[Treatment of peripheral arterial embolisms. Our case series and review of the literature]

Acute arterial obstruction of the limbs represents one of the most frequent events in Emergency Surgery. In 95% of the cases, the cause has to be searched in embolus parting from the heart in patients with rheumatic or fibrillary disease. Currently the two therapeutic methods used for peripheral arterial obstruction are thrombolytic therapy and surgical dysobstruction using Fogarty's catheter. The Authors compare the two methods on the basis of their experience in 129 cases underlying how the thrombolytic therapy (Urokinase, Streptokinase) should be instituted in the early hours from presentation of symptoms, otherwise, the possibility of revascularization will heavily drop. Better results are obtained by positioning a catheter under radiologic guide for intra-arterial infusion. The Authors also believe that up-to-date the surgical approach with Fogarty's catheter represents one of the best procedures, either for its feasibility of for the costs of the thrombolytic therapy. Furthermore, the thrombolysis may be not complete, and account for possible haemorrhagic complications.

Renal Na,K-ATPase in genetic hypertension

Milan hypertensive rats (MHS) develop hypertension because of a primary renal alteration. Both apical and basolateral sodium transport are faster in membrane vesicles derived from renal tubules of MHS than in those of Milan normotensive control rats (MNS). These findings suggest that the increased renal sodium retention and concomitant development of hypertension in MHS may be linked to an altered transepithelial sodium transport. Since this transport is mainly under the control of the Na-K pump, we investigated whether an alteration of the enzymatic activity and/or protein expression of the renal Na,K-ATPase is detectable in prehypertensive MHS. We measured the Na,K-ATPase activity, Rb+ occlusion, turnover number, alpha 1- and beta 1-subunit protein abundance, and alpha 1 and beta 1 mRNA levels in microsomes from renal outer medulla of young (prehypertensive) and adult (hypertensive) MHS and in age-matched MNS. In both young and adult MHS, the Na,K-ATPase activity was significantly higher because of an enhanced number of active pump sites, as determined by Rb+ occlusion maximal binding. The higher number of pump sites was associated with a significant pretranslational increase of alpha 1 and beta 1 mRNA levels that preceded the development of hypertension in MHS. Since a molecular alteration of the cytoskeletal protein adducin is genetically associated with hypertension in MHS and is able to affect the actin-cytoskeleton and Na-K pump activity in transfected renal cells, we propose that the in vivo upregulation of Na-K pump in MHS is primary and linked to a genetic alteration of adducin.

Pravastatin reduces carotid intima-media thickness progression in an asymptomatic hypercholesterolemic mediterranean population: the Carotid Atherosclerosis Italian Ultrasound Study

PURPOSE

The Carotid Atherosclerosis Italian Ultrasound Study (CAIUS) was performed to test the effects of lipid lowering on the progression of carotid intima-media thickness (IMT) in 305 asymptomatic patients from a Mediterranean country.

PATIENTS AND METHODS

Eligibility included hypercholesterolemia (baseline means: low-density lipoprotein [LDL] = 4.68 mmol/L, high-density lipoprotein [HDL] = 1.37 mmol/L), and at least one 1.3 < IMT < 3.5 mm in the carotid arteries. Patients (mean age 55 years, 53% male) were assigned to pravastatin (40 mg/day, n = 151) or placebo (n not equal to 154). Ultrasound imaging was used to quantify IMT at baseline, and semiannually thereafter for up to 3 years. The mean of the 12 maximum IMTs (MMaxIMT), was calculated for each patient visit, and used to determine each patient's longitudinal progression slope. The intention-to-treat group difference in the MMaxIMT progression was chosen a priori as the primary end point.

RESULTS

Five serious cardiovascular events (1 fatal myocardial infarction), and 7 drop-outs for cancer were registered. In the pravastatin group, LDL decreased -0.22 after 3 months versus -0.01 in the placebo group, and remained substantially unchanged afterward (-0.23 versus +0.01 at 36 months, respectively). Progression of the MMaxIMT was 0.009 +/- 0.0027 versus -0.0043 +/- 0.0028 mm/year (mean +/- SE, P < 0.0007) in the placebo and pravastatin groups, respectively. IMT progression slopes diverged after 6 months of treatment.

CONCLUSIONS

Pravastatin stops the progression of carotid IMT in asymptomatic, moderately hypercholesterolemic men and women. This finding extends the beneficial effects of cholesterol lowering to the primary prevention of atherosclerosis in a population with relatively low cardiovascular event rates, and suggests that this benefit is mediated by specific morphological effects on early stages of plaque development.

Renal artery stenosis: value of screening with three-dimensional phase-contrast MR angiography with a phased-array multicoil

PURPOSE

To evaluate screening with three-dimensional (3D) phase-contrast magnetic resonance (MR) angiography with a phased-array multicoil to detect renal artery stenosis.

MATERIALS AND METHODS

Fifty consecutive patients suspected of having renovascular disease were prospectively examined with 3D phase-contrast MR imaging with a phased-array multicoil. Findings were correlated with those at intra-arterial digital subtraction angiography (DSA) as the standard of reference for grade of stenosis.

RESULTS

MR angiography depicted 101 of 103 renal arteries depicted at intraarterial DSA; the two missed arteries were an accessory artery outside the imaging volume and an artery with a stent. At intraarterial DSA, a stenosis was found in 31 of 101 arteries. On the basis of findings at 3D phase-contrast MR angiography, the presence of any degree of stenosis was correctly depicted in 29 of 31 cases and the absence of stenosis was correctly depicted in 66 of 70 cases (accuracy, 94%; sensitivity, 94%; negative predictive value, 97%). Overall accuracy was 97% for correct depiction of severe renal artery stenosis (> 50%).

CONCLUSION

3D phase-contrast MR angiography with a phased-array multicoil was an accurate noninvasive screening technique in patients with suspected renal artery stenosis.

[Foreign bodies in the gastrointestinal tract. Our cases and a review of the literature]

The ingestion or introduction of foreign bodies is a common situation in emergency surgery. The patients who usually ingest foreign bodies for different reasons are children, psychotics, alcoholics, prisoners and old people. The authors analyzed 65 cases observed in the I Institute of Surgery of the University of Rome "La Sapienza": 45 males and 20 females. Both the anal introduction and ingestion may be accidental or voluntary. The incidence of complications is estimated about 5 to 7%. The authors underline the opportunity of a conservative removal through endoscopic procedures especially for intraesophageal corps. This procedure is recommended to reduce morbidity and mortality rates, as well as hospitalization and social costs.

Efficacy of a surveillance program for early detection of hepatocellular carcinoma

BACKGROUND

Contrasting data have so far been reported on the utility and efficacy of screening patients with cirrhosis for early detection of hepatocellular carcinoma (HCC). The goal of this study was to evaluate the efficacy of a regular ultrasonographic and laboratory follow-up for the early detection of small HCC, and to identify parameters correlated with a higher risk of developing HCC.

METHODS

One hundred and sixty-four consecutive patients with liver cirrhosis living in Emilia Romagna, Italy, were enrolled in the period 1989-1991. All patients underwent clinical, biochemical, and ultrasonographic evaluations at entry and at 3- and 6-month intervals during follow-up.

RESULTS

By April 1995, 34 patients had developed HCC. In 76% of the patients, ultrasonography identified HCC when it was still single and small (< 4 cm). At discriminant, logistic regression and univariate analyses, sex and the entry concentration of alkaline phosphatase, alpha-fetoprotein, gamma-glutamyl transpeptidase, and albumin were associated with a higher risk of developing HCC, whereas at multivariate analysis (Cox's model), only sex and the entry concentration of alkaline phosphatase, albumin, and alpha-fetoprotein were independently and significantly related to the appearance of HCC.

CONCLUSIONS

A regular ultrasonographic follow-up, timed at 3- to 6-month intervals according to the risk of HCC development in patients with cirrhosis, allows the detection of liver carcinoma at an early stage in a high proportion of patients, possibly improving the prognosis of the disease.

Quantification of prostate-specific antigen immunoreactivity in human breast cyst fluids

The frequency of gross cystic breast disease in premenopausal women and its possible association with increased breast cancer risk emphasises the importance of investigations relating to breast cyst fluid composition. In order to contribute to a better analysis of this medium, we have measured the presence of prostate-specific antigen immuno-reactivity in sixty-four human breast cyst fluids. Data analyses show that 35% of samples presented a level of this antigen < 0.05 micrograms/L, whereas 42 out of 64 cysts show a significant increase in the mean value of metabolically active apocrine cysts when compared to flattened cysts (p < 0.01). We report the first evidence that breast epithelium of gross cysts produces, secretes, and accumulates large amounts of prostate-specific antigen, a glycoprotein produced by prostatic tissue but recently detected in breast tumours, normal tissues, and during pregnancy. The production and intracystic accumulation of this serine protease in biosynthetically active apocrine type cyst can play a feasible role in the natural history gross cystic breast disease as well as in the mechanism of cyst formation, enlargement, and transformation.

Genetic determinants and renal mechanisms in essential hypertension

Human essential hypertension is a polygenic disease whose phenotypic expression is modulated by the environment. Though the kidney could play a major role in the initiation and maintainment of hypertension, many questions remain open. Rat models of primary hypertension provided the substantial information with experiments on kidney cross-transplantation, showing that at least a portion of hypertension could be transplanted with the kidney in all strains where such an experiment has been carried out. Data consistent with those of rats have also been obtained in humans. Many abnormalities in kidney function and cell membrane ion transport have been described in hypertensive rats and humans, but the logical sequence of events from a genetic-molecular abnormality to a cellular abnormality which causes hypertension via a modification of kidney function is difficult to prove. We established this sequence in Milan hypertensive rats using a variety of experimental techniques such as the study of isolated kidney and renal cell function, cell membrane ion transport, cross-immunisation with membrane proteins, molecular biology, genetic crosses and manipulation. Such study led to the identification of a polymorphism in the cytoskeletal protein adducin. Recently, alpha-adducin variants have been associated to both primary hypertension and salt sensitive hypertension. Finally, recent findings strongly support the hypothesis that adducin variants may affect kidney function by modulating the overall capacity of the tubular epithelial cells to transport ions through both a modification in the assembly of actin cytoskeleton, and a modulation of sodium pump activity.

The course of galactose elimination capacity in patients with alcoholic cirrhosis: possible use as a surrogate marker for death

There is increasing interest for the use of surrogate end points in the evaluation of treatments in patients with liver disease, but adequate validation is seldom available. This study aimed to describe the different course of galactose elimination capacity in patients with alcoholic cirrhosis who continued to drink or abstained from alcohol consumption during follow-up, and to validate changes in galactose elimination as a surrogate end point for death from liver-related causes. Forty-five patients with alcoholic cirrhosis (22 who continued drinking throughout the study period, and 23 who stopped drinking and were abstinent throughout the study period) were retrospectively selected among patients who had galactose elimination capacity measured at 6-month intervals. During follow-up 10 drinkers and 3 abstainers died of liver-related causes (P = .025). Abstainers showed a transient improvement in galactose elimination capacity, followed by a decrease. Continuous drinkers showed a reduction from the beginning. According to Cox's regression analyses, persistent alcohol abuse and galactose elimination capacity were separately related to the risk of death, but, when a time-dependent model was fitted containing galactose elimination capacity and persistent alcohol abuse, only the former remained significant. This implies that variations in the risk of death occurring as a consequence of abstinence from alcohol consumption may be predicted from changes in galactose elimination capacity, and that the mechanisms through which abstinence influences survival are strictly linked to the mechanisms responsible for the changes in the test. Because of the strict association of decrease in galactose elimination capacity and short survival, as proved in several series, this observation represents adherence to the criteria requested for adequacy of a surrogate end point. In conclusion, in alcoholic cirrhosis the decrease in galactose elimination capacity is an adequate surrogate end point for death from liver-related causes, which is worth testing in other conditions and in response to other treatments.

Estrogen and progesterone receptors in breast cancer: comparison between enzyme immunoassay and computer-assisted image analysis of immunocytochemical assay

Evaluation of estrogen (ER) and progesterone (PR) receptor content is now an important procedure in the management of breast cancer patients. Production of monoclonal antibodies to ER and PR has permitted development of an enzyme immunoassay (EIA) and immunocytochemical assay (ICA). This study compared the results of ICA and EIA to evaluate ER and PR in 197 breast cancers using the same monoclonal antibodies. The ICA results were obtained by automated computer-assisted image analysis using CAS 200. The cut-off values adopted were 15 fmol/mg protein for EIA and 10% of the positive neoplastic area of the nuclei for ICA. For statistical analysis, Spearman's correlation coefficient and chi 2 were used. There was good correlation between ICA and EIA for both ER (r = 0.714; p < 0.0001) and PR (r = 0.815; P < 0.0001). Of 197 tumors, 136 (69.04%) were ER-ICA+, and 138 (70.05%) were ER-EIA+; 111 (56.35%) were PR-ICA+, and 115 (58.38%) were PR-EIA+. Results were concordant, positive or negative with both methods, in 175 cases for ER and in 173 cases for PR. ER and PR results were only discordant in 22 and 24 cases, respectively. Concordance of results obtained by the two methods was 88.83% (P < 0.0001) for ER and 87.81% (P < 0.0001) for PR. Correlation of results obtained by EIA and ICA to determine ER and PR was good. The data obtained suggest that ICA with automated image analysis is an effective means for evaluating ER and PR content in human breast cancer, especially when, as happens ever more frequently nowadays, the tumor is too small to perform EIA or when retrospective studies are performed.

Efficacy of a surveillance program for early detection of hepatocellular carcinoma

BACKGROUND

Contrasting data have so far been reported on the utility and efficacy of screening patients with cirrhosis for early detection of hepatocellular carcinoma (HCC). The goal of this study was to evaluate the efficacy of a regular ultrasonographic and laboratory follow-up for the early detection of small HCC, and to identify parameters correlated with a higher risk of developing HCC.

METHODS

One hundred and sixty-four consecutive patients with liver cirrhosis living in Emilia Romagna, Italy, were enrolled in the period 1989-1991. All patients underwent clinical, biochemical, and ultrasonographic evaluations at entry and at 3- and 6-month intervals during follow-up.

RESULTS

By April 1995, 34 patients had developed HCC. In 76% of the patients, ultrasonography identified HCC when it was still single and small (< 4 cm). At discriminant, logistic regression and univariate analyses, sex and the entry concentration of alkaline phosphatase, alpha-fetoprotein, gamma-glutamyl transpeptidase, and albumin were associated with a higher risk of developing HCC, whereas at multivariate analysis (Cox's model), only sex and the entry concentration of alkaline phosphatase, albumin, and alpha-fetoprotein were independently and significantly related to the appearance of HCC.

CONCLUSIONS

A regular ultrasonographic follow-up, timed at 3- to 6-month intervals according to the risk of HCC development in patients with cirrhosis, allows the detection of liver carcinoma at an early stage in a high proportion of patients, possibly improving the prognosis of the disease.

Hypertension may be transplanted with the kidney in humans: a long-term historical prospective follow-up of recipients grafted with kidneys coming from donors with or without hypertension in their families

In several genetic hypertensive rat strains, transplantation studies have established that the kidney carries at least a portion of the genetic message for hypertension. In man it has, of course, been more difficult to obtain clearcut results. This historical prospective observational study, double-blinded for knowledge of donors' and recipients' family history for hypertension, concerns 85 transplanted patients, not treated with cyclosporine and with stable renal function, followed up for an average of 8 yr. Both the donors' and the recipients' families were carefully characterized for presence or absence of hypertension. After transplantation, in recipients without hypertension in their own families, a kidney coming from a "hypertensive" family determines less withdrawal and more introduction of antihypertensive therapy (AHT) than a kidney from a "normotensive" family (odds ratio for AHT introduction 5.0, confidence interval, 1.4 to 17.8; P = 0.017). In recipients with familial hypertension, the origin of the kidney does not influence the prevalence of hypertension after transplantation. More detailed analyses show that, in recipients without familial hypertension, the transplantation of a "hypertensive" kidney determines a tenfold larger increase in the requirement of antihypertensive therapy than the transplantation of a "normotensive" kidney, to obtain a similar blood pressure control (P = 0.003). This results is confirmed by the analysis of time-profile trends for antihypertensive therapy, adjusted for missing data, in the most clinically stable period (2nd to 10th yr after transplantation). The transmission of familial hypertension with the kidney is thus seen only in recipients coming from "normotensive" families, because a familial tendency for hypertension blunts the effect of receiving a "hypertensive" kidney.

Migratory Response of Human NK Cells to Monocyte-Chemotactic Proteins

NK cells are present mostly in blood and spleen but under certain pathological and physiological conditions rapidly accumulate at extrahematic sites. The present study investigates the responsiveness of NK cells to C-C chemokines and the mechanisms of emigration from the bloodstream. MCP-1 induced migration across polycarbonate filters of IL-2-activated NK cells, whereas it was a weak attractant for unstimulated cells. The related chemokines MCP-2 and MCP-3 were also active. IL-2-activated NK cells showed specific binding sites for labeled MCP-1, and cell migration was inhibited by both cholera and Bordetella pertussis toxins. In agreement with functional assays the expression of mRNA specific for MCP-1 receptors was detectable only in IL-2-activated NK cells. The ability of NK cells to respond to MCP-1 and related chemokines may be one important determinant of NK cell emigration and recruitment in tissues.

Hypertension-associated point mutations in the adducin alpha and beta subunits affect actin cytoskeleton and ion transport

The adducin heterodimer is a protein affecting the assembly of the actin-based cytoskeleton. Point mutations in rat adducin alpha (F316Y) and beta (Q529R) subunits are involved in a form of rat primary hypertension (MHS) associated with faster kidney tubular ion transport. A role for adducin in human primary hypertension has also been suggested. By studying the interaction of actin with purified normal and mutated adducin in a cell-free system and the actin assembly in rat kidney epithelial cells (NRK-52E) transfected with mutated rat adducin cDNA, we show that the adducin isoforms differentially modulate: (a) actin assembly both in a cell-free system and within transfected cells; (b) topography of alpha V integrin together with focal contact proteins; and (c) Na-K pump activity at V(max) (faster with the mutated isoforms, 1281 +/- 90 vs 841 +/- 30 nmol K/h.mg pt., P < 0.0001). This co-modulation suggests a role for adducin in the constitutive capacity of the epithelia both to transport ions and to expose adhesion molecules. These findings may also lead to the understanding of the relation between adducin polymorphism and blood pressure and to the development of new approaches to the study of hypertension-associated organ damage.

Renal mechanisms of genetic hypertension: from the molecular level to the intact organism

Human primary hypertension is a polygenic disease; its phenotypic expression is modulated by the environment. Though the kidney can play a major role in the initiation and maintainance of hypertension, many questions remain open. Kidney cross-transplantation demonstrated that hypertension can be transplanted with the kidney in all strains of genetically hypertensive rats where such experiments have been carried out. Data consistent with those in rats were also obtained in humans. Many abnormalities in kidney function and ion transport were described in hypertensive rats and humans, but the logical sequence from genetic-molecular to cellular abnormality that causes hypertension via modification of kidney function is difficult to prove. We established this sequence in Milan hypertensive rats using a variety of experimental techniques (isolated kidney and renal cell function, cell membrane ion transport, cross-immunization with membrane proteins, molecular biology, genetic crosses and manipulation). Such studies led to the identification of a polymorphism in the cytoskeletal protein adducin. This polymorphism seems involved in blood pressure regulation both in rats and humans. Preliminary results suggest that adducin polymorphism affects kidney function by modulating the overall capacity of tubular epithelial cells to transport ions modifying the assembly of actin cytoskeleton.

Laparoscopic surgical lymphadenectomies in urological tumours

In the last few years laparoscopie surgery has also been used in urological pathologies. Various types of operations have been performed with this technique, but only recently has there been an attempt to give precise indications. Laparoscopy is being used to carry out pelvic lymphadenectomy for cancer of the prostate, the penis and the female urethra, and retroperitoneal lymphadenectomy for non-seminomatous germinal cancer of the testis. The aim of this work, which reports the authors’ experience with this technique, is to define its advantages and limitations in order to identify correct indications.

Association between plasma membrane (Ca+Mg) ATPase and calpain/calpastatin system in rat erythrocytes

We studied the activity of plasma membrane (Ca+Mg)ATPase from erythrocytes of Milan hypertensive rat strain (MHS) and Milan low calpastatin rat strain (MLCS), that show an activity level of the specific calpain inhibitor, calpastatin, about five fold reduced in comparison with the Milan normotensive rat strain (MNS), while the protease activity level is similar. This imbalance of calpain:calpastatin ratio leads to a decrease of the erythrocyte plasma membrane (Ca+Mg)ATPase activity and to the appearance of 124 kDa fragments, which are the typical products of proteolytic calpain action on the 136 kDa (Ca+Mg)ATPase native form.

The galactose elimination capacity test: a study of the technique based on the analysis of 868 measurements

OBJECTIVES

Our objective in this study was to analyze the correspondence of galactose concentration-on-time-decay curve to theoretical assumptions and the confidence limits of the determination of galactose elimination capacity.

METHODS

We analyzed a retrospective series of 868 galactose elimination tests, performed on subjects with and without liver disease. Zero-order kinetics of galactose elimination was tested by comparison of the residual variance of linear regression with that obtained after quadratic transformation. The uncertainty in determination of galactose elimination capacity was calculated on the regression line by computing the 95% confidence limits of the estimate.

RESULTS

The time-course of galactose concentration suggested an initial uneven distribution, and the first (20-min) data point deviated significantly from the regression. The galactose decay curve in plasma rejected linearity in 13% of tests; after exclusion of the first data-point, linearity was rejected in only 3% of cases. The 95% confidence interval of galactose elimination capacity was on average +/- 16%, but in individual tests it was as large as +/- 60-80%. The uncertainty of the test was not affected by linearity. It was larger, with poor fitting of the experimental data on the regression of galactose concentration on time, low number of data points, and low galactose elimination. It was maintained within +/- 20% only when residual variance was > or = 2% of total variance (nearly 50% of tests).

CONCLUSION

The methodology for the determination of galactose elimination capacity leads to considerable uncertainty as to the final result, which must be considered whenever the test is used for clinical purposes in the decision-making process. It tends to be larger in patients with advanced disease and can be accurately calculated so as to contribute to a proper evaluation of the test result.

Zinc supplementation and amino acid-nitrogen metabolism in patients with advanced cirrhosis

Zinc deficiency is common in cirrhosis and has been involved in the altered nitrogen metabolism. In this study, we measured the effects of zinc supplementation on the dynamics of amino acid-derived urea synthesis in cirrhosis with mild or latent encephalopathy. The hepatic conversion of amino acids into urea was studied in eight patients with advanced cirrhosis under controlled conditions of substrate availability (continuous alanine infusion), before and after 3-month oral zinc sulfate supplementation (600 mg/d). Eight more patients, matched for hepatocellular failure and encephalopathy, served as controls. Plasma zinc levels were reduced in all patients and returned to normal after oral zinc. The alanine-stimulated urea nitrogen synthesis rate in relation to alpha-amino-N concentration--the functional hepatic nitrogen clearance--increased by 25% after zinc supplementation, i.e., more urea was produced at any alpha-amino-N concentration. Basal and alanine-induced glucagon decreased by 50%, and the ammonia response to alanine decreased by 30%. Psychometric tests improved, as did routine and dynamic liver function tests and the Child-Pugh score. Also, the plasma concentration of lipid peroxides was reduced by zinc. No significant changes were observed in the control group. Our data indicate that long-term oral zinc speeds up the kinetics of urea formation from amino acids and ammonia. Changes in the hormonal drive and/or the antioxidant activity of zinc might be involved in the general improvement in liver function, whereas the beneficial effects on encephalopathy might stem from decreased ammonia.