[Liver resection with the water dissector; preliminary experience of 8 cases]. / Resezioni epatiche con dissettore ad acqua: esperienza preliminare di otto casi.

New methods for the resection of liver parenchyma was developed in order to simplify liver surgery. The object of our study was to test a method using the water dissector, a rather new equipment. Eight patients, four men end four women, have been operated, from March to September 1997, using the water dissector. Age of the patients ranged from 42 to 83 years (mean age 67 years). Indication for surgery was liver metastasis from colon cancer (6 patients), and gallbladder cancer (2 patients). 1 right lobectomy, 1 left side segmentectomy, 2 V and IV segments resection, 1 unitectomy of the VII segment and 2 III and IV segment resections was performed. In the first four patients we used the Pringle manoeuvre (clamping of the liver stalk), while we did not do it in the last four so we could compare both the operation time and the loss of blood with or without this manoeuvre. One patient died of ARDS in the seventh post-operative day, another patient, who underwent a right lobectomy, developed a biliary fistula which healed in the 10 degrees postoperative day. All the seven surviving patients was in good health, with normal liver ultrasonography when checked on the 31/12/1997. Our results show that the water dissector offers the possibility to isolate vascular stalks very easily, both with a posterior ilar approach and with an intraparenchymal approach, making possible a very accurate haemostasis, in such minimizing blood and biliary losses. This method allows the performing of oncologically correct dissections and in the meanwhile the saving of as much healthy parenchyma as possible.

Increasing survival time after AIDS in Italy: the role of new combination antiretroviral therapies. Tuscany AIDS Study Group.

BACKGROUND: In Italy, antiretroviral combination therapy was adopted in mid-1995 and protease inhibitors in mid-1996. OBJECTIVE: To conduct a prospective, population-based, observational study to evaluate the effect of these therapies on the survival of persons with AIDS (PWA). METHODS: PWA living in the Tuscany region diagnosed between 1985 and 31 March 1997 (National AIDS Registry) were studied. Information on antiretroviral drugs, prophylactic treatment, CD4 cell count, and AIDS-defining illnesses was collected for PWA still alive at 1 January 1996 and those diagnosed thereafter (analysis cut-off date, 30 November 1997). Kaplan-Meier curves were calculated by year of diagnosis. A Cox model was then used to estimate the adjusted (by sex, age, HIV exposure category, CD4 cell count, type and number of AIDS-defining illnesses) relative hazard (RH) of death by year of diagnosis and calendar date (considered as a time-dependent variable). Similar analyses were repeated for PWA diagnosed after 1989, having been stratified by disease-specific AIDS condition. A final analysis was performed for PWA still alive at 1 January 1996 or diagnosed thereafter for estimating the effect of single, double and triple combination therapy (time-dependent variables), having adjusted for the above variables and for prophylactic treatment. RESULTS: A total of 1683 (79.5%) out of 2118 PWA died before 1 December 1997. Use of more potent combination therapies, including protease inhibitors, greatly increased during 1997. Median survival was 2.9, 12.3, 13.4, 11.4 and 17.6 months for diagnoses before 1987, in 1987-1990, 1991-1993, 1994 and 1995, respectively; an estimated 62% of those diagnosed in 1996-1997 had survived 15 months after diagnosis. The Cox model showed a trend of decrease of RH for calendar time starting in the first half of 1996, compared with 1994. When stratifying by specific AIDS-defining disease there was no statistically significant evidence that the improved overall survival was due to increased survival only for certain diseases. The final multivariate analysis for the 771 PWA still alive at 1 January 1996 or diagnosed thereafter estimated significant RH < 1.0 for double and triple therapy (RH, 0.61 and 0.36, respectively) compared with no therapy. CONCLUSIONS: A significant reduction in risk of death after AIDS was observed from the second half of 1996, apparently due to the widespread use of antiretroviral combination therapies.

Survival after AIDS diagnosis in Tuscany (Italy), 1985-1992.

The study evaluated the overall survival after AIDS diagnosis of 1,014 patients reported to the Italian AIDS Registry as resident in Tuscany, stratified by age, gender, year of diagnosis, HIV transmission category, initial AIDS-defining disease and CD4+ cells count. The study was a population-based survival analysis, carried out through Kaplan-Meier method (mean survival times-MST-, 1, 2 and 3-year observed survival) and Cox models (crude and adjusted relative risk-RR). The MST was 12.4 months for all cases, increasing from 4-7 months in 1985-1987 to 14 months in 1991-1992. The observed survival was 51.4% at the first year of follow-up, 28.4% at the second year and 14.5% at the third year. The multivariate analysis showed an independent prognostic effect of age, year of diagnosis, initial AIDS-defining disease and CD4+ cells count. The prognosis was worse in cases aged over 44 (reference: 25-29), diagnosed before 1988 (reference: 1991) and with wasting syndrome, toxoplasmosis, HIV encephalopathy or multiple diseases (reference: PCP alone); and better in cases with more than 100 CD4+ cells/mm3 (reference: < or = 50 cells/mm3). The differences in gender and among HIV transmission categories disappeared after age-adjustment. The study confirmed, in an European population-based series, the poor long-term AIDS prognosis and, once AIDS has became clinically manifest, the prognostic value of some clinical and demographic variables.

The effect of the 1993 European revision of the AIDS case definition in Italy: implications for modelling the HIV epidemic.

OBJECTIVES: To evaluate the effect of the 1993 European AIDS definition on reducing pre-AIDS mortality and to what degree an earlier diagnosis can be made. DESIGN: Prospective observational study. METHODS: All patients diagnosed between January 1993 and December 1994 and reported to the National AIDS Registry from four Italian regions, who met only the new criteria for the 1993 case definition (AIDS-1993) were studied. Follow-up of patients who did not eventually meet the 1987 definition (AIDS-1987), or had not died from other causes (pre-AIDS-1987 death), was censored at the last available clinical visit before 1 April 1996. We analysed the data using Kaplan-Meier non-parametric survival analysis and Cox proportional hazards model. RESULTS: A total of 74 (4.1%) individuals met only the new criteria. Of these, 49 (62.2%) were men, 42 (56.8%) had pulmonary tuberculosis, 22 (29.7%) had recurrent bacterial pneumonia, and 10 (13.5%) had cervical cancer. During follow-up, 35 (45.3%) individuals developed an AIDS-1987 disease, and 10 (13.5%) died without fulfilling the AIDS-1987 definition. Pre-AIDS-1987 death accounted for 22.2% (10 out of 45) of the subsequent outcomes observed prior to 1 April 1996. Using Kaplan-Meier technique, we estimated that after 9.8 months 50% of these individuals were diagnosed with AIDS-1987 disease, or died without such a diagnosis. Individuals with lower CD4+ count at the time of the AIDS-1993 diagnosis progressed more rapidly to AIDS-1987 than those with a higher count. In contrast, pre-AIDS-1987 mortality was strongly associated with injecting drug use, whereas no association was found with CD4+ count. CONCLUSIONS: Approximately 50% of individuals with one of the three new AIDS-defining diseases will develop an AIDS-1987 disease or will die within 1 year. Time from AIDS-1993 to AIDS-1987 disease is strongly associated with CD4+ count at diagnosis. AIDS_1993 diagnosis reduced the pre-AIDS-1987 mortality in injecting drug users. Furthermore, approximately 20% of individuals diagnosed with AIDS-1993 disease are expected to die without developing an AIDS-1987 disease. These data should be useful for correcting the AIDS incidence curve in Europe for the effect of the changes in the AIDS definition.

Completeness of AIDS reporting and quality of AIDS death certification in Tuscany (Italy): a linkage study between surveillance system of cases and death certificates.

In Italy, the AIDS cases defined according to the CDC criteria are reported to the National AIDS Registry (RAIDS, compulsory surveillance system). The aim of the present study is to evaluate the completeness of AIDS cases reported and the quality of AIDS death certification in an Italian Region (Tuscany, about 3,500,000 inhabitants). The 737 AIDS cases reported to RAIDS as residents in Tuscany (1987-91) were cross-linked (key link: name and date of birth) with the data of the Mortality Registration system of the Region (RMR). For the residents in Tuscany decreased with a 279.1 death diagnosis (the code for AIDS deaths stated by the Italian Census Bureau) and not reported to RAIDS as AIDS cases, the clinical records were reviewed to check whether the diagnosis fitted the 1987-CDC diagnostic criteria. This study shows that there is a high completeness (97-98%) of the AIDS cases resident in Tuscany, reported to the RAIDS. The quality of RAIDS data is not as good with regard to life status assessment (23% of under-reporting of death). In Tuscany, the death certification for AIDS (code 279.1 of ICD IX) has a sensitivity of 88% and a specificity around 100% in comparison to RAIDS. About 50% of 'false negatives' in death certification are due to causes of death presumably unrelated to HIV infection. The evaluation of the quality of AIDS surveillance and mortality data is important in the assessment of the impact for AIDS epidemic in a target population.

[Spontaneous transmural rupture of the esophagus (Boerhaave's syndrome)]. / Rottura spontanea transmurale dell'esofago (sindrome di Boerhaave).

A case is presented of spontaneous transmural rupture of the lower third of the esophagus, penetrating the left pleural space. The patient underwent repair under 7 hours by combined approach (laparotomy and left thoracotomy). High mortality and morbidity of Boerhaave's syndrome can be lowered by prompt and careful evaluation of symptoms and radiological signs, so avoiding incorrect or late diagnosis. Results appear to be related more to the time interval between perforation and operation than to the specific technique used.

Linkage between AIDS surveillance system and population-based cancer registry data in Italy: a pilot study in Florence, 1985-90.

The role of the Tuscany population-based Cancer Registry (TCR) in the assessment of cancer incidence in AIDS patients, and the completeness of cancer reporting to the Italian AIDS surveillance system (RAIDS) was evaluated through a linkage between the TCR and the RAIDS in the period 1985-90. In the Province of Florence, the incidence of Kaposi's sarcoma in AIDS cases was underestimated by 24% (95% CI; 9.8%-47%; 6/25 cases) by RAIDS in comparison with the TCR. Of kaposi's sarcomas unknown to RAIDS, 2 were incident at the time of AIDS diagnosis ("truly" unreported cases) and 4 were late manifestations of AIDS. Moreover, 1 non-Hodgkin lymphoma unknown to RAIDS and 10 other malignancies (4 lung cancers) were identified through the TCR. In AIDS patients, the incidence of lung cancer was 95-fold (99% CI, 16-310) the expected one on the basis of age-sex-specific incidence rates in the general population of the same area. Altogether, about 25% of AIDS cases developed a cancer during HIV infection. In spite of the small size of the present study, the results confirm the role of population-based cancer registries in the assessment of the occurrence of malignancies in AIDS patients.

[Suprapubic echography in the diagnosis of benign hyperplasia and cancer of the prostate. A controlled study of 108 cases]. / L'ecografia sovrapubica nella diagnosi dell'iperplasia benigna e del carcinoma della prostata. Studio controllato su 108 casi.

One hundred and eight patients presenting clinical symptoms of prostatic disease have been studied by suprapubic echography, with comparison of clinical and echographical diagnoses with the results shown by histological examination. The authors found the diagnosis by echography to be quite precise, not significantly differing from the results given by histological examination, in contrast to those diagnoses based on clinical examination. Describing the echographic pictures found in benign hypertrophy of the prostate of which a previously uninterpreted nodular picture is resorted (intra- and extra-capsular neoplasms and chronic prostatis) the authors conclude by proposing suprapubic echography as an initial instrumental approach in the diagnosis of prostatic diseases.

[Preventive vasectomy. Review of 755 cases]. / In tema di vasectomia preventiva. Revisione di 755 casi.

PIP: The importance of preventive vasectomy during surgery and endoscopy on vescica, prostate, and urethra in those over age 60 is due to the etiopathogenesis of orchiepididymitis which demonstrates the paramount role played by infection via the ascending canalicular route. A series of 755 cases is reported here. (author's modified)^ieng