[Therapeutic options for metabolic syndrome in obese patients]

The metabolic syndrome (MS), a cluster of risk factors, such as obesity, hyperglycemia, hypertension and dyslipidemia, contributes to the development of cardio-vascular diseases and type 2 diabetes mellitus (DM2). Insulin resistance (IR) plays a key role in MS being strongly linked to abdominal visceral fat. Treatment for obese patients with MS should aim at improving IR, delaying the onset of DM2 and at reducing cardio-vascular risk. Weight loss, first therapeutic target, may be obtained through life-style modifications and anti-obesity drugs or bariatric surgery, at need. In these patients drug therapy is necessary if therapeutic life-style changes are not sufficient. Some drugs have adverse metabolic effects, therefore the therapeutic choices must be specific and rational. Metformin, Thiazolidinediones and Acarbose are anti-hyperglycemic drugs of choice: they reduce the incidence of DM2 and IR (or improve insulin sensitivity) and they decrease or stabilize the visceral adipose tissue mass (Thiazolidinediones increases subcutaneous fat only). Also Angiotensin II receptor blockers and Angiotensin-converting enzyme inhibitors reduce the incidence of DM2 and insulin resistance and they are first-line antihypertensive drugs in MS. Calcium channel blockers, Alpha-1 antagonists and Alpha-2 agonists drugs are metabolically neutral and slight weight gains are related to the hydro-sodium retention. Beta-blockers and Diuretics, except for Indapamide and Anti-aldosterone drugs, can reduce insulin sensitivity, impair lipid profile and increase DM2 incidence; they are not first-line therapy yet they are necessary in selected cases only. Statins, Fibrates and omega-3 Fatty acids are indicated to normalize dyslipidemia. Low doses of acetylsalicylic acid are also recommended.

Assessment of the efficacy of Umonium38 on multidrug-resistant nosocomial pathogens

INTRODUCTION

We investigated the efficacy of a biocide Umonium38 on multidrug-resistant strains by comparison with a chloride derivative (Decs).

METHODS

In vitro susceptibility tests were performed by agar diffusion disk and results were interpreted according to Clinical and Laboratory Standards Institute (CLSI). In vitro antibacterial efficacy of Umonium38 and Decs over selected strains was evaluated according to European Standards protocol with or without organic substance.

RESULTS

In vitro tests with Umoniumnr at 2.5% concentration demonstrated an overall drop in microbial and yeast charges after 5 min. contact without organic substance. The same results were obtained in presence of organic substance. In vitro tests with chloride derivative at 5% without organic substance also resulted in overall drop in bacterial and mycotic charges. Conversely, in presence of organic substance, the hypochlorite reduced the initial 10 UFC/ml to 10 UFC/ml for all bacterial strains with a decrease of 4 log except for Enterococcus faecalis and Candida albicans whose reduction was 2 and 1 log units respectively.

DISCUSSION

The organic substance in water requires large use of oxidising disinfectants (chloride, ozone) implying in the need for higher-than-standard concentrations. The disinfecting effect of chloride is only visible when the "requirement" of organic substance has been met. By contrast, Umonium38 behaves like a powerful biocide even in presence of organic substance, as it is not "consumed" by possible organic residues.

CONCLUSIONS

Umonium38 resulted beneficial and effective. It is to be stressed, however, that all these experiments were in vitro tests and still requires validation from a correct use of clinical practice.

Retroperitoneoscopic lumbar sympathectomy for nonreconstructable arterial occlusive disease

AIM

The aim of this study was to present our experience with video-assisted lumbar sympathectomy for non-reconstructive arterial occlusive disease in a series of 23 consecutive patients whose predominant symptoms were unilateral rest pain, limited skin ulcerations or gangrene of the toes.

METHODS

All the procedures were performed with retroperitoneal approach, dorsal position of the patient and simple digital dissection of the retroperitoneal space.

RESULTS

The operations were successfully performed in all patients except for 2, who immediately underwent open conversion. A urinoma caused by ureteral lesion was the only severe complication in this series. The mean operative time of the procedure was 55 min and the hospital stay was 2 or 3 days. No parenteral analgesics were administered postoperatively. At 1 month from operation, 20 patients out of 23 had significant relief of rest pain and improvement of ischemic lesions. After a median follow-up of 36 months, 2 patients had died, 4 underwent some type of distal amputation, 1 had recurrent rest pain and the other 16 reported persistent improvement of pain or dystrophic changes.

CONCLUSIONS

Retro-peritoneoscopic technique appears the modern and less invasive version of the lumbar surgical sympathectomy.

Quantitative profiling of the pathological prion protein allotypes in bank voles by liquid chromatography-mass spectrometry

The conversion of the cellular prion protein (PrP(C)) into a misfolded isoform (PrP(TSE)) that accumulates in the brain of affected individuals is the key feature of transmissible spongiform encephalopaties (TSEs). Susceptibility to TSEs is influenced by polymorphisms of the prion gene suggesting that the presence of certain amino acid residues may facilitate the pathological conversion. In this work, we describe a quantitative, fast and reliable HPLC-MS method that allowed to demonstrate that in the brain of 109(Met/Ile) heterozygous bank voles infected with the mouse adapted scrapie strain 139A, there are comparable amounts of PrP(TSE) with methionine or isoleucine in position 109, suggesting that in this TSE model the two allotypes have similar rates of accumulation. This method can be easily adapted for the quantitative determination of PrP allotypes in the brain of other natural or experimental TSE models.

Metastatic breast cancer: an updating

This article reports on recent advances on metastatic breast cancer. Detection, prognostic factors, predictors of response to therapy and therapy, with particular regard to targeted therapies, were examined.

DETECTION

Unlike current guidelines that yet do not routinely recommend intensive clinical-instrumental post-operative follow-up of breast cancer patients, relatively large data collected in the last decades have shown that an intensive post-operative follow-up with 'dynamic evaluation' of a suitable tumour marker panel precedes a few months as average the clinical and/or instrumental sign of a pending relapse in most relapsed patients and largely limits the use of the common instrumental examinations.

PROGNOSIS AND THERAPY PREDICTORS

Disease-free interval (DFI)<or=24 months, adjuvant chemotherapy, liver and distant soft tissue involvement or DFI>24 months and disease confined to bony skeleton are prognostic factors more often correlated with relatively poor or prolonged survival, respectively. Estrogen receptor (ER) expression in primary tumour and at the relapse correlates strongly with response to salvage hormone therapy and data from large trials showed that 38-59% of ER and/or PR+ post-menopausal patients had clinical benefit from first line tamoxifen or aromatase inhibitors. An inverse correlation of ER with epidermal growth factor receptor (EGFR) has been found. The co-expression of HER-2/neu and/or elevated serum HER-2/neu protein level were associated with a low rate and shorter duration of response of ER+ patients to first line hormone therapy. Accordingly, ER-EGFR- compared with ER-EGFR+ tumours are usually more responsive to endocrine therapy. High class III beta-tubulin expression or fall in insulin-like growth factor binding protein-3 (IGFBP-3) from baseline levels have been found to significantly predict resistance to chemotherapeutic agents.

THERAPY

Liposomes as carrier of doxorubicin (Caelix, Evacet, Myocet) is one approach to decrease the anthracycline-related cardiac toxicity. Weekly paclitaxel or docetaxel and oral formulation of vinorelbine and 5-fluorouracil (5-FU) (capecitabine) provide new effective and well tolerated options that reach greater dose intensity and cumulative dose than with the conventional schedules. As to the so called 'tailored' or targeted therapies, the more potent and highly selective third generation of aromatase inhibitors (letrozole, anastrozole, exemestane) targeting ER+ tumours by estrogen deprivation, challenge tamoxifen as current standard first line therapy in postmenopausals. One pilot study showed that stimulation of cellular immunity by the addition of beta-interferon-interleukin-2 sequence in patients on clinical benefit on first line tamoxifen significantly prolonged median overall survival (OS) and duration of response compared to that observed in similar patients only treated with tamoxifen. Trastuzumab, a humanised monoclonal antibody to extracellular domain of HER-2, plus conventional chemotherapy has become a standard of care for women with overexpressing HER-2 tumours. Bevacizumab is a recombinant humanised monoclonal antibody to vascular endothelial growth factor (VEGF) that in refractory metastatic breast cancer doubled the response rate of capecitabine although it did not affect survival. Finally, the so called 'oligometastatic' and a few stage IV diseases are conditions amenable to be rendered with no evidence of disease (NED) after local surgery and/or radiation. In both, as well as in complete responders to chemotherapy, minimal residual disease (m.r.d.) likely continues to be present. Recent data suggest that 'biological' therapy (immunomodulators and/or retinoids with or without hormone therapy), might be suitable to be successfully tested in these patients as maintenance treatment given soon after local intervention or chemotherapy.

Combined treatment with ceftriaxone and linezolid of pneumococcal meningitis: a case series including penicillin-resistant strains

This study evaluated the role of linezolid in the treatment of patients suffering from pneumococcal meningitis. Treatment included ceftriaxone (4000 mg every 24 h), linezolid (600 mg every 12 h) and dexamethasone (8 mg every 6 h). Linezolid was withdrawn if a penicillin-susceptible isolate of Streptococcus pneumoniae was identified. Of 16 patients studied, seven were infected with penicillin-non-susceptible isolates of S. pneumoniae, two died, and three reported sequelae. No toxicity was reported. It was concluded that linezolid can be used for the treatment of pneumococcal meningitis, as an alternative to vancomycin or rifampicin, in regimens including a third-generation cephalosporin.

Are surgical scrubbing and pre-operative disinfection of the skin in orthopaedic surgery reliable?

This study attempts to establish the actual effectiveness of pre-surgical disinfection of the patient and surgeon's hands. We evaluated bacterial density and composition on the skin of 15 patients undergoing knee arthroscopy and the left hand of two surgeons after standard disinfection with povidone-iodine. Three samples were taken after the first 6-min scrub in the first surgical operation from the periungual space of the 1 degrees finger, from the interdigital space between the 2 degrees and 3 degrees fingers and from the transverse palmar crest of the left hand of two surgeons for seven consecutive surgical sessions, for a total of 42 samples, and two samples from the pre-patellar skin and from the popliteal skin of 15 patients undergoing knee arthroscopy, for a total of 30 samples. Pre-surgical handwashing and disinfection procedures were identical in each case. Pre-surgical disinfection of the patient's skin with povidone-iodine was shown to be completely effective, with 100% of samples negative. Samples taken from the interdigital space and the palmar crest (100% of samples negative) demonstrated the efficacy of disinfection of the surgeon's hands with povidone-iodine, while the periungual space was contaminated in 50% of the samples. The bacterial strains isolated belong to the staphylococcus genus in 100% of the cases, with pathogenic strains in 29.6% of the cases. Standard pre-surgical disinfection of skin in areas easily accessible to the disinfectant is sufficient in itself to guarantee thorough sanitization. Standard scrubbing of the surgeon's hands is insufficient in eliminating bacterial contamination, including pathogenic germs, in the periungual space, where it is probably difficult for the disinfectant to come into contact with the skin.

Factors influencing the presentation and outcome of tuberculous meningitis in childhood

Tuberculosis (TB) is an important cause of morbidity and mortality worldwide. Here, we describe our experience of childhood tuberculous meningitis (TBM), focusing on factors influencing presentation and outcome.

PATIENTS AND METHODS

Children aged 0-14 years, with diagnosis of TBM and 24 months of post-therapy follow-up, were evaluated in this retrospective study.

RESULTS

Thirty-two patients with TBM were identified. Fever, nuchal rigidity and vomiting were the main presenting symptoms. Fourteen cases (44%) presented with cranial nerve palsy. Seventeen (53%) patients were in advanced stage of the disease on admission. Cerebrospinal fluid (CSF) examinations showed low glucose, high proteins and pleocytosis. A central nervous system device was placed in 4 cases (13%) because of worsening hydrocephalus. Four (13%) patients died, while 6 (19%) had sequelae. Faster normalization of CSF parameters was associated with better outcome.

CONCLUSION

Early antimycobacterial therapy and close monitoring of TBM in childhood improve the outcome.

[Results of surgical treatment of varicocele in male infertility]

To evaluate the results of surgical treatment of varicocele on infertile men, especially regarding sperm count, 245 patients, surgically treated from 1993 to 2003, were evaluated. Patients underwent to ligature and section of the pampiniform plexus, through the subinguinal approach and local anaesthesia. At the follow-up (3-6-12 months) an improvement of sperm count was relieved in 79.5% of patients and the incidence of complications and relapses was of 3.7% and 1.2%, respectively. The Authors stress the efficacy of surgical treatment of varicocele in male infertility and hold the subinguinal approach as an effective treatment, minimally invasive and low cost.

Identification of the pathological prion protein allotypes in scrapie-infected heterozygous bank voles (Clethrionomys glareolus) by high-performance liquid chromatography-mass spectrometry

Cerebral formation of the pathological isoform of the prion protein (PrP) is a crucial molecular event in prion diseases. The bank vole (Clethrionomys glareolus) is a rodent species highly susceptible to natural scrapie. The PrP gene of bank vole is polymorphic (Met/Ile) at codon 109. Here we show that homozygous 109Met/Met voles have incubation times shorter than heterozygous 109Met/Ile voles after experimental challenge with three different scrapie isolates. An HPLC-MS/MS method was optimized and applied to investigate whether in heterozygous animals both PrP allotypes are able to undergo pathological conversion. The results demonstrate that both allotypes of the prion protein participate to pathological deposition.

Management of hypertension in chronic kidney disease: the Italian multicentric study

BACKGROUND

Guidelines have indicated the achievement of blood pressure target (BP <130/80 mmHg) as a priority in the conservative treatment of chronic kidney disease (CKD), but the current implementation of these recommendations in clinical practice is unknown.

METHODS

We assessed control rates, treatment and clinical correlates of hypertension in 1201 adult non-dialyzed CKD patients followed up by a nephrologist for at least 6 months.

RESULTS

Estimated glomerular filtration rate (GFR) was 32 (SD 15) mL/min/1.73 m2. BP target was not achieved in 88% of patients (95% confidence interval (95% CI): 86-90%). In 84% of patients, BP levels were also above the target at the first visit to the nephrology unit 4.5 yrs previously. The risk of not achieving BP target during the nephro-logy follow-up was associated with older age (odds ratio (OR): 1.24, 95% CI 1.06-1.45, p=0.008), diabetes (OR: 2.25, 95% CI 1.20-4.20, p=0.011), and the duration of hypertension (OR: 1.13, 95% CI 1.02-1.24, p=0.016). Among patients with uncontrolled BP, about 70% received multidrug antihypertensive therapy including renin-angiotensin system (RAS) inhibitors; conversely, diuretic treatment was prescribed in a minority of patients (37%), and at insufficient doses in half the cases, despite the insufficient implementation of a low salt diet (18%).

CONCLUSIONS

BP target was not reached in most CKD patients routinely seen in the renal clinics. The main barrier to guideline implementation is possibly the inadequate treatment of extracellular volume expansion despite the large prevalence of factors, such as older age and diabetes, which further enhance the intrinsic BP salt sensitivity of CKD.

An unusual association of contralateral congenital small kidney, reduced renal function and hyperparathyroidism in sponge kidney patients: on the track of the molecular basis

Of unknown pathogenesis, sponge kidney (SK) is variably associated with nephrocalcinosis, stones, nephronic tubule dysfunctions and precalyceal duct cysts. Amongst 72 unrelated renal SK patients with renal stone disease, we detected one with unilateral bifid renal pelvis and six with unilateral small kidneys (longitudinal diameter difference >15%). Secondary causes of small kidney were excluded. Of the seven cases, four had reduced renal function (67 vs 7% in the entire cohort), and three developed hyperparathyroidism during follow-up (43 vs 4%). The pathogenesis of SK ought to explain why anatomical structures of different embryological origin are involved (the precalyceal and collecting ducts and the nephron) and why there is frequent association with hyperparathyroidism. In embryogenesis, the metanephric blastema synthesizes the chemotactic glial-derived neurotrophic factor (GDNF) to prompt the ureteric bud to branch off from Wolff's mesonephric duct, and to approach and invade the blastema. The bud's tip expresses the GDNF receptor (RET). RET-GDNF binding is crucial not only for the correct formation of ureters and collecting ducts (both of Wolffian origin), but also for nephrogenesis. We advance the hypothesis that SK results from a disruption in the ureteric bud-metanephric blastema interface, possibly due to one or more mutations or polymorphisms of RET or GDNF genes. This would explain: the concurrent alterations in precalyceal ducts and the functional defects in the nephron, the occasional association with size and the functional asymmetry between the two kidneys, some degree of renal dysplasia causing the reduction in the glomerular filtration rate and (given the role of RET in parathyroid cell proliferation) the association with hyperparathyroidism.

Silent chronic kidney disease epidemic seen from Europe: designing strategies for clinical management of the early stages

Given the alarming predictions of the potentially devastating future epidemic of end-stage renal disease (ESRD), further knowledge is still urgently needed on this topic. The real dimensions of the problem are still unclear. It is difficult to compare Europe and the USA because different criteria are used in data collection and not much information is available, but the epidemic of silent chronic kidney disease seems to be more widespread in the States than in Europe, and more severe in terms of cardiovascular mortality. Defining early chronic renal insufficiency carrying a definite risk of ESRD is not easy, particularly for chronic renal conditions in which the clinical picture is still faint and the renal dysfunction minimal. It is also hard to say which tools are most suitable for diagnosing such renal disorders (renal filtration indexes vs. composite indexes of renal damage, e.g. the NKF's CKD stages). Furthermore, it is still not clear which strategies best identify subjects with these conditions (screening vs. early interception; general population vs. high-risk groups), how effective therapeutic approaches are, which subject categories benefit from early diagnosis and intervention, and how clinical measures should be structured (multidisciplinary case management-based approaches vs. general practitioner-oriented approaches). These issues are discussed in this paper.