Magnetic seed versus skin tattoo localization of non-palpable breast lesions: a single institution cohort study

OBJECTIVE

The objective of this retrospective study was to investigate the accuracy and feasibility of magnetic seed compared to skin tattoo in preoperative localization of impalpable breast lesions in terms of accuracy of placement, re-excision and positive margins rates, and breast/surgical specimen volume ratio.

METHODS

We retrospectively analyzed 77 patients who underwent breast conservative surgery in our center from November 2020 to November 2021, with previous localization with skin tattoo or magnetic seed.

RESULTS

Thirty-seven magnetic seeds were placed in 36 patients (48.6%) and 40 skin tattoos were performed in the remaining cases (51.4%). The seeds were placed correctly at the two-view mammogram acquired after the insertion in 97.6% (36/37) of cases. With both methods, 100% of the index lesions were completely removed and found in the surgical specimen. The reported re-excision rate was 0% for both groups. A significant difference was observed in the volume of breast parenchyma removed between the two groups, inferior in the seed group (p = 0.046), especially in case of voluminous breasts (p = 0.003) and small lesions (dimension < 8 mm, p = 0.019).

CONCLUSIONS

Magnetic seed is a non-radioactive localization technique, feasible to place, recommended in case of non-palpable breast lesions, saving the breast parenchyma removed compared with skin tattoo, without reducing the accuracy.

CLINICAL RELEVANCE STATEMENT

Our findings contribute to the current evidence on preoperative localization techniques for non-palpable breast lesions, highlighting the efficacy of magnetic seed localization for deep and small lesions.

KEY POINTS

• Magnetic seed is a non-radioactive technique for the preoperative localization of non-palpable breast lesions studied in comparison with skin tattoo. • Magnetic seed is feasible to place in terms of post-placement migration and distance from the target lesion. • Magnetic seed is recommended in case of non-palpable breast lesions, saving the breast parenchyma removed without reducing the accuracy.

The Impact of COVID-19 Pandemic Lockdown on the Relationship between Pediatric MAFLD and Renal Function

BACKGROUND

Both direct and indirect effects of COVID-19 have been found in all age groups. In particular, adult data demonstrated significant changes in patients with chronic and metabolic disease (e.g., obesity, diabetes, chronic kidney disease (CKD), and metabolic associated fatty liver dysfunction (MAFLD)), while similar pediatric evidence is still limited. We aimed at investigating the impact of the COVID-19 pandemic lockdown on the relationship between MAFLD and renal function in children with CKD due to congenital abnormalities of the kidney and urinary tract (CAKUT).

METHODS

A total of 21 children with CAKUT and CKD ≥ stage 1 underwent a comprehensive evaluation within 3 months before and 6 months after the first Italian lockdown.

RESULTS

At follow-up, CKD patients with MAFLD presented higher BMI-SDS, serum uric acid, triglycerides, and microalbuminuria levels and lower eGFR levels than those without MAFLD (all p < 0.05). Higher ferritin and white blood cell concentrations were also found in patients with CKD diagnosed with MAFLD than peers without MAFLD (both p = 0.01). Compared to children without MAFLD, a higher delta of BMI-SDS, eGFR levels, and microalbuminuria levels was found in patients with MAFLD.

CONCLUSIONS

Due to the negative influence of the COVID-19 lockdown on cardiometabolic health in childhood, a careful management of children with CKD is warranted.

Life cycle assessment of air-pollution-control residues from waste incineration in Europe: Importance of composition, technology and long-term leaching

Air pollution control residues (APCr) are hazardous materials generated from municipal solid waste incineration and require appropriate management. This life cycle assessment (LCA) study investigates the environmental impacts of current and alternative management options, considering the possibility of a cascading management of APCr, where one treatment technology is followed by another. In total, 14 base case scenarios and 30 sensitivity scenarios were evaluated. The effects of APCr composition, leaching, time horizon, and uncertainties were investigated. The APCr management options with the lowest environmental impacts and the smallest uncertainties were i) backfilling of underground salt mines and ii) neutralization treatment followed by backfilling (Langøya, Norway). These options were followed by iii) scenarios that included Zn extraction, iv) cement stabilization of fresh APCr followed by landfilling and v) production of cement aggregates made from carbonated APCr followed by their utilization in construction works. Recovery of salts from APCr required further performance optimizations before being environmentally competitive with other options. Long-term leaching emissions of Zn, Cr and As were among the largest contributors to toxicity-related impacts, emphasizing the need for management strategies that minimize their leaching. The investigated scenarios demonstrate that increased "processing" and cascading utilization of the residues, contribute with increased uncertainty of the results compared to landfilling and may not necessarily lead to decreased environmental impacts. LCA studies of APCr management should address the full management chain, rather than just the first treatment. Overall, the results of this study were found robust, also considering potential changes in the surrounding energy system.

Mitochondrial diseases in adults

Mitochondrial medicine is a field that expanded exponentially in the last 30 years. Individually rare, mitochondrial diseases as a whole are probably the most frequent genetic disorder in adults. The complexity of their genotype-phenotype correlation, in terms of penetrance and clinical expressivity, natural history and diagnostic algorithm derives from the dual genetic determination. In fact, in addition to the about 1.500 genes encoding mitochondrial proteins that reside in the nuclear genome (nDNA), we have the 13 proteins encoded by the mitochondrial genome (mtDNA), for which 22 specific tRNAs and 2 rRNAs are also needed. Thus, besides Mendelian genetics, we need to consider all peculiarities of how mtDNA is inherited, maintained and expressed to fully understand the pathogenic mechanisms of these disorders. Yet, from the initial restriction to the narrow field of oxidative phosphorylation dysfunction, the landscape of mitochondrial functions impinging on cellular homeostasis, driving life and death, is impressively enlarged. Finally, from the clinical standpoint, starting from the neuromuscular field, where brain and skeletal muscle were the primary targets of mitochondrial dysfunction as energy-dependent tissues, after three decades virtually any subspecialty of medicine is now involved. We will summarize the key clinical pictures and pathogenic mechanisms of mitochondrial diseases in adults.

Abstract P4-14-05: Confirmation of the TAILORx 21-gene expression trial using a real world observational database

Background: The TAILORx study (NCT00310180)(TRx) has demonstrated the efficacy of endocrine therapy alone in early stage, lymph node negative, hormone receptor positive, her2neu oncogene negative breast cancer harboring an intermediate recurrence score (RS) on a 21-gene profile (OncotypeDx), obviating the need for adjuvant chemotherapy in a large subset of women. The study randomized and followed 6711 patients (pts) and required 9 years to reach its conclusion endpoints. The availability of the electronic health record (EHR) permits automated reviews, facilitating more rapid “real world” hypothesis testing (but not a replacement for randomized clinical trials), especially when there are clear variations in common practice patterns. However physician bias in treatment selection needs to be considered.

Methods: A retrospective review of the Cota Observational Cancer database, drawn from EHRs, of female pts with breast cancer who were 18 to 75 years of age; had hormone-receptor–positive, human epidermal growth factor receptor 2 (HER2)–negative, axillary node–negative breast cancer harboring an OncotypeDx RS 11-25 receiving adjuvant therapy following surgical resection of a 11-50 mm primary tumor (similar to TRx eligibility).

Results: 1009 pts from 23 cancer centers (107 oncologists) were identified, 850 (84.2%) received adjuvant endocrine therapy alone (E) and 159 (15.8%) received adjuvant chemoendocrine therapy (CE) as part of standard care (no randomization). 285 pts were age &lt;50 yrs (E:218, CE:67) and 601 pts has RS 16-25 (E:453, CE:148). Treatment selection was imbalanced with oncologists more likely to utilize CE in younger pts (median age E: 59 yrs, CE: 53 yrs; p&lt;0.01), larger tumors (median tumor size E: 16mm, CE: 20mm; p&lt;0.001) and higher RS (median RS E: 16, CE: 21; p&lt;0.001). With a median follow-up for survival since diagnosis of 3.7 years, the Kaplan-Meier estimated 5 yr overall survival rates were 98.9% with E and 97.8% with CE (p=0.23); the corresponding 5-yr OS in TRx were E: 98% and C: 98.1%. With a median 1.7 years follow-up for recurrence, 19 pts have suffered a disease distant or local recurrence (E: 13, CE: 6) yielding a 5-year recurrence-free survival of E: 95.2% and CE: 91% (p=0.05); the corresponding TRx result was E: 96.9% and CE: 97%. The 5-yr invasive disease-free survival (IDFS = death, local/distant, second primary) with 32 events was E: 92.7% and CE: 81.9% (p= 0.05); corresponding TRx E: 92.8 % and CE: 93.1%. Given the imbalance in treatment allocations, a multivariate analysis was performed, with older age (&lt;0.001), CE choice (&lt;0.006) and larger tumor size (p&lt;0.05) remaining significant, but not increased RS (p=0.16) for 5-year IDFS. Among women age &lt;50 with RS 16-25 (E: 118; CE: 60) the 5-yr IDFS was E: 95% and CE: 94%; the corresponding RS 16-20 TRx E: 92% and CE: 94.7% and RS 21-25 E: 86.3% and CE: 92.1%.

Conclusions: Using a real world data source, endocrine therapy alone appears to yield excellent 5-yr survival rates among pts with 21-gene RS 11-25 similar to the TAILORx trial. Treatment selection bias (with perceived higher risk pts allocated to CE) and shorter median follow-up limits full confirmation by this dataset.

Citation Format: Waintraub SE, Isaacs C, Norden AD, Graham DA, McNamara DM, O'Neill SC, Lakshmanan A, Wu T, Maresca A, Pecora AL, Goy AH, Goldberg SL. Confirmation of the TAILORx 21-gene expression trial using a real world observational database [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-14-05.

Influence of wood ash pre-treatment on leaching behaviour, liming and fertilising potential

In Denmark, increasing amounts of woody biomass are being used for the production of renewable energy, resulting in more wood ashes being generated. While these materials have been mainly landfilled, wood ashes may also be utilised for fertilizing and liming purposes on top of soils. Pre-treatments involving hardening or granulation may be carried out prior to soil application. In this study, two Danish wood ash samples were hardened and/or granulated. Lab-hardening induced rapid changes in the shape of the acid neutralisation capacity curve of the ashes. Up-flow column tests, assuming local equilibrium conditions, were employed to investigate the leaching from pre-treated ashes. Granules and loose ashes demonstrated similar leaching behaviours, indicating that similar geochemical processes were governing their leaching. In comparison with untreated fresh ashes, the hardened ashes demonstrated reduced leaching of Ca, Ba, Pb and Zn with concentration levels generally below or close to the analytical limits of quantification; to the contrary, the leaching of As, P, Sb, Si, V and Mg was enhanced in the hardened ashes. The release of alkalinity was reduced by hardening. In general, all granules were barely breakable by finger-pinching and they could withstand one month of continuous leaching, preserving their overall shape. The solubility of phosphorous in neutral ammonium citrate indicated that about 30-51% of the total P content in the ash samples was released, suggesting that the ashes could be potentially valuable as P-fertiliser if applied onto soil.

Unusual presentation of recurrent subtrochanteric non-union in a patient with hip arthrodesis: A case report

This case report describes the management and therapeutic solution for the treatment of subtrochanteric non-union in a patient with hip arthrodesis. Two techniques can be used in the treatment of these non-unions: a closed intramedullary nailing or an open technique with plate, preferably carried out together with cortical bone graft. The surgical technique varies depending on the fixation method used for the initial treatment of the fracture and on the characteristics of the non-union. We report an unusual case of a patient who started her long clinical history more than 40 years ago with a septic arthritis of the hip healed in arthrodesis. 35 years later, after having undergone various surgeries, she fractured the proximal femur, which had to be operated seven times before reaching healing. Satisfactory outcomes were finally obtained. Arthrodesis proved to be the main cause of failed healing and of the recurrent non-union.

Long-term leaching of nutrients and contaminants from wood combustion ashes

With increasing amounts of woody biomass being combusted for energy purposes worldwide, more wood ash is being generated and needs management. As an alternative to landfilling, residues may be utilised for liming and fertilising purposes on forest soils. Comprehensive evaluations of long-term leaching from these residues are needed in order to assess potential environmental impacts associated with their utilisation. Two Danish wood ash samples, one fly ash and one mixed ash (a combination of fly ash and bottom ash), were evaluated in long-term percolation column tests (up to L/S ∼2000 L/kg), in order to quantify the release of major, minor and trace metal(loid)s. While columns of three different lengths were used, the leaching of individual elements could be described as a function of the L/S ratio - irrespective of the column length. At L/S 1000 L/kg, the cumulative releases of K, S, Na, Ca and Rb were at 40-100% of their respective solid contents, followed by Ba, Cr, Sb, Sr and V at 15-40% and Al, Mg, Zn, Cd, Co, Fe, Pb, Tl, Mn and P at < 5%. Speciation calculations indicated that (i) the observed concentrations of Ca, Mg, Al, Ba, Si and sulphate from both ash types could be described through the dissolution/precipitation of a limited set of minerals and that (ii) leaching of silicates should be included in long-term assessment of alkalinity release from wood ashes. Non-equilibrium conditions were indicated by flow interruptions. However, the presence of non-equilibrium did not have significant effect on the calculated cumulative releases at high L/S ratios. Based on the assessment of cumulative releases at L/S 10 L/kg and L/S 1000 L/kg it is concluded that low L/S-based data may not provide sufficient background for prediction of long-term release from wood ash, in particular for Ba, Cr, Sb and V, and less critically also for As, Cd, Cu, Mo and Ni.

Recirculation of biomass ashes onto forest soils: ash composition, mineralogy and leaching properties

In Denmark, increasing amounts of wood ashes are generated from biomass combustion for energy production. The utilisation of ashes on top of forest soil for liming purposes has been proposed asan alternative to landfilling. Danish wood ash samples were collected and characterised with respect to chemical composition, mineralogy and leaching properties (batch leaching at L/S 2 and 10L/kg, and pH-dependent leaching at 10L/kg). Large variations in the ash liming properties were observed (ANC_7.5: 1.8-6.4meqH⁺/g), indicating that similar soil application dosages may result in different liming effects. High contents of Ca, Si, P, K and Mg were observed in all samples, while the highest contents of S and N were found in fly ashes and mixed ashes (combination of fly and bottom ashes). Similarly, the highest contents of some trace metals, e.g. Cd, Mo and Se, were observed for fly ash. Releases of major, minor and trace elements were affected significantly by pH: high releases of PO₄^3-, Mg, Zn, Cu and Cd were found for acidic conditions relevant to forest soils, while the highest releases of Mo and Cr were observed in alkaline conditions. Mineral phases were selected based on XRD analyses and the existing literature, and they were applied as inputs for the geochemical modelling of pH-dependent leaching. Mineral dissolution was found adequate for a wide range of major elements and nutrients, while the description of trace elements could be done only for parts of the pH-range. Content and leaching of PAHs were observed below detection limits. The source-term release of Ca, K, Mg, Mn, and P in acidic conditions relevant to forest soils was higher than ten years of atmospheric deposition, in contrast to the relatively low release of Al, Fe and Na. The potential release of Cd was found to be the most critical element compared with soil quality criteria, whereas the maximum theoretical loads of Ba, Cd, Cr, Sr, Mo, Ni, Pb, Sb, Se, Sn and V were relatively low.

Why a surgically treated humeral shaft fracture became a nonunion: review of 11 years in two trauma centers

AIM

The aim of this study was to evaluate nonunion causes of surgically treated humeral shaft fractures in two different trauma centers.

METHODS

A total of 327 cases of humeral shaft fractures were treated in 11 years in two trauma centers. We retrospectively reviewed in detail some factors in order to understand the reasons for nonunion: (1) fracture type, according to the AO classification, (2) grade of open fracture, according to Gustilo-Anderson, (3) timing, (4) reduction and (5) fixation.

RESULTS

We observed 19 nonunions, 10 women and 9 men, with an average age of 57 years. Fractures were 1 A1 case, 2 A2 cases, 4 B2 cases, 6 B3 cases, 2 C1 cases, 1 C2 case and 3 C3 cases. Three cases had a simple fracture with two fragments; all the other were comminuted. Fifteen cases were closed, four open. The major criticalities observed were fracture comminution, exposure, unstable fixation and bone resorption. All 19 patients with nonunion underwent surgical fixation with compression plate and frozen cortical bone graft. A 4.5 LCP plate was used in 17 cases. The remaining 2 cases had an anatomical site-specific proximal humeral 3.5-mm LCP plate (Synthes, Paoli, PA, USA). In 17 patients, the nonunion healed: 15 cases treated with a 4.5 straight plate, and 2 cases with an anatomical site-specific proximal humeral 3.5 mm LCP plate, at a mean of 5 months. In 2 cases, consolidation was not reached.

CONCLUSIONS

We believe that humeral diaphyseal fractures should be treated surgically to avoid many complications. Our retrospective analysis indicates that factors that lead to a fixation failure are fracture comminution, open fracture, unstable fixation. The 19 nonunions treated with compression plating and frozen bone graft demonstrated consolidation in almost 90% of the cases.

Results of a collaborative study on DNA identification of aged bone samples

AIM

A collaborative exercise with several institutes was organized by the Forensic DNA Service (FDNAS) and the Institute of the Legal Medicine, 2nd Faculty of Medicine, Charles University in Prague, Czech Republic, with the aim to test performance of different laboratories carrying out DNA analysis of relatively old bone samples.

METHODS

Eighteen laboratories participating in the collaborative exercise were asked to perform DNA typing of two samples of bone powder. Two bone samples provided by the National Museum and the Institute of Archaelogy in Prague, Czech Republic, came from archeological excavations and were estimated to be approximately 150 and 400 years old. The methods of genetic characterization including autosomal, gonosomal, and mitochondrial markers was selected solely at the discretion of the participating laboratory.

RESULTS

Although the participating laboratories used different extraction and amplification strategies, concordant results were obtained from the relatively intact 150 years old bone sample. Typing was more problematic with the analysis of the 400 years old bone sample due to poorer quality.

CONCLUSION

The laboratories performing identification DNA analysis of bone and teeth samples should regularly test their ability to correctly perform DNA-based identification on bone samples containing degraded DNA and potential inhibitors and demonstrate that risk of contamination is minimized.

Distal-third diaphyseal fractures of the humerus: choice of approach and surgical treatment

PURPOSE

Distal-third diaphyseal fractures of the humerus are often hard to treat due to location and pattern of the fractures, radial nerve injury, and quality of bone and age of patients. The aim of this retrospective study is to propose the best approach and the best surgical technique according to the pattern of extra-articular fracture of the distal humerus.

METHODS

We have treated 37 fractures of the distal humerus between January 2010 and July 2015 classified according to the AO classification. There were 2 open fractures. We treated all fractures with open reduction and internal fixation with plates and screws. In 20 cases, we performed a posterior midline triceps-splitting approach, with patients in prone decubitus position; in 2 cases, the triceps-splitting approach with the patients in supine decubitus position; in 3 cases, the olecranon osteotomy approach in prone decubitus position; and in 12 cases, the lateral approach in supine decubitus position.

RESULTS

Thirty cases had a medium follow-up of 6 months. We observe 2 post-operative radial nerve palsies healed in 5 months and 2 cases of non-union. The average time to union of remaining cases was 16 weeks (range 12-24). Elbow motility was complete in 25 cases, in 4 cases there was an extension loss of 5°, and in one case there was an extension loss of 10°.

CONCLUSIONS

The use of plates allows an anatomical fracture reduction, a better control of alignment of humerus and, with a rigid fixation, an early elbow mobilization. The best approach and the best surgical technique depend on the pattern of the fracture of distal humerus.

Cigarette toxicity triggers Leber's hereditary optic neuropathy by affecting mtDNA copy number, oxidative phosphorylation and ROS detoxification pathways

Leber's hereditary optic neuropathy (LHON), the most frequent mitochondrial disease, is associated with mitochondrial DNA (mtDNA) point mutations affecting Complex I subunits, usually homoplasmic. This blinding disorder is characterized by incomplete penetrance, possibly related to several genetic modifying factors. We recently reported that increased mitochondrial biogenesis in unaffected mutation carriers is a compensatory mechanism, which reduces penetrance. Also, environmental factors such as cigarette smoking have been implicated as disease triggers. To investigate this issue further, we first assessed the relationship between cigarette smoke and mtDNA copy number in blood cells from large cohorts of LHON families, finding that smoking was significantly associated with the lowest mtDNA content in affected individuals. To unwrap the mechanism of tobacco toxicity in LHON, we exposed fibroblasts from affected individuals, unaffected mutation carriers and controls to cigarette smoke condensate (CSC). CSC decreased mtDNA copy number in all cells; moreover, it caused significant reduction of ATP level only in mutated cells including carriers. This implies that the bioenergetic compensation in carriers is hampered by exposure to smoke derivatives. We also observed that in untreated cells the level of carbonylated proteins was highest in affected individuals, whereas the level of several detoxifying enzymes was highest in carriers. Thus, carriers are particularly successful in reactive oxygen species (ROS) scavenging capacity. After CSC exposure, the amount of detoxifying enzymes increased in all cells, but carbonylated proteins increased only in LHON mutant cells, mostly from affected individuals. All considered, it appears that exposure to smoke derivatives has a more deleterious effect in affected individuals, whereas carriers are the most efficient in mitigating ROS rather than recovering bioenergetics. Therefore, the identification of genetic modifiers that modulate LHON penetrance must take into account also the exposure to environmental triggers such as tobacco smoke.

Bone graft from greater trochanter in posterior wall fractures with impacted fragments

Background

Posterior wall fracture is the most common acetabular fracture. Comminuted fractures with an impacted segment represent a subtype of this injury. The subchondral bone of the articular zone is compressed and causes a bone defect. The impacted fragment should be isolated, mobilized, and then reduced. A bone graft should be used to fill the gap. The other fragments are fixed following the reduction of the impacted segment.

Materials and methods

Ten patients with comminuted fractures and impacted segments with bone defects were enrolled in our study, from January 2010 to July 2012. Autogenous bone grafts from the greater trochanter were used to fill the gap in all patients. The reduction was achieved through the insertion of the graft above the impacted fracture, and plate fixation was performed subsequently. Merle d’Aubigne and Postel scoring, modified by Matta, was applied to evaluate the patients during follow-up. The mean follow-up was 12 months.

Results

The clinical results included one “excellent”, four “very good”, four “good” and one “poor”. Pain in the zone of graft harvesting was not detected in any patient. Femoral head necrosis was observed in one case. No other severe complications were detected.

Conclusions

Using an autogenous bone graft to fill the bone defect supplies excellent mechanical stability without any severe complications at the donor site. This surgical technique seems to be effective and safe in treating a comminuted fracture of the posterior wall in association with an impacted segment.

Level of evidence

Level IV.

Leiomyoma of the hand: a case report

We report a case of leiomyoma of the finger in the right hand of a 12-year-old boy: a rare site for localization and unusual for age. This is a benign tumor originating from non-striated muscle that is very uncommon in the hand. The uterus is considered the most common location for leiomyoma and when it occurs in the extremities, it is more common in the leg, ankle and foot. It usually occurs in the third and fourth decades of life and it is rarely diagnosed before surgery as the diagnosis can only be confirmed histologically.

Distal diaphyseal fractures of the tibia treated by modified Grosse-Kempf nail

Fractures of the distal fourth of tibia are difficult to treat because of the possible involvement of the joint, the comminution of the fragments, the local skin conditions and the surgical method required. There are many methods of osteosynthesis, and these range from external fixation to use of a plate to combined methods. Intramedullary nailing is generally not indicated in the treatment of such fractures, but if the correct technical procedure is used, indications may be widened, and the method may even be used in cases such as these. It is necessary to saw the tip of the nail so that the distal holes go beyond the fracture line. A total of 30 cases of fracture of the distal fourth of the tibia treated by Grosse-Kempf nailing sawed distally are reported.

Subtrochanteric nonunion of the femur

Nonunion of the subtrochanteric region is usually secondary to incorrect surgical treatment. The main cause of failed osteosynthesis is related to interruption of the medial cortex of the femur. Either a closed method, with intramedullary nailing, or an open method, using cortical osteosynthesis and opposing bone graft, may be used to treat the pathology. Surgery differs depending on the instrumentation used for the initial treatment of the fracture. A total of 8 cases of intra- and subtrochanteric nonunion with intramedullary nailing and cortical osteosynthesis are reported.

[Nosocomial fungal infections in surgical patients. Older age as factor of risk and early presumptive and systemic therapy versus prophylactic therapy]

Objective of our study has been to verify if the age is a factor of additional risk for the opportunistic fungal infections and if prophylactic therapy cause real advantages in terms of reduction of morbidity, mortality and times of hospitalization. To such we report the experience of the Operational Unity of Emergency Surgery of the Hospital of Relief National and High Specialization of Caserta relatively to the patients submitted to intervention of great abdominal surgery. In the year 2000 antifungal therapy has been administered to 20 patient (of which 18 over 65 years) on the escort of an laboratory diagnosis; in the year 2001 we have administered prophylactic therapy to 53 high-risk patient (of which 48 over 65). In the group of patients essays with preventive therapy the middle hospitalization has been slightly inferior with a reduction of around 2 days of refuge for the elderly patients and of around 1.5 days in the youngest patients. Mortality in the elderly patients has been reduced from 38% of the year 2000 at 23% of the year 2001. Our data confirm that the age is an important factor of risk for the fungal infections in the surgical departments and we believe to a prophylactic therapy can be of benefit in well selected patient, although an ordinary application of antifunfal therapy can not have recommended without an laboratory diagnosis because to emerge of new resistances to the medicines.

The Fixion nail in the lower limb. Preliminary results

The Fixion nail is an intramedullary nail made of stainless steel, that may be used to treat fractures of the humerus and in the lower limb. This nail is made up of a cylinder that has 4 longitudinal bars which, once inserted in the bone segment, expands via a pressure hydraulic system using physiological solution. The nail may be introduced without reaming and after its expansion it adheres to the bone walls producing stabilization of the fracture. In order to guarantee good stability, the apex of the nail must exceed the fracture line by 5 cm. Indications were initially limited to type 32 and 42 A1-2-3 fractures of the mid third of the lower limb, to then be expanded to type B1 fractures in the AO system. A total of 20 nails were used in 19 patients, with an average time of 7 days for partial weight-bearing and 40 days for total weight-bearing, achieving consolidation on day 18 after an average of 5 months in the femur and 4 months in the tibia. Reaming of the intramedullary canal was carried out in all of the cases.

Osteoid osteoma of L4: excision by videoendoscopy

It is the purpose of this study to demonstrate how in the surgical treatment of vertebral osteoid osteoma a video-aided mini-invasive method may be used as an alternative to modern percutaneous X-ray-CT-guided mini-invasive methods such as radiocoagulation, interstitial photocoagulation with laser injection. Reported here is the case of a female aged 13 years where instrumental testing showed the presence of an osteoid osteoma involving the internal surface of the lamina of L3 and spreading in the lumen of the vertebral canal. Once we established that it was impossible to carry out the aforementioned mini-invasive percutaneous treatment because of the closeness of the osteoid osteoma to the nervous structures, thus risking complications, the only procedure that could guarantee complete removal of the tumor was open aminarthrectomy. But to reduce surgical aggressiveness to a minimum, we decided to proceed by means of a video-aided mini-invasive method with the purpose of limiting hospitalization and recovery time in order to obtain economically favorable results.

Locked nailing in subtrochanteric fractures of the femur in the elderly patient

Subtrochanteric fractures are a typical pathology in the elderly patient, they are not very common and they are difficult to treat. The general conditions of these patients, often at the limit of operability, are further compromised by surgery and time spent in bed, leading to the death of the patient in a high percentage of cases. The fracture is often spyroid, it has multiple fragments, with interruption of the medial cortical bone. The quality of the bone, because of the marked osteoporosis, does not guarantee the good hold of the means of fixation used. The use of intramedullary nailing is a safe method, that allows for stabilization of the fracture without excessive blood loss, it allows for early partial weight-bearing and it has a lower number of complications as compared to other methods. Between 1-1-97 and 31-12-00 a total of 59 persubtrochanteric fractures were treated; there were 15 males and 44 females. A Gamma Long nail was used in 46 cases, a Gamma Standard in 13. Eleven of the patients died within 6 months. A total of 27 patients aged an average of 78 years (minimum 65, maximum 87) were evaluated at a mean follow-up of 10 months (minimum 7, maximum 27). A Gamma Long nail had been used in 18 cases, and Gamma Standard in 8. Partial weight-bearing was allowed after a mean of 20 days (minimum 10, maximum 35), total weight-bearing after a mean of 60 days (minimum 40, maximum 75). Consolidation was obtained after a mean of 4 months (minimum 3, maximum 7). There were no significant complications.

Hypertension and cerebrovascular diseases: a specific role of vascular protection for the prevention of dementia

Despite the use of antihypertensive drugs, mortality (but not morbidity) from cerebrovascular diseases has been reduced significantly. As a consequence, an increasing number of patients suffer from recurring strokes and from the debilitating consequences of cerebrovascular diseases and develop progressive cognitive impairment. Its pathological substrates are regional alteration of cerebral perfusion, lacunae, white matter lesions, progressive cortical atrophy, even in the asymptomatic patient and in the absence of extracranial carotid artery stenosis. Lacunar infarction and white matter lesions are particularly frequent in the hypertensive diabetic patient. Lacunae and white matter lesions sometimes coexist and may favour the development of dementia in the hypertensive patient, through focal ischaemia, perivascular oedema, disruption of the blood-brain barrier, cerebral diaschisis and cortical deafferentation. Treatment with calcium channel blockers, angiotensin converting enzyme inhibitors and diuretics smooth the patchy hypoperfusion despite the fall in pressure. However, the time course and the extent of this effect vary according to the drug administered. In particular, only a calcium channel blocker increased perfusion of both cortical and subcortical areas, while diuretic treatment increased perfusion only after prolonged treatment, and this effect was limited to the cortical areas. Such differences may explain the discrepant results on risk reduction for dementia observed in large intervention trials.

Adolescent hepatitis B vaccination: comparison among 2 high school-based health centers and an adolescent clinic

OBJECTIVE

To compare the completion rate of hepatitis B vaccination among adolescents who receive primary care at 2 comprehensive high school-based health centers (SBHCs) and a hospital-based adolescent health center (AHC) to assess predictors for successful immunization.

METHODS

A retrospective chart review of patients seen for comprehensive history and physical examinations from September 1997 to March 1998 at 2 SBHCs and an AHC was conducted to determine the immunization status for hepatitis B. One SBHC (SBHC-A) had previously implemented an outreach strategy consisting of advertising through the school's loudspeaker, whereas the other SBHC (SBHC-B) and the AHC did not. Completion rates were assessed among all students requesting comprehensive history and physical examinations. A subset analysis among those without prior immunizations was performed.

RESULTS

Of 510 records reviewed, 406 had documented data for hepatitis B immunization status, and 191 (37 for SBHC-A, 59 for SBHC-B, 95 for AHC) did not have any prior hepatitis immunizations. The completion rate of hepatitis B vaccination was significantly higher at SBHC-A (76%) compared with the other 2 sites (29% for SBHC-B and 24% for AHC) (P<.001).

CONCLUSION

Patients with access to SBHC services that strongly emphasize outreach were more likely to complete the hepatitis B vaccination series.

Cerebral perfusion in hypertensives with carotid artery stenosis: a comparative study of lacidipine and hydrochlorothiazide

Focal cerebral hypoperfusion is a common finding in uncomplicated hypertensives even in the absence of large vessel atherosclerosis, and neuropsychological deficits correlate with cerebral hypoperfusion in hypertensive patients with cerebral microangiopathy. We investigated the effects on cerebral perfusion of the dihydropiridine calcium antagonist lacidipine and of hydrochlorothiazide (HCTZ) in asymptomatic hypertensive patients with concomitant atherosclerosis of the carotid arteries. Fifteen essential hypertensives (including 13 males, aged 55-75 years) with at least one 30-60% stenosis of the internal carotid artery at echo-color Doppler examination were treated in a double-blind, randomized, parallel study with lacidipine (4-6 mg od) or HCTZ (25-50 mg od) for 3 months after a 4-week single-blind placebo period. Regional cerebral perfusion was assessed at baseline and at the end of the treatment period with HMPAO-SPECT. Relative perfusion of cortical and subcortical areas was calculated as the ratio between their tracer activity and that of the cerebellum. At baseline, mean relative perfusion (MRP) of the cortical and subcortical areas was similar in the stenotic and the contralateral side. Despite the fall in pressure, lacidipine increased MRP both in the cortical and in the subcortical areas, whereas HCTZ increased MRP only in the cortical areas. The mean change in local vascular resistance, adjusted for initial perfusion value, was -20 A.U. (arbitrary unit) with lacidipine and -12 A.U. with HCTZ (p < 0.001). These differential effects of antihypertensive drugs on subcortical perfusion may be of benefit in the long-term prevention of vascular dementia in hypertensive patients.

Cerebral Perfusion in Hypertensive Patients: Effects of Lacidipine and Hydrochlorothiazide

Previous studies have shown areas of cerebral hypoperfusion in the frontal and parietal lobes of asymptomatic hypertensives, in the absence of extracranial carotid artery stenosis. The aims of the present study were: (a) to correlate the presence of focal cortical hypoperfusion with the presence of white matter lesions (WML), lacunae and extracranial carotid artery stenosis; and (b) to compare the effects on cerebral perfusion of the dihydropyridine calcium entry blocker lacidipine and of hydrochlorothiazide (HCTZ) in hypertensive patients with carotid artery stenosis. Forty-one patients (30 males, aged 40-75) with mild to moderate essential hypertension and with negative history for cerebrovascular diseases were investigated. Twenty-four had normal extracranial carotid arteries at echo-colourDoppler examination, while 17 had at least one 50-70% stenosis of the internal carotid artery (ICA). At computed tomography (CT) scan, five patients had one or more lacunar infarctions, four WML, three lacunar infarctions and WML, and 26 a normal CT scan. Three, with old cortical infarctions, were excluded from further analysis. The prevalence of lesions was significantly higher among the patients with carotid artery stenosis (44% vs. 29%; p < 0.05). Distribution of mean relative cortical perfusion (MRCP) of regions of interest [hexamethyl-propileneamine oxime-single photon emission tomography (SPET)] was not normal, with a negative skewness in patients with lacunae. MRCP was slightly but significantly reduced in patients with lacunae in comparison with hypertensives with normal CT scan and with WML. The asymmetry index of tracer distribution was significantly greater in the patients with lacunar infarctions and WML than in the hypertensive patients with normal CT scan, irrespective of the presence of internal carotid artery stenosis. Fifteen hypertensives (13 males, aged 55-75 years) with at least one moderate stenosis of ICA at duplex scanning were treated in a double-blind, randomised, parallel study with lacidipine (4-6 mg o.d.) or HCTZ (25-50 mg o.d.) for 3 months after a 4-week single-blind placebo period. At baseline, perfusion of the cortical and basal areas was similar in the stenotic and the contralateral side. Despite the fall in pressure, both treatments increased MRCP in the stenotic side and in the contralateral side. The lower the baseline perfusion, the larger its increase with treatment. The decrease of local cerebral vascular resistance was significantly greater with lacidipine than with HCTZ. We conclude that in hypertensive patients, the distribution of cerebral flow is uneven, mostly in the presence of small asymptomatic subcortical lesions and independently from internal carotid artery stenosis. Antihypertensive treatment with lacidipine and HCTZ reduces local cerebral resistance and corrects focal hypoperfusion without inducing steal effects in patients with ICA stenosis.

Isolation of a specific DNA fragment and development of a PCR-based method for the detection of Mycobacterium genavense

The rise of Mycobacterium genavense infections is making identification ever more important for diagnosis and treatment. Moreover, isolation and identification of M. genavense are made difficult by the lack of growth on solid media and by its low generation rate in BACTEC liquid media. Thus, amplification by PCR or similar techniques represents the only possibility of detecting and identifying M. genavense from tissue samples. In order to set up a simple and species-specific method based on the use of PCR and non-radioactive hybridization technique, we decided to search for and clone a specific DNA fragment of this bacterial species. In the present study, a 1734-bp fragment was isolated. This fragment was found to be highly specific for M. genavense strains. A species-specific pair of primers (MG22 and MG23) and two oligonucleotide probes (MG18 and MG19) were selected. They were successfully used to amplify and detect a 155-bp DNA fragment from the 13 available strains of M. genavense which were isolated from clinical specimens or from birds. Conversely, the primers and probes did not hybridize with DNA from any of the 20 other mycobacterial species tested. It is worth noting that the chosen primers and probes did not hybridize with DNA of M. simiae, although it is closely related to M. genavense. The present PCR technique uses species-specific primers for M. genavense. Followed by a non-radioactive hybridization technique on microplates it is able to distinguish M. genavense from other mycobacteria in one step, without sequencing or restriction analysis. On the basis of the Southern blot hybridization, PCR and sandwich hybridization results, we concluded that the isolated 1.7-kb sequence was specific for the M. genavense chromosome. The method developed here for M. genavense identification uses a simple methodology and commonly available reagents. Furthermore it can be easily automated.

[Mycobacterium gordonae infections in human immunodeficiency virus infection]

OBJECTIVES

Non-tuberculous mycobacteria infections are frequent in patients infected with the human immunodeficiency virus (HIV). Mycobacterium avium intracellulare is the most frequent organism isolated but several other mycobacteria are also seen. Mycobacterium gordonae is a saprophytic mycobacteria which is rarely pathogenic. It was observed in 9% (7 patients) of the mycobacterial infections observed in our unit over a period of 3 years.

METHODS

In order to determine whether M. gordonae plays a pathogenic role in HIV-infected patients, we re-evaluated the 7 clinical files of patients with M. gordonae infection. The findings were compared with data in the literature.

RESULTS

All seven of our patients had a poor general health status with fever and pulmonary infection. The chest X-ray was abnormal in 5 patients. M. gordonae was isolated from blood cultures in 2 patients and from sputum or gastric contents in 5. Outcome was favourable using anti-tuberculosis combinations.

CONCLUSION

A pathogenic role for M. gordonae cannot be excluded in HIV-infected patients. However, since this mycobacterium is an ubiquitous organism, diagnosis should be based on a typical clinical presentation and certain laboratory identification from appropriate samples.

Bronchial brushing and biopsy: a comparative evaluation in diagnosing visible bronchial lesions

One hundred and forty patients underwent 142 brushings and conventional biopsies of suspected malignant lesions of the lung through a fibreoptic bronchoscope. Both samples were taken from the same area. One hundred and three patients showed positive results on brushing and 90 on biopsy. Thirty-nine diagnoses were negative on brushing and 52 on biopsy. A correct cell typing was obtained in 105 of 109 diagnoses of malignancy. Final diagnoses showed 118 malignant lesions and 22 benign conditions. False positives were respectively, 2 on brushing and 1 on biopsy, while false negatives were 17 on brushing and 30 on biopsy. Brushing showed higher sensitivity (85.5%) and accuracy (86.6%) than biopsy. A combination of the two techniques gives an accuracy rate of 94.3%.

Genomic organization of low copy number sequences that are associated with deca-satellite DNA in the monkey genome

A previously described segment of African green monkey DNA (cloned in phage lambda MkA) contains deca-satellite linked to DNA sequences that are estimated to occur once per genome. Sequences homologous to the low copy number sequences in lambda MkA are also associated with species-specific satellite DNAs in the human and mouse genomes. A second clone, lambda Mk8, contains a monkey DNA region that is colinear and homologous to a portion of the low copy number sequences in lambda MkA, but no satellite sequences. The two cloned segments are markedly different starting at a point proximal to the satellite DNA region in lambda MkA. DNA-blotting experiments indicate that lambda Mk8 but not lambda MkA represents the typical genomic organization and that the low copy number segments occur only once per haploid genome. The data suggest that rearrangements such as deletions or inversions occurring in monkey cells account in part for the structure of lambda MkA. Additional rearrangements may have occurred during cloning in E. coli. This unique chromosomal region may be particularly susceptible to recombination.

A polymorphic DNA probe located to human chromosome 4p16 (D4S62)

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Isolation of low-copy-number sequences that neighbor satellite DNA in mammals

To investigate the role of satellite DNA in eukaryotic genomes, we isolated from an African green monkey (Cercopithecus aethiops) genomic library cloned segments containing the previously described deca-satellite linked to low-copy-number genomic sequences. Three such clones were obtained. The low-copy-number sequences in the three clones do not cross-hybridize suggesting that they derive from different genomic loci. The structure of one of the clones, lambda MkA, is described in detail. Subcloned segments containing the low-copy-number sequences from lambda MkA anneal to monkey, human and mouse genomic DNA. The subcloned probes were used to select clones containing homologous sequences from a second, independent monkey library as well as from human and mouse genomic libraries. Several of the newly isolated monkey clones hybridized to probes containing the species-specific deca- and alpha-satellites, confirming the genomic association of the low-copy-number sequence in lambda MkA with satellite DNA. Moreover, several of the human and mouse clones hybridized to species-specific human and mouse satellite DNAs, respectively. These experiments indicate that the low-copy-number sequence in lambda MkA and its association with satellite DNA is conserved in primates and rodents.

Continuous reorganization leads to extensive polymorphism in a monkey centromeric satellite

Previously we reported the existence of a highly polymorphic satellite, deca-satellite, in the African green monkey genome; deca-satellite probe anneals to complex sets of repeated restriction endonuclease fragments that differ from individual to individual in the monkey population. Here we present experiments aimed at clarifying the structure and organization of deca-satellite sequences and investigating the mechanisms that generate the polymorphisms. Deca-satellite represents less than 1% of the monkey genome but the percentage varies from one monkey to another. The core sequence 5'-C-C-G-G within the ten base-pair deca-satellite repeat unit is well conserved and the central 5'-C-G is sometimes but not always methylated. Restriction endonuclease analysis with BamHI and EcoRI defines separate satellite domains that have evolved in an independent manner. In situ hybridization shows deca-satellite to be located at the centromeric regions of some but not all monkey chromosomes. This location is independently confirmed by a high frequency, in monkey libraries, of segments containing junctions between deca-satellite and alpha-satellite, the main monkey centromeric satellite. The total number of metaphase chromosomes that show centromeric grains after in situ hybridization with a deca-satellite probe varies from one monkey to another. Moreover, in situ hybridization to endoreduplicated diplochromosomes showed that deca-satellite is occasionally distributed asymmetrically on one or the other of the two pairs of sister chromatids in one diplochromosome. This indicates that major reorganization of the satellite can occur frequently in somatic cells. We discuss several possible mechanisms by which deca-satellite sequences could be either amplified or deleted during a single replicative cycle. Also, on the basis of the marked fluidity of deca-satellite abundance and organization and other well-known attributes of centromeric satellites, we suggest that the existence and maintenance of centromeric satellite rests on the role of the tandem repeats themselves and not on any particular nucleotide sequence, repeat length or organization.

Deca-satellite: a highly polymorphic satellite that joins alpha-satellite in the African green monkey genome

Three different cloned segments of African green monkey DNA that contain alpha-satellite sequences linked to a previously undescribed, distinct monkey satellite (called deca-satellite) are described here. The cloned segments were derived from a monkey DNA library in lambda Charon 4A that was constructed to select for junctions between alpha-satellite and other DNA sequences. The structure of the deca-satellite and of a junction between deca-satellite and alpha-satellite were studied by subcloning appropriate fragments of the original cloned segments and by sequence analysis. Deca-satellite has a ten base-pair repeat unit; the consensus sequence of the repeat units is 5' A-A-A-C-C-G-G-N-T-C. Sequences homologous to the deca-satellite are in the middle repeated class of genomic DNA. Analysis of the organization of deca-satellite sequences by digestion of total DNA with various restriction endonucleases and hybridization with a cloned deca-satellite probe revealed extensive polymorphism in the genomes of different individual monkeys but not among the tissues of one organism. These observations indicate that the arrangement of deca-satellite sequences is continually changing. An unusual alpha-satellite repeat unit occurs at a junction between the alpha-satellite and deca-satellite. It resembles the major baboon alpha-satellite more closely than it does monkey alpha-satellite and thereby provides evidence in favor of the "library" hypothesis for satellite evolution.

Myoglobin in the heart ventricle of tuna and other fishes

The myoglobin content in the hearts of several fishes is positively correlated with the ecological physiology of the species. In the tuna heart, where the highest myoglobin values are found, the logarithmic relationship between myoglobin content and body weight is reported.

Human alpha-fucosidase. Single residual enzymatic form in fucosidosis

Four major forms of alpha-fucosidase (EC 3.2.1.51) activity were separated by isoelectrofocusing from sera of normal control individuals. All forms shifted towards less acidic pI values after neuraminidase treatment. In two patients affected with fucosidosis, only a single major acidic peak was observed and this was affected to a lesser degree by neuraminidase treatment. The kinetics of heat inactivation of the residual activity found in these two patients showed two decay rates while the controls showed only one rate. These data are considered in relation to the hypothesis of the existence of interconvertible thermolabile and thermostable forms of the enzyme which has been discussed in the preceeding paper. The residual alpha-fucosidase found in patients could be structurally altered so that its ability to form the thermostable higher molecular weight aggregates is impaired.