Clinical variables associated with late-onset thrombotic and cardiovascular events, after SARS-CoV-2 infection, in a cohort of patients from the first epidemic wave: an 18-month analysis on the "Surviving-COVID" cohort from Bergamo, Italy

Importance

Population studies have recorded an increased, unexplained risk of post-acute cardiovascular and thrombotic events, up to 1 year after acute severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Objectives

To search for clinical variables and biomarkers associated with late post-acute thrombotic and cardiovascular events after SARS-CoV-2 infection.

Design

Retrospective cohort study.

Setting

Third-level referral hospital in Bergamo (Italy).

Participants

Analysis of an existing database of adult patients, who received care for SARS-CoV-2 infection at our institution between 20 February and 30 September 2020, followed up on a single date ("entry date") at 3-6 months.

Exposure

Initial infection by SARS-CoV-2.

Main outcomes and measures

Primary outcome: occurrence, in the 18 months after entry date, of a composite endpoint, defined by the International Classification of Diseases-9th edition (ICD-9) codes for at least one of: cerebral/cardiac ischemia, venous/arterial thrombosis (any site), pulmonary embolism, cardiac arrhythmia, heart failure. Measures (as recorded on entry date): history of initial infection, symptoms, current medications, pulmonary function test, blood tests results, and semi-quantitative radiographic lung damage (BRIXIA score). Individual clinical data were matched to hospitalizations, voluntary vaccination against SARS-CoV-2 (according to regulations and product availability), and documented reinfections in the following 18 months, as recorded in the provincial Health Authority database. A multivariable Cox proportional hazard model (including vaccine doses as a time-dependent variable) was fitted, adjusting for potential confounders. We report associations as hazard ratios (HR) and 95% confidence intervals (CI).

Results

Among 1,515 patients (948 men, 62.6%, median age 59; interquartile range: 50-69), we identified 84 endpoint events, occurring to 75 patients (5%): 30 arterial thromboses, 11 venous thromboses, 28 arrhythmic and 24 heart failure events. From a multivariable Cox model, we found the following significant associations with the outcome: previous occurrence of any outcome event, in the 18 months before infection (HR: 2.38; 95% CI: 1.23-4.62); BRIXIA score ≥ 3 (HR: 2.43; 95% CI: 1.30-4.55); neutrophils-to-lymphocytes ratio ≥ 3.3 (HR: 2.60; 95% CI: 1.43-4.72), and estimated glomerular filtration rate < 45 ml/min/1.73 m2 (HR: 3.84; 95% CI: 1.49-9.91).

Conclusions and relevance

We identified four clinical variables, associated with the occurrence of post-acute thrombotic and cardiovascular events, after SARS-CoV-2 infection. Further research is needed, to confirm these results.

COVID-19 impact on hospitalizations in older adults with chronic conditions: a real-world analysis from Lombardy, Italy

Background

Healthcare delivery reorganization during the COVID-19 emergency may have had a significant impact on access to care for older adults with chronic conditions.

Methods

We investigated such impact among all adults with chronic conditions aged ≥65 years, identified through the electronic health databases of two local health agencies - ATS Brianza and ATS Bergamo - from the Lombardy region, Italy. We considered hospitalizations for 2020 compared to the average 2017-2019 and quantified differences using rate ratios (RRs).

Results

Overall, in 2017-2019 there were a mean of 374,855 older adults with ≥1 chronic condition per year in the two ATS and 405,371 in 2020. Hospitalizations significantly decreased from 84,624 (225.8/1000) in 2017-2019 to 78,345 (193.3/1000) in 2020 (RR 0.86). Declines were reported in individuals with many chronic conditions and for most Major Diagnostic Categories, except for diseases of the respiratory system. The strongest reductions were observed in hospitalizations for individuals with active tumours, particularly for surgical ones. Hospitalization rates increased in individuals with diabetes, likely due to COVID-19-related diseases.

Conclusions

Although determinants of the decrease in demand and supply for care among chronic older adults are to be further explored, this raises awareness on their impacts on chronic patients’ health in the medium and long run.

Healthcare services access during the COVID-19 pandemic among older people

The COVID-19 pandemic strongly impacted older people, not only in terms of clinical outcome but also in care provision. Investigating trends of changes in healthcare services access among older subjects during the pandemic, along with studying potential determinants, is of utmost interest to identify the most at-risk individuals. We used data from LOST in Lombardia, a cross-sectional study conducted on a representative sample of 4,400 older adults (aged 65 or more) in autumn 2020. Data were collected about lifestyles, mental health, and access to healthcare services before and during the pandemic. To investigate potential determinants of changes in healthcare access, we presented prevalence ratios (PRs) estimated through multivariable log-binomial regression models. Twenty-one per cent of the participants increased telephone contacts with general practitioner (GP), 9.6% specialist visits for a fee, while 22.4% decreased GP visits, 7.5% ED access, 6% hospitalisations, 12.3% outpatient visits, 9.1% diagnostic exams. The prevalence of the cancellation or delay of medical appointments by the patient's decision was 23.8%, with higher proportions among men, among individuals aged 75 or over as compared to those aged 65-74, and among individuals with a higher self-reported economic status (p-value&lt;0.05). People with comorbidities more frequently cancelled or postponed visits, reduced ED access or hospitalisations. Moreover, individuals with worsened mental health status showed a higher prevalence to cancel or delay visits and to reduce ED access. The decrease in healthcare provision and consultations could result in mortality and morbidity excess. Our results should inform targeted intervention to bridge the gaps and overcome the health inequalities that the pandemic has deepened. Exploring the underlying reasons and determinants for healthcare avoiding or delaying among the most vulnerable groups is crucial for epidemic preparedness and planning future interventions.

It never rains but it pours: COVID-19 pandemic impact on mental health in older adults

Italy was the first country to be hit by the 2019 coronavirus disease (COVID-19) in Europe holding one of the highest clinical burdens. Older adults are those paying the highest price for the COVID-19 emergency. Within the Lost in Lombardy project, a web-based cross-sectional study assessing the prevalence of depressive and anxiety symptoms, hopelessness and insomnia before and during the COVID-19 pandemic, was conducted on a representative sample of 4,400 older adults aged 65 years or more from the Lombardy region recruited between November 17th and 30th 2020. The prevalence of depressive symptoms increased by + 112% during the pandemic, anxiety symptoms by + 136%, insufficient sleep by + 12%, unsatisfactory sleep by + 15%. Feelings of hopelessness were more frequent among women compared to men (15.1% vs. 10.4%) and increased with increasing age. A worsening in each of the four specific mental health outcomes was more frequently observed in women (OR = 1.50, depression; OR = 1.31, anxiety; OR = 1.57, sleep quality; OR = 1.38, sleep quantity), in subjects who decreased their physical activity during the pandemic (OR = 1.64, depression; OR = 1.48, anxiety; OR = 2.05, sleep quality; OR = 1.28, sleep quantity), and with increasing number of pre-existing chronic diseases (p for trend<0.001 for depression and anxiety; p for trend=0.010 for sleep quality; p for trend=0.012 for sleep quantity). A worsening in depressive symptoms was more frequently observed in more educated subjects (p for trend=0.008), while a worsening in anxiety symptoms in subjects living in main towns compared to outskirt with an economic status below the mean. The use of at least one psychotropic drug - mostly antidepressants/anxiolytics - increased by + 26% compared to pre-pandemic. The protection of the mental health status of this vulnerable segment of population needs to be recognized as a real public health priority.

Gender and socioeconomic inequalities in changes in a Mediterranean lifestyle among elderly Italians

The COVID-19 pandemic and the adoption of restrictive measurements to control the SARS-CoV-2 spread disrupted general population lifestyles including dietary behaviours. However, there is poor knowledge on potential socioeconomic and gender disparities in dietary changes. We conducted a telephone-based survey during fall 2020 on a sample of 4,400 participants representative of the population aged 65-99 years living in Lombardy, Italy. Changes in a Mediterranean lifestyle were assessed retrospectively by asking participants to report modifications in the consumption of nine food groups and five diet-related behaviours (e.g., consumption of organic and local foods) compared to the previous year (2019). We then computed a Mediterranean COVID-19 Pandemic Score (MedCovid-19 Score), reflecting changes during pandemic, ranging from -14 to 14, with increasing values indicating improvements in line with a Mediterranean lifestyle. Overall, 18.3% of the study participants worsened their Mediterranean lifestyle (MedCovid-19 Score <0), 35.1% remained stable (MedCovid-19 Score = 0), while 46.6% reported improvements (MedCovid-19 Score ≥1). Predictors of favourable changes toward a Mediterranean lifestyle were educational level (OR = 1.52; 95% CI 1.19-1.95 for postgraduate vs lower education), wealth (OR = 1.52; 1.14-2.02 for high vs low wealth), and skilled manual occupations (OR = 1.57; 1.28-1.92 vs white collars). Women were more likely than men to move away from a Mediterranean lifestyle (OR = 1.86; 1.58-2.21). In conclusion, improvements in line with a Mediterranean lifestyle prevailed in almost half of a large sample of elderly Italians surveyed during the COVID-19 pandemic. However, changes towards a Mediterranean lifestyle were disproportionately distributed across gender and socioeconomic strata. These findings were similar to those from the general population of the Moli-sani study, where it was observed that healthful dietary changes were associated greater wealth.

Assessing determinants of SARS-CoV-2 infection in a large older adult representative sample

Most COVID-19-related deaths occurred in older adults, however to date, evidence on determinants of SARS-CoV-2 infection in this population is limited and mostly based on case series without a comparison group. A telephone-based cross-sectional study was conducted in November 2020 on a representative sample of 4,400 people aged ≥65 years from the Italian region of Lombardy. We determined the prevalence of participants reporting a SARS-CoV-2 infection in the period between the onset of the pandemic and the time of the interview. To investigate the determinants of the infection, we estimated odds ratios (OR) and their corresponding 95% confidence intervals (CI) thorough unconditional multiple logistic models. We further evaluated if the infection was a determinant of a worsening in mental health wellbeing. Overall, 4.9% of participants reported a history of SARS-CoV-2 infection. No significant relationship between sex and infection was observed. SARS-CoV-2 infection was less frequently reported in subjects aged ≥70 (OR = 0.55; 95% 0.41-0.74) compared to 65-69 years. We didn't observe any trend after 70 years of age. Participants reporting at least one chronic condition had a lower infection rate compared to healthy subjects (OR = 0.68 95% CI: 0.49-0.93). Separated/divorced subjects more frequently reported infection than married/cohabiting ones (OR = 2.33 95% CI: 1.29-4.20). Self-reported history of SARS-CoV-2 infection resulted being a determinant of an increase in depressive symptoms (OR = 1.57; 95% CI: 1.17-2.10). In this large study - among the few assessing the determinants of SARS-CoV-2 infection in a representative sample of older adults -, the prevalence of a history of infection in November 2020 approached 5%. We found that persons aged 70 and above and those with chronic conditions, thus individuals with likely less social interactions, were less frequently exposed to SARS-CoV-2 infection.

Lipoteichoic acid stimulates the proliferation, migration and cytokine production of adult dental pulp stem cells without affecting osteogenic differentiation

AIM

To model in vitro the contact between adult dental pulp stem cells (DPSCs) and lipoteichoic acid (LTA), a cell wall component expressed at the surface of most Gram-positive bacteria.

METHODOLOGY

Human DPSCs obtained from impacted third molars were cultured and exposed to various concentrations of S. aureus LTA (0.1, 1.0 and 10 µg mL^-1 ). The effects of LTA on DPSCs proliferation and apoptosis were investigated by MTT assay and flow cytometry. Mineralization of DPSCs was evaluated by alizarin red staining assay. Migration was investigated by microphotographs of wound-healing and Transwell migration assays. Reverse transcription polymerase chain reaction was used to examine the effects of LTA on p65 NF-κB translocation and TLR1, TLR2 or TLR6 regulation. Enzyme-linked immunosorbent assay was used to investigate LTA-stimulated DPSCs cytokine production. One-way or two-way ANOVA and Tukey post hoc multiple comparison were used for statistical analysis.

RESULTS

DPSCs expressed TLR1, TLR2 and TLR6 involved in the recognition of various forms of LTA or lipoproteins. Exposure to LTA did not up- or down-regulate the mRNAs of TLR1, TLR2 or TLR6 whilst LPS acted as a potent inducer of them [TLR1 (P ≤ 0.05), TLR2 (P ≤ 0.001) and TLR6 (P ≤ 0.001)]. Translocation of p65 NF-κB to the nucleus was detected in LTA-stimulated cells, but to a lesser extent than LPS-stimulated DPSCs (P ≤ 0.001). The viability of cells exposed to LTA was greater than unstimulated cells, which was attributed to an increased proliferation and not to less cell death [LTA 1 μg mL^-1 (P ≤ 0.001) and 10 μg mL^-1 (P ≤ 0.01)]. For specific doses of LTA (1.0 µg mL^-1 ), adhesion of DPSCs to collagen matrix was disturbed (P ≤ 0.05) and cells enhanced their horizontal mobility (P ≤ 0.001). LTA-stimulated DPSCs released IL-6 and IL-8 in a dose-dependent manner (P ≤ 0.0001). At all concentrations investigated, LTA did not influence osteogenic/odontoblastic differentiation.

CONCLUSIONS

Human DPSCs were able to sense the wall components of Gram-positive bacteria likely through TLR2 signalling. Consequently, cells modestly proliferated, increased their migratory behaviour and contributed significantly to the local inflammatory response through cytokine release.

The first-generation phosphodiesterase 5 inhibitors and their pharmacokinetic issue

Background

Erectile dysfunction (ED) is a relatively frequent disease that negatively impacts the overall quality of life, well‐being, and relationships. Although the use of phosphodiesterase 5 inhibitors (PDE5is) has revolutionized the treatment of ED, a high percentage of ED patients discontinue PDE5i treatment.

Objectives

(i) To analyze the reasons for patient dissatisfaction leading to PDE5i discontinuation; (ii) analyze the pharmacokinetics of new formulations focusing on the time needed to reach an effective plasma concentration of PDE5is (T_onset) following drug intake; and (iii) summarize the physicochemical properties of sildenafil to understand which excipients may increase the absorption rate.

Material and methods

An online PubMed literature search was conducted to identify English language publications from inception to January 2019.

Results

The main reasons for patient dissatisfaction when using PDE5is on demand are the relatively long T_onset after taking vardenafil and sildenafil, including formulations such as film‐coated tablets, fine granules, orally disintegrating tablets (ODTs), and oral thin films (ODFs). The relatively long T_onset, further worsened when accompanied by eating, highlights the following: (i) the need for planning intercourse, determining partner‐related issues; (ii) issues when having sex before the maximum effect of the drug; and (iii) lower drug‐related placebo effects. Some data suggest that sildenafil is a ‘difficult’ molecule, but T_onset can be improved following absorption by buccal mucosa using appropriate excipients.

Conclusions

We conclude that several ODT and ODF formulations can improve the ‘discretion’ issue because they are taken without water, but they have similar pharmacokinetics to corresponding film‐coated tablet formulations. One ODF formulation of sildenafil was characterized by a shorter T_onset and could potentially increase patient satisfaction following treatment. However, more clinical studies are needed to confirm the findings. Surfactants and ascorbic acid appear to be crucial excipients for achieving a high absorption rate, but more studies are needed.

Between history and gossip: the state of women relative to syphilis, a traditionally male disease

Despite the new World Health Organization data remind us how syphilis is a disease which affects both sexes equally, this pathology has always been mainly considered a male disease. While several famous men are known to be affected by syphilis, there are very few women affected by this pathology of which we have historical records. Through the lives of Mary Todd Lincoln, Catherine of Aragon, Karen Blixen and Florence Foster Jenkins, this article would like to grant dignity to all the women who contracted syphilis in the wrong historical era where, for a woman, admitting to contracting it was shameful. Through the important women who lived their lives fighting against this disease and its complications, we would like to pay tribute to all those women who still today, in an era of antibiotics and where syphilis is a treatable pathology, they cannot be cured because they are both geographically and socially disadvantaged.

A short novel about the spread of two important diseases in history: syphilis and SARS

Throughout the centuries, the undefended nature of man has very often manifested in cases of epidemics, which have determined scenarios of suffering and death. Through “historical” observation lens, it is possible to understand the relationship between the spread of viruses, bacteria and parasites responsible for these epidemics and the displacement of ancient or contemporary travellers. We have analysed two infective diseases, syphilis and SARS, and their role in history and in medicine.

Severe obstructive sleep apnoea syndrome and erectile dysfunction: a prospective randomised study to compare sildenafil vs. nasal continuous positive airway pressure

BACKGROUND

A high incidence of erectile dysfunction (ED) among patients with obstructive sleep apnoea syndrome (OSAS) has been reported, with a strong correlation between obstructive sleep apnoea, ED, and quality of life (QOL), and it has been estimated that 10-60% of patients with OSAS suffer from ED. In this prospective randomised controlled trial, we investigated 82 men with ED consecutively who were referred to the outpatient clinic for sleep disorders and had severe OSAS (AHI> 30 events/h) without any other comorbidities as a possible cause of ED. The aim of this study was to evaluate and compare the efficacy of sildenafil vs. continuous positive airway pressure (CPAP) in men with ED and severe OSAS.

METHODS

Eighty-two patients were randomised to two main treatment groups: group 1 patients (n = 41) were treated with 100-mg sildenafil 1 h before sexual intercourse without CPAP, and group 2 patients (n = 41 men) were treated with only nasal CPAP during night time sleep. Both groups were evaluated with the same questionnaires (International Index of Erectile Function-EF domain; Sex Encounter Profile; Erectile Dysfunction Inventory Treatment Satisfaction) 12 weeks after treatment.

RESULTS

In patients receiving sildenafil treatment, 58.2% of those who attempted sexual intercourses were successful compared to 30.4% in the CPAP group. The mean number of successful attempts per week was significantly higher in the sildenafil group compared with the CPAP group (2.9 vs. 1.7, respectively; p < 0.0001). The mean IIEF-EF domain scores were significantly higher in the sildenafil group compared with the CPAP group (p < 0.0001). The overall satisfaction rate was 68% with sildenafil treatment and 29% with CPAP treatment.

CONCLUSIONS

This study confirms that severe OSAS is strongly associated with erectile dysfunction. CPAP and sildenafil (100 mg) are safe and effective therapies for OSAS-related ED patients. In the present study sildenafil was more effective than CPAP in treating ED associated with OSAS, as indicated by a significantly higher rate of successful attempts at intercourse and higher IIEF-EF domain scores. Our study, to date, is the only that has investigated sildenafil in patients with severe OSAS.

[Efficient prevention of overweight and obesity in the experience of family practitioners and "nutrition units" of the public health system in Lombardy]

General practitioners (GP's) presence is homogeneously distributed in the Lombardy territory. GP's are easy accessible by people so they could play a key role in the prevention of overweight and obesity. In this study GP's included in everyday medical activity a primary prevention strategy regarding nutrition and lifestyle. The goal was to maintain a constant BMI for one and a half year for at least 50% of the patients (stable means without progression within BMI's range). During the same time another endpoint was to decrease from 1 to 3 units the BMI in overweight patients in half of the observed population. Subjects were randomly recruited during routinely ambulatory activity, without a specific BMI based selection. Diet quality was assessed with a food frequency questionnaire regarding "protective foods" as vegetables, fruits and legumes. Some "basic" information about nutrition and lifestyle where then provided through explanation of issues printed on A4 page brochure. Percentage BMI's range variation before and after the intervention show a stability in the observed population, with an increase 0,3% for normal weight males and 0,9% for females. BMI was constant in 72,2% of the subjects considering a 1 unit variation and in 92,2% considering 3 units variation. Within subjects who varied 1 unit (27,7%) more subjects decreased rather than gained weight (16% vs 11,7%); within subjects who varied 3 units (7.8%), 4,5% decreased and 3,3 increased their BMI. GP's demonstrate to have an efficient role in weight gain control with a simple and regular prevention strategy towards healthy lifestyles and simple nutritional tips. It is important for patients to comprehend the importance the doctor give to the overweight and obesity problem, apart from the medical issue considered during the visit. GP's have a key role for healthy life-style change programs among their patients. These results provide new arguments about the opportunity to invest public resources towards population (managed in collaboration with GP's coordinated by a public health department such as NU), rather than towards a single patient. The project management was supervised by the Nutrition Unit (NU) of the public heath system SIAN (ASL di Brescia).

Recovery of sexual function after nerve-sparing radical retropubic prostatectomy: is cavernous nitric oxide level a prognostic index?

The preservation of NANC nerve fibers (producing nitric oxide, NO) is necessary for erection recovery after retropubic radical prostatectomy (RRP). Yet, it is impossible to establish when and if a patient will recover erections; therefore, we investigate the prognostic value of cavernous blood NO levels on this parameter. Nerve-sparing RRP was performed on 14 patients for localized prostate cancer. We evaluated all patients 3 months after surgery by IIEF score: no patients had erections. A cavernous blood sample was also taken to determine NO levels (as nitrite). Patients were evaluated again 18 months after surgery. In six cases, erectile function was compromised, whereas in seven cases, potency was restored. Statistical analysis showed a relationship between nitrite levels in cavernous blood 3 months after surgery and the recovery or erectile function at 18 months. We propose that cavernous NO blood levels are a prognostic index of erection recovery.

Uterine Preservation or Hysterectomy for the Uterovaginal Prolapse

For many years uterine prolapse has been an indication for hysterectomy, quite apart from the presence or the absence of any uterine disease and independently of the patients’ desire. Many studies on pelvic statics showed the central role of uterus on the pelvic static itself. Aim of the study is to prospectively compare sacropexy with and without hysterectomy in patients with uterovaginal prolapse. Surgical techniques, efficacy and overall results are described.

Material and Methods

Fifty-six consecutive patients affected by grade III-IV uterovaginal prolapse underwent colposacropexy: hysterectomy followed by sacropexy (SP) in 29 and hysterocolposacropexy (ISP) in 27. Before surgery all patients provided a detailed case history and replied to a questionnaire on urinary symptoms (Urogenital distress inventory). Patients underwent a clinical urogynaecological examination (HSW), a pelvic ultrasound scan and urodynamic test. Check-ups were scheduled at 3, 6, 12 months and then annually.

Results

No significant differences emerged in demographic and clinical characteristic in the SP and ISP groups. Mean operating times, intraoperative blood loss and hospital stay are significantly less after ISP (p<0.001). No patient required surgery for recurrent prolapse. Urodynamic results showed the pressure/flow parameters improved significantly (p< 0.001). 24/27 patients (88.9%) in the ISP group and 25/29 (86.2%) in the SP are satisfied and would repeat surgery again. 5/7 patients who would not repeat surgery were incontinent.

Conclusions

Sacrocolpopexy provides a secure anchorage restoring an anatomical vaginal axis and a good vaginal length. ISP can be safely offered to women who request uterine preservation. Long-term results in terms of prolapse resolution, urodynamic outcomes, improvements in voiding and sexual dysfunctions are excellent.

New therapeutic options for refractory neurogenic detrusor overactivity

AIM

Current pharmacologic treatment of detrusor overactivity relies on anticholinergic drugs. However, they often have untolerable side effects so that they are administered in doses insufficient to restore urinary continence. Recently, intravesical instillations and injections into the detrusor muscle of new pharmacological agents have been developed. The present study report our own experience in the treatment of detrusor overactivity with intravesical administrations of vanilloid agents and with botulinum-A toxin injections into the detrusor muscle in a group of spinal cord injured patients. In particular, we compared the clinical and urodynamic effects of the 2 drugs in an attempt to find a new and valid therapeutic option in those cases unresponsive to conventional treatment.

METHODS

Seventy-five patients with spinal cord injury and refractory detrusor overactivity were included in the study: 35 patients received repeated intravesical instillations of resiniferatoxin (RTX) dissolved in normal saline; 40 patients received repeated injections of 300 units botulinum A-toxin diluted in 30 ml normal saline. Clinical assessment and urodynamics were performed at baseline and 6, 12 and 24 months after treatment.

RESULTS

With both treatments there was a significant reduction in mean catheterization and episodes of incontinence and a significant increase in mean first involuntary detrusor contraction and in mean maximum bladder capacity at 6, 12 and 24 months after therapy. We did not detect any local side effects with either treatment. Botulinum-A toxin significantly reduced also the maximum pressure of uninhibited detrusor contractions more than RTX at all follow-up time points.

CONCLUSION

In patients with spinal cord injury and refractory detrusor overactivity intravesical RTX and botulinum-A toxin injections into the detrusor muscle provided beneficial clinical and urodynamic results with reduction of detrusor overactivity and restoration of urinary continence in most patients. Botulinum-A toxin injection provided better clinical and urodynamic benefits than intravesical RTX.

First Italian report of onychomycosis caused by Onychocola canadensis

Onychocola canadensis is a non-dermatophytic mould that has been associated with onychomycosis particularly in temperate climates. Until now, O. canadensis has been isolated from patients in Canada (14 cases), New Zealand (three), France (nine), UK (four) and Spain (two). We describe the first Italian case of onychomycosis caused by this fungus.

Stage pT1 renal cell carcinoma: review of the prognostic significance of size

INTRODUCTION

The last TNM classification (before 1997) defined T1 kidney tumour as a tumour <2.5 cm, limited to the kidney: this cut-off point was changed in 1997 and T1 neoplasm was defined as <7 cm. This new cut-off now includes past T1 and T2 diseases, without any differences in terms of prognoses. We performed a retrospective analysis of our cases and specifically investigated if there were any differences in terms of prognosis in a group of patients, currently identifiable as pT1, if they were divided into two subgroups based on tumour pathological sizes.

MATERIALS AND METHODS

Our analysis involved 128 patients (mean age 57.6 years) who underwent radical nephrectomy or nephron-sparing surgery in the period between 1990 and 2000. All these patients were pT1 according to the new TNM classification and were divided into two groups according to different cut-off point sizes (from 2.5 to 5 cm). We analysed the surgical approach, overall survival and cancer-specific mortality in the two subgroups, renamed as pT1a and pT1b, and performed a statistical analysis of the results using the Kaplan-Meier method to prove if this substaging identified changes in survival outcome.

RESULTS

We obtained more interesting results for a 5-cm cut-off: the two groups showed a similar follow-up and overall survival rate but different cancer-specific mortality rate (6 vs. 12.1%). The statistical analysis showed that the two survival curves (pT1a vs. pT1b disease) had a similar trend up to about 60 months; after this period the two curves diversify with a drop in survival rate among patients with larger tumours (pT1b patients).

CONCLUSIONS

It would seem reasonable to reassess the TNM classification of stage pT1 in order to better define prognosis in this group of patients.

Four-corner colposuspension: clinical and functional results

We report our experience with four-corner colposuspension and the long-term functional and objective results. Thirty-seven women aged 42-74 affected by cystocele, associated with stress incontinence in 27, underwent four-corner colposuspension, combined with posterior colpoperineoplasty in 5 and vaginal wall sling in 5. Preoperative work-up included clinical examination, a symptoms questionnaire, transrectal dynamic ultrasonography and a urodynamic test. The mean follow-up to date is 62 months (range 36-83). Check-ups included a clinical examination, responses to a questionnaire on symptoms, uroflowmetry, transrectal ultrasound, and a urodynamic test in 25. All patients underwent four-corner colposuspension, together with vaginal wall sling in 5 with severe incontinence and colpoperineoplasty in another 5 with symptomatic rectoceles. There were no major complications. The urethrocele was stably corrected in all. No relapses occurred in 19 patients with grades I-II cystocele preoperatively. Various forms of prolapse recurred in 12/18 patients with grade III cystocele. Incontinence was successfully resolved in 23/27 patients (85%). Instability persisted in 8/14 patients. Obstruction persisted in 6 patients with prolapse recurrence. The ideal candidate for four-corner suspension is a patient with moderate cystocele and no signs of uterine prolapse who may, or may not, be incontinent.

In vitro and in vivo study of 5-methoxypsoralen skin concentration after topical application

The aim of this work was to study the skin distribution of 5-methoxypsoralen (5-MOP) after application of topical gels, in vitro and in vivo, in both healthy and psoriatic skin sites of 6 psoriatic patients. Drug skin distribution was determined using the thin slicing technique and subsequent HPLC analysis. In the presence of dermatological disease, i.e. psoriasis, the permeability of the tissue changed considerably, leading to an important increase in the cumulative amount of 5-MOP recovered in the skin after topical application. The amount of 5-MOP found in vitro in the human skin was intermediate between those cumulated in healthy and psoriatic skin sites during an in vivo experiment. The gel formulation is an efficacious carrier for the topical photochemotherapy of psoriasis with 5-MOP, since it allows drug penetration in psoriatic skin.

Renal cell carcinoma: histological findings on surgical margins after nephron sparing surgery

PURPOSE

We evaluated the incidence of peritumoral satellite lesions in nephron sparing surgery and examined whether these findings have a negative effect on cancer specific survival and on the percent of local recurrence.

MATERIALS AND METHODS

We performed nephron sparing surgery in 63 patients with kidney cancer, including 53 elective (group 1) and 10 imperative (group 2) operations. In all cases we removed 10 mm. of apparently healthy peritumoral parenchyma with the tumor. This tissue was subsequently examined by an anatomical pathologist to identify any satellite lesions.

RESULTS

Four satellite lesions were identified, including 3 in group 1 and 1 in group 2, at a mean of 5.3 mm. from the primary lesion. None of the patients in either group had local recurrence at followup. Cancer specific survival was 96.3% in group 1 (mean followup 61 months) and 58% in group 2 (mean followup 39 months). It was not influenced by the presence of satellite micro-lesions.

CONCLUSIONS

Despite common perplexities concerning the risk of multifocality in renal cell carcinoma we believe that the nephron sparing procedure in select patients is as effective as radical surgery. Based on our experience the surgical safety margin must be at least 10 mm. of macroscopically healthy, peritumoral tissue.

Differing expression of enzymes of the glyoxalase system in superficial and invasive bladder carcinomas

This work aimed to study the activities of the glyoxalase system enzymes (glyoxalase I (GI) and glyoxalase II (GII) and their gene expression in human bladder carcinomas compared with the corresponding normal mucosa. Samples of these tissues were collected from 26 patients with superficial (SBC) or invasive bladder cancer (IBC) and used to evaluate enzyme activity and gene expression by northern blot analysis. In keeping with the electrophoretic pattern and the expression level of the respective genes, GI activity significantly increased in SBC samples, while it remained unchanged in IBC samples compared with the normal mucosa. In contrast, GII showed a higher activity in the tumour (either SBC or IBC samples) versus normal tissues. These results confirm the role of the glyoxalases in detoxifying cytotoxic methylglyoxal (MG) in bladder cancer. The differing levels of GI activity level and gene expression of GI between the SBC and IBC samples could help in their differential diagnosis.

Peyronie's disease: corporoplasty using saphenous vein patch graft

OBJECTIVE

To establish who the best candidates for corporoplasty are. The standard guidelines include patients with partial erections, and/or recurvature preventing normal and satisfying intercourse. In our unit we prefer to implant prostheses even in patients with slight erectile dysfunction, therefore patients with full erections routinely undergo corporoplasty.

MATERIALS AND METHODS

We report our experience with corporoplasty using a vein patch graft after plaque incision or excision in 12 patients affected by Peyronie's disease.

RESULTS

The operation is easy to perform. Recovery of normal spontaneous erectile activity was observed in 10/12 (83%) patients at a mean of 1 month postoperatively. The results of checkups with Rigiscan and EchocolorDoppler have confirmed the stability of the graft and recovery of potency.

DISCUSSION

Autologous material is easy to harvest and it is elastic enough to support traction during erection. The patch can be modelled to fashion patches in any shape required. The risk of scar shrinkage, with the consequent onset of recurvature, is lower than with other materials such as Gore-tex or Derma. Corporoplasty ensured rapid rehabilitation of sexual functions in all patients. We do not usually perform the Nesbit procedure as shortening of the penis (which is characteristic of Peyronie's disease) would, in most patients, be accentuated by albuginea plication.

[When and why to use penile prostheses: seven years of experience]

During the last years important changes in the management of the patients with erectile dysfunction have been verified. Psychologist, neuro-physiologist and bioengineers have given a valuable help in this field. Implant surgery represents, to our notice, the curative more acceptable choice for patient and the partner, since the results are excellent and the materials used extremely manageable. In each case the degree of satisfaction of the patient remains the only legitimate indicator currently for establish the effectiveness of the therapy.

Plasma and skin concentration of 5-methoxypsoralen in psoriatic patients after oral administration

The aim of this work was to investigate the distribution of 5-methoxypsoralen in the skin after oral administration of the drug and to examine the correlation between skin and plasma concentrations. 5-Methoxypsoralen skin concentration was measured in both healthy and psoriatic sites of 10 psoriatic patients after single and multiple oral doses. The results obtained show that 5-methoxypsoralen accumulates at higher levels in the more external layers of the skin after oral administration. The high affinity of drug for the stratum corneum was confirmed by in vitro skin affinity measurements. The concentration of 5-methoxypsoralen in the skin was similar in both psoriatic and healthy sites, indicating that the pathology does not influence drug distribution in the skin. After single dose administration, a linear correlation was found between skin and plasma drug concentration. After multiple dose administration, drug concentration in the skin was fairly constant despite the variable plasma concentrations in different subjects.

Ureterointestinal anastomosis in orthotopic neobladders

OBJECTIVE

This study reports our experience with a ureteroileal reimplantation technique based on the Leadbetter-Clarke method, which is used for orthotopic neo-bladders, constructed preferably with the Camey II technique.

METHODS

We carried out 114 ureteroileal reimplantations using this technique in 58 patients undergoing radical cystectomy and orthotopic neobladder reconstruction. The incidence of neobladder-ureteral stenosis and reflux were analyzed during the follow-up.

RESULTS

During the mean follow-up of 31 months, the incidence of stenosis was 2.6% (3 ureteroileal implants, including 1 case of neoplastic stenosis). The incidence of slight-to-moderate reflux was 9.6% but did not cause any deterioration in renal function or an increased incidence of reflux-related pyelonephritis.

CONCLUSION

This technique provided good functional results and a low incidence of complications, and may be recommended as a valid alternative to standard methods of creating ureterovesical anastomosis.

Penile prosthesis implantation and couple's satisfaction

OBJECTIVE

Implant surgery is the most acceptable curative choice for patients with erectile dysfunction and their partners, since the results are excellent with regard to the couple's pleasure and the materials used are extremely manageable.

MATERIALS AND METHODS

We performed 46 prosthesis implantations in patients with erectile dysfunction: in 22 patients we implanted soft prostheses; in 20 malleable prostheses; in 1 a mono-component prosthesis, and in 3 patients a tri-component model. All patients and partners were evaluated using a questionnaire.

RESULTS

We obtained a degree of satisfaction equal to 82% against 18% dissatisfaction due to a sensation of 'unnaturalness' report by the partner, with low perioperative and postoperative complications.

CONCLUSION

In our opinion the degree of satisfaction of the patient is currently the only legitimate indicator to establish the effectiveness of therapy.

Detubularized rectosigmoid neobladder in women after cystectomy for bladder cancer

BACKGROUND AND OBJECTIVES

We present the long-term functional results of a new technique for bladder substitution after cystectomy for bladder cancer in women.

METHODS

Between 1991 and 1995, 10 women underwent radical cystectomy for bladder cancer with a new technique. We created a detubularized rectosigmoid neobladder associated with either a terminal colostomy or intrasphincteric perineal colostomy section (Heitz-Boyer-Hovelacque). We evaluated neobladder functioning over almost 5 years by means of urodynamic studies, ultrasound scans, urograms and pouchgrams, and renal function tests.

RESULTS

Neobladder function was excellent in all patients, with good diurnal and nocturnal urinary continence, voiding patterns, and preservation of the upper urinary tract.

CONCLUSIONS

This new technique, which is a modification of the standard rectal or rectosigmoid neobladder technique, is a valid alternative to the ortothopic neobladder in women, with good functional results.

Immunohistochemical and quantitative study of mast cells in La Peyronie's disease

OBJECTIVE

In order to investigate the possible association between mast cells (MCs) and the fibrous plaque of La Peyronie's disease, the number of MCs in normal penile tissue and in the fibrous plaque was determined.

METHODS

The control group consisted of 5 total and 3 partial penectomies with no fibrotic lesions, while the study group consisted of 23 excisional biopsies from cases of La Peyronie's disease dating back to at least 2 years earlier and with no signs of activity. The biopsies included tissues from the tunica albuginea (TA), the areolar tissue (Br) between the tunica and the erectile tissue (CC) and from the latter. The number of MCs was counted with the aid of an image analysis program following staining the antibody antitryptase.

RESULTS

In the cases of La Peyronie's disease the number of MCs/mm(2) was significantly higher in the TA and Br but lower in the CC. The MCs were related to fibroblasts and vasculonervous channels in the TA, and were concentrated around the fibrous plaques and granulation tissue between the TA and BR and between the latter and the CC.

CONCLUSION

Our data indicate that MCs have a role in the genesis of the fibrous plaque in the TA and in the persistent inflammation in the Br. Medical treatment aimed at repressing MC activation and proliferation locally might be useful in La Peyronie's disease.

No-mortality liver resection for hepatocellular carcinoma in cirrhotic and noncirrhotic patients: is there a way? A prospective analysis of our approach

BACKGROUND

Low resectability rates and significant morbidity and mortality rates often make surgery for hepatocellular carcinomas (HCCs) unfeasible.

HYPOTHESIS

Our policy for surgical treatment of cirrhotic and noncirrhotic patients with HCC is adequate and safe.

DESIGN

Prospective validation cohort study.

SETTING

University hospital.

PATIENTS

One hundred seven consecutive patients with HCCs. Associated cirrhosis was present in 64 (59.8%), and only 7 (6.5%) had normal livers.

INTERVENTIONS

The presence of ascites, serum bilirubin level, and indocyanine green retention rate at 15 minutes were considered when selecting patients for surgery. Preoperative recovery of liver function was achieved with portal venous branch embolization, liver volumetry, bed rest, and control of serum aminotransferase levels. The surgical techniques mainly involved bloodless dissection using intraoperative ultrasonography and intermittent warm ischemia. The main perioperative care regimen was fresh frozen plasma infusion and strict limitation of blood transfusion.

MAIN OUTCOME MEASURES

The 30-day postoperative mortality and morbidity rates.

RESULTS

All the patients underwent surgery (37 major resections, 45 segmentectomies, and 25 limited resections), with no 30-day postoperative mortality, overall morbidity of 26.2%, and no major complications. Multiple logistic regression analysis revealed that only the type of operation was associated with a significantly higher morbidity risk (P = .05).

CONCLUSION

With high resectability, low morbidity, and no mortality, our policy represents a solution to the drawbacks of surgical resection for treatment of HCCs, especially in patients with associated liver cirrhosis.