Reintervention in abdominal surgery. Personal experience in emergency

The Authors, regarding their emergency surgical experience, examine the need of reintervention in abdominal surgery at a distance (operations carried out not less than 30 days after previous procedure), a controversial situation, usually dealt with empirical approach. Such a feature is not rare in the experience of a surgeon; nevertheless still few are the studies concerning the severity of the disease and related complications requiring surgery. Occasionally it is really difficult--quite impossible- in these often complex clinical conditions, to identify the aetiology and even to perform a pre-operative diagnosis. Sometimes other factors may inhibit an exhaustive evaluation (acute onset of the symptoms, time spent from the former procedure, choice of the patient to refer to another surgeon) thus conditioning an adequate review of the first surgical act. The Authors study the more frequently observed clinical features, post-surgical abdominal adhesive syndrome, cancer recurrence, incisional hernia. Former surgical diseases and the latter one may be the same, but not necessarily. Surgery is only a feature of the treatment (multimodal treatment) in case of neoplastic recurrence. Morbidity and mortality concerning the latter surgical procedure are higher than the mere sum of those related to both the former and last operation performed (pre-operative disease understaging). Finally it must be stressed the need for early and accurate diagnosis to clearly steer the choice and course of surgical action.     

External validation of severity scoring systems for acute renal failure using a multinational database

OBJECTIVE: Several different severity scoring systems specific to acute renal failure have been proposed. However, most validation studies of these scoring systems were conducted in a single center or in a small number of centers, often the same ones used for their development. Therefore, it is not known whether such severity scoring systems may be widely applied. DESIGN: Prospective clinical investigation. SETTING: Intensive care units. PATIENTS: One thousand seven hundred and forty-two intensive care unit patients with acute renal failure who were either treated with renal replacement therapy or fulfilled predefined criteria. INTERVENTIONS: Demographic and clinical information and outcomes were measured. MEASUREMENTS AND MAIN RESULTS: Scores for four acute renal failure-specific scoring systems and two general scoring systems (Simplified Acute Physiology Score II and Sequential Organ Failure Assessment) were calculated, and their discrimination and calibration were tested with receiver operating characteristic curves and Hosmer-Lemeshow goodness-of fit-tests. For the receiver operating characteristic curves, blood lactate levels were also used as a reference. All scores had an area under the receiver operating characteristic curve <0.7 (Mehta 0.670, Liano 0.698, Chertow 0.610, Paganini 0.643, Simplified Acute Physiology Score II 0.645, Sequential Organ Failure Assessment 0.675, lactate 0.639). For scores that can calculate predicted mortality, the Hosmer-Lemeshow goodness-of-fit test showed poor calibration. CONCLUSIONS: None of the scoring systems tested had a high level of discrimination or calibration to predict mortality for patients with acute renal failure when tested in a broad cohort of patients from multiple countries. A large, multiple-center database might be needed to improve the discrimination and calibration of acute renal failure scoring system.     

Human endothelial cells allow passage of an archetypal BK virus (BKV) strain – a tool for cultivation and functional studies of natural BKV strains

Summary. The ubiquitous human polyomavirus BK (BKV) causes the serious condition BKV-nephropathy in an increasing number of renal-transplant patients. The lack of authentic cell cultures for multiplication of naturally occurring strains has hampered cultivation and functional studies of BKV.Here we demonstrate that the most common urine shed BKV strain, the archetype, multiplies in the human endothelial cell line HUV-EC-C. Additional variants with deletions in the non-coding control region (NCCR) appear upon prolonged propagation. Although the titer produced was low, at the present HUV-EC-C is the only cell line shown to allow propagation of archetypal BKV. HUV-EC-C may therefore be a useful tool for BKV cultivation as well as functional studies.     

The narrow lower esophageal ring: Pathogenesis and physiology

Summary In 8 cases of narrow lower esophageal ring, which occurs chiefly in men between 50 and 60 years old, the cardinal symptom was dysphagia. Reflux was uncommon and weight loss absent.The radiographs revealed a ring-like structure no greater than 1.2 cm. in internal diameter.In the 7 patients operated upon, the narrow area was found to be at the esophagogastric mucosal junction. Its histologic appearance was that of a chronic inflammatory lesion at the mucosal junction, only a few millimeters in length.Pressure waves in the body of the esophagus were normal. The inferior esophageal sphincter pressures were lower than normal but in the range of those of hernia patients, supporting the radiologist's concept that patients with rings have hernias.The ring was found to move proximally during swallowing and then return distally to its resting position. This movement may explain why some peroral biopsies have shown only esophageal mucosa below the ring.Max D. Clark, M.D., assisted in the performance of the radiographic studies.     

Teratoma of the middle ear: a real entity or a non-entity?

Space-occupying lesions of the middle ear range from wholly benign developmental anomalies to highly virulent and aggressive malignancies. Amongst the benign entities classed with the family of developmental anomalies, the middle ear choristoma is well known. But what of the middle ear teratoma? Recent reports suggest that, while rare, teratomas of the middle ear do exist. Middle ear teratomas are defined as tumors consisting of benign tissues derived from all three embryologic layers: endoderm, mesoderm and ectoderm. They are lesions of the neonatal period and early infancy. While complete surgical excision will be curative, a thorough histologic examination of the specimen is recommended to exclude the possibility of immature and/or frankly malignant elements being admixed with the benign teratomatous elements.     

Merkel cell carcinoma of the auricle

Merkel cell carcinoma (MCC) is an uncommon cutaneous neoplasm which arises in adults with a peak incidence in the sixth and seventh decades. MCC most often arises in the head and neck area and extremities. Among head and neck primary sites, auricular MCC has proven to be rare and only 20 cases have been reported in the literature. Auricular MCC follows the same aggressive course as has been documented for MCC arising elsewhere: the tumor has a propensity for recurring locally and metastasizing to regional lymph nodes and distant sites. Location of MCC in the auricular regions does not appear to confer any survival advantage compared with MCC arising elsewhere. The mainstay of treatment is surgery, with attempts at complete surgical excision being of paramount importance. What role regional node dissection, radiation therapy and chemotherapy may play in the standard treatment of auricular MCC remains to be clearly established.     

Localization and quantification of fluorescent inclusions embedded in a turbid medium

A set-up, based on a CCD camera, to localize fluorescent inclusions in diffusing media was developed. This set-up allows one to acquire a huge dataset along two axes. This aspect is fundamental to performing a tomographic reconstruction in order to quantify the fluorescence amplitude in each voxel of the sample. Firstly, a simple analytical approach to recover the position of a single inclusion, embedded in a turbid medium, was developed. Then, we implemented a reconstruction algorithm to recover the position of one and two inclusions and to estimate their relative concentrations. Finally, we studied the dependence of reconstructed data on the number of injection points of excitation light and the number of detection points of fluorescence emission.     

Virosome-based active immunization targets soluble amyloid species rather than plaques in a transgenic mouse model of Alzheimer’s disease

Active vaccination with amyloid peptides shows promise for the treatment and prevention of Alzheimer's disease (AD). Several studies in transgenic mouse models of AD have revealed the potency of vaccination to prevent or even clear amyloid plaques from mouse brain. However, the idea that soluble oligomeric species of beta-amyloid (Abeta), rather than plaques, trigger the disease has gained momentum, and current active vaccination strategies affect the levels of total or soluble brain Abeta little or not at all. We describe an active vaccination method based on Abeta1-16 presented on the surface of virosomes, which triggered a dramatic decrease in both soluble Abeta40 (75% reduction; p=0.01) and soluble Abeta42 (62% reduction; p=0.03) in a double transgenic mouse model of AD. Whereas Abeta40 and Abeta42 levels in the insoluble fraction tended to be reduced (by 30% and 27%, respectively), the number of thioflavine-S-positive amyloid plaques was not affected. The high specific antibody responses, obtained without eliciting T-cell reactivity, demonstrate that immunostimulating reconstituted influenza virosomes are a promising antigen carrier system against the neuropathology of AD.     

Clinical biochemical genetics in the twenty-first century

Genetic disorders are recognized to play an increasing role in pediatrics. Close to 10% of diseases among hospitalized children have been ascribed to Mendelian traits inherited as single gene defects, not a surprising figure considering that approximately 1000 inborn errors of metabolism (IEM) have been identified to date, primarily through the detection of endogenous metabolites abnormally accumulated in biological fluids and tissues. The laboratory discipline that covers the biochemical diagnosis of IEM is known as clinical biochemical genetics, and is defined as one concerned with the evaluation and diagnosis of patients and families with inherited metabolic disease, monitoring of treatment, and distinguishing heterozygous carriers from non-carriers by metabolite and enzymic analysis of physiological fluids and tissues. The biochemical genetics laboratory differs from the clinical chemistry laboratory in the extent of interpretation necessary to make its results meaningful to the clinician. While dramatic advances in molecular genetics have greatly changed the landscape of diagnostic options for many genetic disorders, a biochemical approach remains the dominant force for the diagnosis and monitoring of IEM. Owing to the stereotypical clinical presentation of many of these disorders, a major role of the biochemical genetics laboratory is to analyze ever more complex metabolic profiles to reach a preliminary diagnosis, which then needs to be confirmed by enzymic and/or molecular studies in vitro. Accordingly, the role of biochemical genetics in the pediatric practice of the 21st century is to provide a multicomponent screening process that can be divided into four major components: (i) at-risk screening (prenatal diagnosis); (ii) newborn screening (testing of presymptomatic patients); (iii) high-risk screening (testing of symptomatic patients); and (iv) postmortem screening (metabolic autopsy). The focus of our laboratory is to apply state-of-the-art technology such as tandem mass spectrometry to bring as many as possible IEM within the boundaries of newborn screening programs, and to investigate the role played by individual disorders in maternal complications of pregnancy, pediatric acute/fulminant liver failure, and sudden and unexpected death in early life.