group 7 patients had unilobar involvement while 5 patients had multilobar tumour.

RESULTS

We reported patients underwent RFTA because not candidates to surgical procedures and patients underwent liver resection and open radiofrequency treatment associated. We successfully used percutaneous and intraoperative approach being the last one significantly advantageous in lesions greater than 5 cm, multiple bilobar tumours and tumours close to the hilum and major vessels: the laparotomic approach permitted the temporary occlusion of the vascular inflow allowing Pringle manoeuvre.

DISCUSSION

Hepatocarcinoma still represent one of the major causes of cancer related death worldwide. Systemic therapeutic agents and locoregional agents are rarely correlated to complete response and usually associated to high toxicities: the potentially curative or palliative benefit of RFTA in non surgical candidates improve overall patients survival significally better then the chemotherapy regimens.

CONCLUSION

RFTA appears to have several advantages, which also include a reducing in morbidity, a shortening of the hospital stay and good response to patients requirement in term of enduring pain.

Radiofrequency ablation of liver tumours with transpleurodiaphragmatic access

Radiofrequency thermoablation (RFA) is used to treat unresectable liver tumours. RFA is performed using an abdominal access (laparotomic, laparoscopic and percutaneous). A transpleurodiaphragmatic approach has recently been proposed, particularly for the treatment of tumours which are placed near to inferior vein cava and hepatic veins and which are difficult to reach for an abdominal access. A patient with a liver metastasis of the segment VIII underwent RFA with an associated wedge resection of the segment VII, both were performed with a transthoracic access. Peri- and postoperative complications did not occurred. The patient was discharged on fifth postoperative day, and she is disease free after a follow up of 6 months. A transpleurodiaphragmatic access can be considered a safe and efficacy procedure to perform an RFA of a liver tumour in selected cases.

Laparoscopic billroth II gastrectomy for completely stricturing duodenal ulcer: technical details

BACKGROUND

The authors report a series of three patients who underwent laparoscopic gastrectomy for gastric outlet obstruction due to stricturing duodenal ulcer.

MATERIALS AND METHODS

In all cases an intracorporeal resection of the antrum and an antecolic end to side gastrojejunostomy (Billroth II) were performed. Technical details are discussed in the paper.

RESULTS

Mean operative time was 260 minutes, mean blood loss was 43 millilitres. There were no postoperative complications and all patients were discharged on the fifth postoperative day. A follow up of three years shows that no patient had recurrence and post-gastrectomy syndromes.

CONCLUSIONS

Laparoscopic Billroth II gastrectomy is a safe and feasible procedure with benefits such as quick hospital stay, decreased postoperative pain, good cosmesis and reduced morbidity.

[Atypical presentation of angiomiolypoma in a patient with peritoneal metastases from ovarian cancer: a case report]

A renal mass with not typical instrumental characteristic in patient in follow-up for ovarian neoplasia sets to the surgeon serious doubts about proper surgical strategy. Achieve of the conservative renal surgery assisted by the intraoperative use of the radiofrequency energy has allowed to preserve the renal function and the diagnosis of unknown angiomyolipoma.

Evaluation of donor skin viability: fresh and cryopreserved skin using tetrazolioum salt assay

Cell viability assessment in allograft skin is an essential step to ensure a supply of good quality allograft skin for clinical repair of wounds. It is widely recognised that 'take' of allografts is strongly influenced grafted by tissue viability. The aim of this study was to set-up storage protocols that maintain high viability of the allograft after harvest, treatment and storage. In this study, the viability of post-mortem allografts (n=350) harvested from 35 different donors, was investigated using the MTT salt assay. The conditions of preparation and storage of the allograft included: 1. Fresh skin samples (about 12, 30, and 60h after harvesting). 2. The same specimens (stored at 4 and 37 degrees C) tested for at least 1 month. 3. Samples after cryopreservation and thawing. 4. Thawed specimens tested daily for at least 6 days. Parallel histomorphological analysis performed, under each of these conditions, showed a correlation between changes in structure and changes in viability as measured by the MTT quantitative assay. The viability index (VI) of skin is expressed as the ratio between the optical density (O.D.) produced in the MTT assay by the skin sample and its weight in grams. The percentage viability index is the ratio of the VI of the fresh sample (considered as 100% viability) and the value of specimens from the same harvest batch after storage or cryopreservation. The results indicated that samples tested within 12-30h from harvesting have an average viability index of about 75 with little variation. Samples tested within 60h have an average viability index of 40, showing a viability decrease of about 50%. A protocol to treat skin within a maximum of 30h was, therefore, set-up. The data suggested that skin stored at 37 degrees C, undergoes a viability increase during the first 2 days after harvesting. However, the viability under these conditions then decreased very quickly. After 6 days of preservation at this temperature the samples were no longer viable (PVI = 0). The tissue structure started to become damaged after 3 days. On the other hand, skin stored at 4 degrees C, showed a very slow viability decrease. After 15 days, viability was still almost 25% of the fresh sample. The tissue architecture showed no signs of damage under these conditions until day 7 from harvesting. MTT analysis was performed on the specimens cryopreserved with DMSO at 10%. These measurements were compared to viability assessment of the same fresh skin samples (considered as 100%) that were analysed within 30h from harvesting. The average PVI of thawed skin was 54% of the fresh sample. This result demonstrates that the viability of cryopreserved skin is comparable to the viability of fresh skin stored at 4 degrees C for 4 days. The PVI of thawed skin samples decreased dramatically within 24h, and had reached 0% within 6 days.

In vitro mechanical compression induces apoptosis and regulates cytokines release in hypertrophic scars

Hypertrophic scars resulting from severe burns are usually treated by continuous elastic compression. Although pressure therapy reaches success rates of 60-85% its mechanisms of action are still poorly understood. In this study, apoptosis induction and release of interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha) were evaluated in normal (n = 3) and hypertrophic (=7) scars from burns after in vitro mechanical compression. In the absence of compression (basal condition) apoptotic cells, scored using terminal deoxyribonucleotidyl transferase assay, were present after 24 hours in the derma of both normal scar (23 +/- 0.4% of total cell) and hypertrophic scar (11.3 +/- 1.4%). Mechanical compression (constant pressure of 35 mmHg for 24 hours) increased apoptotic cell percentage both in normal scar (29.5 +/- 0.4%) and hypertrophic scar (29 +/- 1.7%). IL-1beta released in the medium was undetectable in normal scar under basal conditions while in hypertrophic scar the IL-1beta concentration was 3.48 +/- 0.2 ng/g. Compression in hypertrophic scar-induced secretion of IL-1beta twofold higher compared to basal condition. (7.72 +/- 0.2 ng/g). TNF-alpha basal concentration measured in normal scar medium was 8.52 +/- 4.01 ng/g and compression did not altered TNF-alpha release (12.86 +/- 7.84 ng/g). TNF-alpha basal release was significantly higher in hypertrophic scar (14.74 +/- 1.42 ng/g) compared to normal scar samples and TNF-alpha secretion was diminished (3.52 +/- 0.97 ng/g) after compression. In conclusion, in our in vitro model, mechanical compression resembling the clinical use of elastocompression was able to strongly increase apoptosis in the hypertrophic scar derma as observed during granulation tissue regression in normal wound healing. Moreover, the observed modulation of IL-1beta and TNF-alpha release by mechanical loading could play a key role in hypertrophy regression induced by elastocompression.

[Intraoperative use of radiofrequency thermoablation of liver tumors: considerations on indications and related therapeutic aspects]

PURPOSE

To evaluate the usefulness of intraoperative radiofrequency thermoablation of liver tumours in association or not with hepatic resection.

MATERIALS AND METHODS

21 patients were treated between January 1998 and December 2001, there were 4 hepatocellular carcinoma and 17 metastasis. In 13 cases radiofrequency was associated to hepatectomy, in 3 cases to resection of extraepatic disease and in 5 cases were performed alone. 23 lesions were treated by radiofrequency (range 1-3); the mean dimension was 26 millimetres (range 8-70). A clamping of the liver pedicle was always done.

RESULTS

There were no operative deaths, 3 (14.3%) patients developed complications related to radiofrequency (2 biliary leakages, 1 hepatic abscess). 14 (66.7%) patients were alive after a mean follow up of 14.5 months, 2 of all (9.5%) had a recurrence in the site previously treated with thermoablation. Association between hepatectomy and radiofrequency increased the number of curative liver resections from 10.1% to 16.3% (in case of colorectal metastasis).

DISCUSSION

Intraoperative radiofrequency is useful to increase the number of curative hepatectomies, to treat liver masses which demonstrate unresectable or found by ultrasonography at the operating time and even to reach tumours difficult to manage by percutaneous approach. In any case the aim is to obtain the absence of macroscopic neoplastic disease (RO status). It is a safe and effective therapeutic strategy, anyway all procedures and indications are still not completely cleared.

CONCLUSIONS

Intraoperative thermoablation of liver tumour is safe and effective and increases therapeutic the number of curative hepatectomies. Further progresses may improve the efficacy and extend the indications of this strategy.

International clinical recommendations on scar management

Many techniques for management of hypertrophic scars and keloids have been proven through extensive use, but few have been supported by prospective studies with adequate control groups. Several new therapies showed good results in small-scale trials, but these have not been repeated in larger trials with long-term follow-up. This article reports a qualitative overview of the available clinical literature by an international panel of experts using standard methods of appraisal. The article provides evidence-based recommendations on prevention and treatment of abnormal scarring and, where studies are insufficient, consensus on best practice. The recommendations focus on the management of hypertrophic scars and keloids, and are internationally applicable in a range of clinical situations. These recommendations support a move to a more evidence-based approach in scar management. This approach highlights a primary role for silicone gel sheeting and intralesional corticosteroids in the management of a wide variety of abnormal scars. The authors concluded that these are the only treatments for which sufficient evidence exists to make evidence-based recommendations. A number of other therapies that are in common use have achieved acceptance by the authors as standard practice. However, it is highly desirable that many standard practices and new emerging therapies undergo large-scale studies with long-term follow-up before being recommended conclusively as alternative therapies for scar management.

Release and activation of matrix metalloproteinase-9 during in vitro mechanical compression in hypertrophic scars

OBJECTIVE

To investigate induction of matrix metalloproteinases (MMPs) during mechanical compression of hypertrophic scars. Mechanical pressure blocks hypertrophy inducted on extracellular matrix in scars by a mechanism that involves MMP-2 (gelatinase A) and MMP-9 (gelatinase B).

DESIGN

We assayed conditioned media obtained from normotrophic and hypertrophic scars during 24 hours of in vitro mechanical compression using gelatin zymography.

SETTING

Scars from various areas of the bodies of hospitalized patients.

PATIENTS

We obtained 3 normotrophic and 7 hypertrophic biopsy specimens from 10 patients (5 men and 5 women).

INTERVENTION

In vitro compression at a pressure of 35 mm Hg/cm(2) for 24 hours.

MAIN OUTCOME MEASURES

Vitality of scars was analyzed by means of lactic dehydrogenase test; medium samples were collected for zymographic analysis of MMP activity.

RESULTS

We found MMP-2 in basal (uncompressed) samples from normotrophic and hypertrophic scars. Mechanical compression induced MMP-9 release and activation (range, 86.7%-78.7%) in hypertrophic scars after 4 hours.

CONCLUSION

Production, release, and activation of MMP-9 in hypertrophic scars could be an effector mechanism responsible for hypertrophy regression induced by mechanical compression.

[Dialytic therapy in severely burnt patients with acute renal failure]

BACKGROUND

Appearance of acute renal failure (ARF) in severely burnt patients (GU) is a serious complication. It has a negative prognostic value and almost always develops in the context of multiple organ dysfunction syndrome (MODS) induced by sepsis. Over the last 20 years, according to data available, the mortality rate has been reported to reach about 75%. We have analyzed the initial results obtained in GU patients who were admitted to the Intensive Care Unit of the Burns Center in Turin.

METHODS

Out of 105 GU patients admitted between July 1999 and September 2000 (burned surface area (BSA) 23.8%, range 2-95%, mortality rate 13.7%), 7 patients (6.4%) had complications of ARF requiring extracorporeal dialytic therapy (38 HF sessions lasting 4-6 hours, 2 HF + 12 HDF + 1 UF sessions lasting 8-11 hours).

RESULTS

Total BSA of 7 GU patients with ARF was 62.5+/-11.3% (mean +/-SEM). Mortality rate was 71.4% which was due to septic shock and MODS. ARF onset was at 28.4+/-8.4 days from admission. Dialytic treatment started at Crs 2.3+/-0.42 mg/dl, and patients were treated for 7.6+/-3.5 days with a weight loss of 1859+/-161 gr/die. Circuit anticoagulation was obtained by minimal amount of heparin (132.2+/-26.5 U/hour) and no hemorrhagic complications were observed.

CONCLUSIONS

In GU patients with ARF the dialytic treatment with daily long-lasting convective- diffusive techniques permitted us to achieve a survival and dialytic adequacy similar to those reported with continuous renal replacement therapies; however, mortality rate is high and related to septic shock and MODS.