Trends in mortality associated with surgical site infections: a cohort study in Italy, 2009-2019

Background

Surveillance programs have proven to be effective in reducing surgical site infection (SSI) rates. In 2008 Piedmont joined the Italian national surveillance system. The aim of this study was to evaluate mortality rates and trends associated with SSIs in Piedmont from 2009 to 2019 for the two most frequently performed surgical procedures, hip arthroplasty (HPRO) and colon surgery (COLO).

Methods

Data were collected through the national surveillance system, which includes 42 hospitals in Piedmont who participated in the surveillance program from 2009 to 2019. Procedure-specific SSI rates, overall mortality rates and case fatality rates (CFR) associated with SSIs were calculated, overall and per year. Trends were evaluated using the chi-squared test for trends. Analyses were performed using Epi Info v. 7.2.

Results

A total of 33438 surgical procedures (21645 HPRO, 11793 COLO) were monitored over the study period from the hospitals participating in the network. 1215 SSIs (293 HPRO, 922 COLO) were observed and 617 deaths were registered (222 HPRO, 395 COLO). For HPRO procedures, an overall SSI rate of 1.35% was found, with an overall mortality of 1.03% and a CFR of 3.75%. No significant trend was observed. Considering COLO interventions, an overall SSI rate of 7.82% was found, with an overall mortality of 3.35% and a CFR of 6.94%. There was a statistically significant downward trend in SSI and overall mortality rates (p = 0.046 and 0.005, respectively).

Conclusions

Considering HPRO, it is possible that the lack of significant trends could be due to the already low SSI and overall mortality rates, with the protective effect of surveillance having reached a plateau. Regarding COLO procedures, a significant reduction in SSI and overall mortality rates was observed during the study period. The reduction in mortality could be due to the decrease in SSI rates, however other factors not analysed in our study could have contributed.

Key messages

• This study brings further evidence to the protective effect of surveillance, attributable to an improvement in healthcare quality and patients’ safety.

• A significant decrease in COLO mortality rates was observed, which could be due to the decreasing trend in SSI rates.

Evaluating the pandemic’s impact on surgical site infections after abdominal surgery in Italy

Background

The COVID-19 pandemic led to important disruptions in surgical activity. The aim of this study was to evaluate the impact of COVID-19 on abdominal surgery outcomes in the region of Piedmont, in northern Italy.

Methods

Data were gathered from 42 hospitals participating in the regional surveillance network from 2018 to 2020. SSI, overall mortality and case fatality rates (CFR) were calculated, comparing 2020 to mean 2018-19 data. Chi-squared tests were used to assess both the differences among the proportion of urgent and oncological procedures (based on ICD-9-CM codes) and rates between the two periods. Subgroup analyses on 2020 data were carried out comparing urgent vs. elective and oncological vs. non-oncological procedures using chi-squared tests. Analyses were performed using SPSS v. 28.0.1.0.

Results

5407 procedures were recorded in 2018-19; 310 SSIs and 120 deaths were observed. The mean proportions of urgent and oncological operations were, respectively, 21.90% and 43.24%. In 2020, 1057 procedures were recorded, along with 44 SSIs and 29 deaths. 34.44% of procedures were urgent and 39.74% oncological. The mean 2018-2019 SSI rate was 5.73%, with an overall mortality of 2.22% and a CFR of 7.42%. The SSI rate in 2020 was 4.16%, with an overall mortality of 2.74% and a CFR of 9.09%. The proportion of urgent procedures significantly differed between the two periods (p < 0.001), as did the proportion of oncological procedures and SSI rates (both p = 0.05). Considering 2020, significant differences were found comparing overall mortality between urgent vs. elective procedures (4.95% vs. 1.59%, p = 0.002) and comparing SSI rates between oncological vs. non-oncological patients (3.57% vs. 2.20%, p = 0.02).

Conclusions

During the pandemic, patients undergoing surgical procedures significantly differed, reflecting public health decisions. Even though these differences did not reach statistical significance, overall mortality and CFR increased in 2020.

Key messages

Intermediate-sized Filament Proteins (Keratin, Vimentin, Desmin) in Metaplastic Carcinomas, Carcinosarcomas and Stromal Sarcomas of the Breast

The distribution of intermediate-filament (IF) proteins of the keratin, vimentin and desmin type in breast stromal sarcomas, carcinosarcomas, metaplastic carcinomas and phyllodes tumors has been compared using the avidin-biotin complex immunoperoxidase technique. Keratin reactivity was found in carcinomatous and pseudosarcomatous areas of all metaplastic carcinomas, in the cuboidal epithelial cells of carcinosarcomas and in the epithelial component of phyllodes tumors. Vimentin and desmin were detected in the sarcomatous portion of carcinosarcoma, focally in the stromal component of phyllodes tumors and not always in the stromal sarcomas. These data confirm that combined analysis of IF expression is a reliable and convincing way to differentiate stromal sarcomas, metaplastic carcinomas and carcinosarcomas in breast pathology.

A novel use of social media to evaluate the occurrence of skin lesions affecting wild dusky grouper, Epinephelus marginatus (Lowe, 1834), in Libyan coastal waters

The social media network Facebook^™ was used to gather information on the occurrence and geographical distribution of dusky grouper dermatitis, a skin lesion affecting the dusky grouper, Epinephelus marginatus. Dusky grouper are common targets for spear fishermen in the Mediterranean and by monitoring spearfishing activity in Libyan waters, it was possible to document skin lesions from their entries on Facebook. Thirty-two Facebook accounts and 8 Facebook groups posting from 23 Libyan coastal cities provided a retrospective observational data set comprising a total of 382 images of dusky grouper caught by spearfishing between December 2011 and December 2015. Skin lesions were observable on 57/362 fish, for which images were of sufficient quality for analysis, giving a minimal prevalence for lesions of 15.75%. Only dusky grouper exceeding an estimated 40 cm total length exhibited lesions. The ability to collect useful data about the occurrence and geographical distribution of pathological conditions affecting wild fish using social media networks demonstrates their potential utility as a tool to support epidemiological studies and monitor the health of populations of aquatic animals. To our knowledge, this represents the first time that such an approach has been applied for assessing health in a wild population of fish.

Ulcerative dermatitis in wild dusky grouper Epinephelus marginatus (Lowe) from Libyan waters

In the period 2013-2015, wild dusky grouper, Epinephelus marginatus (Lowe), caught in Libyan coastal waters and ranging in size from 42 to 92 cm in total length, were observed to have distinctive skin lesions of unknown aetiology. Histopathologically, the lesions comprised a multifocal, unilateral or bilateral dermatitis, involving the epidermis, superficial dermis and scale pockets, and sometimes, in severe cases, the hypodermis. Severe lesions had marked epidermal spongiosis progressing to ulceration. Healing was observed in some fish. Bacteria and fungi could be isolated from severe lesions, although they were not seen histopathologically in early-stage lesions. By contrast, metazoan parasite eggs were observed in the dermis and epidermis of some fish with mild and moderate dermatitis. Unidentified gravid digenean trematode parasites carrying similar eggs were also seen within the blood vessels of the deep and superficial dermis. The cause of this distinctive condition, termed dusky grouper dermatitis (DGD), and its potential impact upon already threatened Mediterranean wild dusky grouper populations and upon cultured grouper more widely have yet to be established.

Efficacy of ginger-based treatments against infection with Gyrodactylus turnbulli in the guppy (Poecilia reticulata (Peters))

Monogenean infections of commercially farmed fishes are responsible for significant economic losses and existing chemical therapeutants, often stressful to the fish, pose associated risks. As part of a recent trend to move towards the use of alternative, plant-based remedies for commonly occurring aquaculture-related diseases, the efficiency of ginger (Zingiber officinale) was investigated against the monogenean parasite Gyrodactylus turnbulli in the guppy. In vitro trials revealed the clear anti-parasitic effects of ginger. Ethanolic and aqueous extracts, prepared from freeze dried ginger, were tested. An increase in extract concentration was associated with reduced time to parasite immobilisation, with ethanolic extract being more efficient; at 75 and 200ppt aqueous ginger extract parasites died at 65.6±2.8 and 1.8±0.2min, respectively, whereas at 5 and 40ppt ethanolic extract parasites died at 26.1±0.7 and 4.9±0.3min, respectively. Bathing G. turnbulli-infected fish in ethanolic ginger extract (i.e. 5 and 7.5ppt for 90 and 30min, respectively) significantly reduced infection prevalence and intensity when compared to the water and ethanol controls. The higher concentration (i.e. 7.5ppt) proved as equally effective as Praziquantel, the conventionally used chemical treatment for gyrodactylosis, with the fish appearing to be completely cleared of the infection in both cases. Oral treatments of G. turnbulli-infected guppies with diets supplemented with 10 and 20% ginger powder proved to be ineffective in decreasing parasite load. These findings demonstrate that immersion in ginger extract offers an effective, alternative treatment against monogenean infection in fish.

Transversus abdominis plane block for analgesia after Cesarean delivery. A systematic review

Cesarean delivery is a major surgical procedure, after which a woman can experience substantial postoperative discomfort or pain. Inadequate postoperative analgesia is one of the most common reasons for poor patient satisfaction following cesarean delivery. Although spinal or systemic opioids are currently the gold standard to achieve effective analgesia, they are often associated with side effects. In the last few years there has been growing interest in abdominal plane blocks, with promising data on their efficacy. The transversus abdominis plane (TAP) block is a regional analgesic technique which is gaining acceptance in postoperative analgesia for lower abdominal surgeries. In this systematic review of articles published as of 31 December 2013, we searched the principal medical databases for randomized controlled trials that assessed the efficacy of ultrasound (US)-guided TAP block following cesarean delivery and reported on postoperative opioid consumption and pain score, opioid-related side-effects and patient satisfaction. Although controversy surrounds the utility of US-guided TAP block in cesarean section, evidence suggests that when correctly executed as part of a multimodal analgesic regimen, TAP block may reduce postoperative opioid consumption and opioid-related side effects, improving postoperative pain control and patient satisfaction. Further studies are necessary to explore this field of research.

Switching to anastrozole versus continued tamoxifen treatment of early breast cancer. Updated results of the Italian tamoxifen anastrozole (ITA) trial

BACKGROUND

Tamoxifen, for many years the 'gold standard' in the adjuvant setting for the management of endocrine sensitive early breast cancer, is associated with an increased risk of endometrial cancer and other life-threatening events. Moreover, many women relapse during or after tamoxifen therapy due to the development of resistance. This provided the rationale for a switching trial with anastrozole, the updated results of which are reported here.

PATIENTS AND METHODS

This trial investigated the efficacy of switching to anastrozole for women already receiving tamoxifen. After 2-3 years of tamoxifen treatment, postmenopausal, node-positive, ER-positive patients were randomized to receive either anastrozole 1 mg/day or to continue tamoxifen, 20 mg/day, giving a total duration of 5-years treatment. The primary end point was disease-free survival and secondary endpoints were event-free survival, overall survival and safety.

RESULTS

A total of 448 patients were enrolled. At a median follow-up time of 64 months (range 12-93), 63 events had been reported in the tamoxifen group compared with 39 in the anastrozole group [HR 0.57 (95% CI 0.38-0.85) P = 0.005]. Relapse-free and overall survival were also longer in the anastrozole group [HR 0.56 (95% CI 0.35-0.89) P = 0.01 and 0.56 (95% CI 0.28-1.15) P = 0.1]. However, the latter difference was not statistically significant. Overall more patients in the anastrozole group experienced at least one adverse event (209 versus 151: P = 0.000). However, numbers of patients experiencing serious adverse events were comparable (37 versus 40, respectively: P = 0.7).

CONCLUSIONS

Switching to anastrozole after the first 2-3 years of treatment was confirmed to improve event-free and relapse-free survival of postmenopausal, node-positive, ER-positive early breast cancer patients already receiving adjuvant tamoxifen.

Quantitative p21(waf-1)/p53 immunohistochemical analysis defines groups of primary invasive breast carcinomas with different prognostic indicators

We used image cytometry to quantify the immunohistochemical expression of p21(waf-1) and p53 in primary breast carcinoma. Ratio analysis of the quantified p53/p21(waf-1) protein expression allowed us to define 3 groups of carcinomas, each characterized by specific pathological and biological profiles. The negative (NEG) group, characterized by negligible expression of both proteins, comprised small-sized, low-grade tumors associated with high contents of hormonal receptors and low growth fraction. In the NEG group, Ki-67 labelling index area (%LIa) was the only significant prognostic indicator. The P53H group, characterized by prevalence of p53 %LIa, was constituted by large-sized, high-grade tumors showing low hormonal receptor contents and high growth fraction. In the P53H group, both p53 and Ki-67 were inversely associated with both estrogen receptor (ER) and progesterone receptor (PGR), suggesting that extensive p53 immunostaining is related to poor differentiation and high proliferation. Only N status was prognostically significant in the P53H group. The P21H group, characterized by prevalence of p21(waf-1) %LIa, displayed intermediate pathological and biological features. A significant association between p53 and p21(waf-1) expression suggested functional stabilization of wtp53 and therefore possible DNA damage-dependent G1/S arrest (genetic instability) in the P21H group; P21(waf-1)expression was significantly associated with the presence of node metastasis. Patients in the P21H group had a higher recurrence rate and a shorter disease-free time interval from surgery with respect to the NEG group. Proportional hazard regression analysis disclosed Ki-67 %LIa and, to a lesser degree, PGR %LIa as significant relapse-free survival prognostic indicators.

[Total arterial myocardial revascularization with both mammary arteries without extracorporeal circulation]

INTRODUCTION

Tector has described the off-pump total arterial revascularization technique, using multiple anastomosis with both internal thoracic arteries. To reduce surgical morbid-mortality, we have proposed the use of this technique without extracorporeal circulation.

PATIENTS AND METHODS

From April, 1998 the off-pump <<Tector>> technique was performed in 92 patients, 74 male (80%) and 18 female (20%), with a mean age of 64.9+/-8.1 years (42-78). Preoperative angiography demonstrated triple-vessel disease in 58 (63%) patients, and left main disease was present in 19 (20.5%) patients. Forty patients (43.5%) showed unstable angina, 24 patients (26%) significant peripheral vascular disease, and 26 (28%) diabetes mellitus. Both internal thoracic arteries were harvested using the skeletonization technique and were used like a <<T or T>> graft. The flow in the graft was measured using a flowmeter, and in 24 (26%) patients by angiographic study.

RESULTS

A total of 274 distal anastomoses were performed, 122 (44.6%) in the lateral or inferior wall, and 69 (25.2%) were sequential, with an average of 2.98 bypass/patient. In 59.8% of the patients a triple bypass was performed, 22% double bypass, 17% cuadruple bypass and 1 patient a quintuple bypass. During the initial six hours 64.9% of patients were extubated. Only one patient (1.1%) needed intraaortic ballon pumping and 3 (3.2%) inotropics during the postoperative course. Hospital mortality was 3 (3.2%) patients. Reoperation for bleeding was needed in just one patient (1.1%), and 78.3% of patients were not transfused. Mediastinitis occurred in 3 patients (3.2%). Postoperative stroke was not observed. At 7.7+/-2.8 months of mean follow-up all patients were free of symptoms and the global patency rate of 94%.

CONCLUSIONS

Off-pump Tector technique appears to be safe, offering a complete arterial revascularization and showing a reduction of surgical morbidity.

Is HLA B27 a true marker of axial involvement in psoriatic arthropathy?

Sixty-six patients with psoriatic arthropathy were subdivided into nine groups on the basis of the presence of peripheral arthritis, axial disease whether or not fulfilling the New York criteria for ankylosing spondylitis both associated and not associated with peripheral arthropathy and bilateral or monolateral lateral sacro-iliitis. Only the group with axial disease sacroiliitis+spondylitis) without peripheral arthritis and not fulfilling the NY criteria showed a truly increased B27 prevalence. However, in this atypical group, only 2 patients had a true ankylosing pattern-like spondylitis. On the other hand, in the group with axial disease fulfilling the NY criteria, only one of 9 patients was B27+. We conclude that B27 is not a true marker of axial involvement in psoriatic arthropathy.

[Rheumatoid arthritis and chronic granular T-cell lymphocytosis with neutropenia. A clinical condition distinct from Felty's syndrome]

103 cases of rheumatoid arthritis who had been diagnosed between 1984 and 1985 have retrospectively been analyzed, in order to identify those patients who had presented with associated neutropenia and in whom it was thus possible to suggest a presumptive diagnosis of either Felty's syndrome or chronic granulated lymphocytosis with neutropenia. Four patients (3.8%) satisfied the clinical criteria for the latter diagnosis while only one had typical Felty's syndrome. They were again studied using blood counts, microscopy of bone marrow and surface antigen analysis of mononuclear cells and the above mentioned diagnoses were confirmed. Though clinically indistinguishable, these two conditions are clearly distinct on both hematologic and immunological grounds. The four patients with rheumatoid arthritis and chronic granulated T cell lymphocytosis with neutropenia represent 36.3 per cent of our institution's patients with chronic granulated T cell lymphocytosis of undetermined significance. Caution should be used in the treatment of rheumatoid arthritis of the patients with associated granular lymphocyte proliferation, considering the possible adverse effects that drugs such as gold salts, penicillamine, cyclosporine and methotrexate may exert not only on the immunological system but also on granulocytopoiesis.

[Chronic granular T lymphocytosis of undetermined significance]

The clinical, morphologic, immunologic, functional, serologic and cytogenetic features of 4 cases of chronic granular T cell lymphocytosis with neutropenia were studied. The records of these patients were reviewed and an infectious event preceding the development of the disorder could be documented in 3 cases, suggesting a cause and effect relationship. A benign monoclonal gammopathy was detected in the remaining patient. The clinical picture was characterized by moderate blood and bone marrow lymphocytosis, neutropenia, hepatosplenomegaly, absence of lymphadenopathy, and a stable course, observed over a period of up to 11 years. Surface marker analysis in all the patients showed the common membrane phenotype of granular T cell lymphocytosis (CD3+, CD4-, CD8+, Leu7+). One patient treated with steroid therapy had reversal of lymphocytosis and severe neutropenia, which both recurred after steroids were withdrawn. The disorder again resolved after pulse steroid treatment. From these findings and a review of the literature, we suggest that granular T cell lymphocytosis with the immunologic phenotype exemplified by our cases is a distinct reactive or immunoregulatory disorder. In view of the similarities in character to benign monoclonal B cell lymphocytosis and idiopathic paraproteinaemia, we suggest that this disorder be termed chronic granular T cell lymphocytosis of undetermined significance.

[Idiopathic monoclonal gammopathy. Long-term study of 313 cases]

The records of 519 patients with a paraproteinaemia who where examined at our institutions before January, 1, 1983, were reviewed. After patients with multiple myeloma, macroglobulinemia, amyloidosis, lymphoma or related diseases had been excluded, 363 cases remained which fulfilled the criteria for a diagnosis of idiopathic monoclonal gammopathy (IMG). Also excluded were the cases in which follow-up efforts failed and those in which the paraprotein had disappeared. A long-term study was thus possible in 313 patients with IMG. They were arbitrarily subdivided into two groups: 213 patients with a follow-up of 5-8 years and 100 patients whose follow-up was longer than 8 years. Fourteen per cent of the patients from the former group and 18 per cent from the latter developed a malignant B cell dyscrasia, on the average this event becoming clinically detectable after 63 months (27-138 months) from initial recognition of the paraprotein. A retrospective analysis of the clinical data at the diagnosis of IMG, revealed that none of the patients could have been identified in advance in whom a malignant transformation later occurred.

Prophylactic and therapeutic role of rioprostil in NSAIDs induced gastroduodenal lesions

In a randomized, double-blind, placebo-controlled, prospective trial, the activity of rioprostil, a new prostaglandin E1 alcohol analogue, on non-steroidal anti-inflammatory drug-induced gastroduodenal mucosal lesions is studied in 30 patients with rheumatic diseases. Both treatment regimens, rioprostil, 150 micrograms t.i.d., and rioprostil, 200 micrograms b.i.d., for a period of 12 weeks, significantly reduce the rate of mucosal lesions in all patients when compared to placebo. Furthermore, rioprostil achieves a reduction in gastrointestinal symptoms without enhancement of joint disease activity, and significantly reduces antacid intake. Therapy is safe and well tolerated by all patients. It can be concluded from this study that prostaglandins could play an important part in the prevention and treatment of gastrointestinal damage due to NSAIDs.

[Selective hypoaldosteronism with hyperkalemia. Clinical and physiopathological study of 22 cases with hypo- or hyperreninemia]

Twenty-two patients with selective hypoaldosteronism (SH) were studied. In 18 of them decreased levels of plasma renin activity (PRA) were associated with the syndrome: 12 patients showed the idiopathic form of SH, while in 6, the syndrome was attributable to the administration of non-steroid anti-inflammatory drugs. In the remaining 4 patients, the hypoaldosteronism was characterized by associated increased PRA levels but functional studies excluded a diagnosis of adrenocortical insufficiency. From a critical review of the literature and from the present observations it seems likely that SH is a syndrome with a heterogeneous pathogenesis. The possibility exists that the major alterations in potassium homeostasis that characterize the syndrome of SH, though mainly attributable to deficiency of aldosterone secretion may actually depend on the concurrence of underlying mechanisms, in particular on the presence of distal nephron dysfunctions.

[Chronic idiopathic neutropenia: a benign hematological disorder]

Clinical data in 23 consecutive patients with chronic idiopathic neutropenia are reported. During a long-term follow-up (4 to 11 years), none had leukemia or autoimmune diseases. In particular, in no case did serious recurrent infections develop despite severe neutropenia. Immunological studies showed the presence of antibodies to neutrophils in a unique case and of the marker make-up of K lymphocytes in other two with chronic T8 lymphocytosis and associated neutropenia. The immunological features of this syndrome is briefly discussed. Chronic idiopathic neutropenia, even in the presence of an immunological imbalance, is a benign haematological disorder and does not need any treatment.

[Angiosarcoma of the breast]

Two cases of angiosarcoma of the breast observed in 1981 and 1982 are reported; one of these is still living, but with local recurrence. The pathogenesis, classification, prognosis and therapy of this malignant tumor are analysed. The review of the literature and personal experience seem to suggest that the treatment of choice should be surgical with complementary radiotherapy.

[Side effects of d-penicillamine in the treatment of rheumatoid arthritis]

In the present study, the side effects of d-Penicillamine therapy in 54 patients with rheumatoid arthritis are analyzed. The therapeutic efficacy of the drug is emphasized; but in the meantime, the necessity is also stressed that the choice of this antirheumatic agent must imply the knowledge of the possible complications caused by its use and of the clinical features and laboratory data which would be useful for their early detection.

[Development of polycythemia vera during chronic idiopathic myelofibrosis]

A case of typical idiopathic myelofibrosis turning into polycythaemia vera 6 years after diagnosis is reported. This transformation occurred after treatment with busulphan. The present case is added to similar previous observations to give further support to the contention that the transition of chronic idiopathic myelofibrosis to polycythaemia vera may be a consequence, though rare, of therapy rather than a spontaneous event occurring during the course of the disease.

Bone scintigraphy in the diagnosis of pulmonary calcification in multiple myeloma

We present a case of multiple myeloma in which pulmonary calcification was clinically shown by bone scintigraphy and subsequently confirmed at autopsy. It is suggested that, in patients with myeloma, radionuclide bone scanning may be of value for differentiating deposits in the lung due to calcification from those due to other types of pulmonary infiltration revealed by chest X-rays. A thorough review of the relevant literature is presented.

Treatment of perinfarction recurrent ventricular fibrillation by percutaneous pharmacological block of left stellate ganglion

A patient suffering from an acute myocardial infarction presented on the seventh and eighth days of hospitalization recurrent episodes of ventricular fibrillation refractory to antiarrhythmic treatment. The life-threatening ventricular fibrillation was suppressed by percutaneous pharmacological block of the left stellate ganglion.

[Immuno-allergic side effects induced by the administration of carbamazepine. Case contribution]

Carbamazepine is one of the drugs most widely prescribed for the treatment of trigeminal neuralgia and psychomotor seizures. Coincidentally with its use, hypersensitivity reactions to this agent have ben reported with increasing frequency. This report documents our recent encounter with 2 patients who developed hepatitis within one month of beginning carbamazepine therapy for temporal-lobe epilepsy. The occurrence of fever, skin rash and arthralgias suggest immunologic hypersensitivity as does eosinophilia and raised level of IgE, as seen in our patients. After withdrawal of the drug, symptoms and signs disappeared rapidly. We also describe a patient with psychomotor seizures who had ingested carbamazepine for less than 2 months before presenting with a febrile illness characterized by rash, arthritis, lymphadenopathy, epatosplenomegaly and diffuse pulmonary infiltrates with eosinophilia. The reaction cleared on cessation of the drug. Besides showing antinuclear antibody without DNA-precipitating antibody, this patient had an increased helper-T-cell count as well as a decreased number of T lymphocytes with suppressor activity. Taken together, these observations make it reasonable to speculate that carbamazepine may have interfered with lymphocyte triggering, thereby favouring the emergence of B cells with autoimmune propensities.

Indomethacin-induced hyperkalemia and renal failure in multiple myeloma

3 patients with multiple myeloma developed hyperkalemic hypoaldosteronism and renal insufficiency while receiving indomethacin for bone pain. Claims are made that indomethacin has been responsible for these complications, possibly by inhibiting prostaglandin biosynthesis. Careful observation of myeloma patients during administration of this agent and perhaps other prostaglandin inhibitors appears warranted.

Peyronie's disease and systemic lupus erythematosus syndrome associated with metoprolol administration: a case report

Peyronie's disease (induratio penis plastica) and a syndrome resembling systemic lupus erythematosus (S.L.E.) contemporaneously developed in a 50-year-old man six months after initiation of treatment with metoprolol. In view of the improvement in symptoms and signs on withdrawal of metoprolol, it seems likely that the drug was responsible for both these conditions. Peyronie's disease has been observed in relation to treatment with other adrenergic blocking agents, including practolol, and the S.L.E. syndrome is thought to be a possible untoward effect of practolol therapy. The relationship between practolol and sclerosing conditions elsewhere in the body is well recognized and an immunological basis for the fibrosis has been suggested. Similarly, the possibility is raised that Peyronie's disease may be in this case a particular expression of the auto immune disorder induced by metoprolol administration.

[Angioimmunoblastic lymphadenopathy. Anatomoclinical and immunological study of a case]

The clinical course of a 54-year-old man with generalized lymphadenopathy bearing all physical, laboratory and histologic characteristics of angioimmunoblastic lymphadenopathy with dysproteinemia is described. Morphologic and laboratory features of a hyperimmune state with autoimmune hemolytic anemia, elevated cold agglutinin levels and polyclonal gammopathy, but with paradoxical cutaneous anergy and decrease in blood T-lymphocytes, were found. Therapy with levamisole was without significant benefit and the patient died 2 months after initial diagnosis. Our findings give further support to the contention that this disease is an abnormal, but non-neoplastic, immune reaction resulting from a loss of suppressor T cells with hyperfunction of the B lymphocyte system.

Effect of chemotherapy on the anion gap in multiple myeloma

In 12 myeloma patients responding to chemotherapy (7 IgG and 5 IgA), we studied the effect on the anion gap of a 50% reduction in the serum paraprotein concentration. In contrast to the pretreatment anion gap which was decreased in IgG myeloma and increased in IgA myeloma, the value calculated when the paraprotein spike was halved showed a tendency towards normalization in the former type of myeloma, whereas it appeared as quite normalized in the latter. Our results lend further support to the conceptions that IgG and IgA paraproteins behave in the serum as cations and anions, respectively, and that serial determinations of the anion gap may be of value for monitoring the response to treatment in patients with multiple myeloma.

[Excessive prolactinemic response to sulpiride in patients with mild essential hypertension. Index of diminished hypothalamic dopaminergic activity]

Plasma prolactin concentrations and prolactinaemic response to sulpiride, a prolactin releaser with pituitary dopamine receptor blocking activity, were examined in 16 subjects with mild essential hypertension and in 20 patients with long-sustained essential hypertension. When compared with 16 normotensive controls only the former showed raised plasma renin activity (P < 0.001) and higher plasma prolactin levels either after two-hour ambulation (P < 0.05) or at supine rest (P < 0.05). The average of maximal sulpiride-induced prolactin values was 157 +/- 53 ng/ml (mean +/- SD) in the mild hypertensive, significantly different from 60.2 +/- 21.4 ng/ml (mean +/- SD) as resulted in the controls (P < 0.001). In contrast, patients with sustained hypertension had a mean level of 60.2 +/- 21.4 ng/ml (mean +/- SD), indifferent from the one of the normal volunteers. It is suggested that the excessive prolactinaemic response to sulpiride detected in patients with mild hypertension reflects a reduced hypothalamic dopaminergic activity and that such an alteration may assume some pathogenetic relevance in the natural history of essential hypertension. Further, in the mild hypertensive a positive prolactin-renin correlation was found (r = + 0.76; P < 0.01), so suggesting that in these patients a peripheral sympathetic overactivity is associated to an impaired central dopamine control. The individuation of such cases may be important since they could benefit by dopamine agonists as L-dopa and bromocriptine.

Benign Bence Jones gammopathy

A case of isolated lambda-light chain proteinemia and proteinuria is reported. During a 42-month follow-up, no sign of myelomatosis or amyloidosis developed and Bence Jones proteinuria remained nearly of the same magnitude. This case of apparently idiopathic Bence Jones gammopathy, the first lambda-type so far reported, is added to similar observations to give further support to the contention that a benign counterparty to light-chain myeloma may exist.

Anion gap in multiple myeloma

The anion gap was evaluated in 26 consecutive patients with multiple myeloma (15 IgG and 11 IgA). The average union gap was found reduced only in IgG myeloma. Instead, in the subjects with IgA myeloma it resulted as increased. The partial differences between our results and those of other authors are discussed. The finding of correlations between the anion gaps and paraproteinemic concentrations (direct in IgA myeloma, inverse in IgG myeloma) gives further support to the conception that the charge exhibited in the serum by IgG and IgA paraproteins is, respectively, positive and negative. It is suggested that a 'normalization' of the anion gap during chemotherapy may be a useful tool to judge the efficacy of the treatment of multiple myeloma.

[Evaluation of the bone marrow granulocyte reserve in patients with Hodgkin's disease during antiblastic polychemo- and radiation therapy]

The ethiocholanolone test was used to evaluate the granulocyte reserve in 22 patients with Hodgkin's disease before and during polychemical antiblastic and radiation therapy. Under basal conditions, the reserve was normal and its behavior was fairly constantly related to histological type. Stress is laid on the inadequacy of the simple leukocyte count as a guide to the planning of treatment by comparison with the more accurate picture offered by the granulocyte reserve.