Suppression of the alveolitis in pulmonary sarcoidosis by oral corticosteroids

We evaluated the effects of daily prednisone therapy on alveolitis parameters and pulmonary function tests over a six month period in patients with active pulmonary sarcoidosis (>28% T lymphocytes in bronchoalveolar lavage and positive gallium-67 (⁶⁷Ga) lung scans). 10 patients with biopsyproven lung disease were studied. Analysis of bronchoalveolar lavage cells and of⁶⁷Ga scanning at the beginning and at the end of the study period demonstrated that prednisone treatment significantly lowered the percentages of T lymphocytes in bronchoalveolar lavage in all patients (baseline 48±3%, after treatment 19±5%, p<0.01) while⁶⁷Ga lung scans improved in 8 of the 10 patients. Pulmonary function tests showed improvement of the parameters studied (+7.5±2.1% mean change in vital capacity, +4.7±1.6% mean change in total lung capacity, +5.4±2% mean change in forced expiratory volume in one second and +6.2±1.5% mean change in diffusing capacity). In addition none of the treated patients deteriorated functionally and 9 of the 10 patients improved more than 10% in at least one parameter. These results indicate that daily oral prednisone therapy is effective in suppressing the alveolitis in pulmonary sarcoidosis and that it is able to preserve lung functions in patients who, without treatment, would be likely to deteriorate. Supported by C.N.R. grants n^o 82.00200.04 and 82.02057.56     

Percutaneous transluminal renal angioplasty in patients with solitary kidney

We report our experience with percutaneous transluminal angioplasty of renal arteries (PTRA) in solitary kidney patients. Our series includes 31 patients (mean age: 52 years). 7 with solitary kidney following surgical nephrectomy and 24 with functioning solitary kidney. PTR indicated in presence of stenoses ranging from 60–95 % of vessel lumen. Procedure, with 29 patients were technically successful and mean values for stenosis dropped from 77 % to 33 %. In order to assess the results technically, changes in arterial blood pressure (according to Martin's classification) and creatinine levels were considered. Of 25 followed-up patients, 13 were cured (52%), 8 improved (32%),and 4 were unchanged (16%%). Complications were observed during procedures in five patients (16. 1 % ), superimposing that of nonsolitary kidney patients. Good revasculariiation, reduction of blood pressure, preservation or even improvement of renal function and low complications, make PTRA the best procedure with solitary kidney patients.     

MR angiography in abdominal neoplasms

The role of magnetic resonance angiography (MRA) in the evaluation of vascular involvement was studied in 55 patients with abdominal neoplasms. A 2-D time-of-flight (TOF) technique was used in 18 patients. All patients underwent CT and MR examinations before MRA. Also, MR angiograms were compared with digital subtraction angiography in 22 cases, with Doppler US in 13 cases, and with surgical findings in 20 cases. In all patients with liver neoplasms (n = 29) MRA demonstrated the absence of flow in the infiltrated segments. Pericapsular neovascularization was observed in 12 patients. Portal vein involvement was correctly detected in 27 patients. In all cases MRA demonstrated the relationship between the tumor and venous structures. Portosystemic shunts were visualized in 20 of 21 patients with portal hypertension. Vena cava thrombosis (3 cases), compression (5 cases), and displacement (2 cases) were correctly demonstrated. In renal (n = 6) and adrenal gland (n = 3) tumors renal vein compression was correctly detected in 2 cases, displacement in 1 case, and thrombosis in 3 cases, with only 1 false-positive finding. In 7 patients with pancreatic tumors MRA demonstrated splenic vein thrombosis in 2 cases and compression in 2 cases, with one false-positive finding. Our results indicate that MRA provides precise information regarding venous vascular involvement in abdominal neoplasms, but preoperative arterial mapping is still problematic. Correspondence to: E. Squillaci     

Six-Year Follow-Up of Botulinum Toxin A Intradetrusorial Injections in Patients with Refractory Neurogenic Detrusor Overactivity: Clinical and Urodynamic Results

Background

Most reports in the literature on botulinum toxin A (BoNTA) therapy for neurogenic detrusor overactivity (NDO) are based on the results of a single injection. Because most patients may require retreatment, the efficacy and safety of multiple injections must be addressed clearly.

Objective

To investigate the effectiveness and safety of BoNTA intradetrusorial injections in a group of spinal cord–injured (SCI) patients with refractory detrusor overactivity (DO).

Design, setting, and participants

Seventeen SCI patients were prospectively included in the study and followed up to 6 yr.

Intervention

All patients received repeat intradetrusorial injections of BoNTA 300 units (Botox, Allergan, Irvine, CA) under cystoscopic control on an inpatient basis.

Measurements

The preliminary assessment included voiding diary, urodynamics, kidney and bladder ultrasound, and cystourethrography. Patients also completed a standardised quality-of-life (QoL) questionnaire. Clinical evaluation, urodynamics, urinary tract imaging, and QoL assessment were repeated every year throughout the follow-up.

Results and limitations

Before treatment, all patients complained of urinary incontinence and had DO. Bilateral and monolateral renal pelvis dilatation were detected in six and five patients, respectively, and a monolateral and third-grade vesicoureteral reflux was observed in three. At 6-yr follow-up, a significant decrease in the frequency of daily incontinence episodes (p < 0.01), a significant increase in first uninhibited detrusor contraction and in maximum bladder capacity (p < 0.001 for both), and a significant decrease in maximum pressure of these contractions (p < 0.01) were observed. Fifteen patients (88.2%) were completely continent. Renal pelvis dilatation and vesicoureteral reflux resolved in all cases, and the QoL index significantly increased. Limitations of the study are related to the small number of included patients.

Conclusions

In SCI patients with refractory NDO who do not want or are unfit for invasive reconstructive surgery, BoNTA intravesical treatment represents a valid alternative to control DO and urinary incontinence and to preserve upper urinary tract function over a long-term follow-up.     

Noncardiac surgical procedures in patient supported with long-term implantable left ventricular assist device

Background

Left ventricular assist devices (LVADs) are increasingly used as bridges to transplantation or as destination therapy. As sicker and older patients are more frequently considered for mechanical support, general surgical problems are expected to increase in these patients.

Methods

Anesthesia records and clinical charts were reviewed for 11 recipients of LVADs undergoing 12 general surgical procedures between January 1988 and March 2007.

Results

Eight patients underwent major surgical procedures: 1 intracranial hematoma drainage, 1 right hemicolectomy with ileocolostomy, 1 splenectomy, 1 surgical repair of an iliac-femoral artery pseudoaneurysm, 2 cholecystectomies, 1 pyelolithotomy, and 1 coil embolization of a femoral side-branch disruption. Four patients underwent minor surgical procedures. The mean duration of LVAD support before surgery was 58.7 ± 45.6 days. All patients survived the procedures.

Conclusion

Noncardiac surgery in LVAD recipients is feasible, without significant morbidity or mortality. Intraoperative coagulation management has a key role in safely performing these procedures.     

Stereotactic vacuum biopsy of calcifications with a handheld portable biopsy system: a validation study

To prospectively evaluate a compact portable 10-gauge handheld battery-operated biopsy system for stereotactic biopsy of microcalcifications. The ethics committee of the hospital approved this prospective multicentric study, and informed consent was obtained. Biopsy under stereotactic guidance was performed in 215 patients for 219 lesions consisting of microcalcifications without mass. The feasibility and the tolerance of the procedure were evaluated. The mean weight of the specimen was calculated. In patients with surgical diagnoses, the underestimation rate in biopsy diagnoses of atypical ductal hyperplasia and ductal carcinoma in situ were evaluated. The sampled specimens were separated according to the presence of calcifications on magnified specimen radiographs and to the probe the rotation number in order to evaluate the contribution of each rotation and the contribution of the specimen with and without calcifications on the radiographs. The macrobiopsy was feasible in 98.5% of the patients and was well tolerated in 82% of patients. It identified 4.6% invasive carcinomas, 18.5% ductal carcinomas in situ, 14.8% atypical ductal hyperplasias, 22.2% benign proliferative mastopathies and 39.8% benign non-proliferative mastopathies. The underestimation rate was 26.6% when an atypical ductal hyperplasia was diagnosed at biopsy, and 7.7% when a ductal carcinoma in situ was diagnosed. In the 77 patients with surgical correlation, the accurate diagnosis was obtained in specimens sampled during the first, second, and third in 69%, 9%, and 4% of the biopsies, respectively, and the analysis of specimens without microcalcification had an added value in 8% of patients. The compact portable battery-operated biopsy system can be used successfully for stereotactic biopsy of microcalcifications and constitutes a valid alternative to current systems.     

Neurologic symptoms after great saphenous vein harvesting for coronary artery bypass grafting

AIM: Incidence evaluation of cutaneous neurologic symptoms in the lower limbs as a new event after great saphenous vein (GSV) harvesting for coronary artery bypass grafting (CABG). Each day we harvest the GSV for CABG. Some authors have reported the onset of saphenous neuralgia complex as a new event of which we would evaluate the incidence. METHODS: From January 2000, until June 2001, 2,091 patients underwent cardiac surgery; 1,326 underwent CABG, 1,227 of them using the GSV as a conduit for almost one graft. These patients were prospectively reviewed; all were preoperatively examined to determine the presence of normal sensation in the lower limbs and elude the presence of saphenous neuralgia. Then, we evaluated sensations in the lower limbs at 5 days, 8 weeks, and 5 months after operation to determine the new onset of saphenous neuralgia. The areas of sensory loss were recorded each time and reported in a diagram to obtain 3 areas. RESULTS: Hyperaesthesia and pain were noted in a few patients, especially at 5 days and 8 weeks control, but at 5 months none of them complained of real pain. CONCLUSION: This study demonstrates that saphenous neuralgia after harvesting the GSV for CABG is a rare consequence. The main symptom is anaesthesia but its duration is generally no longer than 2 months. Hyperaesthesia and pain, for the early onset and the early disappearance, are considered as a normal consequence of surgical procedure.     

Transclavicular access as an adjunct to standard cervical incision in the treatment of mediastinal goitre

There are cases in which resection of cervico-mediastinal goitres requires additional thoracic access as an adjunct to standard transverse cervicotomy, and typically this takes the form of sternotomy or thoracotomy. The authors propose transclavicular access as an alternative to thoracotomy or sternotomy access for the removal of such goitres. This technical variant is performed by means of resection of the middle third of the clavicle and extraperiosteal disarticulation. They report a case of cervicomediastinal or "plunged" goitre associated with mediastinal metastasis from a follicular thyroid carcinoma in a 77-year-old woman, in whom this technical variant was used. They conclude by stressing the greater effectiveness, ease of execution and relatively limited "aggressiveness" of the technique in comparison with other ways of reaching the mediastinum. The variant proves effective in solving a number of technical, functional and aesthetic problems.     

Adenocarcinoma of the Ampulla of Vater: T-Stage,Chromosome 17p Allelic Loss,and Extended Pancreaticoduodenectomy are Relevant Prognostic Factors

Objective To evaluate the prognostic significance of different clinico-pathological and molecular factors, and to compare survival after standard and extended pancreaticoduodenectomy (PD) in ampulla of Vater adenocarcinoma (AVAC). Summary Background Data There are discordant data on factors affecting prognosis, and hence therapeutic choices, in AVAC. Patients and Methods Clinical-pathological factors were evaluated in 59 patients, subjected to PD for AVAC; in 42 subjects information on chromosome 17p and 18q allelic losses (LOH) and microsatellite instability (MSI) was also available. The association between survival and type of PD was investigated in the 25 patients operated between 1990 and 2001 (16 standard and nine extended). Results The overall 5- and 10-year tumor-related survival rates were 46% and 33%, respectively. Sixteen patients had T-stages 1–2, 14 T-stage 3, and 29 T-stage 4 cancers. Chromosome 17p and 18q LOH were detected in 23 (55%) and 15 cases (36%), respectively, and in 12 cases (29%) coexisted. Five cases were MSI-positive (12%). At univariate analysis, poor survival was associated with cancer ulceration (P = 0.051), poor differentiation (P = 0.008), T-stage 4 (P < 0.001), nodal metastases (P = 0.004), chromosome 17p (P < 0.001) and 18q LOH (P = 0.002), and absence of MSI (P = 0.009). At multivariate analysis, only T-stage (P = 0.002) and 17p LOH (P = 0.001) were independent predictors of survival. All patients with MSI-positive cancers were long-survivors (>12 yrs), whereas only 30% of MSI-negative cancer patients survived at 5 years. Extended pancreaticoduodenectomy was associated with a 3-year disease-related survival higher than standard resection (83% vs 31%; P = 0.018). Conclusion MSI and chromosome 17p status allow to better define prognosis within ampullary cancers at the same stage. Surgery alone resulted curative in MSI-positive cancer patients, whereas it was inadequate in patients showing allelic losses, who might benefit from adjuvant therapy. In this observational study, extended PD was associated with increased survival compared to standard procedures. Presented at the 2006 Annual Meeting of the American Hepato-Pancreato-Biliary Association, Miami Beach, Florida, March 9–12, 2006     

Detection of 90K/MAC-2BP in the seminal plasma of infertile males with accessory gland infection and the autoimmune pathogenetic hypothesis

The purpose of the study was to evaluate 90K/MAC-2BP, a glycoprotein member of the Scavenger Receptor Cystein Rich superfamily, in the seminal plasma of infertile male patients with male accessory gland infection in order to investigate a putative autoimmune pathogenesis. 90K seminal concentration and sperm parameters were evaluated in 50 patients with male accessory gland infection at baseline and after cycles of treatment with Levofluoxacin 500 mg daily for 15 days plus serratiopeptidase 10 mg daily for 30 days. Treatment was continued for up to 6 cycles in cases of persistant bacteriospermia and/or clinical and ejaculatory signs of the disease. Patients with persistant male accessory gland infection after 6 cycles were defined as nonresponders. The same parameters were evaluated at baseline and after a 2-month period in 30 healthy controls. Patients with male accessory gland infection showed impaired sperm parameters and had lower seminal 90K concentration compared to controls. After treatment, seminal 90K level significantly increased in patients compared to controls. Twenty-two patients responded to treatment (44%), while 28 were nonresponders (56%). No difference in pretreatment and posttreatment sperm parameters and seminal 90K was observed between the 2 subgroups. Thirteen patients (26%) had identifiable bacteriospermia: significantly less pretreatment seminal 90K was observed compared to patients without bacteriospermia. Seminal 90K is decreased in patients with male accessory gland infection, and may be restored by a treatment with quinolones. However, the clinical utility of a 90K assay in these patients remains uncertain, as its level is not predictive of response to treatment.