CT volume of enhancement of disease (VED) can predict the early response to treatment and overall survival in patients with advanced HCC treated with sorafenib

OBJECTIVES

To analyse the predictive value of the volume of enhancement of disease (VED), based on the CT arterial enhancement coefficient (ΔArt%), in the evaluation of the sorafenib response in patients with advanced hepatocellular carcinoma (HCC).

METHODS

Patients with sorafenib-treated advanced HCC, who underwent a multiphase contrast-enhanced CT before (T0) and after 60-70 days of starting therapy (T1), were included. The same target lesions utilised for the response evaluation according to modified Response Evaluation Criteria in Solid Tumors criteria were retrospectively used for the ΔArt% calculation ([(HUarterial phase - HUunenhanced phase) / HUunenhanced phase] × 100). ΔArt% was weighted for the lesion volume to obtain the VED. We compared VEDT0 and VEDT1 values in patients with clinical benefit (CB) or progressive disease (PD). The impact of VED, ancillary imaging findings, and blood chemistries on survival probability was evaluated.

RESULTS

Thirty-two patients (25 men, mean age 65.8 years) analysed between 2012 and 2016 were selected. At T1, 8 patients had CB and 24 had PD. VEDT0 was > 70% in 8/8 CB patients compared with 12/24 PD patients (p = 0.011). Patients with VEDT0 > 70% showed a significantly higher median survival than those with lower VEDT0 (451.5 days vs. 209.5 days, p = 0.032). Patients with VEDT0 > 70% and alpha-fetoproteinT0 ≤ 400 ng/ml had significantly longer survival than all other three combinations. In multivariate analysis, VEDT0 > 70% emerged as the only factor independently associated with survival (p = 0.037).

CONCLUSION

In patients with advanced HCC treated with sorafenib, VED is a novel radiologic parameter obtained by contrast-enhanced CT, which could be helpful in selecting patients who are more likely to respond to sorafenib, and with a longer survival.

KEY POINTS

• To achieve the best results of treatment with sorafenib in advanced HCC, a strict selection of patients is needed. • New radiologic parameters predictive of the response to sorafenib would be essential. • Volume of enhancement of disease (VED) is a novel radiologic parameter obtained by contrast-enhanced CT, which could be helpful in selecting patients who are more likely to respond to therapy, and with a longer survival.

Urea Determination in Dialysis, based on a Differential pH Technique

The application of a new technique, based on differential measurements of pH, to determine urea concentration in patients of a dialysis center, is reported. Urea in plasma, whole blood or dialysis fluids is measured by an enzymatic reaction, with urease; the procedure, requiring 10 μL of sample, is simple, fast and correlates well with a reference spectrophotometric method, in the 0-300 mg/dL concentration range, according to the equation y = 1.0291 x - 0.0777; r = 0.9991; n = 73.

The prion protein regulates glutamate-mediated Ca2+ entry and mitochondrial Ca2+ accumulation in neurons

The cellular prion protein (PrP^C) whose conformational misfolding leads to the production of deadly prions, has a still-unclarified cellular function despite decades of intensive research. Following our recent finding that PrP^C limits Ca²⁺ entry via store-operated Ca²⁺ channels in neurons, we investigated whether the protein could also control the activity of ionotropic glutamate receptors (iGluRs). To this end, we compared local Ca²⁺ movements in primary cerebellar granule neurons and cortical neurons transduced with genetically encoded Ca²⁺ probes and expressing, or not expressing, PrP^C Our investigation demonstrated that PrP^C downregulates Ca²⁺ entry through each specific agonist-stimulated iGluR and after stimulation by glutamate. We found that, although PrP-knockout (KO) mitochondria were displaced from the plasma membrane, glutamate addition resulted in a higher mitochondrial Ca²⁺ uptake in PrP-KO neurons than in their PrP^C-expressing counterpart. This was because the increased Ca²⁺ entry through iGluRs in PrP-KO neurons led to a parallel increase in Ca²⁺-induced Ca²⁺ release via ryanodine receptor channels. These data thus suggest that PrP^C takes part in the cell apparatus controlling Ca²⁺ homeostasis, and that PrP^C is involved in protecting neurons from toxic Ca²⁺ overloads.

The pedicled buccal fat pad in oral reconstruction

AIM

Aim of the study was to present a follow-up on 46 cases in which pedical buccal fat pad (BFP) flaps were used to repair oral defects without any additional local flaps or skin grafts.

METHODS

The study comprised 46 patients, 31 men and 15 women, with an age range of 30-78 years (mean age 57.3 years). They were treated with a pedicled flap to repair defects of the ipsilateral maxilla (anterior or posterior), soft palate or retromolar mandibular area following tumor resection, osteonecrosis or the closure of oro-antral fistulae. The defects ranged from 2 × 2.5 cm to 4.5 × 5 cm. All patients were treated under general anesthesia.

RESULTS

The flap fully covered the intraoral defect with any aesthetic deficits. After one month, the flap was fully epithelialized and of adequate thickness in all cases. Three postoperative complications were reported: one superficial necrosis and two small fistulae.

CONCLUSION

Although the BFP has long been recognized and despite the simplicity of preparing the flap itself, numerically significant reports concerning the use of this technique in reconstructive facial surgery have only recently been published. The pedicled buccal fat flap is convenient and reliably repairs oral defects up to 4.5 cm in diameter on the ipsilateral side of the soft and hard palate, posterior alveolar region of the maxilla and the retromolar mandibular area. The surgical procedure is simple and morbidity at the donor site in not significant.

Edentulous mandible: clinical results of reconstruction with fresh frozen bone

AIM

The aim of this study was the clinical and radiological evaluation in severe mandibular atrophy (class V-VI Cadwood-Howell) of bone grafts with homologous fresh frozen bone (FFB) in patients with dysesthesia of the inferior alveolar nerve with or without transposition of the NAI in order to perform a proper implant-prosthetic rehabilitation.

METHODS

This article presents our experience in mandibular reconstructions performed in 12 patients with severe mandibular atrophy and dysesthesia performing onlay grafts with FFB and subsequent implant-prosthetic rehabilitation.

RESULTS

The surgical protocol of homologous bone graft in symptomatic patients with severe mandibular atrophy presented an excellent clinical outcome with disappearance of dysesthesia in all patients treated, good graft integration and a complete implant-prosthetic rehabilitation with loss of only 3 implants at the 24-36 month follow up visit.

CONCLUSION

Homologous bone grafting in patients with severe mandibular atrophy may be a viable therapeutic option in cases of prosthetic reconstruction in those symptomatic patients who cannot tolerate removable dentures, reducing intraoperative time, patient morbidity and the complications in common sites of autologous bone graft removal.

The prion protein constitutively controls neuronal store-operated Ca(2+) entry through Fyn kinase

The prion protein (PrP^C) is a cell surface glycoprotein mainly expressed in neurons, whose misfolded isoforms generate the prion responsible for incurable neurodegenerative disorders. Whereas PrP^C involvement in prion propagation is well established, PrP^C physiological function is still enigmatic despite suggestions that it could act in cell signal transduction by modulating phosphorylation cascades and Ca²⁺ homeostasis. Because PrP^C binds neurotoxic protein aggregates with high-affinity, it has also been proposed that PrP^C acts as receptor for amyloid-β (Aβ) oligomers associated with Alzheimer’s disease (AD), and that PrP^C-Aβ binding mediates AD-related synaptic dysfunctions following activation of the tyrosine kinase Fyn. Here, use of gene-encoded Ca²⁺ probes targeting different cell domains in primary cerebellar granule neurons (CGN) expressing, or not, PrP^C, allowed us to investigate whether PrP^C regulates store-operated Ca²⁺ entry (SOCE) and the implication of Fyn in this control. Our findings show that PrP^C attenuates SOCE, and Ca²⁺ accumulation in the cytosol and mitochondria, by constitutively restraining Fyn activation and tyrosine phosphorylation of STIM1, a key molecular component of SOCE. This data establishes the existence of a PrP^C-Fyn-SOCE triad in neurons. We also demonstrate that treating cerebellar granule and cortical neurons with soluble Aβ_(1–42) oligomers abrogates the control of PrP^C over Fyn and SOCE, suggesting a PrP^C-dependent mechanizm for Aβ-induced neuronal Ca²⁺ dyshomeostasis.

Cannabis Abuse at First Episode Psychosis (FEP): Data from Mental Health Centres in Modena and Bologna, Italy

Aims:

To evaluate the clinical and functional effects of cannabis abuse in patients at First Episode Psychosis (FEP) referring to Community Mental Health Centre (CMHC) “Bologna Ovest” and in patients admitted with a diagnosis of psychosis at the Modena Emergency Psychiatry Ward (EPW).

Method:

All FEP patients, aged 18-35, referring to CMCH “Bologna Ovest” in a 6-years period were evaluated and followed-up at 3 and 12 months. Of the 1559 psychiatric admissions at the Modena EPW in a 3-year period, those with a positive history for substance abuse were selected.

Results:

Among the 88 Bologna Ovest FEPs, 32% were cannabis abusers (FEP-c). In Bologna, FEP-c were more frequently natives (23.39% vs 31.13%; c sq=5.1; p=0.02) single (26.38% vs 0,0% c sq=7.3, p=0.007) and unemployed (13.50% vs 18.32%, c sq=2.4, p=0.1). Non FEP-c did not use any other drug (0.0% vs 26.1%, c sq=77.5; p< 0.001). A trend towards higher prevalence of hospital admission at follow-up was found for FEP-c (4.20% vs 2.4%, c sq=3.8, p=0.07). 22.0% of patients admitted at the Modena EPW had a positive history for substance abuse: of these, 7% were diagnosed with paranoid schizophrenia, which significantly correlated with the use of cannabinoids (alone or in association).

Discussion:

Our results enlighten that cannabis use is frequent among psychotic patients admitted to hospital and worsens clinical course of FEP patients, consistently with previous evidence (Hambrecht & Hafner, 1996; Hafner et al., 2004).

Assessment of right ventricular function and interstitial fibrosis in idiopathic dilated cardiomyopathy: hemodynamic correlates and prognostic value

BACKGROUND

Right ventricular (RV) function and morphometric quantitation of interstitial fibrosis in idiopathic dilated cardiomyopathy (IDC) have not been the subject of specifically designed clinical observations. In particular, their role in routine assessment and prognostic evaluation of patients (pts) with IDC remains to be settled.

METHODS

Eighty-one consecutive IDC patients (63 M, 18 F; mean age 52 +/- 11 yrs) with left ventricular (LV) systolic dysfunction (angiographic ejection fraction - EF - < 55%), normal coronary arteries and no histologic evidence of myocarditis were studied. Cardiac catheterization and endomyocardial biopsy (EMB) were routinely performed in all cases. RV volumes and EF were obtained by angiography according to Ferlinz' method and interstitial fibrosis was quantitated by computer-assisted morphometric analysis. These data were analyzed in order to study correlations with hemodynamic parameters and to assess their prognostic value in a long-term follow-up.

RESULTS

In the study population, right ventricular EF was significantly lower than in normal controls (35 +/- 11% vs 53 +/- 6%, p < 0.0001) and showed a significant positive correlation with LV EF (r = 0.54; p < 0.0001), and a weak but significant negative correlation with fibrosis (r = -0.29; p = 0.03). RV volumes, but not EF, were significantly related to mean pulmonary pressure. At multivariate analysis, RV end-diastolic volume (EDV) and EF were the two independent predictors of severe heart failure (NYHA class III-IV). After a mean follow-up of 64 +/- 36 months, 20 pts died and 9 had heart transplantation, for a 63% transplant-free survival rate (TFS). Multivariate analysis identified three independent predictors of TFS: LV stroke work index (p < 0.0001), RV stroke work index (p = 0.02) and RV EDV (p = 0.03). Fibrosis was predictive of survival only in the subgroup with LV EF < 20%.

CONCLUSIONS

Assessment of RV function provides useful information in the evaluation of hemodynamic profile and prognosis of pts with IDC. Quantitation of interstitial fibrosis by morphometry provides little additional data.

Rescue PTCA for a totally occluded left main coronary artery in acute myocardial infarction with cardiogenic shock: technical success and long-term survival

Percutaneous transluminal coronary angioplasty was performed after failed thrombolysis in a 54-year-old man for total occlusion of the left main coronary artery in the setting of acute myocardial infarction with cardiogenic shock. The procedure was successful in terms of vessel recanalization and restoration of flow. The recovery of muscle function was limited due to the time lag between onset of symptoms and recanalization. This case highlights the crucial role of early identification and prompt referral of patients with extensive ischemia to centers with the capability for emergency percutaneous revascularization procedures.

[Troponin T, Troponin I and CK-MB (mass) in the detection of periprocedural myocardial damage after coronary angioplasty]

The development of methods for the detection of circulating CK-MB mass, cardiac troponin T (cTn-T) and troponin I (cTn-I) has increased the diagnostic potential in the identification of myocardial damage. Coronary angioplasty (PTCA) represents a widely accepted revascularization procedure and a clinical model of induced ischemia. Using these new biochemical markers, we evaluated the incidence and the clinico-procedural correlates of minor myocardial damage (MMD) in a series of patients treated with PTCA in our Department. In 57 consecutive patients (75% males; mean age 58 years; range 35-80) undergoing elective PTCA from March 1 to June 30, 1995, serum levels of CK-MB mass, cTn-T and cTn-I were measured at baseline and at 6, 12 and 24 hours after the procedure. Seventy-eight coronary stenoses were dilated (mean 1.4 lesion/patient), 17 of these were in infarct-related vessels; 8 were total occlusions and 2 were located in saphenous vein grafts. Twenty-two procedures were completed by coronary stenting (17 elective). cTn-T and cTn-I were considered abnormal when serum levels were > 0.2 ng/ml and > 0.6 ng/ml, respectively. CK-MB mass was also determined in all patients (abnormal > 5 ng/ml). No patients had clinical or electrocardiographic evidence of myocardial infarction after the procedure. Overall, 16 patients (28%) developed biochemical evidence of post-procedural MMD (defined as the presence of at least one abnormal sample of any among the three markers tested). Four (7%) had abnormal CK-MB mass (at least one sample), 9 (16%) abnormal cTn-T, and 15 (26%) abnormal cTn-I. When CK-MB mass was elevated, both cardiac troponins were also elevated. In patients positive for MMD and abnormal CK-MB mass, peak cTn-I was significantly higher than in patients with normal CK-MB (3.02 +/- 1.07 vs 1.02 +/- 0.11 ng/ml; p = 0.009). The difference was not evident when comparing the same groups of patients for cTn-T (0.26 +/- 0.04 vs 0.18 +/- 0.10 ng/ml; p = 0.16). Also, peak cTn-I but not peak cTn-T had a positive correlation with peak CK-MB mass (r = 0.89; p < 0.0001 and r = 0.23; p = 0.40). The elevation of either marker of MMD was not related to clinical, angiographic or procedural variables. A possible interpretation for MMD was found in 2/3 of cases: bail-out (2); late occlusion (1); minor side branch occlusion (3); distal embolization from saphenous vein grafts (2) or total occlusions (2). In our series, MMD after PTCA occurs in 28% of cases and is unrelated to clinical, angiographic and procedural variables. Both cTn-T and cTn-I increase the sensitivity of CK-MB mass in the detection of MMD after PTCA, cTn-I being the most sensitive marker. In about 1/3 of cases, the presence of MMD remains unexplained. The prognostic implications of MMD are as yet undefined.

Troponin T, troponin I and creatine kinase-MB mass after elective coronary stenting

OBJECTIVE

To assess whether and to what extent elective coronary stenting is associated with biochemical evidence of minor myocardial damage (MMD), as defined by the detection of abnormal post-procedural serum levels of one more among the following markers of ischaemic injury: creatine kinase (CK)-MB mass, troponin T (Tn-T) and troponin I (Tn-I).

METHODS

Nineteen elective procedure of coronary stenting were compared with a matched group of 25 conventional percutaneous transluminal coronary angioplasty (PTCA) procedures performed in our laboratory from March to June 1995. Cases with evolving or recent (< 2 weeks) myocardial infarction, chronic total occlusions and dilation of saphenous vein grafts were excluded. By definition, all of the patients had undergone uneventful deployment of a single palmaz-Schatz stent, with no chest pain and no persistent ECG changes after the procedure. Serum levels of CK-MB mass, Tn-T and Tn-I were determined at baseline and 6, 12 and 24 h after the procedure. The frequency of abnormal results was determined for each marker. Baseline and peak post-procedural levels in the two groups were compared and related to procedural variables.

RESULTS

Baseline values were normal in all cases. The quantitative analysis showed that post-procedural levels of each marker (including total CK) were significantly higher with respect to baseline in both groups. In the stent group, two patients had positive CK-MB mass, four positive Tn-T and seven positive Tn-I. Absolute changes in Tn-T and Tn-I were closely related to changes in CK-MB mass (r = 0.76, P < 0.0001; r = 0.90, P < 0.0001), respectively). Three of these patients developed clinically silent side-branch occlusion. All of them were positive for troponins and two were positive for CK-MB. No correlation was found between procedural variables and the results of biochemical assays. In the PTCA group, three patients were positive for Tn-I, whereas the CK-MB mass and Tn-T remained constantly normal. No side-branch occlusion was observed. The peak CK-MB mass and Tn-I were significantly higher in the stent group than they were in the PTCA group (3.04 +/- 4.1 versus 1.27 +/- 1.3 ng/ml, P = 0.046; 0.78 +/- 1.17 versus 0.28 +/- 0.3 ng/ml, P = 0.046, respectively). This difference was no longer apparent when patients with side-branch occlusion were excluded.

CONCLUSIONS

In our series, Tn-I measurement shows the highest ability to detect MMD, being positive in 37% of stent and 14% of PTCA cases. Elective coronary stenting associated with greater release of CK-MB mass and Tn-I than is conventional PTCA. This finding is mainly determined by cases of side branch occlusion, which account for most, but not all, periprocedural MMD in the stent group.

Chronic peritoneal dialysis in paediatrics: experience of a national registry

The results of the first 3 years' collaboration of the Italian Registry of Paediatric Chronic Peritoneal Dialysis (CPD) (1986-1988) are presented. This Registry acquired data on the majority of the paediatric patients treated with CPD in Italy, thus providing a national picture in a field where few nationwide surveys are available. Patients of less than 15 years of age at the start of dialysis were enrolled and clinical data collected until the age of 19 years. The number of nephrological paediatric centres participating in the Registry increased from 7 in 1986 to 11 in 1988. The total number of patients on CPD was 70 and the percentage of dialysed children treated with CPD ranged from 40.2% to 43.6%. Data on 89 peritoneal catheters were collected: during 1417 dialysis-months 70 catheter-related complications were observed (1:20.8 dialysis-months); actuarial catheter survival was 92.7% at 6 months, 84.8% at 1 year and 68.8% at 2 years. the incidence of peritonitis changed from 1 episode every 10.9 patient-months in 1986 to 1 every 19.8 in 1988. Abdominal hernias were the other main clinical complication observed. The survival of patients was 92.5% at 3 years, while the technique survival at the same time was 84%.

Five years' experience of the Italian Registry of Pediatric Chronic Peritoneal Dialysis

The results of the first 5 years' experience of the Italian Registry of Pediatric Chronic Peritoneal Dialysis (CPD) (1986-1990) are presented. Patients of less than 15 years of age at start of dialysis were enrolled and clinical data collected until the age of 19. The number of the dialysis centres participating in the Registry increased from 7 in 1986 to 15 in 1990. The total number of patients on CPD was 119, the number of new patients per year ranged from 15 to 28 and the percentage of all dialysed children treated with CPD increased from 40% in 1986 to 49% in 1990. The age of patients at start of CPD was 8.5 +/- 4.9 years and 16% of them were under 2 years. Only CAPD was utilized in 1986, while CCPD/NPD accounted for 53% and 65% of the treated patients in 1989 and 1990, respectively. At 4 years, patient survival was 91.3% and technique survival 79.3%. A comparison between data of 48 patients on CPD and 34 on hemodialysis, who started dialysis in the period 1989-1990, showed that CPD was the most frequent form of initial therapy (56%) and was the treatment of choice for children younger than 4 years.

Atresia of the left main coronary artery: Clinical recognition and surgical treatment

Atresia of the left main coronary artery is an extremely rare anomaly with very few cases presented in the literature. Even more uncommon are reports of successful surgical repair. This article concerns two cases of atresia of the left main coronary artery treated surgically with a favourable outcome. The two patients (a 16 year-old boy and a 43 year-old woman) had a different clinical presentation but identical angiographic and morphologic features. The authors examine the embryogenetic defect underlying this anomaly. The differential diagnosis involves two congenital malformations (single coronary artery and anomalous origin of the left coronary artery from the pulmonary trunk) and acquired atherosclerotic disease of the left main coronary artery; the distinguishing features of these conditions are reviewed. Surgical management by means of internal mammary artery revascularization is discussed in light of recent reports about adequacy of blood flow in internal mammary artery bypass grafts.

Effect of hemodialysis and hemodiafiltration on uremic neuropathy

This study was undertaken to compare the effect of 1 year hemodialysis (HD) or hemodiafiltration (HDF) treatment on peripheral neuropathy. Thus 21 of 42 patients on chronic HD (1-1.3 m2 cuprophane dialyzer, Qb 300 ml/min) were switched to HDF (1.3 m2 polysulfone dialyzer, Qb 400 ml/min, substitution volume 9-13 liters, ultrafiltration rate 60-70 ml/min), while the remaining patients were considered as a control group. Treatment time was scheduled both in HD and HDF to maintain adequate BUN levels in relation to protein catabolic rate. However, HDF provided a significantly greater weekly inulin (MW 5,000) clearance than HD (5.8 +/- 1.2 vs. 1.6 +/- 0.2 ml/min; p less than 0.001). HD and HDF groups were comparable for age, time on dialysis and starting electroneurographic parameters, which were on average within the normal range. After 1 year follow-up, creatinine, hematocrit, calcium, phosphate, PTH, BUN, protein catabolic rate and residual GFR were comparable in the two groups, whereas beta 2-microglobulin was significantly reduced in HDF patients (29 +/- 6.7 vs. 38.8 +/- 13.9 mg/l in HD patients, p less than 0.01). During the 1-year treatment, electroneurographic parameters did not change in HDF patients, whereas a significant decrease of ulnar motor nerve conduction velocity, ulnar muscle action potential amplitudes, median sensory nerve conduction velocity and peroneal muscle action potential amplitudes was detected in HD patients. We conclude that HDF might prevent the worsening of the electroneurographic indices occurring during chronic HD treatment, as it provides a more effective removal of middle and larger molecules than HD. The use of a more biocompatible membrane in HDF might further contribute to this favorable effect on uremic neuropathy.

Acute coronary occlusion after recent coronary angioplasty. Association with exercise and successful treatment with intracoronary thrombolysis

A case of coronary occlusion occurred seven days after successful percutaneous transluminal coronary angioplasty. The acute complication occurred shortly after a negative exercise stress test and was resolved with intracoronary urokinase.

Improved biocompatibility by modified cellulosic membranes: the case of hemophan

The rising problem of biocompatibility is encouraging the development of new dialysis membranes, but the high cost of synthetic ones precludes their wide use. The authors compared the biocompatibility of cuprophan (CU), cellulose acetate (CA), and hemophan (HE), evaluating both in vitro and in vivo polymorphonuclear leukocyte (PMN) oxidative metabolism activation by resting chemiluminescence and complement activation by C3a; in vivo PMN counts during dialysis were also performed. The lowest increase in in vitro PMN resting chemiluminescence using HE was + 71.3% with CA, +49.3% with CU, and + 21.4% with HE (p less than 0.001 versus CA and CU); furthermore, HE did not significantly stimulate PMN resting chemiluminescence during in vivo hemodialysis: + 56.6% with CA, + 38.8% with CU, and + 3.7% with HE (p less than 0.01 versus CU and p less than 0.001 versus CA). C3a concentration increased with all membranes both in vitro and in vivo, but HE (in both experimental conditions) showed the lowest increase at any time (p less than 0.001 versus CA and CU). After 15 min of dialysis, PMN count dropped to 20.3% of basal values with CU, to 49.8% with CA, and to 76.5% with HE (p less than 0.001 versus CU and CA). Among cellulosic membranes, HE is the most biocompatible and appears to be an important step in preventing blood-membrane interactions and related complications.

Urea determination in dialysis, based on a differential pH technique

The application of a new technique, based on differential measurements of pH, to determine urea concentration in patients of a dialysis center, is reported. Urea in plasma, whole blood or dialysis fluids is measured by an enzymatic reaction, with urease; the procedure, requiring 10 microL of sample, is simple, fast and correlates well with a reference spectrophotometric method, in the 0-300 mg/dL concentration range, according to the equation y = 1.0291 X -0.0777; r = 0.9991; n = 73.

Prolidase deficiency in two siblings with chronic leg ulcerations. Clinical, biochemical, and morphologic aspects

Prolidase deficiency occurred in two sisters suffering from recurrent leg ulcers that appeared in early childhood. The patients presented the typical clinical symptoms of the disease, including characteristic facies, dermatologic manifestations of the lower extremities, splenomegaly, and hematologic anomalies. Large amounts of iminodipeptides were excreted into the urine, and prolidase activity in their erythrocytes was virtually absent. Changes associated with a connective-tissue disorder were demonstrated by light and electron microscopic studies of the patients' apparently normal skin. Collagen fibers were smaller than in controls and were irregularly packed; the fibrils had normal aspect but were significantly smaller than in one age-matched control. Elastin fibers appeared altered both in size and structure.

[Diverticular aneurysm of the right atrium]

A case of right atrium aneurysm (diverticulum) detected in an asymptomatic 61-year-old woman is described. Diagnosis was made according to echocardiographic and echocontrastographic findings and was confirmed by both angiographic data and surgical pathology. The rarity of this finding and the possibility of a correct non-invasive assessment can be considered the two most peculiar features of this case.

[Current status of Senning's physiologic correction of transposition of the great vessels. Personal experience]

From January 1978 to December 1985, 70 children affected by TGA have been operated with the Senning operation. Among the 70 cases, 64 were simple TGA and 6 were TGA + VSD. The mean age at operation was 6 months (range 2 day - 3 years). Of 64 cases with simple TGA, two (respectively of 2 days and 40 days) died with an operative mortality rate of 3.1% of 6 cases with TGA and VSD, one died with a mortality rate of 16.6%. The total mortality was 4.2%. Since 1981 in a continuative series of 47 patients there were no deaths. Our current policy is now the following: after the diagnosis of simple TGA by ECHO, if the Rashkind septostomy is successful, we perform Senning operation over 3 months; if the Rashkind is unsuccessful, we give prostaglandin (PGE1) for a long period (25-30 days) and in case we do a Blalock-Hanlon septectomy. In conclusion we think that in our hands, the policy followed in the treatment of simple TGA is justified by the results achieved but this policy does not prevent us from using different techniques if the results are better.

Renal tubular acidosis associated with vitamin D-resistant rickets. Role of phosphate depletion

3 children with vitamin D-resistant rickets (VDRR), and severe phosphate depletion had moderate metabolitic acidosis and evidence of impaired distal tubular acidifying mechanisms. Therapy with 1-alpha-OH-vitamin D3 and phosphate supplementation improved the clinical and radiological rachitic manifestations, and resulted in the normalization of systemic acid-base parameters as well as of tubular acidification. Profound phosphate depletion is another cause of acquired, reversible distal renal tubular acidosis (RTA).

Plasma levels of chlorodesmethyldiazepam in humans

Chlorodesmethyldiazepam (I) concentrations were followed for 72 h in the plasma of four volunteers given 2 mg of the drug orally. The drug appears to be well absorbed, reaching peak plasma levels of 20--30 ng ml-1 1--2 h after administration; 72 h after administration, plasma concentrations are still measurable (5 ng ml-1). The analytical method involved a single extraction of I from the plasma into benzene followed by centrifugation, evaporation, and gas-chromatographic analysis of the samples.

A safe blood transfusion procedure for immunization against major histocompatibility complex determinants in man

A standardized procedure is proposed for deliberate immunizations against human major histocompatibility complex determinants. The data presented demonstrate its effectiveness and, by using a number of necessary precautions, this procedure has proven to be very safe. The following points are especially important: (1) exclusive utilization of regular blood donors as immunizers; (3) use of whole blood as an immunizing agent; and (3) use of small immunizing stimuli rather than large transfusions. This procedure can be recommended for the production of monospecific anti-HLA antisera and it may be useful if and when a deliberate transfusion policy for prospective kidney recipients is adopted.

"Silent" alleles at the HLA-C locus

Defined specificities of the HLA-C locus possess a significantly lower immunogenicity as compared with the HLA-A and HLA-B specificities. HLA-C "blanks" are not immunogenic at all. Among the possible explanations, the most likely one appears to be a low phenotypic expression of these alleles. C locus antigens as a whole are thus likely to be of minor relevance in donor/recipient matching for transplantation.