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Parathyroid carcinoma is a rare disease in normal population as well as in patients with end-stage renal disease. Approximately 700 cases have been reported and, of these, 20 occurred in patients receiving chronic hemodialysis. We describe a case of parathyroid carcinoma in a 59-year-old female patient with end-stage renal disease secondary to membranous glomerulonephritis treated by hemodialysis since 1995. In September 1998, the calcium level was 12.4 mg/dl and intact parathyroid hormone serum levels were 1366 pg/ml (normal range, 25-65). A routine ultrasonographic examination of the neck revealed enlargement of two parathyroid glands, the left inferior gland being the largest and measuring 2x3x2 cm. In October 1998, resection of two parathyroid glands was performed. On the basis of histology, which documented the presence of proliferating cells arranged in sheets or in a trabecular pattern, numerous mitosis and vascular invasion, a diagnosis of parathyroid carcinoma was made.

Malnutrition is common in hemodialysis patients and is a powerful predictor of morbidity and mortality. Although much progress has been made in recent years in identifying the causes and pathogenesis of malnutrition in hemodialysis patients, as well as recognizing the link between malnutrition and morbidity and mortality, no consensus has been reached concerning its management. Along with such conventional interventions as nutritional counseling, oral nutritional supplements, and intradialytic parenteral nutrition, novel preventive and therapeutic strategies have been tested, such as appetite stimulants, growth hormone, androgenic anabolic steroids, and anti-inflammatory drugs, with contradictory and nonconclusive results. Malnutrition still remains a great challenge for nephrologists in the third millennium.

Background: Among the causes of malnutrition in hemodialysis (HD) patients, inadequate dietary intake (IDI) seems to be one of the most frequent and important. Although it has been hypothesized that IDI might be secondary to uremia, anorexia, underlying illness, psychosocial conditions, loss of dentures, depression, aging, or chronic inflammation, definite data on the etiology of IDI in HD patients are still lacking. The goal of this study was to measure the actual dietary energy and protein intakes in stable HD patients and to evaluate which demographic, clinical, dialytic, and humoral variables were associated with a dietary intake lower than recommended by international guidelines., Methods: Thirty-seven patients maintained on regular HD, 3 times per week for 4 hours per session, were included in the study. In addition to epidemiologic data, patients were scrutinized for dry weight, weight change in the last 6 months, height, Body Mass Index, Kt/V, serum leptin, leptin-BMI ratio, presence of anorexia, and dietary energy and protein intake. Anorexia was assessed by means of a questionnaire in which the presence of major symptoms, namely meat aversion, taste and smell alterations, nausea and/or vomiting, and early satiety, was investigated. Dietary intake was recorded for 3 days after questionnaire administration by means of 3-day diet diaries., Results: Overall, the mean (+/- standard deviation) dietary energy and protein intakes were 24.9 +/- 10.1 kcal/kg/day and 0.64 +/- 0.4 g protein/kg/day, respectively. Twenty-six patients (70.2%) had energy and protein intakes lower than recommended, 7 (18.9%) had adequate energy intake but inadequate protein intake, 1 (2.7%) had adequate protein intake and inadequate energy intake, and 3 (8.1%) had both adequate energy and adequate protein intakes. Anorexia was present in 14 of the 26 (53%) patients with low protein and energy intakes, and was absent in the other groups ( P =.003). The age of patients with inadequate energy and protein intakes was significantly higher than the age of patients with adequate energy and protein intakes (62.1 +/- 10.4 versus 37 +/- 20.8, P <.001) and the age of patients with only adequate energy intake (40.5 +/- 10.4, P <.001). Twenty-seven patients (73%) had an energy intake <30 kcal/kg/day, and 10 (27%) had an energy intake > or =30 kcal/kg/day. Compared with patients with energy intakes > or =30 kcal/kg/day, patients with energy intakes <30 kcal/kg/day were significantly older ( P =.0001) and more frequently were anorexic (P <.05). Compared with patients with protein intakes > or =1.2 g/kg/day, patients with protein intakes <1.2 g/kg/day were significantly older (P <.001). Limiting the analysis to the 33 patients with protein intakes <1.2 g/kg/day, we found a significant negative correlation between age and energy intake ( r =-0.612; P <.001) and between age and protein intake ( r =-0.723; P <.001). Correlations between both energy and protein intakes and age, dialytic age, Kt/V, C-reactive protein, parathyroid hormone, and leptin-BMI were not statistically significant., Conclusions: This study shows that dietary energy and protein intakes are inadequate in the majority of HD patients and are negatively related to the presence of anorexia and age. These data may be potentially useful in the identification of nutritional strategies as well as in improving food intake in HD patients.

Background: This study was aimed at evaluating the determinants of postoperative dialysis-requiring acute renal failure and at identifying eventual correlations between the different etiologic mechanisms and postoperative prognosis., Methods: We evaluated the preoperative and intraoperative features of the 69 out of 6,542 consecutive cardiac surgery patients who developed postoperative dialysis-requiring acute renal failure at our Institution during a 10-year period., Results: Age, valvular and aortic surgery, hypertension, extracardiac vasculopathy, timing of surgery, cardiopulmonary bypass time, and preoperative creatinine level greater than 2.0 mg/dL were identified as predictors by multivariate analysis. In a second analysis, patients were divided in two groups according to the preoperative creatinine level: group A (preoperative creatinine 2.0 mg/dL or less; 38 cases) and group B (preoperative creatinine 2.1 mg/dL or more; 31 cases). The two groups significantly differed in preoperative and intraoperative characteristics and in postoperative outcome: group A patients were younger, had a lower incidence of cardiac and vascular risk factors and comorbidities, were mainly operated on urgent or emergent basis for valvular or aortic pathologies, had longer cardiopulmonary bypass and cross-clamp time, and worse in-hospital outcome but higher midterm survival. Group B patients were older, had a higher prevalence of comorbidities, required more often in-hospital or after-discharge dialysis, had lower in-hospital mortality, but reduced midterm survival., Conclusions: Postoperative dialysis-requiring acute renal failure can be the result of two different pathophysiological pathways: complicated perioperative course due to urgent-emergent surgery or main intraoperative technical complications in patients with preoperative normal renal function and uncomplicated perioperative course associated with reduced preoperative kidney function. The two patient groups significantly differ in baseline preoperative features, as well as in in-hospital and in midterm outcome.

Background: Hemodiafiltration (HFR) with on-line regeneration of the ultrafiltrate, a technique of hemodiafiltration in which the ultrafiltrate passes through a cartridge containing uncoated charcoal, has been shown to be safe, simple, and well tolerated and has been claimed to improve nutritional status or to prevent its deterioration while decreasing the inflammatory response via a reduced production of proinflammatory cytokines. The purpose of the present prospective study was to ascertain whether HRF improves the nutritional status, reduces microinflammation, and decreases serum beta2-microglobulin levels in patients with end-stage renal disease (ESRD)., Methods: Eight patients, four males and four females, with a mean age of 49.4 +/- 16.8 years, stable on hemodialysis over a period of 8.7 +/- 6.1 years and on standard 4-4.5 h three-times-a-week bicarbonate hemodialysis, were switched to three-times-a-week, 4-h HFR. At baseline and every two months for 12 months at mid-week, serum levels of urea, creatinine, albumin, total cholesterol, C-reactive protein, fibrinogen, complement, ferritin, beta2-microglobulin, intact parathyroid hormone (PTH), hemoglobin concentrations, and hematocrit and the EPO weekly dose were determined. At baseline and at the end of the study, the Malnutrition Inflammatory Score (MIS) was calculated., Results: Nutritional and inflammatory parameters remained constant during the 12-month period of the study. After 12 months of HFR, the MIS trended to be lower, but the difference was not statistically significant. Serum beta2-microglobulin and PTH levels remained constant during all time intervals. Neither hematocrit nor hemoglobin changed over the course of the study as well as the weekly EPO dose., Conclusion: The change from bicarbonate hemodialysis to HFR was safe and well tolerated but was not associated with an improvement of nutritional and inflammatory parameters or a reduction of serum beta2-microglobulin levels.

Bone implants must simultaneously satisfy many requirements, even though the surface properties remain a crucial aspect in osseointegration success. Since a single material with a uniform structure cannot satisfy all of these requirements, composite materials specifically designed for orthopedic or dental implant application should be envisaged. Two poly(methylmethacrylate)/hydroxyapatite composites reinforced by E-glass fibres, uncoated (PMMA/HA/Glass) and poly(2-hydroxyethyl methacrylate) (PMMA/HA/Glass+pHEMA) coated by the biomimetic method, were mechanically (push-out test) and histomorphometrically (Affinity Index, AI) investigated in an in vivo rabbit model. Cylindrical implants (diameter 2 mm x 5 mm length) were inserted into rabbit femoral cortical (mid-diaphysis) and cancellous (distal epiphysis) bone, under general anesthesia. The highest values of push-out force and ultimate shear strength were observed for the PMMA/HA/Glass at 12 weeks, which significantly (p < 0.001) differed from those of PMMA/HA/Glass+pHEMA at the same experimental time and from those of PMMA/HA/Glass at 4 weeks. At both experimental times, significantly (p < 0.0005) lower values of AI were observed in the PMMA/HA/Glass+pHEMA versus PMMA/HA/Glass (distal femoral epiphysis: 4 weeks = 33%; 12 weeks = 19%; femoral diaphysis: 4 weeks = 15%; 12 weeks = 11%). The good mechanical and histomorphometric results obtained with PMMA/HA/Glass should be followed by further evaluation of bone remodeling processes and mechanical strength around loaded PMMA/HA/Glass implants at longer experimental times. Finally, the biomimetic method applied to pHEMA needs to be further investigated in order to improve the positive effect of SBF on pHEMA and to enhance the coating adhesion.

Background and Aims: Hyperleptinemia is a common feature in hemodialysis (HD) patients. However, the role of increased serum leptin levels in the pathogenesis of HD-related anorexia is still controversial. The purpose of the present prospective study was to ascertain whether hyperleptinemia is causally implicated in the pathogenesis of HD-related anorexia., Methods: We measured the serum leptin levels and the serum leptin/body mass index (BMI) ratio in 24 healthy subjects and in 49 end-stage renal disease patients on maintenance HD. HD patients were subdivided into anorexic (14/49, 28.5%) and non-anorexic (35/49, 71.5%) according to a questionnaire discriminating for the presence of anorexia-related symptoms., Results: Calorie (kcal/kg/day) and protein (g/ kg/day) intakes were significantly lower in anorexic than in non-anorexic patients (20.1 +/- 1.1 vs. 27.9 +/- 1.3, p = 0.004, and 0.82 +/- 0.05 vs. 1.19 +/- 0.05, p = 0.001, respectively). Accordingly, serum albumin, total lymphocyte count, mid-arm muscle circumference, and the protein equivalence of nitrogen appearance (PNA) were significantly lower in anorexic patients. The serum leptin concentration (ng/ml) was significantly higher in HD patients than in controls, in males (15.33 +/- 3.4 vs. 3.7 +/- 0.3, p = 0.003) and in females (42.3 +/- 7.2 vs. 10.5 +/- 1.3, p = 0.03). Similarly, serum leptin/BMI ratio was significantly higher in HD patients than in controls, in males (0.56 +/- 0.1 vs. 0.16 +/- 0.02, p = 0.0028) and in females (1.8 +/- 0.2 vs. 0.4 +/- 0.04, p < 0.0001). However, serum leptin levels were similar in anorexic and in non-anorexic patients, in males (15.3 +/- 5.6 vs. 16.9 +/- 4.2, p = 0.85) and in females (46.6 +/- 12.9 vs. 47.4 +/- 9.4, p = 0.96). No differences were observed between the 2 groups in the serum leptin/BMI ratio, in males (0.59 +/- 0.2 vs. 0.58 +/- 0.14, p = 0.92) and in females (1.5 +/- 0.4 vs. 1.8 +/- 0.3, p = 0.94). Similarly, no statistically significant differences in terms of serum leptin levels and leptin/BMI ratio were observed between patients with dietary energy intake of <30 or > or =30 kcal/kg/day and between those with a dietary protein intake of <1.2 or > or =1.2 g/kg/day. No significant correlations were found between serum leptin levels and PNA, albumin, cholesterol, total lymphocytes number, weight change, C-reactive protein, fibrinogen, ferritin, and complement., Conclusion: The present results indicate that mechanisms other than increases in serum leptin levels might be involved in the pathogenesis of HD-related anorexia., (Copyright 2004 S. Karger AG, Basel)

Background: In patients in chronic hemodialysis via upper extremity arteriovenous fistula in whom ipsilateral internal thoracic artery graft was used for myocardial revascularization, hemodynamic interference between the fistula and the graft during dialysis can be hypothesized., Methods and Results: In 5 patients undergoing chronic hemodialysis via upper extremity arteriovenous fistula, ipsilateral to an internal thoracic to left anterior descending graft mammary flow was studied by means of transthoracic echo-color Doppler at baseline and during hemodialysis. Flow in the contralateral mammary artery was used as control. Transthoracic echocardiography was performed in concomitance with flow evaluation to assess eventual modifications of left ventricular segmental wall motion. Immediately after hemodialysis pump start there was a marked reduction of peak systolic and end-diastolic velocities and time average mean velocity and flow in the ITA ipsilateral to the fistula, whereas no substantial hemodynamic modification was evident in the contralateral artery. Dialysis-induced reduction of ipsilateral ITA flow was accompanied by evidence of hypokinesia of the anterior left ventricular wall. Three cases also experienced clinical angina., Conclusions: Hemodynamically evident flow steal and consequent myocardial ischemia develop during hemodialysis in patients with upper extremity arteriovenous fistula and ipsilateral internal thoracic artery to coronary graft. These data have major implications for patients' management, both for nephrologists and cardiac surgeons.

Background: The use of interferon-alpha (IFN-alpha) to treat viral hepatitis C (HCV) occurring in kidney transplant recipients is controversial. This study reports an HCV patient successfully treated with IFN-alpha therapy achieving sustained response, negative serum HCV-mRNA and the disappearance of HCV antibodies, without impairment of renal function., Method: A young kidney transplant recipient developed a proven HCV infection 70 months post-transplantation. The patient received IFN-alpha therapy, and for a 32-month follow-up period was evaluated clinically, serologically and virologically., Results: IFN-alpha therapy resulted in normal transaminase activities within 2 months. Serum HCV-mRNA was negative after 4 weeks of treatment and is still negative. Ten months after IFN-alpha therapy withdrawal, the enzyme immunoassay revealed that HCV antibodies (HCVAb) were absent in the serum. IFN-alpha therapy was safe, well tolerated and renal function was not impaired.

Background: Pregnancy is uncommon in women with end-stage renal disease (ESRD) requiring chronic dialysis. An increasing number of successful pregnancies in women in hemodialytic treatment have been recently reported but few institutions experienced more than one or two cases of pregnancy., Methods: Between 1988-1998 five pregnancies in patients receiving hemodialysis were observed in our center. Medical records of these patients were reviewed., Results: At the conception the mean age was 27 years. One patient started dialysis after conception. All patients received bicarbonate dialysis. Three patients were dialyzed six times per week, the other two patients three-four times per week. The dry weight was increased progressively; on average of 1.2 +/- 0.5 kg in the first trimester and of 0.5 kg per week since the second trimester. The predialysis BUN was maintained between 50-100 mg/dL (17.85-35,70 mmol/L) during the pregnancy. Four patients were treated with erythropoietin to maintain hematocrit between 30-35%. Erythropoietin related-complications were not observed. Polyhydramnios was observed in all cases. All deliveries occurred before term. The mean gestational age of infants was 28.6 +/- 4 weeks. Four out of five pregnancies resulted in liveborn infants. Two infants had an Apgar score of zero. All neonates were of low birth weight (1,431 +/- 738 g) with percentile of birth weight in the normal range. No one was small for date., Conclusion: A successful pregnancy is possible in women on chronic dialysis. Prematurity occurs frequently as well as low weight birth leading to increased perinatal morbidity and mortality.

Background: Loss of lean body mass is frequently reported in patients with end-stage renal disease (ES-RD). Inadequate nutrient intake, superimposed illnesses, endocrine disorders, uremia and acidosis are some of the potential causes of muscle depletion. Previous reports on experimental models show that lean body mass depletion results from enhancement of muscle tissue protein catabolism, mainly associated with activation of ATP-ubiquitin-dependent proteolysis. Little is known, however, about the affects on this proteolytic system in ESRD patients on maintenance hemodialysis (HD). The present study was designed to investigate the expression of ubiquitin mRNAs in skeletal muscle of patients with ESRD on maintenance HD., Methods: Biopsies from the rectus abdominis muscle were obtained from eight ESRD patients and from six control subjects undergoing surgery for benign disease. Ubiquitin mRNA levels were measured by Northern blotting analysis., Results: Patients with ESRD had mild metabolic acidosis, as a result of chronic intermittent HD. There were no significant differences between HD patients and controls with regard to the 1.2kb polyubiquitin mRNA species (332.9+/-139 vs 324.2+/-60; ns), but the levels of the 2.4 kb mRNA species were significantly lower in HD patients than in controls (1687+/-542 vs 2529.9+/-325, p=0.01). No correlation was observed between ubiquitin mRNA levels and nutritional parameters and degree of acidosis., Conclusions: The present study found that the ubiquitin mRNA levels were not increased in the muscle of stable, mildly acidotic hemodialysis patients.

The biomimetic method was used in order to deposit, on titanium substrates, an hydroxyapatite (HA) coating. The bioactive HA layer was obtained by using, in the first stage of the process, a glass having the composition 2.5CaO.2SiO(2) different from the one proposed for the application of the biomimetic method. This glass can be obtained via sol-gel, a method that allows one to obtain, easily, very pure products. The growth of HA crystals was confirmed by Fourier transform infrared, SEM, EDS and X-ray photoelectron spectroscopy (XPS) results. The experimental results suggest that, as reported in the literature for other supports, the silicate ions released from the glass in the first stage bind themselves to the titanium support. In particular, from XPS analysis it is evident that the titanium substrate is well covered by a calcium phosphate layer of the type of HA.

Glasses were prepared whose compositions are defined by the following general formula: (2.5 - x)CaO x x/3M2O3 x 2SiO2 (0 < or = x < or = 0.6) (M = Ga, Al, In). Their bioactivity was studied "in vitro" by soaking the glasses in a simulated body fluid (SBF). The consequent formation of calcium phosphate layer was studied by means of electron microscopy (EM) equipped with an energy-dispersive system (EDS) for elemental analysis and Infrared (IR) spectroscopy. The results are compared to the literature relative to the substitution of La2O3 and Y2O3 for CaO. It is observed that, in general, the substitution of M2O3 for CaO in the binary CaO-SiO2 glass composition progressively reduces the ability to form a calcium phosphate layer on the surfaces exposed to simulated body fluid (SBF). The composition limit can be related to the ionic field strength of the substituting cation and to the CaO content of the base glass. According to the mechanism reported in the literature a silica gel-like surface layer initially forms on the surfaces exposed to SBF. The observed results can be attributed to the effect of the substitution of M2O3 for CaO on the acidic properties of the silanolic groups.

Poly(2-hydroxyethyl methacrylates) (PHEMAs) structurally modified by means of polymer blends and random copolymers are intensively studied in order to improve mechanical properties. It was recently shown that a hydroxyapatite coating, which should improve the bonding of this biomaterial to the bone, can be obtained by means of the biomimetic method. When PHEMA is submitted to the biomimetic method, its swelling ratio is improved. This can be ascribed to the deposition of a silicatic layer, which improves the hydrophilicity, on the surface of the internal pores during the first stage of the method. This appears to be a valuable result for producing modified PHEMAs with improved mechanical properties and good swelling. The experimental results indicate the following: stronger interactions with the water molecules are set up, an induction period is observed that is linked to the rate of the reactions occurring at the surface of the glass and the establishment of a convenient concentration of the silicate ions at the external surface of the polymer, and the diffusion of simulated body fluid into the pores is the limiting stage of the process., (Copyright 2001 John Wiley & Sons, Inc.)

Background: A retrospective study was conducted to determine incidence and predisposing factors of incisional hernia after an emergency midline laparotomy., Patients and Methods: The study population consisted in 197 patients of whom 138 were followed-up for 2 years after surgery., Results: An incisional hernia developed in 25 (18.1%) patients at a mean follow-up of 11.2 months. Multivariate analysis showed the importance of age (> 60 years, p < 0.004), obesity (p < 0.008) and occurrence of post-operative wound infection (p < 0.00001) for the development of an incisional hernia. Univariate analysis showed that intestinal occlusion (p < 0.02), peritonitis (p < 0.006), upper abdominal access (p < 0.04) and post-operative wound infection (p < 0.003) in older patients and obesity (p < 0.003) and the presence of a neoplasm (p < 0.006) in younger patients, played a significant role. The comparison between young and old patients showed that upper abdominal access (p < 0.007), interrupted and layered wound closure (p < 0.02 and p < 0.01, respectively) and contamination of the operative field (p < 0.004) played a statistically significant role in older patients., Conclusions: The rate of incisional hernia after an emergency midline laparotomy is higher than after elective procedures. However, it could be reduced with proper attention to the suture technique, i.e. mass and continuous suture, better preparation of the operative field and scrupulous sterility throughout the procedure in order to decrease the incidence of post-operative wound infection.

In order to evaluate the risk connected with wood dust exposure in millwork on a group of 13 craft industries, 74 area dust samplings and 74 personal dust samplings were made. In personal samplings both the total portion and the respirable fraction were calculated. Area samplings showed dust levels (average, standard deviation, fiducial limit, FLS95%) under ACGIH TLV-TWA for soft wood dust: TLV-TWA for hard wood was basically reached, and OTL levels gave evidence for high risk of exceeding TLV-TWA in the medium-long term. The exposure levels by personal samplings (average, standard deviation, fiducial limit, FLS95%) were clearly over TLV-TWA, both for hard woods and, although less clear, for soft woods. OTL levels gave evidence for a frankly unacceptable exposure condition in the medium-long term. Differences between average levels of total dust exposure (2.5 mg/m3) and respirable portion (2.3 mg/m3) were not statistically significant (p > 0.05) as well as the differences among the 4 groups of companies with homogeneous product activity (p > 0.05). In consideration of toxicological peculiarity of wood dust and carcinogenicity of wood manufacture as exposure circumstances classified in group 1 by IARC, the results show the need for prevention measures to reduce workers' exposure risk, by means of environmental improvement and better work organization, technological structures, individual attitudes and personal protection.

The present study is concerned with the influence of processes occurring during dialysis on the antioxidant capacity of plasma and saliva. The biological fluids were also tested for uric acid and total protein content. Before hemodialysis, plasma antioxidant status of hemodialyzed patients appears slightly higher than the corresponding status in normal subjects; after hemodialysis it is found unchanged. The result can be explained by a balance between a reduction in uric acid plasma content, due to the dialytic procedure, and an increase in protein content, possibly due to a dialysis-related hemoconcentration. Moreover, pre-dialysis total antioxidant capacity of whole saliva samples is higher than in healthy individuals and drastically decreases towards normal values following dialytic procedure. Our data indicate a certain concentration of the uric acid in the saliva of hemodialyzed patients and evidence that both total protein concentration and uric acid level show a good correlation with saliva total antioxidant capacity, suggesting that proteins are major antioxidants of this fluid. Further observations are needed to assess whether this improved saliva antioxidant ability has any consequence on the periodontal conditions of hemodialyzed subjects.

Background: Round-tipped blunt needle (BN) may decrease the risk of needlestick injuries and hand contamination. We prospectively determined the incidence of glove perforations in emergency abdominal procedures and the efficacy of BN in increasing the safety for surgeons., Methods: Two hundred patients were randomized to undergo closure of the abdominal fascia using sharp needle (SN) or BN. Gloves were tested at the end of the procedure., Results: Surgeons had 14 needlestick injuries and 76 perforations recorded in 69 pair of gloves. Sharp needles were responsible for all injuries and 58 (76%) perforations (P < 0.00004 and P < 0.00001, respectively). This difference was still higher when considering the perforations related to the abdominal fascia closure (BN 7% versus SN 50%; P < 0.0006)., Conclusion: The risk of glove perforation is sevenfold greater if SN are used. Blunt needles reduce sharp injuries and improve safety for surgeons.

Pheochromocytoma (Pheo) is an uncommon neoplasm producing blood pressure troubles and it may be undiagnosed in chronic dialyzed patients in whom hypertension is a common finding. The symptoms in Pheo syndrome depends on the prevalent catecholamine released, the most common being epinephrine (E) and norepinephrine (NE). Recently, a particular clinical picture has been described for dopamine (DA)-producing Pheos, in whom a normo-hypotensive status is more often observed. The authors report a case of mainly dopamine-producing Pheo in a long-term dialyzed patient, successfully treated with adrenalectomy. The main steps in diagnosis and preoperative management are described and debated also in view of the particular background produced by the end-stage renal failure. The common imaging techniques adopted for adrenal medullary neoplasms (US, CT, MIBG scintiscan) confirmed to be decisive for diagnosis; HPLC assay of plasma catecholamines is the only biochemical test available in these patients although its significance is questionable due to the poor knowledge of catecholamine metabolism in chronic renal failure. The clinical findings observed in this case seem in disagreement with those already reported in DA producing Pheos. Pheo in hemodialyzed patients is a rare event and it may be hidden by other more common causes of hypertension. However, more awareness from the medical staff allows to diagnose the neoplasm correctly by the currently available methods and to plan a safe surgical therapy also in high-risk patients.

An unusual case of alimentary tract duplication located in the left anterior mediastinum and observed in a 37-year-old woman is reported. Resection of the lesion through a left thoracotomy approach was resolutive and followed by an excellent long term outcome. Etiology, diagnosis and therapeutic problems as well as differential diagnosis with benign and malignant chest lesions of adult population are briefly discussed.

The Authors propose an organizational model for a surgical day hospital program, which is being used for a pilot day surgery unit in the I Department of Surgery of the Rome University "La Sapienza". The program requires little capital investment, as it is closely linked, geographically and administratively, to the main surgical unit, and uses the present staff, facilities and support services. The model is based on a computerized LAN (Local Area Network), providing fast recording, scheduling, management and trannsfer of medical data for each patient. The present situation is reported in detail. Data from the authors' outpatient department for 1988, have been recorded and elaborated. The results show a low use of surgical day care, limited to minor surgical procedures, and with not a single operation performed under general anesthesia. The authors hope to see a growth in the use of day surgery and a more selective use of inpatient care.

Troponin C has been suggested as a possible target for the negative inotropic action of volatile anesthetics. This study has examined the effect of halothane on the structure and response of isolated cardiac troponin C to Ca2+ and the response of skinned soleus and cardiac muscle fibers to Ca2+. The high-affinity Ca(2+)-binding sites of cardiac troponin C were assessed by measurement of the change in intrinsic tyrosine fluorescence and ultraviolet circular dichroism in response to Ca2+ in the presence and absence of halothane. Halothane (0.9 mM, 1.4%) did not alter the 45% enhancement in intrinsic tyrosine fluorescence that occurs with saturation of the high-affinity sites or change the Ca2+ concentration at which half-maximal enhancement occurred. The molar ellipticity in the far ultraviolet region, a measure of the secondary structure, increased to a similar extent with addition of 10(-6) M Ca2+ in the absence and presence of 1.0 mM (1.6%) halothane. The binding rate of the sulfhydryl reagent, 5,5'-dithiobis (2-nitrobenzoic acid), to troponin C in response to Ca2+ titration was used as a measure of the integrity of the low-affinity Ca(2+)-binding site in troponin C in the presence and absence of 1.0 mM (1.6%) halothane. The rate of reaction was stimulated twofold, and the half maximal effect was observed at pCa 4.8 +/- 0.2 in both control and halothane-treated samples. Halothane (5 mM; 7.8%) did not change the pCa/tension response of skinned soleus fibers; the data were fit to the Hill equation and yielded dissociation constants of 6.2 x 10(-7) M for control and halothane-treated specimens.(ABSTRACT TRUNCATED AT 250 WORDS)

The existence of two allelic determinants, subtypic to W28 (named TO54 and TO55), and of an antibody cross-reacting W28 times HL-A10, is demonstrated. These new determinants have been studied by means of population and family studies and with the following serological techniques: absorption, elution, lysostrip and blocking by F(ab)-2 fragment. The results suggest that determinants TO54 and TO55 are very similar each other and are spatially close to the supertypic factor.

The distribution of T-lymphocyte subpopulations bearing receptors for the Fc portion of IgG (TG) or IgM (TM) was monitored in 22 renal allograft recipients treated with immunosuppressive therapy and in 10 uraemic patients on haemodialysis. No significant difference in the distribution of T cells and T-cell subsets was found between normal controls and haemodialysed patients. In transplanted patients, however, a significant reduction of the total T-cell percentage (P less than 0.005), of TM subset percentage (P less than 0.025) and absolute number (P less than 0.005) and of TG absolute number (P less than 0.05) was observed. Considering patients with allografts functioning for more than 1 year only, the reduction in TM cells in terms of percentage (P less than 0.0005) and absolute number (P less than 0.025) was significant, while TG subset levels did not change significantly. In patients transplanted less than 1 year previous to our study, total T cells and T-cell subsets were reduced significantly only as absolute numbers. During the 1st year we observed several increments of TM values towards normal levels, especially in the first 2 months after transplantation. During this period, TM subset levels sharply increased at acute rejection crisis and returned to previous values with rejection reversal. Our results suggest that the TM subset plays a prominent role in the mechanisms involved in the immunological response to allografts, and therefore repeated TM cell monitoring could be useful in the follow-up of renal transplant patients.

Restricted ocular myasthenia gravis (OMG) and generalised myasthenia gravis (GMG) have been shown to differ in a number of respects. In OMG, antiacetylcholine receptor, antistriational and antinuclear antibodies were rare relative to their frequency in GMG. In contrast, antithyroid antibodies and a history of thyroid disease were much more prevalent in OMG than in GMG, OMG was not associated with the female predominance seen in GMG and appeared to be relatively common in some races rather than others. It is suggested that different pathogenetic mechanisms are responsible for these two forms of MG.

Fenoterol with ipratropium bromide (Duovent) is a recently used combination between an anticholinergic and a beta-adrenergic drug useful in obtaining a more effective bronchodilatation and/or reducing the single drug doses. It has been suggested that, as in the case of beta-agonists, its clinical efficacy may be limited by the development of tolerance. We studied the effects of inhaled Duovent in 15 asthmatic patients for 3 months, using a rigidly controlled protocol. Appropriate serial physiological measurements were made at regular intervals during the 90-day study. In all instances the day-one bronchodilator response was significant, prompt and sustained: at 1, 4, 8 and 12 weeks the response was statistically the same as on day 1. It is concluded that, when the important variables are properly controlled, no evidence of tolerance to long-term therapy with Duovent is demonstrable.

In order to avoid the host foreign-body reaction which is probably responsible for the long-term failure of the artificial membrane diffusion chambers currently used for protecting the implanted islet tissue from rejection, we tested the human amniotic membrane as a possible new tool for enclosing transplanted islets of Langerhans. Bag-shaped chambers were made with human amniotic membranes and the diffusion of 125 I-Insulin out and of D-glucose into the chambers was measured. The diffusion patterns of insulin and glucose were shown to be better than those described for the best artificial membranes, the 50% diffusion being reached at min 42 for 125 I-Insulin and at min 11 for D-glucose. Moreover, it was shown that no lymphocytes diffused into the amniotic membrane chambers. These results, together with the already known characteristics of the human amniotic membrane, induce us to propose it as a suitable material for further experimental work in islet tissue transplantation.

A double-blind study was carried out in a group of 9 patients with partially reversible airway obstruction, to evaluate the bronchodilator effect of gradually increased doses of fenoterol (cumulative doses: 100, 200, 400, 800 and 1,600 micrograms), ipratropium bromide (40, 80, 160, 320 and 640 micrograms) and a combination of these (100 + 40, 200 + 80 micrograms, etc.), denominated Duovent. The three treatments were carried out at random at the same time on 3 days, usually not consecutive days, whereby 1, 1, 2, 4 and 8 puffs (altogether 1, 2, 4, 8 and 16 doses) of each product were given in identical pressurized aerosols at intervals of 60 min. Respiratory (spirometry and flow-volume curve) and cardiovascular (blood pressure, heart rate) parameters were measured under basal conditions and 60 min after each administration. On average, with all three products, the bronchodilatory effect showed a linear correlation with the logarithm of the dose given. With the same number of puffs the side-effects (tremor in particular) of the combination fenoterol and ipratropium bromide or Duovent (FIB) were markedly fewer than those of fenoterol, while ipratropium bromide was very well tolerated. The three dose-response curves (parallel) show that, in respect of an increase in FEV1, 1 puff of Duovent (100 micrograms fenoterol + 40 micrograms ipratropium bromide) is approximately equal to 2 puffs of fenoterol (200 micrograms) and 4 puffs of ipratropium bromide (160 micrograms). FIB, therefore, makes it possible to maintain the same bronchodilatory effect as the full dose (400 micrograms) of fenoterol while improving the therapeutic value.

In ten angina patients responding with a myocardial anaerobic metabolic pattern to isoproterenol infusion, a new beta-blocking agent, bunitrolol, was effective in normalizing the myocardial lactate extraction ratio. The correlation with lipid metabolism was also interesting because beta-blocker action reduced significantly arterial non-esterified fatty acids (NEFA) level as well as myocardial NEFA extraction. The metabolic behavior suggests the effectiveness of bunitrolol in the treatment of ischemic heart disease.

The human allogeneic serum RM3 recognizes a lymphocyte structure inherited with the HLA chromosome. Population studies show several positive associations with antigens of the HLA-A and HLA-B series. Negative association have been found with antigens of the HLA-C series. Moreover the distribution of the RM3 factor is in Hardy-Weinberg equilibrium with that of the HLA-C alleles. However, serological investigations (namely the 'lysostrip' technique) bring evidence that RM3 serum does not appear to contain antibodies directed against any of the antigens of the HLA-A, B and C series. The study of a segregant family, showing a crossing over between the HLA-A and HLA-B loci, shows that the RM3 factor segregates on the side of the HLA-A locus. In conclusion, within the limits of the serological approach used, the present study presents evidence of a new serologically defined HLA locus, different from those so far described.

The inhibitory effect of glucocorticoids on the in vitro response to phytohaemagglutinin of the residual circulating T lymphocytes in renal transplant patients during maintenance immunosuppressive therapy with glucocorticosteroids and azathioprine has been investigated. As in normal subjects, the steroid-induced inhibition of transplanted patients' lymphocyte response was inversely correlated with the mitogen concentration used. On the other hand, the response of the various lymphocyte preparations from transplanted patients appeared less inhibited by steroids than the corresponding preparations from normal subjects. The addition to the culture of the adherent cell product interleukin 1 was effective in removing to a similar extent the steroid inhibitory effect on lymphocytes from normal and transplanted subjects. Thus, the lesser inhibitory effect of glucocorticoids on transplanted patient lymphocytes could be explained by the higher percentages of monocytes present in all peripheral blood mononuclear cell preparations. These results suggest that during immunosuppressive therapy with glucocorticoids and azathioprine the residual circulating lymphocytes have a responsiveness to in vitro dexamethasone suppression similar to that of normal peripheral blood lymphocytes.