Effectiveness of cyclosporine A in patients with moderate to severe plaque psoriasis in a real-life clinical setting in Italy: the TRANSITION study.

BACKGROUND: Cyclosporine A (CsA) is one of the systemic therapeutic options for moderate-to-severe psoriasis, based on its efficacy and rapidity of action. The current study investigated the response to CsA in patients with moderate-to-severe plaque psoriasis. MATERIALS AND METHODS: TRANSITION was an observational, cross-sectional, multicentre study which evaluated the proportion of partial- and suboptimal-responders among patients with moderate-to-severe plaque psoriasis treated with continuous CsA for ≥12 weeks. Patients demonstrating a Psoriasis Area and Severity Index (PASI) response of ≥90, ≥75 and <90, ≥50 and <75 and <50 were defined as responders, suboptimal-responders, partial-responders, and non-responders, respectively. RESULTS: A total of 196 patients (mean age, 46.6 years; 62.8% males) from 14 sites in Italy were evaluated. At the study visit, the mean (SD) PASI score was 4.2(5.5) compared with 15.3(7.1) prior to the last CsA cycle. For response categories, 39.8%, 22.4%, 16.8%, and 20.9% of patients were responders, suboptimal-responders, partial-responders, and non-responders to CsA treatment. Overall, 28.6% of patients permanently discontinued treatment with CsA (lack of efficacy [10.2%], poor tolerability and voluntary discontinuation [3.6% each], and other [11.7%]). CONCLUSION: Patients were only partially satisfied with CsA treatment, reporting measurable impact on quality of life. Only 40% patients showed a satisfactory response to CsA.

Treatment of psoriasis with different dosage regimens of etanercept: preliminary results from the Tαranta Plastic Study Group.

This pilot open-label study is aimed to assess clinical response in psoriasis patients receiving diverse dose regimens of etanercept, consisting of the same global cumulative dose of etanercept administered over different treatment periods. Eligible patients were assigned sequentially in a 1:1 ratio to receive: etanercept 50 mg once weekly (QW) or 50 mg twice weekly (BIW) for 12 weeks. The final analysis included a total of 72 patients. At week 12 the Psoriasis Area and Severity Index (PASI) and Skindex-29 scores notably improved in both treatment arms, without significant differences between the two groups. The rate of patients attaining a PASI improvement >or= 50% (PASI 50) at week 12 was 92% in the high-dose group. In these patients, etanercept dosage was decreased to 50 mg QW from week 13, with persistence of the PASI 50 response at week 24 in all cases. Thereafter, treatment was discontinued up to week 36 and almost 30 % of patients experienced a gradual relapse of their psoriasis within this period. In the low-dose group, the PASI 50 response was observed in 75% of patients. These responders continued to be treated with etanercept 50 mg QW up to week 36 with persistence of the PASI 50 in 100% of cases at week 24 and 93% at week 36. In the low-dose regimen, 8 patients who did not respond at week 12 underwent dose escalation to 50 mg BIW for a further 12 weeks. At week 24, six of these patients gained the PASI 50 response, 4 of whom maintained the response up to week 36, after treatment discontinuation from week 24. Our results confirm that etanercept is very effective and well-tolerated in psoriasis and that the drug dosages and treatment duration may be modulated and adapted to clinical needs in a flexible way.

[Traumatic lesions of the pancreas: diagnosis and treatment]. / Le lesioni traumatiche del pancreas: diagnosi e trattamento.

The diagnosis and treatment of traumatic lesions of the pancreas are difficult. The deep anatomical location of the organ, the lack of truly accurate non-invasive diagnostic investigations and the frequent initial scarcity or absence of specific symptoms, often mean that a clinical assumption based on the dynamics of the trauma is fundamental for a rapid, correct diagnosis. The state of the main pancreatic duct is the most important element in establishing the prognosis and guiding the treatment, and should therefore be accurately defined before or during surgery. If the Wirsung duct is intact, even when radiological, clinical and laboratory signs indicate a pancreatic lesion, conservative treatment can be attempted. On the contrary, if there is evidence of a lesion of the duct, surgery is mandatory, bearing in mind that pancreatic resections involving removal of the portion of the gland distal to the lesion have a lower incidence of complications than do reconstructive and/or anastomotic procedures and are therefore to be preferred. Nevertheless, in selected cases, especially in young patients, Roux-en-Y pancreaticojejunostomy can avoid the risk of functional insufficiency, sparing large tracts of otherwise sacrificed glandular tissue. Only the more serious complex lesions of the head of the pancreas also affecting the duodenum require pancreaticoduodenectomy.

A review of rosiglitazone in type 2 diabetes mellitus.

The thiazolidinedione rosiglitazone maleate works primarily to improve insulin sensitivity in muscle and adipose tissue. It may have additional pharmacologic effects, however, as its main target is peroxisome proliferator-activated receptor-gamma. Data using the homeostasis model assessment and proinsulin:insulin ratio in patients with type 2 diabetes mellitus suggest that rosiglitazone may have the potential to sustain or improve beta-cell function. In these patients the drug reduces fasting plasma glucose, glycosylated hemoglobin, insulin, and C-peptide. In clinical trials, rosiglitazone monotherapy significantly reduced glycosylated hemoglobin by 1.5% compared with placebo and led to significant improvements in glycemic control when given in combination with metformin, sulfonylureas, or insulin. A dosage of 4 mg twice/day significantly reduced fasting plasma glucose levels and produced comparable reductions in glycosylated hemoglobin compared with glyburide. Rosiglitazone has a low risk of gastrointestinal side effects and hypoglycemia, reduced insulin demand, potential sparing effects on beta-cells, and favorable drug interaction profile. Adverse events of clinical significance are edema, anemia, and weight gain. Premarketing data indicate no significant difference in liver enzyme elevations for rosiglitazone, placebo, or active controls. Another drug in the thiazolidinedione class, troglitazone, was associated with idiosyncratic hepatotoxicity and was removed from the market. Therefore, until long-term data are available for rosiglitazone, liver enzyme monitoring is recommended.

Use of insulin lispro in the outpatient management of ketonuria.

OBJECTIVE: To compare the effectiveness of the use of insulin lispro with the use of regular insulin in managing children with diabetes in outpatient settings. DESIGN: In this prospective study, telephone records of 75 children treated for ketonuria were analyzed. Outcome was based on the number of successful home treatment episodes (hospitalization not required), the amount of insulin the patients needed, and the time to resolution of ketonuria. RESULTS: Doses of supplemental insulin used to treat patients with both moderate and large urine ketone values were similar (P>.05) in the insulin lispro and regular insulin groups. Likewise, the time to resolution of moderate or large ketonuria was not statistically different (P>.05) between the 2 groups. No hospitalizations were required for any of the patients for whom management via telephone was attempted. CONCLUSION: These data indicate that insulin lispro is an effective option for the outpatient management of ketonuria.

Nifedipine can preserve renal function in patients undergoing aortic surgery with infrarenal crossclamping.

Sixteen patients diagnosed with an aneurysm of abdominal aorta or Leriche disease underwent elective aortic surgery involving crossclamping of infrarenal aorta (ICC). These patients were randomized into two equal groups and 8 patients were infused with nifedipine starting from the isolation of aorta until the end of surgery (group A) while another 8 patients were infused with low-dose dopamine (group B) over the same surgical course. Plasma endothelin (ET) was measured before the induction of anesthesia, at the beginning and at the end of the clamp period and at the end of the operation. Intraoperatively, creatinine clearance and urinary excretion of PGE2, 6-keto PGF1 alpha and TxB2 were also determined before, during and after aortic crossclamping. Preoperative GFR as well as preinduction cardiac index (CI) and pulmonary capillary wedge pressure (PCWP) of the two groups did not differ. During cross-clamping plasma ET rose significantly in both groups. However, after clamp removal, plasma ET decreased in group A while it remained elevated in group B. Urinary excretion of TxB2, PGE2 and 6-keto PGF1 alpha increased during clamp in both groups, but the ratio of PGE2 + 6-keto PGF1 alpha/TxB2 during and after clamp was significantly higher in group A than in B. Postclamp creatinine clearance decreased in group B, and increased in group A; postoperative value of GFR was unchanged in group A and decreased significantly in group B. In conclusion, infusion of nifedipine, in contrast to dopamine, prevented the decrease of GFR in patients undergoing aortic surgery. This effect could be mediated by a nifedipine modulation of ET vascular synthesis and/or a preferential renal synthesis of vasodilating prostanoids.

[Venereal perihepatitis: Fitz-Hugh-Curtis syndrome]. / La periepatite venerea: sindrome di Fitz-Hugh-Curtis.

A case of Fitz-Hugh-Curtis syndrome (venereal perihepatitis) is reported. This syndrome is observed almost exclusively in women as a complication of genital gonococcal or chlamydial infections. A sudden, acute biliary-type pain generally characterizes the disease; only a few cases present symptoms related to associated genital infection. The real clinical incidence of venereal perihepatitis is quite high; in fact, a lot of the emergency admitted patients diagnosed with biliary colic or acute cholecystitis as a matter of fact suffer from this syndrome. If haematological investigations, ultrasonography and cholangiography do not confirm a suspected biliary lithiasis, it will be needed to investigate the genital tract. After clinical and ultrasound examinations, neisseria gonorrhoeae and chlamydia trachomatis must be sought in vaginal and cervical secretions and serum antichlamydial antibodies level is to be sought too. Through these examinations, the venereal perihepatitis can usually be diagnosed. In uncertain cases laparoscopy can be useful: in fact, it can reveal the typical violin-string-like adhesions between the anterior liver capsule and the anterior abdominal wall, and, in the same session, it allow to resect them. Tetracycline, doxycycline and, more recently, ofloxacine gave good results in the syndrome's treatment.

Toxic epidermal necrolysis after initiation of felbamate therapy.

A 33-year-old woman with a 13-year history of partial complex seizures experienced toxic epidermal necrolysis requiring management in a regional burn treatment center after 16 days of single-agent treatment for epilepsy with felbamate 3600 mg/day. Within 24 hours the target lesions involved 45% of her total body surface area. They coalesced and progressed to exfoliation involving the mucosa and the conjunctiva. The patient was hospitalized for 25 days. Reports in the literature describe life-threatening rashes after treatment with felbamate in combination with other anticonvulsant agents. We believe this to be the first reported case of felbamate-induced toxic epidermal necrolysis induced by single-agent therapy. Although felbamate provides many advantages as an anticonvulsant, its structure can be arranged to a conformation in space similar to that of hydantoins and barbiturates, and thus warrants careful patient monitoring for life-threatening rashes.

Pleural mesothelioma associated with non-Hodgkin's lymphoma.

Occupational exposure to asbestos has been associated with an increased incidence of lung and gastric cancers, mesotheliomas, and myelolymphoid malignancies. A new observation of a patient with indirect exposure to asbestos who developed mesothelioma and plasmacytoid lymphocytic non-Hodgkin's lymphoma is described. This report and the previously described stimulation of B lymphocytes by asbestos suggests that the association of mesothelioma with lymphoid and plasma cell malignancies is not merely a coincidence.

Enhanced blood pressure response to mineralocorticoid stimulation in normotensive members of hypertensive families.

Currently normotensive offspring of essential hypertensive parents often have disturbances in blood pressure (BP) regulation such as abnormalities in electrolyte homoeostasis, increased salt-sensitivity and/or impaired renal Na(+)-excretion. Whether an altered reactivity to mineralocorticoids may also play a role is presently unknown. Therefore, we investigated BP (recorded during 24 h), plasma atrial natriuretic factor (ANF), cyclic guanosine monophosphate (cGMP), aldosterone (PA) and renin activity (PRA), 24-h urine electrolyte and cGMP excretions measured on 4 consecutive days, as well as other variables, after 1 week on placebo and after 3 weeks of 9 alpha-fludrocortisone-acetate (9 alpha F) administration, 0.6 mg/d in 12 normotensive sons of essential hypertensive parents (SEH) and 12 body-mass-index- and age-matched (25 +/- 1[+/-SEM]yr) sons of normotensive parents (SN). On placebo, the 2 groups did not differ significantly in average 24 h BP (mean BP 95 +/- 2 vs 95 +/- 2 mmHg), plasma-ANF (40 +/- 7 vs 30 +5 pg/ml), cGMP (6 +/- 0.4 vs 6 +/- 0.5 nmol/l), PRA (1.3 +/- 0.1 vs 1.6 +/- 0.2 ng/ml/h), PA (9 +/- 0.5 vs 10 +/- 0.9 ng/dl), hematocrit (44 +/- 0.7 vs 44 +/- 0.4%) and 96-h urinary-Na+ (mean 205 +/- 13 vs 195 +/- 16 mmol/d), -K+ (69 +/- 6 vs 78 +/- 7 mmol/d) or -cGMP (461 +/- 35 vs 483 +/- 32 nmol/d). 9 alpha F significantly increased BP in SEH (p < 0.005) but not SN (107 +/- 2 vs 100 +/- 2 mmHg, p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Bacteriologic monitoring in a surgical department with emergency services. Epidemiologic analysis and study of sensitivity to antibiotic therapy]. / Monitoraggio batteriologico in una divisione chirurgica con servizio d'urgenza. Analisi epidemiologica e verifica di sensibilità alla antibioticoterapia.

The two year experience with 2091 biological cultures and the related antibiograms has been reported on the basis of a prospective, computerized study. The incidence of germs coming from each fluid collected has been analyzed as well as the sensibility to various antibacterial drugs. The gram negative such as Escherichia Coli, Enterococcus, Pseudomonas, Proteus, Klebsiella, Serratia and Enterobacter resulted more frequently isolated; in addition a revival of gram positive strains (Staphylococcus, Streptococcus) was noted too.

[Cefoxitin in the preventive treatment of infectious complications in high-risk gastro-jejuno-colic and biliary surgery]. / La cefoxitina nel trattamento preventivo delle complicanze infettive nella chirurgia gastro-digiuno-colica e biliare a rischio.

Cefoxitin is a bactericidal beta lactam antibiotic of the cephamycins group, with wide antimicrobial efficacy and active against both aerobes and anaerobes. In this study, 58 patients were divided in four groups according to the site of the disease (stomach, gallbladder and biliary tract, jejunum ileum and colon-rectum). The efficacy of cefoxitin in the prophylaxis of surgical infections was assessed for each group and for all patients. When compared with the combination of antibiotics used previously, cefoxitin led to a reduction of the mean duration of fever (7.2 and 5 days respectively with ampicillin/cloxacillin and lincomycin/gentamycin, 3.2 days with cefoxitin). Cefoxitin also led to a reduction in the incidence of surgical infections (50% with ampicillin/cloxacillin, 9.19% with lincomycin/gentamycin, 8.6% with cefoxitin) and in the incidence of localized surgical infections (29.6%, 20.3%, 8.6% respectively). In this study, cefoxitin has been found to be very useful and well tolerated in the prophylaxis of surgical infections.

[Updating case studies of primary tumors of the mesentery: angiofibroma involving the superior mesenteric artery]. / Aggiornamento casistico sui tumori primitivi dei meso: angiofibroma coinvolgente l'arteria mesenterica superiore.

The authors describe a rare case of jejunal mesenteric angiofibroma involving the superior mesenteric artery, referred to them as a clinical finding of an abdominal mass with associated disorders of alimentary transit. A review of the literature reveals the controversies existing to date on the subject of mesenteric neoplasms. In addition to their rare incidence, also confirmed by our personal experience in two surgical centres, intraligamentous abdominal tumours arouse interest owing to the diagnostic difficulties which as a rule hinder a precise pre-operative orientation and to surgical problems of a tactical nature related to the frequent involvement of adjacent anatomical structures.