Association between End-Stage Renal Disease and Major Adverse Limb Events after Peripheral Vascular Intervention

PURPOSE

To examine the effect of end-stage renal disease (ESRD) on the likelihood of major adverse limb events (MALEs) in patients with Rutherford Category 4-6 critical limb ischemia (CLI) who underwent percutaneous vascular intervention (PVI).

MATERIALS AND METHODS

Two contemporaneous cohorts of patients who underwent PVI for symptomatic CLI from 2012 to 2022, differing in ESRD status, were matched using propensity score methods. This database identified 628 patients who underwent 1,297 lower extremity revascularization procedures; propensity score matching yielded 147 patients (180 limbs, 90 limbs in each group). Kaplan-Meier and Cox proportional hazard analyses were used to assess the effect of ESRD status on MALEs, stratified into major amputation (further stratified into above-knee amputation and below-knee amputation [BKA]) and reintervention (PVI or bypass).

RESULTS

After PVI, 31.3% of patients in the matched cohorts experienced a MALE (45.7% ESRD vs 18.2% non-ESRD), and 15.6% experienced a major amputation (27.1% ESRD vs 5.2% non-ESRD). Cox proportional hazards analysis revealed that ESRD was an independent predictor of MALE (hazard ratio [HR], 3.15; 95% CI, 1.58-6.29; P = .001), major amputation (HR, 7.00; 95% CI, 2.06-23.79; P = .002), and BKA (HR, 7.56; 95% CI, 1.71-33.50; P = .008).

CONCLUSIONS

ESRD is strongly predictive of MALE and major amputation risk, specifically BKA, in patients undergoing PVI for Rutherford Category 4-6 CLI. These patients warrant closer follow-up, and new methods may become necessary to predict and further reduce their amputation risk.

Identification of the novel HLA-DPA1*01:130 allele by next-generation sequencing

The novel HLA-DPA1*01:130 allele differs from HLA-DPA1*01:03:01:03 by one nucleotide substitution in Exon 3.

The new HLA-DQB1*05:304 allele identified in an Italian patient

DQB1*05:304 allele was identical to DQB1*05:02:01 except for a single nucleotide substitution.

Identification of the novel allele, HLA-A*02:653, in an Italian patient

HLA-A*02:653 differs from A*02:01:01:01 by a C to T substitution in exon 2.

Characterization of the novel HLA-C*02:106 allele in a hematopoietic stem cell volunteer donor

HLA-C*02:106 allele differs from C*02:02:02:01 by a C to T substitution in exon 4.

Prospective assessment of peripheral neuropathy in Duodopa-treated parkinsonian patients

BACKGROUND

Although peripheral neuropathies (PN) have been described in patients with Parkinson's disease (PD) treated with oral dopaminergic therapies, anecdotal reports of subacute severe PN have been reported during treatment with enteral levodopa/carbidopa infusion (Duodopa).

AIM OF THE STUDY

We prospectively assessed clinical and electrophysiological data of 15 consecutive patients with PD treated with Duodopa for a mean follow-up of 9 months.

METHODS

Nerve conduction studies and a clinical evaluation with a standardized battery of peripheral neuropathy scales were performed at baseline and after a mean follow-up of 9 months.

RESULTS

At baseline, mild signs of PN were observed in three subjects, and vitamin B12 serum levels were found to correlate with the amplitude of sural sensory action potentials. Follow-up data were available for 10/15 subjects: one patient developed a subacute sensory-motor PN and three subjects with pre-existing PN showed a moderate worsening of electrophysiological and clinical features. Subclinical electrophysiological alterations of peripheral nerves were observed in two subjects. No significant changes were observed in vitamin B12, folate, homocysteine and methylmalonic acid levels.

CONCLUSIONS

In this consecutive series of patients treated with Duodopa, we observed one subacute sensory-motor PN and few length-dependent alterations of peripheral nerves, similar to those described during oral levodopa treatment.

Genotypes and haplotypes in the 3' untranslated region of the HLA-G gene and their association with clinical outcome of hematopoietic stem cell transplantation for beta-thalassemia

Polymorphisms in the 3' untranslated region (3'UTR) of HLA-G, an important player in immunological tolerance, could be involved in post-transcriptional expression control, and their association with different clinical immune-related conditions including autoimmunity and transplantation is of mounting interest. Most studies have focused on a 14 base pair (bp) insertion/deletion (ins/del), while additional single-nucleotide polymorphisms (SNPs) in the HLA-G 3'UTR have been described but not extensively investigated for their clinical relevance. Here we have comparatively studied the association between 3'UTR haplotypes of HLA-G, or the 14 bp ins/del, with clinical outcome of HLA-identical sibling hematopoietic stem cell transplantation (HSCT) in 147 Middle Eastern beta-thalassemia patients. Sequence based typing of 3'UTR HLA-G polymorphisms in the patients and in 102 healthy Italian blood donors showed strong linkage disequilibrium between the 14 bp ins/del and five 3'UTR SNPs, which together could be arranged into eight distinct haplotypes based on expectation-maximization studies, with four predominant haplotypes (UTRs1-4). After HSCT, we found a moderate though not significant association between the presence of UTR-2 in double dose and protection from acute graft versus host disease (hazard ratio (HR) 0.45, 95% confidence intervals (CI): 0.14-1.45; P = 0.18), an effect that was also seen when the corresponding 14 bp ins/ins genotype was considered alone (HR 0.42, 95% CI: 0.16-1.06; P = 0.07). No association was found with rejection or survival. Taken together, our data show that there is no apparent added value of considering entire 3'UTR HLA-G haplotypes for risk prediction after allogeneic HSCT for beta-thalassemia.

Characterization of the novel HLA-C*07:195 allele in an Italian hematopoietic stem cell volunteer donor, detected by sequence-based typing

The new allele shows one nucleotide change from C*07:02:01:01 at 351 nt from C to A, resulting in an amino acid change at codon 93 of exon 3 from H to Q.

Fractional CO2 laser: a new therapeutic system forphotobiomodulation of skin remodeling and cytokineproduction in the course of tissue reparation

Eighteen female patients with the signs of photoageing underwent skin rejuvenation using a fractional CO2 laser (SmartXide DOT, DEKA M.E.L.A., Florence, Italy) with varying energy density (2.07, 2.77 and 4.15 J/cm2). Clinical efficacy of the said laser irradiation parameters was assessed in all of the subjects, and the skin cytokine profile was studied by using the immunohistochemistry technique based on skin tissue samples taken prior to the treatment, right after the treatment and in 3 and 30 days. There were significant improvements in the wrinkle and skin texture condition, and hyperpigmentation was reduced as a result of the treatment, which proves the efficacy of using the fractional CO2 laser for the skin photorejuvenation. The technique ensures good clinical results and is distinguished by a short rehabilitation period and excellent safety profile. In the course of the immunohistochemistry, a relation between the skin cytokine production, reepithelization and laser irradiation density was established.

Identification of the new HLA-A*31:48 allele in an Italian patient

Human leukocyte antigen (HLA) class I sequence-based typing (SBT) for hematopoietic unrelated donor searching in an Italian Caucasian patient showed the presence of a novel HLA-A allele defined as A*31:48. HLA-A*31:48 has one nucleotide change from A*31:01:02 at nt 727 from C to T, resulting in an amino acid change at codon 219 of exon 4 from Arg to Trp.

The evolving paradigm of revascularization for wound healing: which intervention for which wound?

Chronic limb ischemia (CLI) presents a therapeutic challenge. A collaborative multidisciplinary model utilizes the collective skills of the vascular surgeon, podiatrist, and plastic surgeon to achieve optimal outcomes. As treatment paradigms continue to evolve toward minimally invasive approaches, a thoughtful comparison of the available options is essential for wound care specialists. Minimally invasive, catheter-based options offer less morbidity with reduced patency compared to traditional, open bypass. Individualized selection of the most appropriate revascularization option should be made after careful consideration of the wound severity, anatomic location of occlusive disease and patient comorbidities.

Infliximab efficacy in nail psoriasis. A retrospective study in 48 patients

BACKGROUND

Nail psoriasis occurs in up to half of psoriatic patients and can lead to significant physical impairment and pain. To date, patients and clinicians are actually dissatisfied by current therapeutic approaches.

OBJECTIVE

Our main aim is to evaluate Infliximab efficacy in nail psoriasis.

METHODS

We performed an open-label and uncontrolled retrospective study considering all psoriatic patients presenting recalcitrant nail involvement and receiving Infliximab in our Department during the period between January 2008 and March 2009. We calculated nail psoriasis severity index (NAPSI) score at 0, 14, 22 and 38 weeks and percentage of patients achieving NAPSI-50,-75,-90 at 14, 22 and 38 weeks.

RESULTS

We observed a rapid nail improvement in most cases after 22 weeks of Infliximab therapy, but a complete nail clearing was reached in only five (10.4%) patients. We don't have a follow-up longer than 38 weeks to assess long-term efficacy of this treatment in nail psoriasis.

CONCLUSIONS

Infliximab, in our experience, has proved to be effective in reducing nail lesions and, in some cases, even clearing them. Our data demonstrate long-term efficacy of this biological agent in nail psoriasis.

Comparison of body weight and clinical-parameter changes following the treatment of plaque psoriasis with biological therapies

OBJECTIVE

This study is a retrospective analysis evaluating the presence of comorbidities, as well as the changes in body weight and clinical parameters in psoriasis patients following treatment with anti-TNF-alpha agents and with the anti-CD11a agent efalizumab.

RESEARCH DESIGN AND METHODS

A total of 268 patients affected by chronic plaque psoriasis, and receiving systemic monotherapy with efalizumab, etanercept, or infliximab, were included. The follow-up period was 2, 4 and 6 months.

MAIN OUTCOME MEASURES

Clinical data including age, gender, weight, type and severity of psoriasis and age of onset were collected. Severity of psoriasis was assessed according to the Psoriasis Area and Severity Index (PASI) and body surface area (BSA).

RESULTS

Hypertension and hyperlipidaemia were the comorbidities present with the higher frequency in our group of patients. PASI score was reduced by between 43.8 and 52% in all treatment groups. No relevant blood chemistry changes were observed following therapy, with the exception of a decrease in neutrophils and an increase in leukocyte numbers reported in the efalizumab and etanercept groups. Interestingly, after 6 months of therapy, the weight of the patients remained unvaried in those taking efalizumab (-0.05%) but was moderately increased in the etanercept (+0.72%) and in infliximab groups (+0.3%).

CONCLUSIONS

The present study shows that there were clinically significant differences in weight gain effects between efalizumab and anti-TNF-alpha agents in psoriatic patients. The changes in body weight gain increase did not reach statistical significance, although there is a trend towards this, and this may be due to the relatively small number of patient studied.

Rituximab in dermatological diseases

Rituximab is a chimeric monoclonal antibody currently used for the treatment of non-Hodgkin lymphoma that targets the transmembrane protein CD20 of B cells. Recently it has also been used for the treatment of several autoimmune diseases, including skin disorders such as Paraneoplastic Pemphigus, Pemphigus Vulgaris, Pemphigus Foliaceus, Mucosal pemphigoid, Bullous pemphigoid, Epidermolysis bullosa acquisita, Systemic lupus erythematous and Dermatomyositis. Frequently all these conditions required intolerably high doses of corticosteroids and additional immunosoppressants, which can increase the risk of severe adverse events. Therefore, new therapeutic options are needed for such patients. The intent of the authors in this review is to provide the reader with a panoramic view of the studies reported to date.

Identification of a novel HLA-B*07 allele in an Iranian family: B*0769

New allele B*0769 showed one nucleotide difference with B*0732 at codon 272 (TTC-->TGC).

Use of a small bilateral external fixator for ankle fusion

A variety of methods are available for surgeons to use in an effort to achieve fusion ankle arthrodesis. Among these, external fixation devices have proven to be effective. In this article, we describe the use of a small external fixation frame that is affixed to the medial and lateral aspects of transfixation pins, and used to compress the arthrodesis interface.

Radiation therapy in urinary cancer: state of the art and perspective

Invasive urinary tumours are relatively rare, and their treatment may cause important changes in urinary, sexual and social functions. A systematic review of external radiation therapy studies in urinary cancers was performed. This synthesis of the literature is based on data from meta-analyses, randomised and prospective trials and retrospective studies. There are few controlled clinical trials using adjuvant or radical radiotherapy with or without chemotherapy in cancer of the kidney, ureter and urethra. There are several reports on multimodality treatment in invasive bladder cancer: intravesical surgery and neoadjuvant chemotherapy to radiotherapy or concomitant radiochemotherapy with organ preservation. The conclusions reached for renal cancer are controversial, and data on cancers of the urethra and ureter are few and inconclusive. Sufficient data now exist in the literature to demonstrate that conservative management with organ preservation is a valuable alternative to radical cystectomy, the traditional gold standard, in invasive bladder cancer.

Diagnostic and prognostic value of erythrocyte sedimentation rate in contiguous osteomyelitis of the foot and ankle

This is a 95-patient prospective study evaluating diagnostic and prognostic efficacy of erythrocyte sedimentation rate (ESR) for contiguous pedal osteomyelitis. ESRs, bone and soft tissue microbiologic cultures, and pathologic examination of the suspected bone involved were obtained. ESRs were drawn within 48 hours before surgically obtaining the bone specimen. A subset of 16 patients, determined by pathology to have osteomyelitis, had intermittent erythrocyte sedimentation rates drawn for at least 56 days to determine trends based on the patient being healed or not healed. Pathology resulted in diagnosis of osteomyelitis in 66 patients. A statistical significance of ESR was found when comparing those with and without osteomyelitis. Seventy-four had a secondary diagnosis of diabetes mellitus. No statistical significance was found in regards to ESR in absence or presence of osteomyelitis when considering the variable of diabetes mellitus. Negative and positive predictive values were calculated at different ESR levels to determine the diagnostic value of ESR. Eight patients with osteomyelitis, determined to be healed over 56 days of treatment, showed a decline of ESRs. No trend of declination was seen in 8 patients determined not healed after 56 days. A statistically significant difference in average ESR between patients with osteomyelitis who had no bacterial growth of bone and those with one or more organisms growing in bone was found. ESR as a diagnostic tool for contiguous pedal osteomyelitis has been found in this study to be both valuable and significant. The comorbidity of diabetes mellitus did not significantly change the ESR values in patients with or without osteomyelitis. ESR as a modality to document the success of treatment for those with osteomyelitis proved valuable in the subset of patients who were followed up.

Role of external radiation therapy in urinary cancers

Invasive urinary tumors are relatively rare and their treatment may cause important changes in urinary, sexual, and social functions. A systematic review of external radiation therapy studies in urinary cancers has been carried out. This synthesis of the literature is based on data from meta-analysis, randomized and prospective trials, and retrospective studies. There are few controlled clinical trials using adjuvant or radical radiotherapy +/- chemotherapy in kidney, ureter, and urethra cancers; there are several reports of muscle-invasive bladder cancer using multimodality treatment: intravesical surgery and neo-adjuvant chemotherapy to radiotherapy or concomitant radiochemotherapy with organ preservation. The conclusions reached for renal cancer are controversial; urethra and ureter cancers data are few and inconclusive; sufficient data now exist in literature to demonstrate that conservative management with organ preservation, for muscle-invasive bladder cancer, is a valid alternative to radical cystectomy, viewed as the gold standard.

In vivo effects of recombinant-interferon-beta1b treatment on polymorphonuclear cell and monocyte functions and on T-cell-mediated antibacterial activity in patients with relapsing-remitting multiple sclerosis

Treatment with Interferon (IFN)-beta has been proposed as a therapeutic approach in multiple sclerosis (MS) patients, mostly in view of its immunomodulating actions. At the same time, evidence has been provided that MS patients exhibit polymorphonuclear cell (PMN) deficits, which can explain the increased susceptibility to infections in these subjects. Here, in 28 patients with relapsing-remitting (RR) MS under treatment with recombinant (r)-IFN-beta PMN polarization and PMN and monocyte (MO) phagocytosis and killing, as well as T-cell mediated antibacterial activity, were evaluated before treatment and over a period of nine months of treatment. Our results point out an enhanced rate of polarization (both "spontaneous" or N-formyl-methionyl-leucyl-phenylalanine-induced) in MS patients. After r-IFN-beta1b treatment the polarization rate was further increased. On the contrary, PMN and MO phagocytosis and killing were depressed in comparison to controls and values were further reduced by r-IFN-beta1b treatment. In patients T-cell mediated antibacterial activity was decreased at T0 and dramatically dropped in the course of r-IFN-beta1b therapy.

[Radiotherapy alone in endometrial neoplasms. The authors' own experience]

INTRODUCTION

Adenocarcinoma of the endometrium is the most common invasive genital malignancy in women and the majority of the cases are in stage I (80-85%) at the time of diagnosis. Total abdominal hysterectomy with bilateral salpingo-oophorectomy is the treatment of choice for most patients with uterine carcinoma. However, a number of women with endometrial cancer cannot undergo surgical treatment because of poor medical conditions. In these patients, who cannot tolerate surgery, radiation therapy is the only effective alternative. It is performed either as external treatment plus intracavitary brachytherapy or as brachytherapy alone. This retrospective study reports our data on survival, complications and local control in a consecutive series of patients treated with curative radiotherapy.

MATERIAL AND METHODS

From January, 1985, to December 1995, at the Radiotherapy Department of "Casa Sollievo della Sofferenza" Hospital in San Giovanni Rotondo (Foggia, Italy), 60 patients were treated with combined external beam radiation therapy (ERT) and high-dose-rate intracavitary brachytherapy (HDR-BRT) or with high dose rate intracavitary brachytherapy alone. The average age of patients was 69 years (range 50-90). FIGO stage distribution was: 41 patients in stage I, 11 in stage II and 8 in stage III. The ERT was given by means of 6-8 MV linear accelerator, with conventional technique (with two opposed AP-PA pelvic fields in 15 patients, with the four fields-box technique in 41 patients) and a daily fraction to a total dose of 45-50 Gy. HDR-BRT was delivered by means of an HDR remote afterloading unit, containing a linear source of 192-Iridium (370 Gbq). The dose was specified to Point A in 32 patients and to uterine outline in 26. 2-3 intracavitary insertions (mean dose 6-8 Gy per fraction) were performed with weekly intervals.

RESULTS

At the time of the analysis, all the patients were available for follow-up. Median follow-up was 25 months. 60% of patients were alive and well with no evidence of disease; 3.3% were alive with disease; 20% had died of this and 16.7% of other diseases. Five-year actuarial specific survival, obtained with the Kaplan and Meier method, was 77.7% in stage I, 90% in stage II, and 75% in stage III. Local relapses were observed in 14 patients. Complications (grade 2-3) scored with the French-Italian Glossary, were gastrointestinal in 10% of cases and genital in 6.6%.

CONCLUSIONS

Radical radiotherapy achieved acceptable specific survival, local control and complications rates in patients with medically or surgically inoperable uterine carcinomas. Complications and survival rates, in our experience, are consistent with the literature data. The treatment is comfortable for the patients, because there is no need for long immobilization and it can frequently be performed on an outpatient basis. Besides, the completely standardized procedure was carried out easily with remote control allowing maximal radiation protection.

[Preliminary results of preoperative radiotherapy schedule in the treatment of rectal tumors]

From March, 1988, to October, 1993, fifty-six consecutive patients with rectal adenocarcinoma in clinical stage T3NxM0, underwent preoperative radiation therapy at the "Casa Sollievo della Sofferenza" Hospital of San Giovanni Rotondo (Italy). The patients were treated with the four-field technique with 6 to 8 MV X photons on the pelvis. The dose given was 36 Gy in 12 fractions of 3 Gy each. Surgery was performed 2-3 weeks after completion of radiotherapy. Six patients were excluded from this study for metastatic involvement of the liver found at surgery. 48% of 50 assessable patients underwent abdominoperineal resection and 52% anterior resection. 68% of patients were in pathologic stage pT0-3 pN0 and 32% in pT0-3 pN1-2. Metastatic nodes were found in 16 patients (32%) (11 pN1 and 5 pN2). 4% of patients achieved a complete response. The follow-up ranged 24 to 91 months (mean: 46 months). None of the 50 patients died during the postoperative period and the specific morbidity was 26%. Side-effects, requiring surgery, were found in 4% of patients (1 retroperitoneal fibrosis and 1 small bowel occlusion). The incidence of local relapse was 8%. The overall survival at 5 years, in all stages, calculated with the Kaplan and Meyer method, was 76.5%. The disease-free survival rate was 81.1% in all stages: 94.1% in pT0-3 pN0 patients and 54.1% in pT0-3 pN1-2 patients. The disease-free survival rate related to nodal involvement was 72.7% in pN1 patients and 20% in pN2 patients. Our experience confirms the effectiveness of preoperative radiation therapy to improve local control in rectal cancer patients. In the future, it will be useful to assess the impact on prognosis of the schedules using chemotherapy, different fractionation of radiotherapy, delayed surgery and biological predictors of response to irradiation.

[Idiopathic scoliosis in a student population]

The etiology of idiopathic thoracic scoliosis is a relevant problem in the fields of scholastic medicine and orthopaedics. This disease affects a population of pre-adolescent between ten and fifteen years of age. This study is based on our observations within a population of junior high school students in a suburban town of central Italy. Our data are based on clinical examinations, and the analysis of biophysical and environmental factors evidentiate the genetic and hereditary factors that are of prime importance in the pathogenesis of thoracic idiopathic scoliosis. It's our goal, to inform the scholastic doctor, the orthopaedist, the pediatrician and the internist on the main clinical and evolutionary aspects of thoracic idiopathic scoliosis and other related vertebral pathology. We therefore believe, that a good diagnosis should be based on a thorough genetic and clinical examination; not to mention an examination of vertebral bone morphology in order to exclude other forms of thoracic scoliosis.