Combination therapy including serratiopeptidase improves outcomes of mechanical-antibiotic treatment of periimplantitis.

This study was designed as a retrospective analysis of clinical outcomes of cases of periimplantitis treated by mechanical debridement and the administration of antibiotics combined or not with the administration of either the proteolytic enzyme serratiopeptidase (SPEP) or non-steroidal anti-inflammatory drugs (NSAIDs). Clinical charts of 544 partially edentulous patients treated for periimplantitis between June 1996 and December 2010 were analyzed to obtain clinical data of the affected implants just before the beginning of treatment and 12 months later to evaluate the outcomes of combined mechanical antibiotic treatment alone or in combination with the co-administration of the anti-inflammatory SPEP or NSAIDs. The comparative analysis revealed that therapeutic outcomes were significantly different in the three groups. Failure rate in the group that received SPEP (6 percent) was significantly lower compared to the group that received NSAIDS (16.9 percent; P less than 0.01) and to the group that received no anti-inflammatory therapy (18.9 percent; P less than 0.01). Treatment including SPEP was associated with significantly better healing also when successful treatments alone were considered. The data reported in this paper strongly support the hypothesis that SPEP is a valid addition to protocols for the combined therapy of peri-implantitis. In fact, it allows to enhance success rates significantly and also favors better tissue repair around successfully treated implants as compared to other regimens.

Influence of oral conditions on colonization by highly toxigenic Staphylococcus aureus strains.

OBJECTIVES: As the oral cavity is regarded as a relevant site for Staphylococcus aureus colonization and interhuman transmission, this study aimed to investigate whether different oral conditions influence the rates of S. aureus oral carriage and genetic characters of S. aureus isolates. SUBJECTS AND METHODS: Staphylococcus aureus was searched in samples collected from cheek, gingival margin, and anterior nares of 45 healthy subjects, 27 periodontitis affected subjects, and 29 subjects with fixed prosthetic restorations. Isolates were screened for 17 genetic determinants, and Partial Least Square Discriminant Analysis was performed to evaluate whether specific characters correlated with oral condition or site of isolation. RESULTS: The three subject groups showed comparable nasal carriage rates but, both the periodontitis and prosthetic restoration groups showed significantly higher oral carriage rates, as compared to healthy subjects (P = 0.01 and 0.02, respectively). Moreover, periodontitis affected subjects hosted strains possessing a distinct genotypic and phenotypic background, characterized by the presence of a larger number of exotoxins encoding genes. CONCLUSIONS: These data confirm that the oral cavity is an important site of S. aureus colonization and demonstrate that conditions modifying the oral environment, as the presence of periodontitis and of fixed prosthetic restorations, promote S. aureus carriage and may favor the spread of more pathogenic strains.

Effect of imatinib on haematopoietic recovery following idarubicin exposure.

SCF is a potent pro-proliferative cytokine crucial for haematopoiesis, which binds to c-kit and activates its tyrosine kinase activity. Inactivating mutations of either SCF or c-kit have been described in mice and lead to increased sensitivity to treatment with ionising radiation. Imatinib is a tyrosine kinase inhibitor with high affinity for c-Abl, PDGFR and c-kit. In this study we investigated the effect of concomitant administration of imatinib and idarubicin, an anthracycline with haematosuppressive activity, in nu/nu mice and murine bone marrow cells. Double-treated animals showed significantly increased mortality compared to mice that received imatinib or idarubicin alone only when idarubicin and imatinib were given simultaneously. The combined treatment induced a more severe neutropenia with a slower recovery when compared to mice treated with idarubicin alone. The myeloid metaplasia usually observed in the spleen after idarubicin treatment was absent in mice co-treated with imatinib. Bone marrow from double-treated animals also showed decreased numbers of megakaryocytes and myeloid precursor cells. In vitro culture of murine bone marrow cells in the presence of imatinib inhibited SCF-induced proliferation and recovery from treatment with idarubicin. Our results indicate that the simultaneous administration of imatinib enhances idarubicin-induced haematopoietic toxicity in vivo and in vitro.

Abdominal aortic aneurysm resection following cholecystectomy and heart transplantation. Case report.

The case of a patient who underwent heart transplantation and cholecystectomy in 1993 and admitted for resection of abdominal aortic aneurysm in May 1997, is reported. About 25 minutes after unclamping the abdominal aorta the patient s blood pressure fell suddenly to 70/40 mmHg. In spite of vigorous fluid administration and infusion of Dopamine and Adrenaline the hemodynamic pattern returned to normal only 15 minutes later. The authors discuss the possible explanations of this behaviour (mesenteric traction syndrome, hypovolemia) and conclude that heart transplant patients are particularly affected by hypotension. Of paramount importance remains therefore the correct evaluation of adequate filling pressures which should be maintained slightly above normal range.

Relationship of unrecognised myocardial infarction, diabetes mellitus and type of surgery to postoperative cardiac outcomes in vascular surgery.

OBJECTIVES: to evaluate preoperative clinical, surgical and instrumental variables as predictors of postoperative cardiac events in patients undergoing different types of elective major vascular surgery. MATERIAL AND METHODS: on the basis of an algorithm including clinical and test echocardiographic data, we prospectively stratified 604 consecutive patients into low, intermediate and high-risk groups. The value of the variables in predicting postoperative cardiac events was assessed by means of multivariate analysis. RESULTS: there were 16 major postoperative cardiac events and six of 16 postoperative deaths were cardiac related (1%). Significant predictors of cardiac complications were unrecognised myocardial infarction (odds ratio - (OR) 5.6), coronary artery disease (OR 2.5), severe hypertension (OR 2.1) and peripheral vascular surgery (OR 1.9). In the intermediate-risk group, the best correlates with cardiac complications were unrecognised myocardial infarction (OR 3.3) and diabetes (OR 2.5). CONCLUSIONS: our results suggest the importance of identifying patients with unrecognised ischaemic heart disease and of using aggressive perioperative protocols for managing diabetic patients undergoing peripheral vascular procedures.

Preoperative assessment of cardiac risk in noncardiac major vascular surgery.

We evaluated whether a preoperative clinical algorithm allows an adequate stratification in cardiac risk and the predictive value of dipyridamole thallium-201 scintigraphy and rest echocardiography for postoperative adverse cardiac outcomes. Three hundred twenty patients undergoing 338 vascular surgery procedures were prospectively stratified into low, intermediate, and high risk. The low- and intermediate-risk patients underwent surgery without further diagnostic evaluation. In 7 high-risk patients the vascular procedure was canceled (1 died of myocardial infarction at 6-month follow-up), 9 underwent presurgical myocardial revascularization (1 died of myocardial infarction), and 49 underwent vascular surgery with perioperative intensive care treatment. Hospital mortality was 3.8%. Cardiac mortality and morbidity were 1.5% and 10.4%, respectively. We observed a significant difference in "hard" (death, myocardial infarction, pulmonary edema, major arrhythmias) and "soft" (myocardial ischemia, minor arrhythmias) events between groups, p <0.001. Previous pulmonary edema was a predictive variable of cardiac outcomes (multiple logistic regression analysis). Ninety-nine of 220 intermediate-risk patients randomly underwent dipyridamole thallium-201 scintigraphy: 37 had redistribution, 10 persistent, and 52 no defects; 7 of 13 soft and hard cardiac events occurred in patients without redistribution defects. Sensitivity, specificity, and positive and negative predictive values of redistribution defects for postoperative adverse outcomes were 38%, 63%, 14%, 87%, respectively. This algorithm may provide a safe and cost-effective approach (average cost saving per patient $1,500) to cardiac risk stratification. These results suggest that routine use of dipyridamole thallium-201 scintigraphy for screening of intermediate-risk patients may not be warranted.

Change in major amputation rate in a center dedicated to diabetic foot care during the 1980s: prognostic determinants for major amputation.

From 1990 to 1993, 115 diabetic patients were consecutively hospitalized in our diabetologic unit for foot ulcer and 27 (23.5%) major amputations were carried out. The major amputation rate of this series of cases was compared with that occurring in diabetic subjects taken into our hospital for foot ulcer in two previous periods: 1979-1981 (17 major amputations in 42 inpatients or 40.5%) and 1986-1989 (26 major amputations in 78 inpatients or 33.3%). The comparison shows a progressive reduction in major amputation rate [Odds ratio 0.66, 95% confidence interval (CI) 0.46-0.96]. Univariate and multivariate analysis, carried out in the population of the 1990-1993 period, in order to detect the independent factors associated with major amputation show the following prognostic determinants of major amputation: Wagner grade (odds ratio 7.69, CI 1.58-37.53), prior stroke (odds ratio 35.05, CI 3.14-390.53), prior major amputation (odds ratio 3.49, CI 1.26-9.38), transcutaneous oxygen level (odds ratio 1.06, CI 1.01-1.12), and ankle-brachial blood pressure index (odds ratio 4.35, CI 1.58-12.05), while an independent protective role was attributed to hyperbaric oxygen treatment (odds ratio 0.15, CI 0.03-0.64). In accordance with other studies, we, therefore, conclude that a comprehensive protocol as well as a multidisciplinary approach in a dedicated center can assure a decrease in major amputation rate. The parameters of limb perfusion were the modifiable prognostic determinants most strongly predictive for amputation.

In vitro evaluation of the cytotoxicity of pure eugenol.

The aim of this study was to assess the cytotoxicity of pure eugenol in an in vitro method by diluting it to various concentrations in alcohol and determining the maximum noncytotoxic concentration. We used solutions of eugenol and ethyl alcohol that are soluble in water in any given proportion. The cytotoxicity of the alcohol itself was determined by using a dose-response curve for concentrations of between 0.017 M and 1.7 M. Various strength concentrations (0.015 to 947 microM) of eugenol in alcohol were prepared; 20 microliters (0.34 M) of ethyl alcohol was added to 1 ml of cell medium. The experiment showed that pure eugenol is toxic for human gingival fibroblasts. Eugenol in an alcohol solution at concentrations of < 1.9 microM is noncytotoxic.

Ultrastructural aspects of two different mast cell populations in human healthy gingival tissue.

The results of our recent microscopy studies clearly have demonstrated the constant presence of numerous metachromatic cells in healthy human gingival connective tissue. Despite the great number of studies on mast cell population in many human organs (lung, skin, uterus, and bowel), at the present time few are the studies regarding the morphostructural aspects of mast cells in the human gingiva. The aim of this study was to assess by transmission electron microscopy the presence of mast cells in the healthy human gingiva and to characterize the ultrastructural aspects of mast cells populations. 30 specimens of human gingival tissue were collected from 30 patients with informed consent. The samples were prepared for T.E.M. examination. In all the ultrathin sections observed we detected numerous and ubiquitarious mast cells. These exhibited several morphological types of cytoplasmic granules with characteristic subgranular architectural variety in shape and density. This allowed us to divide mast cells into two groups: cells with granules consisted of compact coiled scrolls, fine granular material and lattice--grafting configuration, and cells containing granules with discrete scrolls formed by more concentric lamellae and particulate structure. The two ultrastructural aspects observed correspond to McTC and McT of the international literature. Therefore in the human gingival connective tissue, like in other organs, two types of mast cells are clearly present. Surprisingly, the human gingival tissue shows, like the lung, McT as the prevailing subpopulation, in contrast to the skin, uterus and gastrointestinal submucosa where McTC prevail.

[Carotid stenosis with contralateral occlusion. Surgical indications and results]. / Stenosi carotidea con occlusione controlaterale. Indicazioni chirurgiche e risultati.

Recent American and European trials have clearly defined that surgery provides best treatment for unilateral critical stenosis of internal carotid artery. Isolated reports seem to confirm this trend also in cases with carotid critical stenosis with controlateral occlusion, even if a major surgical risk may be expected. In our experience in the last two years, out of 96 carotid enderterectomies 20 presented a controlateral occlusion. After routine pre-operative assessment, with particular regard to DSA "cross-filling" study, intervention has been performed under general anesthesia with BP+EEG cerebral monitoring in both groups of patients. In the non occluded group temporary shunt has been used in 19.7% of cases, in occluded the incident of shunting was 40%. Operative morbidity and mortality in the second group was surprisingly absent, with cumulative 4.1% complication rate. Our experience confirms that risks and results in carotid endoarterectomy are similar in both groups of patients.

[Results of revascularization and amputation of the gangrenous diabetic foot. Importance of a multidisciplinary approach]. / Risultati della rivascolarizzazione ed amputazione nella gangrena diabetica del piede. Importanza dell'approccio multidisciplinare.

A total of 89 diabetic patients with foot lesions were treated using amputation during the past 5 years at Niguarda-Ca' Grande Hospital. All patients suffered from gangrene which in 76% of cases was classified as Wagner's stage IV. The lesion was infected in 67 patients. Emergency surgical cleansing was performed in order to drain abscesses and remove necrotic tissue, taking care not to damage healthy tissue. An accurate multidisciplinary study was performed in all cases which included neurological, oculistic and vascular assessment. 83% of patients presented retinopathy and 62.5% were nephropathic. Angiographic tests revealed the presence of distal vascular lesions in 90% of cases. A femoro-distal by-pass was used in 17 cases and the limb was salvaged in 13 patients; ileal-femoral PTA was performed in 10 cases and the limb was salvaged in 7 patients. Amputations were limited wherever possible to distal segments: toes (55 cases), transmetatarsal (12 case), leg (12 cases), thigh (5 cases), atypical resections or ample cleansing of the foot (5 cases). This approach allowed us to record: 1) a low operative mortality (1 case); 2) higher quality of life; 3) the possibility of reoperating on more proximal portions of the limb in the event of immediate or long-term failure. This was necessary in 19 cases which can be classified as follows: reamputation of toe (11 cases), transmetatarsal (4 cases), amputation of leg (4 cases).

Treatment with low dose metformin in patients with peripheral vascular disease.

Low dose metformin (500 mg b.i.d.) was tested in 11 patients with symptomatic peripheral vascular disease (PVD) in an open design. At -1, 0, 1, 4, 7 months the major lipid and lipoprotein parameters, arterial function, and fibrinolytic activity were monitored. Arterial function changes were similar to those found with a high dose (850 mg t.i.d.) metformin but plasma lipids did not change to an appreciable extent. Post-ischaemic blood flow, by plethysmography, rose 30%; the exercise capacity, evaluated by treadmill test, also increased significantly by 105.7% for relative and 53.3% for absolute claudication. Total fibrinolytic activity did not change during the treatment but the antigens of two of the major components of the fibrinolytic system, i.e. t-PA and PAI-1, were significantly reduced at the end of the study. This study gave results quite consistent with those obtained with higher metformin doses, associated with a potentially higher risk of lactic acidosis.

Pylorus preserving pancreatoduodenectomy versus Whipple procedure for adenocarcinoma of the head of the pancreas.

Thirty eight patients underwent pancreatoduodenectomy for histologically confirmed adenocarcinoma of the head of the pancreas. Twenty one underwent a pylorus preserving pancreatoduodenectomy and seventeen the classical Whipple procedure. We undertook this retrospective analysis to compare longterm survival following the two different surgical procedures. Patients in the two groups were comparable for preoperative laboratory data, age and pathological staging. Minor and major morbidity was not different between the two group (33.3% and 35.2% respectively). In the pylorus preservation group a delayed resumption of full oral diet and a consequent prolonged hospital stay has been noted (21.3 days vs 15.4 days, p less than 0.05). Mean survival was 21 months in the pylorus preservation group and 17 in the Whipple group. No statistical difference was observed between the two survival curves. According to these data the pylorus preserving pancreatoduodenectomy represents a reasonable option for adenocarcinoma of the head of the pancreas.

Thromboendarterectomy (TEA) in the recipient as a major risk of arterial complication after kidney transplantation.

The authors analyze a series of 383 kidney transplantation pointing out the role of recipient's vessels atherosclerosis in the determination of vascular complication of the kidney graft. Three groups were considered. The first included 55 patients which required TEA for severe atherosclerotic lesion of the anastomosed vessels. The second group included 305 patients who didn't required TEA; the third group was of 20 patients who received a graft with multiple arteries which required more than one anastomosis. A significative higher rate of arterial complications was evident in the first group (p less than 0.001). Within this group the end to end arterial anastomosis was more frequently associated to thrombosis or stenosis than the end to side one (p less than 0.05). Kidney with multiple vessels also presented with an higher rate of complications (p less than 0.05).

[Aneurysms of the splenic artery. Considerations on 33 cases]. / Gli aneurismi dell'arteria splenica. Considerazioni su 33 casi.

After a short historical, pathogenetic and clinical review, the value of the radiological examinations in the diagnosis of splenic artery aneurysms is analyzed. A personal series of 33 cases is reported, 25 of which in patients with portal hypertension; incidence, number, site, size and other features are discussed. The strict relationships with portal hypertension and the choice of the best surgical treatment for each case are studied.

A critical re-appraisal of lymph-venous shunt in the management of massive ascites.

Lymph-venous shunt is one of most investigated procedures in the management of intractable ascites. However, there is considerable variation in the reported results. Personal experience with twenty-one operated cases reveals a dubious role for this intervention. Frequent anatomical variations and uncertain role and incidence of duct-end stenosis, in our opinion, reduces the efficacy of the procedure.