[Prophylaxis of toxic effects on the peripheral venous system associated with intravenous administration of vinorelbine]

Vinorelbine is effective in the treatment of a number of malignancies. However, beside the haematologic and not haematologic toxicity as thrombocytopenia, granulocytopenia, fatigue, paresthesias, nausea and vomiting, one of the most common side effects is the local irritation with thrombophlebitis. The side effect, reported in about 10-26% of patients receiving vinorelbine infusions, is due to the vescicant and irritant action of the drug. Many studies have been performed in order to reduce the incidence of venous irritation either with concomitant administration of anti-inflammatory drugs as defibrotide or ketorolac, or changing infusion schedule from bolus infusion to a 20-30 minute infusion. Aim of this review is to define peripheral venous system toxicity of vinorelbine and the best way of administration.

Molecular characterization of the signal responsible for the targeting of the interleukin 2 receptor beta chain toward intracellular degradation

During receptor-mediated endocytosis, most growth factor receptors are transported to late endocytic compartments and degraded. This process is important to control their expression on the cell surface and requires sorting in early endocytic compartments. Little is known about the mechanisms and the signals involved. We have studied the signal involved in targeting the interleukin 2 receptor beta chain (IL2Rbeta), a member of the cytokine receptor superfamily, toward degradation after internalization. We show that a motif of 8 amino acids in the cytosolic tail of IL2Rbeta is sufficient to target a normally recycling receptor toward degradation. Deletion of this signal strongly impairs IL2Rbeta degradation. Further molecular characterization of the motif shows that it does not resemble the well documented tyrosine and dileucine families of trafficking signals.

[Ballistic data for plastic surgeons]

After a brief review of portable firearms or small caliber guns, the authors discuss various concepts concerning wound ballistics. Kinetic energy plays an important part in the damaging action of bullets, while the concepts of "shock wave" and "stopping power" have been supereded by the definition of wound profiles. These profiles are characteristic of each bullet. Clinically, they take the form of a temporary cavitation zone and a permanent cavity. The reaction of tissues crossed by the bullet largely depend on the elasticity of these tissues and the presence of bone. The concept of high velocity bullets should be abandoned. The phenomenon of cavitation alone and its dramatic clinical consequences should be taken into account and must guide the therapeutic approach.

[Gunshot injuries of the face. Clinical observations in 21 cases]

The authors report their experience of facial ballistic trauma based on a series of twenty one homogeneous cases. After a review of the aetiopathogenesis, the characteristics of facial shocks by missiles of fire arms are described, with particular emphasis on specific wounds encountered in the head and neck. Two classifications are suggested: on based on the main clinical features and the other based on the various types of bullets organized according to wound profiles and modern ballistics. This new ballistic classification is related to the clinical features. Although a better approach to ballistics and wound profiles helps to guide the clinical assessment, the medical and surgical treatments are based on same principles and approaches in war surgery and in civilian practice.

Rapid identification of Mycobacterium tuberculosis complex on urine samples by Gen-Probe amplification test

The aim of the study was to evaluate the applicability to urine samples of the Amplified Mycobacterium tuberculosis Direct Detection Test (AMTD), which is currently used to identify this organism in respiratory specimens within a few hours. The study was performed on 95 patients, comprising 35 subjects with a high index of suspicion for active tuberculosis of the urinary tract and 60 subjects with evidence of non-mycobacterial disease. One urine specimen from each subject was examined by microscopy, culture and AMTD. AMTD was positive in 38 specimens and negative in 57. Assuming culture as the reference standard, the sensitivity, specificity, positive predictive value and negative predictive value of AMTD were 100%, 91.93%, 86.84% and 100%, respectively. Reassessing the discrepancies between AMTD and culture by review of patients' charts, the sensitivity, specificity, positive predictive value and negative predictive value of AMTD were 100%, 93.44%, 89.47% and 100%. The results of the study as well as the characteristics of AMTD encourage its use for the rapid recognition of urinary tract tuberculosis, although its findings should be interpreted cautiously when the clinical picture is not consistent with an active tuberculosis.

Oestrogen receptors in meningiomas: a correlative PET and immunohistochemical study

There have been a number of indications that sex hormones can affect the rate of growth of meningiomas during pregnancy. The presence of oestrogen or progesterone receptors in meningiomas and the influence of sex hormones upon cell cultures derived from human meningiomas have been extensively investigated. The results have been controversial, with most of the discussion centring upon the presence and possible role of oestrogen receptors. The aim of the present study was to assess oestrogen receptors in human meningiomas with 16alpha[l8F]fluoro-17beta-oestradiol ([18F]FES) and positron emission tomography (PET). With this purpose in mind, we measured the regional brain uptake of [18F]FES in six patients with a neuroradiological and histological diagnosis of meningioma, comparing the in vivo PET data with the immunohistological analysis of oestrogen receptors performed on formalin-fixed, paraffin-embedded tissue obtained at surgery. Two analyses were used for the in vivo measurement of [18F]FES binding to oestrogen receptors: the ratio of tumour activity to that of normal tissue (T/NT), calculated 90 min after tracer injection, and the ratio between the equilibrium distribution volume (DV) in normal and pathological tissues, calculated by means of a graphical kinetic analysis. PET studies demonstrated a marked uptake of [18F]FES by the tumour in four of the six patients. Immunohistochemical assay using a manual staining method capable of detecting oestrogen receptors at a level of > 10 pmol mg(-1) of protein detected only sparse immunostaining in one of the six meningiomas. Distinct albeit weak immunostaining was demonstrated in five of the six meningiomas when the sensitivity of the immunohistochemical assay was increased to < 10 pmol mg(-1) of protein by use of an automated staining method (Bioteck 1000). Comparison of the in vivo and immunohistochemical results showed a correlation in five of the six patients, thus indicating the high sensitivity of [18F]FES for the in vivo evaluation of oestrogen receptor expression.

Double-blind, multicenter, randomized trial to compare the effect of two doses of adrenocorticotropic hormone versus placebo in controlling delayed emesis after high-dose cisplatin in adult patients with cancer

PURPOSE

To compare, in a double-blind, placebo-controlled, randomized trial, the efficacy of two different doses of the depot formulation of adrenocorticotropic hormone (ACTH) in controlling delayed emesis after cisplatin.

PATIENTS AND METHODS

One hundred fifty-two patients were enrolled onto the study. On day 1, all patients received cisplatin (60 to 120 mg/m2) and a combination of dexamethasone 20 mg plus ondansetron or metoclopramide to prevent acute emesis. On day 2 (24 hours after cisplatin administration), patients were randomized to receive placebo, or ACTH 1 mg intramuscularly (I.M.), or ACTH 2 mg I.M. plus one additional dose of 1 mg on day 4. Details of vomiting, nausea, and adverse effects were recorded daily for every 24-hour period from day 2 to day 6. In a subset of patients, serum cortisol levels were measured between 20 and 72 hours after cisplatin administration.

RESULTS

One hundred fifty patients were assessable. Over the 5 days of the study, delayed vomiting occurred less frequently in the patients treated with ACTH 2 mg plus 1 mg than in those treated with ACTH 1 mg or placebo (28%, 38%, and 65%, respectively; P = .001). The greatest observed differences were seen on days 2 (24 to 48 hours; P = .01) and 3 (48 to 72 hours; P = .01). On days 4, 5, and 6 (96 to 144 hours), no significant differences were observed among the three arms. The severity of delayed emesis expressed as the mean number of emetic episodes per day was 0.48, 0.70, and 0.80, respectively (P = .002). Patients treated with the higher dose of ACTH had the least nausea on day 3 (P = .02) and day 4 (P = .03). Adrenal cortisol secretion rapidly increased after ACTH injection, but was suppressed for approximately 44 hours in the placebo group. Toxicity was mild and transient in all groups.

CONCLUSION

ACTH reduces the incidence and severity of delayed vomiting and nausea after cisplatin. A dose of 2 mg 24 hours after cisplatin is better than one of 1 mg. Whether the activity of ACTH is mediated only by adrenal corticosteroids needs to be verified.

A comparison of brain biopsy and CSF-PCR in the diagnosis of CNS lesions in AIDS patients

Twenty patients with AIDS who had intracranial lesions underwent both brain biopsy and cerebrospinal fluid (CSF) examination to compare histological diagnosis with the polymerase chain reaction (CSF-PCR) for the identification of infectious agents. CSF-PCR was performed for herpes simplex virus, varicella zoster virus, cytomegalovirus (CMV), JC virus (JCV), Epstein-Barr virus (EBV), Toxoplasma gondii and Mycobacterium tuberculosis. A definitive diagnosis was obtained by brain biopsy in 14 patients (2 with astrocytoma, 12 with brain infection). CSF-PCR was positive for EBV DNA in 3 of 3 cases of primary cerebral lymphoma, positive for JCV DNA in 6 of 7 biopsy-proven (and one autopsy-proven) cases of progressive multifocal leukoencephalopathy (PML). CSF-PCR was positive for CMV DNA in one biopsy-proven and one autopsy-proven case of CMV encephalitis (the former also had PML) and positive for M. tuberculosis DNA in one case of tuberculous encephalitis. None of the five toxoplasmic encephalitis cases (one definite, four presumptive) were T. gondii DNA positive. There was close correlation between histology and CSF-PCR for CMV encephalitis, PML and PCL. Antitoxoplasma therapy affected the sensitivity of both histological and CSF-PCR methods.

Nefrectomia laparoscopica: Nostra esperienza

In this work we report our experience in the use of laparoscopie nephrectomy for benign renal disease. From September 1995 to April 1997, 10 patients, with age range from 36 to 67 years, underwent laparoscopie nephrectomy (4 for hydronephrosis, 4 contracted kidneys, 1 staghorn stone with excluded kidney, 1 tubercular contracted kidney). The average operating time was 150’. Average blood loss was about 200 cc. The patients resumed oral intake and started walking within 1 day, while just 1 patient required 500 ml of autologous blood. The average post-operative hospital stay was 4 days. Although laparoscopie operating times (average: 150’) are longer than those for traditional surgery, we achieved a considerable reduction in pain, post-operative hospital stay and in the time taken to resume normal activities. We therefore consider that laparoscopie nephrectomy may be a good alternative to traditional surgery for selected patients.

Surrenectomia laparoscopica: Nostra esperienza

Laparoscopy has been described as an alternative approach for performing adrenalectomy. From January ‘96 to April ‘97, 14 laparoscopie adrenalectomies were performed in our Division. Patient age ranged from 33 to 64 years. The clinical diagnosis included 5 Conn's syndrome, 3 pheochromocytoma, 3 Cushing's syndrome, 1 Cushing's disease and 3 incidentalomas. Average operating time was 70’ and 90’ for right and left adrenalectomy respectively. The average estimated blood loss was 70 ml. All the patients resumed oral intake antalgic therapy with Ketorolac in the first 12 post-operative hours. The patients resumed oral intake within 1 day. Two patients received 500 ml of autologous blood in the post-operative period. The average hospital stay was 3.5 days. These results suggest that laparoscopie adrenalectomy is a minimally invasive alternative to traditional open adrenalectomy.

[Echographic aspects of renal tuberculosis]

In this study the Authors examine the utility of the ultrasonographic investigation in the preoperative evaluation of 22 patients submitted to nephrectomy for tubercular lesions, comparing the informations obtained from this procedure with the histologic report. The renal ultrasonography execute with a Toshiba 3.5 Mhz probe, has been utilized to value morphology, volume, parenchymal echostructure and hydronephrosis. According to the Author's series, the ultrasonography has shown a 100% sensitivity permitting to well value the presence of parenchymal lesions and hydronephrosis. As regards the tubercular renal injuries the ultrasonography is non-specific because it does not allow to have pathognomonic images. The results obtained from the U.S. are overlapping to the Results Related from the literature for abdominal CT. The Authors argue that U.S., rapid and economical investigation is an efficient complement to the urography for an exhaustive preoperative evaluation of patients suffering from renal Tuberculosis.

[Usefulness of transvaginal echography in the study of organic pathology of the female urethra]

The Authors describe their experience about the use of vaginal ultrasound in the diagnosis of some organic disease of the female urethra. The ultrasonography was performed with the 5 Mhz endocavitary probe and patients in lithotomy position and filled bladder. With this method has been possible value the urethral and peri-urethral echostructure and urethral calibre during micturition. the Authors visualized 20 urethral diverticula, 6 stenosis, 2 carcinomas and 1 leiomyoma. They show the great reliability of this investigation and argue that it may be present as a first instrumental approach in the clinical suspicion of an organic pathology of the female urethra.

[Treatment of a solitary renal cyst using percutaneous drainage and repeat alcoholization]

The Authors report their results on the treatment of simple voluminous renal cyst with percutaneous drainage and three times repeated sclerosis with pure alcohol every 24 hours. After a mean follow-up of 28 months They report a 96% of success with only two recurrences. Since the fair results and low invasiveness of the method, the Authors propose the repeated alcoholization in the treatment of simple voluminous renal cysts.

[Transvaginal echography in the study of urinary stress incontinence]

Hypermobility of the bladder neck in response to increased intraabdominal pressure is one cause of stress urinary incontinence in women. Vaginal ultrasound (u.s.) is reliable and minimally invasive method for demonstrating bladder neck hypermobility. The Authors studied 50 women with S.U.I. and 40 with no history of S.U.I. measuring the distance from the bladder neck to the midline of the symphysis pubis (P.V.) and the angle between the BP line and the midline of the symphysis pubis (A.I.U.). The continent women were characterized by a median A.I.U. of 70 degrees and mean B.P. of 25.6 mm, at rest, a median A.I.U. of 80 degrees and a mean B.P. of 20 mm. at stress. The incontinent women were characterized by a median A.I.U. of 80 degrees and mean P.V. of 22.5 mm. at rest, and a median A.I.U. of 95 degrees and mean P.V. of 10 mm. at stress. There is a significant difference between the two groups. The Authors recommend the vaginal u.s. as reliable, practical, economical and patient accepted method to study the bladder neck mobility.

Structural peculiarities of a truncated V kappa III immunoglobulin light chain in myeloma with light chain deposition disease

We report on the primary sequence of the monoclonal immunoglobulin light chain (LC) REV involved in myeloma-associated light chain deposition disease (LCDD). This sequence was deduced from that of the corresponding complementary (c)DNA in bone marrow plasma cells. Products of three independent amplifications by polymerase chain reaction (PCR) were sequenced and found to be identical. The kappa mRNA encoding this N-glycosylated LC showed an overall normal structure consisting of a V kappa III segment rearranged to J kappa II. Direct N-terminal amino acid sequencing of the circulating monoclonal IgA2, kappa showed identity with the bone marrow-derived sequence. The kappa-chain presented several unusual features affecting both the leader sequence and the variable (V) region. Four unique amino acid substitutions were found at positions -8, -3, -2 and -1 in the leader sequence and probably resulted in an unusual cleavage by signal peptidase, thus making the LC truncated by one residue and accounting for its unique hydrophobic N-terminus: Ile-Ile-Leu. Additional peculiarities were observed in the V region, including a Thr74-->Asn substitution creating a N-glycosylation site, and Thr53-->Ile, which was only reported once among human kappa III chains, in another LCDD case, and may be of special significance at a position usually harbouring a polar amino acid.

Abnormal response to exercise in middle-aged NIDDM patients with and without autonomic neuropathy

The cardiovascular response to exercise in middle-aged non-insulin-dependent diabetes mellitus (NIDDM) patients and the potential role of clinical characteristics and autonomic function were evaluated. One hundred and eight NIDDM patients, aged 40-65 years, were compared with a control group of 112 subjects, matched by age, sex, physical fitness, and presence of hypertension. All subjects performed a maximal exercise test. The diabetic patients completed cardiovascular autonomic neuropathy (CAN) tests: deep breathing, postural hypotension and lying to standing. There were no significant differences in total work capacity, heart rate, and blood pressure, either at rest or at peak exercise between the two groups. Diabetic patients showed significantly lower values of systolic and diastolic blood pressure during exercise, significantly slower recovery of heart rate (at 5th minute the average values were 102.7 +/- 14.1 beats min-1 vs 91.9 +/- 11.1, p < 0.001); and significantly higher proportion of blunted increase of heart rate (9.2% vs 0.9%, p < 0.001) and systolic blood pressure (9.2% vs 0.7%, p < 0.001) during exercise. No correlation between the exercise results and the main clinical characteristic (presence of hypertension, BMI, duration of diabetes, treatment, microalbuminuria, total score of CAN) was observed. These findings suggest that the cardiovascular response to exercise could be impaired also in the absence of signs of CAN. This impairment was higher in patients showing a dysfunction of orthosympathetic activity.

Endovascular treatment of bacterial intracranial aneurysms

We report three patients with bacterial intracranial aneurysms treated by the endovascular approach: two presented with sudden severe neurological deficits after a diagnosis of endocarditis; the other had suspected vasculitis. CT showed an intracerebral haematoma in all cases; angiography revealed bacterial aneurysms of distal branches of the middle cerebral artery in one. Because of the patients' condition and the location of the aneurysms, endovascular treatment was considered the fastest and safest treatment. Hyperselective catheterisation of the parent branch, close to the aneurysm, was performed with a microcatheter. A small amount of glue was injected to occlude both the aneurysm and a short segment of the diseased vessel. Follow-up angiography revealed occlusion of the aneurysm in all cases. One patient recovered completely; one recovered over some months, with neurological deficit due to the haematoma. The third patient suddenly worsened and died 9 days after treatment for a contralateral haematoma, due to rupture of a new bacterial aneurysm of the middle cerebral artery. Endovascular occlusion of the aneurysm and parent vessel may be an alternative to surgery in selected, severe cases of deep or distal bacterial intracranial aneurysms.

Clinical value of TRUS hypoechoic peripheral zone lesion

To evaluate the hypoechoic peripheral zone lesions detected at trans-rectal ultrasound (TRUS) in patients with normal PSA, we carried out a retrospective study on 12 men who underwent transrectal ultrasound-guided biopsy. None of them showed prostatic cancer at first mapping. We therefore did a follow-up with TRUS, PSA and digital rectal exploration (DRE). 9 patients underwent mapping again. The only patient who was positive for prostatic cancer had PSA > 4 ng/ml, negative TRUS and DRE. Our results confirmed the low predictive value of hypoechoic peripheral zone lesions and the change in TRUS Patterns. We therefore consider that patients with just a TRUS suspicion which is negative at first mapping, can be monitorized with PSA while TRUS should only be used for biopsy.

p53 protein expression as prognostic factor in patients undergoing radical prostatectomy for prostatic cancer

The authors give preliminary data on the evaluation of the p53 protein expression as prognostic factor in patients subjected to radical prostatectomy for prostatic cancer. p53 protein immunohistochemical nuclear staining was carried out on neoplastic tissue obtained from systematic sextant prostatic biopsies at the time of diagnosis. Out of 46 Patients 15 (32%) were p53 positive (p53+). No statistical correlation was observed between P53 staining, preoperative PSA and pathological Gleason Score, while the rate of patients with nodal involvement (pN+) was higher in the p53+ group than the P53- group with low statistical significance (p<0.03). The authors cannot yet evaluate Progression time and survival because the mean follow-up of the patients is still too short (30 months). The study is still in progress.

Role of light chain variable region in myeloma with light chain deposition disease: evidence from an experimental model

Light chain deposition disease (LCDD) results from a propensity of some human monoclonal L chains to form tissue deposits. We designed an experimental model for in vivo expression of human kappa L chain sequences in mice and compared a somatically mutated LCDD chain with a closely related control kappa chain, both encoded by the unique V kappa IV gene. Mice secreting the LCDD chain but not those producing the control chain showed deposits with a distribution similar to that observed in patients. These data show that discrete changes in V region sequences can play a major role in tissue deposition of human L chains.

Sequences of V kappa L subgroup light chains in Fanconi's syndrome. Light chain V region gene usage restriction and peculiarities in myeloma-associated Fanconi's syndrome

Certain monoclonal Ig light chains (LC) are responsible for marked disturbances of proximal tubule cell functions (Fanconi's syndrome, FS). In patients with FS, intracellular crystal-like inclusions containing LC determinants are commonly found in plasma cells, macrophages, and renal tubular cells. In an attempt at understanding the pathogenesis of myeloma-associated FS, we recently determined the first complete primary sequence of a kappa-LC (CHEB) responsible for the disease. We now report on the primary structure of three other kappa-LC of the V kappa l variability subgroup associated with FS (TRE, TRO, and DEL). After PCR amplification, cDNA encoding these LC were sequenced. CHEB, TRE, and TRO LC genes were found to be highly homologous to the same germline gene O2/O12. These patients had numerous intracellular crystals, whereas the fourth patient, DEL, had no detectable crystals. The LC from the latter patient was homologous to another germline gene, O8/O18. Comparison of these LC sequences to previously reported LC of the V kappa l subgroup allowed identification of a number of unusual amino acid substitutions in the V region that had rarely or never been previously described at the corresponding positions. Some of these unusual substitutions affect highly conserved amino acids located either in an external loop (residue 30) or in inner (residues 48 and 55) and outer (positions 63 and 72) beta-sheets that may be important for the structure and binding properties of the kappa-chains. These and several other substitutions, some of them shared with amyloidogenic kappa-LC, could induce conformational alterations and represent a determinant pathogenic factor.