Vacuum-assisted closure therapy for patients with infected sternal wounds: a meta-analysis of current evidence.

Acute and chronic wound infections are the main reasons for the observed increase in mortality rate and represent a significant risk factor in hospitalisation. From the patient's perspective, wound therapy is an uncomfortable, painful and long-term treatment. Modern sternal-wound-treatment systems would be expected to shorten wound healing and hospital stay periods. Vacuum-assisted closure (VAC) therapy is a system that promotes wound healing through the application of negative pressure by controlled suction to the wound surface. The application of controlled levels of negative pressure accelerates healing in many types of wounds. There are a number of scientific publications that have used meta-analysis to compare VAC and traditional therapy, considering changes in wound size. This article surveys the research literature focussing on the management of wound infections. The objective of this study is to assess the impact of VAC compared with conventional therapy on length of stay (LOS) and mortality. Six articles were selected that included a total of 321 patients (169 for VAC therapy and 152 for conventional therapy). The meta-analysis showed that VAC therapy resulted in a decrease of 7.18 days in hospital LOS (confidence interval (CI) 95%: 10.82, 3.54), with no significant impact on mortality. Our data provide robust evidence of the effectiveness of VAC therapy.

Plasma polychlorobiphenyl and organochlorine pesticide level and risk of major lymphoma subtypes.

BACKGROUND: There is conflicting epidemiological evidence concerning an increase in risk of non-Hodgkin's lymphoma (NHL) associated with elevated blood levels of persistent organochlorine (OC) pesticides and polychlorobiphenyls (PCBs). METHODS: We measured the concentration of 17 OC pesticides, including hexachlorobenzene (HCB), four lindane isomers (alpha-, beta-, gamma- and delta-hexachlorocyclohexane (HCH)), two chlordane species (heptachlor and oxy-chlordane), four cyclodiene insecticides (aldrin, dieldrin, endrin and mirex), six dichloro-diphenyl-trichloroethane (DDT) isomers and nine PCB congeners (PCBs 28, 52, 101, 118, 138, 153, 170, 180 and 194) in plasma samples of 377 subjects, including 174 NHL cases and 203 controls from France, Germany and Spain. The risk of NHL and its major subtypes associated with increasing blood levels of OC pesticides and PCBs was calculated using unconditional logistic regression. RESULTS: Risk of NHL, diffuse large B cell lymphoma (DLBCL) and chronic lymphatic leukaemia (CLL) did not increase with plasma levels of HCB, beta-HCH, p,p'-dichloro-diphenyl-dichloroethylene (DDE), or total and individual PCBs or their functional groups, in the overall study population. Substantial heterogeneity in DLBCL risk associated with immunotoxic PCBs (p = 0.03) existed between the Spanish subgroup (odds ratio (OR) for immunotoxic PCB plasma level above the median vs below the median was 0.7, 95% CI 0.3 to 1.6) and the French and German subgroups combined (OR 3.2, 95% CI 0.9 to 11.5). CONCLUSION: We did not find evidence of an association between NHL risk and plasma level of OC pesticides and PCBs.

[Intellectual quotient and environmental exposure to low doses of lead]. / Quoziente intellettivo ed esposizione ambientale a basse dosi di piombo.

The effects of low-level lead exposure on children's intelligence quotient (IQ) were investigated in 64 Sardinian adolescents (13-16 years old). To estimate potential early adverse effects on the Central Nervous System (CNS) due to very low-level lead, the Intelligence Quotient (IQ) of adolescents with present blood lead concentrations (PbB) generally below 10 microg/dl was measured. We analyzed blood lead concentration and individual IQ of 32 Sardinian children living in Portoscuso, a town 2 Km far from a lead smelter, and of other 32 controls living in S. Antioco, a town about 15 Km far from the same smelter. The Wechsler Intelligence Scale for Children Revised (WISC-R) was administered. The relation between IQ and blood lead concentration was estimated by linear multivariate models adjusting for several potential confounders, such as the educational and socio-economic level of the parents. The blood lead concentration was in average significantly higher in the Portoscuso group compared to controls. The linear model applied to the total population studied (n 64) showed that the blood lead concentration was inversely and significantly associated with IQ, with an extrapolated decline of 1.29 points in total IQ for each microg/dl increase of lead blood concentration. According to the recent scientific literature on this topic, results of our pilot study suggest the need to further lower the blood lead concentration for children to a threshold significantly below 10 microg/dl, value till now considered "safe" for the children's CNS.

[Urinary and blood markers of internal mercury dose in workers from a chlorakali plant and in subjects not occupationally exposed: relation to dental amalgam and fish consumption]. / Indicatori urinari ed ematici di dose interna di mercurio in lavoratori di un impianto clorosoda e in soggetti non professionalmente esposti: relazione con gli amalgami dentali ed il consumo di pesce di mare.

OBJECTIVES: The aim of this paper was both to evaluate the internal dose of Hg in occupationally exposed workers (35 Chloralkali workers) compared to that of non occupationally exposed controls (40 workers of the same plant of Portotorres and 22 residents on the island of Carloforte, usual consumers of local fish, mostly tuna fish with relatively high Hg levels) and to assess the relevance of environmental and individual exposure factors linked to lifestyle, sea fish consumption and amalgam fillings. METHODS: All subjects filled out a questionnaire concerning the working history and lifestyle. The amalgam fillings area was measured by medical inspection using a standardised schedule attached to the questionnaire. Mercury in urine (HgU) was measured in all cases, while in a subgroup of our study total blood mercury (HgB) and its organic and inorganic component were also assessed. Furthermore, for 8 of the Carloforte group mercury in hair was also available. RESULTS: Values of urinary mercury excretion of the Chloralkali workers were significantly higher (median value of 15.4, range 4.8-35.0 micrograms/g creatinine, 94.3% of the cases having values > 5 micrograms/g creatinine) than those observed both among the reference group (median value of 1.9, range 0.4-5.6 micrograms/g creatinine, 12.5% of the cases having values a little greater than 5 micrograms/g creatinine) and among the residents in Carloforte (median value of 6.5, range 1.8-21.5 micrograms/g creatinine, 59.1% of the cases having values > 5 mcg/g creatinine). The HgU values observed in this group were in turn significantly higher than those of the non occupationally exposed workers living near Sassari (p = 0.03). Only in this last group were the HgU concentrations statistically significantly related to the extension of the amalgam fillings area (Pearson r = 0.53, p < 0.01). In the Carloforte group HgU was significantly related to the number of fish meal consumed per week (Pearson r = 0.48, p < 0.02). HgB (median value of 5.9, range 3.4-21.6 micrograms/l) as well as its inorganic component (median value of 2.4, range 1.8-4.6 micrograms/l) were significantly higher in the Chloralkali group compared to the other two groups. In all cases of the Carloforte group the ratio between the organic component and the total HgB was higher than 85%, while this ratio was significantly lower in the other two groups. The relationship between HgU and HgB was statistically significant, considering both total blood mercury and the inorganic and the organic components separately. A statistically significant relationship between the sea fish consumption per week and both total HgB (Pearson r = 0.82) and the organic component in this matrix (Pearson r = 0.84, p < 0.001) was observed among 16 non-occupationally exposed subjects. However, the significant relationship between organic blood mercury and sea fish consumption was almost entirely supported by the data observed in the Carloforte group. Total hair mercury levels analysed in 8 subjects of the Carloforte group were high (median value of 9.6, range 1.4-34.5 micrograms/g) and significantly related to sea fish consumption, and to both the individual Hg urinary excretion (Pearson r = 0.83) and to the organic component of blood mercury (Pearson r = 0.87). CONCLUSIONS: According to several experimental human and animal trials and to some recent studies on methylmercury toxicokinetic models, our results suggest that the organic compounds absorbed by usual sea fish consumption may be partially demethylated, increasing the inorganic Hg concentration in the kidney and consequently its urinary excretion, as was observed in the Carloforte group.

[Neuroendocrine and neurobehavioral effects associated with exposure to low doses of mercury from habitual consumption of marine fish]. / Effetti neuroendocrini e neurocomportamentali associati con esposizione a basse dosi di mercurio derivanti da consumo abituale di pesce di mare.

OBJECTIVES: To evaluate neuroendocrine and neurobehavioral effects possibly associated with increased dietary intake of organic mercury (Hg), a group of 22 subjects living on the island of Carloforte (south-west Sardinia) was examined, who were regular consumers of tuna fish with relatively high Hg content. This group, never exposed occupationally to either Hg or to other neurotoxic substances, was compared with 22 age-matched controls employed at a chemical plant in Portotorres (northern Sardinia). METHODS: Hg in urine (HgU) and serum prolactin (PRL) were measured in all cases, whereas measurements of total (HgB) and organic blood mercury were available only for 10 subjects from Carloforte and 6 controls. Data about working history and lifestyle (education, smoking habit, alcohol and sea fish consumption) were collected by an interviewer using a standardised questionnaire. Neurotoxic symptoms were evaluated by a self-administered questionnaire, whereas a test battery, including some computerised tests of the Swedish Performance Evaluation System (SPES) to assess vigilance and psychomotor performance, some tests on motor coordination (Luria-Nebraska and Branches Alternate Movement Task) and one memory test for numbers (Digit Span) was administered to assess neurobehavioral changes associated with exposure to dietary intake of organic mercury. In all cases, characteristics of hand tremor were evaluated by the CATSYS System 7.0. RESULTS: HgU values were significantly higher in the Carloforte group (median 6.5, range 1.8-21.5 micrograms/g creatinine) compared with controls (median 1.5, range 0.5-5.3 micrograms/g creatinine). Serum PRL was significantly higher among subjects from Carloforte and correlated with both urine and blood Hg levels. The scores of each item of the questionnaire investigating neurological symptoms were not statistically different in the two groups. In some tests of the SPES battery (Color Word Vigilance, Digit Symbol and Finger Tapping) the performance of the Carloforte group was significantly worse than that of controls, whereas in the other neurobehavioral tests poorer performances by the Carloforte group were not statistically significant. None of the tremor parameters was significantly different comparing the two groups. Multivariate analysis--controlling for education level and other covariates--carried out for the Symbol-Digit Reaction Time and for the Branches Alternate Movement Task (BAMT) showed that organic Hg concentration in blood was the most significant factor negatively affecting individual performance in these tests. Serum PRL was correlated with some neurobehavioral tests (Digit Symbol, Finger Tapping and BAMT). CONCLUSIONS: Some of the neurobehavioral tests were sensitive enough to discriminate groups with different Hg body burden, even in the low-dose range. However, the pattern of results suggests adverse neurobehavioral effects, especially on psycho-motor coordination, with a significant dose-effect relationship, mostly associated with long-term exposure to low levels of organic mercury due to the usual consumption of large fish with relatively high levels of Hg in the flash.

Effect of socioeconomic status on aphasia severity and recovery.

Low levels of educational attainment and low socioeconomic status have been significantly linked to poor health and increased incidence of disease, including Alzheimer's disease and diseases of the cardiovascular, pulmonary, renal, and gastrointestinal systems. Our goal in the present study was to determine the degree to which educational level and socioeconomic status influence initial severity of aphasia and subsequent recovery. We evaluated the records of 39 persons with aphasia twice: at about 4 months and 103 months postonset. We found early severity of aphasia to be significantly greater for subjects in the lower educational and occupational groups. However, rate of recovery (the slope of the recovery curve) was the same regardless of educational or occupational status.

Neurotoxic effect of lead at low concentrations.

The effects of lead exposure at low concentrations were evaluated by studying the post-rotatory nystagmus (PRN) in two groups of rats exposed for 3 months to 50 parts per million (ppm) of sodium acetate and 50 ppm of lead acetate, respectively, in the drinking water. Only animals treated with lead acetate showed changes of the PRN parameters which were significantly related to the concentration of lead in the blood and in brain structures. The patterns of PRN responses were characterized and classified into four types: progressively inhibitory (40%), prematurely inhibitory (25%), late inhibitory (25%), and excitatory-inhibitory (10%). No alterations of the PRN parameters were observed in the animals treated with sodium acetate. The results show that exposure to lead, even at low concentrations, impairs both sensory and motor functions. The findings also point out that the vestibular system and brain stem structures which generate and control the PRN represent targets of the action of this heavy metal. Finally, the results indicate that the evaluation of the vestibulo-ocular-reflex can provide a test suited for the screening of the neurotoxic effects of lead even in the absence of clinical signs typical of lead intoxication.

[Middle lobectomy for bronchiectasis: clinical case and review of the literature]. / Lobectomia media per bronchiectasie. Caso clinico e revisione della letteratura.

Over the past few years bronchiectasis, among the chronic lung diseases, has been the second most important after tuberculosis in terms of frequency and mortality. Although the incidence of the disease has been decreasing in recent years, the illness is currently of great surgical interest because of an upsurge of cases among people considered to be below the bread line. The authors present the clinical case and surgical treatment of a young adult with middle lobe bronchiectasis, with a 10-year primary IgG deficiency and severe bronchopneumonia requiring hospitalisation. Medical treatment, long regarded as the treatment of choice in this condition, has reduced the short-term morbidity of patients suffering from the disease, without affecting its ultimate mortality which is still very high today. The policy in the past to reserve surgery only for the most complicated cases or for patients not responding to medical treatment can now be considered obsolete, due to the reduced surgical risks (less than 1%) and to faster patient recovery. Further surgical indications are mono- or bilaterally located forms of the disease and failure to respond to medical treatment for more than 2 years. A review of the literature enables the authors to affirm that in the absence of randomised trials on the effectiveness of surgical vs medical treatment, it seems clear that surgical therapy is the best option, being curative and safe, with a high percentage of complete remission of disease and very low operative risks and mortality. It can therefore guarantee good quality of life, radically changing the prognosis which otherwise is fatal in 1/3 of patients suffering from this orphan disease.

[An esophagoaortic fistula due to a foreign body]. / Fistola esofagoaortica da corpo estraneo.

Starting from a case of aortoesophageal fistula caused by a foreign body, some aspects of the treatment of upper gastrointestinal hemorrhage of uncertain etiology are discussed. The time between bleeding and perforation often notes it possible to perform resolutive diagnostic tests (aortography, esophagoscopy, CT).

Effect of dexamethasone on the nerve growth factor-induced increase in the NILE glycoprotein in PC12 cells.

The long-known and well-documented increase in the NILE glycoprotein produced by nerve growth factor in PC12 cells is prevented by simultaneous treatment with dexamethasone. The absence of this surface marker on the fully differentiated cells has been demonstrated by both glucosamine incorporation and immunohistofluorescence.

Differentiation of PC12 cells with K-ras: comparison with nerve growth factor.

The cell line PC12, derived from a rat pheochromocytoma, has served as a model for studies on the mechanism of action of nerve growth factor, as well as for the exploration of neuronal differentiation in general. When treated with nanomolar concentrations of nerve growth factor, these neoplastic chromaffin-like cells stop dividing and acquire, for all intents and purposes, the phenotype of mature sympathetic neurons. This phenotype is characterized by the extensive outgrowth of electrically excitable neurites, the ability to form functional synapses, and the acquisition of a number of biochemical markers. Treatment of PC12 cells with retroviral vectors encoding the K-ras, the N-ras, or the v-src oncogenes also produces a marked morphological differentiation very similar to that seen upon treatment with nerve growth factor. Treated cells stop dividing and develop an extensive network of neurites. It has recently been shown that PC12 cells differentiated with v-src, while resembling, morphologically, those treated with nerve growth factor, differ substantially in the biochemical characteristics normally associated with nerve growth factor-induced differentiation. Cells infected with K-ras also develop a neurite network similar to that seen after treatment with nerve growth factor. In addition, such cells develop tetanus toxin-binding sites and saxitoxin-binding sites, as do cells treated with nerve growth factor. Decreases in the binding of epidermal growth factor and in the activity of calpain also occur and these, as well, are characteristic of nerve growth factor-treated cells. But the adhesive properties of cells infected with K-ras are different than those of nerve growth factor-treated cells, and the former do not show an increase in the NILE glycoprotein. Finally, K-252a, an inhibitor of the actions of nerve growth factor on PC12 cells, has no effect on the neurite outgrowth produced by infection with K-ras. Thus, many of the key markers of nerve growth factor-induced differentiation of PC12 cells also appear upon differentiation with K-ras, but there are, nevertheless, some crucial differences in the properties of these two sets of cells.

Differentiation of PC12 cells with v-src: comparison with nerve growth factor.

The PC12 rat pheochromocytoma cell line is used extensively as a model to study neuronal differentiation. These cells resemble adrenal chromaffin cells, differentiating both morphologically and biochemically when cultured in the presence of dexamethasone, but develop a sympathetic neuron-like phenotype when cultured in the presence of nerve growth factor. Expression of the protein product of the v-src oncogene in PC12 cells also induces neurite outgrowth similar to that resulting from nerve growth factor treatment (Alema et al: Nature 316:557-559, 1985). It is thus possible that c-src or a src-like tyrosine kinase participates in the signal transduction pathway by which nerve growth factor acts on PC12 cells. In this study a temperature-sensitive v-src gene has been introduced into PC12 cells. When cultures of these src-transformed cells are switched from the nonpermissive (40 degrees C) to the permissive (37 degrees C) temperature they elaborate neurites. The differentiation induced by src has been compared with that induced by nerve growth factor by determining whether src-transformed PC12 cells at 37 degrees C exhibit the same biochemical alterations as those induced in PC12 cells treated with nerve growth factor. Neurite extension at 37 degrees C in v-src-transformed cells, like NGF-induced differentiation, is accompanied by an increase in the nerve growth factor-inducible large external (NILE) protein. However, neurite extension in v-src-transformed cells is not blocked by the protein kinase inhibitor K-252a, which completely blocks NGF-induced neurite extension. Likewise, EGF receptor down-regulation and the development of saxitoxin and tetanus toxin binding sites are either much reduced or completely absent in src-differentiated compared with NGF-differentiated PC12 cells.

[Polychlorobiphenyl content in adipose tissue of subjects not exposed professionally]. / Contenuto di PCB nel tessuto adiposo di soggetti non esposti professionalmente.

Polychlorinated biphenyl (PCB) levels were determined in 52 samples of adipose tissue removed during surgery from patients residing in a central region of Sardinia who had no previous occupational exposure. The average PCB value of the whole group was 0.72 microgram/g (range 0.11-2.81 micrograms/g); in males the average value (means = 0.97 microgram/g) was significantly higher than in females (means = 0.60 microgram/g). A positive correlation was observed between age and PCB levels in adipose tissue. This analysis could be usefully performed in occupationally exposed subjects so as to better assess the exposure level.

Decreased levels of nerve growth factor receptor on dexamethasone-treated PC12 cells.

Treatment of PC12 cells with dexamethasone leads, in a period of days, to a 60% decrease in the binding of (125I)nerve growth factor. The decrease was maximal after 3 days of treatment with 1 microM dexamethasone, but some decrease was seen after 6 hr and at concentrations as low as 10 nM. The effect was specific for the glucocorticosteroids. Scatchard plots confirmed the overall loss of nerve growth factor binding, and studies with trypsin digestion and Triton X-100 extraction indicated that the decrease in binding was largely due to a decrease in the number of low-affinity receptors. Nerve growth factor-induced changes, such as the induction of ornithine decarboxylase and the generation of neurites, were inhibited, but only minimally, in dexamethasone-treated cells.