Corrigendum: HLH as an additional warning sign of inborn errors of immunity beyond familial-HLH in children: a systematic review

[This corrects the article DOI: 10.3389/fimmu.2024.1282804.].

HLH as an additional warning sign of inborn errors of immunity beyond familial-HLH in children: a systematic review

Background

Hemophagocytic Lymphohistiocytosis (HLH) is a rare and life-threatening condition characterized by a severe impairment of the immune homeostasis. While Familial-HLH (FHL) is a known cause, the involvement of other Inborn Errors of Immunity (IEI) in pediatric-HLH remains understudied.

Objective

This systematic review aimed to assess the clinical features, triggers, laboratory data, treatment, and outcomes of pediatric HLH patients with IEI other than FHL (IEInotFHL), emphasizing the importance of accurate identification and management.

Methods

A systematic search for studies meeting inclusion criteria was conducted in PubMed, EMBASE, MEDLINE, and Cochrane Central. Quality assessment was performed through JBI criteria.

Results

A comprehensive search yielded 108 records meeting inclusion criteria, involving 178 patients. We identified 46 different IEI according to IUIS 2022 Classification. Combined immunodeficiencies, immune dysregulation disorders, and phagocyte defects were the IEI most frequently associated with HLH. In 75% of cases, HLH preceded the IEI diagnosis, often with an unrecognized history of severe infections. Triggers reflected the specific infection susceptibilities within IEI groups. Liver and central nervous system involvement were less common than in FHL cases. Treatment approaches and outcomes varied, with limited long-term follow-up data, limiting the assessment of therapeutic efficacy across IEI groups.

Conclusion

A comprehensive evaluation encompassing immunological, infectious, and genetic aspects is essential in pediatric-HLH. Relying solely on FHL or EBV susceptibility disorders tests is insufficient, as diverse other IEI can contribute to HLH. Early recognition of HLH as a potential warning sign can guide timely diagnostic investigations and facilitate tailored therapeutic interventions for improved outcomes.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=371425, PROSPERO, CRD42022371425.

Food Protein-induced Enterocolitis Syndrome Due to Cuttlefish in a Child with Anaphylaxis to Crustaceans

Shellfish is defined as any edible marine invertebrate and refers to crustaceans and mollusks. Crustaceans belong to the phylum Arthropods. Mollusks belong to the phylum Mollusca. This report illustrates a rare case of a 6-year-old girl with challenge-proven acute food protein-induced enterocolitis syndrome (FPIES) to cuttlefish (phylum Mollusca, class Cephalopoda), anaphylaxis to crustaceans (phylum Arthropoda), and tolerance to other mollusks, including clams and mussels (phylum Mollusca, class Bivalvia). The association of IgE-mediated food allergy and acute FPIES seen in this case is rare. To our knowledge, this is the first case of FPIES to cuttlefish reported in a child. This challenge highlights the need for further research into the allergens and mechanisms underpinning FPIES at a molecular level, enabling a better understanding of cross-reactivity patterns and the development of diagnostic and predictive tests to assist in clinical practice.

CD38high/HLA-DR+ CD8+ T cells as potential biomarker of hemophagocytic lymphohistiocytosis secondary to visceral Leishmania infection

Leishmaniasis is a cause of infection associated with hemophagocytic lymphohistiocytosis (HLH). The measurement of the CD8⁺ CD38^high/HLA-DR⁺ T cells in children presenting with acute onset of shock and multisystem organ failure represents an important parameter to distinguish HLH from sepsis or healthy control.

CONCLUSION

We report a case series of 4 Italian children suffering from HLH secondary to visceral Leishmaniasis in which the lymphocyte subset assay suggests a potential role of CD38^high/HLA-DR⁺ CD8⁺ T cells as HLH diagnostic biomarkers.

WHAT IS KNOWN

• Visceral Leishmaniasis is a well-known cause of infection associated with hemophagocytic lymphohistiocytosis (HLH). • The measurement of the CD8⁺ CD38^high/HLA-DR⁺ T cells in children presenting with acute onset of shock and multisystem organ failure represents an important diagnostically useful parameter to readily distinguish HLH from sepsis or healthy controls.

WHAT IS NEW

• We report a case series of 4 Italian children suffering from HLH secondary to visceral Leishmaniasis in which the lymphocyte subset assay suggests a potential role of CD38^high/HLA-DR⁺ CD8⁺ T cells as HLH diagnostic biomarker. • The flow cytometry assay, performed at the disease onset before starting treatment, revealed a mean percentage value of CD38 cells of 36.95% among CD8⁺ T cells.

Severe pertussis disease in a paediatric population: The role of age, vaccination status and prematurity

AIM

To estimate hospitalisation rate and investigate the role of age, prematurity and vaccination status in severe pertussis cases.

METHODS

We retrospectively evaluated 200 children aged 0-14 years, admitted to the emergency rooms of Meyer Hospital of Florence and Pisa Hospital with a diagnosis of pertussis from 1 October 2010 to 31 January 2020.

RESULTS

Children younger than 12 months were 63.0%. Preterm infants were 6.5%. The rate of hospitalisation was 49.0%. Among hospitalised cases, 80.6% were younger than 5 months. Overall, 62.0% were unvaccinated; this percentage increased among hospitalised (73.5%) and preterm subsamples (76.9%). Delays in pertussis vaccination were found in 57.7% of term infants and in 80.0% of preterms. Multivariable analysis confirmed the age under 2 months as the variable at higher risk for hospitalisation (OR 4.49, 95% CI 1.85-10.96, p < 0.001). Being fully vaccinated represented a significant protective factor (OR 0.12, 95% CI 0.04-0.35, p < 0.001).

CONCLUSION

Older classes of age and a complete vaccination, in time with the recommended schedule, are both protective factors for hospitalisation in severe pertussis disease. The widespread vaccination delay frequently observed in preterm children may be the cause for their higher rate of hospitalisation.

Surveillance on Healthcare Workers During the First Wave of SARS-CoV-2 Pandemic in Italy: The Experience of a Tertiary Care Pediatric Hospital

Healthcare workers (HCWs) play a central role in handling the ongoing coronavirus disease 2019 (COVID-19) pandemic. Monitoring HCWs, both symptomatic and asymptomatic, through screening programs, are critical to avoid the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the hospital environment to rapidly identify and isolate infected individuals and to allow their prompt return to work as soon as necessary. We aim to describe our healthcare surveillance experience (April 2–May 6, 2020) based on a combined screening consisting of real-time PCR (RT-PCR) on nasopharyngeal (NP) swabs and rapid serologic tests (RST) for SARS-CoV-2 in all HCWs of Meyer Children's University Hospital in Florence. Among the analyzed workers, 13/1690 (0.8%), all of them without clinical manifestations, was found positive for SARS-CoV-2 by using RT-PCR on NP swab: 8/1472 (0.5%) were found positive during the screening, 1/188 (0.5%) during contact with a positive individual (p > 0.05 vs. screening group), while 4/30 (13.3%) were found positive on the day of re-admission at work after an influenza-like-illness (p < 0.05). Concerning working areas, the majority of RT-PCR positivity (12/13) and serologic positivity (34/42) was found in non-COVID-19 dedicated areas (p > 0.05 vs. COVID-19 dedicated areas). No cases were registered among non-patients-facing workers (p = 0.04 vs. patient-facing group). Nurses and residents represented, respectively, the working role with the highest and lowest percentage of RT-PCR positivity. In conclusion, accurate surveillance is essential to reduce virus spread among HCWs, patients, and the community and to limit the shortage of skilled professionals. The implementation of the surveillance system through an efficient screening program was offered to all professionals, regardless of the presence of clinical manifestations and the level of working exposure risk, maybe wise and relevant.

Epidemiology of Respiratory Syncytial Virus-Related Hospitalization Over a 5-Year Period in Italy: Evaluation of Seasonality and Age Distribution Before Vaccine Introduction

Respiratory Syncytial Virus (RSV) is associated with most of the acute viral respiratory tract infections causing hospitalization with a peak during the first months of life. Many clinical trials of RSV vaccine candidates are being carried out. The aim of this study was to obtain epidemiologic information to give suggestions on target populations and prevention strategies before the introduction of new vaccines or monoclonal antibodies. We retrospectively evaluated, over a 5-year period (September 2014–August 2019), a population of hospitalized Italian children aged 0–6 years with a laboratory confirmed diagnosis of RSV infection. Risk factors, seasonality of RSV infection, distribution according to age, cases of coinfections and reinfections and cases needing Intensive Care Unit were evaluated. Hospitalizations due to RSV were 624 in the period under study. The peak was found between November and April, with 80.4% of cases recorded between December and February. 62.5% of cases were found in children under three months of age and 41% in children under 30 days old. The need for intensive care was associated with younger ages, with 70.9% of cases in children below three months of age. Unless the incoming vaccines demonstrate a strong herd protection effect, preventive strategies should be aimed at newborns or at maternal immunization.

Imaging Work-Up for Peritoneal Access Care and Peritoneal Dialysis Complications

Peritoneal dialysis (PD) represents a treatment opportunity for patients with end-stage renal failure, but it has particular complications that sometimes force cessation of this procedure (1–9). These complications are due to the presence of the peritoneal catheter and of dialysis solution within the peritoneal cavity. Infections are the most common complications of PD, followed by mechanical complications.

Diagnostic imaging of the complications of PD is important because such an evaluation can aid in the diagnosis and in the decision making process about the treatment. In this review we present the main radiologic investigations employed: plain radiograph, US, peritoneography, computed tomography peritoneography, magnetic resonance peritoneography, peritoneal scintigraphy.

To diagnose catheter-related problems plain radiograph, ultrasonography and peritoneography can be useful. US is useful in diagnosing and following-up exit-site and tunnel infections. Peritoneography and C T-peritoneography, alone or in combination, can be recommended as gold standard investigation to assess mechanical peritoneal dialysis complications, such as catheter malfunction, leaks, hernias and sclerosing peritonitis. Newer methods, such as MR peritoneography or scintigraphy could be useful in selected patients, on center-based experience. An appropriate use of radiology may significantly improve technique survival, morbidity and mortality of patients treated with PD.

Variations in the susceptibility to landslides, as a consequence of land cover changes: A look to the past, and another towards the future

Land cover is one of the most important conditioning factors in landslide susceptibility analysis. Usually it is considered as a static factor, but it has proven to be dynamic, with changes occurring even in few decades. In this work the influence of land cover changes on landslide susceptibility are analyzed for the past and for future scenarios. For the application, an area representative of the hilly-low mountain sectors of the Italian Southern Apennines was chosen (Rivo basin, in Molise Region). With this purpose landslide inventories and land cover maps were produced for the years 1954, 1981 and 2007. Two alternative future scenarios were created for 2050, one which follows the past trend (2050-trend), and another one more extreme, foreseeing a decrease of forested and cultivated areas (2050-alternative). The landslide susceptibility analysis was performed using the Spatial Multi-Criteria Evaluation method for different time steps, investigating changes to susceptibility over time. The results show that environmental dynamics, such as land cover change, affect slope stability in time. In fact there is a decrease of susceptibility in the past and in the future 2050-trend scenario. This is due to the increase of forest or cultivated areas, that is probably determined by a better land management, water and soil control respect to other land cover types such as shrubland, pasture or bareland. Conversely the results revealed by the alternative scenario (2050-alternative), show how the decrease in forest and cultivated areas leads to an increase in landslide susceptibility. This can be related to the assumed worst climatic condition leading to a minor agricultural activity and lower extension of forested areas, possibly associated also to the effects of forest fires. The results suggest that conscious landscape management might contribute to determine a significant reduction in landslide susceptibility.

Does a Varicose Saphenous Vein Exist?

Objective:

Duplex ultrasound evaluation of the clinically diagnosed varicose long saphenous vein (LSV).

Design:

Prospective, single patient group study.

Setting:

Department of Surgery, University of Ferrara, Italy (teaching hospital).

Patients:

378 patients, 509 limbs with primary varicose veins; 94 patients, 103 limbs with a visible, superficial varicose vein trunk on the medial aspect of the thigh.

Main outcome measure:

Duplex ultrasound detection of a varicose saphenous vein and/or segmental saphenous dilatation and their relationship to saphenous reflux.

Results:

In 98% of cases the varicose trunk visible in the thigh was demonstrated to be a tributary of the saphenous vein; 34% of the observed saphenous veins exhibited segmental dilatations in the thigh. This finding was related in every case to saphenous vein reflux with high velocity and turbulence ( p < 0.0001).

Conclusions:

High-resolution ultrasonography demonstrated that when a dilated varicose longitudinal vein trunk is visible and palpable on the medial aspect of the thigh it is most likely to be a tributary rather than the LSV. In addition, a varicose saphenous vein along its entire length essentially does not exist. However, when a dilated saphenous segment occurs, it seems to be related to high diastolic flow velocity and turbulence.

Reducing properties of 1,2-dipyridyl-1,2-disodioethanes: chemical validation of theoretical and electrochemical predictions

Theoretical calculations and electrochemical analysis were used to set up a relative scale for the reducing strength of the dianions of 1,2-dipyridylethenes, validated by studying their reactivity towards halogenated benzoic and arylacetic acids.

[In vitro activity of voriconazole and other antifungal agents against clinical isolates of 138 Candida spp]

Voriconazole is used for treating invasive Aspergillosis, Fusarium and Scedosporium infections as well as resistant candidiasis. It is referred to as a second generation triazole. The purpose of this study was to evaluate the concordance of the results of antifungal voriconazole susceptibility tests for yeast isolates, comparing the Sensititre YeastOne method, Atb Fungus 3 and Etest. In all, 138 yeast isolates (42 C. tropicalis, 36 C. glabrata, 14 C. albicans, 8 C. famata, 6 C. parapsilosis, 4 C. dubliniensis, 3 C. krusei, 3 C. lusitaniae, 2 C. zeylanoides, 20 Candida spp.) were tested for susceptibility to amphotericin B, flucytosine, fluconazole , itraconazole and voriconazole with Atb Fungus 3 method. The concordance between the Sensititre YeastOne method, Atm Fungus 3 and Etest for voriconazole was high (90%).

Urinary excretion of IgG and alpha(1)-microglobulin predicts clinical course better than extent of proteinuria in membranous nephropathy

In idiopathic membranous nephropathy (MN), the main predictors for progression to chronic renal failure (CRF) are the amount of proteinuria and extent of tubulointerstitial damage. The aim of this study is to evaluate whether urinary excretion of proteins reflecting the alteration of permselectivity in the glomerular capillary wall, such as immunoglobulin G (IgG), and the reabsorption impairment of low-molecular-weight proteins, such as alpha(1)-microglobulin (alpha(1)m), correlates with the extent of tubulointerstitial damage and have a predictive value for functional outcome and response to therapy better than 24-hour proteinuria. In 78 patients with MN, urinary excretion of albumin, transferrin, IgG, and alpha(1)m was measured by immunonephelometry in second-morning urine samples and expressed in milligrams per gram of urinary creatinine (uCr). In 48 patients with characterization of proteinuria and renal biopsy performed at the same time, excretion of IgG (P = 0.0087) and alpha(1)m (P = 0.0024), but not albumin (P = 0.37), transferrin (P = 0.38), or 24-hour proteinuria (P = 0.32), was associated significantly with the extent of tubulointerstitial damage (score, 0 to 1 versus >/=2). Only alpha(1)m excretion was associated significantly with global glomerular sclerosis (P = 0.0032) and arteriolar hyalinosis (P = 0.0004). Moreover, urinary excretion of alpha(1)m was significantly dependent on IgG excretion (r = 0.67; P = 0.0001), but not on albumin (P = 0.66) or 24-hour proteinuria (P = 0.07). Functional outcome could be evaluated in 38 patients with nephrotic syndrome and baseline normal renal function (serum creatinine, 0.99 +/- 0.20 mg/dL; follow-up, 44 +/- 22 months). Remission was 100% versus 20% in patients with IgG excretion less than 110 mg/g uCr versus 110 mg/g uCr or greater (P = 0.0001) and 77% versus 17% in patients with alpha(1)m excretion less than 33.5 mg/g uCr versus 33.5 mg/g uCr or greater (P = 0.0009), respectively. In patients with IgG and alpha(1)m excretion less than or greater than the cutoff value, progression to CRF was 0% versus 35% (P = 0.0026) and 0% versus 58% (P = 0.0001), respectively. Nineteen patients treated with immunosuppressive therapy were compared with 19 untreated patients. There was no difference in remission or progression between treated and untreated patients when IgG and alpha(1)m excretion were less than the cutoff value. There was a significant difference for progression to CRF between treated and untreated patients when alpha(1)m excretion was greater than the cutoff value (17% versus 100%; P = 0.0076). In conclusion, IgG excretion is associated significantly with the extent of tubulointerstitial damage and alpha(1)m excretion. This observation supports the hypothesis that IgG may be the toxic moiety of proteinuria. Excretion of IgG and alpha(1)m has a significant predictive value for both remission and progression and is useful to identify patients who are at risk for progression and for whom treatment with immunosuppressive therapy is indicated soon after diagnosis.

A multi-centre randomized trial of two different doses of nicotinamide in patients with recent-onset type 1 diabetes (the IMDIAB VI)

BACKGROUND

Intensive insulin therapy is the gold standard by which Type 1 diabetes is treated. In addition to this therapy, administration of nicotinamide (NA) can be beneficial. This concept is reinforced by the results of a recent meta-analysis of the use of NA in patients with recent-onset Type 1 diabetes.

METHODS

In this study we compared two different doses of NA in 74 patients with duration of Type 1 diabetes <4 weeks (mean age 13 years). Patients were randomly allocated in blind to two treatment groups: 38 patients received a dose of 25 mg/kg (b.w.) of NA and 36 patients received a dose of 50 mg/kg (b.w.) of NA. Intensive insulin therapy was carried out in order to optimize metabolic control as soon as possible after diagnosis and to maintain blood glucose level as near to normal as possible. Response to therapy was monitored throughout the study by investigating the occurrence of clinical (complete) remission defined, according to the recommendations of the International Diabetes Immunotherapy Group, as restoration of normal fasting and post-prandial blood glucose without any insulin administration for more than 2 weeks. Moreover, the integrated measures of metabolic control (C-peptide, HbA(1c) and insulin dose) were analysed at 3- month intervals up to 1 year after diagnosis.

RESULTS

There were no significant differences in the integrated measures of metabolic control between the two NA treated groups either at onset of the disease or at each 3-month interval up to 1 year after diagnosis, although there was a tendency toward higher insulin dosages in the 50 mg NA group. No significant differences were observed in the rate of clinical remission between the two groups.

CONCLUSION

We conclude that patients with recent-onset Type 1 diabetes treated with two different doses of NA, in addition to intensive insulin therapy, show similar residual beta-cell function 1 year later. Since both doses of NA are likely to be effective in reducing beta-cell dysfunction, the smaller dose of 25 mg/kg NA would be sufficient as a higher dose may induce insulin resistance.

Ultrasonographic assessment of ambulatory venous pressure in superficial venous incompetence

PURPOSE

In spite of its invasiveness, measurement of ambulatory venous pressure (AVP) is widely considered the gold standard measurement of venous function. We studied a technique for noninvasive ultrasonographic AVP determination in superficial venous incompetence.

METHODS

A linear relationship between venous pressure (measured by echo-guided venous puncture) and diameter (measured by transverse axis duplex imaging) was preliminarily demonstrated with multiple measurements in different conditions (supine, sitting, standing, and Trendelenburg positions, after exercise with and without cuff occlusion) in a saphenous tract at the thigh of 82 limbs in which reflux had been previously demonstrated. Then AVP was measured in another group of 44 patients who had demonstrated superficial venous incompetence, both with and without proximal occlusion, using again the same invasive method and a new noninvasive technique. The latter technique consisted in the construction of a linear diameter/pressure curve obtained after saphenous diameter (by high-resolution sonography) and noninvasive pressure (using hydrostatic values) determinations in the sitting and standing positions. Further measurement of saphenous diameter after standardized exercise permits extrapolation of the AVP values from the curve.

RESULTS

Linear regression analysis demonstrates that (1) beginning from 20 mm Hg, the pressure/diameter relationship of the incompetent greater saphenous vein is linear; and (2) AVP values derived invasively and noninvasively are significantly correlated (r = 0.7347 and p < 0.0001 for AVP derived without occlusion; r = 0.7270 and p < 0.0001 for values recorded with occlusion).

CONCLUSIONS

The proposed technique appears able to reliably assess noninvasively AVP values in superficial venous incompetence. In addition, it can be performed with equipment that is widely used for vascular investigations.

Vitamin E and nicotinamide have similar effects in maintaining residual beta cell function in recent onset insulin-dependent diabetes (the IMDIAB IV study)

OBJECTIVE

Protection of residual beta cell function at the time of diagnosis of insulin-dependent diabetes mellitus (IDDM) by intensive insulin therapy and the addition of nicotinamide (NA) has been established. The objective of this study was to evaluate the effect of a free oxygen radical scavenger such as vitamin E (Vit E) on residual beta cell function and parameters of metabolic control in patients with recent onset IDDM undergoing intensive insulin therapy.

DESIGN

The effect of Vit E was compared with that of NA (control group) in a randomized multicentre trial.

METHODS

Eighty-four IDDM patients between 5 and 35 years of age (mean age 15.8 +/- 8.4 (s.d.) years) entered a one year prospective study. One group of patients (n = 42) was treated with Vit E (15 mg/kg body weight/day) for one year; the other group (n = 42) received NA for one year (25 mg/kg body weight/day). All patients were under intensive insulin therapy with three to four injections a day. Basal and stimulated (1 mg i.v. glucagon) C-peptide secretion, glycosylated haemoglobin and insulin dose were evaluated at diagnosis and at three-monthly intervals up to one year.

RESULTS

Preservation and slight increase of C-peptide levels at one year compared with diagnosis were obtained in the two treated patient groups. No statistically significant differences were observed in basal or stimulated C-peptide levels between the two groups of patients for up to one year after diagnosis. Glycosylated haemoglobin and insulin dose were also similar between the two groups; however patients receiving Vit E under the age of 15 years required significantly more insulin than NA-treated patients one year after diagnosis (P < 0.04).

CONCLUSIONS

Our data indicate that Vit E and NA possess similar effects in protecting residual beta cell function in patients with recent onset IDDM. Since their putative mechanism of protection on beta cell cytotoxicity is different, combination of these two vitamins may be envisaged for future trials of intervention at IDDM onset.

Membranous obstruction of the inferior vena cava and Budd-Chiari syndrome. Report of a case

Membranous obstruction of the inferior vena cava (MOIVC) is a rare, congenital or acquired, cause of Budd-Chiari syndrome leading to hepatocellular carcinoma in 20 to 40% of the patients. It has a very poor prognosis when treated medically and balloon angioplasty (PTA) represents, nowadays, the treatment of choice, having no mortality or significant morbidity with follow-up as long as 5 years; transatrial membranotomy, direct reconstruction of IVC and bypass surgery are alternative techniques when PTA is not feasible. One case of Budd-Chiari syndrome due to an incomplete membranous obstruction of the suprahepatic portion of the inferior vena cava is reported. A PTA was not feasible as it was not possible to pierce the membranous obstruction. A successful inferior vena cava-right atrium PTFE bypass, with a 3.5-year follow-up, was performed. This surgical approach is a valuable alternative to transatrial membranotomy and direct reconstruction of the IVC.

Pyrazole-related nucleosides. 4. Synthesis and antitumor activity of some 1-tetrahydropyranyl-4-substituted pyrazoles

Continuing our studies on the structure-activity relationships of some pyrazole nucleosides (1a-h) structurally related to ribavirin, tiazofurin and selenazofurin, we describe here the synthesis and antitumor/antiviral/antimicrobial activity of a new series of 1-tetrahydropyranyl-4-substituted pyrazoles. In this study, the tetrahydropyranyl moiety (THP), designed as a mimic of the glycosidic portion of the parent compounds 1a-h, has led to a few derivatives with moderate cytotoxic activity against leukemia/lymphoma and solid tumor-derived cell lines (IC50 14-100 microM). The compounds obtained through substitution of the ribofuranosyl moiety by the THP moiety were still active, the free heterocyclic bases were devoid of any activity.

Alternative saphenous vein sparing surgery for future grafting

OBJECTIVE

Evaluation of long saphenous vein sparing surgical procedures alternative to high ligation and distal stab avulsion, in terms of effectiveness and suitability for eventual by-pass surgery.

EXPERIMENTAL DESIGN

Prospective evaluation of 125 operations for primary varicose veins, 52 external valve-plasties of the sapheno-femoral junction (EV-SFJ) (42 performed using the hand sewing technique and 10 using the Veno-cuff device), mean follow-up 45 months, and 73 hemodynamic correction of varicose veins (French acronyms: CHIVA), mean follow-up 30 months.

SETTING

Department of General Surgery, University of Ferrara. Institutional practice, one-day surgery.

PATIENTS

Patients were selected using clinical, Doppler cw, and duplex scanning evaluations. Patients with early varices due to sapheno-femoral reflux with duplex scanning evidence of mobile valve leaflets underwent EV-SFJ. The other patients were operated on using the hemodynamic correction technique. Both groups underwent preoperative ambulatory venous pressure (AVP) and light reflection rheography-refilling time (LRR-RT) measurements.

INTERVENTIONS

EV-SFJ restores valve function correcting vein wall dilitation by applying an external prosthesis. CHIVA consists of selected ligatures of the superficial veins that allow superficial blood aspiration in the deep veins through the perforators.

MEASURES

The outcome was evaluated with clinical and ultrasonographic examinations, AVP and LRR-RT measurements.

RESULTS

Long saphenous vein patency registered after EV-SFJ and CHIVA was 94.2% and 90.4%, respectively. Both treatments preserve the drainage function in the saphenous system. Varicose veins recurrence percentage rate was 9.6% and 10.9%, respectively.

CONCLUSIONS

Following the proposed selection criteria, these two alternative procedures seem to be more effective in varices treatment than high ligation and have the advantage of preserving saphenous veins suitable for eventual by-pass surgery.

[Video-laparoscopic splenectomy: experience in 3 cases]

BACKGROUND

In selected cases the spleen can be removed:

METHODS

2 women and 1 men with immune thrombocytopenic purpura, with hypersplenism without splenomegaly, underwent splenectomy by laparoscopic means.

RESULTS

In 2 cases the splenectomy has been performed entirely by laparoscopic means. In 1 case the operation has been converted as we have not been able to control a venous bleeding from injured hilar spleen vessels.

DISCUSSION

No particular technical problems arose in the 2 cases entirely conducted by laparoscopic means. Care must be taken manipulating the hilar vessels as the veins are fragile and their bleeding is difficult to be controlled in laparoscopy. The laparoscopic splenectomy seems to offer less postoperative pain, shorter hospitalization and improved cosmesis according to our previous experience with open splenectomy.

CONCLUSIONS

The good result of the operations encourages the laparoscopic approach to splenectomy, in selected cases.

The use of sulodexide in the treatment of peripheral vasculopathy accompanying metabolic diseases. Controlled study in hyperlipidemic and diabetic subjects

Thirty vasculopathic subjects with hyperlipoproteinemia (18) and/or diabetes (22) underwent a clinical double-blind study in order to evaluate the effect of sulodexide on lipid and hemorheologic parameters. The experimental design consisted of a first 20-day i.m. therapeutic period with either sulodexide (300 Lipasemic Units twice daily via intramuscular route) or placebo and the following 70 days with the active compound for both groups at the same posology. Results obtained demonstrated that sulodexide yields a hypotriglyceridemic effect on type IV hyperlipoproteinemia and hypofibrinogenic effect, as well. Moreover, this compound exerted a beneficial effect on HDL Cholesterol levels and on the antithrombin III activity by increasing both parameters significantly. Signs and symptoms were alleviated, particularly in the most severe cases of peripheral vascular disease. Insignificant and slight changes were observed at the end of treatments as regards the efficacy of the two administration routes, the i.m. one being more efficacious on lipid parameters and faster acting. No side effects or intolerance were observed during the different periods of the trial.

[Psoriatic arthritis: considerations on recent studies: serum beta 2 microglobulin and circulating T-gamma lymphocytes]

The results of two recent studies of our group have been reported. They regard two immunological parameters of psoriatic arthritis: the proportions of T gamma lymphocytes in peripheral blood and the beta 2 microglobulin in the serum. The data obtained in psoriatic arthritis patients have been compared to those found in normal controls and in rheumatoid arthritis patients. T gamma mean values in psoriatic arthritis were significantly lower than those present in healthy subjects and in rheumatoid patients. These last patients showed beta 2 microglobulin mean values significantly higher than those observed in normal controls and in psoriatic arthritis patients. Conversely, the mean of beta 2 microglobulin levels in psoriatic arthritis has been found to be similar to that observed in normal controls, but a superimposition in the range of individual values of these two groups with the concentrations determined in rheumatoid subjects has been found. These results seem to be of interest in relation to the immunopathogenetic mechanism of psoriatic arthritis, but are of little help in the clinical differentiation of the two rheumatological affections considered.

T gamma lymphocytes of peripheral blood and synovial fluid in rheumatoid arthritis: quantitative determination and qualitative analysis

The distribution of T gamma lymphocytes in the peripheral blood of one group of rheumatoid patients and in the synovial fluid in a second group was determined. The results were compared to those found for peripheral blood (PB) lymphocytes of normal subjects and for synovial fluid lymphocytes of osteoarthrosis and meniscitis patients. Besides recording percentage and absolute number, we also used cytofluorographic analysis to determine individual capacity of PB T gamma cells to bind heat-aggregated IgG (agg-IgG). The following results were found: 1) there is no significant difference between the percentage and absolute number of PB T gamma lymphocytes of rheumatoid arthritis (RA) patients and those of controls, 2) individual RA PB T gamma cells had a greater number and/or avidity of Fc receptor for IgG than those cells of controls, and 3) the percentage of RA T gamma lymphocytes in synovial fluid, revealed by IgG-EA ox rosetting, is significantly lower than that found in control patients. The factors that may determine a similar lymphocyte picture in RA are discussed.

Electrospinogram of the rabbit. Monitoring of the spinal conduction in acute cord lesions versus clinical observation

The electrospinogram was investigated in 18 adult rabbits before and after acute spinal lesions of variable entity. The first positive wave is widely distributed from L7 to Th11-12 and seems to be generated by a dipole placed within the cauda. The following 'M'-shaped complex is propagated up to the cervical segments probably along the primary afferent pathways in the dorsal columns ipsilateral to the stimulated side. Local reflexes of mono- and polysynaptic loops are also present. Standardized seriate clinical observations did not provide reliable data on level and extension of the lesion until 16-24 h, while the electrospinogram showed a 'killed end' potential already within the first 60 min. Furthermore, this noninvasive test furnishes early tools about the width of the anatomical damage.

Somatosensory evoked potentials (S.E.P.) in slow pathological compression of the spinal cord

Somatosensory evoked potentials (S.E.P.) were used to examine twelve patients who had slow compressive lesions of the spinal cord (ten cases of spondylotic myelopathy, one neurinoma, one metastasis of a vertebral body). 73 per cent of the recordings were found to be abnormally reduced in amplitude, and/or showed prolonged latency times aa regards the primary and secondary complex. Patients with a clinical lesion of the dorsal column showed a clear reduction in amplitude in the recordings (sometimes coupled with slowed latency), especially in the primary complex. Patients with symptoms indicative of an injury to the ventrolateral region of the spinal cord showed tracings with alterations most of all related to the secondary complex. In 76 per cent of cases, the somatosensory evoked potentials were in accordance with the level of the compression, the degree of invalidity, and the clinical picture.