Immediate loading on two adjacent single dental implants with definitive nonsplinted restorations: A proof of concept in the posterior zone

OBJECTIVES

To evaluate clinical, clinician- and patient-reported outcomes (PROs) of two adjacent single posterior implants immediately loaded with definitive single crowns up to 1 year. Ten patients in need of two adjacent posterior single implants were included. All implants were placed applying a fully digital workflow. Definitive screw-retained single zirconia crowns were delivered within 72 h after implant placement. Clinical parameters, patient- and clinician-reported outcomes were assessed up to 1 year of follow-up.

CLINICAL CONSIDERATIONS

Clinical outcomes remained stable, with no implant failures or technical and biological complications throughout the observation period. Patient satisfaction was very high at baseline (crown delivery) and remained consistently high at 6 and 12 months of follow-up. Crown insertion 3 days after implant placement was rated as an easy procedure by clinicians.

CONCLUSIONS

Two adjacent single implants with immediate definitive restorations (<72 h) in the posterior region appear to be a viable and easy treatment option to shorten the overall treatment time and potentially enhancing patient satisfaction. However, randomized controlled trials are needed to confirm the advantages of this treatment protocol over a delayed loading approach.

CLINICAL SIGNIFICANCE

In selected cases, immediate implant loading with definitive restorations in the posterior region appears a valuable and straightforward option to shorten the overall treatment time.

Efficacy of different mouthwashes against COVID-19: A systematic review and network meta-analysis

To evaluate the effectiveness of antiseptic mouthwashes in reducing SARS-CoV-2 load clinically and in vitro. A systematic electronic search (MEDLINE/Scopus/Cochrane) was conducted to identify prospective clinical and in vitro studies published between 2019 included and 16 June 2023 assessing the effectiveness of mouthwashes in reducing SARS-CoV-2 load in saliva or surrogates. Data were summarized in tables and a network meta-analysis was performed for clinical trials. Thirty-five studies (14 RCTs, 21 in vitro) fulfilled the inclusion criteria. The risk of bias was judged to be high for 2 clinical and 7 in vitro studies. The most commonly test product was chlorhexidine alone or in combination with other active ingredients, followed by povidone-iodine, hydrogen peroxide and cetylpyridinium chloride. Overall, the descriptive analysis revealed the effectiveness of the mouthwashes in decreasing the salivary viral load both clinically and in vitro. Network meta-analysis demonstrated a high degree of heterogeneity. Among these studies, only chlorhexidine 0.20% was associated to a significant Ct increase in the saliva 5 min after rinsing compared to non-active control (p = 0.027). Data from clinical and in vitro studies suggested the antiviral efficacy of commonly used mouthwashes. Large well-balanced trials are needed to identify the best rinsing protocols.

Adaptable Poly-Articulated Bionic Hands EnhanceBoth Performance and User's Perception in Bilateral Amputation: A Case Study

This article evaluates and compares the performance and perception of prosthetic devices based on different design principles, a traditional rigid gripper and an adaptable poly-articulated hand, in a pre- and post-training protocol with an individual with bilateral amputation. As a representative of the first class, we use commercial hands (Ottobock's MyoHand VariPlus Speed), which is a widely adopted model by prosthesis users worldwide. We compare these with two SoftHand Pro hands, which are experimental prototypes exhibiting 19 articulations actuated by one single motor, and are inspired by human hand motor control models. Results show that the individual with bilateral amputation, who was a non-expert myoelectric user, achieved better performance with adaptive poly-articulated hands. Furthermore, the acceptation, satisfaction and perceived functionality of the user were considerably higher for the SoftHand Pro. An observational analysis of the patient's behaviour by experienced therapists suggests that adaptable poly-articulated hands reduced compensatory movements and cognitive load. Using soft technologies may be especially advantageous for individuals with bilateral amputation, who present a very limited residual mobility and can largely benefit from the active use of their artificial arms in everyday life.

Four atypical cases of misdiagnosed facial cutaneous sinuses of dental origin

BACKGROUND

Odontogenic cutaneous sinus tracts are frequently misdiagnosed as cutaneous non-dental related pathologies, due to their lack of a typical morphology, their extraoral location, and the frequent absence of concomitant dental symptoms. An erroneous diagnosis may lead to long-lasting, invasive, and not resolutive surgical and medical treatments.

METHODS

Four patients referred to our department lamenting the presence of a recurrent facial cutaneous sinus tract. They all had already had different wrong diagnoses and were treated with not resolutive therapies or surgeries. After a clinical and radiographical oral examination, the cutaneous fistulas were found to have a dental etiology, and the extraction of the compromised tooth was performed.

RESULTS

One week after the tooth extraction, all the patients presented good healing of the intraoral mucosa. At the long-term follow-up in all four cases, the definitive closure of the extraoral sinus tract and a reduction of the scar was found.

CONCLUSIONS

If a facial sinus tract is present, the odontogenic etiology should always be considered, since it can easily bring to the correct diagnosis, leading to a rapid resolution of the fistula. Once the dental origin has been confirmed, the suggested treatment for a conclusive resolution of the cutaneous sinus tract is the endodontic treatment or the extraction of the affected tooth.

Generalized infinite factorization models

Factorization models express a statistical object of interest in terms of a collection of simpler objects. For example, a matrix or tensor can be expressed as a sum of rank-one components. However, in practice, it can be challenging to infer the relative impact of the different components as well as the number of components. A popular idea is to include infinitely many components having impact decreasing with the component index. This article is motivated by two limitations of existing methods: (i) the lack of careful consideration of the within component sparsity structure; and (ii) no accommodation for grouped variables and other non-exchangeable structures. We propose a general class of infinite factorization models that address these limitations. Theoretical support is provided, practical gains are shown in simulation studies, and an ecology application focusing on modelling bird species occurrence is discussed.

Effects of the Antihypertensive Fixed-Dose Combinations on an Early Marker of Hypertensive Cardiac Damage in Subjects at Low Cardiovascular Risk

BACKGROUND

In hypertensive subjects (HTs), isolated left ventricular diastolic dysfunction (LVDD) is an early marker of cardiac damage and is associated with poor prognosis. However, few intervention trials investigated the effects of antihypertensive therapy on isolated LVDD regression. This study investigates the blood pressure (BP)-lowering efficacy and the effect on LVDD of antihypertensive drugs administered as fixed-dose combinations in untreated HTs with isolated LVDD.

METHODS

A total of 168 HTs (23% of them having impaired fasting glucose (IFG)) aged 48±4.2 years were randomized to receive open-label once-daily oral treatment of beta-blocker + diuretic, angiotensin-converting enzyme inhibitor (ACEI) + diuretic, angiotensin II receptor blocker (ARB) + diuretic, ARB + calcium channel blocker (CCB), or ACEI + CCB. Clinic and 24-hour ambulatory BP values were measured before randomization and at the follow-up. Regression of LVDD was defined as normalization of both the E/A (ratio of early-to-late ventricular filling wave velocity) and E/E' (mitral velocity to early diastolic velocity of the mitral annulus) ratios. Comparisons were made between categorical variables using the χ(2) test and between continuous variables by gender using analysis of variance for repeated measures.

RESULTS

BP reduction did not differ between groups. LVDD regression was significantly more prevalent in the ARB + CCB or ACEI + CCB groups than with other combinations; in HTs with IFG, it was most prevalent (46%) with ACEI + CCB.

CONCLUSIONS

Independently of BP reduction, the fixed-dose combinations ARB + CCB and ACEI + CCB led to regression of isolated LVDD. In those with an IFG, ACEI + CCB was most effective.

25-Hydroxycholecalciferol response to single oral cholecalciferol loading in the normal weight, overweight, and obese

After a single cholecalciferol load, peak serum 25-hydroxycholecalciferol (25OHD) is lower in individuals with a higher body mass index (BMI), probably due to it being distributed in a greater volume. Its subsequent disappearance from the serum is slower the higher the individual's BMI, probably due to the combination of a larger body volume and a slower release into the circulation of vitamin D stored in adipose tissue.

INTRODUCTION

The aim of the study is to examine 25-hydroxycholecalciferol (25OHD) response to a single oral load of cholecalciferol in the normal weight, overweight, and obese.

METHODS

We considered 55 healthy women aged from 25 to 67 years (mean ± SD, 50.8 ± 9.5) with a BMI ranging from 18.7 to 42 kg/m(2) (mean ± SD, 27.1 ± 6.0). The sample was divided into three groups by BMI: 20 were normal weight (BMI ≤ 25 kg/m(2)), 21 overweight (25.1 ≤ BMI ≤ 29.9 kg/ m(2)), and 14 obese (BMI ≥ 30 kg/m(2)). Each subject was given 300,000 IU of cholecalciferol orally during lunch. A fasting blood test was obtained before cholecalciferol loading and then 7, 30, and 90 days afterwards to measure serum 25OHD, 1,25 dihydroxyvitamin D [1,25 (OH)2D], parathyroid hormone (PTH), calcium (Ca), and phosphorus (P). Participants' absolute fat mass was measured using dual energy X-ray absorptiometry (DEXA).

RESULTS

The fat mass of the normal weight subjects was significantly lower than that of the overweight, which in turn was lower than that of the obese participants. Serum 25OHD levels increased significantly in all groups, peaking 1 week after the cholecalciferol load. Peak serum 25OHD levels were lower the higher the individuals' BMI. After peaking, the 25OHD levels gradually decreased, following a significantly different trend in the three groups. The slope was similar for the overweight and obese, declining significantly more slowly than in the normal weight group. In the sample as a whole, there was a weakly significant negative correlation between fat mass and baseline 25OHD level, while this correlation became strongly significant at all time points after cholecalciferol loading.

CONCLUSIONS

The lower peak 25OHD levels seen in the obese and overweight is probably due to the cholecalciferol load being distributed in a larger body volume. The longer persistence of 25OHD in their serum could be due to both their larger body volume and a slower release into the circulation of the vitamin D stored in their adipose tissue.

Nutraceutical approaches to homocysteine lowering in hypertensive subjects at low cardiovascular risk: a multicenter, randomized clinical trial

Although the role of homocysteine (HCys) in secondary cardiovascular prevention has been scaled down, hyper-homocysteinemia remains a risk factor for cerebrovascular events. The aim of this study was to investigate the efficacy of nutraceuticals in lowering HCys serum levels versus a conventional vitamin supplementation in hypertensive subjects at low cardiovascular risk. One-hundred and four patients (mean age 62.8±14.5 years, 63.5% males), 52 for each treatment group, were enrolled. The study recruited patients with stage 1 essential hypertension and hyper-homocysteinemia (HCys ≥15 μmol/L), without a history of cardiovascular and cerebrovascular disease. They were sequentially randomized to receive a combined nutraceutical containing 400 μg folate-6-5-methyltetrahydrofolate, 3 mg vitamin B6, 5 μg vitamin B12, 2.4 mg vitamin B2, 12.5 mg zinc and 250 mg betaine (Normocis^400®) once daily for two months, or supplementation with highly dosed folic acid (5 mg/day) (control group). Differences in serum HCys values were compared by ANOVA for repeated measures. A significant HCys reduction in comparison to baseline was found in both groups at the end of the study treatment, from 21.5±8.7 to 10.0±1.7 μmol/L for Normocis^400® subjects (p less than 0.0001), and from 22.6±6.2 to 14.3±2.8 μmol/L for controls (p less than 0.0001). HCys reduction was significantly higher among patients treated with Normocis^400® (p less than 0.035). The ideal HCys level (i.e. less than 10 μmol/L) was reached in 55.8% of cases in theNormocis^400® group, and it was significantly higher than in controls. No side effects were observed in either treatment group. Randomized clinical trials are ongoing to test the effect of folate, B6, and B12 supplementation in primary prevention of cardiovascular and cerebrovascular events. In the meantime, especially when the ideal HCys level is far from being reached, Normocis^400® appears to be safe, well tolerated and effective in reducing HCys levels.

(99m)Tc-DTPA scintigraphy assesses the absence of glomerular filtration rate impairment of Aliskiren in high-risk hypertensive subjects. A 12-month follow-up study

AIM

Glomerular filtration rate (GFR) is commonly calculated using the modification of diet in renal disease (MDRD) and Cockroft-Gault (CG) formulas and recently by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) algorithm and not directly measured, so that the real impact of antihypertensive therapy on GFR could not be well defined. In this study, the effect of Aliskiren on the GFR measured by radionuclide clearance of 99mTc-diethylene triamine penta-acetic acid (DTPA) was investigated.

METHODS

In 106 hypertensive subjects (53% men) aged 61.9±12.7 years with uncontrolled blood pressure (BP) receiving at least 2 antihypertensive medications, Aliskiren was added once-daily at a dose of 150-300 mg for 12 months. Clinic BP measurements were taken at every follow-up visit (1st, 6th and 12th month), while 24-hours ambulatory BP and GFR (in mL/min/1.73 m2) were evaluated at baseline and at the end of the follow-up. Analysis of variance for repeated measures of BP, GFR and microalbuminuria was provided.

RESULTS

With the use of Aliskiren a significant reduction of BP and microalbuminuria was found (P<0.0001). Only in male population, a significant reduction in GFR calculated with CKD-EPI (82.4±15 vs. 78.6±18.2, P<0.01) and CG (81.6±29.5 vs. 74.2±28.4, P<0.0001) formulas was observed. This impairment of GFR was not found either with MDRD formula (70.5±19.6 vs. 68.3±23.4) or by radionuclide clearance (62.4±18.6 vs. 61.4±20.5).

CONCLUSION

This study seems to demonstrate that the efficacy on BP control of Aliskiren is not accompanied by an impairment of GFR. In order to evaluate the effect of Aliskiren on GFR scintigraphy technique or MDRD formula resulted to be the most accurate methods.

Aliskiren improves blood pressure control and prevents cardiac damage in high-risk hypertensive subjects

AIM

Longitudinal study aimed to evaluate the antihypertensive efficacy, safety and the effect on cardiac damage of Aliskiren, administered to a group of high-risk hypertensive patients with mild impairment of renal function and uncontrolled blood pressure (BP) despite a two-drug antihypertensive treatment.

METHODS

One hundred and six patients (56 men and 50 females) aged 61.9±12.7 years, were assigned to receive Aliskiren 150-300 mg once-daily for 12 months. Clinic BP measurements were taken at every follow-up visit (1st, 6th and 12th month), while biochemical tests, estimated glomerular filtration rate (eGFR), 24-hours ambulatory BP measurements (ABMP) and echocardiography were evaluated at baseline and at the end of follow-up. Analysis of variance for repeated measures compared BP, left ventricular mass index (LVMI) and eGFR values changes.

RESULTS

A significant reduction (all P<0.0001) of clinic systolic (-28.6 mmHg) and diastolic (-12.8 mmHg) BP values, mean 24h-systolic (-12.3 mmHg) and 24h-diastolic (-6.5 mmHg), day-time systolic (-11.5 mmHg) and diastolic (-6.4 mmHg), night-time systolic (-11.9 mmHg) and diastolic (-7 mmHg) ABPM values and in the use of antihypertensive drugs was observed (3.0±0.9 vs. 2.0±0.7, p=0.01). LVMI was significantly reduced (130.2±36.1 vs. 115.9±33.4 g/m2, P<0.0001); eGFR was steady (75.3±17.3 vs. 73.1±21.5 ml/min/1.73m2, P>0.05). Putative adverse events caused withdrawal of 7 subjects (6 for gastrointestinal disturbances, 1 for alopecia).

CONCLUSION

Aliskiren was effective in decreasing both clinical and ABPM values and in reducing LVMI in both genders without any influence on eGFR. The treatment resulted safe, even in combination with ACE-inhibitors and angiotensin II receptor blockers. A significant reduction in the use of concomitant antihypertensive drugs was observed.

Aliskiren improves blood pressure control and prevents cardiac damage in high-risk hypertensive subjects

Aim: Longitudinal study aimed to evaluate the antihypertensive efficacy, safety and the effect on cardiac damage of Aliskiren, administered to a group of high-risk hypertensive patients with mild impairment of renal function and uncontrolled blood pressure (BP) despite a two-drug antihypertensive treatment. Methods: One hundred and six patients (56 men and 50 females) aged 61.9±12.7 years, were assigned to receive Aliskiren 150-300 mg once-daily for 12 months. Clinic BP measurements were taken at every follow-up visit (1st, 6th and 12th month), while biochemical tests, estimated glomerular filtration rate (eGFR), 24-hours ambulatory BP measurements (ABMP) and echocardiography were evaluated at baseline and at the end of follow-up. Analysis of variance for repeated measures compared BP, left ventricular mass index (LVMI) and eGFR values changes. Results: A significant reduction (all P<0.0001) of clinic systolic (-28.6 mmHg) and diastolic (-12.8 mmHg) BP values, mean 24h-systolic (-12.3 mmHg) and 24h-diastolic (-6.5 mmHg), day-time systolic (-11.5 mmHg) and diastolic (-6.4 mmHg), night-time systolic (-11.9 mmHg) and diastolic (-7 mmHg) ABPM values and in the use of antihypertensive drugs was observed (3.0±0.9 vs. 2.0±0.7, p=0.01). LVMI was significantly reduced (130.2±36.1 vs. 115.9±33.4 g/m2, P<0.0001); eGFR was steady (75.3±17.3 vs. 73.1±21.5 ml/min/1.73m2, P>0.05). Putative adverse events caused withdrawal of 7 subjects (6 for gastrointestinal disturbances, 1 for alopecia). Conclusion: Aliskiren was effective in decreasing both clinical and ABPM values and in reducing LVMI in both genders without any influence on eGFR. The treatment resulted safe, even in combination with ACE-inhibitors and angiotensin II receptor blockers. A significant reduction in the use of concomitant antihypertensive drugs was observed.

Glycaemic fall after a glucose load. A population-based study

BACKGROUND AND AIMS

A blood glucose (BG) fall after an oral glucose load has never been described previously at a population level. This study was aimed at looking for a plasma glucose trend after an oral glucose load for possible blood glucose fall if any, and for its impact on coronary mortality at a population level.

METHODS AND RESULTS

In subjects from an unselected general population, BG and insulin were detected before and 1 and 2h after a 75-g oral glucose load for insulin sensitivity and β-cell function determination. Blood pressure, blood examinations and left ventricular mass were measured, and mortality was monitored for 18.8±7.7 years. According to discriminant analysis, the population was stratified into cluster 0 (1-h BG < fasting BG; n=497) and cluster 1 (1-h BG ≥ fasting BG; n=1733). To avoid any interference of age and sex, statistical analysis was limited to two age-gender-matched cohorts of 490 subjects from each cluster (n=940). Subjects in cluster 0 showed significantly higher insulin sensitivity and β-cell function, lower visceral adiposity and lower blood pressure values. Adjusted coronary mortality was 8 times lower in cluster 0 than 1 (p<0.001). The relative risk of belonging to cluster 1 was 5.40 (95% CI 2.22-13.1).

CONCLUSION

It seems that two clusters exist in the general population with respect to their response to an oral glucose load, independent of age and gender. Subjects who respond with a BG decrease could represent a privileged sub-population, where insulin sensitivity and β-cell function are better, some risk factors are less prevalent, and coronary mortality is lower.

Serum uric acid shows a J-shaped trend with coronary mortality in non-insulin-dependent diabetic elderly people. The CArdiovascular STudy in the ELderly (CASTEL)

The relationship between serum uric acid (SUA) and risk of coronary heart disease (CHD) mortality remains controversial, particularly in diabetic subjects. The aim of the present study is to evaluate whether SUA independently predicts CHD mortality in non-insulin-dependent elderly people from the general population and to investigate the interactions between SUA and other risk factors. Five hundred and eighty-one subjects aged >/=65 years with non-insulin-dependent diabetes mellitus were prospectively studied in the frame of the CArdiovascular STudy in the ELderly (CASTEL). Historical and clinical data, blood tests and 12-year fatal events were recorded. SUA as a continuous item was divided into tertiles and, for each tertile, adjusted relative risk (RR) with 95% confidence intervals (CI) was derived from multivariate Cox analysis. CHD mortality was predicted by SUA in a J-shaped manner. Mortality rate was 7.9% (RR 1.28, CI 1.05-1.72), 6.0% (reference tertile) and 12.1% (RR 1.76, CI 1.18-2.27) in the increasing tertiles of SUA, respectively, without any difference between genders. In diabetic elderly subjects, SUA independently predicts the risk of CHD mortality in a J-shaped manner.

Living Donor Liver Transplantation and Management of Portal Venous Pressure

Small-for-size syndrome occurs in the presence of a reduced mass of liver that is insufficient to maintain normal liver function. It has been speculated that this dysfunction is principally associated with graft exposure to excessive portal perfusion. The aim of these cases was to evaluate the efficacy of octreotide, a splanchnic vasoconstrictor, and esmolol, a selective beta-blocker, to modify the portal perfusion in the postoperative phase after left living related liver transplantation (LRLT). Four patients who underwent left LRLT with graft-to-recipient weight ratios of 0.60 +/- 0.24 were studied with a catheter placed in a jejunal vein. We observed high basal values of hepatic venous pressure gradient (HVPG) and portal vein flow (PVF). Octreotide infusion decreased HVPG, an effect that was more pronounced when it was combined with esmolol. The administration of both drugs was also associated with an improvement in portal vein oxygen saturation. Despite variation in PVF, the plasma disappearance rate of indocyanin green did not change during the infusion of the two drugs. In conclusion, octreotide and esmolol infusion allowed a manipulation of portal vein pressure that should be measured in left LRLT using a small-for-size graft.

Triglycerides + high-density-lipoprotein-cholesterol dyslipidaemia, a coronary risk factor in elderly women: the CArdiovascular STudy in the ELderly

BACKGROUND

The relationship between serum triglycerides (TG) level and the risk of coronary heart disease (CHD) mortality remains controversial.

AIMS

To evaluate whether TG level is a risk factor for CHD in elderly people from general population, and to look for interactions between TG and other risk factors.

METHODS

3257 subjects aged >or= 65 years followed up for 12 years from the CArdiovascular STudy in the ELderly. Blood tests and anthropometric measurements were performed. Continuous items were divided into quintiles and, for each quintile, adjusted hazard ratio (HR) with 95% confidence interval (CI) for CHD mortality was derived by genders from Cox analysis.

RESULTS

In women, the HR of being in the fifth rather than in the first quintile of TG was 2.45 (CI 1.48-3.51). In turn, high-density-lipoprotein cholesterol (HDL-C) inversely predicted CHD mortality; the HR of being in the first rather than in the fifth quintiles of HDL-C was 1.52 (CI 1.24-2.36). The risk of CHD mortality further increased up to 3.81 (CI 1.62-5.43) when high TG and low HDL-C were combined. No predictive role for either TG or HDL-C was detected in men.

CONCLUSIONS

TG and HDL-C were independent predictors of CHD mortality in elderly women. The combination high TG + low HDL-C quadrupled the risk of CHD mortality in this gender only.

Transitional Cell Carcinoma of the Posterior Urethra in Men: Our Experience

We present the experience of the Division of Urology of Mantova Hospital about the primitive carcinoma of the posterior male urethra. This kind of tumor is very rare and there are't great experiences that permit to define a standardize therapy.

Material and Methods.

Three cases of primary posterior urethral carcinoma who had been treated at our institution between 1999 and 2001 were retrospectively analyzed. The location of the tumor was in 2 cases in the prostatic urethra and in 1 case in the membranosus urethra. The treatment was cistoprostatectomy in 1 case, cistoprostcatectomy associated with penectomy in the case of carcinoma of the membranosus urethra and a prostatectomy in one case of the carcinoma of the prostatic urethra. In 2 cases an adiuvant chemotherapy with cispaltinum was performed while in the third patient a chemiotherapy with gemcitabina was performed at the presentation of a local relapse of tumor.

Results.

In the case of carcinoma of the prostatic urethra treated with cistoprostatectomy and uretrhectomy and adiuvant chemotherapy there was a good local and distand controll of the cancer with a follow up of 24 months. The patients with carcinoma of the membranosus urethra treated with cistoprostcatectomy associated with penectomy and adiuvant chemiotherapy had a local relapse at 24 months and was treated with radiotherapy. The patient treated with only prostatectomy presented a local relapse at 2 months and distant metastasis at 15 months. After 2 years this patient is still alive but in clinical progression.

Conclusions.

The most adequate treatment in the cases of posterior urethral cancer seems the major surgical treatment with urethrectomy associated with radical cistectomy. In advanced stages chemotherapy which by necessity must follow the guidelines established for the treatment of other urothelial cell malignancies seems to give good results. The follow-up of these patients has to be very close.

Five Year Results after Radical Prostatectomy in Patients with pT3a Patological Stage and Positive Surgical Margins

Five year results in men with pT3a disease and positive surgical margins after radical retropubic prostatectomy were evaluated.

Materials and Methods

Between 1/90 and 12/98, 250 men underwent radical retropubic prostatectomy for prostate cancer. In 63 cases (25%) we found positive surgical margin. In these group 32 patients presented pathological stage T3a N0 with a Gleason score between 5 and 8. In 21 patients no adiuvant therapy was made while 11 patients underwent an adiuvant therapy (in 2 patients ormonal therapy, in 9 radiotherapy).

Results

The actuarial 5 years post prostatectomy biochemical, local and distant recurrence rates were 9%, 3% e 3 % respectively. For 21 men who didn't receive adiuvant therapy, 17 were biochemical recurrence free, in 3 cases a biochemical recurrence occurred, 1man underwent a radiotherapy of salvatage for a local recurrence. For 9 patients who received adiuvant radiation therapy, 8 are biochemical free while 1 presents metastatic desease at 5 years of follow-up. The 2 patients who received adiuvant hormonal therapy are biochemical recurrence free at 5 years.

Conclusions

The role of positive surgical margins on local recurrence of desease is still under debate. In our experience isolated local recurrence is rare during long term follow up of men with pT3a No stage and positive surgical margins at radica prostatectomy. The adiuvant radiotherapy seems to give a good local desease control at 5 years of follow-up.

Total cholesterol and mortality in the elderly

OBJECTIVE

To evaluate, at a population level, whether total cholesterol (TC) is a risk factor of mortality. To verify whether or not this is true for both genders.

DESIGN

Population-based, long-lasting, prospective study.

SETTING

Institutional epidemiology in primary care.

SUBJECTS

A total of 3257 subjects aged 65-95 years, recruited from Italian general population.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Total cholesterol was measured, analysed as a continuous variable and then divided into quintiles and re-analysed. For each quintile, the multivariate relative risk (RR) of mortality adjusted for confounders was calculated in both genders. Stratification of mortality risk by TC quintiles, body mass index and cigarette smoking was also performed in both genders.

RESULTS

Total cholesterol levels directly predicted coronary mortality in men [RR being in the fifth rather than in the first quintile: 2.40 (1.40-4.14)] and any other mortality in women. It also inversely predicted miscellaneous mortality in both genders. This trend was more evident when low cholesterol was associated with malnutrition or smoking.

CONCLUSIONS

High TC remains a strong risk factor for coronary mortality in elderly men. On the other hand, having a very low cholesterol level does not prolong survival in the elderly; on the contrary, low cholesterol predicts neoplastic mortality in women and any other noncardiovascular mortality in both genders.

[Interstitial cystitis: epidemiology]

The epidemiological assessment of intestitial cystitis (IC) is not definitive as no diagnostic criteria, such as endoscopy or biochemical and anatomopathological examination, exist. The diagnosis is solely based on symptoms like urgency, frequency and pelvic pain. The first studies on the population date back from 20 years ago and show a percentage of 10 cases every 100 thousand inhabitants. There is weak link between genetic factors, immunological diseases, previous cystitis or eating habits and intestitial cystitis. Epidemiological studies have highlight the frequency of this disease, and stressed the importance of stricted behavioural rules for the first stages of intestitial cystitis.

[Interstitial cystitis: surgical treatment]

Surgical therapy of interstitial cystitis must never be considered a first option but must be reserved for cases, less than 10%, in which conservative therapy has proven ineffectual. Surgical therapy includes a variety that started at the turn of the century. Neurosurgical denervation and perivesical denervation like cysto-cystoplasty and cystolysis, manipulate the innervation to reduce the bladder's hypersensitivity. This surgical approach may be considered in patients in whom bladder capacity is normal. The results are uncertain and the complications like neurogenic bladder relevant. Enterocystoplasty is much more widespread because interstitial cystitis is a benign disease that rarely required radical surgery. Augmentation cystoplasty and substitution cystoplasty are two variants but only the later has a rationale as it involves the resection of the detrusor which is the source of the pain. Detubularization drastically reduced urinary incontinence. The resection of the detrusor can be supratrigonal, subtrigonal or at the proximal urethra like in the orthotopic neobladder. If urinary diversion is chosen, the bladder must be removed. Before recommending surgical therapy each patient should undergo tests for the localization of the pain; moreover psychological and gynaecological evaluations should be made. If the bladder capacity exceeds 400 cc surgical operation is not advisable. If, on the other hand, the bladder capacity is lower than 400 cc substitution cystoplasty is first choice. If the patient suffers from trigonal cystitis or urethral hypersensitivity, urinary diversion is a better therapy. According to the questionnaires send to the Urologic Departments in Lombardy in 1998, the most widespread type of operation seems to be supratrigonal cystectomy + enterocystoplasty and augmentation cystoplasty. Subtrigonal cystectomy or urinary diversion are only occasionally chosen; continent pouch is the least frequent therapy at all.

Shock Wave Treatment of Peyronie'S Disease: Our Experience

From September 1997 to April 1998, 40 patients with induratio penis plastica were treated with extracorporeal shock waves (ESWT). This work compares our results with those of the main Italian centres that first used this method. The aim of this study is to assess the efficiency of the treatment in the period before the main guidelines were laid down: guidelines which from now on should standardise indications and methods of application whilst optimising results.

Uretero-lithotripsy with the Swiss Lithoclast

Technological developments in ureteroscopy and extracorporeal shock wave lithotripsy (ESWL) have changed the treatment of ureteral stones over the last decade. “In situ” ESWL is now the treatment of choice in the management of ureteral calculi. Ureterolithotripsy should be preferred in certain cases, however, especially when the stone cannot be perfectly sighted or when the urinary tract needs to be drained due to obstruction and/or sepsis, with a saving of one ESWL session in 50% of patients. Current options that can be applied with lithotripsy are: electrohydraulic, laser, ultrasound and ballistic tripsy. The authors describe their experience with the Lithoclast in 82 patients. This technique has proved to be simple, safe, effective and particularly economic.

Uretroplastica a lembo libero dorsale

The Authors report their experience in the new urethroplasty technique by Barbagli for penile and bulbar urethral strictures. This procedure involves a free skin graft sutured to the corpora cavernosa. With this dorsal approach mechanical weakening is virtually impossible, so pseudo-diverticulum or urethrocele cannot develop. We adopted this technique in 5 patients during the last 12 months. The strictures of the urethra were 2.5 to 8 cm long. The follow-up, even thought short, show that this technique is safe and quite simple.

Amiloidosi polidistrettuale. Implicazioni urologiche

Amyloidosis covers a group of morbid processes which have the common characteristic of amyloid being deposited in an extracellular site of one or more organs. The mechanisms causing amyloidogenesis are still unknown. Involvement of the urinary apparatus is more frequent with primary amyloidosis and myeloma (AL form) as well as inflammatory or neoplastic diseases (AA form). The disease in the kidney is characterised by proteinuria progressing to the nephrotic syndrome and renal failure, while frank hematuria is typical of the disease in the bladder. In our case emergency cystectomy was performed because of severe anemia consequent to hematuria. Prodromal symptoms were asthenia, loss of weight, purpura and subsequent to involvement of the urinary tract, also gastroenteric, cardiac, neurovegetative, articular and thyroid disorders typical of multi-district involvement. Diagnosis is confirmed only after the histological examination and average survival rate is 20 months. There is no fully effective therapy.

Adenocarcinoma ureterale primitivo di tipo intestinale. Caso clinico

Intestinal type primitive ureteral adenocarcinoma is an uncommon neoplasm of the upper urinary tract, where the normal urothelium is replaced by an intestinal type glandular metaplastic epithelium. Our case concerns a 55-year-old man who 10 years ago had his left kidney and ureteral stump removed up to the junction with the iliac vessels due to a lumbar ureter filling defect. The ureter presented a 2 cm oedematous area with papillary vegetation. Histology revealed T1 adenocarcinoma with safe resection margin. Transurethral prostatectomy was performed and resectioning of a tumefaction of the left ostium, which proved to be an intestinal type of adenocarcinoma infiltrating the prostate. The patient underwent radical cystoprostatectomy with urinary diversion. The onset of primitive adenocarcinoma of the ureter may pass unnoticed in a chronically irritated urothelium. This case may be considered a multicentric, probably metachronous tumour and maximum surgical radicality is indicated as therapy.

[Replacement neobladders in men and women: our experience]

We present our clinical and metabolic follow-up data of 74 patients submitted to total bladder substitution using an ileal orthotopic neobladder in one group of 64 patients and a continent stomal pouch in another group of 10 patients. In the first group the mean follow-up was 41.5 months. The daytime continence was early achieved in 89% (57/64) and was maintained with time; at 12 month follow-up nocturnal continence was reached in 71% (45/64). Post voiding residual was significant only in 4 patients (2 men and 2 women). No clinical signs of pyelonephritis nor renal scars at IVP was evidenced in all but 7 patients in which a silent uretero-ileal stenosis developed. No severe metabolic acidosis or B 12 deficiency occurred. In the second group (Continent Pouch) the long term 3-Year follow-up shows a complete continence in all patients with an average capacity of 600 cc. No late complications occurred in all patients but one in which self intermittent catheterization was uncomfortable and now he prefer permanent catheter and in another patient with a stone in the Pouch treated with Lithoclast. In conclusion, total bladder substitution after radical cystectomy is now represented by orthotopic neobladder or continent Pouch in men and women. Early and late complication rate is relatively low and continence generally good.

[T1G3 bladder tumors: 5 years later]

We have evaluated 79 patients affected by bladder cancer T1G3: 31 underwent just endoscopy, 11 radiotherapy, 10 cystectomy and 27 topical chemotherapy. At five years 44 patients were alive and disease free, 7 were alive but recurrent in TA, 3 were alive but in metastatic progression, 17 were died because of the tumor, 3 died because of the therapy, and 5 died disease free. The authors believe that this patients could be treated with BCG as first treatment choice performing cystectomy when relapse or progression occuring.

[Turbo TURP]

Transurethral resection of the prostate (TURP) is just one of the numerous options available in the modern treatment of benign prostatic hyperplasia (BPH), but it's still now the "gold standard". Absorption of irrigating fluid is the greatest complication and results in clinical manifestations in 2% of the TURPs performed. There is a statistically significant relationship between gland size and the total volume of irrigant absorbed. To reduce this absorption Reuter introduced suprapubic trocar drainage to obtain the same results from both the small and the large prostates. Operating time, in fact, is reduced because, also at the same time, this large tube drains both irrigation fluid and prostatic chips.

Ectopic “blind ureterocele”: Report of 2 cases

— Ureterocele without corresponding renal tissue has been called blind ureterocele. We observed this rare malformation in two cases: a 17-year-old youth with the ureteral orifice located at the seminal vesicle and a 25-year-old woman with the orifice at the bladder neck. In both cases the proximal ureter ended in the lumbar fossa without renal parenchyma. The etiology of this ureterocele is unclear. Functioning renal tissue is supposed to be necessary for the development of a ureterocele: in blind ureterocele the renal parenchyma could subsequently disappear.

Quality of micturition after prostatectomy for pT3 carcinoma

— The purpose of radical prostatectomy for neoplasia is to cure the patient and maintain a good micturition. The first aim is achieved only in patients with localized prostatic cancer. With cancer not confined to an organ, we cannot be sure of radicality. These patients run the risk of local recurrence and worsening of micturition. The quality of micturition is determined by both surgical procedure (sphintecal weakness, stenosis of the urethro-vesical anastomosis) and local staging of the neoplasia (whether local recurrence is present or not). We studied 56 pT3 patients with uroflowmetry and symptom score. The flowmetry was always good even when local relapse occurred, but worsened when stenosis started. Urgency was the most frequent symptom in patients with local relapse.

[Our experience with impotence following radical pelvic surgery]

The etiology of impotence after radical prostatectomy and radical cystoprostatectomy is unclear, although a variety of potential factors have been cited: neurogenic, psychogenic and vascular. Injury to the pelvic nerve plexus and the branches that innervate the corpora cavernosa (cavernous nerves), seems to be the most important iatrogenic factor. The Authors selected 14 patients candidate to radical prostatectomy or radical cystoprostatectomy and studied their potency pre and post operatively by anamnesis and/or Rigiscan test. The sacral-evoked potential was determined in all these patients in order to detect a neurological etiologies. The average latency of the bulbo cavernous reflex was similar in the patients that lost their potency after surgery and in the patients that didn't lose their potency after surgery. The sacral-evoked response seems not to be a diagnostic test in the study of the impotence after pelvic radical surgery.

Impalamento e lesioni retto-vescicali

Impalement with associated bladder injuries was observed in 4 patients. The treatment should be individualised but careful debridement of all necrotic tissue, urinary and fecal diversion, separation of the injured sites with wall-vascularised tissue such as peritoneum or omentum should reduce the high incidence of fistulae or bladder stones. Endoscopic or surgical exploration of the bladder is mandatory because foreign bodies risk creating calculi, like in our 2 cases.

Lo studio dell'impotenza nel paziente diabetico

In our Andrologic Unit a diagnostic trial for studying impotence in diabetic men has been assessed in co-operation with the Metabolic Diseases Center and Neurologic Division of this Hospital. By metabolic, hormonal, vascular and peripherical neurological examinations it has been possible to find in a short time diseases where impotence was only the first sign.

[Transrectal echography in the diagnosis of cervico-urethral obstruction in the young]

The authors present a case of severe cervico-urethral obstruction by Von Brunn cysts. These cysts are often found even in macroscopically healthy bladders, but only rarely reach such a size as to be revealed by ultrasound. They can be asymptomatic or cause obstruction if large. They are no longer considered preneoplastic lesions and are therefore treated according to symptoms. When these cysts cause dysuria they are removed, preferably by transurethral resection, as it is the only method (unlike needle aspiration) which prevents recurrence.

Rare Renal Ectopia: Description of 2 Cases

Two cases of kidney ectopia are reported; a rare thoracic kidney and a very unusual supernumerary ectopic pelvic kidney. The patient with toracic kidney was casually referred to us, the second instead had a low urinary tract syndrome: burning and mild urgency. The diagnostic management and clinical characteristics of these rare pathologies are reported.

Urinary Tuberculosis: From Demolition to Reconstruction

Tuberculosis is increasing in Italy and even today is still a progressive fatal illness if not treated quickly. Drug therapy still plays an important role, while endoscopy and surgery offer further therapeutic possibilities compared to the past, with excellent results regarding the most feared complication - cicatricial stenosis. Simple ureteral endoscopic dilation with catheters has given way to the insertion of modern well-tolerated in-dwelling stents that can be used even with upper calyceal stenoses. Reconstructive bladder surgery, making new orthotopic-bladders, is a valid method for treating retracted bladders. The authors report their experience in treating TBC complications in 45 patients and in particular one paradigmatic case of urinary tuberculosis with serious stenosis involving the complete urinary system between the pelvis and the distal urethra. Urethroplasty and new orthotopic ileal bladder allowed the patient, who previously had an external deviation, to micturate naturally again.

Topical Epirubicin as Treatment of in Situ Bladder Carcinoma

15 patients with primitive carcinoma in situ of the bladder were administered 50 mg/week of Epirubicin; 14 responded to this control therapy with negative urinary cytology and biopsies within an average of 25.6 months. After an average follow up of 47.7 months, 8 out of the 15 patients are still in a state of complete remission, 1 has a recurrent grade 3 carcinoma, 5 are in progression (3 T1 and 2 T2) and 1 has a grade 2 Ta recurrence. 3 patients died from the disease.

Pelvic floor rehabilitation for the treatment of female urinary incontinence. Our experience

The authors report their experience in the treatment of female urinary incontinence with pelvic floor rehabilitation. Electrostimulation and biofeedback technique is applied. Results are satisfactory both in stress incontinence and urge incontinence. In the latter case urine lass in non-elderly patients, must be reduced and out-patients’ rehabilitation must absolutely be carried out. Anticholinergic drugs have often been administered in urge incontinence.

Supernumerary kidney

The authors report the case of a supernumerary kidney with pelvic ectopy in a 22-year-old man complaining of dysuria with leukocyturia and sterile urine. Urography, ultrasonography, C.T. and endoscopic probe revealed a small, supernumerary kidney in the left side of the pelvis between the bladder and the seminal vesicles with short ureter ending in ureterocele. Symptoms cleared up thanks to the quick pharmacological treatment so that no further ureterocele endoscopic probe was considered necessary, to avoid submitting the patient to the risk of secondary vesicles ureteral reflux and subsequent sepsis requiring difficult nephroureterectomy.

Severe obstruction by Von Brunn cysts

The authors present a case of severe cervico-urethral obstruction by Von Brunn cysts. These cysts are often found even in macroscopically healthy bladders, but only rarely reach such a size as to be revealed by ultrasound. They can be asymptomatic or cause obstruction if large. They are no longer considered preneoplastic lesions and are therefore treated according to symptoms. When these cysts cause dysuria they are removed, preferably by transurethral resection, as it is the only method (unlike needle aspiration) which prevents recurrence.

The study of erectile deficit by Rigiscan

The most widely used tests for a correct diagnosis of organic and psychogenic impotence are nocturnal erection monitoring, penile Doppler and intracavernous injection. 45 patients affected by impotence underwent NPT test while penile Doppler was performed in 32 cases; another 9 patients were given a PGE1 injection followed by real-time monitoring. A Rigiscan monitoring unit for penile rigidity and tumescence measurement was used to perform NPT and real-time FIC. NPT showed organic alteration in 15 cases, psychogenic deficit in 23 and dubious results in 9, (NPT was repeated in 2 cases). Doppler flowmetry was negative in 24 cases while it detected disease in 8. 13 of these 32 patients showed organic disease on NPT, 11 had negative results and 8 cases were considered dubious. Rigiscan nocturnal erection test seems to be the most reliable test for a correct assessment of impotence especially if it is used in combination with intracavernous injection.

[Suprapubic bladder ultrasonography and urinary cytology: indications and limits in the follow-up of superficial bladder tumors]

139 patients underwent urinary cytology and bladder sonography in follow-up of superficial bladder cancer (Ta G1-3) alternatively or at the same time of cystoscopy. Medium follow-up was 27.2 mos. In 7.91% there was progression to T1 o T2 but no case escaped this protocol. In 9% urinary cytology and bladder sonography were both falsely negative: tumors were smaller than 0.5 cm and low grade. In 76 patients with Tar bladder cystoscopy rate was 1/5.2 mos. before this study and 1/7.2 mos. after this study. In our opinion this protocol reveals the recurrence of superficial bladder tumor, reduce cystoscopy rate with no risk of ignored progression.