Encephalitis lethargica. What is still wrong?

Encephalitis lethargica developed in epidemic from 1919 to 1926 in Europe and throughout the world. From the clinical point of view, the disturbances of consciousness and alertness and the possible outcomes of a postencephalitic Parkinsonism has attracted much attention. For a long time, it was thought that such a disease may still occur sporadically. In this review, the authors examined historical and current pictures of epidemics that may be related to Encephalitis lethargica. The previous Nona and Russian Influenza exhibited frequent neurological symptoms. The Spanish flu, formerly related to Encephalitis lethargica, would appear an epidemic that had its development in a partially overlapping period. The current pandemic linked to COVID-19 sometimes has aspects that can resemble Encephalitis lethargica. Based on historical analysis and the more recent immunological data, it could be suggested that Encephalitis lethargica was an autoimmune encephalitis that arose in a secondary form to the action of a viral agent. It cannot be ruled out that this agent was a coronavirus. From the nosological point of view, the term Encephalitis lethargica should be abolished in designating autoimmune encephalitis pictures that run sporadically.

Visceral and subcutaneous adipose tissue as markers of local and systemic inflammation: a comparison between celiac and obese patients using MRI

BACKGROUND

Celiac disease (CD) is a systemic inflammatory disease, which primarily affects the gastrointestinal tract. It has been recently demonstrated that adipose-tissue infiltration by proinflammatory immune cells causes a chronic low-grade inflammation in obese patients. Magnetic resonance imaging (MRI) has already proved to be useful in evaluation of inflammatory states. The aim of the present study was to determine whether alterations of visceral and subcutaneous adipose tissue, identified with MRI, could serve as markers of local and systemic inflammation in patients with CD.

METHODS

A pilot study was conducted comparing alterations in visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) in CD patients vs obese patients and healthy controls. Fifty patients were enrolled and assigned to one of the following groups: Group A: 11 active CD patients; Group B: 11 CD patients in remission; Group C: 16 obese patients; Group D: 12 healthy controls. A 3-T MRI unit was used and T2-weighted TSE images of VAT and SAT were obtained in specific regions of interest. Serum cytokine concentrations (TNF-α, IL-6, adiponectin, leptin, IL-2, IFN-γ) were determined.

RESULTS

There was a significant difference in VAT T2 relaxation time between Group A and B (p < 0.001), A and D (p < 0.01), B and C (p < 0.001). There was a statistically significant difference in SAT T2 relaxation time between Group A and B (p < 0.001), A and C (p < 0.05), A and D (p < 0.001), B and C (p < 0.01). In addition, VAT/SAT T2 relaxation time ratio showed a statistically significant difference between Group A and C (p < 0.05) and between Group B and C (p < 0.01). Only TNF-α and IL-6 significantly correlated with both VAT and VAT/SAT ratio in active CD.

CONCLUSIONS

MRI showed similar increased visceral inflammatory signals in patients with active CD and obese patients. However, subcutaneous inflammatory signals were higher in active CD than in all the other groups. These data show that there is a systemic inflammatory state in active CD, whereas chronic inflammation appears confined to VAT in obesity. These data were only partially confirmed by serological cytokine profiles, which showed less specificity than MRI.

Ionized and total serum magnesium in hemodialysis: predictors and variability. A longitudinal cross-sectional study

Background

Ionized Magnesium (ion-Mg) represents the active biological fraction of the serum magnesium content. The assessment of total serum Mg (tot-Mg) might not accurately identify patients with hypo-or hyper-magnesaemie. In hemodialysis, serum tot-Mg levels in the upper part of the distribution, have been associated with reduced mortality and fewer vascular calcifications; thus, resulting in the tendency to increase the Mg concentration in the dialysate, traditionally set at 0.5 mmol/L.

Methods

Single-center study in chronic hemodialysis patients, designed in two phases, cross-sectional and longitudinal, aimed to investigate: (1) the sensitivity for pathological values of ion-Mg compared to tot-Mg (2) the predictors of ion-Mg developing ad hoc equations; (3) the inter- and intra-individual variabilities of ion-Mg; and (4) the risk factors for hypermagnesemia. Tot-Mg, ion-Mg, and covariates of 42 hemodialysis sessions, in 42 patients during the cross-sectional phase and of 270 sessions in 27 patients in the longitudinal one were analysed.

Results

Ion-Mg significantly correlates with tot-Mg: β = 0.52; r = 0.88, p < 0.001. Multiple linear regressions in normo- and hypo-albuminemic patients gave the following results: ion-Mg = tot-Mg/2-K⁺/50 + Ca²⁺/5-HCO³⁻/100 and ion-Mg = tot-Mg/2 + albumin/100. Ion-Mg showed a high temporal variability in the longitudinal phase (between months p < 0.001; winter vs. summer, p < 0.027). A high intra-individual variability was also found: coefficient of variation 0.116. Comparing patients with high and low intra-individual variability, we found: age 67 vs. 77 years; p < 0.001; urea 26.3 ± 0.5 vs. 21.2 ± 0.4 mmol/L, p < 0.001; nPCR 0.92 ± 0.1 vs. 0.77 ± 0.1 g/kg day, p < 0.001; PTH 46.3 ± 4 vs. 28.5 ± 3 pmol/L, p < 0.001.

Conclusions

Ion-Mg can be useful in unmasking unrecognized hyper- and hypo-magnesemic and false hyper-magnesemic patients. Ion-Mg is characterized by high intra- and inter-individual variabilities particularly in younger women and those with better nutrition. Patients with greater variability could potentially be at risk if exposed to higher concentrations of magnesium in the dialysate. An interventional study, with controlled increase of magnesium concentrations in the dialysate has been planned.

Innate immunity in cutaneous melanoma

The skin immune system is composed of a vast network of immune cells, including lymphocytes, macrophages, neutrophils, dendritic cells and Langerhans cells, which not only are involved in inflammatory responses but also contribute to homeostatic function and may participate in the various steps of carcinogenesis. Many studies support the notion that innate immunity has a key role in the development, growth and prognosis of cutaneous malignant melanoma (MM), through the release of pro- and/or anti-inflammatory cytokines and tumour growth factors. The tumour environment in a major subset of cutaneous MM shows evidence of a T cell-infiltrated phenotype, but there is less known about the presence and the phenotype of other immune system cells. Response to immunotherapy is largely correlated with the presence of T cells in the tumour microenvironment, while the regulation exerted by stromal components such as macrophages and mast cells has been less investigated. In the current report, we review the recent literature, focusing our attention on the role of macrophages, dendritic cells, mast cells and natural killer cells in orchestrating MM progression, to better understand tumour immunobiology. The identification of new therapeutic targets and the application of approaches aimed at modulating crosstalk between immune and tumour cells, could have a crucial impact on immunotherapy and result in better clinical outcome. We hope this review will be helpful in cutaneous MM research.

Impact of gluten-free diet on quality of life in celiac patients

BACKGROUND AND AIM

Celiac disease (CD) is a common gluten-related disorder, whose only treatment is a gluten-free diet (GFD). Since a unique view on psychological consequences of a GFD still lacks, our aim was to assess the quality of life (QoL) and the depression state in symptomatic CD patients after GFD. Socio-demographic features were considered.

PATIENTS AND METHODS

210 adult CD patients were recruited and divided into 3 groups : 70 newly diagnosed patients (​Group A​),70 patients who have been on GFD for 6-12 months (​Group B​), and 70 patients who have been on GFD for more than 12 months (​Group C​). We recruited 210 healthy controls (​Group D). Psychological General Well-Being Index (PGWBI) and Beck Depression Inventory (BDI) questionnaires were administered. Each group was evaluated according to age, gender and school ranking.

RESULTS

Groups A ​and B showed lower PGWBI scores compared with both Group C ​and D (p <0.001 for each comparison). Moreover, Groups A and B showed higher BDI scores compared with both ​Group C ​and D (p <0.001 for each comparison).Women, the elderly and the poorly educated seemed to suffer more psychological stress.

CONCLUSION

GFD induces an improvement of well-being and a decrease of depression state after 12 months of strict GFD. Negative psychological implications were observed only in specific risk categories. (Acta gastroenterol. belg., 2016, 79, 447-453).

Elastofibroma dorsi: a histochemical and immunohistochemical study

Elastofibroma dorsi (ED) is considered a member of a heterogeneous group of benign fibrous (fibroblastic or myofibroblastic) softtissue tumors, frequently localized in the periscapular region in middle aged or older individuals. However, the pathogenesis of ED is still unclear and many authors believe that ED results from a reactive hyperproliferation of fibroblastic tissue, while others suggest that it may be a consequence of a mechanical friction. In our study, we examined 11 cases of ED using histochemical and immunohistochemical methods, in order to extend the knowledge about extracellular matrix composition and histopathogenesis of ED. From the results it appeared that stroma and interspersed spindle cells of ED were positive for both periostin and tenascin-C. Mast cells tryptase-positive were also abundant throughout the lesion. The perivascular distribution of periostin and tenascin-C, associated with the CD34 positivity, suggest that endothelial-mesenchymal transition events can account for neovascularization and production of fibroelastic tissue characteristic of elastofibroma. Our data obtained in endothelial cells cultures demonstrated that elastin production is higher when the status of confluence of the cells is low. So, we can assume that such a phenomenon is a characteristic of mesenchymal/endothelial cells CD34 positive, in which elastin production results to be inversely proportional to the vascular differentiation of cellular elements. In the light of these considerations, we think that a cancerous nature of ED is unlikely. Overall, our study report, for the first time, a detailed description of extracellular matrix composition in ED, suggesting that a mechanical strain-dependent reactivation of periostin and tenascin-C expression, as well as of elastin deposition, could be responsible for development of ED.

Detection and quantification of EBV, HHV-6 and CMV DNA in the gastrointestinal tract of HIV-positive patients

Human herpes viruses (HHVs) have been frequently detected in the gastrointestinal (GI) tract and may contribute to the development of gastric cancer. In the present study, the detection rate and viral load of Epstein Barr virus (EBV), HHV-6 and Cytomegalovirus (CMV) were assessed in the GI tract of human immunodeficiency virus (HIV) positive patients and of uninfected patients. The analysis revealed a significantly higher detection rate of EBV and HHV-6 in HIV-infected individuals than in uninfected subjects (88.5 vs 63%; p = 0.03). Moreover, EBV DNA load was significantly higher in the stomach of HIV patients than in controls. These data suggest that the HIV infection status may increase the persistence of these viruses in the GI compartment. Intriguingly, CMV DNA was undetectable in all biopsy specimens analyzed.

Macrophage Activation and Patterns of Inflammation in Obese and Non-Obese Women with Breast Carcinoma

Tumor-associated macrophages (TAMs) with M2 phenotype provide an immunosuppressive microenvironment for tumor growth. In contrast, A great deal of evidence indicates that macrophages in obese patients' adipose tissue undergo a phenotypic change from M2 to Ml polarization accelerating adipose tissue inflammation. Interestingly, obesity is considered a major risk factor for breast cancer. Here, we report a case-control study comparing normal-weight and obese women with breast cancer. Activation states of macrophages and patterns of inflammation associated to breast invasive ductal carcinoma were analyzed by immunohistochemistry. iNOS positive macrophages were counted as a Ml polarized population. Our study demonstrates that classically activated macrophages in obese patients outnumber classically activated macrophages in the breast of non-obese patients with infiltrating ductal carcinoma. However, cancer cell linked factors may strongly antagonize Ml macrophages' positive effects by both stimulating their switching to M2 TAMs and inhibiting their effects.

Rare adult masseteric rhabdomyosarcoma and a review of the literature

BACKGROUND

Rhabdomyosarcomas (RMSs) are a group of soft-tissue malignant tumors which derive from primitive skeletal muscle tissue that mainly affect children and adolescents. RMSs are very rare in adults, where they are usually located in the extremities.

CASE PRESENTATION

A previously healthy 32-year-old male presented at our ENT (ear, nose and throat) outpatient clinic after experiencing a parotid region swelling for 2 months. The patient was treated surgically by excising the mass and by modified radical ipsilateral neck dissection. Histological and immunohistochemical examination indicated masseteric alveolar RMS with lymphatic metastasis. The patient received radiochemotherapy, and he is still alive with no evidence of disease spread 1 year after diagnosis.

CONCLUSION

This is the first case of a masseter alveolar RMS to be reported in the literature in a patient older than 25 years; it highlights the broad spectrum of neoplasms that cause parotid region swellings and the importance of considering rare tumors during differential diagnosis.

Neurocutaneous Melanosis in a Woman with Multiple Brain Melanocytomas, Cutaneous Melanocytosis and Oral Involvement

A 34-year-old female was referred to us for a consultation of her dermatological lesions (pigmented lesions present in her oral cavity and on her right shoulder) in May 2007. These lesions had been present since childhood. Recently, the patient had developed seizures and a headache. An MRI of the brain showed the presence of two intracranial masses. The intracranial tumours were surgically removed whereas skin and mucosal lesions were biopsied. Histological findings of brain tumours were consistent with a diagnosis of “melanocytoma” while cutaneous lesions presented “benign dermal melanocytic infiltrations”. Whole brain irradiation was performed. After 3 months a new melanocytic skin lesion appeared on the scalp with histological picture similar to the other cutaneous ones. At the 5-year follow-up examination no recurrence of intracranial tumour or other skin or mucosal lesions were registered. According to the clinical and histological findings, we classify our case as a form of neurocutaneous melanosis in a young adult patient and we present it for the rarity of this syndrome, for the difficulty of the diagnosis, for the potential aggressive behaviour of intracranial lesions that necessitates a constant attentive follow-up and for the unusual feature of new developing skin lesion during the course of the disease.

Skewed T-cell receptor variable β repertoire and massive T-cell activation in idiopathic orofacial granulomatosis

Orofacial granulomatosis (OFG) is a clinicopathologic entity describing oral lesions with noncaseating granulomas including a spectrum of diseases such as the Melkersson-Rosenthal syndrome. The involvement of abnormal T-cell responses has been suggested in the pathogenesis of OFG although few and contrasting data are currently available on this issue. In a patient with OFG, we observed virtually complete CD4 and CD8 T-cell receptor (TCR) β-chain variable region (BV) repertoires at the lesion level and in circulation. However, oligoclonal profiles were found in CD4 and, to a greater extent, in CD8 subsets. These findings were seen in association with a massive peripheral T-cell activation, decreased naive T cells, reduced thymic output, altered cytokine production, and increased apoptosis. Our data, pointing to a random influx of T cells at the site of inflammation, argue against the hypothesis of a main allergen acting at the level of oral mucosa. The profound dysregulation of the peripheral T-cell compartment suggests that OFG should be regarded as a systemic disorder with localized manifestations.

Jaw osteonecrosis in patients treated with bisphosphonates: an ultrastructural study

Osteonecrosis of the jaw is a severe bone disorder traditionally associated with periodontal disease, local malignancy, chemotherapy, glucocorticoid therapy, or trauma. Recently a growing number of publications reported the occurrence of osteonecrosis of the jaw in patients undergoing treatment with bisphosphonates. The mechanism by which bisphosphonates might contribute to the development of osteonecrosis of the jaw is far from being fully elucidated. Suppression of bone turnover, infection, tissue hypoxia and cellular toxicity were proposed as possible mechanisms by which bisphosphonates may exert adverse effects on bone metabolism. Here, we studied 25 consecutive patients treated with bisphosphonates for osteoporosis or tumoral pathologies. We provide good evidence of hyperactive osteoclastic bone resorption and suggest a direct cytotoxic effect of bisphosphonates on bone tissue through induction of osteocyte cell death. We also demonstrate that bisphosphonates only have limited adverse effects on bone vascular network.

Chronic abdominal pain associated with intermittent compression of the celiac artery

Recurrent abdominal pain (RAP), surely one of the most frequent causes of medical intervention, is frequently present in many gastrointestinal disease. Usually no structural and/or biochemical alterations can be demonstrated. This condition is, therefore, considered to be due to functional disorders such as irritable bowel syndrome (IBS) or functional dyspepsia. Previous observations suggest the presence of a rare alteration of celiac vessels among the possible causes of RAP. This pathological condition was known as Dunbar syndrome. We report 2 cases of chronic abdominal pain. The former reported weight loss and the latter anemia with iron deficiency. It is remarkable that patients with initial diagnosis of IBS can be affected by celiac disease (CD), which is the cause of their abdominal pain. Our patients were tested for CD; the former was negative and IBS was diagnosed, the latter was positive and a gluten free diet was prescribed. The presence of an epigastric bruit, accentuated during expiration, suggested a possible vascular alteration known as tripod celiac artery compression syndrome. Duplex Doppler sonography suggests the diagnosis of celiac arterial constriction due the diaphragmatic ligament. These cases show that tripod celiac artery compression syndrome might be a cause of RAP and that it may be evaluated and investigated when the clinical examination discloses an abdominal systolic bruit.

Occult hepatitis C virus infection in type II mixed cryoglobulinaemia

Mixed cryoglobulinaemia, when not secondary to other well-defined immunological disorders, is commonly associated with hepatitis C virus (HCV) infection. However, a minority of cases lack evidence of HCV infection and are, therefore, defined as 'true essential' mixed cryoglobulinaemias. We thoroughly investigated three such patients to determine the aetiology of this disorder. Antibodies to HCV (anti-HCV) and HCV RNA, detected by sensitive enzyme-linked immunosorbent and polymerase chain reaction assays in serum and in concentrated cryoglobulins, were repeatedly negative in the three patients. Despite the lack of evidence for HCV infection, two of them were still treated with interferon alpha-2a assuming unrecognized viral infection. Both patients demonstrated excellent clinical and laboratory responses, but cryoglobulinaemia relapsed after the withdrawal of therapy. At the time of relapse, HCV RNA genomic sequences were detected for the first time in the cryoprecipitates of both patients. In the third case, HCV RNA was demonstrated for the first time during a flare of cryoglobulinaemia coincident with varicella infection. In all three patients anti-HCV antibodies remained negative throughout follow-up. We conclude that some apparently 'essential' forms of mixed cryoglobulinaemia can be caused by occult HCV infection. Interferon therapy can be taken into consideration in such HCV-negative cases.

Effects of Ginko Biloba and caspase inhibitors on brain ischemia in the Mongolian Gerbil

AIM

Data reported in previous studies and our own previous experience have led us to explore the mechanism of and the degree of protection afforded by Ginko Biloba in a model of cerebral ischemia in the Mongolian Gerbil evaluating histological and neurological effects in this rodent.

METHODS

Mongolian Gerbils were divided into experimental groups: Group A consisted of animals subjected only to experimental ischemia; 5 minutes occlusion of the carotid arteries. Group B consisted of animals subjected to experimental ischemia and to a dose of Ginko Biloba, given intraperitoneally immediately before the surgical procedure. Group C consisted of animals subjected to experimental ischemia and to a dose of Ginko Biloba, given intraperitoneally immediately after the surgical procedure. Group D consisted of animals subjected to experimental ischemia and to a dose of the caspase inhibitors z-VAD.FMK and z-DEVD.FMK injected intracerebroventricularly through the right hemisphere before the surgical procedure. Group E consisted of animals subjected to experimental ischemia and to a dose of caspase inhibitors injected after the surgical procedure. Group F consisted of Sham-operated animals. Histological controls were done by H and E and the TUNEL method in the frontal cortex and caudate-putamen.

RESULTS

The percentage of normal cells was not statistically significant at analysis with H and E, whereas the TUNEL method showed good protection with Ginko Biloba and caspase inhibitors, when the latter is given in the reperfusion phase. These data were in agreement with data obtained at neurological examination.

CONCLUSION

We could say that cellular morphology is in itself an untrustworthy tool for judging the effects of ischemia and protective drugs; the TUNEL method may add important information about the different components of cellular death; the reperfusion phase may be critical for apoptotic phenomena; Ginko Biloba might protect neurons of the frontal cortex from both necrotic and apoptotic death in this model of ischemia.

High incidence of Helicobacter pylori infection in patients with systemic sclerosis: association with Sicca Syndrome

To test the incidence of Helicobacter pylori (HP) infection in patients affected by Systemic Sclerosis (SSc) a swift urease test, followed by histologic confirmation for the presence of HP was verified in 35 SSc patients. Serum samples from 46 patients were tested for HP IgG antibodies by an enzyme-linked immunosorbent assay. Urease test demonstrated the presence of HP in 23 patients out of 35 (66&#x0025;); 12 of them were negative to colonization. A Sicca syndrome, with abnormal Schirmer’s test and dry mouth was detected in 66&#x0025; of the patients. 78&#x0025; of the patients with Sicca syndrome had a concomitant HP infection, compared to 42&#x0025; of those without the syndrome (p=0,029). Altered peristalsis and reduced salivary clearance usually encourage HP infection. In patients with Systemic Sclerosis we found an enhanced frequency of HP infection.

[Histopathologic examination of the intervertebral lumbar disk. Evaluation of its usefulness and limitations]

A retrospective clinical-pathological review of 192 lumbar intervertebral discs removed via an interlaminar approach or percutaneous nucleotomy from patients suffering from sciatic pain was carried out in order to assess if routine examination is useful. Only for a case of our series, which showed ill defined features at preoperative neuroradiologic imaging, an intraoperative pathologic examination was necessary. Immunohistochemical study was never required. A routine examination with a hematoxilin-eosin stain was sufficient also to recognize postoperative scar in patients reoperated. In conclusion we think that routine examination of the intervertebral disc is a procedure which is not expensive and useful to assess the nature of the lesion in reoperated patients and in rare cases showing unclear radiologic pattern.

Calf pseudohypertrophy in a patient with double neurogenic pathology

A pseudohypertrophy of the calf can be rarely associated with neurogenic pathologies as S-1 radiculopathy, poliomyelitis, spinal muscular atrophy, traumatic lesions of peripheral nerves, intraspinal neurinoma. The causes of this particular phenomenon are unknown. The authors present the case of a 52-year-old man with an enlargement of the left calf suffering from a mild form of spinal paralytic poliomyelitis in the early childhood and episodes of severe left sciatica in the last four years. Electromyography demonstrated a pattern of denervation in both legs and an H-reflex absent when the left tibial nerve was stimulated. An open muscle biopsy of the left calf was performed. Light microscopic and ultrastructural examination of the muscle confirmed the presence of a pattern of "neurogenic type" pseudohypertrophy. Our results could be interesting for the understanding of the mechanism of neurogenic pseudohypertrophy. This case suggests that timing of stimulus or "dose" of denervation may be important factors in such a phenomenon.

[Renal ptosis. Results of a national survey]

BACKGROUND

Renal ptosis is the caudal acquired displacement of one or both of the kidneys, with different degree and etiology, considered as a urological pathology because of its urodynamic changes and, in the last years, almost completely neglected.

METHODS

The aim of the work is to research a parenchymal involvement, through a close examination of our outpatient's record; compared with data from the literature on renal ptosis and with the results of a national questionnaire to specialists.

RESULTS

The literature reports a largest incidence in females; in our cases, instead, the incidence is nearly the same. The 2nd degree ptosis is the most frequent, but, in females, bilateral ptosis is prevalent (77%). We agree with the literature about urinary symptoms; actually, the most of the patients shows urinary colics or lumbar pain. We also noticed UTI (62%), urinary lithiasis (26%) and pyelocalyceal ectasia (46%). A lot of patients suffer from microscopic hematuria (77%) and, in 12%, gross haematuria was noticed. Hypertension affects about an half of the patients (46%) and the proteinuria too (42%). Echography highlights a reduced cortex (12%), cysts (14%) and other changes (8%). GFR is decreased in 30% of cases, in different degree. The patients show different changes, according to their age. The results of the national questionnaire are also reported.

CONCLUSIONS

In conclusion, considering the remarkable incidence and anatomical and functional changes, it is suggested to consider renal ptosis as a cause of chronic renal damage, also because it is included among the causes of obstructive nephropathy, which according to some researchers, can cause severe glomerular and tubular-interstitial changes, triggered off by a short urinary stasis and evident in the contralateral kidney too.

[High-flux arteriovenous fistula at the anatomic snuffbox]

Based on 25 years of haemodialysis experience, the authors confirm the importance of arteriovenous fistula at the anatomic snuff-box by L-L anastomosis with vessel end-tie, and assert that, even using small vessels, through simple devices, it is possible to achieve high-flux vascular access, that can be employed also for high-efficiency treatments (HF, HDF). The advantages and the troubles of this vascular access are considered and also the reasons that lead to dropping this arterio-venous fistula too. The authors describe the surgical technique and the devices of the procedure, based on their case-reports of 131 arteriovenous fistulas at the anatomic snuff-box, immediately working in 95% of the cases and compatible with high-flux blood in 67% of cases. Fine adventitial bridle resection is very important, because this procedure allows us to rest the venous vessel wall on the top of the fistula; the ligature of all collateral vessels is very important too. The arteriovenous fistula at the anatomic snuff-box (L-L terminated, with anastomotic leak of 5 mm) is the most advisable vascular access for all the patients in whom we can plan the start of dialysis some months advance.

Telangiectatic osteosarcoma of the skull. A post-Paget case

We report a case of post-Paget telangiectatic osteosarcoma of the skull in a 75-year-old woman. Such a neoplasia is a rare variant of osteosarcoma, a tumor rare in the cranic bones. The patient was submitted for a careful analysis by the following procedures: technetium scintigram, X-rays, CT scan, and MRI. After the surgical procedure, pathological examination confirmed the diagnosis. Both radiological and pathological pattern of this tumor are discussed in relation to the differential diagnosis. Our report shows that benign lesions may represent a possible cause of diagnostic errors. They must be excluded by histological analysis.

[Protozoan infection (Blastocystis hominis) concomitant with Pseudomonas sp. peritonitis in continuous ambulatory peritoneal dialysis (CAPD)]

Case-report of protozoal infection (Blastocystis bominis) during Pseudomonas peritonitis in male patient with intestinal diverticulosis on continuous ambulatory peritoneal dialysis (CAPD) treatment for chronic renal failure (CRF). Microscopic morphology and cultural characteristics are summarized from current literature. Photographic images in phase contrast from fresh-observation of faeces and peritoneal fluid are reported. Although other Protozoa (e.g. Acanthamoeba free-living) have already been found in dialysis fluid, this is the first case, referred in literature, of Blastocystis bominis infection in CAPD patients. Some pathogenetic hypothesis are done involving Blastocystis bominis in peritoneal infection, especially in immunodepressed patients like dialysed ones. Although many chemotherapeutics are provided for this protozoiasis during enteritis, in our case no supplement was required except specific antibiotic therapy for Pseudomonas infection. Symbion or pathogen? Is now-a-day the question which troubles parasitologists. Systemic research of Protozoa in dialysed patients is anyhow advisable.

Kartagener's syndrome in a woman with a normal ciliary structure and an intracranial meningioma

Kartagener's syndrome is usually associated with ciliary abnormalities. We describe a case of Kartagener's syndrome observed in a woman with an intracranial meningioma and a normal axonemal structure. This finding confirms that ultrastructural defects of bronchial cilia are not always present in Kartagener's syndrome.

[Renal ptosis: nephrologic consequences of an organ malposition]

Renal ptosis is the caudal acquired displacement of one or both of the kidneys, with different degree and etiology, considered as a urological pathology because of its urodynamic changes and, in the last years, almost completely neglected. The aim of the work is to research a parenchymal involvement, through a close examination of our outpatient record of cases, compared with data from the literature about renal ptosis. The literature reports the largest incidence in females; in our record of cases, instead, the incidence is nearly the same. Second degree ptosis is the most frequent, but, in females, bilateral ptosis is prevalent (77%). We agree with the literature about urinary symptoms; actually, the most of the patients shows urinary colics or lumbar pain. We also noticed UTI (62%), urinary lithiasis (26%) and pyelocalyceal ectasia (46%). A lot of patients suffer from microscopic haematuria (77%) and, in 12%, we noticed gross haematuria. Hypertension affects about half of the patients (46%) and proteinuria too (42%). Echography highlights a reduced cortex (12%), cysts (14%) and other changes (8%). GFR is decreased in 30% of cases, to a different degree. The patients show different changes, according to their age. In conclusion, considering that the incidence and the anatomic and functional changes are remarkable, we think it opportune to take renal ptosis into account as a cause of chronic renal damage, also because it is included among the causes of obstructive nephrophaty, which according to some researches, can cause severe glomerular and tubular-intestinal changes, triggered off by a short urinary stasis and evident in the controlateral kidney too.

[Utilization of an electronic archive in the organization of clinical data from patients at a dialysis center]

Today multiple programs allow storing of clinical data not yet satisfactory to practical management of nephrological patients. This work presents an electronic case history realized for nephrologic hospitalized or out patients, both in dialysis and in maintenance treatment, processed on a data-base (Fourth Dimension of Apple- Macintosh) which uses a "fourth generation" programming language and allows a personal or a multiple choice and a full data protection. As well as the personal or a multiple choice and a full data protection. As well as the storage of data about a single patient, the program allows an evaluation with correlations of data about all the patients. Fourth Dimension allows any sort of printing too, reports, accounts, cards, requests for tests, prescriptions and labels, with any kind of information coming from different files, which allows: a) to program pharmacological and dialytical treatments; b) to organize the employment of kidney machines according to the real needs and the availability; c) to balance weekly times, improving the working program; d) to plan prospects of expenses for the following year.

Biologic effect of 1,24(R)(OH)2D3 versus 1,25(OH)2D3 administration in chronic renal failure

1,24(R)(OH)2D3 is a synthetic analogue of 1,25(OH)2D3 which binds to the same receptors as the physiologic metabolite with a lower affinity. The aim of the present study was to compare the activity of 1,24(R)(OH)2D3 and 1,25(OH)2D3 on several target organs in patients with chronic renal failure. Treatment with 1,24(R)(OH)2D3 at doses of either 1 or 2 micrograms daily was carried out in two groups of 9 patients, with serum creatinine of 4.61 +/- 1.59 and 4.66 +/- 1.46 mg/dl, respectively. Doses of 1,25(OH)2D3 were 0.5 and 1 microgram daily and were administered to 9 and 13 patients, serum creatinine of 4.52 +/- 1.67 and 4.3 +/- 1.16 mg/dl, respectively. Treatment periods were of 2 weeks. Administration of 1,25(OH)2D3, 1 microgram, induced significant increments of intestinal calcium absorption (ICA), ionized calcium, osteocalcin, serum creatinine, urine Ca/GFR, and a decrease in iPTH. 1,25(OH)2D3, 0.5 microgram, induced a significant increase in ICA and osteocalcin and a decrease in iPTH. Similarly 1,24(OH)2D3, 2 micrograms daily, significantly stimulated ICA and raised serum levels of osteocalcin and creatinine while lowering serum iPTH. In addition, 1,24(R)(OH)2D3 administration induced a significant fall of serum 1,25(OH)2D3. Following 1 microgram, only osteocalcin increased. Therefore, the dose of 2 micrograms of 1,24(R)(OH)2D3 has biologic activity similar to 0.5 microgram 1,25(OH)2D3 (4:1). However the activity ratio on osteocalcin production appears to be 2:1. In addition, 1,24(R)(OH)2D3 is able to inhibit renal tubular 1 alpha-hydroxylase. In conclusion 1,24(R)(OH)2D3 may prove to be useful in the treatment of metabolic bone disease.

The extracellular matrix in slow-growing tumors of the central nervous system

This report describes and illustrates the results of the histopathological and histochemical investigation on five slow-growing tumors of the central nervous system: four meningiomas and an ependymoma of the spinal cord. We have studied, by means of polarizing microscopy, sections stained with picro-sirius red F3BA that enhance the birefringence of collagen and reticulum fibres. The heterogeneous behaviour of the distribution of the collagen let us conclude that the fibrillar component of the extracellular matrix have a scarce importance for the speed of growth of these tumours.

Serum neuron-specific enolase in various pathological conditions

Quantitative determination of neuron-specific enolase in the serum was performed by RIA method in 18 neurological patients and in 22 patients with pulmonary diseases. The data confirmed that the specificity of this marker is not absolute for the detection both of the nature and of the seat of origin of the disease. Further problems are posed in patients which simultaneously suffer from endocrine, nervous and pulmonary abnormality.

Symptomatic tension pneumocephalus after evacuation of chronic subdural haematoma: report of seven cases

We present seven cases of tension pneumocephalus developing after burr hole evacuation of chronic subdural haematoma. After a careful review of the literature we discuss the physiopathology, the diagnosis and the treatment of this complication of chronic subdural haematoma surgery.

Bone GLA protein in predialysis chronic renal failure. Effects of 1,25(OH)2D3 administration in a long-term follow-up

Serum bone GLA protein (BGP) was measured by radioimmunoassay in 42 patients (age, 47.5 +/- 16.6 years; serum creatinine, 4.32 +/- 1.9 mg/dl) with predialysis chronic renal failure (CRF). Nineteen patients were studied within a short period of time, while 23 were followed with repeated measurements of serum BGP, creatinine, iPTH, and alkaline phosphatase (AP) for a mean period of 17.1 +/- 8.1 months. Eleven of these patients were treated with 1,25(OH)2D3 for a mean of 16.8 +/- 6.4 months. In 23 patients at various stages of CRF, a transiliac bone biopsy was performed for histomorphometric evaluation. In the untreated patients, serum BGP was higher than normal and showed a positive correlation with creatinine levels (P less than 0.001). Serum BGP was also positively correlated with iPTH, AP, serum phosphate, active resorption surface, active osteoblastic surface, osteoid surface, and volume. During treatment with 1,25(OH)2D3, BGP, iPTH, and AP were significantly lower than in the untreated patients. The reduction in iPTH and BGP was proportional, while BGP and AP no longer correlated. Repeated measurements of BGP during the long-term follow-up showed a progressive rise in the untreated patients and a downward course of BGP levels during treatment. In conclusion, serum BGP increases progressively in CRF, rising with advancing renal damage in close correlation with iPTH, AP, and the severity of renal osteodystrophy. Treatment with 1,25(OH)2D3 causes a parallel decline in BGP and iPTH levels and dissociation between BGP and AP can be observed. Compared to AP, BGP seems to be a more reliable index of secondary hyperparathyroidism and potentially more useful in the long-term monitoring of treatment with 1,25(OH)2D3.

Circannual versus seasonal variations of longitudinally sampled 25-hydroxycholecalciferol serum levels

Seasonal variations in human serum levels of 25-hydroxycholecalciferol (25OHD) have been largely documented in transverse studies of population. But seasonality is not per se a demonstration that 25OHD serum levels fluctuate along the course of year according to a waveform profile with a periodic rhythm. Because of this, we attempted to investigate the possible occurrence of a circannual rhythm for 25OHD serum levels in a longitudinal design, by fitting a 365.25-day cosine curve to temporal biodata recorded in 10 clinically healthy subjects, monthly sampled for RIA determinations of 25OHD. Cosinor procedure statistically validated the occurrence of a circannual rhythm for 25OHD serum concentrations at a highly significant level of probability (P = 0.0015) for null hypothesis amplitude = 0. With 95% of probability, amplitude ranges from 5.0 to 16.5 ng/ml (mean value of oscillation = 10 ng/ml), while acrophase is temporally located from September 14 to December 3 (mean timing = October 21). Yearly, mean values for 25OHD serum concentrations is of 40.3 +/- 5.4 ng/ml as quantified by the line which transversely divides the cosine curve interpolating original biodata. By calculating the band of a complete 12 months variability which includes 90% of the distribution with 90% confidence limits, the circannual chronodesm of 25OHD serum levels has been obtained. Such a chronodesmic sinusoid has been compared to the circannual chronogram. By this comparison, a dissociation between the crest (October) and the peak (August) has been detected. The finding suggests that seasonal variations are superimposed to the circannual rhythm. Seasonal but also circannual changes, thus, characterize the yearly variability of 25OHD serum levels in man.

Normal ranges of hip motion in infants six weeks, three months and six months of age

Flexion contracture, internal rotation and external rotation of the hip were reported in 40 infants at 6 weeks and 3 months and in an independent sample of 40 infants at 6 months of age. Population means and normal ranges of motion were determined for use in the evaluation of hip problems and their treatment. A mean hip flexion contracture of 19 degrees was present at 6 weeks of age, decreasing to 7 degrees by three months, but still persisting at 6 months suggesting that forceful extension of the hip in infants may be contraindicated. Hip flexion contracture decreased in every child from 6 weeks to three months. In all cases, external rotation was greater than internal rotation. Internal rotation greater than external rotation before the age of 6 months appears contrary to normal development. There was a significant correlation between the changes in hip flexion contracture and internal rotation from 6 weeks to 3 months. An interesting extension of this study would be a longitudinal follow-up of infants beyond 6 months of age to further define these developmental trends.