The detection of circulating plasma cells may improve the Revised International Staging System (R-ISS) risk stratification of patients with newly diagnosed multiple myeloma

The Revised International Staging System (R-ISS) stratifies patients affected by Multiple Myeloma (MM) into three distinct risk groups: R-ISS I [ISS Stage I, Standard-Risk cytogenetics and normal Lactase DeHydrogenase (LDH)], R-ISS III (ISS stage III and either high-risk cytogenetics or high LDH) and R-ISS II (any other characteristics). With the aim to verify whether the three R-ISS groups could be divided into subgroups with different prognostic factors based on the detection of Circulating Plasma Cells (CPCs) at diagnosis, in this retrospective analysis, we evaluated 161 patients with MM treated at our centre between 2005 and 2017. In all, 57 patients (33·9%) were staged as R-ISS III, 98 (58·3%) as R-ISS II and six (3·6%) as R-ISS I. CPCs were detected in 125 patients (74·4%), while in 43 patients (25·6%) no CPCs were seen. Our analysis revealed that Overall Survival (OS) and progression-free survival (PFS) rates in R-ISS II patients were higher in the subgroup without CPCs compared to the subgroup with ≥1 CPCs (OS: 44·7% vs. 16·3%, P = 0·0089; PFS: 27·8% vs. 8·1%, P = 0·0118). Our present findings suggest that the detection of CPCs at diagnosis may be used as a further prognostic biomarker to improve the risk stratification of patients with MM staged as R-ISS II.

Assessment of the interlaboratory variability and robustness of JAK2V617F mutation assays: A study involving a consortium of 19 Italian laboratories

To date, a plenty of techniques for the detection of JAK2^V617F is used over different laboratories, with substantial differences in specificity and sensitivity. Therefore, to provide reliable and comparable results, the standardization of molecular techniques is mandatory.

A network of 19 centers was established to 1) evaluate the inter- and intra-laboratory variability in JAK2^V617F quantification, 2) identify the most robust assay for the standardization of the molecular test and 3) allow consistent interpretation of individual patient analysis results. The study was conceived in 3 different rounds, in which all centers had to blindly test DNA samples with different JAK2^V617F allele burden (AB) using both quantitative and qualitative assays.

The positivity of samples with an AB < 1% was not detected by qualitative assays. Conversely, laboratories performing the quantitative approach were able to determine the expected JAK2^V617F AB. Quantitative results were reliable across all mutation loads with moderate variability at low AB (0.1 and 1%; CV = 0.46 and 0.77, respectively). Remarkably, all laboratories clearly distinguished between the 0.1 and 1% mutated samples.

In conclusion, a qualitative approach is not sensitive enough to detect the JAK2^V617F mutation, especially at low AB. On the contrary, the ipsogen JAK2 MutaQuant CE-IVD kit resulted in a high, efficient and sensitive quantification detection of all mutation loads. This study sets the basis for the standardization of molecular techniques for JAK2^V617F determination, which will require the employment of approved operating procedures and the use of certificated standards, such as the recent WHO 1st International Reference Panel for Genomic JAK2^V617F.

Traumatic brain injury in pedestrian-vehicle collisions: Convexity and suitability of some functionals used as injury metrics

BACKGROUND AND OBJECTIVE

Abrupt accelerations or decelerations can cause large strain in brain tissues and, consequently, different forms of Traumatic Brain Injury (TBI). In order to predict the effect of the accelerations on the soft tissues of the brain, many different injury metrics have been proposed (typically, an injury metric is a real valued functional of the accelerations). The objective of this article is to make a formal and empirical comparison, in order to identify general criteria for reasonable injury metrics, and propose a general guideline to avoid ill-proposed injury metrics.

METHODS

A medium-sized sample of vehicle-pedestrian collisions, from Post Mortem Human Subject (PMHS) tests, is analyzed. A statistical study has been conducted in order to determine the discriminant power of the usual metrics. We use Principal Component Analysis to reduce dimensionality and to check consistency among the different metrics. In addition, this article compares the mathematical properties of some of these functionals, trying to identify the desirable properties that any of those functionals needs to fulfill in order to be useful for optimization.

RESULTS

We have found a pair-wise consistency of all the currently used metrics (any two injury metrics are always positively related). In addition, we observed that two independent principal factors explain about 72.5% of the observed variance among all collision tests. This is remarkable because it indicates that despite high number of different injury metrics, a reduced number of variables can explain the results of all these metrics. With regard to the formal properties, we found that essentially all injury mechanisms can be accounted by means of scalable, differentiable and convex functionals (we propose to call minimization suitable injury metric any metric having these three formal properties). In addition three useful functionals, usable as injury metrics, are identified on the basis of the empirical comparisons.

CONCLUSIONS

The commonly used metrics are highly consistent, but also highly redundant. Formal minimal conditions of a reasonable injury metric has been identified. Future proposals of injury metrics can benefit from the results of this study.

Dislocated Tongue Muscle Attachment and Cleft Palate Formation

In Pierre Robin sequence, a retracted tongue due to micrognathia is thought to physically obstruct palatal shelf elevation and thereby cause cleft palate. However, micrognathia is not always associated with palatal clefting. Here, by using the Bmp7-null mouse model presenting with cleft palate and severe micrognathia, we provide the first causative mechanism linking the two. In wild-type embryos, the genioglossus muscle, which mediates tongue protrusion, originates from the rostral process of Meckel's cartilage and later from the mandibular symphysis, with 2 tendons positive for Scleraxis messenger RNA. In E13.5 Bmp7-null embryos, a rostral process failed to form, and a mandibular symphysis was absent at E17.5. Consequently, the genioglossus muscle fibers were diverted toward the lingual surface of Meckel's cartilage and mandibles, where they attached in an aponeurosis that ectopically expressed Scleraxis. The deflection of genioglossus fibers from the anterior-posterior toward the medial-lateral axis alters their direction of contraction and necessarily compromises tongue protrusion. Since this muscle abnormality precedes palatal shelf elevation, it is likely to contribute to clefting. In contrast, embryos with a cranial mesenchyme-specific deletion of Bmp7 (Bmp7:Wnt1-Cre) exhibited some degree of micrognathia but no cleft palate. In these embryos, a rostral process was present, indicating that mesenchyme-derived Bmp7 is dispensable for its formation. Moreover, the genioglossus appeared normal in Bmp7:Wnt1-Cre embryos, further supporting a role of aberrant tongue muscle attachment in palatal clefting. We thus propose that in Pierre Robin sequence, palatal shelf elevation is not impaired simply by physical obstruction by the tongue but by a specific developmental defect that leads to functional changes in tongue movements.

Circulating plasma cells in newly diagnosed symptomatic multiple myeloma as a possible prognostic marker for patients with standard-risk cytogenetics

Detection of circulating plasma cells (PCs) in multiple myeloma (MM) patients is a well-known prognostic factor. We evaluated circulating PCs by flow cytometry (FC) in 104 patients with active MM at diagnosis by gating on CD38(+)  CD45(-) cells and examined their relationship with cytogenetic risk. Patients had an average follow-up of 36 months. By using a receiver operating characteristics analysis, we estimated the optimal cut-off of circulating PCs for defining poor prognosis to be 41. Patients with high-risk cytogenetics (n = 24) had poor prognosis, independently of circulating PC levels [PC < 41 vs. PC ≥ 41: overall survival (OS) = 0% vs. OS = 17%, P = not significant (n.s.); progression-free survival (PFS) = 0% vs. 17%, P = n.s.]. Patients with standard-risk cytogenetics (n = 65) showed a better prognosis when associated with a lower number of circulating PCs (PC < 41 vs. PC ≥ 41: OS = 62% vs. 24%, P = 0·008; PFS = 48% vs. 21%, P = 0·001). Multivariate analysis on the subgroup with standard-risk cytogenetics confirmed that the co-presence of circulating PCs ≥ 41, older age, Durie-Salmon stage >I and lack of maintenance adversely affected PFS, while OS was adversely affected only by lactate dehydrogenase, older age and lack of maintenance. Our results indicate that the quantification of circulating PCs by a simple two-colour FC analysis can provide useful prognostic information in newly diagnosed MM patients with standard-risk cytogenetics.

6q deletion detected by fluorescence in situ hybridization using bacterial artificial chromosome in chronic lymphocytic leukemia

Deletions of the long arm of chromosome 6 are known to occur at relatively low frequency (3-6%) in chronic lymphocytic leukemia (CLL), and they are more frequently observed in 6q21. Few data have been reported regarding other bands on 6q involved by cytogenetic alterations in CLL. The cytogenetic study was performed in nuclei and metaphases obtained after stimulation with a combination of CpG-oligonucleotide DSP30 and interleukin-2. Four bacterial artificial chromosome (BAC) clones mapping regions in bands 6q16, 6q23, 6q25, 6q27 were used as probes for fluorescence in situ hybridization in 107 CLL cases in order to analyze the occurrence and localization of 6q aberrations. We identified 11 cases (10.2%) with 6q deletion of 107 patients studied with CLL. The trends of survival curves and the treatment-free intervals (TFI) of patients with deletion suggest a better outcome than the other cytogenetic risk groups. We observed two subgroups with 6q deletion as the sole anomaly: two cases with 6q16 deletion, and three cases with 6q25.2-27 deletion. There were differences of age, stage, and TFI between both subgroups. By using BAC probes, we observed that 6q deletion has a higher frequency in CLL and is linked with a good prognosis. In addition, it was observed that the deletion in 6q16 appears to be the most frequent and, if present as the only abnormality, it could be associated with a most widespread disease.

Coagulation assessment in normal pregnancy: thrombelastography with citrated non activated samples

BACKGROUND

Thrombelastography (TEG) provides an effective and convenient means of whole blood coagulation monitoring. TEG evaluates the elastic properties of whole blood and provides a global assessment of hemostatic function. Previous studies performed TEG on native blood sample, but no data are available with citrated samples in healthy pregnant women at term. The aim of this study was to investigate the effect of pregnancy on coagulation assessed by TEG and establish normal ranges of TEG values in pregnant women at term comparing them with healthy non pregnant young women.

METHODS

We enrolled pregnant women at term undergoing elective cesarean section or labour induction (PREG group) and healthy non-pregnant women (CTRL group). Women with fever or inflammatory syndrome, defined as C-reactive protein (CRP) >5 mg/L and with a platelet count <150.000/mm(3) have been excluded. For each women hemochrome and standard coagulation test were assessed. At the same time we performed a thrombelastographic test with Hemoscope TEG(®) after sample recalcification without using any activator.

RESULTS

One hundred thirty patients were studied, 65 for each group. There were no differences between groups regarding demographic data. Hemoglobin, platelet count, International Normalized Ratio and Activated Partial Thromboplastin Time Ratio were lower and fibrinogen was higher in PREG group. All TEG parameters resulted as being significantly different between the groups with a hypercoagulable pattern in PREG group compared to CTRL group.

CONCLUSION

The main findings of this study confirm the hypercoagulability status of pregnant women at term. This coagulation pattern is well represented by thrombelastographic trace obtained by recalcified citrate blood sample.

Variation of B-type natriuretic peptide concentrations and intrauterine growth restriction: mother, fetus and newborn

To evaluate maternal, fetal, neonatal B-type natriuretic peptide (BNP) concentrations related to Intra Uterine Growth Restriction (IUGR). BNP concentrations in 43 IUGR and 35 healthy, Appropriate for Gestational Age (AGA) infants/paired mothers have been compared, from delivery/birth to first month of life. Maternal and IUGR cord BNP concentrations were coupled to fetal ultrasonography. Neonatal echocardiography was performed too. On delivery BNP was higher in all IUGR mothers, suffering or not from gestational hypertension, than in AGA (median 37.14 vs 11.1 pg/ml p=0.002). Maternal BNP was not associated to cord/neonatal BNP or fetal ultrasonographic parameters. Cord BNP was higher in IUGR than AGA newborns (median 23.9 vs 11.4 pg/ml p=0.0007) independently of gestational age, while varied with amniotic fluid (p=0.0044) and umbilical artery flowmetry (p=0.0121). Earlier drop of BNP on day 3 was reported in IUGR neonates (p=0.0001).Ventricular mass change/body weight varied positively in AGA newborns (p<0.001), while declined in IUGR ones (p=0.003). Carrying IUGR fetus is a stress factor resulting in high maternal BNP concentration. Altered fetal ultrasonographic parameters in IUGR newborns lead to higher BNP cord levels. A rapid BNP drop and probable ventricular mass adjustment of IUGR newborns may indicate earlier post-natal cardiovascular adaptation than AGA infants.

The R304X mutation of the aryl hydrocarbon receptor interacting protein gene in familial isolated pituitary adenomas: Mutational hot-spot or founder effect?

BACKGROUND

Mutations in the aryl hydrocarbon receptor interacting protein (AIP) gene have been described in about 15% of kindreds with familial isolated pituitary adenomas and in a minority of early onset sporadic pituitary adenomas (PA). Among the AIP mutations reported so far, the R304X (AIPR304X) represents, together with the "Finnish mutation" Q14X, the most common one.

METHODS

Three AIPR304X Italian families, including a newly reported kindred, have been genotyped for 12 genetic markers surrounding the AIP gene in order to look for a potential founder effect in Italy. Disease penetrance and genotype-phenotype correlations were also addressed.

RESULTS

Analysis of chromosome 11' genetic markers revealed a common haplotype in 2 AIPR304X kindreds originating from central Italy. Overall, 17 mutations carriers were identified, including 7 patients and 10 unaffected subjects, respectively, arguing in this case for a disease penetrance of 41%. Mean age at diagnosis was 19.1±6.7 yr old, with females tending to be older than males. Though most PA were somatotropinomas (6/7), a great variability in disease severity was observed, even between subjects sharing the same at-risk haplotype.

CONCLUSION

These data provide strong evidence for a new founder effect of the AIPR304X mutation in central Italy and the observed variations in disease severity point out the role of additional genetic or environmental factors in such kindreds.

Involvement of endocannabinoid CB1 receptor in the modulation of stress responses related to xenoestrogen exposure

The endocannabinoid system, through the cannabinoid receptor CB1, is involved in the modulation of adaptive responses to environmental conditions. However, little is known about the role of the cannabinergic system, particularly CB1 receptor expression, in relation to the effects induced by xenoestrogens concerning the reproductive axis. Our results demonstrate that only 10(-8) mol/L of 17beta-estradiol was able to induce significantly higher levels of CB1A mRNA, while no effects were found after treatment with 4-nonylphenol (10(-8) or 10(-6) mol/L); moreover, mRNA expression titers of CB1B did not show any significant change. The estrogenic effects of treatments were evidenced by a dose-dependent induction of plasma hepatic vitellogenin titers. It can be concluded that low doses of estrogens, and possibly of xenoestrogens, may increase endocannabinoid signaling pathways.

Influence of dietary feeding of low monomer content grape seed extract on vitellogenin production and cholesterol levels in goldfish, Carassius auratus

Grape seed extract (GSE) is a source of naturally occurring compounds known as proanthocyanidins and flavan-3-ols, which are recognized to exert a protective effect on human health, so GSE is widely used mainly as a nutritional supplement. However, polyphenols may have, in some cases, estrogenic effects or may interfere with the endocrine system. For that reason, it was considered of interest to investigate the beneficial or detrimental effects induced by low monomer content grape seed extract (LMC-GSE) in a teleost experimental model, the juvenile goldfish (Carassius auratus); therefore, biomarkers of estrogenic exposure together with cholesterol titers were assessed in both plasma and tissue samples taken from fish fed with different doses of LMC-GSE for 4 weeks. Dietary LMC-GSE (71 or 35 mg/g diet) did not affect vitellogenin (VTG) synthesis; on the contrary, VTG production was exclusively induced in fish fed with an estradiol-17beta (E2)-incorporated diet. In addition, it was found that both plasma E2 levels and hepatic total cholesterol were not affected by LMC-GSE dietary regimens.

AVALIAÇÃO CLÍNICA DE CAPRINOS ACOMETIDOS POR ARTRITE. DIFERENCIAL ENTRE ARTRITE VIRAL (CAE) E BACTERIANA (MYCOPLASMA SPP.) EM DOIS CASOS ATENDIDOS NO HOSPITAL VETERINÁRIO DA FMVZ-USP

RESUMO Foi realizada a avaliação clínica de 2 caprinos acometidos por artrite atendidos junto a Clínica de Bovinos e Pequenos Ruminantes da FMVZ-USP. O diferencial entre artrite viral causada pelo vírus da CAE e a artrite bacteriana pelo Mycoplasma spp. foi feito baseado no exame específico, sorodiagnóstico, nas técnicas de isolamento, detecção do vírus pela PCR do líquido sinovial e laparoscopia.

[Screening for pre-eclampsia in a low-risk population at 24 weeks: uterine artery Doppler flow velocimetry and genetic variants of factor V, prothrombin and methylenetetrahydrofolate reductase]

AIM

Pre-eclampsia is one of the major causes of maternal and fetal morbidity and mortality. The aim of this study was to evaluate the clinical usefulness of screening of genetic thrombophilic mutations and uterine artery Doppler flow velocimetry at 24 weeks of gestation in the prediction of pre-eclampsia in low risk pregnant women.

METHODS

We performed the genetic analysis for Leiden mutation of factor V gene (FV), G20210A mutation of the prothrombin gene (PT) and C677T polymorphism of the methylenetetrahydrofolate reductase (MTHFR) gene in 103 women that had already attended routine ultrasonography scanner at 24 weeks at our Department.

RESULTS

The frequency of heterozygous carriers of the Leiden FV was 17.4% in women with pre-eclampsia and abnormal artery Doppler flow velocimetry compared with 3.12% in patients with normal pregnancies. This difference was statistically significant (P<0.05). The frequency of mutation G20210A of PT gene was 1.5% vs 4.3% between women with normal pregnancies and with pre-eclampsia. This difference is not statistically significant. The frequency of homozygous patients for the C677T mutation of MTHFR gene among patients with pre-eclampsia was 21.7% and in the control group was 10.3%, but this difference is not statistically significant. No thrombophilic genes variants were found in women with pre-eclampsia and normal uterine artery Doppler flow velocimetry.

CONCLUSION

We demonstrated the important association between FV Leiden mutation, abnormal uterine artery Doppler flow velocimetry at 24 weeks and pre-eclampsia in our low-risk population.

[Inguinal hernia surgery. Review of a caseload and description of a technique variation]

BACKGROUND

To evaluate the efficacy of the tension free surgical technique for the treatment inguinal hernia.

METHODS

The authors propose personal experience of 172 patients, treated for inguinal hernia in the period from 1986 to 1993, selecting two patients groups. In the first group the patients (80 cases) were treated with traditional hernioplasty, in the second group (92 cases) hernioplasty tension-free was performed.

RESULTS

In the first group 6 cases of recurrence (6.7%), have been observed and in the second group only one case.

CONCLUSIONS

The results obtained, and literature survey show the advantages of hernioplasty tension-free.

[Not Available]

Lots of theories about generation up to the XXVII century base themselves on the marvelous power of parents' imagination - the mother's above all - of conveying resemblance to the foetus or conditioning its shape till to the extreme monstruosity. For a long time mother's fancies explain the appearance of naevus, cravings, skin spots, hair colour, congenital deformities and so on. We can recognize one of the grounds of that idea, perhaps the most authoritative, in a biblical passage having Jacob the Patriarch as protagonist. This essay deals with history of the imaginationist theory from Jacob's episode and its following interpretation, with a particular attention for its influence on eugenic doctrines in fashion during the centuries XVI and XVII.

Isolated intestinal neurofibromatosis of colon. Single case report and review of the literature

Isolated intestinal neurofibromatosis of the colon is a most unusual disease: from 1937 to 1999 only 12 cases have been reported. The differential diagnosis and treatment of this lesion are very difficult. A review of the literature is made and personal experience in the diagnosis and treatment of a case in a 68-year-old female is described.

Fine needle aspiration and core needle biopsy techniques in the diagnosis of nodular thyroid pathologies

It is widly accepted that Fine Needle Aspiration Biopsy (FNAB) is the main test to distinguish benign from malignant thyroid lesions. Nevertheless, this technique presents some limits such as the possibility of false-negative or inadequate samples and it is unable to cytologically discriminate among adenomathosus goiter, follicular adenoma and well-differentiated follicular carcinoma. The aim of this study was to evaluate the possibility of restricting these limitations using Core Needle biopsy (CN) technique. Therefore we selected for CN, 40 out of 136 patients who underwent FNAB during a one year period; among these patients only 32 agreed a to this technique. Forty-two out of 136 patients underwent surgery; 29 of them were subjected to both biopsies. Sixteen of the diagnostic microbiopsies have been histologically confirmed. We had no discordant cases between cytological and microhistological diagnosis, except for one case which appeared cytologically colloid goiter, microhistologically follicular neoplasm and histologically follicular adenoma. In this case it was not possible to microhistologically discriminate benign from malign follicular lesion. In our experience not all patients accepted CN biopsy as well as FNAB and, moreover, this technique showed no advantage over FNAB diagnosis. On this base we think that actually FNAB should be the main procedure in the diagnosis of the thyroid lesions. It is easily performed, accepted by the patients and has a low cost-benefit ratio. If the sample is not diagnostic it can be easily repeated and false-negative cases could be discovered thanks to an adequate clinical and ultrasonographical follow-up of the patients.

Surgical treatment of multinodular goiter: incidence of lesions of the recurrent nerves after total thyroidectomy

The problems concerning surgical goiter treatment are discussed, particularly the morbidity of total thyroidectomy and possible injury to recurrent nerves in comparison to the partial resection of the gland. We discuss our case material and review the literature. We conclude that total thyroidectomy seems to be the most effective surgical procedure with lower morbidity than subtotal thyroidectomy.

Diagnosis controversies for adrenal ganglioneuroma

The authors report a case of adrenal ganglioneuroma which was incidentally diagnosed performing preoperative examination for a sigmoid carcinoma. The authors took this finding as a starting point to underline the rarity of this condition and its chance discovery, this being due to the rare presence of signs and symptoms and its frequent association with other synchronous neoplasms; all this makes differential diagnosis rather difficult.

Neuroendocrine tumors of the gastroenteric canal. Anatomopathological and diagnostic-therapeutic definition. Description of a case with a rare cecal localisation

The authors take the case of a neuroendocrine tumour of the cecum as the starting point for an analysis of the anatomopathological and diagnostic-therapeutic aspects of these neoplasms. Furthermore, the authors underline that neuroendocrine tumours (NET) of the colon represent an extremely rare nosological entity and that they are heterogeneous from a clinical and biochemical point of view, thus making a reliable preoperative diagnosis a problem that is still difficult to resolve today.

[The usefulness and limits of echo-endoscopy in the clinical staging of esophageal cancer]

Endoscopic ultrasonography (EUS) is a diagnostic method of considerable value for the local staging of esophageal cancer, in particular for T and N evaluation. After an extensive review of the literature, the authors underline the possibility of using EUS to improve the treatment and prognosis of esophageal neoplasms based on the use of various stage-dependent therapeutic strategies. EUS is regarded as a gold-standard technique for esophageal cancer staging in order to select appropriate treatment options, but is currently hampered by the intrinsic difficulty and subjectivity of interpreting ultrasonographic images. In order to ensure safe and reliable data, EUS must be carried out by operators who have undergone suitable training at a specialised centre.

[A case of thymoma: histological and diagnostic aspects and surgical considerations]

The histological and diagnostic features of a thymoma case observed recently have been investigated in the present study. Comparing the case under investigation with the literature, the Authors conclude that the proper surgical approach is that indicated by Jaretsky. By means of a longitudinal sternotomy associated with minimal cervical incision, the whole mediastinal cellular tissue together with that of the thyroid inferior poles is easily removed. Moreover oncological and myastenic recurrences have a very low incidence in cases surgically treated with this procedure.

Neuroendocrine tumors of the gastroenteric canal. Anatomopathological and diagnostic-therapeutic definition. Description of a case with a rare cecal localisation

The authors take the case of a neuroendocrine tumour of the cecum as the starting point for an analysis of the anatomopathological and diagnostic-therapeutic aspects of these neoplasms. Furthermore, the authors underline that neuroendocrine tumours (NET) of the colon represent an extremely rare nosological entity and that they are heterogeneous from a clinical and biochemical point of view, thus making a reliable preoperative diagnosis a problem that is still difficult to resolve today.

[Experience at an ambulatory surgical service for thyroid diseases]

Based of a personal series of 206 patients, the authors evaluate their personal experience of an outpatient surgery ward for thyroid pathologies. The paper reports the diagnostic and therapeutic approaches both in patients undergoing surgery and those who do not. Attention is focused on the importance of the multidisciplinary team and the quality of the results of a homogeneous follow-up.

Primary non-Hodgkin lymphoma of the parotid gland

The rarity of primary non-Hodgkin lymphomas of the parotid gland triggers this report on a case treated and now in the fourth year of follow-up, which offers the opportunity for a review of the literature on the subject. The paper also describes the criteria for accurate classification, the diagnostic tools available and the problems of differential diagnosis. Treatment protocols and survival are also considered.

[Adrenal cysts. Description of a clinical case]

Starting from the study of a personal case, the authors underline that adrenal cysts are a very rare pathology, occasionally observed and without symptoms. Moreover they point out diagnostic methods, don't permit a certain diagnosis and therapies are not univocal.

[Laparoscopic appendicectomy. Personal experience and results]

The paper discusses the indications, limits and basic technical principles of laparoscopic appendicectomy, comparing the costs and benefits to the laparotomic method. The authors review the Literature on this subject and report their personal experience of 11 cases with a nil morbidity and mortality rate.

Pattern of cytokines and pharmacomodulation in sepsis induced by cecal ligation and puncture compared with that induced by endotoxin

The production of tumor necrosis factor alpha (TNF-alpha), interleukin-1 beta (IL-1 beta), and IL-6 and their pharmacomodulation were evaluated in a model of polymicrobial sepsis induced in mice by cecal ligation and puncture (CLP) and were compared with the effects of endotoxin (lipopolysaccharide [LPS]) treatment. LPS levels rose as early as 1 h after CLP and increased further after 2 and 21 h. TNF-alpha was detectable in serum, spleen, liver, and lungs during the first 4 h, with a peak 2 h after CLP. IL-1 beta was measurable in serum after 24 h, and levels increased significantly in spleen and liver 4 and 8 h after CLP. IL-6 levels increased significantly in serum throughout the first 16 h after CLP. These cytokines were detectable after LPS injection, with kinetics similar to those after CLP but at a significantly higher level. To cast more light on the differences between these two animal models of septic shock, we studied the effects of different reference drugs. Pretreatment with dexamethasone (DEX); ibuprofen (IBU), an inhibitor of cyclooxygenase; and NG-nitro-L-arginine, an inhibitor of nitric oxide synthase, significantly reduced survival, while chlorpromazine (CPZ) and TNF did not affect it. Only the antibiotics and pentoxifylline significantly increased survival in mice with CLP. However, CPZ and DEX protected the mice from LPS mortality. On inhibiting TNF-alpha with DEX, CPZ, or pentoxifylline, survival was reduced, unchanged, and increased, respectively, and on increasing TNF-alpha with IBU and TNF, survival was decreased or unchanged, respectively, suggesting that the modulation of this cytokine does not play a significant role in sepsis induced by CLP, unlike treatment with LPS. The negative effects of IBU and N(G)-nitro-L-arginine suggest a protective role by prostaglandins and nitric oxide in sepsis induced by CLP.

[Laparoscopic treatment of acute cholecystitis. Personal experience and preliminary results]

At the beginning of their experience the authors limited laparoscopic treatment to simple cholelithiasis. They then extended this method to acute cholecystitis. They report here 11 cases with no mortality and morbidity and a conversion rate equal to 18.18% (2 cases of new acute phase of chronic cholecystitis after deferred emergency surgical treatment). The postoperative stay in hospital never exceeded 72 hours for the 9 cases of laparoscopic cholecystectomy, while the 2 cases of laparotomic respectively on the VII and VIII days. In consideration of what is reported in the literature and of personal experience, even if limited, the authors acknowledge that laparoscopic cholecystectomy if it is practised by an expert surgeon in the presence of precise indications and with a low conversion rate.

A comparison of the local tolerability, safety and efficacy of meloxicam and piroxicam suppositories in patients with osteoarthritis: a single-blind, randomized, multicentre study

The local tolerability, safety and efficacy of meloxicam 15 mg suppositories were compared with piroxicam 20 mg suppositories over a 3-week period in a single-blind, randomized study in patients with osteoarthritis. Patients were randomized 2:1 to receive meloxicam (n = 216) or piroxicam (n = 109). More than 90% of patients and investigators assessed local tolerability of both treatments as good or very good (primary endpoint). There was no significant difference between the groups. Global efficacy was reported by approximately 80% of patients in both groups to be good or very good. Pain on movement and at rest and joint mobility showed statistically significant improvements compared with baseline with both meloxicam and piroxicam; there were no statistically significant differences between treatment groups. Piroxicam and meloxicam suppositories were equally well tolerated, with no serious adverse events recorded in either treatment group. Local adverse events occurred in 11.9% of patients receiving piroxicam and 6.9% of those receiving meloxicam. Overall, gastrointestinal adverse events were the most frequent of all 11.9% of piroxicam-treated patients). In both groups, about 90% of global tolerability assessments were classified, by the investigator and the patient, as either very good or good. In conclusion, meloxicam 15 mg suppositories showed excellent local tolerability accompanied by good safety and efficacy in osteoarthritis, which was comparable to that of an established non-steroidal anti-inflammatory drug (NSAID) administered by the rectal route, and to that previously observed with oral formulations of meloxicam 15 mg.

Long-term antimicrobial prophylaxis in lung cancer surgery: correlation between microbiological findings and empyema development

This study was planned in order to determine the value of antimicrobial prophylaxis in preventing post-operative empyema in patients undergoing lung cancer surgery. Two-hundred consecutive subjects operated upon for lung cancer received teicoplanin and aztreonam, starting at the induction of anesthesia and lasting until removal of the pleural drains. Cultures for aerobic and anaerobic bacteria were taken from: (1) the bronchus at the time of surgical division; (2) the pleural space before closure of the chest; (3) the pleural fluid during the post-operative period; and (4) the tips of chest drains at the time of their removal. In the 200 patients receiving antibiotic prophylaxis, the number of post-operative empyemas (1%) was lower than that (7.5%) found in 53 comparable patients who were previously treated with placebo. In the 'placebo group', empyema was due to gram-positive bacteria, while in the 'prophylaxis group', it was caused by Gram-negative bacteria (Pseudomonas aeruginosa). A significant (P < 0.05) correlation between infected bronchial secretions, pleural space contamination at surgery, contamination of chest fluid and drains during the post-operative period, and empyema development was demonstrated. In conclusion, antibiotic prophylaxis, while being effective in preventing post-operative empyema, may induce the colonization of the respiratory tract with highly resistant gram-negative bacteria.

[Current trends in the treatment of flail chest]

The authors make a wide-ranging review of the literature, examine the epidemiological aspect of fail chest and underline the importance of its correct anatomopathological classification for a more qualified physiopathologist, diagnostic and therapeutic approach. They make a historical excursion on volet's treatment and underline the complementarity of surgical and resuscitation therapies.

[Comparative study of the effectiveness of imipenem versus ceftazidime and ceftriaxone in the prevention of postoperative infections]

A comparative study was performed on the efficacy, safety and tolerability of three different antibiotics (imipenem, ceftazidime, ceftriaxone) in the prevention of postoperative infection. Evaluations were made on the basis of the results obtained in a group of 90 patients subdivided into three matched groups each of which was treated with one of the three compounds. The trend of cutaneous temperature showed differences at the limit of significance (p congruent to 0.05). Variations in leucocyte concentrations showed an analogous pattern in all patients, although there were fewer and with a shorter duration in subjects treated with imipenem. The wound healing process was improved in patients receiving prophylactic antibiotic treatment in the form of imipenem (0.01 < p < 0.05) who also showed a greater respect for therapeutic protocols (80%), a higher percentage of remission of fever and a shorter mean hospital stay (9 days). In the light of these preliminary results the authors express their favourable judgement regarding the choice of imipenem for the prophylaxis of postoperative infection; however, each of the three protocols showed a considerable prophylactic capacity as well as good tolerability and ease of use.

Pharmacokinetic studies of diosmin and diosmetin in perfused rat liver

1. The kinetics and metabolism of diosmin and diosmetin were investigated in the isolated perfused rat liver in order to assess the role of the liver. 2. Diosmetin and especially diosmin disappeared quickly from the perfusion medium. 3. Both flavonoids were rapidly metabolized and diosmetin was partly excreted in bile as the glucuronide and sulphate and diosmin was partly excreted in bile as such and as the glucuronide conjugate. 4. Diosmin and diosmetin did not appear to affect various parameters of liver function.

[Surgical treatment of non-toxic multinodular goitre. Retrospective evaluation of a personal case series]

The authors base their study on a retrospective evaluation of a personal series of patients and on a review of the literature on this topic. They focus their attention on surgical problems relating to the type of treatment of non-toxic multinodular goitre. On the basis of the data obtained, they underline that in this pathology total thyroidectomy is the most appropriate form of surgery and does not entail a higher morbidity in relation to more conservative resection.

A new rheometer with special features designed for bronchial mucus analysis in clinical practice

Changes in production and in physico-chemical properties of bronchial mucus is a common denominator of many pulmonary diseases. A rheometer with innovative features aimed at bronchial mucus routine investigation in clinical practice at the bedside of the patient has been designed. Searle-type configuration with a coaxial cylinder sensor system and the Mooney-Ewart geometry has been adopted. Another new feature is that bob and cup are disposable. Dynamic viscoelasticity is calculated through a microprocessor with specific software and by means of a magnetic torque--motor electronically driven by the microprocessor. The self-zeroing procedure and the autorange greatly simplify the measuring-cycle which is driven by only one switch. Data (eta and G') are automatically printed on paper. The whole measuring-cycle at the bedside of the patient takes 3-5 min, so that in 1h about 12 samples can be investigated.