Scintigraphy and Doppler ultrasonography for the evaluation of obstructive urinary calculi

Forty-seven patients with unilateral obstructive calculi (12 males and 35 females) were submitted to 99mTc-diethylene triamine pentaacetic acid (DTPA) or 99mTc-dimercaptosuccinic acid (DMSA) scans for assessment of renal function. The scans revealed unilateral functional deficit in 68 and 66% of the patients, respectively. A calculus size of 1.1 to 2.0 cm was significantly associated with deficit detected by DTPA, but duration of obstruction and calculus localization were not. After relief of the obstruction, the mean percent renal function of the affected kidney was found to be significantly increased from 25 +/- 12% to 29 +/- 12% in DTPA and from 21 +/- 15% to 24 +/- 12% in DMSA. Initial Doppler ultrasonography performed in 35 patients detected an increased resistive index in 10 (29%). In the remaining patients with a normal resistive index, ureteral urinary jet was observed, indicating partial obstruction. The high frequency of renal function impairment detected by DTPA and of tubulointerstitial damage detected by DMSA as well as the slight amelioration of unilateral renal function after relief of obstruction suggest that scintigraphy assessment may help evaluate the unilateral percentage of renal function and monitor renal function recovery when it occurs. The presence of a urinary jet detected by Doppler ultrasonography further indicates the severity of obstruction and the recovery prognosis.

Effects of chronic exposure to anaesthetic gases on some immune parameters

A cross-sectional survey was carried out to evaluate the relation between occupational exposure to low levels of anaesthetic gases (nitrous oxide and isoflurane) and immune parameters. Fifty-one anaesthetists were recruited among different Services of Anaesthesiology and Reanimation. The control group consisted of non-exposed physicians, similar for gender, age, and job grade. Total number of lymphocytes, lymphocyte subpopulations and the natural killer (NK) cytotoxic activity were measured. Information on personal and professional characteristics and on short- and long-term exposure was collected. Percentages of T cells (CD3) decreased significantly in anaesthetists compared to controls, whereas numbers of NK cells (CD16+ CD3-) increased. After correction for confounders, short-term (last 2 weeks) exposure was associated with a decrease in percentages of total T and T helper (CD4) cells. Furthermore, T helper percentages were significantly reduced with increasing individual exposure score evaluated on the basis of working days and levels of anaesthetic gases in operating rooms. A significant X-ray-associated increase of numbers and percentages of NK cells was lastly observed. Despite limited present exposure to anaesthetic gases, a specific derangement in lymphocyte subpopulations, with T lymphocytes more affected than B, has been observed.

[Unusual case of inverted papilloma in a fibro-epithelial polyp of the ureter]

Inverted papilloma of the upper urinary tract is a rare lesion and the differential diagnosis with transitional cell carcinoma is really hard. A case of 49 year-old male with recurrent right flank pain is reported. Excretory urogram suggested a filling defect involving the right mid ureter and bilateral retrograde pyelogram that confirmed a solitary filling defect in the right mid-ureter, while selective urinary cytology was positive for transitional cell carcinoma G1. Conservative therapy was carried out and 2 years follow-up with several excretory urograms and ultrasound studies revealed no recurrence.

Primary lymphoma of the penis: diagnosis and treatment

A rare case of primary penile B cell non-Hodgkin's lymphoma is reported. We reported on 75-year-old man with primary penile lymphoma with consideration of the diagnosis and the various therapeutic approaches. We treated this case with local radiotherapy and systemic chemotherapy with good cosmetic and functional results. There was absence of recurrence 42 months after therapy.

Is intra-operative gamma probe detection really necessary for inguinal sentinel lymph node biopsy?

CONTEXT

Sentinel node (SN) biopsy has changed the surgical treatment of malignant melanoma. The literature has emphasized the importance of gamma probe detection (GPD) of the SN.

OBJECTIVE

Our objective was to evaluate the efficacy of patent blue dye (PBD) and GPD for SN biopsy in different lymphatic basins.

DESIGN

Patients with cutaneous malignant melanoma in stages I and II were submitted to biopsy of the SN, identified by PBD and GPD, as part of a research project.

SETTING

Patients were seen at Hospital São Paulo by a multidisciplinary group (Plastic Surgery Tumor Branch, Nuclear Medicine and Pathology).

PATIENTS

64 patients with localized malignant melanoma were studied. The median age was 46.5 years. The primary tumor was located in the neck, trunk or extremities.

INTERVENTIONS

Preoperative lymphoscintigraphy, lymphatic mapping with PBD and intraoperative GPD was performed on all patients. The SN was examined by conventional and immunohistochemical staining. If the SN was not found or contained micrometastases, only complete lymphadenectomy was performed.

MAIN MEASUREMENTS

The SN was identified by PBD if it was blue-stained, and by GPD if demonstrated activity five times greater than the adipose tissue of the neighborhood.

RESULTS

Seventy lymphatic basins were explored. Lymphoscintigraphy showed ambiguous drainage in 7 patients. GPD identified the SN in 68 basins (97%) and PBD in 53 (76%). PBD and GPD identified SN in 100% of the inguinal basins. For the remaining basins both techniques were complementary. A metastatic SN was found in 10 basins. Three patients with negative SN had recurrence (median follow-up = 11 months).

CONCLUSION

Although both GPD and PBD are useful and complementary, PBD alone identified the SN in 100% of the inguinal lymphatic basins.

Synthesis of pyrrolinylnaphthalenes and evaluation of their antinociceptive activity

In this paper the regioselective preparation of (R/S)-1,2-dimethyl-3-[2-(6-substituted naphthyl)]-2H,5H-pyrrolines 2a-d is reported. These compounds were prepared by thermal dehydration of the corresponding alcohols (2R,3S/2S,3R)-1,2-dimethyl-3-[2-(6-substituted naphthyl)]-3-hydroxy-pyrrolidines (2R,3S/2S,3R)-1a-d with anhydrous FeCl3-SiO2, under vacuum. Pharmacological properties of (R/S)-2a-d are also described. Analgesic activity was investigated by the hot plate test, also in the presence of selective antagonists of mu, delta and kappa opioid receptors. Preliminary analysis of the side-effects was also accomplished using the rota-rod test. Interesting antinociceptive activity was shown by all compounds and in particular by (R/S)-2a (AD50 = 0.31 mg/kg); delta opioid receptors were found to be mainly involved in the pharmacological process and, in general, it was found that the compounds influenced locomotory activity to a much lesser extent than did morphine.

Synthesis and antinociceptive activity of pyrrolidinylnaphthalenes

In this paper the synthesis of the racemates (2R,3S/2S,3R)-1,2-dimethyl-3-[2-(6-substituted naphthyl)]-3-hydroxypyrrolidine 1b-d [(2R,3S/2S,3R)-1b-d] are reported. Compounds 1b-d were prepared by reaction of the racemic 1,2-dimethyl-3-pyrrolidone 2 with the lithiation product obtained from 2-bromo-6-substituted naphthalene 3b-d. Pharmacological properties of (2R,3S/2S,3R)-1a-d are also described. Analgesic activity was investigated by the hot plate test and binding affinities towards mu, delta and kappa opioid receptors were evaluated. A preliminary evaluation of the in vivo side-effects was also accomplished using the rota-rod test. Interesting antinociceptive activity was shown by all compounds and in particular by 1d, which is the most active compound, since it is six-fold more potent than morphine and has lower side effects on the locomotory activity.

Relation between immune variables and burnout in a sample of physicians

OBJECTIVES

To evaluate in a group of physicians the relation between burnout, demographic or job characteristics, anxiety, and immune variables.

METHODS

Seventy one physicians of all grades were recruited among different departments to a cross sectional survey. The Maslach burnout inventory, scales of emotional exhaustion, depersonalisation, and personal accomplishment, the trait scale of anxiety inventory (STAI-Y2), and a questionnaire on personal and professional characteristics were administered. The immune profile included quantitative (number (%) of lymphocytes and subsets) and functional (natural killer cytotoxicity) measures.

RESULTS

With a model of stepwise multiple regression analysis, emotional exhaustion was significantly affected by both personal (marital, sex) and job characteristics (qualification, working activity), whereas only patient contact explained a portion of variation in depersonalisation. Furthermore, trait anxiety was found to predict the Maslach burnout inventory scores. After correction for potential confounders, physicians who scored high levels of personal accomplishment showed significantly higher numbers of total lymphocytes, T cells (CD3), T helper cells (CD4), and T suppressor cells (CD8) than those who scored low levels. No other correlation was found between burnout and immune variables.

CONCLUSIONS

In our group of relatively young physicians a high degree of personal accomplishment was associated with an increase in the number of peripheral lymphocytes, particularly T subsets. The meaning of this is not clear, although it could be speculated that to evaluate oneself positively, particularly with regard to work with patients in the health services, might help to stimulate the immune system. By contrast, there is no evidence that to work hard, to feel tired from work, and to have a cynical reaction towards patient care is related to immunosuppression.

Preparation and configuration of racemic and optically active analgesic cycloaminoalkylnaphthalenes

Cycloaminoalkylnaphthalene 3 shows interesting opioid-like analgesic properties. It possesses two chiral centers and can exist as two racemic pairs and four diastereomers. Since the binding of opioids with receptors is stereoselective, it was important to have the two racemic pairs as well as the four diastereomers. In this paper the synthesis of the (2R,3S/2S,3R) racemate and the (2R,3S) and (2S,3R) enantiomers of the 1,2-dimethyl-3-[2-(6-hydroxynaphthyl)]-3-hydroxypyrrolidine 3 is considered and the determination of absolute configuration is described. The (2R,3S/2S,3R)-3 racemate and the (2R,3S)-3 and (2S,3R)-3 enantiomers were prepared by reaction of the racemic and optically active 1,2-dimethyl-3-pyrrolidone 2, respectively, with the lithiation product obtained from 2-bromo-6-tetrahydropyranyloxy-naphthalene 1 and acidic hydrolysis. The above-mentioned enantiomers of 3 were also obtained by optical resolution via fractional crystallization of the salts with D- and L-tartaric acids. The configuration of the optically active compounds was determined by X-ray analysis of a crystal of (-)-(2S,3R)-3.HCl.H2O. The pharmacological test HPT showed that (-)-(2S,3R)-3.HCl.H2O enantiomer is able to induce opioid-like analgesia with a relative potency 1.5 times that of (2R,3S/2S,3R)-3 and approximately 1.5 times that of morphine.

[Cardiac rupture in thoracic trauma]

Thoracic trauma frequently involve damage to the cardiac structures and in the worst cases, the progressive degeneration and necrosis of the damaged tissue lead to cardiac rupture. The high mortality resulting from cardiac tamponade requires the prompt execution of diagnostic tests to provide as much useful information as rapidly as possible in order to start immediate therapy. A case of cardiac rupture manifested by the onset of atrial fibrillation in a patient admitted to Intensive Care after a car accident is described. The scarce significance of objective examination, the aspecific nature of chest X-ray and ECG alterations prompted the execution of a more thorough diagnosis. Transthoracic and transesophageal ultrasonography are both minimally invasive and highly specific: in a short time, not only did they confirm cardiac rupture, but they also focalised the site of the lesion, thus allowing a more targeted and rapid surgical approach. The relative frequency of cardiac lesions following closed thoracic trauma, the lack of incontrovertible signs and symptoms of late cardiac rupture, and the extreme severity of its clinical consequences argue in favour of using specific and sensitive diagnostic tests that can not only exclude or ascertain the presence of these lesions, but also allow subsequent serial controls aimed at diagnosing late cardiac ruptures.

[Ileal conduit: our experience]

In the last 100 year, many progresses have been done in the ileal urinary diversion after cystectomy. Although the interest for the continent urinary diversion has increased enormously in the last ten years, the ileal conduit still represents the golden standard. We report our experience.

Dialkylaminoalkylnaphthalenes as novel opioid-like analgesics

The study of dialkylaminoalkylnaphthalenes as novel opioid-like analgesics is reported. In particular, the synthesis of (1R,2R/1S,2S)-1-ethyl-1-[2-(6-hydroxynaphthyl)]-1-hydrox-2-m ethyl-2-dimethylaminoethane and its structural analogue (1R,2R/1S,2S)-1-ethyl-1-[2-(6-fluoronaphthyl)]-1-hydroxy-2-methyl- 2-dimethylaminoethane and the configurational analysis by X-ray and 1H NMR spectroscopy are described. Pharmacological profiles are discussed on the basis of the experimental results of analgesia tests (hot plate and writhing test) and rota-rod test, which was performed to distinguish analgesia from drug-induced motor changes. The compounds showed dose-dependent antinociception, with less potency than morphine. Motor coordination appeared to be less involved.

[Surgical treacheotomy in intensive care]

BACKGROUND

To test validity, safety, costs and healing-outcome of surgical minitracheotomy after cannula removing.

METHODS

DESIGN

Opened, perspective. Site: Polyvalent ICU.

PATIENTS

40 patients underwent surgical minitracheotomy, in a year. Traditional surgical technique was adopted. Minitracheotomy was performed by intravenous general anesthesia with curarization and in mechanical ventilation. Intra-operative monitoring: ECG, non-invasive blood pressure and SaO2 by digital pulse oximetry. If a bleeding appeared, hemorrhage was stopped by vessel binding.

RESULTS

Technical difficulty was the same in every tracheotomy carried out. Complications appeared in 7 patients. There were 2 infectious cases for stoma, resolved in 7 and 12 days respectively by local disinfection and antibiotic therapy. There were 5 cases with moderate bleeding; in one patient only a surgical procedure was necessary.

CONCLUSIONS

Surgical tracheotomy represents a good and safe method in ICU; complications are few, if safety conditions are observed. Tracheotomy made in ICU reduced the use of medical and paramedical staff and operative rooms; unlike percutaneous procedure, in the surgical technique an always the same set after simple sterilization is used. Healing-outcome of surgical tracheotomy, after cannula removing, is the same with both techniques.

Modulation of nucleotide sensitivity of ATP-sensitive potassium channels by phosphatidylinositol-4-phosphate 5-kinase

ATP-sensitive potassium channels (K(ATP) channels) regulate cell excitability in response to metabolic changes. K(ATP) channels are formed as a complex of a sulfonylurea receptor (SURx), a member of the ATP-binding cassette protein family, and an inward rectifier K(+) channel subunit (Kir6.x). Membrane phospholipids, in particular phosphatidylinositol (PI) 4,5-bisphosphate (PIP(2)), activate K(ATP) channels and antagonize ATP inhibition of K(ATP) channels when applied to inside-out membrane patches. To examine the physiological relevance of this regulatory mechanism, we manipulated membrane PIP(2) levels by expressing either the wild-type or an inactive form of PI-4-phosphate 5-kinase (PIP5K) in COSm6 cells and examined the ATP sensitivity of coexpressed K(ATP) channels. Channels from cells expressing the wild-type PIP5K have a 6-fold lower ATP sensitivity (K(1/2), the half maximal inhibitory concentration, approximately 60 microM) than the sensitivities from control cells (K(1/2) approximately 10 microM). An inactive form of the PIP5K had little effect on the K(1/2) of wild-type channels but increased the ATP-sensitivity of a mutant K(ATP) channel that has an intrinsically lower ATP sensitivity (from K(1/2) approximately 450 microM to K(1/2) approximately 100 microM), suggesting a decrease in membrane PIP(2) levels as a consequence of a dominant-negative effect of the inactive PIP5K. These results show that PIP5K activity, which regulates PIP(2) and PI-3,4,5-P(3) levels, is a significant determinant of the physiological nucleotide sensitivity of K(ATP) channels.

Perforated jejunal diverticulitis: personal experience and diagnostic with therapeutical considerations

A case of perforated jejunal diverticulitis in a 87-year-old man is described and the literature is reviewed. Jejunal diverticulosis (JD) is estimated to occur in 0.02% to 1.3% of the adult population and is found most often in the elderly. The acute diverticulitis with perforation has been reported as high as 2.3% among patients with JD and is associated with high mortality. Clinical presentation mimic other more common acute intraperitoneal inflammatory conditions. Enteroclysis and abdominal CT are the most specific diagnostic tests. The common treatment is surgical resection of the involved segment. Laparoscopic resection and medical and medical/radiological approaches have also been proposed. Diagnostic and therapeutical aspects of this pathology are discussed.

Diabetes mellitus and cardiovascular complications: pathophysiological peculiarities and therapeutic implications

Diabetes mellitus is a chronic illness frequently associated with cardiovascular complications. The cardiologist must therefore play an important role in the management of diabetic patients, aware of the different natural history of the insulin-dependent and non-insulin-dependent forms, as well as of the pathophysiological peculiarities of the disease which requires particular diagnosis and therapy. Unfortunately, treatments which have proved to be most effective are still underused. Cardiovascular complications in diabetic patients are aggravated by higher morbidity and mortality rates than in the general population. In an attempt to prevent major cardiovascular events, the cardiologist must identify those patients at greater risk, particularly those with asymptomatic coronary heart disease.

Madness and method in stress echo reading

AIM

To assess whether 'eye education' through short-term, high-intensity joint reading sessions may improve diagnostic accuracy and inter-observer agreement among beginners.

METHODS AND RESULTS

Seventeen cardiologists with absent to minimal (<100 studies performed) previous stress echo experience independently and blindly read 18 stress echo studies, nine at the beginning ('pre-training' set) and nine at the end ('post-training' set) of a 2 day stress echo school which included a joint reading session of 50 tapes. The two sets were balanced as far as type of stress and image quality. The 17 observers had an average accuracy score of 51+/-16.4 before and 64.3+/-8.7% after the training (P<0.005). Concordant (i.e. >14 readers giving the same response) interpretation occurred in three out of nine studies before and in eight out of nine studies after the training (33% vs 88%, P<0.01). Kappa values went from 0.14 (poor) before to 0.39 (fair, close to moderate) after the training.

CONCLUSION

Short-term, high-intensity dedicated training in stress echo, with joint reading sessions and consensus development of reading criteria significantly increased accuracy and markedly reduced the inter-observer variability in the reading of stress echoes by beginners. If there is a Shakespearean madness in stress echo reading, 'yet there is a method in't' (Hamlet, II, II, 205-206).

Liver ischemia modifies the concentration of plasmatic catecholamines after reperfusion in the rat

Pulmonary hypertension is one of the most frequent and severe consequences of liver ischemia. The aim of this study is to evaluate the presence of humoral vasoactive mediators, generated during liver ischemia, which could be able to determine the onset of pulmonary hypertension. Thus, we evaluated the plasmatic concentration of catecholamines (adrenaline, noradrenaline, dopamine) during the immediate reperfusion period. Wistar rats were used. Animals (n = 89) were divided into four groups. Group 1 served as control (sham-operated). In group 2 animals underwent 60 min of left hepatic exclusion. In group 3 animals underwent to bilateral adrenectomy. In group 4 animals had both bilateral adrenectomy and liver ischemia. Ischemia in group 2 and 4 was induced by interrupting the vascular supply to the left and median lobes, so avoiding the use of a portal shunt. Blood samples were collected from the suprahepatic inferior caval vein immediately after reperfusion. Strips of the main pulmonary artery were put into an isolated organ bath and tested for the response to noradrenaline, adrenaline and plasma samples. Plasma samples collected after ischemia caused a significantly greater (p < 0.01) contraction of the pulmonary artery compared to controls. Plasma samples collected after adrenectomy caused a weak contraction which was not different from that obtained in the adrenectomy + ischemia group. Plasma concentrations of catecholamines after liver ischemia were significantly increased in the control group (p < 0. 01). In adrenectomized rats only the adrenaline level was greatly reduced. However ischemia did not increase plasma catecholamines as it occurred in sham-operated rats.

Peyronie's disease--incision and dorsal vein grafting combined with contralateral plication in straightening the penis

OBJECTIVES

To evaluate the effectiveness of incisions of Peyronie's plaque and vein grafting combined with contralateral plication to straightening the penis.

PATIENTS AND METHODS

Twenty-four patients with Peyronie's disease were treated surgically with a vein patch grafting technique to correct penile curvature. Median penile deviation was 70 degrees (range 60-90 degrees ), in 1 patient curvature was 30 degrees and all were unable to have normal sexual intercourse. The deep dorsal vein was excised and opened longitudinally. Transverse relaxing incisions about 1-2 cm long were made on the plaques at the point of maximal curvature, then, two other lateral incisions were made on both ends at 3 and 9 o'clock. The endothelial side of the harvested vein was placed in contact with the cavernous tissue to cover the defect created. Application of the contralateral surface of the tunica albuginea was performed in 21 cases to straighten the penis.

RESULTS

After a median follow-up of 24 months, 19 patients were able to perform sexual intercourse, 3 patients who required intracavernous injection to maintain erection presented pre-operative adverse factors affecting erectile function. One patient returned to baseline pre-operative curvature. Twelve patients reported penile shortening, although only 5 patients were concerned about it. None of the patients permanently lost sensation in the glans of the penis. Palpable knots on the site of plication were reported in 5 patients.

CONCLUSIONS

Plaque incision and placement of a deep dorsal vein patch graft, combined with contralateral corporeal plication, is a relatively simple, safe and effective alternative to correct angulations greater than 60 degrees.

[Exercise test: abnormal ST segments restricted to recovery phase]

PURPOSE

To determine the incidence of atherosclerotic coronary artery disease (CAD) and or myocardial ischemia in patients (pt) with abnormal ST segments restrict to recovery phase (RRAST) of exercise testing (ET).

MATERIAL AND METHOD

Retrospective study in 19 non consecutive pt with RRAST, related to coronary arteriography or exercise planar scyntillography (18 men, 58 +/- 9 years, 18 asymptomatic).

RESULTS

RRAST corresponded to ST segment depression from 1 to 4 mm, with T inversion during early recovery (2 pt); late (14 pt) or both (4 pt). It was documented CAD (14 pt and 9) with artery-by-pass surgery); hypertensive myocardiopathy with normal coronary (3 pt), and mitral prolapse valve (1 pt). In 13 pt with coronary arteriography or exercise scyntillography, within the first 6 months from exercise testing, myocardial ischemia was confirmed in 8 pt in 3 pt, successive exercise testing showed RRAST reproductive in 2 cases.

CONCLUSION

The authors report the high incidence of CAD and or transitory hypoperfusion during myocardial scyntillography in symptomatic men with middle age with RRAST during exercise testing.

[Sertoli cell tumor. Case report]

A case of Sertoli cell tumor is described. It represents 1% of testicular neoplasms. Its clinical features, histology, histogenesis and treatment on the basis of the current literature are reported. The malignant potential of this kind of tumor is also stressed.

[Eosinophilic cystitis: an incidental diagnosis. An underdiagnosed entity]

The authors report on two cases of eosinophilic cystitis diagnosed by chance, are reported. Both patients had suffered from prostatic and vesical diseases. Since the endoscopic appearance and clinical manifestation of this disease are aspecific, the diagnosis of eosinophilic cystitis is always made on histological specimen. Even if it has been described as a rare entity, personal opinion is that the real incidence of eosinophilic cystitis is underestimated. The main features of pathogenesis and therapy are also described.