Risk factors and stroke subtypes: results of five consecutive years of the Perugia Stroke Registry

To understand the etiopathogenetic mechanisms of stroke and to target prevention, we need to know how risk factors differ among etiological subtypes. Our aims were to determine the different profile of risk factors for ischemic and hemorrhagic stroke subtypes in our cohort from the Perugia Hospital-Based Stroke Registry. We analyzed the characteristics and the different risk factors of 2,395 first-ever consecutive stroke patients admitted to the Perugia Hospitals in the period between January 1, 1998 and December 31, 2002. The prevalence of cerebrovascular risk factors in each stroke subtype was analyzed independently and compared with other subtypes of stroke pooled together by means of univariate analysis and logistic regression models. Hypertension occurred in 61% of patients; familial history of stroke in 41.6%; vascular disease in 27.2%; embolic heart disease in 22.3%; cigarette smoking in 21.6%. Different potentially modifiable risk factors profiles were identified for each ischemic subtype of stroke, while in hemorrhagic lobar stroke subtypes, only male gender was an independent risk factor.     

Safety and effectiveness of photoselective vaporization of the prostate (PVP) in patients on ongoing oral anticoagulation

OBJECTIVES: Ongoing oral anticoagulation (OA) contraindicates transurethral electroresection of the prostate. We evaluated the safety and effectiveness of photoselective vaporization of the prostate (PVP) in patients on ongoing OA with coumarin derivatives, aspirin, or clopidogrel, complaining of symptomatic benign prostatic hyperplasia (BPH). METHODS: We evaluated perioperative parameters, functional outcome, and adverse events up to 24 mo postoperatively of patients on OA, and compared results with 92 men at normal risk without anticoagulant therapy undergoing PVP for the same indication (control). RESULTS: Within 40 mo, 116 men on OA were included, with 31% (n=36) receiving coumarin derivatives; 61% (n=71), aspirin; and 8% (n=9), clopidogrel. Mean prostate volume (62+/-34ml vs. 57+/-25ml; p=0.289) and mean operation time (67+/-28min vs 63+/-29min; p=0.313) were comparable with control. We observed no bleeding complications necessitating blood transfusions. Average postoperative decrease of haemoglobin was 8.6% for patients on OA versus 8.8% for control. At 3, 6, 12, and 24 mo postoperatively, improvement of the International Prostate Symptom Score ranged from 60-70%; postvoid residual volume, 80-88%; and average maximum urinary flow rate, 116-140%, respectively. Postoperative complications were low and comparable with control. CONCLUSIONS: PVP is characterized by excellent haemostatic properties and very low intraoperative complication rate even in patients on OA. On the basis of our perioperative results, we recommend PVP as first-line procedure for patients with symptomatic BPH at high risk of bleeding.     

The IGF-I axis in thyroid carcinoma

Insulin like-growth factor I (IGF-I) has been involved in the pathogenesis of a variety of human neoplasia due to the mitogenic and anti-apoptotic properties of its cognate receptor. In human thyroid carcinomas, we have previously documented an increased immunoreactivity of both IGF-I and the IGF-I receptor (IGF-I R) associated with up regulation of IGF-I mRNA . Immunoreactivity of IGF-I and cognate receptor positively correlated with tumor diameter and wide intrathyroidal extension but not with patient's gender and age or with the stage of the tumors and the occurrence of limph node metastases. Most experimental studies indicate that the effects of IGF-I on target cells are regulated in a complex fashion and depend on the simultaneous occurrence of IGF-IR and the binding proteins.     

Results from the ARTEMIS DISK Global Antifungal Surveillance Study, 1997 to 2007: a 10.5-Year Analysis of Susceptibilities of Candida Species to Fluconazole and Voriconazole as Determined by CLSI Standardized Disk Diffusion

Fluconazole in vitro susceptibility test results for 256,882 isolates of Candida spp. were collected from 142 sites in 41 countries from June 1997 to December 2007. Data were collected for 197,619 isolates tested with voriconazole from 2001 to 2007. A total of 31 different species of Candida were isolated. Increased rates of isolation of the common non-albicans species C. glabrata (10.2% to 11.7%), C. tropicalis (5.4% to 8.0%), and C. parapsilosis (4.8% to 5.6%) were noted when the time periods 1997 to 2000 and 2005 to 2007 were compared. Investigators tested clinical isolates of Candida spp. by the CLSI M44-A disk diffusion method. Overall, 90.2% of Candida isolates tested were susceptible (S) to fluconazole; however, 13 of 31 species identified exhibited decreased susceptibility (<75% S), similar to that seen with the resistant (R) species C. glabrata and C. krusei. Among 197,619 isolates of Candida spp. tested against voriconazole, 95.0% were S and 3% were R. About 30% of fluconazole-R isolates of C. albicans, C. glabrata, C. tropicalis, C. rugosa, C. lipolytica, C. pelliculosa, C. apicola, C. haemulonii, C. humicola, C. lambica, and C. ciferrii remained S to voriconazole. An increase in fluconazole resistance over time was seen with C. parapsilosis, C. guilliermondii, C. lusitaniae, C. sake, and C. pelliculosa. Among the emerging fluconazole-R species were C. guilliermondii (11.4% R), C. inconspicua (53.2% R), C. rugosa (41.8% R), and C. norvegensis (40.7% R). The rates of isolation of C. rugosa, C. inconspicua, and C. norvegensis increased by 5- to 10-fold over the 10.5-year study period. C. guilliermondii and C. rugosa were most prominent in Latin America, whereas C. inconspicua and C. norvegensis were most common in Eastern European countries. This survey identifies several less-common species of Candida with decreased susceptibility to azoles. These organisms may pose a future threat to optimal antifungal therapy and underscore the importance of prompt and accurate species identification and antifungal susceptibility testing.Antifungal susceptibility testing is playing an increasing role as a means to track the development of antifungal resistance in epidemiological studies (2, 10, 12, 17, 27, 45-47, 55, 63). One of the important by-products of the standardization of antifungal susceptibility testing has been the ability to conduct surveillance for antifungal resistance using uniform methods (44). Meaningful large-scale surveys of antifungal susceptibility and resistance conducted over time would not be possible without a standardized broth microdilution (BMD) or disk diffusion (DD) method for performing the in vitro studies (12, 38, 60). Global surveillance programs such as the ARTEMIS antifungal surveillance program for DD testing (49, 57, 60) and MIC testing (12, 13), the European Confederation of Medical Mycology (ECMM) survey of candidemia (68), and the SENTRY Antifungal Surveillance Program (36-38) promote the use of standardized DD and BMD methods and provide useful and consistent antifungal susceptibility data from a broad international network of hospitals and laboratories.The ARTEMIS global antifungal surveillance program is among the most comprehensive and long-running fungal surveillance programs (12, 45, 57, 58, 60). The ARTEMIS program was designed to address many of the potential limitations of resistance surveillance studies (26): (i) it is both longitudinal (1997 to present) and global (142 participating sites in 41 countries) in scope, (ii) it employs standardized DD (7) and BMD (9) antifungal susceptibility test methods, (iii) both internal quality control (QC) performed in each participating laboratory and external quality assurance measures are used to validate test results (48, 50, 61), (iv) results are recorded electronically using the Biomic image analysis plate reader (Giles Scientific, Santa Barbara, CA) and are stored in a central database, and (v) both Candida and non-Candida (60) yeast isolates obtained from consecutive clinical samples from all body sites are tested locally, thus avoiding misleading results based on biased selective testing. Thus, the ARTEMIS program generates massive amounts of data that have been externally validated and that can be used to identify temporal and geographic trends in the species distribution of Candida and other opportunistic yeasts, as well as the resistance profiles of these organisms to fluconazole and voriconazole as determined by standardized Clinical and Laboratory Standards Institute (CLSI) DD methods.In the present study, we expand the ARTEMIS database to include the time period from June 1997 through December 2007 and a total of 256,882 isolates of Candida from 142 study sites in 41 countries. We provide comparative susceptibility data for fluconazole and voriconazole for more than 190,000 isolates collected from 2001 to 2007 and include an analysis of resistance rates by year, geographic location, hospital location, and specimen type for selected species.     

A double buccal fat pad flap for middle palate defect closure--a new technique for palate closure

In this article a new method of closing palatal defects by means of buccal fat pad flaps is reported. A double buccal fat pad flap in association with Le Fort I osteotomy approach was adopted to remove tumours of the palate and nasal fossae. The technique is described in a case of adenocarcinoma arising from the nasal septum and its indications and advantages are discussed.     

Evaluation and improvement of the efficiency of the Seidel humeral nail by numerical-experimental analysis of the bone-implant contact

Seidel intramedullary humeral nail is locked distally by a spreading device and proximally by transverse cross locking screws. The main problems found in its use are: the loosening of the distal anchorage, even after X-ray verification of the correct expansion of the device; the formation of distal fractures, occurring even 1 month after the operation; the system's low stability. The problems noted can be ascribed to the behaviour of the spreading device for distal fixing. The present study, therefore, was directed at analysing the contact between the spreading mechanism and the medullary canal in relation to the geometric parameters of the mechanism itself. The main objective was to define the correct regulation of the expansion in the operating theatre, and to delimit the more appropriate conditions of use, allowing the surgeon to evaluate the suitability of this particular device for the type of fracture under treatment. Numerical and experimental techniques were used to perform an analysis of the implant behaviour. This investigation, referred to immediate post-operative condition, allowed to evaluate the stability to traction of the system, to define the typology and properties of the bone-implant contact zone and to quantify the stresses produced, all as a function of the parameter on which the surgeon intervenes in the operating theatre: the number of turns used to tighten the spreading screw. The results obtained confirm and explain the disadvantages associated with the distal expansion system: the bone-implant contact turns out to be inefficient, as revealed by the distribution of the pressure on the inner wall of the medullary canal. On the basis of the results, it is possible to define the optimal conditions of use of the nail, and to formulate a simple solution for the improvement of its performance.