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Necrotizing fasciitis is a rare polymicrobial, infection, characterized by a rapid and destructive spread within the subcutaneous tissue and along the superficial fascial planes, initially not affecting underlying muscles but with a common systemic involvement. Necrotizing fasciitis confined to the cervico-facial region is extremely rare (10% of cases) and is characterized by a high mortality rate due to airway compromise and to involvement of the supra-aortic vessels. The prognosis for survival is based on the severity of the necrotizing fasciitis, on the patient's systemic condition and on the prompt diagnosis and adequate surgical and medical management. We discuss a case of cervico-facial necrotizing fasciitis in a 25-year-old patient beginning with an odontogenic abscess, resistant to antibiotic therapy, rapidly progressing into an important right-sided swelling of the neck with worsening dyspnea and dysphagia. Because of his worsened general condition, the patient was transferred to the operating room for an emergency treatment. Under general anesthesia, the right cervical and left buccal purulent material was drained via right lateral cervicotomy an aggressive debridement of necrotic tissue, a disruption and excision of the all-necrotic fascia and a removal of the right submandibular gland. Thus, a portable mini-VAC device was applied. The early intervention with a specific diagnostic and therapeutic protocol and the wound treatment by means of vacuum assisted closure therapy allowed to obtain a quick healing, preventing the systemic involvement, minimizing morpho-esthetic outcome and limiting the costs of post-operative wound care.

The fundamental role of antibodies in the development of acute graft rejection has been established recently. Antibody-mediated acute rejection may develop at any time during the post-transplant period. Several therapeutic approaches have been proposed in the last decades. However, there is no standardized therapy. The aim of this study is to report the Sapienza University experience of combined plasma treatment and high-dose intravenous immunoglobulin ± extracorporeal photopheresis. From January 2006 to September 2009, 6 patients were treated at Sapienza University. In 5 cases (83%) complete regression of the acute rejection was observed, followed by stable renal function (median creatinine value at 1-year follow-up: 1.5 mg/dL). No adverse events were reported. Our approach seems to give good results in terms of graft survival and procedure safety. Further studies on a larger number of patients will be needed to confirm the validity of these findings. Moreover, comparison between our protocol and other treatments is necessary.

Hepatitis C virus (HCV) infection occurs much more frequently in the hemodialysis population than in the general population. Patients with chronic kidney disease with persistent HCV infection may develop serious and progressive chronic liver disease, with associated long-term morbidity and mortality related to cirrhosis and hepatocellular carcinoma. Monocytes and macrophages are known to produce extrahepatic breeding sites and spread the disease. Our aim was to lower the levels of macrophages, granulocytes, monocytes, proinflammatory cells and viremia using an extracorporeal device: the Adacolumn ® leukocyte apheresis system (Otsuka). The Adacolumn is a direct hemoperfusion-type leukapheresis device. The column is a single-use (disposable) polycarbonate column with a capacity of about 335 mL, filled with 220-g cellulose acetate beads of 2 mm in diameter bathed in physiological saline. The carriers adsorb ''activated'' granulocytes and monocytes/macrophages that bear Fc and complement receptors. The patients underwent five 1-hour sessions for five consecutive days. The column was placed in an extracorporeal setting with a perfusion rate of 30 mL/min and a duration of 60 minutes. A reduction of viremia was observed in all patients in association with a decrease in cytokine levels and a proportional decrease in immune cells. Although this study investigated responses in a small number of patients, it was shown that the Adacolumn changed the cellular immunity and promoted early viral response.

The OLR1 gene encodes a cell-surface endocytosis receptor (LOX-1) for oxidized low density lipoprotein (OxLDL). LDL is oxidized in vascular endothelial cells to a highly injurious product that results in endothelial cell injury, which is implicated in the development of atherosclerosis. Vascular endothelial cells also internalize and degrade oxLDL though the OLR1 receptor. This receptor is upregulated by ox-LDL itself and by angiotensin II, endothelin, cytokines, and shear stress, important factors of atherosclerosis. This receptor is upregulated in the arteries of hypertensive, dyslipidemic, and diabetic animals. Two independent studies have demonstrated genetic association between polymorphisms in the OLR1 gene and myocardial infarction. Based on genetic and functional studies we propose LOX-1 as a novel biomarker and target in cardiovascular disease diagnosis and prevention.

Aim: The liver as a solid graft has a known immunological privilege. Its tolerogenic property has been demonstrated in rodents. In humans the onset of chronic rejection and the severity of such complication is less frequent after liver transplantation compared to other organs. The underlying events whose effect is graft acceptance instead of rejection should be further investigated. Their control could open new ways to decrease the need for long-term immunosuppression after transplantation of other organs. Aim of this study is to evaluate a model of liver transplantation in swine as a preliminary step for immunological studies., Methods: Ten outbred Landrace/Large White mismatched swine underwent to liver transplantation with a simple passive portocaval jugular bypass. The onset of rejection was monitored daily by liver function test. After death or sacrifice the liver parenchyma was studied to evaluate tissue damage and inflammatory infiltrate., Results: The postoperative liver function showed a critical period for organ rejection about postoperative day 5. The animals that survived longer were sacrificed with a normal biochemical hepatic function. However, histology consistently showed a pattern of mild rejection in a still preserved architecture., Conclusions: The evidence of a prolonged liver function in a rejecting model of liver transplantation makes this model suitable for studies of tolerance induction.

Aim: The aim of this study was to compare the time course characteristics of cisatracurium (C) and vecuronium (V) induced neuromuscular block (NMB) following multiple doses, allowing spontaneous complete recovery (SCRT) and evaluating the influence of age., Methods: Following institutional approval and signed informed consent, 177 adult ASA 1-2 patients were included in a randomized, double-blind, multicenter study under N20/02/fentanyl/propofol anesthesia. Muscle relaxation was induced with 0.15 mg/kg C or 0.l mg/kg V and was maintained with 0.03 mg/kg of C or 0.02 mg/kg of V injected at T1 25% recovery. Intubating conditions were assessed at 2 min after the initial dose. Time course of NMB was monitored using accelerography (Tofguard) of the adductor pollicis with train-of-four (TOF). Data were analyzed with parametric (Anova) and non parametric statistics (c2, Kruskal Wallis)., Results: Both drugs offered good/excellent intubating conditions: duration of action of NMB (mean values +/- SD, minutes) were: dur25 first dose: V 38.20+/-13.2 vs C 51.5+/-11.3 (P<0.02 ); dur25 following repeated boluses (average): V 23.2+/- 8.6 vs C 28.2+/-9.5, ns; dur25 last dose: V 25.1+/-11.5 vs C 31.5+/-11.4, ns: SCRT following last dose: V 50.2+/-23.2 vs C 46.4+/-17.5, ns: t125% to t4/T1 0.80:V 27.1+/-18.7 vs C 18.8+/-10.2, ns. Stratifying for age >or< 65 no differences were noted in the intervals studied following C, while all were longer following V. The duration of block of C was longer than V; the SCRT after the final dose of C was shorter than V albeit not significant. There was a clinically significant increase in duration of block and recovery time in elderly patients for V but not for C., Conclusions: C and V allow predictable NMB duration and spontaneous recovery even if administered in multiple repeated doses; but in elderly patients duration of block and recovery time is longer following V.

Purpose: The latest innovation in MR imaging is SENSE (SENSitivity Encoding), a technology providing an important solution for the time necessary for signal encoding. In the SENSitivity Encoding (SENSE) approach, an array of multiple, simultaneously operated receiver coils is used for signal acquisition. In particular, the efficacy of SENSE technology is able to reduce the number of phase encodings by a factor (named R factor or Reduction factor) and to evaluate the same k space with fewer readout lines obtaining higher spatial and temporal resolution., Materials and Methods: An heterogeneous group of 30 patients with a variety of clinically proven diagnoses underwent Cardiac MR with SENSE technology to evaluate the technique's diagnostic efficacy. The sequences used were "Balanced" Ultrafast Gradient Echo (B-FFE) characterised by a hyper-intense blood signal with multislice multiphase and single slice multiphase acquisitions., Results: In addition to reducing scan times, SENSE technology improved spatial and temporal resolution (40 frames/cardiac cycle) providing optimal dynamic evaluation of valve structures and wall kinesis. Furthermore, the use of the SENSE technique with B-FFE sequences (sB-FFE) enabled the qualitative evaluation of abnormal blood movements and transvalvular flows., Conclusions: The considerable time savings allowed by SENSE technology and the clear improvement in image quality constitute a step forward in cardiac MR imaging. The possibility of executing morphologic, dynamic, perfusional and spectroscopic studies in the same MR examination session with short acquisition times and good image quality are becoming more feasible.

Background: Numerous publications have analysed the hemodynamic effects of "small volume resuscitation" during the initial phases of hemorrhagic shock. Nevertheless nowadays the information about microcirculatory effects are poor. The aim of this study was to estimate the change of tissue perfusion in hypovolemic rats, before and after infusion of Ringer's lactate (RL), hypertonic saline solution (HS) or blood., Methods: Mesocecal microcirculation was visualized by intravital microscopy during 30 minutes of hemorrhagic hypovolemia (MAP, mean arterial pressure of 40 mmHg) and subsequent reinfusion period. Rats were resuscitated with RL (shed volume), HS (one-seventh of the shed volume), or blood (shed volume). The perfusion was estimated through speed of red blood cells. Moreover MAP, pH and B.E. was measured., Results: Thirty minutes after hemorrhage a very important decrease of capillary flow was noticed and in lesser quantity, of the flow in arterioles and venules. The RL infusion did not cause measureable changes of microcirculatory blood flows. The HS infusion caused an improvement in the flow of arterioles and venules but not in capillaries. The blood infusion caused a progressive improvement in the flow of arterioles, venules and capillaries, however at slightly lower values than previous hemorrhage., Conclusions: Neither RL nor HS seem as efficient as blood to restore the microcirculatory blood flow in the mesocecum of the rats submitted to hemorrhagic hypovolemia.

Background: The so called stop-flow operation is based on locoregional perfusion with an antiblastic hypoxic solution of the region invaded by malignant tissue. Cardiocirculatory complications are common, mainly consisting of reduction of cardiac index, increase of arterial pulmonary pressure, systemic vascular resistance and heart rate. Sevoflurane has been used for its stable hemodynamic profile to reduce cardiocirculatory troubles., Methods: Six patients were submitted to stop-flow operation. General anaesthesia was performed with Sevoflurane 1 MAC in Air/O2. The following parameters were recorded: nitroglycerin infusion m order to maintain the position of the balloon of the catheters, arterial oxygen saturation, end-tidal carbon dioxide, mean arterial pressure, central venous pressure, arterial pulmonary pressure, heart rate and mixed oxygen venous saturation; recordings were performed before stop-flow (T1), during stop-flow (T2) and 10' after reperfusion (T3)., Results: Before stop-flow (T1) all the parameters were normal. At T2 heart rate, cardiac index and pulmonary capillary wedge pressure increased whilst mean arterial pressure, systemic vascular resistance and pulmonary vascular resistance decreased. Ten minutes after the end of perfusion (T3) absence of variations in systemic vascular resistance, in pulmonary vascular resistance, in pulmonary capillary wedge pressure, in cardiac index and in mixed oxygen venous saturation were noticed. Heart rate and central venous pressure showed a tendency to decrease., Conclusions: The hemodynamic profile during stop-flow appears to be stable with general anaesthesia with Sevoflurane.

Background: The aim of this study was to evaluate the discharge rate of children undergoing ophthalmic surgery of medium length (69-120') in a day-hospital regime under general anesthesia with orotracheal intubation and using Sevoflurane as the only anesthetic agent., Experimental Protocol: prospective study., Setting: the study was carried out in the operating theatre of the Ophthalmic Clinic at Florence University., Patients: 58 pediatric patients aged 2-10 years, ASA I-II, 13-34 kg., Operations: correction of strabismus, cataract, glaucoma, palpebral ptosis and intubation of lacrimal tracts. Parameters measure: Any signs of reactivity in the airways to Sevoflurane on induction or reawakening (cough, bronchospasm, laryngospasm and psychomotor agitation), hemodynamic variables (heart rate and NIBP); reawakening time (from turning off the vaporiser to extubation), discharge time from recovery room (SatO2 > or = 97% in ambient atmosphere), discharge time from hospital (stable vital signs, response to simple and complex commands)., Results: The mean reawakening time was 7 min, discharge time from the recovery room was 20 min, discharge time from the hospital 80% after four hours, 100% after six hours. No respiratory and/or cardiovascular complications were reported nor psychomotor agitation., Conclusions: General anesthesia with Sevoflurane and Atracurium was found to be a realistic and reliable technique in pediatric ophthalmic surgery of medium length performed in day hospital.