Parathyroidectomy and survival in a cohort of Italian dialysis patients: results of a multicenter, observational, prospective study

BACKGROUND

Severe secondary hyperparathyroidism (SHPT) is associated with mortality in end stage kidney disease (ESKD). Parathyroidectomy (PTX) becomes necessary when medical therapy fails, thus highlighting the interest to compare biochemical and clinical outcomes of patients receiving either medical treatment or surgery.

METHODS

We aimed to compare overall survival and biochemical control of hemodialysis patients with severe hyperparathyroidism, treated by surgery or medical therapy followed-up for 36 months. Inclusion criteria were age older than 18 years, renal failure requiring dialysis treatment (hemodialysis or peritoneal dialysis) and ability to sign the consent form. A control group of 418 patients treated in the same centers, who did not undergo parathyroidectomy was selected after matching for age, sex, and dialysis vintage.

RESULTS

From 82 Dialysis units in Italy, we prospectively collected data of 257 prevalent patients who underwent parathyroidectomy (age 58.2 ± 12.8 years; M/F: 44%/56%, dialysis vintage: 15.5 ± 8.4 years) and of 418 control patients who did not undergo parathyroidectomy (age 60.3 ± 14.4 years; M/F 44%/56%; dialysis vintage 11.2 ± 7.6 y). The survival rate was higher in the group that underwent parathyroidectomy (Kaplan-Meier log rank test = 0.002). Univariable analysis (HR 0.556, CI: 0.387-0.800, p = 0.002) and multivariable analysis (HR 0.671, CI:0.465-0.970, p = 0.034), identified parathyroidectomy as a protective factor of overall survival. The prevalence of patients at KDOQI targets for PTH was lower in patients who underwent parathyroidectomy compared to controls (PTX vs non-PTX: PTH < 150 pg/ml: 59% vs 21%, p = 0.001; PTH at target: 18% vs 37% p = 0.001; PTH > 300 pg/ml 23% vs 42% p = 0.001). The control group received more intensive medical treatment with higher prevalence of vitamin D (65% vs 41%, p = 0.0001), calcimimetics (34% vs 14%, p = 0.0001) and phosphate binders (77% vs 66%, p = 0.002).

CONCLUSIONS

Our data suggest that parathyroidectomy is associated with survival rate at 36 months, independently of biochemical control. Lower exposure to high PTH levels could represent an advantage in the long term.

[Peritoneal dialysis in the Lazio region: results from 2017 regional audit]

In 2011, a first peritoneal dialysis audit was held in the Lazio region to analyze the problems hindering the spread of this method and to improve the quality of care through the sharing of best practices across Centers. A scientific board was therefore set up, representing all the Centers offering PD, in order to assess clinical effectiveness using KPIs (Key Performance Indicators) and to quantify the objectives to be achieved. The analysis made it possible to identify the main problems and take action, all the while monitoring progress through KPIs. A second audit was carried out in 2017 and the collected data was analyzed and compared with the findings of the previous study. Overall, data showed an increase in prevalence, although the incidence showed a slight decrease. Indicators on the change of dialysis treatment, the dropout from domiciliary treatment and the incidence of late referral appeared stable over time. A slight improvement was observed in clinical data on peritonitis and on the length of hospitalization. All participants in the audit declared that sharing and discussing clinical practices had been really useful. In addition, through the drafting of practical documents (guides for patients, guidance on informed consent, protocols of clinical follow-up), a number of tools have been provided to ensure a uniformly high level of care across the different regional Centers.

Testosterone-mediated activation of androgenic signalling sustains in vitro the transformed and radioresistant phenotype of rhabdomyosarcoma cell lines

PURPOSE

Rhabdomyosarcoma (RMS), the most common soft-tissue sarcoma in childhood, rarely affects adults, preferring male. RMS expresses the receptor for androgen (AR) and responds to androgen; however, the molecular action of androgens on RMS is unknown.

METHODS

Herein, testosterone (T) effects were tested in embryonal (ERMS) and alveolar (ARMS) RMS cell lines, by performing luciferase reporter assay, RT-PCR, and western blotting experiments. RNA interference experiments or bicalutamide treatment was performed to assess the specific role of AR. Radiation treatment was delivered to characterise the effects of T treatment on RMS intrinsic radioresistance.

RESULTS

Our study showed that RMS cells respond to sub-physiological levels of T stimulation, finally promoting AR-dependent genomic and non-genomic effects, such as the transcriptional regulation of several oncogenes, the phosphorylation-mediated post-transductional modifications of AR and the activation of ERK, p38 and AKT signal transduction pathway mediators that, by physically complexing or not with AR, participate in regulating its transcriptional activity and the expression of T-targeted genes. T chronic daily treatment, performed as for the hormone circadian rhythm, did not significantly affect RMS cell growth, but improved RMS clonogenic and radioresistant potential and increased AR mRNA both in ERMS and ARMS. AR protein accumulation was evident in ERMS, this further developing an intrinsic T-independent AR activity.

CONCLUSIONS

Our results suggest that androgens sustain and improve RMS transformed and radioresistant phenotype, and therefore, their therapeutic application should be avoided in RMS post puberal patients.

Peritoneal Equilibration Test Reference Values Using A 3.86% Glucose Solution during the First Year of Peritoneal Dialysis: Results of a Multicenter Study of a Large Patient Population

Background

The original peritoneal equilibration test (PET) was used to classify peritoneal dialysis (PD) patients using a 2.27% glucose solution. It has since been suggested that a 3.86% glucose solution be used because this provides better information about ultrafiltration (UF) capacity and the sodium (Na) sieving of the peritoneal membrane.

Objective

The aim of this study was to determine reference values for a PET using a 3.86% glucose solution (PET-3.86%).

Methods

We evaluated the PET-3.86% in a large population of incident PD patients attending 27 Italian dialysis centers.

Results

We evaluated the results of 758 PET-3.86% in 758 incident PD patients (1 test per patient). The mean duration of PD was 5 ± 3 months. The ratio of the concentrations of creatinine in dialysate/plasma (D/PCreat) was 0.73 ± 0.1 (median 0.74). The ratio between the concentrations of glucose at the end/beginning of the test (D/D0) was 0.25 ± 0.08 (median 0.24). Ultrafiltration uncorrected and corrected for bag overfill was respectively 776 ± 295 mL (median 781 mL) and 675 ± 308 mL (median 689 mL). Sodium sieving was 8.4 ± 3.8 mmol/L (median 8.0 mmol/L).

Conclusion

The results of the study provide PET-3.86% reference values for the beginning of PD that can be used to classify PD patients into transport classes and monitor them over time.

[Best practices on peritoneal dialysis: the audit of Lazio Region]

The diffusion of peritoneal methodology can not be something out of the real organizational context and the regional directive can not be the only means to encourage the diffusion. There is the need to provide effective and sustainable levels of assistance through a clinical scientific support and sharing of best-practises. On one side, the aim is to provide an aid by the centers with great expertise in the methodology, recognized as reference points; on the other side, to establish the shared K.P.I.s (Key Performance Index), to asses the clinical effectiveness and measure the objectives to be achieved, through a modality of valuation to establish the real applicability. For this purpose, a scientific board was founded, composed by the heads of UU.OO, that provide the peritoneal dialysis, to determine which aspects to investigate and identify factors of supply improvement. The selected method was the clinical audit. The analysis of the 2011 data has allowed us to capture the situation of the peritoneal dialysis in the Lazio Region. The formative procedure has enabled the centers to share and standardize protocols and therapeutic procedures, identify the strengths of peritoneal dialysis in the Lazio Region and define the KPIs through whose compare and monitor the centers over time. The conclusive analysis of the audit has enabled to identify a series of activities to be undertaken together in order to improve the situation of the peritoneal dialysis in the Lazio Region. In the following years, surveys will be carried out to verify the KPIs trend.

Endoscopic findings and psychometric abnormalities: what is the relationship in upper endoscopic outpatients?

BACKGROUND

Psychological disorders are often associated with diseases of the upper digestive tract. Although emotions can influence gastrointestinal function in healthy individuals, psychological setting in upper gastrointestinal patients are unclear. We evaluate the psychological alterations prevalence in outpatients submitted to upper endoscopy.

MATERIALS AND METHODS

A total of 130 patients (50 males and 80 females; mean age 54±17 years) submitted to upper gastrointestinal endoscopy, were enrolled over the period May 2009 - September 2010. Subjects were asked to complete questionnaires before endoscopic examination. Alexithymia, anxiety, depression and coping style were assessed using the Toronto Alexithymia Scale, Spielberger Trait Anxiety Inventory, Beck Depression Inventory and Coping Inventory for Stressful Situations, respectively.

RESULTS

Coping impairment, Alexithymia, Anxiety and Depression were found respectively in 80.3%, 25.4%, 24.6% and 17.2%, often in association. Task-oriented, emotion-oriented and avoidance-oriented alterations were found in 41.8%, 40% and 30.6%, respectively. No correlations were demonstrated between diagnosis of upper gastrointestinal disease and psychometric results.

CONCLUSIONS

In our study, a high prevalence of psychometric alterations in gastrointestinal outpatients was unconnected with endoscopic findings, especially considering coping style alterations. This aspect should be taken into account in patients management and a long-term follow-up should clarify a possible role of these factors in patients prognosis and compliance.

Prevention of complications during reoperative thyroid surgery

BACKGROUND

Thyroidectomy performed by an experienced surgeon is associated with a low incidence of recurrent laryngeal nerve injury and permanent hypoparathyroidism. During reoperative thyroid surgery there is a higher technical risk because detection and preservation of the recurrent laryngeal nerves and parathyroid glands are more difficult than in the primary surgery.

AIM

Our retrospective cohort study was to assess short- and long-term complications associated with reoperative thyroid surgery in order to suggest a technical approach to lower the morbidity rate.

MATERIALS AND METHODS

From January 2005 to September 2013, 745 patients underwent surgery for thyroid disease. Before surgery all patients underwent clinical examination, laboratory blood tests, hormonal assays, neck ultrasound, chest radiography and indirect laryngoscopy. Patients were followed up at 1, 3, 6 months and then annually after operation with hormonal assays, blood tests and neck ultrasound.

RESULTS

Eighty (10.7%) out of 745 patients (mean-age= 52.5 years; age-range 18-80) underwent reoperative surgery for recurrent thyroid disease. The primary treatments were enucleoresection (11.2%), thyroid lobectomy(56,3%), thyroid lobectomy with isthmectomy(10%) and subtotal thyroidectomy (22,5%). In the reoperative surgery group (Group Re) the transient RLN complications were 1.3% compared to 0.2% in the primary surgery group (Group P) (p= 0.51). The incidence of temporary hypocalcemia was 45% in the reoperative surgery group vs. 42.7% in the primary surgery group (p=0.72).

CONCLUSIONS

Reoperative surgery should be reserved to experienced surgeons. However, even in this case, when surgical maneuvers reserved for primary surgery are applied, then this surgery is associated with a low complications rate.

Management of Superficial Vein Thrombosis and Thrombophlebitis: Status and Expert Opinion Document

Superficial vein thrombosis is characterized by clotting of superficial veins (ie, following direct trauma) with minimal inflammatory components. Superficial thrombophlebitis is a minimally thrombotic process of superficial veins associated with inflammatory changes and/or infection. Treatments generally include analgesics, elastic compression, anti-inflammatory agents, exercise and ambulation, and, in some cases, local or systemic anticoagulants. It is better to avoid bed rest and reduced mobility. Topical analgesia with nonsteroidal, anti-inflammatory creams applied locally to the superficial vein thrombosis/superficial thrombophlebitis area controls symptoms. Hirudoid cream (heparinoid) shortens the duration of signs/symptoms. Locally acting anticoagulants/antithrombotics (Viatromb®, Lipohep ®, spray Na-heparin) have positive effects on pain and on the reduction in thrombus size. Intravenous catheters should be changed every 24 to 48 hours (depending on venous flow and clinical parameters) to prevent superficial vein thrombosis/superficial thrombophlebitis and removed in case of events. Low molecular weight heparin prophylaxis and nitroglycerin patches distal to peripheral lines may reduce the incidence of superficial vein thrombosis/superficial thrombophlebitis in patients with vein catheters. In case of superficial vein thrombosis/superficial thrombophlebitis, vein lines should be removed. In neoplastic diseases and hematological disorders, anticoagulants may be necessary. Exercise reduces pain and the possibility of deep vein thrombosis. Only in cases in which pain is very severe is bed rest necessary. Deep vein thrombosis prophylaxis should be established in patients with reduced mobility. Antibiotics usually do not have a place in superficial vein thrombosis/superficial thrombophlebitis unless there are documented infections. Prevention of superficial vein thrombosis should be considered on the basis of patient's history and clinical evaluation.

Selective inhibitors of aurora kinases inhibit proliferation, reduce cell viability and impair cell cycle progression in papillary thyroid carcinoma cells

The three members of the Aurora kinase family, Aurora-A, -B and -C, regulate several aspects of the mitotic process, and their aberrant expression and/or function causes mitotic abnormalities leading either to cell death or aneuploidy. They are found overexpressed in several human malignancies, including the papillary thyroid carcinoma (PTC). In the present study, we sought to establish whether Aurora kinase inhibition could be of any therapeutic value in the treatment of aggressive forms of PTC, enduring to radioactive iodide (RAI) ablation. To this end, the effects of selective inhibitors of Aurora-A (MLN8237) and Aurora-B (AZD1152) were analyzed on 3 human PTC cell lines expressing either wild-type (K1 and TPC1) or mutant p53 (BCPAP). The two inhibitors were capable of reducing cell proliferation in a time- and dose-dependent manner, with IC₅₀ comprised between 65.4 and 114.9 nM for MLN8237, and between 26.6 and 484.6 nM for AZD1152. Immunofluorescence experiments confirmed that AZD1152 inhibited Aurora-B phosphorylation of histone H3 on Ser10, however, it did not affect Aurora-A autophosphorylation. MLN8237 inhibited Aurora-A autophosphorylation as expected, but at concentrations required to achieve the maximum antiproliferative effects it also abolished H3 (Ser10) phosphorylation. Time-lapse videomicroscopy evidenced that both inhibitors prevented the completion of cytokinesis, and cytofluorimetric analysis showed accumulation of cells in G2/M phase and/or polyploidy. Apoptosis was induced in all the cells by both inhibitors independently from the p53 status. In conclusion, in the present preclinical study MLN8237 and AZD1152 have emerged as promising drug candidates for RAI-insensitive PTC.

Time Savings with Once-Monthly C.E.R.A.: A Time and Motion Study Conducted in 13 Haemodialysis Centres in Italy

BACKGROUND

We sought to document the time required by health care professionals to administer erythropoiesis-stimulating agents (ESAs) and continuous erythropoiesis receptor activator (C.E.R.A.) in the management of renal anaemia.

METHODS

A Time and Motion study was conducted in 13 centres in Italy. The time spent on preparation, distribution, and injection for both ESA and C.E.R.A. groups was measured. A multilevel model was run to account for the centre-clustering effect.

RESULTS

The average number of ESA injections/patient/year was 89. The average uptake of C.E.R.A. was 26%. The average time per session was 1.54 min for ESA (95% CI 1.21-1.86) vs. 1.64 min for C.E.R.A. (95% CI 1.31-1.97). Estimated time/patient/year was 137 min for ESA and 20 min for C.E.R.A. Assuming a 100% uptake of C.E.R.A., annual time savings/centre would be 84% (194 h).

CONCLUSIONS

Substantial annual time savings on frequent anaemia management-related tasks were found when a switchover was made from ESAs to C.E.R.A.

The endogenous caspase-8 inhibitor c-FLIPL regulates ER morphology and crosstalk with mitochondria

Components of the death receptor-mediated pathways like caspase-8 have been identified in complexes at intracellular membranes to spatially restrict the processing of local targets. In this study, we report that the long isoform of the cellular FLICE-inhibitory protein (c-FLIP(L)), a well-known inhibitor of the extrinsic cell death initiator caspase-8, localizes at the endoplasmic reticulum (ER) and mitochondria-associated membranes (MAMs). ER morphology was disrupted and ER Ca(2+)-release as well as ER-mitochondria tethering was decreased in c-FLIP(-/-) mouse embryonic fibroblasts (MEFs). Mechanistically, c-FLIP ablation resulted in enhanced basal caspase-8 activation and in caspase-mediated processing of the ER-shaping protein reticulon-4 (RTN4) that was corrected by re-introduction of c-FLIP(L) and caspase inhibition, resulting in the recovery of a normal ER morphology and ER-mitochondria juxtaposition. Thus, the caspase-8 inhibitor c-FLIP(L) emerges as a component of the MAMs signaling platforms, where caspases appear to regulate ER morphology and ER-mitochondria crosstalk by impinging on ER-shaping proteins like the RTN4.

Metachronous elastofibromas

Elastofibroma Dorsi (EFD) is a rare pseudo-tumor characterized by the overgrowth of elastic fibers mixed to adipose and connective tissues typically growing in the subscapular region. This can be bilateral but only rarely synchronous affecting different anatomical sites at the same time. Hereby we present a case of a 42-year-old male patient found with three different metachronous elastofibromas: bilateral EFD and a further third localization by the right elbow. The two EFs in the subscapular region were resected. After surgery pain reoccurred on the right side. This required the implantation of a spinal electro-stimulator. The elbow lesion was not excised as it was asymptomatic.

Dermasilk® briefs in recurrent vulvovaginal candidosis. An alternative option in long-lasting disease

AIM

Recurrent vulvovaginal candidosis (RVVC) can be a long-lasting disease; some patients refuse one of the most used treatment based on the assumption of oral fluconazole and resort to self-medication, risking poor control of symptoms and the development of local side effects. The aim of the study is to compare underwear made of Dermasilk®, a pure fibroin fabric bonded with a permanent antimicrobial protection, with cotton placebo briefs to see whether it would be a useful tool in the management of RVVC in patients not receiving oral or topical antimycotic treatment.

METHODS

A double-blind, randomized study was carried out on 30 women who had a long-term history of RVVC with mild to moderate symptoms. The patients were randomly divided into two groups and instructed to use either white cotton placebo briefs (CT group) or Dermasilk® briefs (DS group) for 6 months.

RESULTS

All vulvovaginal symptoms and signs showed a statistically significant improvement in the DS group compared with the CT group (P<0.001) at the follow-up visits after 3 and 6 months. The number of flares of vulvovaginal symptoms was significantly lower in the DS group compared to the CT group (24 episodes versus 68 episodes during the 6-month study, P<0.001).

CONCLUSION

In the absence of both topical and oral antimycotics, Dermasilk® briefs appear to be a useful tool, in reducing the signs and symptoms and the episodes of vulvovaginal discomfort in patients suffering from RVVC.

Prevalence and progression of cardiovascular calcifications in peritoneal dialysis patients: A prospective study

BACKGROUND

Patients on dialysis may have abnormal serum levels of Ca, P and parathyroid hormone, with related bone diseases. This population has an increased risk of death, with cardiovascular calcification (CC) a contributing factor. Patients on peritoneal dialysis appear to be at increased risk of hyperlipidemia, a contributing factor to atherosclerotic plaque formation. Although several studies have described the presence and progression of CC in hemodialysis populations, there are fewer data in patients on peritoneal dialysis.

STUDY DESIGN

The Renal Osteodystrophy and Calcifications: Key factors in Peritoneal Dialysis (ROCK-PD) study was a 36-month, prospective observational study conducted in Italy. The study examined the presence and progression of CC in two cardiac valves and five arterial sites. The potential associations of serum Ca and P with mortality and cardiovascular morbidity, demographic, clinical and blood chemistry variables was investigated.

RESULTS

CC was present in 77% of patients at baseline (N=369) and in 90% of patients by study end (N=145), progressing in 73% of patients. There were 42 deaths (11%). Analyses showed a marked correlation between baseline P levels and the presence of left ventricular hypertrophy. However, there were no consistent correlations between serum Ca or P with mortality or morbidity.

CONCLUSIONS

CC was common in peritoneal dialysis patients and progressed in a majority of patients.

Gastrointestinal stromal tumors treatment in the Imatinib era. The role of fair indication

AIM

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. Surgery remains the elective treatment. We retrospectively compared two group of patients, who underwent surgery for GIST before and after Imatinib advent in order to analyze the recurrence and survival rate.

METHODS

Two patient groups who underwent surgery for GIST, from January 1997 to December 2002 (Pre-Imatinib group) and from January 2003 to December 2008 (Post-Imatinib group) were compared. Patients were evaluated on the base of gender, age, clinical manifestations, primary location and metastasis positivity, tumor size, mitotic index, immunoreactivity for CD117 and the outcome, including date of death.

RESULTS

In the Pre-IM group only one patient died for prostate cancer, 12 months after operation, the other died because of GIST with a 24.6 months of median survival rate (range 15-51). In the remaining 12 patients the median follow up period was 55 months (range 6-152 months). In the Post-IM group the mean follow up was 50.7 months (range 26-74) and they are still being assessed for oncological as well as surgical treatment.

CONCLUSION

Early diagnosis and radical resection remain the standard of cure for GISTs. To date, the use of Imatinib lead to its utilization as adjuvant and neo-adjuvant therapy in adults. Our experience suggests that there is a correlation between the mutational status of KIT and clinical outcome. These aspects should be explored for targeted therapy that can effectively combine biological therapy to surgery.

Explant-derived human dental pulp stem cells enhance differentiation and proliferation potentials

Numerous stem cell niches are present in the different tissues and organs of the adult human body. Among these tissues, dental pulp, entrapped within the ‘sealed niche’ of the pulp chamber, is an extremely rich site for collecting stem cells. In this study, we demonstrate that the isolation of human dental pulp stem cells by the explants culture method (hD-DPSCs) allows the recovery of a population of dental mesenchymal stem cells that exhibit an elevated proliferation potential. Moreover, we highlight that hD-DPSCs are not only capable of differentiating into osteoblasts and chondrocytes but are also able to switch their genetic programme when co-cultured with murine myoblasts. High levels of MyoD expression were detected, indicating that muscle-specific genes in dental pulp cells can be turned on through myogenic fusion, confirming thus their multipotency. A perivascular niche may be the potential source of hD-DPSCs, as suggested by the consistent Ca²⁺ release from these cells in response to endothelin-1 (ET-1) treatment, which is also able to significantly increase cell proliferation. Moreover, response to ET-1 has been found to be superior in hD-DPSCs than in DPSCs, probably due to the isolation method that promotes release of stem/progenitor cells from perivascular structures. The ability to isolate, expand and direct the differentiation of hD-DPSCs into several lineages, mainly towards myogenesis, offers an opportunity for the study of events associated with cell commitment and differentiation. Therefore, hD-DPSCs display enhanced differentiation abilities when compared to DPSCs, and this might be of relevance for their use in therapy.

[Incisional hernia prosthetic surgery: a prospective study comparing laparoscopic and open techniques]

BACKGROUND

Incisional hernia is a common complication of abdominal surgery and it is often a source of long-term morbidity. Surgical treatment include many different techniques and up to today the choice may be difficult. The employment of prosthetic materials has contributed to a remarkable improvement in the results of this surgery. We performed a prospective study to compare the outcomes after laparoscopic and open incisional hernia repair.

PATIENTS AND METHODS

A total of 60 patients were assigned at random to two groups to be operated for median incisional hernia with mesh. Of these, 30 underwent laparoscopic repair and 30 open repair performed by Rives-Stoppa technique. Early and long-term outcomes were analyzed by a median follow-up of 45 months (range 31-78). Statistical analysis was done to asses differences between the groups.

RESULTS

Both groups were homogeneus in terms of patient age, sex, body mass index, American Society of Anesthesiologists score and incisional hernia features. Laparoscopic repair is associated with a significantly lower incidence of wound infections, shorter operative time and hospitalization and faster return to work. The recurrence rate was similar between the two groups.

CONCLUSION

In our experience laparoscopic incisional hernia repair appear to be a safe, feasible and effective alternative to Rives-Stoppa technique.

[Open mesh technique versus laparoscopic transabdominal preperitoneal (TAPP) approach in inguinal hernia repair. Our experience]

BACKGROUND

In the last ten years the introduction of various open mesh and laparoscopic techniques has increased the interest in inguinal hernia surgery. Anyway controversy persists about the most effective inguinal hernia repair. The aim of this study was to compare the results of open mesh technique and laparoscopic transabdominal preperitoneal (TAPP) repair for inguinal hernia.

PATIENTS AND METHODS

We considered 584 patients, 532 man and 52 woman, between 19 and 86 years: 332 (56.8%) had open mesh repair and 252 (43.2%) laparoscopic TAPP repair of groin hernia. Operative time, complications, recurrences and time to normal activities were recorded in both groups (range follow-up 1-10 years).

RESULTS

The median operative time was 71 min for open group and 92 min for TAPP group. No intraoperative complications were observed. Postoperative complication rate was 4,5% in patients open group and 3% in TAPP group. The recurrence rate was less than 1% in both groups (0,6% for open repair and 0,4% for laparoscopic repair). Significant difference was observed in the median time to return to normal activities: 9,8 days in TAPP group versus 13,4 days in open approach.

CONCLUSIONS

Our experience confirmed the safety and effectiveness of laparoscopic transabdominal preperitoneal (TAPP) approach to inguinal hernia repair as excellent alternative to conventional surgery. The reduction of operative time, complications and recurrences is correlated to the surgeon's experience and learning curve.

[Reoperative thyroid surgery: personal experience and review of the literature]

The goal of this study was to evaluate the complication rate of reoperative thyroid surgery and to find out the way to minimize the morbidity associated with it. We reviewed our experience in 622 patients, who underwent thyroid operation from January 2000 to September 2007. Among these ones, 76 were the patients who underwent reoperative thyroid surgery. Prior surgery in the 76 reoperations was: nucleo-resection in 9 pts (12.9%), lobectomy in 43 pts (55.5%), lobectomy+isthmectomy in 7 pts (9.3%), subtotal thyroidectomy in 17 pts (22.2%). Histologic examination revealed: benign lesions in 67 pts (88.15%), papillary cancer in 4 pts (5.26%), follicular cancer in 2 pts (2.63%), follicular adenoma in 1 pt (1.32%) and Hashimoto thyroiditis in 2 pts (2.63%). Complications included: section of recurrent laryngeal nerve, that was reconstructed in the same operation, and bilateral palsy of the recurrent laryngeal nerve so that was necessary to make a tracheotomy. One of the patient at the first thyroid surgery had monolateral palsy of the recurrent laryngeal nerve with dyspnoea and dysphonia. Temporary hypoparathyroidism (Ca<8 mg/dl) occurred in 47.3% of the patients, who underwent reoperative thyroid surgery and in 45.2% of the patients, who underwent prior thyroid surgery. Conclusions. This study documents that reoperative thyroid surgery can be performed with little morbidity to the patient if precise operative rules are respected.

[Low-protein diet and nutritional status]

Low-protein diets (LPDs) are most useful to control uremic symptoms, but the fear of malnutrition is still an issue. Thanks to commercially available low-protein preparations, reducing the protein intake to 0.6 mg/kg/day and even 0.3 mg/kg/day (very low-protein diets, VLPDs) is quite easy. However, providing palatable low-protein diets without disrupting the patient's lifestyle may not be as easy as reducing the protein intake. The risk is a low compliance with the dietary prescription, resulting in reduction of calorie intake and malnutrition. The risk is even higher in patients beginning dialysis, for some degree of malnutrition is frequent in such subjects. Preserving an adequate nutritional situation is feasible for a long time in LPD-treated and VLPD-treated kidney patients independently of age and diabetes, as demonstrated by the MDRD study. Careful follow-up of protein and calorie intake as well as nutritional status is, however, required. Several anthropometric, laboratory, clinical, and bioelectrical impedance indices are available for follow-up. Moderate yet steady physical activity is highly advisable in patients with progressive renal disease.

[Low-protein diet in Italy today: the conclusions of the Working Group from the Italian Society of Nephrology]

The high estimated prevalence of chronic kidney disease (CKD) forcefully supports the need for collaboration among nephrologists, cardiologists, diabetologists and general practitioners, to reduce the cardiovascular risk of CKD patients and delay the start of dialysis. Many studies confirm that reducing the dietary intake of proteins improves uremia as well as acid-base and phosphorus disorders without exposing the CKD patient to the risk of malnutrition. The possibility of delaying renal death and the start of dialysis by almost one to two years is also recognized, thanks in part to the antiproteinuric effect of low-protein diets supplemented with keto acids and essential amino acids. Reducing the dietary protein intake delays the start of dialysis independently of the effect of renin-angiotensin system (RAS)-active antihypertensive drugs. Reduction of the dietary protein intake is indicated in patients with a glomerular filtration rate <25 mL/min (CKD stages 4 and 5). Some situations may, however, require an earlier switch to a low-protein diet, e.g., high proteinuria, renal function worsening at more than 5 mL/min/year, diabetes, and metabolic decompensation. If well designed and properly carried out, reduction of the dietary intake of proteins is not associated with low serum albumin levels or malnutrition, and does not affect patients death. Today, highly palatable, high-quality reduced protein preparations are widely available to reduce the protein intake of CKD patients.

[Low-protein dietary therapy in patients with chronic kidney disease]

Several prospective studies and meta-analyses including the recent Cochrane meta-analysis have demonstrated that reducing the protein content in the diet delays renal death and the start of dialysis in patients with chronic kidney disease (CKD). Reducing the dietary protein intake offers other benefits such as lowering accumulation of uremic toxins and circulating phosphates and improving symptoms and metabolic derangements. Following the publication of the Cochrane meta-analysis, some of the most renowned experts in Italy on dietary therapy in the CKD patient established a working group within the Italian Society of Nephrology (SIN), the ''Nephrontieres'' project. The current supplement of GIN presents the views of the members of the ''Nephrontieres'' group on a range of issues related to dietary therapy in CKD. A CME program for Italian nephrologists also originated from the collaborative work of the group.

[Extraperitoneal rectal cancer surgery]

Despite recent advances in radiation and chemotherapy, surgical resection remains the only potentially curative procedure for rectal cancer. The introduction of total mesorectal excision with autonomic pelvic nerve sparing and new modalities in restoring bowel continuity has improved significantly the prognosis as well as life quality of rectal cancer patients. Better results will be achieved only with a correct multidisciplinary approach. The Authors report their experience with surgical treatment of extraperitoneal rectal cancer, examine some important technical innovation and emphasize the oncological principles of radical surgery.

Efficacy and safety of once-weekly intravenous epoetin alfa in maintaining hemoglobin levels in hemodialysis patients

BACKGROUND

Although an erythropoiesis-stimulating agent (ESA) is most frequently administered intravenously for treatment of anemia in patients with chronic kidney disease who are on dialysis, few studies have compared the efficacy of different intravenous (i.v.) dosing schedules.

METHODS

This multicenter, phase IIIb, open-label, controlled study randomized 289 stable hemodialysis patients to continue with conventional dosing of i.v. epoetin alfa or darbepoetin, or to switch to once-weekly i.v. epoetin alfa at the same cumulative weekly starting dose, to maintain hemoglobin levels at 11.0-13.0 g/dL, and within 1.0 g/dL of the baseline value. Hemoglobin levels and ESA doses were recorded every 4 weeks for 28 weeks.

RESULTS

Hemoglobin levels fell significantly and ESA doses increased significantly between baseline and week 28 (mean of week 16-28 values) in the once-weekly epoetin alfa group, compared with the conventional treatment group (p< 0.001). The adjusted difference in mean hemoglobin levels between the groups was 0.73 g/dL (greater than the threshold for therapeutic equivalence of 0.5 g/dL). The changes between groups from baseline was significant at all time points for hemoglobin levels (0.36, 0.46, 0.81, 0.87, 0.78, 0.62 and 0.49 g/dL) and from week 12 for ESA dose (718.5, 1,326.5, 1,732.0, 1,839.7 and 1,959.1 IU/week; p=0.005). Hemoglobin was maintained at the target level in 78% and 84% of patients on conventional dosing, and 67% and 64% of those on once-weekly epoetin alfa in the intention-to-treat (p=0.1) and per protocol (p=0.016) populations, respectively.

CONCLUSIONS

This study did not show therapeutic equivalence of once-weekly i.v. epoetin alfa with conventional dosing regimens.

Clinical non-instrumental evaluation of dysphagia

Clinical non-instrumental evaluation plays an important role in the assessment of the dysphagic patient. This evaluation, called "bedside examination", aims to establish whether dysphagia is present, evaluating severity, determining the alterations which cause it, planning rehabilitation, testing outcome of treatment. The assessment takes into consideration anamnesis regarding the swallowing problem, evaluation of the anatomy and functionality, of sensitivity and the reflexes, of the swallowing apparatus. Finally, the oral feeding test is performed, which evaluates the oral and pharyngeal phases of swallowing. The examination performed in the neurologic patient is different from that performed in the patient submitted to ENT or maxillo-facial surgery.

[Adenocarcinoma following restorative proctocolectomy for ulcerative colitis: a case report and review of the literature]

Restorative proctocolectomy with ileal pouch-anal anastomosis has been accepted as the surgical treatment of choice for most patients with ulcerative colitis. The occurrence of adenocarcinoma arising near or into the ileal pouch is rare. Only 19 such cases have been reported so far. The authors report a case of a 67-year old male who developed an adenocarcinoma in the small rectal stump 12 years after a restorative proctocolectomy with double stapled ileal pouch-low rectal anastomosis for ulcerative colitis unresponsive to medical treatment. They, after a literature review, examine same steps of the procedure and emphasize the importance of regular and prolonged follow-up for all patients having restorative proctocolectomy for ulcerative colitis.

Does optical coherence tomography identify arterial healing after stenting? An in vivo comparison with histology, in a rabbit carotid model

OBJECTIVE

To verify whether optical coherence tomography (OCT) can accurately monitor the occurrence of arterial healing after stenting.

SETTING

Delayed stent endothelialisation may predispose to stent thrombosis. OCT is a high-resolution intravascular imaging technique that accurately identifies stent struts and arterial tissues.

DESIGN AND INTERVENTIONS

Eight New Zealand white rabbits underwent the implantation of single bare metal stents (diameter 2-2.5 mm, length 8-13 mm) in the right common carotid artery through the external carotid artery. After a median of 11 days (range 2-28), the stented arteries were visualised by OCT, with images acquired at a pull-back speed of 0.5 mm/sec. The rabbits were then euthanised, vessels were formalin-fixed and finally processed for histopathology.

RESULTS

We analysed 32 cross-sections from eight stented carotid arteries, for a total of 384 stent struts. OCT detected all of the stent struts in 30 of 32 cross-sections (93.7%), and correctly identified the presence/absence of tissue for every strut. Histological and OCT measurements of mean neointima thickness (0.135 (SD 0.079) mm and 0.145 (SD 0.085) mm, respectively, p = NS) were similar and closely related (r = 0.85, p<0.001). Neointima area progressively increased with longer time intervals from stent deployment to sacrifice; histological and OCT measurements were similar for each time interval. The intra-observer and interobserver reproducibility of OCT neointima measurements were excellent (R2 = 0.90 and 0.88, respectively).

CONCLUSIONS

OCT is a promising means for monitoring stent strut coverage and vessel wall healing in vivo, the relevance of which will become even more significant with the increasing use of drug-eluting stents.

[Adenocarcinoma of the appendix. A case report and review of the literature]

Primary adenocarcinoma of the appendix is a rare malignancy that constitutes less than 0.5% of all gastrointestinal neoplasms. Usually the diagnosis is made only after histological examination of surgically removed inflamed appendix. Alternatively represent an unexpected finding, confirmed by frozen section, during surgery performed for acute appendicitis or other non appendiceal pathologies. Natural history is strongly influenced by anatomic peculiarities of the appendix that predispose to early spread and perforation. Frequently is associated with synchronous and metachronous colorectal or extraintestinal cancers. The correct management is the right hemicolectomy as a primary procedure in the case of preoperatively or intraoperatively diagnosis or as secondary procedure, after two-three weeks from appendectomy, when the microscopic examination of specimen reveals the presence of adenocarcinoma. Right hemicolectomy is the best treatment for all histologic types (colonic, mucinous, adenocarcinoid), in presence of perforation and even in Dukes A tumors. A careful intraoperative search for synchronous lesions and a life-long program of surveillance for the detection of early stage metachronous carcinomas are recommended. The Authors report a case of primary adenocarcinoma of the appendix occurred in a 78 year-old female patient, diagnosed incidentally during surgery performed for ileus from suspected cecal neoplasm.

[Parathyroid carcinoma: clinical case and review of the literature]

INTRODUCTION

Parathyroid carcinoma is a rare endocrine neoplasm, difficult to define clinically and histopathologically.

CASE REPORT

The case concerns of a 20 years old male with situs viscerum inversus (with dextrocardia), and symptoms: asthenia, oliguresis, nausea, emesis, myalgia, lower limb paresthesia and very high levels of calcium and PTH. Laboratory findings (PTH 580 pg/ml; Ca 12.40 mg/dl; P 1.9 mg/dl), echography, TC, and parathyroid scintigraphy, associated with clinical data, have suggested hypothesis of parathyroid carcinoma confirmed by histological examination and immunochemistry. Surgery was efficacious with normalization of Calcium and PTH levels, and disappearance of symptoms. After two years no signs of local recurrence were present, but imaging show pulmonary micronodulations of uncertain pathological meaning.

DISCUSSION AND CONCLUSION

No clinical or bio-humoral data allows a preoperative diagnosis of parathyroid carcinoma. Only with definitive pathology and immunohistochemistry it is possible to differentiate an adenoma from a carcinoma. Surgery is the only effective therapy and therefore should be always performed. This neoplasm usually relapses, locally first and later with distant metastases. For this reason after surgery the patients should always undergo a strict follow-up programme including evaluation of PTH and calcemia.

[Complicated diverticular disease. Three cases of colovesical fistulas and review of literature]

Colovesical fistulas represent a possible less frequent complication of diverticular disease of colon. They represent a complex condition because of the possible and unexpected evolution into a septic shock with a high risk of death. The Authors report three cases of colovesical fistula as a complication of diverticular disease. They underline the importance of early diagnosis, specific antibiotic therapy and appropriate surgical therapy realized in one or two stages according to general and local conditions of each patient.

[Mininvasive treatment of strangulated paraesophageal hiatal hernia in emergency. Case report]

The Authors report a case of strangulated paraesophageal hiatal hernia occurred in a elderly woman and treated with laparoscopic approach. After review of the literature regard on this uncommon pathology that present about 5% of the hiatal hernias, they emphasize that the laparoscopic approach is appropriated even in emergency and comprises complete reduction of the stomach in abdomen, control of suitable position of the distal esophagus and cardias and making of effective hiatus-plasty.

Presence of membrane and soluble forms of Fas ligand and of matrilysin (MMP-7) activity in normal and abnormal human semen

BACKGROUND

The aim of this study is to shed some light on the role of the Fas system in human semen, by investigating whether there is an association between the expression of the molecules regulating the Fas system [membrane-bound Fas ligand (mFasL), soluble Fas ligand (sFasL) and matrilysin, the metalloprotease cleaving mFasL to sFasL] and sperm parameters.

METHODS

We investigated, by flow cytometric analysis, the presence of FasL on spermatozoa from normozoospermic and teratozoospermic subjects and, by western blot, the presence of sFasL and matrilysin in the seminal plasma of the same samples as well as on samples from azoospermic subjects. The enzymatic activity of matrilysin was examined by gel zymography.

RESULTS

We observed that sperm cells expressed mFasL in 22% of normozoospermic men, whereas it was absent from spermatozoa from teratozoospermic patients. Higher levels of sFasL and augmented enzymatic activity of matrilysin were found in azoospermic samples.

CONCLUSIONS

The presence of mFasL on sperm from normozoospermic men and its absence in pathological samples emphasize the role of the Fas system in human semen. Moreover, the presence of both sFasL and matrilysin in seminal plasma implies a fine regulation of the function of the Fas system and, consequently, of the apoptotic process in the human genital tract.

An amperometric glucose biosensor prototype fabricated by thermal inkjet printing

The prototype of an amperometric glucose biosensor was realized by thermal inkjet printing using biological and electronic water-based inks, containing a glucose oxidase (GOD) from Aspergillus niger and the conducting polymer blend poly(3,4-ethylenedioxythiophene/polystyrene sulfonic acid) (PEDOT/PSS), respectively. The biosensor was fabricated microdepositing PEDOT/PSS and GOD, in sequence, on ITO-glass, by a commercial inkjet printer, with the help of a commercial software. High density microdots matrices were so-realized, with a calculated resolution of about 221 x 221 dpi (dot per inch). By means of a rapid and easy assay it was demonstrated that no activity loss occurred upon the printing of GOD, despite of the use of a thermal printhead. The device was encapsulated in a semipermeable membrane of cellulose acetate, applied by dip-coating, in order to prevent dissolution of the enzyme and/or PEDOT/PSS in water. The preliminary response of the electrode was measured in an aqueous glucose solution in the presence of ferrocenemethanol (FeMeOH) as a mediator, and resulted linear up to 60 mM in glucose. The best sensitivity value achieved was 6.43 microAM(-1) cm(-2) (447 nAM(-1) U(-1) cm(-2)). The characteristics of the device, and the possible performance improvements have been analyzed and discussed. The reported findings indicate that inkjet printing could be a viable instrument for the easy construction of a working biosensor via direct digital design using biological and conductive polymer based inks. Such an approach may be seen as an example of "biopolytronics".

Peritoneal mesothelioma in a case of inguinal hernia. A review of the literature

The peritoneal mesothelioma (PM) is a rare, benign or malignant, primary tumour, arising from the peritoneal membrane. The most frequent histological form is the malignant one with an incidence of 2-2.6 new cases per million per year. The symptomatology is insidious and poses difficult problems in the diagnosis and the treatment. Instrumental diagnostic investigations are useful only in the diagnostic orientation. Only the pathologic examination allows to distinguish a peritoneal carcinomatosis from PM. The prognosis of MPM is pour. An intense multimodal therapy, combining surgery with CT and RT, increases the survival rates in the patients with MPM. It has been proposed that hernia of abdominal wall play a role in the pathogenesis of this tumor. We believe that hypothesis seems unlikely considering the enormous discrepancy between the incidence of hernial pathology and PM.

[Collaborative study on peritoneal dialysis (PD) as first dialysis treatment in an Italian region: 1994-2000]

BACKGROUND

In Lazio, only about 5% of uremic patients are on peritoneal dialysis (PD). The present study focuses on the parameters of PD selection, the treatment schedules, and the clinical outcomes of PD patients in the nine public facilities offering a PD program. A cohort of 249 first-time PD patients, from July 1, 1994 to December 31, 2000, was retrospectively considered.

METHODS

For the enrollment of the patients, the Regional Dialysis Registry databank was consulted. On December 31, 2000, a systematic review of patient charts was performed to extract the reasons for the PD choice, details of PD schedule, peritonitis episodes, reasons for drop-out, and patient survival rates. In regard to technique success-defined as the probability of having a patient alive on PD-change of modality and death were considered as final events. In regard to patient survival, only death, even in the first 2 months after a shift to hemodialysis, was considered the end point.

RESULT

The main PD selection reasons were patient and/or nephrologist preference in 90% of cases. One-hundred eighty-nine patients (76%) had been started on CAPD. During the follow-up, 38.2% dialysis schedules had been modified at least once. At the end of follow-up, 41.2% patients were on APD. The peritonitis rate was one episode per 30 patient-months (1 per 27 patient-months in CAPD; 1 per 37 patient-months in APD; p = 0.08). The technique success rate was 66.3% after 2 years and 49.8% after 3 years. The patient survival rate was 81.1% after 2 years and 68.7% after 3 years.

CONCLUSIONS

Patients chose PD as a first dialysis treatment mainly because of reasons unrelated to their clinical status. The technique's success, patient mortality rates, and the peritonitis rate do not explain the low PD diffusion in the region. The peritonitis rate meets the target criteria for excellence recommended by the Italian Society of Nephrology. The observed outcomes may have been favored by the selection of motivated patients and by the increased use of APD.

FLIP is expressed in mouse testis and protects germ cells from apoptosis

Apoptosis control in adult testis is crucial to achieve normal spermatogenesis. In this study c-FLIP, an apoptosis-modulating protein, was investigated. In Western blot and immunohistochemical analyses, the 55 KDa c-FLIP long isoform (c-FLIP(L)) was found to be expressed strongly in spermatocytes and spermatids, at low levels in spermatogonia and at almost undetectable levels in Sertoli cells. This expression pattern was confirmed by Northern blot analyses. Further experiments carried out on GC-1spg germ cell line revealed that reducing c-FLIP(L) expression increases Fas-dependent apoptosis. Conversely, restoring c-FLIP(L) expression reduces this response to control levels. Caspase-10 expression was found to match c-FLIP(L) expression pattern; further, caspase-10 activation upon anti-Fas treatment inversely correlated with c-FLIP(L) expression. Finally, TUNEL staining of seminiferous tubules incubated with anti-Fas antibody showed that apoptosis occurs mostly in basally located germ cells, indicating that such cells, expressing low levels of c-FLIP(L), are sensitive to Fas-mediated apoptosis. These data indicate for the first time that c-FLIP(L) might control germ cell apoptosis and caspase activity in the adult testis.