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Complex abdominal wounds (CAWs) are an increasing clinical problem in abdominal surgery and pose a challenge for the surgeon.This review analyzes the results of treating CAWs with a porcine biological mesh and topical negative pressure (TNP) to address the feasibility, effectiveness, level of risk, and overall results.A series of 4 consecutive cases treated with the biologic mesh and TNP at the General Surgery Unit of the Cannizzaro Hospital (Catania, Italy) is reported and analyzed. In addition, a review of the literature published in all languages from 2000 to 2015 in the MEDLINE/PubMed database was performed to identify cases of CAWs treated with the association of biologic mesh and TNP.Taking into account the authors' experience and review of literature, a total of 12 patients (4 treated in the authors' department) were treated with the aforementioned combination. The main indications for using this association were a large abdominal wall defect, laparotomy, or wound dehiscence and wound infection. In almost all cases, this combination demonstrated a successful outcome with a clear improvement in wound healing and no adverse effects.From these cases and the review of the literature, the authors believe TNP can be applied on a biological mesh with effectiveness in improving the treatment of the CAWs without relevant risk to the patient or biological mesh.

Background: Geographical differences in disease prevalence and mortality have been described in the general population and in chronic kidney disease patients in Europe. In this secondary analysis of the Membrane Permeability Outcome (MPO) study, we addressed differences in patient and treatment patterns, and whether these affect patient outcomes. Methods: Participating countries were grouped according to geographical location; thus study centers in France, Greece, Italy, Portugal and Spain were allocated to southern Europe (n=499), and those in all other countries (Belgium, Germany, Poland and Sweden) to northern Europe (n=148). Descriptive analysis of patient and treatment patterns at study start, as well as survival analysis, was performed. Results: In patients from the northern European countries, a higher prevalence of diabetes mellitus and of cardiovascular disease was observed than in those from southern Europe (diabetes 35.1% vs. 21.0%, p=0.0007; cardiovascular disease 40.5% vs. 22.8%, p

Phosphate may promote the onset and progression of chronic nephropathies. Here we evaluated the relationships between baseline serum phosphate levels, disease progression, and response to ACE inhibition in 331 patients with proteinuric nephropathies in the prospective Ramipril Efficacy In Nephropathy (REIN) trial. Independent of treatment, patients with phosphate levels in the highest two quartiles progressed significantly faster either to ESRD or to a composite endpoint of doubling of serum creatinine or ESRD compared with patients with phosphate levels below the median (P < 0.001). Results were similar when we analyzed phosphate as a continuous variable (P ≤ 0.004). The renoprotective effect of ramipril decreased as serum phosphate increased (P ≤ 0.008 for interaction); this modification of the treatment effect by phosphate persisted despite adjusting for potential confounders such as GFR and urinary protein. In summary, these data suggest that phosphate is an independent risk factor for progression of renal disease among patients with proteinuric CKD, and high levels of phosphate may even attenuate the renoprotective effect of ACE inhibitors. Future trials should test whether reducing serum phosphate improves renal outcomes and optimizes the renoprotective effect of ACE inhibition.

Secondary hyperoxalemia is a common feature in patients with chronic renal failure, but oxalate removal is not adequately accomplished by regular dialysis treatment. Oxalate removal in two groups of patients, 11 on continuous ambulatory peritoneal dialysis (CAPD) and 12 on hemodialysis (HD), was investigated. HD patients were studied during a regular bicarbonate dialysis and during hemodiafiltration (HDF) with a high convective component (UF = 66 mL/min) and AN69 filter (Hospal Filtral 12, 1.2 m2, Hospal Industrie, Meyzieu, France). All HD and HDF spent dialysate and all 24 hr CAPD effluents were collected; oxalate concentration was measured by high performance liquid chromatography (HPLC) using an ion exchange column. Both oxalate flux and total extraction were statistically higher during HDF treatments (HDF = 1.87 +/- 0.77 mg/min and 335.9 +/- 131.5 mg/session, respectively; HD = 0.99 +/- 0.74 mg/min, 226 +/- 153 mg/session, respectively; p < 0.02). The positive interaction of convective and diffusive fluxes probably played a major role in oxalate removal during treatment with a high convective component; solute-membrane interactions can occur by using either cellulosic or synthetic fibers. In CAPD patients, oxalate removal (76.42 +/- 50.85 mg/day) was lower than in patients on either HD or HDF, although weekly oxalate extraction was statistically no different between CAPD (535.46 +/- 356 mg/week) and HD (677.72 +/- 460.82 mg/week). It was concluded that HDF is more effective than HD or CAPD in oxalate removal. Long-term studies are needed to demonstrate whether these kinetic findings have clinical relevance.

Several patients undergoing chronic renal replacement therapy present problems related to their vascular access. Low blood flows and high rates of recirculation are common in such patients in which, for this reason, it becomes difficult to apply highly efficient techniques or techniques where diffusion and convection are combined as in hemodiafiltration. In these patients we studied the possibility of partially recirculating the blood in the extracorporeal circuit in order to increase the flow rate per single hollow fiber; we defined our system “double pass dialysis”. We evaluated the system's efficiency in 12 patients during 24 dialysis sessions: 12 high flux dialysis sessions (without reinfusion) and 12 hemodiafiltration sessions (9 liters reinfusion). Different surfaces of polyacrylonitrile dialyzers were utilized (1.3-1.7-2.1 sqm) at 250 and 350 ml/min of blood flow with or without 100 ml/min of recirculation. During each dialysis session blood and dialysate samples were taken in order to calculate BUN, Creatinine, Phosphate and Inuline clearances from both the blood and dialysate side. The clearances of low molecular weight solutes were not really influenced by the artificial increase of the blood flow, but on the other hand, the clearances of higher molecular weight solutes increased from 10 to 30% during both high flux dialysis and hemodiafiltration with recirculation. This increase was evident mostly in hemodiafiltration suggesting that the cleaning effect on the membrane has a positive impact on the permeability. The good clinical results obtained with the double pass dialysis show that the system is safe and reliable and may become a valid support in critical situations in order to reach adequate dialysis treatment.

Clotting of the filters in continuous arteriovenous hemofiltration (CAVH) has been frequently related to filtration pressure equilibrium (FPE). The geometry of the filter and the blood flow, together with filtration fraction, are the factors affecting FPE. A new method based on scintigraphic imaging of the filter is described to demonstrate FPE and identify the operational conditions influencing it. A radiolabelled marker molecule (albumin macroaggregates + Tc99) is added to the blood circulating at various flows through the filter. Changes in the concentration of this molecule detected by a gamma camera are used to calculate the water fluxes in different sections of the filter. When the curve reaches a plateau, no further changes occur and FPE is achieved. The study used Amicon D-30 hemofilters and FPE points were achieved for blood flows of 75, 110 and 150 ml/min respectively 8 cm, 12 cm and 18 cm from the inlet. The study not only demonstrates the occurrence of FPE, but also identifies the length of the filter required at a given blood flow to avoid FPE (achieving less clotting and lower heparin requirement). The Amicon diafilter family, having filters of different length, is useful for “personalizing” the filter in CAVH.

In vitro and in vivo studies were performed on 10 dialyzers with 5 microns thick cuprophan membrane to evaluate hydraulic properties and permeability to solutes. Inlet and outlet pressures of the filter were measured at different blood flows to assess the resistance of the device and the end-to-end pressure drop. Hysolated ultrafiltration was performed to evaluate the spontaneous filtration at increasing blood flows, the ultrafiltration rate at different transmembrane pressures and, finally, the sieving coefficients for solutes. Standard hemodialysis was also performed to study the clearances throughout a 4-h session. During hysolated ultrafiltration the UF rate was increased up to 37 ml/min showing a very high hydraulic permeability of the membrane. The spontaneous filtration rates related to blood flow were quite low. Since the end-to-end pressure drop in the filter was also relatively low at high blood flow we may conclude that the geometry of the device is able to dissociate the influence of blood flow on the hydrostatic pressure inside the filter. This results in a easy modulation of the membrane permeability to water. Sievings were surprisingly high and clearances were stable along the dialysis session (BUN = 196 ml/min, creatinine = 161 ml/min and phosphate = 163 ml/min).

New synthetic membranes have been developed to reduce the ultrafiltration coefficient (Kf) maintaining an adequate permeability to medium-large solutes and a good biocompatibility. The new Fresenius F6 Low Flux Polysulphon Membrane is studied in this paper as far as hydraulic and permeability properties are concerned. For this purpose in vitro and in vivo tests have been carried out in a series of different conditions. In vitro sieving coefficients were near 1 for solutes with molecular weight up to 5000 Daltons. The ultrafiltration coefficient of the device was 5.4 ml/h/mmHg while the value of Kf normalized per square meter was lower than 5 ml/h/mmHg. The geometry of the blood path was adequate even operating at high blood flows without excessive resistance and obligate filtration. This resulted in vivo in a good performance during short dialysis schedules with good clearances of small and large molecules and with no risks of backfiltration. In fact, the low permeability to water permits constant operation with positive transmembrane pressures without excessive ultrafiltration rates. The biocompatibility of the membrane was excellent and high capacity of adsorption for beta-2 microglobulin was demonstrated. These results suggest that these membranes seem to be able to join the advantages of the traditional cellulosic membranes and of the newer synthetic membranes reducing their relative disadvantages.

The authors compared the efficiency of standard HD (t = 240 minutes, Qb = 300 ml/min, Qd = 500 ml/min) with short HD (t = 150 minutes, Qb = 500 ml/min, Qd = 700 ml/min). The study was carried out in 11 patients in two sequential dialysis sessions, utilizing the same high surface area hollow fiber dialyzers, after a 2 day interdialytic period. With short HD, as expected, the clearance (Cl) of BUN, creatinine (Cr), and phosphates (P) was significantly higher than in standard HD:Cl BUN = 331 vs. 225, Cl Cr = 286 vs. 193, and Cl P = 231 vs. 176 ml/min. No significant difference in the total BUN extraction (measured on the total amount of exhausted dialysate) was found between the two techniques. As to Cr and P, despite higher Cl in short HD, the total extractions were significantly lower. In conclusion, in the evaluation of short HD efficiency, instantaneous Cl can be adequate for small molecules, while for larger solutes, other parameters, such as total extraction, must be considered.

The transport mechanisms governing solvent and solute removal during CAVH were elucidated on the basis of in vitro and in vivo observations. Using a typical hemofilter (Diafilter D-20, AMICON), filtration rate rose with inlet blood flow rate until an asymptote was reached at blood flows of approximately 150 ml/min. The onset of the asymptote coincided with transition from a regime controlled by oncotic pressure (filtration pressure equilibrium), to one governed by simple Darcy's law filtration behaviour. Subsequent measurements showed that under clinical conditions, CAVH is generally in the pre-asymptotic regime and operates at filtration pressure equilibrium. These observations offer the theoretical bases for a new design for CAVH hemofilters. As a possible corollary, middle-molecule sieving coefficients were found to be stable with time during CAVH in vivo, whereas in chronic mechanical hemofiltration they declined significantly during clinical treatment. The sieving coefficients, however, were lower in mechanical hemofiltration from the beginning of the session. These observations suggest that the measured sieving coefficient for a membrane is not necessarily a constant directly and solely related to the membrane standard reflection coefficient for a given solute. Concentration polarization and the ultrafiltration rate per unit of surface area may in fact have a major effect on the final concentration of solutes in the ultrafiltrate.

Bicarbonate has been proposed as buffer in CAPD solutions in recent years instead of lactate and acetate. The present study is designed to evaluate peritoneal bicarbonate kinetics using bicarbonate solutions. Seventy kinetic studies have been performed in 7 patients treated with 2 CAPD solutions containing 35 mmol/l (A) and 27 mmol/l (B) of bicarbonate. The changes in dialysate bicarbonate concentration at different dwell times were correlated with bicarbonate blood levels. Furthermore after 2 hours of dwell time and at subsequent observations, no differences in dialysate bicarbonate concentration were found between A and B solutions at the same bicarbonatemia. Thus a feedback between bicarbonate absorption and bicarbonate blood concentration was observed. If the amount of bicarbonate transferred to the patient is over the metabolic acid production, bicarbonatemia will rise: consequently bicarbonate dialysate absorption will decrease. After a few days, an equilibrium point will be reached. In this condition the bicarbonate absorption is equal to metabolic acid production and, in stable clinical conditions, a stable acid base status will be maintained by the patient. Our studies empirically demonstrated that the equilibrium is reached when a difference of 5 mmols between blood and inlet dialysate bicarbonate concentration is observed. Consequently to achieve 25 mmol/l of bicarbonatemia, the bicarbonate concentration of CAPD solution should be about 30 mmol/l.

Desmoid-type fibromatosis (DTF) is a "locally aggressive, but not metastasizing" proliferation of soft tissues that is difficult to diagnose pre-operatively. Surgical en bloc resection of abdominal DTF can be difficult or an overtreatment. The diagnosis is therefore crucial for the decision making to minimize unnecessary morbidity.A 33-year old female patient with an incidental intra-operative diagnosis of a 20 cm mesenteric mass involving the duodenum, jejunum, ileum and right colon underwent extended resection for a DTF. A review of the literature, limited only to mesenteric localization of DTF, was performed for the diagnosis, treatment and outcome.Twentyfive cases of DTF have been analyzed. Pre-operative diagnosis was suspected in 20% but 95,2% of all the patients underwent resection without pre-operative diagnosis. In two cases, intra-operative, frozen section diagnosis was unsuccessfully attempted. Complications were reported in 12%, recurrence in 4%, and mortality in 0% of the patients.Pre-operative diagnosis of mesenteric DTF is challenging in most cases, but it can avoid unnecessary extended surgery. Efforts should be made to achieve a correct pre-operative diagnosis based on more reliable imaging and pathological features, to help in decision making.In accordo con la “World Health Organization”, il tumore desmoide viene definito come una “proliferazione di tipo clonale dei fibroblasti che origina dai tessuti molli posti più in profondità e che risulta essere caratterizzata da una crescita infiltrante con la tendenza a dare delle recidive locali ma con l’incapacità di metastatizzare”. Noi riportiamo il caso di una giovane donna di 33 anni che presentava una sintomatologia aspecifica, con la presenza di una massa palpabile in sede addominale. La prima diagnosi, eseguita in altra Unità Operativa con US, evidenziava una neoformazione classificata come Leiomioma uterino. Il reperto intraoperatorio durante intervento di isterectomia evidenziava, invece, una neoformazione a partenza dal mesentere. L’esecuzione di due esami bioptici estemporanei non ha portato a nessuna diagnosi di certezza. Veniva quindi eseguita una resezione “en bloc”, allargata con criteri oncologici, della massa, comprendendo digiuno, ileo e colon destro. La diagnosi istologica definitiva è stata poi di Tumore Desmoide. La revisione della letteratura condotta con 25 casi di tumore desmoide del mesentere, ha confermato definitivamente come la diagnosi è molto difficile e quasi mai disponibile prima o durante l’intervento chirurgico. Appare quindi chiaro che la prima scelta di trattamento di questa neoplasia rimane quella chirurgica con margini di resezione R0, pur esistendo la possibilità di un trattamento conservativo farmacologico o radioterapico. Il trattamento del Tumore Desmoide rimane comunque difficile e richiede esperienza ed collaborazione interdisciplinare.

Traumatic lesions involving the rectum, perineum and anus are infrequent but difficult to treat, requiring experience with trauma and colo-proctological surgery. The aim of the treatment is to repair the lesions and to minimise the early complications which are the main cause of failure and of late complications and disability. The most complicated lesions present problems concerning either the surgical strategy or the surgical timing, both of which are essential for a successful outcome. The Authors analyse their recent clinical experience with 7 patients with complex traumatic lesions involving the rectum, perineum and anus, excluding those of gynaecological/obstetric origin and those not involving the sphincter. They evaluated the clinical history, causes and types of lesions, as well as treatment, complications and outcomes. Five of the lesions were caused by impalement, one by an explosion and one by a motorboat propeller blade. Six of the patients (85.7%) were treated by direct primary repair and one (14.3%) by secondary repair after a previous colostomy. All 7 patients achieved complete recovery of the lesions. Only two cases (28.6%) of early complications and one case (14.3%) of persistent minimal sphincter dysfunction occurred. On the basis of these good results, the clinical experience and the literature, the Authors suggest that these perineo-ano-rectal lesions, though often complex, may often be cured by early surgery, confining colostomy only to particular cases. In addition to experience with trauma and the timing of colo-proctological surgery, a knowledge of all the available surgical options is mandatory to achieve the best results.

Forty studies of acid-base balance during intermittent peritoneal dialysis (IPD) and during continuous ambulatory peritoneal dialysis (CAPD) were performed on 20 patients who were receiving IPD with acetate buffer (5 patients), IPD with lactate buffer (5 patients), CAPD with acetate buffer (5 patients) and CAPD with lactate buffer (5 patients). Measurements of acetate, lactate and pyruvate levels in blood and dialyzate were taken at different times during dialysis; blood samples for blood gas analysis were drawn at the same times. Calculations of the kinetics of acetate, lactate and bicarbonate during IPD and CAPD were carried out according to the method of Tolchin [1977] but modified for PD. Thus it was possible to quantify the balance of the buffers, their mass transfer rates, bicarbonate generation and the percentage of buffer converted to HCO3. IPD kinetics of acetate and lactate were found to be similar, the main difference being a lower and significant percentage conversion of lactate to bicarbonate (45%) compared to that of acetate to bicarbonate (71%) (P0.005). On CAPD the kinetics of the two buffers was quite different: while the serum lactate level was always low (mean 0.97 +/- 0.33 mM/l), the acetate level was always high (mean 5.12 +/- 3.34 mM/l). Thus the utilization of the two buffers during "acute intermittent" treatment (IPD) and "continuous" treatment (CAPD) is different. On IPD there are no important differences between the two buffers, whilst on CAPD lactate seems to be better and safer than acetate; for instance, serum HCO3 values are relatively constant with lactate (27.7 +/- 2.13 mM/l) while with acetate there is a trend to exceed physiological values (29.5 +/- 1.7 mM/l). When acetate is used in the dialyzate for CAPD the concentration must be less than 38.5 mM/l.

A condition of metabolic alkalosis has been generally observed in patients undergoing regular biofiltration (BF). The aim of this study was to assess buffer kinetics during a dialysis session in five patients regularly treated by BF for 10 months (dialyzer Biospal 3000S, Qb 301; Qd 545; UF 36.76 ml/min; dialysate CH3 COO 38 mEq/L; replacement fluid 1000 ml/h with HCO3 100 mEq/L solution). As usually happens using dialyzers with high surface area and permeability, large HCO3 losses (756 +/- 112 mEq) and CH3COO uptakes (677 +/- 152 mEq) were observed. Acetate plasma levels rose to 10.4 mEq/L, a value potentially dangerous to the cardiovascular system. The dialytic buffer gain (acetate uptake + HCO3 administered - HCO3 loss) was high (230 +/- 137 mEq/dialysis) and excessive for patients' needs. It is therefore very important to reduce either the acetate concentration in dialysate or the amount of reinfused bicarbonate. In view of the plasma acetate levels it is preferable to use a dialysis solution containing less acetate.

Uremic encephalopathy (UE) is a clinical syndrome, closely linked to the progression of renal failure. Many approaches can be utilized to diagnose it: EEG changes, somatosensory evoked potentials, choice reaction time test, cerebrospinal fluid (CSF) studies, brain computerized tomography, plasma and CSF amino acid concentration. On the basis of the data available at present, it is possible to postulate that UE could be caused by amino acid derangements (mainly glutamine, glycine, aromatic and branched-chain amino acids) and by the subsequent imbalance of neurotransmitters (mainly GABA, dopamine, serotonin). Disturbances of mental, neurologic, motor and hormonal functions could derive.

Vaginal evisceration is a rare emergency complication which needs prompt surgical treatment. We report a rare case of a seventy-three year old patient presented with late onset of transvaginal intestinal evisceration, 20 years after hysterectomy. A short review of the literature focused on the last 10 years. The laparoscopic approach represents an additional risk factor for evisceration, but data are poor, and prospective studies are difficult to perform. The treatment of transvaginal evisceration is exclusively surgical, by abdominal, transvaginal or combined abdominal-vaginal approaches along with laparoscopy. The abdominal and combined vaginal-abdominal approaches, allow a complete inspection of the abdominal cavity and to apply a mesh for repairing and preventing recurrences. Transvaginal evisceration despite being rare, can still represent a challenging problem in emergency for general surgeons and gynecologists. Knowledge of the related problems and the surgical approach is mandatory to optimize the outcome.Evisceration Complication, Mesh repair, Post-hysterectomy.L’eviscerazione transvaginale costituisce una emergenza chirurgica piuttosto rara, ma che richiede un tempestivo trattamento chirurgico. Rappresenta una delle complicanze che insorgono dopo isterectomia e può avere un’insorgenza precoce o tardiva. Di seguito viene riportato il caso di una donna di 73 anni giunta alla nostra osservazione con eviscerazione transvaginale del piccolo intestino, verificatasi 20 anni dopo l’intervento di isterectomia. La paziente è stata così sottoposta ad intervento chirurgico: mediante laparotomia mediana le anse intestinali sono state riposizionate in cavità addominale ed essendo in condizioni vitali buone non è stato necessaria la resezione, mentre il difetto vaginale è stato riparato mediante una sutura riassorbibile in punti staccati ed utilizzando una dual mesh in Goretx (Gore Plus ®), fissata alla piccolo bacino così da ricoprire il pavimento pelvico e la sutura vaginale. Negli ultimi 10 anni sono stati riportati 40 casi di eviscerazione vaginale, infatti la sua incidenza dopo isterectomia è bassa sia dopo isterectomia con approccio tradizionale che mininvasivo. Tuttavia è stato notato come l’isterectomia laparoscopica sia un possibile fattore di rischio per l’insorgenza dell’eviscerazione vaginale. Il trattamento dell’eviscerazione è esclusivamente chirurgico, da effettuare in urgenza, eseguibile sia per via laparotomica che per via vaginale o combinando entrambi gli approcci anche utilizzando la chirurgia mininvasiva. La riparazione per via addominale, esclusiva o combinata, è da preferire in quanto permette una completa ispezione della cavità addominale e di poter posizionare una rete protesica al fine di rinforzare il pavimento pelvico e prevenire le recidive. In conclusione l’eviscerazione tran vaginale pur essendo una rara complicanza rappresenta una patologia impegnativa da un punto di vista tecnico e gestionale sia per il chirurgo generale che per il ginecologo, pertanto ulteriori studi sono necessari al fine di migliore l’outcome dei pazienti e prevenirne le recidive.

Different high flux membranes have been recently developed. The present study is aimed at describing the technical features and the clinical performances of a new high flux polysulfone membrane (T-sulfone, Toray, Japan). The study has been carried out on two different dialyzers (surface area = 1.3 and 1.8 m2). The filters have been tested in vivo during hemodialysis and hemodiafiltration. The in vivo study was carried out on 12 ESRD patients on regular hemodialysis treatment. The protocol was reviewed and approved by the local ethical committee. The in vivo clearances (K) at 300 ml/min of blood flow are reported in the following Table: [Table in text]. Beta-2-m reduction ratio exceeded 50% in all sessions. Beta-2-m mass balance executed by collection of spent dialysate and elution from the used filters evidenced that removal is obtained mostly by filtration while absorption is negligible. Excellent tolerance and hemocompatibility was observed in all the studied sessions.

The evolution of hemodialysis therapy has been characterized over the years by the search for reliable devices and supplies, for more efficient treatments and finally for a more tolerable therapy in long term dialysis patients. In this view, three steps can be identified: a) the first step was the creation of safe and reliable vascular access, dialyzers and machines. This step led to the birth of modern dialysis and treatment personalization was the logical consequence. Each patient is a single entity and he requires a specific therapy prescription and delivery. From this concept the search for adequacy and better outcomes has been generated, with the inevitable consequence that newer techniques were explored in the attempt to perform a more efficient and clinically tolerated dialysis therapy. b) The second step was the attempt to consider the intratreatment variations as possible source for dialytic morbidity. In this view, efforts were made to pre-set ultrafiltration and dialysate sodium profiles in the machine to counterbalance the negative effects of uncontrolled water and solute removal. However, this approach failed to provide significant results, because ultrafiltration and sodium profiles were predetermined and no adaptations could be made if the designed profile was inadequate. c) The third step in the evolution of dialysis was the understanding that on-line signals from the machine and from the patients were required in order to prepare and carry out the adequate response and variation of treatment parameters. For this reason a series of sensors have been developed including urea and blood volume sensors which are offering the most important signals from the patient. In this way, accurate responses could be made during treatment and from a simple manual feedback, we have today a completely automatic form of biofeedback. The question that now arises is where to find the financial resources to afford the upcoming technology. Another question is whether this new technology should be for everybody in routine dialysis or it should be designed for specific conditions. In other words, are these toys for nice experimental studies and speculations or are they tools to improve dialytic outcomes and morbidity? Probably, technology cannot be stopped in its evolution. What is exceptional today will probably be part of the routine of tomorrow. It seems that we are struggling more with the complex physiology of human body than with mechanical or electronic problems that certainly find their solution before or after. The increasing use of computers and the evolution of the applied software will certainly help in reducing the costs and improving the performances of our newer dialysis devices.

Pancreatic trauma is a rare event, accounting for approximately 3% of all blunt abdominal traumas. The related mortality is quite high, around 5-30%, mostly due to the associated haemorrhagic lesions and to the delay in establishing the diagnosis, while pancreatic damage is directly responsible for death in only 5-10% of cases. We report here on a case of severe pancreatic trauma, underestimated initially and treated surgically at a later stage. The literature shows that the main difficulty in cases of pancreatic trauma is still related to failure recognizing the injury or to the frequent delay in diagnosing the condition, above all in haemodynamically unstable patients. In these cases, as in the one treated in this report, the clinical evidence and the priority accorded to the treatment of the shock are factors that tend to limit thorough examination. In haemodynamically stable patients, on the other hand, the multislice CT-scan and MR pancreatography-wirsungography are useful for the diagnosis. The treatment can be either conservative or surgical, depending on the extent of the damage, especially to the Wirsung duct. Surgical treatment with preservation of the entire pancreatic parenchyma, as performed in our case, even if technically demanding, makes it possible to maintain the function of the pancreas, thus reducing the risk of metabolic complications.

Conventional continuous extracorporeal treatments such as hemofiltration and hemodiafiltration have not achieved significant reduction in cytokine plasma levels, in spite of their increasing popularity mainly related to the unnecessary fluid restriction thereby rendering adequate caloric intake possible (Actualités Nephrologiques, 1994). This is mainly due to reduced filtration, to saturability of the adsorption-related phenomena and to the absence of a convective mass transfer. New approaches have been more recently introduced. The concept of blood purification has been applied in some new innovative techniques that use non-selective or selective sorbents. We will focus on the criteria used by others and us to assess the efficiency in vitro and in animal models of sepsis of more recently introduced non-selective and selective devices. Among the innovative techniques, modalities aimed at the plasma treatment will receive emphasis. These modalities that are based on plasma filtration with the use of different sorbents. The preliminary results obtained from ongoing clinical trials will be presented. We will also expand on the technical, biological and clinical aspects that should be addressed in order to establish a new modality as innovative in the treatment of sepsis.

Hemangiopericytoma is a rare type of neoplasia originating from the Zimmermann pericytes and can arise in numerous sites. As it is difficult to correlate the histologic aspect with the prognosis, it was considered advisable to take account of other factors such as age and tumoral site. Aggressive surgery followed by irradiation therapy is suggested as the most suitable management. Hyperthermia also was adopted in treating subcutaneous metastasis, but its role has yet to be fully defined.

All haemodynamically stable patients with blunt abdominal trauma can be managed conservatively by non-operative management which is the treatment of choice in 80% of liver trauma. Non-operative management, when feasible, yields very good results in terms of survival, need for blood transfusions, morbidity and reduction of hospital stay. The Authors retrospectively analyse their recent experience with liver trauma. Of 53 patients with blunt liver trauma, 36 underwent surgical treatment whereas 17 haemodynamically stable patients received non-operative management. After CT scans, all patients on non-operative management underwent haemodynamic monitoring, US and blood examinations. A percentage of 47.1 % had aor = grade III trauma. The mortality and morbidity rates were 0% and no blood transfusions were needed. The efficacy of non-operative management was 100% and none of the patients needed subsequent surgical treatment. Our clinical experience demonstrates that non-operative management is feasible and effective even for higher grade traumas, but always requires strict clinical, haemodynamic and US monitoring and careful patient selection. Current progress in the field and recent evidence reported in the literature indicate the likelihood of further developments and more widespread utilisation of non-operative management in liver trauma.

A urea biosensor, inserted into the ultrafiltrate collection-line of paired filtration dialysis (PFD), not only allows on-line dialysis quantification, but also forecasts final (Cend) and 30 min equilibrated urea concentration (Ceq), the most reliable value for calculating dialysis efficiency. The urea biosensor processes plasma ultrafiltrate continuously, delivering a large amount of data to the computer, which estimates the parameters by a mathematical model, thus predicting the whole urea profile with rebound.A multicenter randomized trial on 41 patients was conducted to ascertain the ability of a two-pool variable-volume urea model to forecast Cend and Ceq at 60 and 90 min after the start of dialysis. Two alternative dialytic treatments, A or B, were chosen, the latter being more efficient. Each treatment included six serial PFD. The accuracy of forecasting was evaluated through four indices based on forecast errors, calculated as the difference between observed and forecasted urea values: mean percent error (MPE) (%), mean absolute deviation (MAD) (mg/dl), mean absolute percent error (MAPE) (%) and root mean squared error (RMSE) (mg/dl).Forecasted urea concentrations were lower than those measured by the biosensor. MPE for Cend was negligible in A (+1.2%) and much higher in B (+7.2%); both values improved at 90 min, +1.0% and +5.8%, respectively. MAD for Cend was similar in both treatments and improved slightly at 90 min, ranging from 4.9 to 5.9 mg/dl. MPE for Ceq was +4% in A and and more than doubled in B (+11.5%); both values improved at 90 min, +3.7% and +9.7%, respectively. MAD for Ceq was 7.5 mg/dl in A and 8.5 mg/dl in B; both improved at 90 min, 6.7 and 7.4 m g/dl, respectively. The other indices, MAPE and RMSE, showed similar results. Comparison between the errors of the two treatments with analysis of variance (ANOVA) for repeated measures gave no significant results.Our model forecasts of urea concentrations were overall lower than the measured ones: the bias was negligible for A-Cend, greater for the A-Ceq and when the more efficient treatment B was used. The 60 min predictions improved at 90 min. The comparison between the prediction errors in the two treatments were not statistically significant. The recirculation measurement would probably reduce the bias if it were properly incorporated into the model.

We investigated the pharmacokinetics of cefuroxime sodium, a new parenteral beta-lactam antibiotic, in 15 patients with stable chronic renal failure during intermittent peritoneal dialysis (IPD). Eight patients were administered 1 g cefuroxime as an intravenous bolus 1 h before the start of dialysis. Mean plasma levels of cefuroxime fell from 80 mcg/ml at 1 h to 40 mcg/ml at 6-8 h. At 24 h, concentrations were higher than 20 mcg/ml. In peritoneal fluid cefuroxime reached 16.7 mcg/ml at 1 h and 7.55 mcg/ml at 6 h. Seven patients received cefuroxime added to the dialysis solution at a dose of 2.5 g/10 liters. After 6 h of dialysis, cefuroxime reached plasma levels of 60 mcg/ml; after 24 h, concentrations were 37.5 mcg/ml. These results demonstrate that cefuroxime, administered by the i.v. route, easily diffuses from blood to peritoneal fluid and, from peritoneal fluid to blood when added to the dialysis solution. In both cases concentrations reached by cefuroxime are sufficient to treat peritoneal infections associated with peritoneal dialysis.