Experimental osteomyelitis: what have we learned from animal studies about the systemic treatment of osteomyelitis?

Clinical trials of systemic antibiotic treatment of osteomyelitis are difficult to perform for many reasons, such as low incidence rate of osteomyelitis, variety of anatomic locations, stage and etiologic agents. In this article, we reviewed the experimental studies on osteomyelitis available in the English medical literature since 1968, to ascertain their actual and potential impact on the treatment of human osteomyelitis. Major results are summarized and topics of major interest, such as reproducibility of animal models, predictive value of animal models, correlation of pharmacokinetics between different animals and humans, and the correlation of outcome between animal and clinical studies are discussed. Most of the reviewed animal models are reproducible and dependable. However, establishing the right dose regimen in animals appeared a critical factor, which might undermine the predictive value of the experimental study. Due to difficulties in comparing results of animal and human studies, the predictive value of animal studies about osteomyelitis is still unclear. However, animal models gave valuable information to the clinician for choosing the minimal duration of antibiotic treatment. Even though the use of antibiotic combinations was associated with better outcome in the majority of animal studies, such a finding seems to have limited impact on clinical practice.

Rapid and massive expansion of cord blood-derived cytokine-induced killer cells: an innovative proposal for the treatment of leukemia relapse after cord blood transplantation

We have used a standardized 21-day expansion protocol to produce cytokine-induced killer (CIK) cells starting from very small amounts of nucleated cells (approximately 15 x 10(6) cells) isolated from cord blood. Mononuclear cells are stimulated with anti CD3 (OKT3) and IFNgamma and then expanded with IL-2. Moreover, we show that washouts of cord blood units bags (at the end of the infusion) may be sufficient to yield almost 500 x 10(6) CIK by the same expansion protocol. CIK cells show strong cytotoxic activity against a variety of tumor target cell lines including B and T lymphomas and myeloid leukemias. More importantly, expanded cord blood-derived CIK cells are cytotoxic against fresh leukemic blasts and express perforin, granzyme and NKG2D molecule at high levels. The same in vitro protocol has already been used to expand CIK cells from peripheral blood of adult donors under GMP conditions and therefore these observations open up the possibility of imagining a future clinical application of leukemia relapse following cord blood transplantation with CIK cells obtained from the same cord blood unit.

Human leptospirosis in the Vicenza area (Italy) from 1990 to 2003: an epidemiological and clinical study

All cases of human leptospirosis observed at the S. Bortolo Hospital, Vicenza, Italy, in the period from September 1990 to December 2003 were retrospectively reviewed. The aim of the study was to define the epidemiological, clinical, diagnostic, and therapeutic aspects of this infection and to compare these with an earlier local study (1979-1990) in order to assess if any changes have occurred over time. The screening test was made using macroscopic agglutination and the diagnosis was definitively confirmed using the microscopic agglutination test (MAT). The etiological serotype was identified in 13 patients (68%) and Leptospira poi was the most frequent serovar. Hepatic and renal involvements were present in a high percentage of patients (71% and 74%, respectively), cardiac involvement in 39%, and hypertriglyceridemia and hepatic steatosis were observed in 68% and 43% of cases, respectively. One patient died because of acute renal and respiratory failure. Intravenous penicillin was the treatment of choice. A consistent reduction in the prevalence was observed during the time period of this study (n = 38) compared with the previous period (n = 86); males were more affected than females in both time periods. In industrialized countries the prevalence of leptospirosis is decreasing; nevertheless, this infection is no longer limited to specific occupational groups and remains a potential fatal disease that should be included in the differential diagnosis of all the patients with unexplained fever.

[PTPN11 gene mutation in LEOPARD syndrome]

The multiple lentigines/LEOPARD syndrome (ML/LS) is a rare and complex genetic syndrome. It is an autosomal dominant disorder with a variable expressivity. The syndrome is mainly characterised by growth retardation, multiple lentigines, and congenital heart diseases with electrocardiographic anomalies, dysmorphia of the face and deafness. The incidence of this pathology is still unknown and a familial inheritance is present in 70% of cases. Some of the ML/LS clinical features are the same as those of the Noonan syndrome (NS), such as congenital cardiac abnormalities, dysmorphia and growth retardation. NS and ML/LS are caused by allele mutations of the PTPN11 gene. We report the case of a 3-year-old girl, who was observed for the presence of widespread lentigines, a 1/6-protosystolic murmur at the mesocardium and growth retardation. The diagnosis of ML/LS was made and thus a molecular analysis of the PTPN11 gene was carried out, directly sequencing the codifying region. The molecular analysis revealed a missense mutation (A836G) in hexone 7 (TYR279CYS) of the PTPNII gene. This mutation is has been observed, at present, in a few cases of ML/LS and Noonan syndrome.

Prostate cancer and body size at different ages: an Italian multicentre case-control study

We investigated the influence of anthropometric measures at diagnosis and at different ages on prostate cancer risk using an Italian multicentre case–control study conducted between 1991 and 2002 of 1294 histologically confirmed cases and 1451 controls admitted to the same network of hospitals for acute non-neoplastic conditions. Height, weight, body mass index (BMI), waist-to-hip ratio, lean body mass 1 year before diagnosis/interview were not significantly associated with risk. However, a positive association with high BMI at age 30 years was found (odds ratio=1.2 for BMI⩾24.7 vs <22.7) and: for less differentiated prostate cancer, with BMI 1 year before diagnosis/interview. This study supports possible relationships between high body mass in young adulthood, and a tendency to high weight throughout adult life, and the risk of prostate cancer.

Lumbar Ureteral Lithiasy: Therapeutical Options

Patients with lumbar ureteral stones larger than 5 mm should be addressed towards ESWL. It is an effective nonintrusive modality with limited adverse effects.

In our study we matched treatment effectiveness and patients compliance in standard ESWL versus ureteroscopy with lithotripsy.

Material and Methods.

Since January 2001 to March 2003 72 patients with middle ureteral calculi underwent ESWL treatment, and 48 patients with the same stone location were submitted to ureteroscopy with lithotripsy. It was the first choice modality in strongly symptomatic patients. A 1–5 score system was employed to assess the compliance degree. Patients with the highest compliance were referred as 1 and patients with the lowest one were regarded as 5.

Results.

A 96% stone free rate (46/48) was achieved in the ureteroscopy arm. The stone was pushed back in the lower calyx of the kidney only in 2 (4%) patients. 37 (52%) out of 72 patients in ESWL arm were stone free at the 1st ESWL treatment. 14 (19%) patients were stone free at the 2nd one, and 8 patients (12%) were stone free at the 3rd one. 13 patients (18%) were never stone free and underwent ureteroscopy. The means of compliance degree were 1.6 in the ureteroscopy with lithoripsy, and 3.8 in the ESWL treatment.

Conclusions.

Ureteroscopy with lithotripsy may effectively replace ESWL in the lumbar ureteral lithiasy treatment, because of high stone free rate and low morbility. Expenditure is almost the same in both modalities.

La Tossina Botulinica Tipo a Nel Trattamento Della Prostatite non Batterica: Studio Prospettico di Fase II

Nowadays aetiology, diagnosis and therapy of chronic non bacterial prostatitis are not still universally valuated in international urologic consensus. Recently, the National Institute of Health (N.I.H.) of USA suggested new staging of prostatitis. The aim of the study was to demonstrate the effectiveness of american botulinum toxin injected in external striated urinary sphincter in stage 3a and 3b patients according to NIH classification, with high medium and maximal closure pression of the external anal sphincter, demonstrated at the anorectal manometry.

Methods.

In our ongoing prospectic phase II study, the patients diagnosed to have 3a e 3b prostatis according to NIH classification after Meares-Stamey test, underwent ultrasonography of the whole abdomen, anorectal manometry, uroflowmetry, NIH symptom score (NIH-CPSI). Twentyone patients had elevated medium and maximal closure pressure of the striated anal sphincter and were included in the study. American botulinum toxin 100 unit intraperineal injection was given in these patients. One and six months control uroflowmetry and NIH-CPSI were evaluated. Results were processed with chi-square test (significant for p<0.05).

Results.

One and six months results were significant in respect to baseline values regarding TQ (p<0.0001), max TQ (p=0.0002) e NIH-CPSI (p<0.0001).

Conclusion.

Botulinum toxin is safe and effective in relieving symptoms of 3a and 3b prostatitis patients with high striated anal sphincter pressure.

A novel PTPN11 mutation in LEOPARD syndrome

PTPN11 gene mutations are common to both patients with Noonan (NS) and LEOPARD syndrome (LS). So far only two recurrent mutations have been identified in LS patients by different research groups, i.e., Tyr279Cys and Thr468Met. In this work we describe the third PTPN11 mutation that has been found in a single LS patient. The mutation (c.1517A>C) substitutes a proline for a glutamine at amino acid 506 (Gln506Pro) in the phosphatase domain (PTP) of the PTPN11 peptide SHP2. This region is a mutation hotspot. Changes at amino acids 501 to 504 cause NS. Gln506Pro is predicted, by modeling analysis, to seriously disrupt the normal contacts between the regulating N-SH2 and the active PTP domains, leading to hyperactivity of the phosphatase. This report demonstrates that rarer mutations other than Tyr279Cys and Thr468Met can be found in LS patients and the need of screening the whole gene in those negative for the commonest mutations.

Laparoscopic Lymphadnectomy in the Prostate Cancer

Treating prostate cancer, pelvic lymphadenectomy is still a debating topic in current international licterature. Surgical removal of both internal iliac vessels and obturatory fossa lymphonodes is usefull in order to stage lymphatic spreading of prostate cancer. We evaluated possible indications to laparoscopic limphadenectomy according to present know-ledges.

Methods

From october 2001 to june 2003, at our instituction 18 consecutive patients with clinically advanced prostate carcinoma diagnosed at transrectal ultrasonography guided needle biopsy and >20% preoperative risk of lymphonode metatstasis, underwent laparoscopic pelvic lymphadenectomy. Patients’ surgical postion in the theatre room was according to classic reported transperitoneal approach. Five disposable trocars were used for optical and instruments access.

Results

Mean surgical intervention time, blood loss and number of removed lymphonodes was 163 ± 32.8 minutes, 180 mL ± 25 and 28.7 ± 8.6 respectively. Ten patients (55%) were diagnosed to have lymphonode metastasis. Mean number of metastatic lymphonodes was 3. Conversion to open surgical procedure was not recorded. In 17 out of 18 cases, analgesic therapy was not necessary during hospital stay; in those patients intestinal canalisation, mobilisation and oral food intake restarted in first postoperative day. We had only one major complication. Laparoscopic pelvic lymphadenectomy costs were € 4.244. Regional diagnosis relata groups fee was € 4.463.

Conclusion

Laparoscopic lymphadenectomy, when indicated, was in our experience safe and effective but still expensive procedure with high patient’ satisfaction.

[Quality improvement: evolution and use of nursing records in a complex organization: the experience of Policlinico Umberto I of Rome - Italy]

Nursing documentation evolution is the result of an evolution of care and nurses like change of cultural and legislative type that has place, in way more growing, the patient to the center of nursing action. So it affirms that the nursing folder is the tool that allows to record, to plan, to appraise, to document and communicate patient care results, and of not smaller importance, to develop the search implementing nursing assistance turns to qualitative enhancement of the cares.

Folate intake and risk of oral and pharyngeal cancer

BACKGROUND

Diet has been recognised as having a role in the aetiology of oral and pharyngeal cancer, and dietary factors may account for 10-15% of cases in Europe. Folate deficiency has been linked to risk of several cancers, but has not been studied adequately with respect to oral cancer.

PATIENTS AND METHODS

This case-control study, conducted in Italy and French-speaking Switzerland, included 749 patients with incident cancer of the oral cavity and pharynx, and 1772 hospital controls with acute, non-neoplastic conditions. The interviews used a validated food frequency questionnaire. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using multiple logistic regression.

RESULTS

The ORs were 0.68 (95% CI 0.52-0.88) for the intermediate tertile and 0.53 (95% CI 0.40-0.69) for the highest tertile of dietary folate intake, compared with the lowest tertile. No heterogeneity was found in strata of gender, age, methionine intake or alcohol consumption. The combined OR for low-folate and high-alcohol intake versus high-folate and low-alcohol intake was 22.3 (95% CI 13.1-38).

CONCLUSIONS

Our study supports a protective role of folate against oral and pharyngeal carcinogenesis. Compared with low folate intake, a consistent reduction in risk was already observed from intermediate levels of intake, suggesting that cancer risk may be related to relative folate deficiency.

Management of patients with carotid stenosis

Carotid atherosclerosis is one of the main risk factors for ischemic stroke. The annual risk of ipsilateral stroke for asymptomatic, albeit severe stenoses is as low as 1 to 2%, but increases to 13% in patients with recent ischemic symptoms. However the risk decreases after the first 2-3 years from the symptomatic episode, dropping to 3%. Echo-color Doppler ultrasonography is the screening method of choice, being highly accurate, noninvasive and low-cost. Carotid angiography still represents the gold standard, however, less invasive techniques as RM angiography and Angio-CT are becoming increasingly common. Based on NASCET, ECST and ACAS results, carotid endarterectomy (CE) is strongly recommended for severe symptomatic stenoses, while for the moderate symptomatic and the severe asymptomatic ones the benefit in terms of stroke risk reduction is modest and surgery should be restricted to selected cases in surgical centers of high experience. For severe asymptomatic stenoses NNT is too high to recommend indiscriminate surgery; we are waiting for the results of ACSRS trial, designed to identify a subset of patients at risk of ipsilateral stroke greater than 4%/y, that may be considered for CE, while patients at low risk will be spared from unnecessary operation. Apart from surgery, in all patients with carotid atherosclerosis correction of cardiovascular risk factors is mandatory. Antiplatelet therapy (ASA alone or with dypiridamole, ticlopidine) is effective in secondary prophylaxis of athero-thrombotic stroke; its use in asymptomatic carotid stenoses can be recommended, even if more because of a plausible rationale than of clinical trial-based evidences.

Family history of cancer and risk of ovarian cancer

The aim of this study was to examine the relationship between history of cancer in first-degree relatives and ovarian cancer risk. Between 1992 and 1999, we conducted a case-control study in Italy on 1031 women with epithelial ovarian cancer and 2411 women admitted to hospital for acute non-neoplastic conditions. Odds ratios (OR) were estimated using unconditional logistic regression, adjusted for age and several potential confounders. Overall, 27 cases and nine controls reported a family history of ovarian cancer (OR = 7.0; 95% confidence interval (CI) 3.1-16). The OR was 23 (95% CI 2.6-212) below age 50 years, based on 10 cases and one control only. The risk of ovarian cancer was also increased in women with a family history of cancer of the stomach (OR = 1.5; 95% CI 1.0-2.1), intestine (OR = 1.7; 95% CI 1.2-2.4), lung (OR = 1.3; 95% CI 1.0-1.8), breast (OR = 2.3; 95% CI 1.7-3.1), lymphomas (OR = 2.3; 95% CI 1.0-5.1) and all sites (OR = 1.6; 95% CI 1.4-1.9). Our results confirm the higher ovarian cancer risk in women with a family history of ovarian and breast cancer, and suggest a few associations with other sites.

Cigarette tar yield and risk of upper digestive tract cancers: case-control studies from Italy and Switzerland

BACKGROUND

Tobacco smoking is one of the main risk factors for oral, pharyngeal and oesophageal cancers in developed countries. Information on the role of the tar yield of cigarettes in upper digestive tract carcinogenesis is sparse and needs to be updated because the tar yield of cigarettes has steadily decreased over the last few decades.

PATIENTS AND METHODS

We analysed two case-control studies, from Italy and Switzerland, conducted between 1992 and 1999, involving 749 cases of oral and pharyngeal cancer and 1770 controls, and 395 cases of squamous-cell oesophageal carcinoma and 1066 matched controls. Odds ratios (ORs) were estimated by unconditional multiple logistic regression models, including terms for age, sex, study centre, education and alcohol consumption.

RESULTS

Based on the brand of cigarettes smoked for the longest time, the multivariate ORs for current smokers compared with never smokers were 6.1 for <20 mg and 9.8 for >or=20 mg tar for oral and pharyngeal neoplasms, and 4.8 and 5.4 for oesophageal cancer, respectively. For the cigarette brand smoked in the previous six months, the ORs for >or=10 mg compared with <10 mg were 1.9 for cancer of the oral cavity and pharynx and 1.8 for oesophageal cancer, after allowance for number of cigarettes and duration of smoking.

CONCLUSIONS

The present study confirms the direct relationship between the tar yield of cigarettes and upper digestive tract neoplasms, and provides innovative information on lower tar cigarettes, which imply reduced risks compared with higher tar ones. However, significant excess risks were observed even in the lower tar category, thus giving unequivocal indications for stopping smoking as a priority for prevention of upper digestive tract neoplasms.

Dietary glycemic index, glycemic load and ovarian cancer risk: a case-control study in Italy

BACKGROUND

Dietary carbohydrates vary in their ability to raise blood glucose and insulin levels, which, in turn, influence levels of sex hormones and insulin-like growth factors. We analyzed the effect of type and amount of carbohydrates on ovarian cancer risk, using the glycemic index (GI) and the glycemic load (GL) measurement in a large case-control study conducted in Italy.

MATERIALS AND METHODS

Cases included 1031 women with incident, histologically confirmed epithelial ovarian cancer, from four Italian regions. Controls included 2411 women admitted to the same hospital networks for acute, non-neoplastic conditions. Average daily GI and GL were calculated from a validated food frequency questionnaire. Odds ratios (OR) and the corresponding 95% confidence intervals (CI) were computed using multiple logistic regression.

RESULTS

Ovarian cancer was directly associated with dietary GI (OR for highest versus lowest quartile = 1.7, 95% CI 1.3-2.1) and GL (OR = 1.7, 95% CI 1.3-2.1). The associations were observed in pre- and postmenopausal women, and they remained consistent across strata of major covariates identified.

CONCLUSIONS

This study supports the hypothesis of a direct association between GI and GL and ovarian cancer risk and, consequently, of a possible role of hyperinsulinemia/insulin resistance in ovarian cancer development.

[Significance of health education in schools. Strategy for the prevention of cardiovascular diseases]

Cardiovascular diseases are the first cause of death in our Country. They mainly manifests in adult age but it is the result of initiated lesions since the young age and imputable often to errors of behaviours and to non appropriate styles of life. The knowledges related to the prevention of some illnesses, allows a reduction of the incidence of these, a reduction of the mortality, with consequent reduction of the health and social costs related to the care and to the rehabilitation. In our educational system, unlike what happens in the most greater part of the other European countries, these themes are only partially present and however treated in sporadic and insufficient way. For these raisons Pronto Cuore onlus Association has decided to start, in collaboration with the Regione Lazio, a project of health education to the high schools students considering that a more informed population has a longer expectancy of life and a better life quality. This job wants to underline the necessity to undertake a health education program to teach and inform students and teachers: to recognize some factors of risk as principal causes of cardiovascular diseases; to change life style; to recognize critical situations and behaviours to be adopted.