Development of kidney scars after acute uncomplicated pyelonephritis: relationship with clinical, laboratory and imaging data at diagnosis.

BACKGROUND: Acute pyelonephritis is a potential cause of kidney scars. AIM: To evaluate the relationship between clinical, laboratory and imaging data and the development of kidney scars in acute pyelonephritis. METHODS: All consecutive patients hospitalized for acute uncomplicated pyelonephritis in our nephrology unit from June 1996 to June 2004 were considered: 58 females, median age 25.6 years (16-52). Diagnosis of pyelonephritis required parenchymal lesions shown by CT or NMR scan. RESULTS: The lesions were bilateral in 17.2% (10/58) patients, unilateral, but multifocal in 81.0% (47/58); at CT or NMR, 65.5% of the lesions were classified as simple, 19% with tendency to colliquation and 15.5% abscessual. The median interval between first symptoms and diagnosis was 5 days (1-25); at referral, only 20.7% had a positive urine culture and 94.8% (55/58) had undergone previous antibiotic treatment. The therapeutic protocol required intravenous therapy for > or = 2 weeks, followed by 2-4 weeks of oral therapy. At 6-8 months, the prevalence of kidney scars was 29.3%. Their development was highly correlated with the type of lesions at diagnosis (highest risk with abscessual lesions; uni- and multivariate analysis). No other clinical or laboratory marker (age, fever, positive cultures, levels of acute phase reactants, interval between onset and diagnosis) was correlated with the outcome (scars). CONCLUSIONS: The type of lesion at diagnosis of acute uncomplicated pyelonephritis is highly correlated with the development of kidney scars. Further studies are needed to test the therapeutic schedules tailored according to the imaging data.

Complete reversal of the nephrotic syndrome after preemptive pancreas-kidney transplantation: a case report.

BACKGROUND: Nephrotic syndrome due to diabetic nephropathy is presently considered an indication for pancreas-kidney transplantation even in the absence of severe renal failure. Reversal of the nephrotic syndrome has been reported, but the mechanisms of this effect are unclear. AIM: To describe the renal morphofunctional pattern and the pattern of proteinuria before and after preemptive pancreas-kidney transplantation. METHODS: Methods included quantitative and qualitative assessment of proteinuria as well as renal ultrasound and scintiscan. CASE REPORT: A 42-year-old woman with type 1 diabetes since age 24 had widespread end-organ damage. Renal biopsy (2001) showed a mainly nodular pattern of diabetic nephropathy. Following referral (1999), her serum creatinine ranged from 1.6 to 2.2 mg/dL, with nephrotic range proteinuria (glomerular nonselective, tubular complete). Renal scintiscan revealed bilateral, symmetric, well-perfused kidneys. The functional data before pancreas-kidney graft (February 2003) were: serum creatinine 1.6 mg/dL, creatinine clearance 58 mL/min, serum albumin 2.6 g/dL, proteinuria 9.1 g/d. At hospital discharge (March 2003), the creatinine was 1.2 mg/dL, the creatinine clearance 97 mL/min, the proteinuria 0.676 g/d. Two months later, the creatinine was 1.2 mg/dL and proteinuria 0.421 g/d. A renal scintiscan demonstrated the functional prevalence of the grafted kidney (77% of total function), with vital, almost completely excluded native kidneys (functional contribution, 11.5% each). Proteinuria, ranging from 0.3 to 0.6 g/d, showed a physiological pattern. CONCLUSIONS: Functional exclusion of the native kidneys by renal scintiscan gives morphological support to reversal of the nephrotic syndrome.

Surgical approach to cervical lymph node metastasis in differentiated thyroid cancer.

BACKGROUND: Precautionary locoregional lymph node dissection in thyroid carcinomas for diagnostic and/or staging purposes is useless both in differentiated (papillary and follicular) and undifferentiated forms. It is only indicated in medullary carcinomas because of their frequent spread to regional lymph nodes. The objective of lymphadenectomy is to contain tumor spread; however, the procedure may be associated with intraoperative complications and postoperative sequelae. In order to improve the therapeutic management of patients with thyroid carcinoma, diagnostic scintigraphy with 201T1 or 99mTc-sestamibi is used in the advanced and undifferentiated forms of this tumor. METHODS: We have treated a woman submitted three years previously to total thyroidectomy for papillary carcinoma (pT3) without subsequent radiometabolic treatment. On physical examination we noted a swelling on the left side of the neck. The lesion was confirmed by ultrasonography, CT scan, and scintigraphic examination with 99mTc-sestamibi 24 hours before planned lymphadenectomy. During the surgical procedure we performed radiodetection to localize metastatic lesions. RESULTS: Intraoperative radiodetection may help to identify residual disease, which is often difficult to trace in the presence of post-surgical fibrosis. In our patient, histological examination of the removed tissue specimens demonstrated that intraoperative radiolocalization had been highly accurate. The eradication of residual disease was confirmed by scintigraphic follow-up after 12 months. DISCUSSION AND CONCLUSIONS: Scintigraphy with 99mTc-sestamibi has been proposed as a means to localize metastatic spread and possible residual disease after a supposedly radical thyroidectomy. Surgical eradication of all residual tumor guarantees the best disease control without having to resort to radiometabolic therapy. This approach will reduce the incidence of iatrogenic comorbidity and consequently improve the patients' quality of life.

High-dose mitoxantrone + melphalan (MITO/L-PAM) as conditioning regimen supported by peripheral blood progenitor cell (PBPC) autograft in 113 lymphoma patients: high tolerability with reversible cardiotoxicity.

Hematological and extrahematological toxicity of high-dose (hd) mitoxantrone (MITO) and melphalan (L-PAM) as conditioning regimen prior to peripheral blood progenitor cell (PBPC) autograft was evaluated in 113 lymphoma patients (87 at disease onset). Autograft was the final part of a hd-sequential (HDS) chemotherapy program, including a debulkying phase (1-2 APO +/- 2 DHAP courses) and then sequential administration of hd-cyclophosphamide, methotrexate (or Ara-C) and etoposide, at 10 to 30 day intervals. Autograft phase included: (1) hd-MITO, given at 60 mg/m2 on day -5; (2) hd-L-PAM, given at 180 mg/m2 on day -2; (3) PBPC autograft, with a median of 11 x 10(6) CD34+/kg, or 70 x 10(4) CFU-GM/kg, on day 0. A rapid hematological recovery was observed in most patients, with ANC >500/microL and Plt >20,000/microl values reached at a median of 11 and 10 days since autograft, respectively. The good hemopoietic reconstitution allowed the delivery of consolidation radiotherapy (RT) to bulky sites in 53 out of 57 candidate patients, within 1 to 3 months following autograft; five of these patients required back-up PBPC re-infusion due to severe post-RT pancytopenia. Few severe infectious complications were recorded. There was one single fatal event due to severe pancytopenia following whole abdomen RT. Cardiac toxicity was evaluated as left ventricular ejection fraction (LVEF), monitored by cardiac radionuclide scan. LVEF prior to and after autograft was significantly reduced (median values: 55% vs 46%) in 58 evaluated patients; however, a significant increase to a median value of 50% was observed in 45 patients evaluated at 1 to 3 years since autograft. At a median follow-up of 3.6 years, 92 patients are alive, with a 7-year overall survival projection and 6.7-year failure-free survival projection of 77% and 69%, respectively. We conclude that a conditioning regimen with hd-MITOIL-PAM fits well within the HDS program. It implies good tolerability and reversible cardiotoxicity and it may have contributed to the good long-term outcome observed in this series of patients.

Scintigraphic study of ureteral peristalsis using fast Fourier transforms.

Pathophysiological changes in ureteral kinetics can be monitored externally and non-invasively by means of a time-space matrix approach during the excretory phase of fast-frame routine renography. The main limitations of this method are poor space-time resolution and, in some cases, an inadequate visualization of the peristaltic waves. A new approach to the study of ureteral contractions using the power spectrum obtained from Fourier transforms of the ureteral time-activity curves was developed. The FORTRAN program was tested by an experimental simulation, and its subsequent application on fifty-one subjects indicated that the method is a useful complement to the space-time matrix technique. Moreover, evaluation of the power spectrum offers several advantages for the study of the pathophysiological parameters of peristalsis.

[Use of naltrexone in the treatment of opiate addicts. Efficacy and indications for type categories]. / L'utilizzo del naltrexone nella terapia delle tossicodipendenze da oppiacei. Efficacia ed indicazioni per categorie tipologiche.

Naltrexone is a pure narcotic antagonist with optimum pharmacologic properties for the long-term management of opiate addiction. The above study confirms the usefulness of naltrexone for the prevention of relapse in subjects who have been weaned from narcotics. However, the short follow up does not yet permit evaluation of its medium and long-term efficacy. The better course and outcome of treatment are significantly related to certain characteristics and types of addicts. It may be said that by assuring complete, albeit time-limited, remission the antagonist allows the addict to open a window through which to face the world, and offers the therapist the possibility to apply all the instruments at his disposal in an effective manner.

[Folate and vitamin B12 deficiency. Characterization of parameters for early diagnosis]. / Deficit di folati e vitamina B12. Individuazione di parametri per la diagnosi precoce.

True vitamin B12/folate deficiency is more common than is currently appreciated; it appears in many guises and the classic hematological features of megaloblastic anaemia are often absent. The single most reliable predictor of megaloblastic anaemia is serum vitamin B12/folate concentration, but this determination in a screening program for all patients is difficult in terms of laboratory overload and cost. Early recognition of nutritional anaemias is, however, mandatory and we undertook this study to explore the possibility of identifying, on a demographic basis or because of routine laboratory results, a group of subjects at risk for vitamin B12/folate deficiency. Results obtained in simultaneous radioassay of serum B12 and folate levels and erythrocyte folate concentration in 1.200 hospitalized patients are presented. Coexisting iron deficiency was excluded by ferritin assay. We found no significant difference between males and females and no correlation between serum folate and B12 concentrations and aging. Low serum folic and cobalamin levels were found in 53% of patients with macrocytosis and elevated MCH, even in the absence of anaemia. These observations suggest that increased MCV and MCH may be present before a related anaemia and that serum folate and cobalamin levels must be monitored early in these patients to prevent a deficiency.

Dynamic renal scanning using 99mTc-MAG-3 in man.

99mTc-labelled mercapto-acetyltriglycine (MAG-3) has recently been proposed as an ortho-iodohippurate (OIH) substitute for dynamic renal imaging. Experience with MAG-3 is, however, still limited and its biokinetics are not completely known. Moreover, most of the published studies have used HPLC purified MAG-3 which is inpractical for routine clinical work. In this study a commercially available kit of MAG-3 which does not require high performance liquid chromatography (HPLC) is used in 10 normal subjects and 15 patients with renal disease. The results obtained lead to the following conclusions: a. MAG-3 provided in kit form is suitable for renal imaging and semiquantitative analysis in routine clinical settings. b. There are significant differences between renal handling of MAG-3 and OIH, but the dynamic studies obtained with MAG-3 can be interpreted with the same criteria used for OIH studies. c. More information on MAG-3 kinetics is needed before this new radiopharmaceutical can be considered as an OIH substitute for truly quantitative studies such as effective renal plasma flow determinations.

[Active immunoprophylaxis of type B viral hepatitis. Evaluation of the effectiveness of HEVAC-B vaccine in a population at risk]. / Immunoprofilassi attiva dell'epatite virale di tipo B. Valutazione dell'efficacia del vaccino HEVAC-B in una popolazione a rischio.

Hepatitis B virus (HBV) is the commonest cause of liver disease world-wide, with an estimated 200 million chronically infected individuals. The prevalence of HBV is particularly high in parts of Africa, Far East and South-East Asia. The worldwide distribution of HBV infection with the consequence of chronic liver disease and primary hepatocellular carcinoma implies the need for an efficient and safe vaccine. Three vaccines are today available: HB-VAX (M.S.D.), HEVAC-B (Ist. Pasteur, Paris) and Engerix-B (Smith-Kline Biological) and the first international experience proves that they are harmless, immunogenic and protective. The possibility of eliminating hepatitis B depends on mass vaccination in the high carrier areas of the third world and this in turn depends on supplies of inexpensive vaccine. The present work reports results obtained in Italy in 16 volunteers with high risk, who received HEVAC-B vaccine. Blood samples of the subjects were also tested for HBSAg/IgM complexes.

[Rheumatoid arthritis. Considerations on a rational therapeutic strategy]. / Artrite reumatoide. Considerazioni per una razionale strategia terapeutica.

Rheumatoid Arthritis (RA) is a progressive disease of unknown aetiology which may be caused by faulty immune mechanisms. Early diagnosis and correct treatment can be extremely effective. Fast and lasting results can only be obtained by an appropriate combination of NSAID and DMARD drugs which both reduce subjective symptoms and halt the progression of the disease.

[Idiopathic adult pulmonary hemosiderosis: a new etiopathogenetic hypothesis]. / Emosiderosi polmonare idiopatica dell'adulto: una nuova ipotesi eziopatogenetica.

IPH is an uncommon disease affecting mainly children and adults and has usually a poor prognosis. The basic pathogenesis of the disorder is unknown; many theories have been advanced, but none is proved. A case of IPH in a 35 years old male presenting the atypical feature of a myeloperoxidase deficiency is reported. This unusual feature may be compatible with a generalized redox systems deficiency, which leads, via an impaired flow of iron into alveolar macrophages, to the pulmonary fibrosis.