Recurrent varicose veins due to neovascularisation: can they be prevented?

The authors analyse the problems of recurrent varicose veins on the basis of their own experience. The 5-year incidence of recurrent varicose veins ranges from 25 to 40% after internal saphenectomy. The recurrences should be classified in relation to the site and pathogenetic mechanism. The authors assess the effectiveness of a prevention method for sapheno-femoral stump recurrences. The study population consisted of 80 patients undergoing internal saphenectomy. In 34 (Group A) a traditional safenectomy was performed with short stripping, while in 46 (Group B) closure of the ostium with a flap of pectineal fascia was performed in order to prevent recurrences caused by neovascularisation. In Group A the recurrence rate was 27.1% as against 14.8% in Group B. Recurrences originating from the sapheno-femoral stump are mainly caused not only by an inadequate echo-colordoppler preoperative diagnosis and an inadequate or insufficient crossectomy, but also by neovascularisation. The pectineal flap method in our experience is a very simple, effective and complication-free technique to appreciably reduce recurrent varicose veins originating from the sapheno-femoral stump.     

Iron indices and vitamin D receptor polymorphisms in hemodialysis patients

Cardiovascular disease caused by accelerated atherosclerosis is the major determinant of morbidity and mortality in chronic kidney disease patients. Vitamin D and its analogs provide survival benefit for hemodialysis (HD) patients. Vitamin D exerts its effects through the vitamin D receptor (VDR) that is coded for by a gene showing several polymorphisms that, in turn, are associated with a variety of diseases and differential responses to vitamin D. In this study, we evaluated the association between 4 VDR polymorphisms (ie, those identified by the restriction enzymes BsmI, ApaI, TaqI, and FokI) and iron indices (serum iron, transferrin, transferrin saturation, and ferritin) in 88 hemodialysis patients routinely treated with vitamin D. The absence or presence of the BsmI, ApaI, TaqI, and FokI restriction sites were denominated B and b, A and a, T and t, F and f, respectively. Our results show that in HD patients with transferrin saturation <20%, the F allele was more frequent than in HD patients with transferrin saturation >20% (P = .03). This relationship may provide a link between VDR alleles and iron and nutritional markers, which are highly predictive variables of cardiovascular morbidity and mortality in hemodialysis patients.     

The CT-arthrography in the antero-inferior glenoid labral lesion: Pictorial presentation and diagnostic value

Objective:

To present the Computed Tomography (CT)-Arthrography appearance of the most common types of anterior labral lesion and to assess the diagnostic value of this technique in the detection and classification of the antero-inferior labral tears in glenohumeral joint instability.

Materials and Methods:

The pre-operative CT-Arthrography records of 43 patients, who underwent surgery for anterior shoulder instability, were retrospectively evaluated independently by two radiologists. The data were compared with arthroscopic results and the diagnostic accuracy of CT-Arthrography was calculated to detect the labral lesion and the agreement between the CT-Arthrography lesions classification and the arthroscopy classification.

Results:

The CT-Arthrography sensitivity, specificity and accuracy were: 92% / 89% (reader 1/reader 2), 86% / 86% and 91% / 88% respectively. The CT-Arthrography classification was correct in 86% of cases.

Conclusions:

CT-Arthrography appears to be an accurate means for identification and classification of the anterior labral tears and, identifying the labral degeneration, this technique can be very helpful in the selection of patient for arthroscopic stabilization of the shoulder.     

In vitro mitogen-stimulated T-cell from hepatitis C virus-positive liver transplantation candidates, increases T-cell activation markers and T-cell proliferation

The incidence of acute rejection is significantly higher in hepatitis C virus (HCV) liver-transplant patients than in patients who have received a graft for other liver diseases, i.e., mainly alcoholic cirrhosis. The aim of this study was to assess T-cell function, i.e., intralymphocyte cytokine expression (IL-2 and TNF-alpha), T-cell activation [i.e., transferrin receptor (CD71) and interleukin (IL)-2 alpha-chain (CD25) expression], and T-cell proliferation using a flow-cytometry whole-blood assay in patients waiting for a liver transplantation (n=49). Our data suggest that, in mitogen-stimulated T-cells, (i) intra-lymphocyte cytokine expression is significantly higher in patients with liver disease than in healthy volunteers (n=25); (ii) the expression of T-cell activation markers is decreased in patients with liver cirrhosis compared to healthy volunteers, and (iii) the expression of T-cell activation markers and T-cell proliferation are increased in patients with HCV infection (n=15) compared to those without HCV infection (n=34), particularly compared to patients with alcoholic liver disease (n=19). Circulating CD19-positive cells count was also significantly higher in HCV-positive patients. In conclusion, in vitro, mitogen-stimulated T-cell seem to induce a higher immune response in the blood from patients waiting for a liver transplant for HCV-related liver disease than those without HCV infection, and particularly those with alcoholic liver disease.     

Extraperitoneal prosthesis repair in the surgical treatment of inguinal hernias

The authors analyse the current state of the art of the prosthetic repair of incisional hernia and the problems involved in positioning the prosthesis, comparing their own experience with the most recent literature. From January 1994 to June 2001, 50 patients were operated on for incisional hernia (28 males and 22 females); 12% had recurrent or re-recurrent incisional hernias. Defects smaller than 3 cm were repaired with a polypropylene plug; a double-layer polypropylene mesh placed in a preperitoneal position was used for defects measuring from 3 to 5 cm; in defects greater than 5 cm a double-layer mesh was placed behind the muscle layer. Fifteen patients were operated on under local anaesthesia. Only 22% required postoperative analgesia. The mean hospital stay was 3.95 days. Only 3 recurrences (6%) were recorded. On the basis of our experience it seems appropriate to repair incisional hernias when of small size, preferably under local anaesthesia, avoiding opening the hernia sac, using an extraperitoneal approach with an overlap technique that employs polypropylene.     

Emergency surgical treatment of complicated acute diverticulitis

Twenty-five percent of patients undergoing surgery for acute complicated diverticulitis represent emergencies. This condition is currently treated by colonic resection with primary anastomosis with or without colostomy, or by a Hartmann operation. We report on our experience with 52 consecutive patients with generalized peritonitis (8 cases), peri- and paracolonic abscesses (19 cases), severe pelvic abscesses (12 cases) and multiple abscesses with visceral fistulas (13 cases). All patients had emergency surgery. In 50/52 patients (96.2%) we performed a colonic resection with primary anastomosis using a mechanical stapler and in 2/52 a Hartmann operation. The overall mortality rate was 5.8%. The morbidity rate was 22% with 9 anastomotic leakages. A diverting colostomy was constructed in 16 patients and opened in only 8 patients. In 4 cases a parastomal hernia occurred after late closure and reduction of the colostomy. This data suggest that colonic resection with primary anastomosis, even without colostomy, is a safe procedure for the emergency treatment of acute complicated diverticulitis.     

Superficial parotidectomy as first choice for parotid tumours

Parotid neoplasms represent 3% of all head and neck tumours, and most are benign. Malignant tumours account for 14-25% of cases. Surgery is the treatment of choice, with options ranging from simple enucleation to radical parotidectomy. Sixteen patients presented with a history of a painless parotid lump. Diagnosis was achieved by ultrasound scan and MRI. Fifteen superficial parotidectomies and 1 nerve-sparing total parotidectomy were carried out. At histology, 10 pleomorphic adenomas, 4 Warthin's tumours, 1 lymphoepithelial cyst and 1 sebaceous adenocarcinoma were detected. In the single case of carcinoma, the 6 peri-glandular lymph nodes included in the specimen were metastasis-free. In 3 patients (20%) a transient paresis of the facial nerve was noted. The capsule appeared breached in only 1 case of pleomorphic adenoma. Four patients (26%) were diagnosed as suffering from Frey's syndrome. A salivary fistula was recorded in 2 patients (13%). During follow-up ranging from 3 to 96 months no tumour recurrence was recorded. Superficial parotidectomy seems to be the best choice of treatment for benign parotid tumours, since it allows complete excision of the tumour with sparing of the facial nerve. A radical procedure is, however, needed if malignancy is confirmed at frozen section.     

Gastrointestinal stromal tumours: a broad spectrum of clinical presentations

Gastrointestinal stromal tumours, though rare, are the most common mesenchymal neoplasms affecting the gastrointestinal tract. The most frequent sites of origin are the stomach and the small bowel, but they can occur anywhere in the gastrointestinal tract. Mesenteric and retroperitoneal forms have been described. The Authors present their personal experience with the treatment of gastrointestinal stromal tumours, with particular reference to the broad spectrum of clinical presentations and to the consequent therapeutic implications. We report on a retrospective analysis of the clinical presentations and courses, surgical management and pathological features of 27 patients with such tumours treated in our institution from 1993 to 2005. The variables analysed were the morphological and clinical characteristics of the tumours, demographic data, type of surgical treatment and postoperative course. Long-term survival was evaluated on the basis of clinical and/or telephonic follow-up in all patients. One tumour was located in the oesophagus, 14 in the gastric area, 7 in the small bowel, 2 in the colon-rectum, and 3 in the peritoneum. All patients studied received radical surgical treatment. In 7 patients surgical resection was extended to other organs. No postoperative mortality or major postoperative complications were observed. Twenty-two patients are still alive at follow-up. Three patients died as a result of neoplastic relapse and 2 of other causes. The median survival was 36 months. The actuarial 3- and 5-year survival rates were 89.7% and 67.8%, respectively. Our experience indicates that the site of origin of gastrointestinal stromal tumours with their broad spectrum of clinical presentations may influence both the therapeutic choice (neoadjuvant utilisation of imatinib mesylate) and the surgical treatment (wedge resection vs enlarged operations).     

Patients with Fabry disease on dialysis in the United States.

BACKGROUND.: Fabry disease results from an X-linked deficiency of lysosomal alpha-galactosidase A and is a rare cause of end-stage renal disease. Little is known about the characteristics of patients with Fabry disease that initiate dialysis in the United States, although data from Europe suggests these individuals have a poor survival. METHODS.: Using the United States Renal Disease System database, we first studied in detail 42 Fabry patients who initiated dialysis between April 1995 (following the introduction of the new detailed HCFA 2728 form) and July 1998. To examine crude survival in a larger cohort, 95 Fabry patients were studied who initiated dialysis between 1985 and 1993, similar to the European Registry. Diabetic and non-diabetic controls matched by age, gender, race, year of dialysis initiation, and initial dialysis modality were examined for comparison. RESULTS.: During the years 1995 to 1998, the mean age of Fabry patients that initiated dialysis was 42 years, 83% were Caucasian, and 10% were African American. Despite the X-linked inheritance of Fabry disease, 12% of Fabry patients on dialysis were female. At initiation of dialysis mean serum albumin and creatinine were significantly higher and mean body mass index was significantly lower among Fabry patients, but mean glomerular filtration rate was similar to controls. Fabry patients tended to have a lower three-year survival compared to non-diabetic controls, but the results were not significantly different. In a larger cohort of Fabry patients who initiated dialysis between 1985 and 1993, the three-year survival of Fabry patients was significantly lower than non-diabetic controls: 63% (95% CI, 50 to 75%) versus 74% (95% CI, 67 to 80%; P=0.03). CONCLUSION.: End-stage renal disease is associated with significant morbidity and mortality among patients with Fabry disease. Recent evidence that progression of Fabry disease may be attenuated by enzyme replacement therapy necessitates increased awareness of Fabry disease and its comorbidities.     

Eosinophilic angiocentric fibrosis of the sinonasal tract: report on the clinicopathologic features of a case and review of the literature

BACKGROUND: Eosinophilic angiocentric fibrosis (EAF) is a rare fibroinflammatory lesion of the sinonasal tract that occurs mainly in young to middle-aged female patients. Only two previous cases affecting male patients have been reported, and its etiopathogenesis remains unknown. The authors report on the third case of the entity in a male patient and review the 12 previously reported cases. CASE REPORT: A 52-year-old male patient was initially seen with a 15 years history of allergic rhinitis, progressive nasal obstruction, and left-sided hearing loss. All laboratory tests were unremarkable, except the nasal discharge eosinophil count that showed a conspicuous eosinophilia. The video-assisted-nasofibroscopic examination and CT scans disclosed a thickened deviated nasal septum with a subjacent infiltrative lesion. The histologic analysis of the nasal septum showed a variable mixed inflammatory cellular infiltration mainly composed of eosinophils, plasma cells, and histiocytes with a perivascular distribution; in other areas, an angiocentric fibrosing lesion with a peculiar perivascular onion-skin pattern was observed. The patient had a partial resection of the lesion with symptomatic control. CONCLUSIONS: The presence of rhinitis and nasal eosinophilia in our case associated with the clinical aspects of the previously reported cases further support an allergic cause for EAF.