Outcome of renal transplantation in adult patients with augmented bladders

OBJECTIVE

We studied the long-term renal graft functions, survivals, and complications among patients with augmented bladders.

PATIENTS AND METHODS

Between 1976 and 2008, we performed 6/2600 renal transplantations in patients with augmented bladders. The mean patient age was 52 years. The cause of end-stage renal disease was chronic interstitial kidney disease in all patients, being secondary to lower urinary tract dysfunction. The etiology of bladder dysfunction was tuberculosis in 4 cases, bladder exstrophy in 1, and myelomeningocele in 1. Enterocystoplasty had been performed at a mean of 19 years prior to transplantation. The ureter was implanted into the native ureter in 5 cases and the bowel segment in 1 case.

RESULTS

With a mean follow-up of 56 months (range, 20-100 months), the overall graft survival was 50%. Three grafts were lost due to venous thrombosis (n = 1), and chronic allograft nephropathy (n = 2) at 37 and 100 months posttransplantation. No patient died during follow-up. Mean serum creatinine was 1.44 mg/dL with Modification of Diet in Renal Disease (MDRD) clearance of 76 mL/min/1.73 m(2). One fistula that caused obstructive uropathy and 2 cases of migration of a double J catheter were among the surgical complications. These patients showed a mean of 7 episodes of uncomplicated urinary infections. Only 1 patient was rehospitalized due to a complicated urinary tract infection.

CONCLUSIONS

Patients with enterocystoplasty and renal transplantation show a greater risk of urinary tract infections, albeit mostly uncomplicated. Despite this, the long-term results are acceptable.

Review article: pharmacological therapy for hepatocellular carcinoma with sorafenib and other oral agents

BACKGROUND

Hepatocellular carcinoma (HCC) is the fifth most common malignancy worldwide. Unresectable disease patients have median survival of few months. There is a substantial need for novel treatments for patients with advanced HCC.

AIM

To provide an update review of mechanism of hepatocarcinigenesis and systemic therapies for HCC and the relevant role of Sorafenib in patients with advanced disease.

METHODS

A Medline search was performed to identify pertinent original research and review articles. Selected references in these articles were also evaluated.

RESULTS

Systemic chemotherapy for HCC has been quite ineffective. Preclinical studies demonstrated that Raf/MAPK-ERK kinase (MEK)/Extracellular signal regulated kinase (ERK) pathway has a role in HCC. HCC tumours are highly vascularized and vascular endothelial growth factor (VEGF) augments HCC development and metastasis. Sorafenib blocks tumour cell proliferation by targeting Raf/MEK/ERK signalling and exerts an antiangiogenic effect by targeting VEGF receptors-2/3 and platelet derived growth factor receptor beta tyrosine kinases.

CONCLUSIONS

Currently available therapies are not effective for patients with advanced HCC. Sorafenib has demonstrated for the first time to prolong survival in patients with advanced HCC, and it is the new reference standard for systemic treatment in these patients.

[The upper limb of children with cerebral palsy: surgical aspects]

Cerebral palsy has a complex and multifactorial etiology. The management of the upper limb aims to improve function, hygiene and cosmesis in many patients. Surgical treatment need a good and repeated clinical examination before. The functional surgery has a lot of procedures on the elbow, the wrist, the fingers and the thumb. These procedures include the release or lengthening of spastic muscles, tendon transfers and joint stabilizations. The surgeon must know the indications and contraindications of functional surgery.

Raman spectroscopy of the system iron(III)-sulfuric acid-water: an approach to Tinto River's (Spain) hydrogeochemistry

Acid mine drainage is formed when pyrite (FeS(2)) is exposed and reacts with air and water to form sulfuric acid and dissolved iron. Tinto River (Huelva, Spain) is an example of this phenomenon. In this study, Raman spectroscopy has been used to investigate the speciation of the system iron(III)-sulfuric acid-water as an approach to Tinto River's aqueous solutions. The molalities of sulfuric acid (0.09 mol/kg) and iron(III) (0.01-1.5 mol/kg) were chosen to mimic the concentration of the species in Tinto River waters. Raman spectra of the solutions reveal a strong iron(III)-sulfate inner-sphere interaction through the nu(1) sulfate band at 981 cm(-1) and its shoulder at 1005 cm(-1). Iron(III)-sulfate interaction may also be facilitated by hydrogen bonds and monitored in the Raman spectra through the symmetric stretching band of bisulfate at 1052 cm(-1) and a shoulder at 1040 cm(-1). Other bands in the low-frequency region of the Raman spectra are attributed to the hydrogen-bonded complexes formation as well.

Clinical and pathological characteristics and response to combination therapy of genotype 4 chronic hepatitis C patients: experience from a spanish center

This observational study evaluated the characteristics of genotype 4 chronic hepatitis C (CHC) patients and their response to combination therapy in Spain. 383 patients with CHC, 44 with genotype 4-HCV infection, were investigated. Nineteen genotype 4-HCV infected patients received IFNalpha-2b (3 MU three times weekly) plus ribavirin (1-1.2 g/day) and ten received Peg-IFNalpha-2b (1.5 microg/kg/week) plus ribavirin (1-1.2 g/day) for 12 months. A sustained virological response (SVR) was evaluated. Genotype 4-HCV was detected in 11.5% of patients, and was significantly associated with a higher proportion of infection through intravenous drug use (46% vs 11%; p<0.001), a higher alcohol intake (35% vs. 7%; p<0.001), higher proportion of anti-HBc positivity (41% vs. 22%; p<0.05), lower ALT (87+/-50 vs. 139+/-142 IU/L; p<0.001) and AST (53+/-30 vs. 85+/-126 IU/L; p<0.001) levels, lower viremia (4.1 +/- 7.7 (x 10(5)) vs . 7.3 +/- 9.8 IU(x 10(5) )/mL) p<0.05) and less fibrosis (stage 3-4 in 21% vs. 32%; p<0.06). Sixteen (55%) out of the 29 patients treated with combination therapy achieved a sustained virological response (SVR) while 10 (36%) were non-responders and 3 (9% relapsed. In conclusion, the lower stage of fibrosis, lower viremia and higher SVR rate than genotype 1 suggest a less aggressive pattern of diseased caused by this genotype.

The effect of supplementation with n-3 fatty acids on the physical performance in subjects with spinal cord injury

A global physical evaluation was performed in 21 males with spinal cord injury (SCI), at the beginning and at three and six months of omega-3 fatty acid (FA) supplementation. A significant increase in the proportion of eicosapentaenoic acid and docosahexanoic acid in plasma was observed in response to the supplementation (p<0.05). After six months of FA supplementation, strength endurance time increased from 127.7+/-19.0 s to 215.2+/-45.6 s in the right arm, and from 139+/-27.6 s to 237.7+/-48.7 s, in the left arm. The time to perform 20 repetitions of 70% maximum workload showed a reduction of 41% between the first and the third test. The time taken to cover a 90 meter long track, with a 6% slope, was reduced from 66.9+/-8.0 s to 59.3+/-6.7 s, at the end of the study (p<0.05). In conclusion, omega-3 FA supplementation could contribute to improve the functional capabilities in SCI subjects.

Prevalence, duration and aetiology of bacteraemia following dental extractions

OBJECTIVE

To investigate the prevalence, duration and aetiology of bacteraemia following dental extractions, analysing the factors affecting its development.

SUBJECTS AND METHODS

The study group was composed of 53 patients undergoing dental extractions under general anaesthesia. Peripheral venous blood samples were collected at baseline and at 30 s, 15 min and 1 h after the dental extractions. Samples were inoculated into BACTEC PLUS aerobic and anaerobic blood culture bottles and were processed in Bactec 9240. Subculture and further identification of the bacteria isolated was performed by conventional microbiological techniques.

RESULTS

The prevalence of bacteraemia following dental extractions was 96.2% at 30 s, 64.2% at 15 min and 20% at 1 h after completing the surgical procedure. The bacteria most frequently identified in the positive blood cultures were Streptococcus spp. (63.8%), particularly Streptococcus viridans.

CONCLUSIONS

In our series, the majority of patients undergoing dental extractions developed bacteraemia, usually of a streptococcal nature, independently of the grade of oral health and of the number of extractions performed. Positive blood cultures persisted for at least 1 h after the dental procedure in a considerable number of patients, questioning the supposedly transient nature of bacteraemia following dental extractions.

Association between angiogenesis soluble factors and disease progression markers in chronic hepatitis C patients

OBJECTIVES

Our objectives were to compare angiogenesis soluble factor (ASF) levels in chronic hepatitis C (CHC) patients and healthy individuals, and to investigate potential associations between ASF levels and both histological and biochemical markers of disease progression.

METHOD

Thirty-six patients (69% males) positive for HCV-RNA by PCR analysis were included in the study. All patients underwent liver biopsy before treatment. Serum levels of vascular endothelial growth factor (VEGF), soluble Flt-1 and Flk-1 receptors, placental growth factor (PlGF), angiopoietin-2 (Ang-2) and soluble Tie-2 receptor were determined by ELISA. Fifteen healthy subjects were used as controls.

RESULTS

In comparison to healthy individuals, CHC patients showed significantly increased serum levels of proangiogenic factors PlGF (22 +/- 5 vs. 18 +/- 8 pg/ml; p < 0.05), Ang-2 (1265 +/- 385 vs. 833 +/- 346 pg/ml; p < 0.005) and sFlt-1 (95 +/- 22 vs. 72 +/- 14 pg/ml; p < 0.0001). Interestingly, in CHC patients serum levels of VEGF and Tie-2 correlated with grade of inflammation, PlGF correlated with stage of fibrosis, and Flt-1 and Flk-1 correlated with serum transaminase levels (p < 0.05 in all cases).

CONCLUSIONS

CHC patients showed increased serum levels of ASF, and a significant correlation was shown between serum levels of selected ASFs and grade of inflammation, stage of fibrosis, and transaminase levels.

Sustained virological response to peginterferon plus ribavirin in chronic hepatitis C genotype 1 patients is associated with a persistent Th1 immune response

BACKGROUND

An impairment of cellular immune response may contribute to the persistency of hepatitis C virus infection.

AIM

To analyse the Th1/Th2 cytokine profile in peripheral blood CD4(+) and CD8(+) T cells from patients with chronic hepatitis C (CHC) during treatment with pegylated interferon-alpha2a plus ribavirin and to correlate the Th1/Th2 balance with virological response (SVR).

METHODS

Prospective longitudinal study: 44 naïve genotype 1 CHC patients received PEG-IFNalpha2a plus ribavirin for 48 weeks: 26 (59.1%) achieved a SVR, 13 relapsed (29.5%) and 5 (11.4%) were non-responders. Sixteen healthy controls were analysed. The production of IL-4, IFNgamma and TNFalpha by CD4(+) and CD8(+) T cells was measured using flow cytometry, both in resting and phorbol-ester-stimulated cells.

RESULTS

First three months of treatment: the synthesis of TNFalpha by phorbol-ester-stimulated-CD4(+) T cells was higher in patients with SVR (P < 0.01). At the end of treatment, SVR was associated with higher intracellular expression of IFNgamma by stimulated-CD4(+) and CD8(+) T cells (P < 0.05). At the end of follow-up, a higher intracellular expression of IFNgamma by CD4(+) T cells was associated with a SVR.

CONCLUSIONS

A Th1-type immune response was associated with achievement of a SVR, as indicated by the persistent elevation of intracellular IFNgamma and TNFalpha.

Resultados del tratamiento ortopédico del dedo en martillo por ruptura subcutánea del tendón extensor. Serie de 170 casos

Objetivo: El presente estudio tiene por objetivo demostrar que los pacientes con dedo en martillo por arrancamiento del tendón extensor o ruptura subcutánea, pueden beneficiarse del tratamiento ortopédico, reservando el tratamiento quirúrgico para casos con mala evolución.

Material y Método: Se realizó un estudio retrospectivo de un grupo 170 de pacientes que presentaban una deformación digital en martillo por ruptura subcutánea o arrancamiento del tendón extensor. Todos los casos fueron tratados ortopédicamente, ya sea en consulta precoz y hasta en casos con un retraso máximo de 8 semanas. El tratamiento utilizado fue una férula dorsal en forma de rejilla, moldeada a medida, inmovilizando sólo la articulación interfalángica distal en extensión por un período de tiempo medio de 54 días.

Resultados: Con un seguimiento medio de 5 meses, el déficit de extensión fue de 7° y la flexión alcanzó los 61°. Setenta y ocho pacientes de este grupo fueron evaluados después de un plazo medio de 5 años, obteniendo similares resultados, con un déficit de extensión medio de 5° y una movilidad en flexión media de 61°.

Conclusiones: La férula es pues el tratamiento de elección incluso en caso de consulta diferida; la cirugía sólo la utilizamos para casos de fracaso del tratamiento ortopédico y en pacientes exigentes ya sea por razones profesionales o de ocio.

Report of a National Conference on Donation after cardiac death

A national conference on organ donation after cardiac death (DCD) was convened to expand the practice of DCD in the continuum of quality end-of-life care. This national conference affirmed the ethical propriety of DCD as not violating the dead donor rule. Further, by new developments not previously reported, the conference resolved controversy regarding the period of circulatory cessation that determines death and allows administration of pre-recovery pharmacologic agents, it established conditions of DCD eligibility, it presented current data regarding the successful transplantation of organs from DCD, it proposed a new framework of data reporting regarding ischemic events, it made specific recommendations to agencies and organizations to remove barriers to DCD, it brought guidance regarding organ allocation and the process of informed consent and it set an action plan to address media issues. When a consensual decision is made to withdraw life support by the attending physician and patient or by the attending physician and a family member or surrogate (particularly in an intensive care unit), a routine opportunity for DCD should be available to honor the deceased donor's wishes in every donor service area (DSA) of the United States.

Epidemiological study of Rickettsia typhi infection in two provinces of the north of Spain: analysis of sera from the general population and sheep

Data relating to Rickettsia typhi infection in Spain are scarce. A serological survey of 383 serum samples (184 males, 199 females) from the general population and 120 sera from sheep were studied by immunofluorescence assay (IFA). The human serum samples were collected from the general population of Palencia and Burgos provinces, and sheep serum samples were collected from Palencia province. Of the 383 human serum samples studied, 29 were positive for antibodies against R. typhi (7.5%) No statistical differences were found according to age, sex, origin (rural vs. urban) or geographic distribution, but a significant difference was observed related to occupation. In addition, 69 serums were found positives for R. typhi in sheep samples (57.5%). Our results indicated the circulation of R. typhi infectious for humans and sheep in Palencia and Burgos provinces. This study indicates that sheep may be infected with R. typhi, and that animals can, therefore be used as indicators of the presence of this organism.

Contrast media: future aspects

In spite of the dramatic development in CT, there was no major breakthrough in the iodinated contrast media development. New agents based on hybrid between MRI and CT compounds may be a new innovative alternative. This new approach may also open new indications such as radiotherapy.

Continual supplementation with n-3 fatty acids does not modify plasma lipid profile in spinal cord injury patients

STUDY DESIGN

A prospective study during a diet modification.

OBJECTIVE

To observe the evolution of the plasma lipid profile in a group of spinal cord injury (SCI) patients given a supplement of a mixture of docosahexanoic acid (DHA) and eicosapentaenoic acid (EPA).

SETTING

Department of Physiological Sciences II, Medical School of the University of Barcelona and Guttmann Institut of Badalona, Barcelona, Spain.

METHODS

A total of 19 adult males with SCI, 17 with paraplegia and two with tetraplegia, were given a daily supplement of 1.5 g of DHA and 0.75 g of EPA for 6 months. Determination of plasma values of DHA, EPA, total cholesterol, HDL-c, LDL-c, VLDL-c, triglycerides, and glucose was performed before supplementation and at 3 and 6 months of supplementation.

RESULTS

A statistically significant increase in the plasma concentration of EPA (F=30.556, P<0.05) and DHA (F=106.6, P<0.05) was observed after 3 and 6 months of supplementation. However, there were no observable differences in the plasma concentration of total-cholesterol, HDL-c, LDL-c, VLDL-c, and triglycerides during the study.

CONCLUSION

DHA-EPA supplementation for 6 months does not modify the glycemic and lipid plasmatic levels in SCI patients. Despite its absence of effect on the serum lipid profile, n-3 fatty acids may induce beneficial cardiovascular effects in this population.

[Comparative study on the protective effect of two immunization schemes using a hepatitis B recombinant vaccine in vulnerable health science students]

OBJECTIVE

Demonstrate the protective effect of hepatitis B in vaccine vulnerable health sciences students, under 30 years with three schemes the vaccination, two of them are conventional three doses and another one with two doses.

HYPOTHESIS

Three schedules of vaccination dosage schemes hepatitis B produce antibody response over 10 IU/ml.

DESIGN

Analytical, experimental, longitudinal., prospective and concurrent cohort study.

MATERIALS AND METHOD

100 vulnerable female and male students of the Medical Technology Faculty of the UNMSM Medical School were enrolled at first. 89 students completed the final analysis due to the inclusion and exclusion criteria in accordance with the study purpose. A vaccine dosage of 20 ug of surface antigen in 1 mL through three dosage schemes was administered: month 0, 1, 6; month 0, 1, 2; and month 0, 1. Blood samples were taken before and 1, 2, 6, and 7 months after the first dosage administration to determine the anti-HBs level. Anti-HBs approximately 10 mIU/mL was defined as seroprotective value.

RESULTS

89 students under 30 years (average age: 23.5 years). 46 (51.7%) male individuals, and 43 (48.3%) female individuals.12.4% of students reached protection within 30 days from the first dosage; 98.8% reached protection within 30 days from the second dosage; and 100% reached protection 180 days later. After the second dosage, the three groups reached protection values, and at the end of the study, the average antibody levels were between 532.7 mIU/mL and 1237.2 mIU/mL.

CONCLUSIONS

This study showed an equivalent protective effect 7 months after the first dosage. An equivalent protective effect for hepatitis B was reached through three different vaccination schemes: conventional three dose scheme (month 0, 1, 6); two dose brief scheme (month 0, 1); and three dose brief scheme (month 0, 1, 2). A two dose scheme is suggested for individuals under 30 years, which would imply a higher compliance rate, lower cost, and a similar protection benefit.

Review article: angiogenesis soluble factors as liver disease markers

Angiogenesis is the formation of new blood vessels from pre-existing ones; it has been studied at the molecular level in different pathologies and is currently considered a promising novel therapeutic target in cancer. Recently, the use of angiogenesis soluble factors as markers of tumour growth has been investigated. The knowledge gained has led to test their use as therapeutic agents. Additionally, angiogenesis soluble factors could be used for the follow-up of pathologies that currently require monitoring with invasive techniques, like chronic viral hepatitis or renal and haematological diseases. The different factors have been described in multiple studies. In some cases, such as hepatocellular carcinoma, a potential use as prognostic markers has been suggested.

Effects of herbicide on the kidneys of two Venezuelan cultured fish: Caquetaia kraussii and Colossoma macropomum (Pisces: Ciclidae and Characeae)

The use of chemical pesticides and herbicides has increased environmental pollution and affected ichthyofauna in the watersheds where they are used. We studied the effect of an herbicide, triazine, on the kidneys of two species (Caquetaia kraussii and Colossomna macropomum) widely found in Caribbean and South American rivers. In Venezuela, these species are abundant and have a high aquaculture potential because they may be cultured and reproduced in captivity. Four kidney samples from juveniles of each species exposed to the herbicide were examined by Transmission Electron Microscopy. Kidney tubule alterations included loss of plasmalemma and cell interdigitations, misshaped mitochondria, decrease in rough endoplasmic reticulum and free polysomes, and the presence of autophagic vacuoles and primary lysosomes. These alterations at the cellular level may explain fish behaviour in terms of kidney tubule pathology, and relative amounts and conditions of organelles within affected cells.

La technique de « pseudo-pollicisation » ulnaire dans les différences congénitales

In certain rare cases of thumb aplasia or hypoplasia, pollicisation of the second finger is not recommended or impossible. It happens when the most radial fingers are hypoplastic or abnormal or when an ulnar prehension pattern has already developed. In these cases, if functional, pollicisation of the most ulnar finger in not suitable because of the ugly cosmetic result. In order to combine the functional advantages of the ulnar pollicisation with a satisfactory cosmetic appearance, the authors describe pseudo-ulnar pollicisation by supination osteotomy. This operation combines rotation of the fifth ray with the establishment of a larger web space between the two most ulnar fingers. We have used this technique in five preliminary cases with a minimum follow-up of 18 months.

Déficiences longitudinales ulnaires : proposition d’une classification descriptive

Ulnar longitudinal deficiency is an extended malformation sometimes involving the whole upper extremity, even including sometimes the opposite side. The clinical and radiological aspects are variable and none of the existing classifications takes into account all the possible deformities. Multiple decisive factors in the surgical indications are missing such as shoulder stability, elbow position (extension or flexion with or without pterygium), orientation of the hand (internal rotation), wrist inclination and number of digits. Based on a review of our 46 clinical cases as well as the published cases in the literature we have developed a simple way to describe each level.

Hepatitis C virus-related extra-hepatic disease--aetiopathogenesis and management

Summary Hepatitis C virus infection is often associated with extra-hepatic manifestations, secondary to the elicitation of autoimmune reactions, generalized deposition of immune complexes and lymphoproliferative disorders. The most clearly established associations are those linking chronic hepatitis C with mixed cryoglobulinaemia (and the related glomerulonephritis and cutaneous vasculitis), as well as with the presence of autoantibodies. Less well-documented disorders include non-Hodgkin's lymphoma, thrombocytopenia, sialadenitis, thyroid disease, lichen planus, porphyria cutanea tarda, rheumatoid disorders and neurological disorders. Extra-hepatic manifestations are most frequent in patients of female sex, advanced age, long-lasting infection and cirrhosis. Optimal treatment strategies should be based on the predominant manifestation of the disease. In the case of autoimmune disorders not clearly attributable to the viral infection, corticosteroids may be the most effective option. Interferon-alpha alone or in combination with ribavirin may be indicated for those disorders related to immune complex deposition, such as mixed cryoglobulinaemia, although relapses of extra-hepatic signs often occur on discontinuation of treatment. In some cases, interferon-alpha may induce or exacerbate some extra-hepatic manifestations.

Pollicization in Congenital Differences

Pollicization of the index finger is a well established procedure for some cases of thumb hypoplasia. We reviewed our experience of 27 "normal" index-finger pollicizations with a mean follow-up of seven years, excluding those cases with more extensive radial hypoplasia and abnormal fingers. Even in such an "ideal" situation, strength was deceptive and the frequently slender aspect of the new thumb with quite extensive dorsal scar formation and the "cleft" appearance of the first web disappointing. In a prospective series of 32 cases, we tried to improve both the function and appearance of the thumb by modifying the classical incision as well as the transferred muscles and tendons.

Percutaneous needle aponeurotomy: complications and results

Recently French rheumatologists have repopularized fasciotomy using a percutaneous needle technique. This blind approach has been claimed to be plagued by numerous complications. We reviewed the charts of 211 patients treated consecutively on 261 hands and 311 fingers to assess the rate of postoperative complications. The first 100 patients were evaluated with a mean follow up of 3.2 years to assess the rate of recurrences and extension of the disease. In the whole group the mean age was 65 years and delay between onset and treatment was 6 years. Division of the cords were performed only in the palm in 165 cases, in the palm and finger in 111 and purely in the finger in 35. Complications were scarce without infection or tendon injury but one digital nerve was found injured during a second procedure. Postoperative gain was prominent at metacarpophalangeal joint level (79% versus 65% at interphalangeal level). The reoperation rate was 24%. In the group assessed at 3.2 years follow up, the recurrence rate was 58% and disease "activity" 69%. Fifty nine hands need further surgery. The ideal indication for this simple and reliable technique is an elderly patient with a bowing cord and predominant MP contracture.

Therapeutic advantages of pegylation of interferon alpha in chronic hepatitis C

Modification of the pharmacokinetic profile of interferon-alfa (IFNalfa) through pegylation (addition of a polyethylenglicol molecul) has resulted in a marked improvement of drug efficacy for the treatment of infection due to hepatitis C virus. Two pegylated derivatives of IFNalfa are available: PEG-IFNalfa-2a, with a 40 kDa polyethylenglicol molecule of branched structure, and PEG- IFNalfa- 2b, with a 12kDa linear PEG. Both compounds have slower absorption, more reduced distribution and lower elimination rate than the respective non- pegylated IFNalfa, which assures that concentrations appropriate to inhibit viral replication are maintained during longer periods of time, thus a allowing administration once a week, In addition to archieving greater therapeutic efficacy, the adverse effects related to excessive Cmax are reduced, the risk of therapeutic failure is decreased by eliminating the intervals of inefficient plasma levels, and the uncomfortable thrice weekly injection regimens are avoided. The current recommendations include the use of a combination therapy with pegylated IFNalfa and ribavirin as the standard treatment. However, further research is required to archieve dosage optimization of pegylated IFN and rebavirin according to the patientś characteristics and to evaluate the efficacy and safety of this combined theraphy for difficult- to- treat patients.

Review article: immunopathogenetic and therapeutic aspects of autoimmune hepatitis

Autoimmune hepatitis is a chronic, progressive liver disease that responds well to immunosuppressive therapy, but has a poor prognosis if untreated. Possible triggering factors include viruses, other autoimmune disorders and drugs. The molecular mechanisms contributing to the pathogenesis include: reactions of autoantibodies against their corresponding autoantigens; aberrant expression of histocompatibility antigen class I and II molecules, cell adhesion molecules and cytokines; increased oxidative stress; and the occurrence of angiogenesis. The prevalence of the disease is highest in Caucasians, Europeans and women. The natural history of autoimmune hepatitis shows a poor prognosis, with frequent progression to cirrhosis and hepatic insufficiency in untreated patients. The occurrence of hepatocellular carcinoma is rare and is found only in long-standing cirrhosis. Corticosteroids as monotherapy or in combination with azathioprine are the treatments of choice; different therapeutic schedules and particularities of treatment for pregnant women and children have been established. To avoid treatment-associated adverse effects, alternative therapies have been proposed, including ciclosporin, budesonide, tacrolimus, mycophenolate mofetil, ursodeoxycholic acid, methotrexate, cyclophosphamide, mercaptopurine and free radical scavengers. Liver transplantation is indicated for patients refractory to or intolerant of immunosuppressive therapy.

[The "candlestick" technique for the correction of certain types of congenital metacarpal synotosis]

Metacarpal synostosis is a rare congenital hand malformation requiring only occasionally a surgical correction. However in case of divergent epiphyses there is a progressive accentuation of the deformity. In the "Y" type of symmetrical synostosis, the authors propose a trapezoidal osteotomy with upside down relocation allowing realignement of the epiphyses without distant bone donor site.

Short-term combination of mycophenolate mofetil with cyclosporine as a therapeutic option for renal transplant recipients: A prospective, multicenter, randomized study

BACKGROUND

Mycophenolate mofetil (MMF), compared to azathioprine (AZA), reduces acute rejection and treatment failure in cyclosporine (CsA) and steroid regimens, but its effect on graft survival is unproven from prospective studies and prolonged use is costly. This study evaluated the efficacy and tolerability of replacing MMF by AZA after 3 months.

METHODS

This 28 center, prospective, 12-month, parallel group, open-label study, randomized patients to three groups with microemulsion formulation of CsA (ME-CsA) and steroids as baseline therapy. Group 1 (n=158) received MMF for 3 months, replaced by AZA for 9 months; group 2 (n=162) received MMF for 12 months; and group 3 (n=157) received AZA for 12 months.

RESULTS

Treatment failure and the cumulative rate of acute rejection were significantly lower in the MMF groups compared with the AZA group (P=0.007 and P=0.03, respectively). Graft loss, death, and safety profiles of all three treatments were similar over 12 months, as were mean serum creatinine levels. Switching from MMF to AZA did not affect treatment failure. No patient in group 1 experienced a recurrent rejection after month 3, one patient died, and nine patients experienced first rejection episodes. Most rejections (6/9) were steroid-sensitive and histologically mild.

CONCLUSIONS

Replacement of MMF by AZA after 3 months of therapy with ME-CsA and steroids provides comparable efficacy and safety profiles to continuous MMF over 12 months. Although apparently a cost-effective option, long-term studies are required to assess the benefit/risk ratio of this therapy switch in different patient subpopulations.

[Changes in of plasma lipoproteins after the use of palm oil in the diet of a group healthy adults]

Although saturated fat acids have long known to have harmful effects on cholesterol and triacylglycerides levels in blood, new concepts have emerged form recent research on this matter. The purpose of this study was to know the effect of the consumption of palm olein on triacylglycerides and cholesterol levels as well as lipoprotein fractions in the blood plasma of healthy individuals from both sexes.

MATERIALS AND METHODS

Different types of fats were administered for 12 weeks to 60 subjects, 45 male, 15 female, between 19 and 45 years of age, who were divided into three groups: the mix group (MG) was administered oil, margarine, and mayonnaise prepared with 50% olein; the olein group (OG) consumed fats prepared with 100% olein; and the control group (CG) consumed regular fats of customary use by the population. The diets provided 25 to 30% of calories. Blood samples were obtained for lipid analysis at the beginning and the end of the study. Plasma triacylglycerides and cholesterol concentrations were determined by means of enzyme and lipoprotein methods (VLDL, LDL; and HDL) by ultracentrifugation.

RESULTS AND DISCUSSION

By comparing the groups' means no significant differences were found (p > 0.05) in blood lipids. Individual differences show a slight increase in VLDL-C in OG compared to MG and CG. No differences were found in LDL concentration.

CONCLUSIONS

These results contribute evidence to differentiate between the effects of saturated vegetables oils, such as coconut oil, and of palm olein. The authors recommend not extrapolate the effects of type of oil to another in connection with TC increase in blood.

Assessment of the phototoxic potential of compounds and finished topical products using a human reconstructed epidermis

The goal of this study was to design a model system for the assessment of phototoxic potential using a human reconstructed epidermis (HRE, SkinEthic Laboratories, Nice, France), by testing some representative phototoxic (P) and non-phototoxic (NP) compounds and finished topical products. The tissue response to 24-h application of 5-5000 microg/mL of the test agents in the presence and absence of UVA light was analyzed in terms of viability (Lactate Dehydrogenase release), pro-inflammatory activity (IL-8 release and mRNA expression) and morphology (histopathology). 8-Methoxypsoralen (P) and promethazin (P), but not sodium lauryl sulfate (NP) produced cytotoxicity concentration-response curves significantly different between irradiated and nonirradiated tissues. Only irradiated tissues showed morphological damage. Application of tetracyclin (P) in the culture medium, but not topically, induced similar signs of phototoxicity. 6-Methylcoumarine (weak P) was not cytotoxic, yet it increased IL-8 release and mRNA expression only following UVA irradiation. PUVA therapy creams containing 1% 8-Methoxy-psoralen (P) or coal tar (P) decreased viability and induced histologic damage in UVA-exposed tissues. In conclusion, the phototoxic potential of the tested agents was correctly predicted by using a tiered strategy that involves determining cytotoxicity, production of IL-8, and morphological damage following exposure of the HRE to the compounds and UVA light.

[Secondary treatment of digital mutilations: reconstruction or amputation]

Decision for stump improvement, shortening or reconstruction after finger mutilation is based on multiple factors. Some of them belong to the patient, age, psychological background, job and leisure activities and cosmetic expectation. Others belong to the injury, its mechanism and the anatomical lesions. Abstention, prostheses and rehabilitation are among the options. Conventional techniques are not to be forgotten as age remains an ultimate frontier in microsurgical reconstruction to obtain a good sensory result. Function and appearance are closely linked for a useful and a used hand.

[Recurrence of finger tendon giant cell tumors after excision through a "shark teeth" approach. Report of 25 cases]

Local recurrences after excision of a giant cell tumor of the tendon sheath are classically related to incomplete excision. We have review a special group of circumferential tumors excised through a huge approach. Twenty-six circumferential tumors were excised between 1985 and 1998, through a special incision described by the senior author. It is composed of four triangular flaps drawn around the finger, one dorsal, one palmar (both proximally based) and two lateral (distally based). Six presented already with a recurrence of previous operations (mean 2.5 interventions). Some anatomical neighboring structure was "invaded" in all except one case. However the approach allows for a macroscopically satisfactory excision. Twenty-five patients were reviewed by an independent observator after a mean follow-up of six years. Six patients (24%) presented a recurrence after a mean postoperative delay of 17 months. Among them five have been already operated (83%) and five had multiple tumors. Satisfactory excision does not prevent recurrence and two types of distinct tumors exist. Recent immunohistological studies give support to this view and such examination is recommended.

Metacarpal synostosis: a simple classification and a new treatment technique

The current classification of metacarpal synostosis is based on the extent of the synostosis. The authors propose a new classification that takes into account the shape of the metacarpal bones, the curvature of the epiphysis, and the discrepancy in length between the two bones. This classification provides better guidelines for the correction of all components of the deformity. The classification is based on the authors' observations of and experience with 36 cases of metacarpal synostosis; 13 of the deformities were surgically corrected. The I-shaped deformity, whether with distinct (type d) or fused (type f) metacarpophalangeal joints, does not require surgical correction. The U-shaped deformity has parallel epiphysis and does not require surgery unless the two metacarpals are asymmetrical in length (type a) or tightly fused (type t); in these cases, simple lengthening or widening of the space with a bone graft is sufficient. Y-shaped synostosis should be separated whether the branches are symmetrical or asymmetrical, the latter having one branch shorter than the other. Because the epiphyses are already divergent, simple separation does not effectively correct Y-shaped synostosis. The authors propose an osteotomy to isolate a trapezoidal segment of bone from the bifurcation. The isolated bone segment is then reversed in the proximal-distal direction to provide a "plateau" upon which the two distal metacarpals can be realigned. Two cases of Ys (symmetrical) synostosis were successfully treated with this technique; one case of Ya (asymmetrical) synostosis also required distraction lengthening of the shorter metacarpal to achieve an excellent result. One of the most difficult types of metacarpal synostosis to treat is k-shaped synostosis, observed only between the fourth and fifth metacarpals; in this type, the head of the short fifth metacarpal abuts the metaphysis of the fourth. Osteotomy and distraction lengthening provide predictable results for correction of this deformity. The authors suggest that k-shaped synostosis might represent a late evolution of untreated Ua synostosis.