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Standard hemodialysis is a far from ideal treatment for uremia since the morbidity and mortality of patients on hemodialysis are still significantly higher than those of non-hemodialyzed subjects with similar demographic characteristics. Because it has been suggested that the cause could lie in the inadequate removal of ''middle molecules'' by standard hemodialyis, two alternative treatments have been proposed: high-efficiency hemodialyis and high-flux hemodialyis. The 2002 results of the HEMO study showed that both these treatments are associated with a non-significant reduction in the relative risk of death (4% and 8%, respectively). The MPO study, which - unlike the HEMO study - enrolled only incident cases and not did not allow reuse of dialyzers, evaluated the mortality rate with high-flux and low-flux hemodialysis in a sicker population, i.e., patients with hypoalbuminemia, and showed a significant reduction in the relative risk of death especially in patients with diabetes. In an attempt to define the clinical impact of hemodiafiltration, some of the efficacy data from clinical studies are reviewed in light of a number of factors that may be related to the high mortality among hemodialysis patients. The current state of affairs suggests it is reasonable to prefer high-flux hemodialysis in sicker patients, especially diabetics. Moreover, the use of ultrapure dialysis fluid is recommended to reduce chronic inflammation and its consequences.

Purpose: To evaluate the diagnostic accuracy of the commercial computer-aided detection CADx system for the reading of mammograms., Materials and Methods: The study assessed the Second Look system developed and marketed by CADx Medical Systems, Montreal, Canada. The diagnostic sensitivity was evaluated by means of a retrospective study on 98 consecutive cancers detected at screening by double independent reading. The specificity and the positive predictive value (PPV) for cancer of the CADx system were prospectively evaluated on a second group of 560 consecutive mammograms of asymptomatic women not included in screening program. The radiologist who was present during the test assessed the abnormal mammographic findings by one or more of the following diagnostic procedures: physical examination, additional mammographic detail views with or without magnification, ultrasonography, ultrasound- or mammography-guided fine needle aspiration cytology, and core-biopsy. The exams first underwent conventional reading and then a second reading carried out with the aid of the CADx system., Results: The overall diagnostic sensitivity of the CADx system on the 98 screening cancers was 81.6%; in particular it was 89.3% for calcifications, 83.9% for masses and only 37.5% for architectural distortion. The CADx markings for each mammography were 4.7 on average. Identification of invasive carcinoma was independent from tumour size. In the second group of 560 mammograms, the CADx system marked all cases identified as positive by conventional reading and confirmed by biopsy (7/7), but did not permit the detection of any additional cancer. The CADx markings per exam were 4.2 on average, the specificity was 13.7% and the PPV was 0.55% versus 13.7% recall rate of conventional reading. CADx reading led to a 1.96% (11/560) increase of the women necessitating further diagnostic investigation., Conclusions: The results of our study show that the diagnostic sensitivity of the CADx system is lower than that obtained by double independent reading at screening. Used in association with conventional reading of mammograms of asymptomatic women the CADx system did not increase diagnostic sensitivity.

In order to assure a zero sodium balance in hemodialysis patients, attaining 'constant' values of total body water and plasma water sodium concentration at the end of each dialysis session is a basic pre-requisite. This is achieved by matching the ultrafiltration to the inter-dialytic weight gain and by individualizing dialysate sodium concentration at each dialysis session by making use of a kinetic model. Clinical results suggest that the single pool variable volume sodium kinetic model allows the targeted end-dialysis plasma water sodium concentration to be obtained. Nevertheless, this model is not suitable for routine clinical application, because of difficulties in the real-time determination of initial plasma water sodium concentration and 'effective' sodium dialysance. Measuring dialysate conductivity at the inlet and outlet ports of the dialyzer allows the estimation of sodium transfer during dialysis, if the function of concentration versus conductivity is known. If sodium transfer is measured at two different inlet dialysate conductivities, it is possible to determine ionic dialysance and systemic plasma water conductivity, which can be used routinely to apply the single pool sodium kinetic model. Given that ionic dialysance and plasma water conductivity can be measured easily repeatedly and inexpensively at each dialysis session without the need for blood sampling or laboratory determinations, it can be expected that conductivity kinetic models will soon become a part of everyday clinical practice.

Different antineoplastic drugs have been associated to hyperthermia in the treatment of advanced soft tissue limb sarcoma with a good results in terms of conservative surgery (77%-97%), locoregional control (77%-87%) and overall survival (72%). Two different studies were performed: the first was carried out to analyze the doxorubicin-TNFalpha-hyperthermia association (three different trials) in terms of toxicity and efficacy of the treatment (tumor response, locoregional control, disease free and overall survival). The results showed that the trimodality association (doxorubicin TNFalpha and hyperthermia) is the best regimen able to obtain a 77% of objective response and 77% of limb sparing in patients candidate to amputation but may result in high local toxicity if high temperatures (>41.5 degrees C) were maintained during perfusion. The second study describes the employment of liposomal doxorubicin in hyperthermic antiblastic perfusion (HAP) in terms of tumor response, conservative surgery and toxicity; the maximum tolerable dose (MTD) of doxorubicin was 16 mg/l of perfused limb volume at the temperature of 41.5 degrees C; the conservative surgery was possible in 91% of the cases and mild (grade I and II) toxicity was observed in the perfused limb with high temperature (>41.5 degrees C).

Purpose: It has been suggested that ionic dialysance (ID) can adequately estimate the "effective" urea clearance (eK), i.e. urea clearance corrected for total (access and cardiopulmonary) recirculation. Unfortunately, the results obtained by different authors in determining the relationship existing in vivo between ID and eK do not always agree. Furthermore, it has been recently evidenced that ID values could be different, according to the different methods used to modify the inlet dialysate conductivity during ID measurement., Objective: We aimed to verify the relationship between the mean values of repeated instantaneous ID determinations and the urea clearance values corrected for access recirculation, urea clearance corrected for total recirculation (eK) and urea clearance corrected for both total recirculation and post-dialysis urea rebound (body urea clearance), determined according to the direct quantification method (dKDDQ, eKDDQ and bK, respectively)., Methods: Thirty-one anuric patients on chronic thrice-weekly hemodialysis (HD) were studied in 31 dialysis sessions (one per patient), performed using Integra machines equipped with the Diascan module for the automatic ID determination and the Quantiscan module for the fractional collection of outlet dialysate. The mean values of repeated ID determinations at 30 min intervals throughout each dialytic session by the Diascan module were compared with dKDDQ, eKDDQ and bK values., Results: ID = 179 +/- 24 mL/min; dKDDQ = 200 +/- 27 mL/min; eKDDQ = 188 +/- 26 mL/min; bK = 165 +/- 25 mL/min. The mean (ID - dKDDQ) difference was -21 +/- 10 mL/min (95% confidence interval (95% CI) -25 to -17 mL/min; p<0.001). The mean ID/dKDDQ ratio was 0.90 +/- 0.05, indicating a mean difference between dKDDQ and ID of 10%. The mean (ID - eKDDQ) difference was -9 +/- 9 mL/min (95% CI -12 to -6 mL/min; p<0.001). The mean ID/eKDDQ ratio was 0.96 +/- 0.05; therefore, indicating a mean difference between eKDDQ and ID of only 4%. The mean (ID - bK) difference was 15 +/- 7 mL/min (95% CI 13 to 17 mL/min; p<0.001). The mean ID/bK ratio was 1.09 +/- 0.05, indicating a mean difference between bK and ID of 9%., Conclusions: The mean value of repeated ID determinations could be considered clinically as an adequate estimate of urea clearance corrected for total recirculation (eKDDQ). Given that ID determination does not require either blood sampling or laboratory tests, therefore, it becomes possible to estimate easily and rapidly, once the urea distribution volume (V) has been correctly determined, the Kt/Vsp at each dialytic session.

Purpose: Direct dialysis quantification (DDQ) represents the gold standard for determining urea distribution volume (V) in hemodialysis (HD) patients, but is impractical for routine use because it requires equilibrated post-dialysis plasma water urea concentration. The "formal" single-pool, variable volume, urea kinetic model (SPVV-UKM) is easier to use, needing a blood sample drawn immediately after the dialytic session, but to obtain a V value consistent with the DDQ method, it requires a correct estimate of dialyzer urea clearance (Kd), actually often overestimated. Ionic dialysance (ID) accurately estimates the "effective" urea clearance (Keff), namely Kd corrected for total recirculation. Using ID as an input parameter to SPVV-UKM, correct V values are expected when end-dialysis plasma water urea concentrations are determined in a blood sample drawn after the blood pump speed has been reduced to 50 ml/min for 2 min (Upwt2')., Objective: We aimed to compare the V values determined by SPVV-UKM, ID and Upwt2' (VID), those determined by "formal" SPVV-UKM (VKd) and those determined by the anthropometric method proposed by Watson (VA), with the V values determined by the gold standard DDQ method (VDDQ)., Methods: Thirty-one anuric patients on chronic thrice-weekly HD were studied in 31 dialysis sessions (one per patient)., Results: VDDQ = 26.5 +/- 5.3 L; VID = 26.2 +/- 5.1 L; VKd = 32.1 +/- 5.7 L;. VA = 33.2 +/- 5.8 L. The mean (VID - VDDQ) difference was -0.2 +/- 1.3 L, not statistically significant (95% confidence interval (95% CI) -0.7 to 0.2 L; p=0.302); the mean (VKd - VDDQ) difference was 5.6 +/- 2.3 L, statistically significant (95% CI 4.7 to 6.4 L; p<0.001); the mean (VA - VDDQ) difference was 6.7 +/- 2.7 L, statistically significant (95% CI 5.7 to 7.7 L; p<0.001)., Conclusions: ID use as an input parameter to SPVV-UKM allows adequate V determinations and, at the same time, circumvents the problem of delayed post-dialysis blood samples. On the other hand, the use of "formal" SPVV-UKM or of anthropometric equations leads to a significant overestimation in urea distribution volume.

Acute renal failure (ARF) in patients admitted to the intensive care unit (ICU) is mostly caused by ischemic or toxic injury, with a higher incidence in the latest years due to the growing number of interventions in cardiac and vascular surgery and to the general enhancement of reanimation techniques, which allow a better outcome among ICU patients. In critically ill patients, the ARF incidence reported in the literature ranges between 1 and 25%. Among ICU patients with ARF the mortality is between 40 and 65%, much more than in patients without this complication. Higher mortality rates, longer hospitalisation times and higher therapy costs demand from us an early diagnosis and treatment of ARF. Due to the lack of controlled and randomized proofs, recommended criteria for starting renal replacement therapy (RRT) in critical ARF patients might overlap with those for ESRD therapy. Moreover, randomised and controlled trials, confirming the actual efficacy of early onset of RRT on the mortality rate, are not yet available. As for stable ESRD patients, a direct relationship between dialytic doses and mortality and morbidity has been established for ARF patients. For ARF patients, as well as for ESRD patients, a minimum Kt/V of 1.2 three times a week should be ensured, although higher doses for critical ARF patients may achieve better results. The choice between intermittent (IRRT) and continuous renal replacement therapy (CRRT) in these patients is still a controversial issue. In spite of the fact that most studies report a better outcome in patients treated with CRRT, a recent meta-analysis failed to demonstrate any difference on the relative risk (RR) of mortality and on the rate of renal recovery between patients treated with either IRRT or CRRT. Furthermore, the use of peritoneal dialysis for the treatment of ARF patients in ICU has not been dismissed yet; so far this is indeed considered to be the technique of choice in some specific clinical situations. The intrinsic urgency of dialysis in ARF patients entails the use of temporary central venous catheters. The internal right jugular vein is usually preferred for these catheters because of the easier insertion and the lower risk of stenosis and thrombosis. The anticoagulant procedure should be chosen on the basis of patient characteristics, treatment typology and the likelihood of effectively monitoring its action. The choice of buffers in the dialysate, mostly lactate or bicarbonate, should depend on patient characteristics; so far, however, controlled but not randomized studies do not show any significant difference in the correction of metabolic acidosis between lactate and bicarbonate.

Primary limb melanoma may recur in terms of satellitosis, in transit metastases and/or regional node involvement. Hyperthermic antiblastic perfusion (HAP) permits the isolation of involved extremity from the systemic circulation and to deliver high doses of antineoplastic drugs. The association of cytostatic drugs to hyperthermia (> or = 41.5 degrees C) results in a synergistic effect with an increased therapeutic effectiveness. The overall 5 and 10-year survival rates in relation to the disease stages are st. II 75% and 67%; st. IIIA 59% and 42%; st. IIIAB 36% and 30% respectively. The results confirm that HAP is considered the treatment of choice of loco-regional spreading limb melanoma. Recently, the tumor necrosis factor (TNF) has been combined with Melphalan and hyperthermia. This trimodality association seems to be superior to Melphalan and hyperthermia alone only in patient with bulky tumors (i.e., multiple nodules), as a matter of fact the complete tumor response rates observed in these patients have been 67% and 20% respectively. The greater effectiveness of trimodality association has to be confirmed by multicentric randomized trials.

Pneumothorax in pregnancy raises several problems especially of therapy. In the present study we report a case observed in our Institution and literature data on 15 further cases. Pneumothorax occurred in 9 cases in the course of pregnancy, in 6 cases during delivery and in 1 case in the post-partum period. Immediate treatment was insertion of pleural drain in 13 patients and bed rest in 3 patients. Surgery was required in 8 cases and was performed after delivery in 5 cases and during pregnancy in 3 cases, 6 thoracotomies, 1 bilateral thoracotomy and 1 sternotomy for bilateral pneumothorax were carried out. Actually a videothoracoscopic treatment, requiring general anaesthesia, is also possible. In all observed cases pneumothorax didn't represent a serious risk for both mother and foetus, for the timely therapeutic measures. Pneumothorax represents an uncommon pathology, usually underestimated in literature, that must be taken into account whenever during pregnancy or the post-partum period a progressive respiratory failure arises.

This paper reports a case of endomyocardial disease due to hypereosinophilic syndrome. Two-dimensional echocardiography showed prevalent right ventricular involvement, with obliteration of the apex due to an echogenic mass progressively filling the whole ventricular cavity. RMN accurately defined the presence and the characteristics of the infiltrative mass in the right ventricular chamber. A different intensity of spin-echo imaging sequence was used to differentiate between thrombotic and infiltrative leukemic images. It is concluded that prevalent right ventricular involvement during eosinophilic endomyocardiopathy is a relatively rare disease which can be detected and evaluated by the use of echocardiography and RMN studies.

The Concentration Factors (F.C.) of Coliforms, Enterococci, and Coliphages evaluated in Ciona intestinalis from Darsena Petroli are directly proportional to the relative residence-times into the sea water, stated as T90.