ECMOLIFE intra-hospital transport in life-saving for pulmonary vein obstruction

BACKGROUND

Transport with extracorporeal membrane oxygenation (ECMO) in the hospital setting can become a challenge as well as in the out-of-hospital setting. In particular, the management of intra-hospital transport with ECMO support of the critically ill patient foresees his shift from the intensive care to the diagnostic areas, from the diagnostic areas to the interventional and surgical areas.

CASE PRESENTATION

In this context, we present a life-saving transport case with the veno-venous (VV) configuration of the ECMOLIFE Eurosets system, for right heart and respiratory failure in a 54-year-old woman, due to thrombosed obstruction of the right superior pulmonary vein, following mitral valve repair surgery in minimally invasive approach in a patient already operated on for complex congenital heart disease. After stabilizing the vital parameters with Veno-venous ECMO for 19 h, the patient was transported to hemodynamics for angiography of the pulmonary vessels, where the diagnosis of obstruction of the pulmonary venous return was made. Subsequently, the patient was brought back to the operating room for a procedure of unblocking the right superior pulmonary vein using a minimally invasive approach, passing from the ECMO to the support in extracorporeal circulation.

CONCLUSIONS

The transportable ECMOLIFE Eurosets System was safe and effective during transport in maintaining the vital parameters of oxygenation and CO₂ reuptake and systemic flow, allowing the patient to be mobilized for diagnostic tests instrumental to diagnosis. The patient was extubated 36 h after the surgical procedures and was discharged 10 days later from the hospital.

Perioperative left ventricular perforation in incomplete TAVI and completion of the procedure after surgical repair

Background

The use of transcatheter aortic valve implantation (TAVI) continues to grow worldwide. Despite increased operator experience, evolution of the technique, and deflectable catheters, major complications still occur in ≤ 6% up to 8% of cases. Such major complications have been associated with a 2- to threefold increase in 30-day mortality. Complications specifically involving the aorta, aortic valve annulus, or left ventricle are rare, occurring in only 0.2–1.1% of cases.

Case presentation

We report the case of a 65-year-old female patient with left ventricular lateral wall perforation during incomplete implantation of a TAVI device, and successive percutaneous completion after surgical repair of the lesion under cardiopulmonary bypass. The surgical strategy and the type of surgical treatment depend on the type of perforation. In general, repair of the lesion and aortic valve replacement are performed. Removal of the TAVI prosthesis and excision of the native aortic valve are standard parts of this repair.

Conclusion

Here we propose a safe alternative for the completion of the TAVI approach after surgical repair, which requires close coordination between the members of the heart team (anesthesiologist, perfusionist, cardiologist, nurse and cardiac surgeon).

[Prevalence of use of mobile phones while driving in Italy: results of a multicentric observational study]

OBJECTIVES

to provide an overview of the use of mobile phone in Italy while driving in the years 2015-2017.

DESIGN

road side observational study.

SETTING AND PARTICIPANTS

a sample of 145.107 drivers in 28 cities across the national territory with a resident population of more than 10 million inhabitants (17% of the Italian population). For each city, the survey was carried out in Urban (U), Sub-Urban (SU), and Extra-Urban (EXT) areas. Data were aggregated by three geographic areas: North, Centre and South.

MAIN OUTCOME MEASURES

monitoring of the use of mobile phone when driving.

RESULTS

the prevalence of mobile phone use when driving is 5.6% in the North, 4.1% in the Centre, and 6.3% in the South. The stratification by urban area also shows similar values (U: 5.3%; SU: 5.1%; EXT: 7.4%).

CONCLUSIONS

a considerable prevalence of use of mobile phone when driving is observable throughout Italy, with substantially homogeneous values in different territories and in areas with different levels of urbanization. This behaviour increases the risk of road traffic accidents, according to scientific literature. Despite normative sanction of this behaviour, the prevalence is still high, even though comparable to what observed in other industrialized countries. Multilevel actions could be implemented, effective according to scientific literature, not limited only to the regulatory-sanctioning ones. The reduction of the use of the mobile phone while driving can have a significant impact for public health and traffic safety, because on the prevalence data of this study it is possible to assess that potentially up to 24,000 accidents/year could be avoided in Italy.

Prevalence of use of safety devices on motorized vehicles in Italy. A multicentric road side observational study

OBJECTIVES

to give an overview of the use of safety devices in motorized vehicles in Italy in the years 2015-2017.

DESIGN

road side observational study.

SETTING AND PARTICIPANTS

a sample of 232,283 road users in 28 cities across the Italian territory with a resident population of more than 10 million inhabitants (17% of the Italian population) was considered.

MAIN OUTCOME MEASURES

the use of seat belts (front and rear), child restraints, and motorcycle helmets were monitored. For each city, the survey was carried out in urban, sub-urban, and extra-urban areas. Data were aggregated by three geographic areas: North, Centre, and South. Data for front seat belts was also provided for drivers and passengers separately.

RESULTS

the use of front seat belts shows a dramatic geographical trend ranging from 82.6% (North) to 36.3% (South). Drivers use seat belts more frequently than passengers (63.3% vs 57.4%). The same North-South trend shows the use of rear seat belts (from 19.0% to 3.3%) and child restraints (from 59.9% to 16.6%). Helmet use was high everywhere in Italy (more than 94%).

CONCLUSIONS

despite the use of safety devices, which has been mandatory for many years, compliance seems to depend on the voluntary behaviour of drivers and passengers influenced by socioeconomical and cultural patterns. The use of rear seat belts and child restraints is still far from an acceptable level, as well as the use of front seat belts in the South and in the Centre. The increased use of safety devices would have significant public health and traffic safety implications, as a potential of 327 deaths/year could be saved.

Effective management of extensive tissue loss after abdominoperineal resection for Buschke-Loewenstein tumor

The giant condyloma acuminatum or Buschke-Loewenstein tumor is a rare, sexually transmitted disease. It is an epithelial tumor characterized by its high potential of malignancy towards developing into a highly invasive squamous cell carcinoma. The present case concerns a drug addicted 40-year-old man who smuggled drugs using his rectum. He had a partially ulcerated mass in the perianal area of about 20 x 10 cm. He reported a progressive growth of this neoplasm during the last 3 years associated with perianal pain, obstructed defecation, bad sitting posture, no fever and weight loss. Our first approach was a left laparoscopic loop colostomy for a fecal diversion and antalgic purpose, and biopsy of the perineal mass. Then, he underwent a complete excision of the perianal neoplasm. The pathologist's positive diagnosis of a well differentiated squamous cell carcinoma, evidently necessitated the radicalization of the surgical procedure of abdominal perineal resection. In consideration of the surgical wound depth and size, a VAC Therapy with Negative Pressure Wound Therapy was applied. The BLT incidence rate has been steadily increasing over the last decade especially among male patients. An aggressive surgical approach is usually to get the best oncologic outcome but the difficult management of the perianal wound is challenging. In our experience VAC therapy has been shown to be an effective tool in promoting the healing of the perineal wound after abdominoperineal resection.

Lymph node assessment in colorectal cancer surgery: laparoscopic versus open techniques

AIM

The aim of our study is to compare the outcomes of laparoscopic resection (LR) and open resection (OR) for colorectal cancer surgery evaluating lymph node assessment. It may be important to remove and examine an adequate number of lymph nodes because a more extensive nodal resection has been associated to higher survival rate and lower recurrences.

PATIENTS AND METHODS

150 patients (74 females and 76 males) with colorectal cancer were enrolled and analyzed from January 2006 to March 2010 in our Unit. 100 procedures were performed with traditional laparotomy and 50 procedures laparoscopically. A strict follow-up was scheduled every 1-3-6 months after surgery and, therefore, every year.

RESULTS

Laparoscopic techniques require a longer operating time. 2484 total lymph nodes examined with a mean of 16,56 removed per resection in all procedures. 1632 lymph nodes were removed during open procedures and 852 removed during laparoscopy. The scheduled follow-up demonstrated that local recurrence and distant metastasis presented with no significant differences between two groups and overall survival and disease-free survival were assessed over 5 year in 80% of patients.

CONCLUSIONS

According to our experience, laparoscopic colorectal surgery is safe and feasible, with better short-term outcomes and oncological adequacy comparable to open approach.

Gallstone ileus in a ninety-two years old colecistectomized patient after endoscopic biliary sphincterotomy: a case report

INTRODUCTION

Gallstone ileus is an uncommon condition of mechanical bowel obstruction caused by the passage of a gallstone into the bowel. It occurs more frequently in female patients older than 65 years and often for a biliary-enteric fistula. The pathognomonic features of gallstone ileus - the Rigler's triad - are pneumobilia, ectopic gallstone and bowel obstruction. Less commonly, a gallstone may enter the intestinal lumen through the common bile duct, after endoscopic retrograde cholangiopancreatography, and very rarely in colecistectomized patient.

CASE REPORT

A 92-year old colecistectomized male patient was admitted to our unit for the clinical suspicion of bowel obstruction. He was also submitted to ERCP seven months before. Physical examination revealed tenderness in the lower abdomen and CT showed intrahepatic and extrahepatic biliary dilatation and small bowel obstruction with a hyperdense formation in right iliac fossa as gallstone ileus. It was performed an emergency laparotomy with enterotomy and a 5x3 cm gallstone removal. There were no post-operative complications and the patient was discharged 8 days after surgery.

DISCUSSION

Cholecysto-duodenal fistulas are most frequently described in worldwide-reports. There are only few cases in literature of gallstone which enter the gastrointestinal tract following endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy through papilla of Vater, without a biliary-enteric fistula, causing gallstone ileus. If the patient is cholecistectomized, gallstone removal alone is required.

CONCLUSION

The differential diagnosis in case of small bowel obstruction should always include gallstone ileus, even if the patient previously underwent a cholecystectomy.

Occasionally report of sacral chordoma; treatment and review of literature

INTRODUCTION

Brain notochordal cell tumors (BTCN) are lesions arising from notochordal differentiation which affect the axial skeleton.

PRESENTATION OF CASE

We report a case of a patient treated in our General Surgery Unit of the University Hospital of Bari, Italy, with occasional finding of sacral chordoma at the histological examination.

DISCUSSION

Because of their location, sacral chordomas can affect bowel and bladder with organ specific symptoms. Radiotherapy may be used as a palliative treatment or for recurrence in those patients who cannot be submitted to surgery.

CONCLUSIONS

Due to the high local recurrence rate radiation therapy should be considered mandatory after any type of chordoma resection. Multidisciplinary management of the disease is mandatory and improve patient outcomes. Patients should have maximal tumor debulking with adjuvant radiotherapy when possible.

Squamous carcinoma in pilonidalis sinus: case report and review of literature

AIM

We report a case of squamous carcinoma arising from a pilonidal sinus.

CASE REPORT

Patient of 83 years old, that after 30 years had a recurrence of pilonidal sinus revealed by a sacral abscess studied with pelvic CT scan and MRI. After clinical investigation, traditional open surgical technique was performed and pathologic studies revealed a squamous carcinoma. The patient performed a new CT scan with persistence of disease, and a second surgical look with mass excision until the presacral fascia and V-Y flap was performed. Histological exami-nation was found to be positive for squamous carcinoma on the margin and the patient underwent adjuvant radiotherapy cycles with a close follow-up with evidence of free disease survival. He died after 5 years for old age.

DISCUSSION

The incidence of carcinoma arising from a pilonidalis sinus is about 0.1% and the most important risk factor is represented by a chronic abscess from 20-30 years. In literature there are about 100 cases. Gold standard treatment is surgery with complete excision of the presacral fascia, while radiotherapy decrease the risk of recurrence.

CONCLUSION

All cases reported in literature are submitted as case report. Sacro-coccyxal fistula should be treated early because chronic inflammation can determine neoplastic degeneration. Histological examination should be performed routinely. Gold standard is surgery with wide excision. There is no evidence about the gold standard for the reconstructive time.

3D MRI segmentation and 3D circumferential resection margin evaluation for a standard rectal cancer assessment

AIM

Recent studies focused on rectal cancer suggested that a 3D imaging segmentation obtained from MRI data could contribute in the definition of the circumferential resection margin (CRM) and in the assessment of the tumor regression following neo-adjuvant treatments. Here, we propose a method for defining and visualizing the circumferential margins using 3D MRI segmentation; this methodology was tested in a clinical study comparing 3D CRM assessment vs standard MRI imaging.

PATIENTS AND METHODS

MRI scans performed before neo-adjuvant treatments were selected and reviewed. 3D mesorectal/tumor segmentations were obtained using Digital Imaging and COmmunications in Medicine (DICOM) data; CRMs were calculated using 3D volumes plus a color scale for the closest distances.

RESULTS

3D reconstructions were possible in all selected cases and 3D images implemented by the color scale were positive for immediate CRM visualization. Statistical analyses comparing standard radiology disclosed that the degree of consistency, the reliability of ratings, the correlation and precision were optimal considering the overall cases, but lower in the CRM>0 mm sub-group.

CONCLUSIONS

This new method is not inferior comparing standard radiology; moreover, the imaging segmentation we obtained was highly promising and could be helpful in defining a standard CRM measurement, thus it could improve clinical practice.

Presence of cancer cells in gastric lavage of gastric cancer patients as an indicator of advanced disease, predictor of tumour aggressive phenotype and independent prognostic factor for poor survival: The endoluminal metastatic pathway of gastric cancer and GL0/GL1 classification

OBJECTIVE

As of 2017, the pathobiology of gastric cancer (GC) is far from fully understood; consequently, new methods of basic and advanced research have been proposed and tested. The presence (GL1) vs absence (GL0) of malignant cells exfoliated in gastric lavage (GL) of GC patients was formerly evaluated with diagnostic intent but not for staging or prognostic assessment. We investigated this hitherto unreported application of cytopathology.

METHODS

GL was preoperatively and prospectively collected from 80 GC patients and cytologically analysed. The results were compared with the classic clinicopathological features of GC and related to survival. The prognostic value of GL1 was assessed through univariate and multivariate analyses.

RESULTS

GL1 was detected in 36 samples (45%) and correlated with advanced tumour depth (T3-T4), lymphatic metastasis (N+), distant metastasis (M1) and lymphovascular invasion (LVI1; P=.0317, .0024, .003 and .0028, respectively). Overall survival (OS) was significantly shorter for GL1 (23 months) vs GL0 patients (42 months; P=.005) and GL1 vs GL0 T1 subjects (12.6 vs 47.8 months, P=.0029). Univariate analysis revealed that GL1, N+, M1, LVI1 and advanced stage were significantly associated with OS. Multivariate analysis assessed GL1 as the only independent prognostic factor for worse OS and progression-free survival (P=.0013 and .0107).

CONCLUSIONS

In the present study, GL1 was correlated with advanced disease, aggressive tumour behaviour and poor prognosis. Although additional studies are needed to confirm these findings, the GL0/GL1 classification can be applied to GC patients to achieve higher accuracy in staging, prognostic stratification and treatment selection.

Water-soluble Ru(II)- and Ru(III)-halide-PTA complexes (PTA=1,3,5-triaza-7-phosphaadamantane): Chemical and biological properties

Four structurally related Ru(II)-halide-PTA complexes, of general formula trans- or cis-[Ru(PTA)4X2] (PTA=1,3,5-triaza-7-phosphaadamantane, X=Cl (1, 2), Br (3, 4), were prepared and characterized. Whereas compounds 1 and 2 are known, the corresponding bromo derivatives 3 and 4 are new. The Ru(III)-PTA compound trans-[RuCl4(PTAH)2]Cl (5, PTAH=PTA protonated at one N atom), structurally similar to the well-known Ru(III) anticancer drug candidates (Na)trans-[RuCl4(ind)2] (NKP-1339, ind=indazole) and (Him)trans-[RuCl4(dmso-S)(im)] (NAMI-A, im=imidazole), was also prepared and similarly investigated. Notably, the presence of PTA confers to all complexes an appreciable solubility in aqueous solutions at physiological pH. The chemical behavior of compounds 1-5 in water and in physiological buffer, their interactions with two model proteins - cytochrome c and ribonuclease A - as well as with a single strand oligonucleotide (5'-CGCGCG-3'), and their in vitro cytotoxicity against a human colon cancer cell line (HCT-116) and a myeloid leukemia (FLG 29.1) were investigated. Upon dissolution in the buffer, sequential halide replacement by water molecules was observed for complexes 1-4, with relatively slow kinetics, whereas the Ru(III) complex 5 is more inert. All tested compounds manifested moderate antiproliferative properties, the cis compounds 2 and 4 being slightly more active than the trans ones (1 and 3). Mass spectrometry experiments evidenced that all complexes exhibit a far higher reactivity towards the reference oligonucleotide than towards model proteins. The chemical and biological profiles of compounds 1-5 are compared to those of established ruthenium drug candidates in clinical development.

Palladium complexes with simple iminopyridines as catalysts for polyketone synthesis

A systematic study on iminopyridine palladium complexes demonstrates the relationship among NMR chemical shifts, ligand donor capability and catalytic performances.

An irresolute linker: separation, and structural and spectroscopic characterization of the two linkage isomers of a Ru(ii)-(2-(2′-pyridyl)pyrimidine-4-carboxylic acid) complex

For the first time the two linkage isomers of a Ru(ii) complex with 2-(2′-pyridyl)pyrimidine-4-carboxylic acid (cppH) have been fully characterized individually, both in solution and in the solid state.

Varenicline and neuronal nicotinic acetylcholine receptors: a new approach to the treatment of co-occurring alcohol and nicotine addiction?

BACKGROUND AND OBJECTIVES

Alcohol and nicotine dependence are serious public health problems worldwide. They are associated with substantial morbidity and mortality, as well as adverse social effects and increased healthcare costs. Although efficacious treatments are available for these disorders, additional therapeutic options are required to ensure greater treatment utilization. In this paper, we describe the empirical basis on which varenicline, a nicotinic partial agonist approved for smoking cessation, may also have utility in the treatment of alcohol addiction.

METHODS

We sought to identify papers examining nicotine dependence, alcohol dependence, smoking, alcohol, and varenicline for possible inclusion in the present review. We identified over 600 papers through Pubmed/Medline, PsychINFO, and Google Scholar. We found 12 papers taking into consideration the following criteria: original language English, varenicline effect on alcohol consumption.

RESULTS

Animal studies have shown that varenicline reduces alcohol consumption. Two recent studies showed that varenicline also reduces alcohol consumption in humans. Both nicotine and alcohol interact with α4β2 and α3β4 nicotinic acetylcholine (ACh) receptors located in the ventral tegmental area of the brain, inducing dopamine (DA) release at the nucleus accumbens. Varenicline binds to nicotinic ACh receptors, where it has partial agonist effects, producing a moderate and constant level of DA release both in the mesolimbic pathway and in the prefrontal cortex.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Through these effects, varenicline may reduce alcohol craving, seeking, and consumption, in addition to promoting smoking cessation. Additional studies are needed to confirm the efficacy of varenicline in the treatment of alcohol dependence.

[Overexpression of laminine-5( LN-5) in peritoneal lavage of colorectal cancer patients preliminary results]

Recent studies show that interaction between LN (heterotrimeric protein formed by a3/b3/g2 chains) and cancer cells plays an important role in tumor invasion, also in colorectal cancer. The overall survival was significantly worse in patients with free peritoneal cancer cells(FPTCs): detection of FPTCs after curative surgery is a challenge, because could improve staging and prognosis. Peritoneal citology is the current standard procedure with very low sensivity. We aimed to study the expression of LN5 in the peritoneal lavage of colorectal cancer pts and in controls with semiquantitative reverse trancriptase-polymerase chain reaction (RT-PCR). LN-5 overexpression was evaluated observing PCR- products intensity at electrophoresis: high intensity is correlated to overexpression. Pre and post-operative peritoneal lavages of 30 pts with colorectal cancer (13M;17F), with median age of 69 (58-84), and of 10 controls, were analyzed by conventional cytology and a semiquantitative RT-PCR. No cancer pts showed pre/postoperative negative cytology and did not express LN-5. In cancer pts. cytology was positive in 2 pts in pre/postoperative lavage. LN-5 overexpression was observed in 56,6% preoperatively and in 76,6% postoperatively. LN-5 g 2 chain was most frequent chain. Our study suggests a relationship between LN-5 and FPTCs, as shown by the low expression of lamimine in controls. LN-5 could be a useful marker to identify a subgroup of early-stage patients at increased risk of recurrence; moreover, mortality seems to correlated to LAMB3 chain. The diagnostic accuracy could be improved by using a quantitative RT-PCR or western-blot and detecting serum laminine. Finally, to validate these findings a larger number of pts with follow-up study is required.

A 7-year follow-up of patients with thyroid cysts and pseudocysts treated with percutaneous ethanol injection: volume change and cost analysis

Thyroid cysts and pseudocysts, or hemorrhagic cysts, are quite frequent thyroid pathologies. Surgical theraphy has always been the treatment of choice in this pathology, but percutaneous ethanol injection (PEI) is becoming still more common. PEI was originally used in the treatment of liver nodules and subsequently in solid, hyperfunctioning thyroid nodules, but today it is used exclusively in cysts. The aim of this study was to evaluate the efficacy of PEI in reducing thyroid cyst volume 12 and 84 months after treatment and to compare cost-benefit to that of surgical treatment. The study includes 110 consecutive patients, who all underwent PEI after cytological analysis had excluded the presence of neoplasia. All patients had refused surgical treatment. One patient died during the follow-up due to cerebral hemorrhage. Each patient received an average of 5.3 ± 2.7 PEI treatments. After 12 months, volume was reduced by 82.6% and after 84 months by 93.03%. Dysphonia occurred in 2 cases of which one resolved spontaneously and one received cortisone therapy. The cost of PEI treatment is considerably lower than the cost of surgical therapy (the cost saving in our patient population was about €200,000). PEI should therefore be preferred to surgical treatment due to its efficacy and lower cost.

NEOPLASTIC DISEASE AND DELETION 22q11.2: A MULTICENTRIC STUDY AND REPORT OF TWO CASES

Deletion 22q11.2 is a chromosomal abnormality detected in young patients with clinical manifestations of the DiGeorge/velocardiofacial syndrome. Conotruncal heart defects are also associated with del22q11.2. An association of these cardiac malformations with neoplasias has been observed. Our series includes two cases of malignancies, a hepatoblastoma and a renal-cell carcinoma, arising in children with complex cardiac malformations. The aim of the study was to determine if the deletion at 22q11.2 was present and could be responsible for both pathological processes. Del22q11.2 was identified in both cases. Comparative genomic hybridization revealed terminal gains on chromosomes 1q and Xq and terminal loss on 1p in the hepatoblastoma, and gains in 1p, 12q, 16p, 20q, 22q, and whole chromosome 19 and loss of Xq in the renal-cell carcinoma. Our results confirm a common genetic basis for cardiac malformations, and del22q11.2 presents a risk factor for the development of pediatric tumours.

Delayed closure of ductus arteriosus in term newborns with congenital hypothyroidism: effect of L-thyroxine therapy

Congenital hypothyroidism is associated with increased incidence of congenital defects (15.6%), frequently involving the heart (5.8%). Only few studies have evaluated the association between congenital hypothyroidism and patent ductus arteriosus. We report on two term newborns affected by thyroid agenesis and patent ductus arteriosus that closed after starting L-thyroxine substitutive therapy. This association suggests a close relation between hypothyroidism and patent ductus arteriosus. Hypothyroidism should be considered in term infants with patent ductus arteriosus because thyroid hormone production is among the prerequisites for postnatal ductal closure.

Delayed closure of the ductus arteriosus in term newborns with congenital hypothyroidism: effect of L-thyroxine therapy

Congenital hypothyroidism is associated with an increased incidence of congenital defects (15.6%), frequently involving the heart (5.8%). Only a few studies have evaluated the association between congenital hypothyroidism and patent ductus arteriosus. We report on two term newborns affected by thyroid agenesis and patent ductus arteriosus that closed after starting L: -thyroxine substitutive therapy. This association suggests a close relation between hypothyroidism and patent ductus arteriosus. Hypothyroidism should be considered in term infants with patent ductus arteriosus, because thyroid hormone production is among the prerequisites for postnatal ductal closure.

Investigation of patulin contamination in apple juice sold in retail outlets in Italy and South Africa

A study of apple juice products sold in Italy and South Africa was initially carried out on 20 samples bought in Cesena, Italy, and Tygerberg in Cape Town, South Africa. The samples were bought at random and analysed for patulin contamination. All 12 of the Italian samples had no detectable levels of patulin, except one, which was just slightly above the lowest regulatory limit of 10 ng ml(-1). On the other hand, five of the eight South African samples were all contaminated with patulin levels above 10 ng ml(-1), with one showing a concentration of 75 ng ml(-1), well above the highest regulated limit of 50 ng ml(-1). This latter result led to a more targeted investigation with 14 samples being purchased in the low-income areas of Tygerberg where the initial samples were sourced. These samples confirmed that there might be a problem of mycotoxin contamination in apple juices products sold to low-income consumers because half of the samples showed patulin contamination of which four had levels well above the acceptable limits. This is the first study in South Africa to look at apple juice products in low-income areas and it points to a need to intervene and introduce quality systems in the supply chain of the manufacture and packaging of apple juice products by independent small business.

Energetics and Thermodynamic Stability of the Mixed Valence Ytterbium Germanides

The results of an experimental study concerning the thermodynamic stability of the Yb germanides, described as intermediate valence compounds, complemented by a computational investigation for the Yb3Ge5 compound are reported. These compounds belong to the rare earth (RE) tetrelides (tetrel = Si, Ge, i.e., group 14 elements), a class of intermetallic materials showing unusual and promising physical properties (giant magnetocaloric effect, magnetostriction, and magnetoresistence). The high-temperature decomposition reactions of the Yb-Ge intermediate phases were studied experimentally by means of the KEMS (Knudsen effusion mass spectrometry) and KEWL (Knudsen effusion weight loss) techniques. From the reaction enthalpies derived by measuring the Yb(g) decomposition pressures as a function of temperature, the heats of formation of five out of six of the intermediate phases in the Yb-Ge system were calculated. From the computational side, the stability of the Yb3Ge5(s) compound has been investigated by DFT-LCAO-B3LYP (density functional theory-linear combination of atomic orbitals-hybrid b3lyp exchange-correlation functional) first principles calculations deriving its equilibrium geometry and the enthalpy of formation at 0 K in relation to the intermediate valence state of Yb in the lattice.

Acute alcoholic hepatitis

Acute alcoholic hepatitis (AAH) is a frequent inflammatory liver disease with high short-term mortality rate. In this review, relationships between alcohol abuse and the epidemiology and the outcomes of AAH are discussed, as well as AAH pathogenesis. The role of endotoxins, tumor necrosis factor alpha, fibroblasts, and immune response to altered hepatocyte proteins is discussed. The need of a careful prognosis, supported by the use of Maddrey score, by the model for end-stage liver disease [Mayo end-stage liver disease (MELD)] score or by the Glasgow alcoholic hepatitis score, is outlined, as the use of the most effective drugs (glucocorticoids and anti-tumor necrosis factor alpha infliximab) is recommended only in severe AAH cases. The problems of liver transplant in severe AAH, and the need of a 6-month alcohol abstinence before transplant, are discussed, as well as the need of a careful psychologic assessment before the transplant.

Absent right and persistent left superior vena cava: fetal and neonatal echocardiographic diagnosis

Absence of the right superior vena cava (SVC) is a rare event occurring in patients without congenital cardiovascular abnormalities. Since absence of the right SVC is usually clinically silent, its diagnosis is mandatory prior to invasive medical or surgical procedures. We report two cases of echocardiographic diagnosis of absence of the right SVC with persistent left SVC and a large coronary sinus in structurally normal heart in a fetus of 20 weeks' gestation and in a newborn. The diagnosis was confirmed by transthoracic contrast echocardiography with intravenous injection of agitated saline into the right arm.

[Bleeding caused by pseudoaneurysm rupture after pancreaticoduodenectomy]

The Authors describe two cases of delayed hemorrhage due to ruptured gastroduodenal artery pseudoaneurysm, after pancreatoduodenectomy. The first case underwent surgical treatment, the second underwent interventional radiological procedure. The Authors analyze diagnostic and therapeutic options for early diagnosis in high risk patients, supporting preventive treatment of asymptomatic pseudoaneurysms.

HYPERTENSION IN EARLY ALCOHOL WITHDRAWAL IN CHRONIC ALCOHOLICS

AIMS

Hypertension is an established risk factor in chronic alcoholics, but little is known about the relationship between blood pressure (BP), severity of their alcohol abuse, and severity of alcohol withdrawal syndrome (AWS).

METHOD

BP was assessed daily for 18 days in a series of chronic alcoholics on early alcohol withdrawal (AW), while also assessing the severity of their AWS on the CIWA-Ar scale.

RESULTS

A sharp and sustained decrease in BP was observed after AW; at T0, BP had increased in 55% of patients, and at T18 in 21%. The variation of BP is partially explained by years of at-risk drinking and AWS severity, but other factors may play a role in hypertension in alcoholics, as a large amount of BP variation was not explained by the alcohol-abuse-related parameters that we studied. BP values were not correlated with cigarette smoking, anxiety, or depression. Hypertension found in 'detoxified' alcoholics (approximately 20%) may be related to alcohol-independent hypertension or to a long-lasting alcohol-induced derangement of the BP regulating mechanisms. Further research is needed in these patients to elucidate the mechanisms of persistent hypertension and to set up a treatment protocol. At present, careful monitoring is advisable, as well as pharmacological treatment for moderate or severe hypertension; often a modification of life-style is needed which includes physical activity and possibly sodium (Na) restriction, since hypertension in detoxified alcoholics seems to be Na sensitive.

CONCLUSION

Complete alcohol abstinence must be recommended to all hypertensive alcoholics, as AW-induced transient hypertension was found to be harmless in all our subjects, and abstinence leads to a complete recovery from hypertension in most cases.

Mass spectrometric investigation of gaseous YbH, YbO and YbOH molecules

The high-temperature gaseous molecules YbH, YbO and YbOH have been identified and their thermochemistry investigated by the Knudsen effusion mass spectrometry technique coupled with a controlled pressure gas inlet system. Solid ytterbium monosilicide and disilicide samples were made to react in the Knudsen cell with H2(g) and H2(g)/O2(g); in these conditions, several gaseous species (Yb, YbO, YbH, YbOH, SiO, SiO2, H2O) were formed under equilibrium conditions. The temperature dependences of the partial pressures of the observed gaseous molecules were analyzed to derive the Yb--X bond energies (X = H, O, OH). Selected values are D0o(Yb--H) = 179.4 +/- 2.0 kJ mol(-1), D0o(Yb--O) = 384 +/- 10 mol(-1) and D0o(Yb--OH) = 322 +/- 12 kJ mol(-1), and Delta(at)H0o(YbOH) = 746 +/- 12 kJ mol(-1). Density functional theory (DFT) calculations were also performed. Experimental and computational results are discussed and compared to previous data when available. The SiO/SiO2 high-temperature gaseous equilibrium was also observed.

A mass spectrometric and density functional study of the intermetallic molecules AuBe, AuMg, and AuCa

The intermetallic molecules AuBe and AuCa were identified by means of the Knudsen-Effusion Mass Spectrometry technique in the high-temperature vapors produced by vaporizing Au-Be-Ca alloys of proper composition. The gaseous equilibria AuBe(g)+Au(g)=Au(2)(g)+Be(g) and AuCa(g)+Au(g)=Au(2)(g)+Ca(g) were studied in the temperature ranges 1720-1841 K and 1669-1841 K, respectively, by monitoring the partial pressures of all the species involved. The equilibrium data were analyzed by the third-law method, obtaining for the first time the dissociation energy D(0) ( composite function) of the two intermetallic species: D(0) ( composite function)(AuBe)=234.0+/-4.0 kJ/mol; D(0) ( composite function)(AuCa)=246.7+/-4.0 kJ/mol. These values are significantly higher than the recently published D(0) ( composite function) of the species AuMg (175.4+/-2.7 kJ/mol). Furthermore, the ionization energies (IE) of AuBe, AuMg, and AuCa were obtained by measuring the electron impact ionization efficiency curves, IE(AuBe)=7.5+/-0.3 eV, IE(AuMg)=6.7+/-0.3 eV, and IE(AuCa)=5.5+/-0.3 eV. Theoretical calculations were also carried out for these species by density functional theory methods (PW91 and BP86) used in conjunction with Stuttgart relativistic effective core potentials. Both functionals were found to perform very well in reproducing experimental D(0) ( composite function), IE, and molecular parameters.

Hepatic resections for hepatocellular carcinoma (HCC): short and long-term results on 106 cirrhotic patients

To evaluate the short and long term outcome of liver resections for hepatocellular carcinoma in cirrhotic patients. A retrospective analysis was performed on 106 consecutive cirrhotic patients with hepatocellular carcinoma resected between June 1974 and September 2002 at the Department of Surgery "Pietro Valdoni" - University of Rome "La Sapienza" and at the Liver and Multivisceral Transplant Unit of the University of Modena. Univariate and multivariate analyses were performed on several clinicopathological variables to analyze factors affecting the long-term outcome and intrahepatic recurrence. Overall mortality and morbidity were 10.7% and 26% respectively. These rates significantly decreased in the last years: from 1997 to 2002 no hospital mortality has been recorded. After a median follow-up of 19 months (interquartile range: 10-36), tumour recurrence appeared in 25 patients (23,5%). The 1-, 3-, and 5-year overall survival rates were 86,6%, 70,3%, and 60,6%, respectively. The 1-, 3-, and 5-year disease-free survival rates were 86,3%, 58,1%, and 40,7%. On univariate analysis, viral ethiology of cirrhosis (p=0.03), presence of multiple nodules (p=0.02) and vascular invasion (p=0.05) were found to be related to a worse long-term survival. At the multivariate analysis only the viral ethiology of cirrhosis and the presence of multiple nodules were confirmed as indipendent prognostic factors. Early results after hepatic resection for HCC can be improved by using a limited surgical approach. The viral ethiology of cirrhosis, the presence of multiple nodules and vascular invasion negatively affected recurrence rate and long-term survival.

[Ciliated hepatic foregut cysts: a case report]

The ciliated hepatic foregut cysts (CHFC) are uncommon benign lesions with columnar ciliated epithelium covering a connective lapse tissue. They are solitary uniloculate cysts localized in the left lobe of the liver. The diagnosis is made occasionally during autopsy or imaging studies for not related symptoms. The Authors report a case of CHFC with a review of the literature that allowed them to find only 60 cases.

[Multidisciplinary treatment in Budd-Chiari syndrome: clinical case]

Budd-Chiari Syndrome (BCS) is characterized by obstruction of hepatic venous outflow. When obstruction is limited to the suprahepatic veins, portocaval shunting provides an immediate relief of symptoms. If the obstacle results also from narrowing of the inferior vena cava (IVC), multimodality treatments seem to offer safer and easier alternative. In the patient herein reported, combination of side-to-side portocaval anastomosis with a cavo-atrial shunt through an expandible metallic stent provided immediate relief of symptoms. The patient is doing well after 85 months from combined treatment. In conclusion infracaval stenting combined to side-to-side portocaval shunting should represent the treatment of choice in acute or subacute forms of BCS.

Experience with first level ultrasound and echocardiography for a selected and an unselected population

OBJECTIVE

To evaluate the difference in prevalence, distribution and prenatal detection rate of congenital heart disease (CHD) in both newborns and second trimester termination of pregnancy (TOP) in two separate time periods.

PATIENTS AND METHODS

At the University Hospital of Bari, an observational study was performed, which included all cases of CHD in newborns and second trimester TOP during the periods 1998-99 and 1992-93. Prevalence, distribution and prenatal diagnosis in each group were evaluated, also selecting cases with and without known risk factors.

RESULTS

Prevalence of CHD in livebirths and aborted fetuses did not change between the two periods and the same was observed for distribution of CHD spectrum. In the more recent period antenatal detection of CHD significantly increased only in TOP. Moreover, classifying all cases as low or high risk, detection rates were significantly increased in high risk cases while they were unchanged in the general population.

CONCLUSION

Our data show that antenatal detection of CHD is ameliorated by concentrating expertise and good equipment on high risk cases, while it remains low in the general population.

Indications and results of resection for hepatocellular carcinoma

AIM

In this retrospective series we evaluate our experience in surgical treatment of HCC and examine early and long-term results of 46 hepatic resections.

METHODS

Eighty-eight patients with HCC have been observed at our Department. Fifty patients (57%) have been operated, but only 46 (92%) could be resected; 43 patients (93.5%) carried liver cirrhosis. We performed 28 non-anatomical resections (60.8%) and 18 anatomical resections (39.2%). Tumour clearance at resection margin of at least 1cm was considered for a curative resections.

RESULTS

Overall mortality and morbidity were 8.7 and 30.4% respectively. These rates significantly decreased in the last years: from 1995 to 2000 no hospital mortality has been recorded. Hospital mortality among non-anatomical and anatomical resection subgroups was 3.5 and 16.6% respectively (P<0.02). After a median f.u. of 41 months, 19 patients (45.2%) had recurrences: it was intrahepatic in 16 (84.4%). We observed a 3-, 5- and 10-years actuarial survival rate 62, 51.1 and 22.5% respectively. Long term survival significantly differed between non-anatomical and anatomical resections, with 5-year and 10-year values of 61.1 and 34.3% vs 37.7 and 18.8% respectively (P=0.0224).

CONCLUSIONS

Early results after hepatic resection for HCC can be improved by using a limited surgical approach. Long-term results are still unsatisfactory, because of the high recurrence rate that is not influenced by different surgical approaches.

[Prevalence and distribution of congenital cardiopathy at birth and in pregnancy termination: impact of prenatal diagnosis in 4 years of experience]

OBJECTIVE

To evaluate in two time intervals the potential impact of prenatal diagnosis on prevalence and spectrum of CHD at birth and in aborted fetuses.

PATIENTS AND METHODS

At the University Hospital of Bari, south-east Italy, in the period between January 1st 1996 and December 31st 1999 a retrospective study was performed of all newborns and termination of pregnancy (TOP) beyond 18 weeks' gestation with postnatally diagnosed CHD. An antenatal fetal ultrasonic evaluation had been always performed between 18-22 weeks' gestation. The prevalence, distribution and detection rate of CHD at birth and in TOP were assessed and compared between two different periods of time (96-97 vs 98-99) to verify an eventual improvement in the prenatal diagnosis due to the learning curve and to new technologies.

RESULTS

Prevalence of severe CHD in livebirths and aborted fetuses showed no significant changes between the two study periods (respectively 4.6@1000 vs 5.4@1000, at birth; 10% vs 11%, in TOP) and the same was observed as for as distribution of CHD. Maternal or fetal risk factors were found in 23% of cases of CHD at birth and in 74% of cases of CHD in aborted fetuses. The antenatal detection rate of CHD did not change between the two study periods in newborns (25% vs 27%, NS) while in aborted fetuses it was higher and showed a significant longitudinal improvement (53% vs 85%, p < 0.05), which was more evident if only selected cases were considered (56% vs 93%, p < 0.03).

DISCUSSION

Our data show that gain in experience in fetal echocardiography has increased the prenatal diagnostic accuracy for congenital cardiac malformations only in selected cases, evaluated by more expert operators. In conclusion the impact of antenatal routine screening for congenital heart disease appears still relatively small.