Key factors for best control of the systemic leakage during hyperthermic isolated limb perfusion (HILP) in ECC. A critical synthesis of our experience.

The L-PAM-ILP procedures under true hyperthermal regime (41.5-41.8 degrees C) require both close control of the physical parameters of the treatment (temperatures profiles and time duration, artero-venous pressure, perfusate flow rate) and medical rationale (drug, dosage, fractioning, timing). All the above essential procedures must be supported by rigorous methodology, reliable operation of the medical devices and apparatus and real-time monitoring of the treatment parameters. Real-time monitoring is essential for proper trimming and modulation of the parameters during treatment. This paper delineates the technical improvements that we have implemented for drug leakage monitoring and control in the systemic circulation aimed at improving the therapeutic efficacy and at reducing the occurrence of unexpected complications.

Early detection of myocardial ischaemia in the emergency department by rest or exercise (99m)Tc tracer myocardial SPET in patients with chest pain and non-diagnostic ECG.

Chest pain (CP) represents a frequent reason for presentation at the emergency department (ED). A large proportion of patients have non-diagnostic ECG on presentation, and in many cases several hours have elapsed since onset of symptoms. Acute rest myocardial scintigraphy (rest SPET) has been shown to have a relevant role in the detection of patients at risk for coronary events, but its sensitivity and negative predictive value are optimal only within the first 3 h following onset of symptoms. In those with delayed presentation, exercise SPET alone, as a screening approach, appears more promising, but its feasibility and diagnostic role in the ED are still unresolved. A total of 231 consecutive patients with a recent-onset (<24 h) first episode of CP had a negative first-line work-up including ECG, troponins, creatine kinase-MB and echocardiography. These patients were considered at low risk for short-term coronary events. Patients were studied with rest SPET if they presented <3 h after onset of CP and exercise SPET if they presented after > or =3 h. The end-points of the study were detection of significant coronary artery disease (CAD) by angiography and major coronary events or cardiac death at 6 months. Eighty patients (35%) underwent rest SPET, while 151 (65%) underwent exercise SPET. Two of the 159 patients with negative SPET had evidence of critical CAD at 6-month follow-up (one patient in the rest SPET group and one in the exercise SPET group; P=NS). Of the 72 patients (31%) with a positive scan, 34 (15%) had documented CAD (16 patients in the rest SPET group and 18 in the exercise SPET group; P=NS). Sensitivity, specificity, accuracy and predictive value were not statistically different between the two groups. In conclusion, the accuracy of exercise SPET in patients with CP and delayed presentation to the ED is comparable to that of validated rest SPET in patients with early presentation. Owing to the high negative predictive value (99%), exercise SPET is especially valuable as a screening tool for the exclusion of CAD in low-risk patients and implementation of early discharge.

Octreoscan SPET evaluation in the diagnosis of pancreas neuroendocrine tumors.

The study describes the results of Octreoscan SPET (OCTSPET) qualitative and semi-quantitative evaluation in 38 patients with suspected pancreatic neuroendocrine tumors. SPET studies were acquired at 4 and 24 hours after the injection of 111-220 MBq of 111-In-pentetreotide (Octreoscan). Qualitative and semi-quantitative evaluations were performed. The semi-quantitative approach was based on the time course of Tumor/Non Tumor ratios (TNTinc) from 4 and 24 hours. The OCTSPET results were true positive in 18 of 19 patients (10 gastrinoma, 5 insulinoma, 1 neuroendocrine tumor, 1 glucagonoma and 1 carcinoid) and false negative in one insulinoma. Besides, 20 of 38 patients (52%) had clinical plans modified after OCTSPET; OCTSPET was the only positive diagnostic test in 14 of 19 patients (73%) and guided the surgery decision in 14 of 25 patients (56%). In conclusion, these data indicate that Octreoscan represents an excellent tool for the diagnosis of pancreatic neuroendocrine tumors.

Copper resinate: preparation, characterisation and study of degradation.

This paper describes a method for the synthesis of Copper Resinate, which disappeared from artists' palettes in the eighteenth century. This was carried out by interpreting ancient recipes following a scientific approach. Its characterisation using Fourier Transform-Infrared Spectrometry and Gas Chromatography-Mass Spectrometry demonstrated that it is a mixture containing copper and oxidised abietic acids, mainly dehydroabietic and 7-oxo-dehydroabietic acids, formed during the preparation of the pigment and the curing of the paint layer. The composition of copper resinate paint layers, artificially aged by U.V. irradiation at 365 nm (UV), heating (T), and exposed to atmospheric pollutants (NOX) in a climatic chamber, was investigated. The combination of irradiation and temperature produced a change in colour along with a significant increase in the recovered amount of 7-oxo-dehydroabietic acid. The identification of copper resinate in a sample from an old painting should be related to the presence of the following resin compounds which are stable in the ageing process: dehydroabietic and 7-oxo-dehydroabietic acid pimaradienic acids. Photo-oxidation of the resin acids co-ordinated with copper seem to be the most probable decay mechanism responsible for the colour change in the pigment.

Radioisotopic lymphatic mapping of the sentinel node in melanoma: importance of immunohistochemistry.

BACKGROUND: Elective lymph node dissection (ELND) for patients with malignant melanoma is still controversial. A possible alternative could be biopsy of the first tumor draining lymph node, the sentinel node (SN), which can be identified by means of radionuclide techniques. AIM: Our study was undertaken to assess the accuracy of lymph node biopsy and to stress the importance of immunohistochemistry (IHC) in the pathological assessment of the SN for improved staging of the primary tumor. METHODS: We performed lymphoscintigraphy (LS) in 183 melanoma patients (89 with melanoma of the legs, 11 of the arms and 83 of the trunk). Our protocol consisted of preoperative peritumoral i.d. injection of 99mTc-labeled microcolloid to define the regional lymphatic basin and identify the sentinel node by means of planar scintigraphy. In 147 of the 183 cases a gamma probe (GP) was used during surgery to trace the SN. Vital blue dye was used during surgery in all cases. The SNs were excised for pathological examination. The pathological status of the SN was defined by means of examination of frozen sections, hematoxylin-eosin staining and immunohistochemistry for S-100 and HMB-45 MAb. RESULTS: At least one separate focus of activity was identified by LS in 182 out of 183 patients; in all 147 cases where a GP was used, it was successful in tracing the SN. LS with cutaneous mapping of the SN successfully guided the surgical excision in 177 of the 183 cases; in the 7 remaining cases, i.e. 7 out of 83 cases with SNs in the axillary basin, GP was not used and no elective node dissection was performed. Metastases were found in 39 of these 177 cases. In all 39 cases the SNs were the only positive nodes in the basin. Of the 39 metastases 18 were identified by means of frozen section, 12 by means of hematoxylin-eosin, and 9 by means of immunohistochemistry. We therefore emphasize the importance of immunohistochemistry in the pathology of LS for improved staging of the primary tumor.

Prediction of post-revascularization functional recovery of asynergic myocardium using quantitative thallium-201 rest-redistribution tomography: has the reverse redistribution pattern an independent significance?

The significance of reverse redistribution on rest-redistribution thallium-201 myocardial scintigraphy is unclear. Previous studies suggested that reverse redistribution segments with normal resting activity include viable myocardium, whilst resting defects with further worsening correspond to scar. We evaluated whether reverse redistribution has an independent significance for the prediction of post-revascularization recovery, particularly as compared with the quantification of redistribution activity. We studied 26 coronary artery disease patients with left ventricular dysfunction, who underwent 201Tl rest-redistribution single-photon emission tomography (SPET) and echocardiography before revascularization. Viability was defined by the detection of wall motion improvement on follow-up echocardiography. 201Tl activity was considered normal if >/=80%, moderately reduced if <80% but >/=50%, and severely decreased if <50%. Reverse redistribution was defined as a defect in redistribution images with >/=10% decrease in relative 201Tl activity compared with the resting value. Reverse redistribution was detected in 33 segments (10%). Baseline dysfunction was equally observed in the reverse redistribution and in the non-reverse redistribution segments (64% vs 56%, P=0.40) and the rate of asynergic segments with post-revascularization recovery was not different between the two groups (33% vs 54%, P=0.11). The rate of functional recovery in redistribution defects without reverse redistribution was 53% in moderate and 30% in severe defects; the corresponding values for the reverse redistribution segments were 50% and 27% (all non-significant versus non-reverse redistribution segments). For the prediction of post-revascularization recovery in asynergic segments, the detection of reverse redistribution on rest-redistribution 201Tl SPET does not add any information to the quantitative analysis of redistribution activity.

HPLC determination of inorganic cation levels in CSF and plasma of conscious rabbits.

An HPLC method is described using conductimetric detection for the quantitative determination of sodium, potassium, magnesium, and calcium in cerebrospinal fluid (CSF) and plasma of conscious rabbits. This method enabled the four cations to be estimated with rapidity, sensitivity, accuracy, and precision. The mean millimolar concentrations +/- SD found in CSF and (plasma) of 15 untreated animals were as follows: sodium, 146.96 +/- 17.84 (135.06 +/- 20.11); potassium, 3.32 +/- 0.56 (4.57 +/- 1.03); magnesium, 0.90 +/- 0.20 (0.72 +/- 0.13); and calcium, 1.47 +/- 0.19 (3.32 +/- 0.59).

[Oral glucose tolerance test reevaluated in 68 subjects for its validity in growth hormone secretors]. / Il test da carico orale di glucosio ricontrollato in 68 soggetti per la sua validita' GH-secretoria.

The aim of this research was to establish both the frequency and the amount of the response of pituitary GH secretion to oral glucose load (OGL) in comparison to the usual, insulin and arginine, stimuli. Previous research on this topic was performed using either a limited number of subjects or experimenting throughout too short a period of time. 68 young subjects, 50 males and 18 females, aged 6-17 years, were studied. All 68 subjects underwent three stimuli of pituitary GH secretion: oral glucose and i.v. administered insulin and arginine. Patients were divided, according to our clinical knowledge and that of Tanner and Co. into: 1) responders, characterized by a plasma GH peak greater than 6 ng/ml, following at least one of the three stimuli; 2) non-responders, characterized by a plasma GH peak inferior to 6 ng/ml, following all three stimuli. A positive response was obtained by OGL in 79.68% of subjects, while a positive response was obtained by insulin stimulus in 72.58% and by arginine stimulus in 77.77%. The presence of positive response to OGL is not correlated to the patients age. The amount of the response, i.e. the mean of plasma GH peaks is similar using both OGL (11.92 +/- 8.57 SD) and insulin stimulus (11.75 +/- 7.48 SD). Some patients (8.82%) responded only to OGL stimulus, lacking a response to arginine and insulin stimuli. The authors emphasized the use of OGL because it is devoid of side reactions and because it simultaneously allows an evaluation of both glucose tolerance and insulin secretion capacity.

Hyperinsulinism and insulin resistance in polycystic ovarian syndrome: a verification using oral glucose, I.V. Glucose and tolbutamide.

Twenty-six female in-patients, aged 14-34 years, suffering from polycystic ovarian syndrome (PCOS) were investigated. Sixteen normal women, matched with patients for age and weight, were used as controls. Both glucose and insulin curves and areas, insulin/glucose area ratio [insulin resistance index (IA/GA)] were studied by oral glucose tolerance test (OGTT), i.v. glucose tolerance test (IVGTT) and tolbutamide test (TT). Plasma insulin and insulin area values of the patients were significantly higher than those of controls. Insulin/glucose area ratios were significantly higher in patients when compared to controls. A correlation was found in some patients (subgroup A) between insulin/glucose area ratio and urinary dehydroepiandrosterone output after the TT. The presence of hyperinsulinism and insulin resistance in our patients suffering from PCOS was confirmed even in the absence of obesity. A relationship between androgens and hyperinsulinism and insulin resistance may thus be confirmed in patients with PCOS.

[Oral glucose tolerance test in polycystic ovary syndrome]. / Il test di tolleranza al glucosio orale nella sindrome dell'ovaio policistico.

OGTT was used to clarify the problem of hyperinsulinism and insulin resistance previously investigated by us in PCOS, using the tolbutamide test. The results of this latter investigation were in agreement with the previous found by us and with the similar already reported by other Authors. 26 women (7 obese), aged 14-34 years, affected by PCOS, were studied. The diagnosis of PCOS was made using clinical, hormonal, radiologic and echographic criteria. 16 age matched healthy women were used as controls. Glucose and insulin curves, glucose (GA) and insulin (IA) response areas and IA/GA ratio (insulin resistance in dex-IRI-) were studied by OGTT. Blood insulin values of patients resulted significantly more elevated than that of controls at any point of the curve and more significantly elevated were decreasing values. Mean values of insulin peaks, of insulin areas and of IRI resulted more elevated than that of controls. The presence of both an hyperinsulinism and an insulin resistance in PCOS seems therefore evident. A correlation was found between IRI values and plasma testosterone levels in non obese patients with increased urinary 17-ketosteroid output. A relationship between hyperandrogenism on one hand and hyperinsulinism and insulin resistance on the other is suggested.

[Intravenous glucose tolerance test in the polycystic ovary syndrome]. / Il test di tolleranza al glucosio endovena nella sindrome dell'ovaio policistico.

The problem of hyperinsulinism and insulin resistance, previously observed by us in PCOS using the tolbutamide test, was studied in the present research using intravenous glucose tolerance test (IVGTT). 16 women (3 obese) aged 14-34 years, affected by PCOS, were studied. The diagnosis of PCOS was made using clinical, hormonal, radiologic and echographic criteria. 8 age matched healthy women were used as controls. Glucose and insulin curves, glucose (GA) and insulin (IA) response areas and IA/GA ratio (insulin resistance index-IRI-) were studied by IVGTT. Both the mean insulin peak and the mean insulin area were significantly more elevated in patients than in controls. Average IRI value also was significantly higher than that of controls. The presence of both an hyperinsulinism and an insulin resistance is shown by the higher values in patients compared to controls. No correlation was found between either insulin areas or IRI values with plasma testosterone and urinary dehydroisoandrosterone, whereas correlations were demonstrated in previous studies, using OGTT, by us and other Authors and by us using tolbutamide test. The difference in the nature of the various stimuli performed seems to explain the different results.

[Hyperinsulinism and insulin resistance in the polycystic ovary syndrome as tested with tolbutamide]. / Iperinsulinismo ed insulinoresistenza nella sindrome dell'ovaio policistico al test con tolbutamide.

The aim of this research was to study both insulin secretion and insulin resistance index (IRI) in seventeen females, aged 16-30, affected by polycystic ovarian syndrome. The diagnosis was made using clinical, hormonal, radiological and echographic criteria. Eight healthy women, carefully matched with our patients for age and for statistical obesity incidence, were studied as controls. Both glycemic and insulinemic curves, areas, insulinemic/glycemic area ratio (IRI) were studied by tolbutamide test (1 g i.v.). Areas were assessed by planimeter, blood glucose by Trinder method, blood insulin by a RIA method, statistical study by t Student test and correlation coefficients. These latter were determined by comparing individual plasma testosterone, FSH, LH and LH/FSH ratio values together with urinary total 17-ketosteroid and delta HEA output values on the one hand and insulin areas and IRI values on the other. Increased glycemic areas, insulinemic peaks and areas, associated with markedly increased IRI values, were observed in the patients. A correlation exists between hyperinsulinism, insulin resistance on the one hand and increased urinary androgens output on the other. delta HEA resulted particularly increased over other androgenic fractions.

GH secretion by arginine stimulus: the effect of both low doses and oral arginine administered before standard test.

Small arginine doses (2 ml of 10% - 200 mg - arginine monohydrochloride i.v. administered) are capable of provoking a significant GH secretion. No correlation was found between GH peak observed after this administration and that observed after a standard arginine stimulus (24.8 g) performed subsequently. GH response to a standard arginine stimulus was blunted, differently from the response to insulin stimulus, by a previous oral arginine administration.