Mini-laparoscopic cholecystectomy

BACKGROUND/AIMS

The authors describe their experience in performing cholecystectomy using mini-laparoscopy in selected cases of uncomplicated cholelithiasis. This involved making one 10 mm, one 5 mm and two 2 mm incisions.

METHODOLOGY

From July 1996 to August 1997, 60 cholecystectomies were performed using mini-laparoscopy, out of a total of 203 video-laparocholecystectomies performed during the same period.

RESULTS

Average length of the operations was 36 minutes from insertion of the first trocar to extraction of the gallbladder. All patients were discharged in the second day after surgery. No short-term intra- or post- operative complications occurred.

CONCLUSIONS

The benefits of mini-cholecystectomy are potential advantages in improved appearance, reduced pain, better respiratory function, fewer wall complications. Therefore, the authors believe that mini-laparoscopy should not be assessed in terms of percentage of use or success, but rather considered as a part of the laparoscopic method to be used in selected cases.

Skin lesions in diabetes mellitus: prevalence and clinical correlations

With the aim to assess the prevalence and the main clinical correlations of skin lesions in diabetes mellitus, 457 diabetic subjects consecutively attending an outpatient clinic underwent a dermatological examination. Neurovascular foot lesions were excluded. Thirty-five of 64 IDDM patients (54%) had skin alterations mainly consisting of vitiligo (9% of all patients), psoriasis (9%) and eczema (8%). The most frequent skin lesions observed in 240/393 NIDDM subjects (61%) were represented by infections (20% of all patients) and diabetic dermopathy (12.5%), while other lesions were not common. NIDDM patients with skin infections had a worse metabolic control, and those with diabetic dermopathy had a greater prevalence of neuropathy and large vessel disease than patients without skin lesions. These data show that the prevalence of skin diseases in a large, unselected diabetic population is higher than expected and indicate that, in most cases, a careful dermatological examination and a better metabolic control are needed in order to improve quality of life in these patients.

[Laparoscopic cholecystectomy in patients who previously underwent major laparotomy]

This paper describes the experience gained and the techniques used by the authors in the laparoscopic treatment of biliary calculosis in patients who previously underwent abdominal surgery, excluding cases with incisions below the horizontal line passing through the umbilicus (in these cases there are usually no adhesions to hinder operative laparoscopy of the gallbladder). Between October 1991 and July 1995,776 laparoscopies were performed on bile ducts (715 for calculosis of the gallbladder and 61 for cholecysto-choledochal calculosis). In 18 cases there was scarring of the abdominal wall due to previous major surgery (12 gastric resections, 3 resections of the colon, 1 splenectomy, 1 case of fundoplication for hiatal hernia, 1 resection of the ileum). In all cases access was by open laparoscopy to the lower right or periumbilical abdominal quadrant. When necessary, local viscerolysis was performed using various techniques with variations depending on the adhesions encountered. In all cases surgery was performed laparoscopically. In 2 cases a calculosis of the common bile duct was treated at the same time. The average duration of surgery was 70 min for cholelithiasis and 145 min for cholecysto-choledochal calculosis. On average patients were released from hospital 4 and 7 days after surgery respectively. No major or minor complications were encountered.

A fatal postpartum Clostridium sordellii associated toxic shock syndrome

Clostridium sordellii is an infrequent human pathogen. It has been demonstrated to be occasionally responsible for myonecrosis or gas gangrene. Interestingly, in the obstetric literature, some cases of postpartum maternal deaths have been associated with C sordellii infection causing a rapidly lethal toxin mediated syndrome. This is the first reported case of postpartum death in a 29 year old woman, in which a toxigenic C sordellii was isolated from the patient's blood antemortem during the fatal toxic shock, strongly indicating its role in this rare syndrome.

The pattern electroretinogram (PERG) after laser treatment of the peripheral or central retina

PURPOSE

To understand whether laser photocoagulation of the retina for the treatment of diabetic retinopathy (DR) alters directly or indirectly the function of the macular region.

METHODS

Transient pattern electroretinograms (PERGs) to 30' checks have been recorded in DR patients before and 7-10 days after one treatment session (established protocol with Argon laser) of either the peripheral retina (panretinal treatment) or the central retina (paramacular focal treatment).

RESULTS

Treatment of the peripheral retina causes, in most eyes, a small increase (about 15% on average) of the PERG amplitude. Focal paramacular treatment causes a marked decrement (about 40% on average) of the PERG amplitude. Simulated retinal amputation induced by focal treatment, obtained by means of adequate stimulus masking, resulted in a 15-20% PERG decrement only.

CONCLUSIONS

The PERG increase after peripheral treatment may be due to rearrangement of both retinal and choroideal hemodynamics and does not necessarily result in useful long term changes. The PERG decrease after focal, paramacular treatment is far larger than that expected on the basis of the amputated area only. This may result from thermal and/or toxic damaging effects spreading outside the treated area. The results are relevant for both a better monitoring of central retinal function in the course of laser treatment and a better evaluation of the cost/benefit ratio after photocoagulation in DR.

Hemophilia and nonprogressing human immunodeficiency virus type 1 infection

Seven of 112 hemophiliacs infected with human immunodeficiency virus type-1 (HIV-1) before 1986 through contaminated plasma products are currently healthy, with CD4 T-cell counts above 500 cells/microL, and have never received antiretroviral therapy (long-term nonprogressors [LTNPs]). Seven age and sex-matched hemophiliacs infected in the same period but who have progressive HIV disease (progressors) and one additional slow-progressing individual were also studied. One hundred-fold, 20-fold, and 10-fold lower levels of full-length HIV RNA in plasma, peripheral blood mononuclear cells (PBMCs), and proviral DNA in PBMCs, respectively, were found in LTNPs compared with progressors. Plasma and cell-associated HIV RNA and proviral DNA were lower in LTNPs who tested negative for viral isolation from PBMCs or who were positive only after removal of CD8+ cells. No substantial differences were observed in the in vitro production of chemokines including RANTES, MIP-1 alpha, MIP-1 beta, MCP-1, and interleukin-8 (IL-8) in supernatants of activated PBMCs or CD8-depleted PBMCs of LTNPs, even when HIV isolation was simultaneously accomplished exclusively after removal of CD8+ cells. Low levels of HIV load and replication in peripheral blood are the strongest correlates of nonprogression in this small number of infected hemophiliacs.

Modifications of diazepam binding inhibitor and peripheral benzodiazepine receptors in the lymphocytes of epileptic patients

Recent experimental evidence has suggested that peripheral benzodiazepine receptors (PBR) may play a role in epilepsy and antiepileptic drug action. Since PBR are also present in circulating lymphocytes, and may interact with anticonvulsant drugs, this study was designed to look for possible modifications of these receptors and their endogenous ligand diazepam binding inhibitor (DBI) in the lymphocytes of epileptic patients treated with various drugs. PBR levels were 50% to 80% higher in patients treated with carbamazepine, phenobarbital and valproic acid than in controls and untreated epileptics. DBI levels were significantly increased in the lymphocytes of untreated patients, and showed only a slight further increase after anticonvulsant therapy. The possibility that PBR and DBI modifications in the lymphocytes of epileptic patients may be linked to the immunological alterations reported in these patients and/or may represent possible markers of neurochemical modifications in the central nervous system is discussed.

Immunity status to polioviruses among non-European union immigrants in Veneto Region (North-East Italy)

Widespread use of poliovirus vaccines has lead to a dramatic decline on the incidence of paralytic poliomyelitis in the Western Hemisphere. In Italy, the use of live attenuated vaccine (OPV) has lead to virtual eradication of poliomyelitis. However, wild poliovirus is still endemic in some less developed countries, and there is still a risk of importation of wild-virus poliomyelitis as result of immigration from these areas. Therefore, a serologic study of the immunologic status to poliovirus was carried out in 242 immigrants from less developed countries in the Veneto Region (North-East Italy). The overall prevalence of serum neutralizing antibodies was 98.3 percent for poliovirus type 1, 99.6 percent for type 2, and 95.9 percent for type 3. The modal titres were 1:128 (21.1 percent), 1:512 (26.4 percent), and 1:32 (22.3 percent) for poliovirus type 1, type 2, and type 3, respectively. No subject was simultaneously lacking neutralizing antibodies to all three polioviruses. The mean duration of stay in Italy before testing was 1.53 years (range 1 month to 7 years). These results show a good level of the immunity status, similar to those found in the Veneto general population. Although the risk of paralytic poliomyelitis in our population is very low, seronegative immigrants originating from areas of high endemicity could reintroduce wild poliovirus. It is therefore important to maintain a careful surveillance system on the importation of wild poliovirus and to plan vaccination programs for unprotected immigrants.

Epidermolysis bullosa junctionalis associated with urinary bladder exstrophy: a case report

We report the second infant of nonconsanguineous parents with epidermolysis bullosa junctionalis associated with urinary bladder exstrophy, epispadias, anteriorized anus, and bilateral inguinal hernias. The family history also included the death of a maternal cousin due to epidermolysis bullosa. Our diagnosis was based on electron microscopy and immunofluorescence evidence. This patient is reported because of the rarity of this constellation of findings.

Psychopathological disorders in a population of mentally retarded young adults

Nosographic, clinical, therapeutic and psychosocial aspects of psychopathological disorders in 43 mentally retarded patients followed from 1988 to 1991 are presented. Mental problems in mentally retarded subjects are linked to mental illness but do not form a continuum with it. The prognosis is generally favourable. Great attention must be given to the psychosocial aspects as social integration is almost always at risk in the mentally retarded.

Effect of anticonvulsant drugs on peripheral benzodiazepine receptors of human lymphocytes

Anticonvulsant drugs, such as carbamazepine, may exert some of their effects through peripheral benzodiazepine receptors (PBR), which are present in glial cells and regulate the synthesis of neurosteroids. PBR have also been demonstrated in human lymphocytes, where they might be used as peripheral markers of anticonvulsant drug effects. In the present paper we investigated the interaction of various antiepileptic drugs with PBR of human lymphocytes and evaluated possible effects of acute and chronic treatment with these drugs. At normal therapeutic concentrations, diazepam, carbamazepine and phenobarbital occupy respectively 70, 30 and 10% of PBR sites in human lymphocytes. Although no change of receptor density or affinity was observed after acute in vitro treatment, in epileptic patients chronically treated with carbamazepine, phenobarbital and valproic acid, PBR Bmax was increased with respect to controls and untreated epileptics. Since PBR of human lymphocytes may be affected by anticonvulsant drug treatment, we suggest that they might be involved in the immunological alterations reported in these patients and might be used as peripheral markers of drug effects on the central nervous system.

Poliovirus neutralizing antibody persistence after vaccination with the Sabin vaccine: a follow-up study

In 1976, a cohort survey on the persistence of neutralizing antibodies in children regularly immunized 1 to 4 years earlier with the Sabin attenuated vaccine (OPV) was undertaken in the Venice mainland. Subsequent serological evaluations in the same cohort were carried out in 1983 and 1993. A macroneutralization test using a 1:4 initial serum dilution was utilized in the 1976 and 1983 survey years. In the 1993 survey a microneutralization test using a 1:2 initial dilution was utilized. In this survey, however, sera were tested using both the latter microneutralization test and the former test. Using the former method, the results indicate that the OPV-induced humoral immunity to poliovirus 1 and 2 remain fairly stable after the initial decrease, whereas antibodies to poliovirus 3 are further declining. Using the latter more sensitive method the seropositivity rates were found to be equal or close to 100 percent. The results of our follow-up survey thus indicate that the OPV-induced humoral immunity is long-lasting when tested with a highly sensitive and reproducible method. The clinical protection that ensues after OPV-immunization is probably lifelong similar to that which follows the natural infection.

Spatial-temporal interactions in the steady-state pattern electroretinogram

It is currently assumed that steady-state pattern electroretinograms can be obtained only at high rates of pattern reversal. However, steady-state responses can also be obtained at very low temporal frequencies (less than 1 Hz), provided that the reversal is sinusoidal. In five healthy volunteers, we studied the frequency characteristics of the pattern-reversal electroretinogram in response to sinusoidal gratings of 0.4 and 4 c/deg, reversed sinusoidally in contrast at frequencies ranging from 1 to 27 Hz. Steady-state responses dominated by the second harmonic component were obtained at all temporal frequencies tested; the amplitude of the second harmonic changed with stimulus temporal frequency. In the low-temporal-frequency range, stimuli of high spatial frequency appear to elicit larger contribution of generators with sustained or tonic characteristics compared with stimuli of low spatial frequency.

Effects of thymostimulin with combination chemotherapy in patients with aggressive non-Hodgkin's lymphoma. A report from the Italian Lymphoma Study Group (GISL)

The purpose of this study was to test the efficacy and safety of thymostimulin (TS) administered in addition to conventional chemotherapy in patients with intermediate- and high-grade non-Hodgkin's lymphoma (IG, HG-NHL). A total of 150 patients with newly diagnosed IG- or HG-NHL were entered in a multicenter trial to compare the effectiveness of two different third-generation regimens (MACOP-B versus ProMACE-CytaBOM) and were randomized to receive chemotherapy (CT) alone or CT + TS. In both regimens doxorubicin was replaced by a 20% higher dose of epidoxorubicin. TS was administered i.m. at a dose of 1 mg/kg daily on days 22-28 of each drug course to patients treated with ProMACE-CytaBOM, and on days 22-29, 50-57, and 77-85 to patients treated with MACOP-B. There were 134 fully evaluable patients: 68 treated with CT alone and 66 treated with CT + TS. Patients treated with CT + TS had a higher complete remission (CR) rate compared to patients given CT alone (59.1% vs 42.4%; P = .05). CR were significantly higher for patients treated with CT + TS in the groups with IG-NHL (P = .01), in those aged less than 60 years (P = .05), with good performance status (P = .05), and normal hemoglobin levels (P = .05). Four-year survival rates are 64.5% for patients treated with CT + TS and 43.0% for those treated with CT alone (P = .30). No difference between the two treatment arms have been observed as regards drug-related toxicity and the number and severity of infectious episodes. The use of TS during the 7 days before chemotherapy has been associated with a significantly superior CR rate. The advantage of CT + TS was mostly obtained in patients with IG-NHL, and those with good performance status or normal hemoglobin levels. In these patients TS may have potentiated the host reactions against the tumor, leading to an increase in NK activity and the production of cytokines. This postulated increase in the effectiveness of chemotherapy after TS might also explain the absence of the expected myeloprotective action.

Immunity status to poliovirus in Veneto region (north-east Italy). A seroepidemiological survey

The immunity state to poliovirus types 1, 2, and 3 of a population aged 2 to 75 years was determined by examining 274 sera collected in the Venice mainland (North-East Italy). Altogether, the neutralizing antibody prevalences (at a titre > or = 1:2) for poliovirus 1, 2, and 3 were 99.0 percent (geometrical mean titres [GMT]: 72.1), 99.6 percent (GMT: 95.9) and 98.2 percent (GMT: 17.3), respectively, and all the age groups also showed very good levels of humoral immunity. High antibody titres (> or = 1:256) to one or more types of poliovirus were demonstrated in older age groups also, possibly indicating exposure to natural polioviruses or contact with vaccine strains. Although probably all the older subjects had practically acquired their antibodies as a result of natural infection and those under 30 through vaccination, these results indicate that the humoral immunity against poliomyelitis in our population is satisfactory, and the maintenance of such good protection level depends on an effective immunization program.

[The laparoscopic treatment of common bile duct lithiasis]

Recently the indications to video laparoscopic approach in abdominal surgery are considerably increased thanks to the very good results of the video laparocholecystectomy technique. The improvement of this methodology and of the instruments employed has permitted to extend the indications also to the treatment of cholecysto-choledochal lithiasis. After considering the actual possibilities of treating this kind of pathology, authors report their experience of 28 cases of choledocholithotomies carried out laparoscopically "at the same time" from October 1991 to October 1993, out of 431 operations on biliary tract performed for benign disease, 350 of which (81.2%) treated with a laparoscopic approach. In 26 cases the treatment has been completed. In one case (3.5%) it was necessary to perform a laparotomy due to an empyema with a wedged choledochal stone, in another case it was necessary to performed a laparoscopic-endoscopic treatment for removing wedged choledochal stone, but because of the failure of this treatment, a laparotomy followed. The only complication worth mentioning out of 27 choledocholithotomies performed is an external biliary fistula (3.7%) treated with a following laparotomy operation. The 25 patients only laparoscopically treated were discharged on the postoperative day 5. Even if a long-term follow-up lacks, authors consider the laparoscopic choledocholithotomy an efficacious cure for the treatment of cholecysto-choledochal lithiasis as it is a mini-invasive technique, which clears up the disease in one time, avoids not necessary papillotomy and reduces the risk of mortality and morbidity to their lowest terms.

Determination of thyreostatic residues in cattle plasma by high-performance liquid chromatography with ultraviolet detection

A procedure is described for the concurrent assay of thiouracil, methylthiouracil, propylthiouracil, phenylthiouracil and methimazole in bovine plasma. In this procedure, reversed-phase high-performance liquid chromatography is performed after liquid-liquid extraction of plasma with ethyl acetate. Compounds are quantified by ultraviolet detection using a wavelength of 276 nm for thiouracil, methylthiouracil, propylthiouracil and phenylthiouracil and 258 nm for methimazole. The linearity range, precision, recovery and detection limits were determined and the method was shown to be applicable to samples of plasma from young bulls experimentally treated with methylthiouracil.

The second harmonic of the electroretinogram to sinusoidal flicker: spatiotemporal properties and clinical application

The photopic, focal electroretinogram elicited by sinusoidal modulation (8 Hz) of the luminance of a uniform field (flicker electroretinogram) presented in the macular region contains two main components: the first harmonic at the stimulus frequency (1F) and the second harmonic at twice the stimulus frequency (2F). Physiologic and clinical studies have demonstrated that the 1F originates in the outer retina, whereas the 2F has multiple postreceptoral sources, with a contribution of the innermost retina. The 2F, unlike 1F, is selectively altered in amplitude and phase in the early stages of optic neuritis and glaucoma. Both 1F and 2F are altered in maculopathies. An additional property of the focal electroretinogram is that the 2F, unlike 1F, has a very limited summation area (i.e., the function relating 2F amplitude with stimulus area is saturated for central stimulus sizes of the order of the macular region). This overrepresentation of the macular activity suggests that the 2F component of the flicker electroretinogram may provide a specific macular test even for full-field stimuli presented through opacities of the optical media.