[Anastomotic fistulas after colorectal resection for carcinoma: incidence and treatment in our recent experience]. / Le fistole anastomotiche dopo resezioni coliche e rettali per neoplasia. Incidenza e trattamento nella nostra esperienza recente.

AIM: The incidence of anastomotic fistula after colorectal surgery did not significantly change in the literature during the last years, despite the advances in the treatment with the use of surgical staplers. Taking into account this and other considerations, the authors present their recent experience in the surgical treatment of colorectal carcinoma, referring in particular to anastomotic fistula, related postoperative mortality and results of consequent reoperations. METHODS: From January 1, 2002 to December 31, 2005, 448 patients affected with colorectal cancer were operated on at the Surgical Department of Valduce Hospital in Como, and in 373 cases an anastomosis was performed, subdivided as follows: 144 ileocolic (38.6%), 10 ileorectal (2.7%), 219 colocolic or colorectal (58.7%). RESULTS: Twenty-five out of 373 anastomotic leaks developed (6.7%). In 9 cases (36%), the fistulas spontaneously closed with conservative treatment, while in 16 (64%) reoperation was necessary. With reference to the anatomical site, the leak occurred in 9 out of 144 patients submitted to right hemicolectomy (6.3%), in 14 out of 219 patients after left hemicolectomy or anterior resection of the rectum (6.4%) and in 2 out of 10 patients (20%) after total colectomy. The following is a detailed report of the therapeutic choices adopted by the authors. Four out of 16 reoperated patients (25%) died postoperatively from infective complications related to the fistula, while the total postoperative mortality was 2.2% (10/448). Therefore, anastomotic dehiscence was responsible for 40% of all postoperative deaths. CONCLUSIONS: Among all the different operative choices, the authors give their preference to the direct suture of the fistula and loop ileostomy, which they consider the best available choice. The subsequent operation of ileostomy closure is easier for the surgeon to perform and for the patient to withstand than colostomy closure, particularly after Hartmann's operation.

Mapping of murine Th1 helper T-Cell epitopes of mycolyl transferases Ag85A, Ag85B, and Ag85C from Mycobacterium tuberculosis.

BALB/c (H-2(d)) and C57BL/6 (H-2(b)) mice were infected intravenously with Mycobacterium tuberculosis H37Rv or vaccinated intramuscularly with plasmid DNA encoding each of the three mycolyl transferases Ag85A, Ag85B, and Ag85C from M. tuberculosis. Th1-type spleen cell cytokine secretion of interleukin-2 (IL-2) and gamma interferon (IFN-gamma) was analyzed in response to purified Ag85 components and synthetic overlapping peptides covering the three mature sequences. Tuberculosis-infected C57BL/6 mice reacted strongly to some peptides from Ag85A and Ag85B but not from Ag85C, whereas tuberculosis-infected BALB/c mice reacted only to peptides from Ag85A. In contrast, spleen cells from both mouse strains produced elevated levels of IL-2 and IFN-gamma following vaccination with Ag85A, Ag85B, and Ag85C DNA in response to peptides of the three Ag85 proteins, and the epitope repertoire was broader than in infected mice. Despite pronounced sequence homology, a number of immunodominant regions contained component specific epitopes. Thus, BALB/c mice vaccinated with all three Ag85 genes reacted against the same amino acid region, 101 to 120, that was also immunodominant for Ag85A in M. bovis BCG-vaccinated and tuberculosis-infected H-2(d) haplotype mice, but responses were completely component specific. In C57BL/6 mice, a cross-reactive T-cell response was detected against two carboxy-terminal peptides spanning amino acids 241 to 260 and 261 to 280 of Ag85A and Ag85B. These regions were not recognized at all in C57BL/6 mice vaccinated with Ag85C DNA. Our results underline the need for comparative analysis of all three Ag85 components in future vaccination studies.

Echo-controlled endomyocardial biopsy in orthotopic heart transplantation with bicaval anastomosis.

Starting in January 1995, we performed heart transplantation, randomly using standard and bicaval techniques. In the latter technique, the anatomy of the right atrium is maintained, since the venae cavae are anastomosed. In 38 patients who received heart transplantation with bicaval anastomosis, 339 endomyocardial biopsies (EMB) were performed. EMB was done under echocardiographic control in 309 cases, whereas the remaining 30 were done under fluoroscopy. When EMB was echo-guided there was one major complication, namely right hemothorax in a 29-year-old man, who had had heart transplantation one week before, and this required surgical exploration. Other complications, correlated to venipuncture were: left hemothorax in a 65-year-old woman determined by arterial puncture, treated by means of chest tube drainage; pneumothorax (1 case). Echocardiographic guidance during EMB allows a better choice of biopsy site, reduces the risk of damaging cardiac structures and allows immediate monitoring of heart performance. Moreover the risk of X-ray exposure to both patient and operators is reduced. In any case, because the superior vena cava suture line is not visualized by two-dimensional echocardiography, if the bioptome cannot be introduced easily through superior vena cava, fluoroscopic control should be immediately applied, particularly in the early post-operative period when cicatrization is not complete.

[Heart transplant over 55 years]. / Il trapianto cardiaco dopo i 55 anni.

BACKGROUND: The age of recipient has been thought for several years to be one of the most important predictors of survival after heart transplantation. Therefore patients older than age 50 years were usually excluded from heart transplantation. The marked improvement in survival after clinical introduction of cyclosporine made a critical revision of selection criteria for heart recipients. In this article we retrospectively analyze the outcome of heart transplantation dividing the patients into two groups: Group A < or = 55 years, Group B > 55 years respectively. METHODS: We analyzed 437 patients who underwent heart transplantation, immunosuppressive protocol for all the patients was cyclosporine, azathioprine and prednisone. Group A included 284 patients, Group B 153 patients. We studied demographic, clinical and haemodynamic data pre- and post-operatory in both groups. RESULTS: In Group A was more frequent dilated cardiomyopathy (p < 0.01) and the patients arrived at heart transplantation in worse haemodynamic conditions requiring more frequently inotropic infusion and/or mechanical support (intraaortic balloon pump, left ventricular assist device). Post-operatory course was more complicated in Group B patients where ischemic cardiomyopathy was more frequent (p < 0.001); intensive care stay, inotropic drugs infusion, mechanical ventilation and hospital mortality were higher in Group B, although non significantly. The donor age was significantly higher in Group B (p < 0.001), anyway the statistical analysis did not show a correlation between donor age and more complicated post-operative course. Follow-up did not show significative differences in the two groups considering haemodynamic data, metabolic disorders, graft coronary disease, infection and rejection rates. On Group B is significantly higher tumor incidence (p < 0.05) and peripheral vascular complications (p < 0.01). Actuarial survival at 5 and 7 years is respectively in Group A 80.3 and 72.9%, in Group B 75.4 and 71% (p = ns). CONCLUSIONS: Heart transplantation in patients older than 55 years with end-stage heart disease is a valid therapeutic option with excellent long-term survival; pre-operative screening must be particularly accurate and older donors should be considered.

[A case of severe malnutrition due to Ascaris lumbricoides infestation in a boy]. / Su di un caso di grave malnutrizione da infestazione da Ascaris lumbricoides in un bambino.

The authors report a case of a child three years old, with severe malnutrition as complication of Ascaris lumbricoides infection. Intestinal nematodes infect many of the world's children and constitute a formidable public health problem. The infected children may suffer nutritional deficits, serious illness and occasionally death. Although infestation is uncommon in our country, it should be considered in children with low social life.

[Allergy to cow's milk proteins: the authors' personal cases (clinical characteristics, diagnostic methodology and prospective follow-up)]. / Allergia alle proteine del latte vaccino: casistica personale (caratteristiche cliniche, metodologia diagnostica, follow-up prospettico).

Because of specific laboratory tests are lacking, diagnosis of cow's milk allergy is always made on the basis of improvement after cow's milk protein withdrawal from diet and relapsed after challenge test. However personal and familial anamnesis, supported by few simple laboratory tests (peripheral blood and stool eosinophiles, hemoccult), are important tools for diagnosis. In this work we report the clinical findings of 68 children, suffered from cow's milk allergy, observed in the last 10 years. Children were divided into three groups on the basis of challenge response: Group 1 consisting of children with averse reaction occurred within the first hour after the administration of cow's milk protein (IgE-mediated reaction, 1st class as Gell-Coombs classification); Group 2 consisting of children with averse reaction occurred between 2nd and 12th hour (1st-3rd class as Gell-Coombs classification); Group 3 consisting of children with averse reaction occurred after 24 hours the administration of cow's milk proteins (4th class as Gell-Coombs classification). Auxological parameters show that while weight is widely involved, particularly in children of group 3, height is interested only in children with prolonged diarrhoea. Cow's milk protein withdrawal from diet determine a rapid normalization of weight increment rate, more evident in children over 25th centile. Height rise up normal values slowly without any differences between children below and over 25th centile. At the age of two years 57 children (83%) became tolerant to cow's milk proteins and after 5-year follow-up in 3 children (4.4%) only persisted cow's milk allergy. All these children presented the IgE-mediate clinical form.

[Multiple benign lung leiomyomatosis]. / Leiomiomatosi polmonare multipla benigna.

The Authors report a case of multiple benign pulmonary leiomyomatosis, recently observed. They offer a short description of the clinical, anatomo-pathological and therapeutical features of this extremely rare condition.

[Importance of antigliadin antibodies determination during the follow-up of childhood coeliac disease]. / Importanza del dosaggio degli anticorpi antigliadina nel follow-up della malattia celiaca del bambino.

Since their introduction in clinical practice, antigliadin antibodies (AGA) have simplified the diagnostic iter of coeliac disease. In addition they have allowed us to recognize an even high number of new cases and also to identify new clinical forms. While AGA are widely used in the diagnostic phase, their determination during follow-up of the disease has been always limited. With the present work we observe the behaviour of AGA during the various phases of coeliac disease. The study was carried out on 288 coeliac children divided as follows: 96 at diagnosis, 136 on gluten-free-diet (75 diet adherent and 61 non adherent) and 56 on gluten-challenge. 145 healthy children were also studied as a control group. In all children AGA (IgA and IgG) were determined, with a micro-ELISA method, every two months in the children on gluten-free-diet and monthly in the children on gluten-challenge. Data obtained showed AGA behaviour strictly related to the diet. In fact while children with good compliance to the diet had AGA normalization within the 2nd and 6th month, respectively for IgA and IgG, children with poor adherence to diet had constantly positive AGA. Noteworthy was the AGA behaviour during challenge. Gluten introduction determined a rapid increase of IgA and a slow increase of IgG. Our results confirm the usefulness of AGA determination during the follow-up of coeliac children giving us the possibility to avoid one or more biopsies included in the ESPGAN protocol.

[Cisapride efficacy in gastroesophageal reflux in children]. / Efficacia della cisapride nella malattia da reflusso gastroesofageo del bambino.

In the last years gastroesophageal reflux disease received more attentions, due to an improving in diagnostic techniques. Motility disorders, such as reduced competence of lower esophageal sphincter, motor esophageal disorders, delayed gastric emptying are important factors in the pathogenesis of the disease. Therefore therapy using prokinetic agents has been considered useful. A variety of drugs such as bethanecol, metoclopramide and domperidone have been used. There are conflicting report on the effects of these drugs and it should also be emphasized that they are not devoid of side effects related to dopamine antagonism. Recently cisapride, prokinetic agent which acts through facilitation of acetylcholine release, has been considered effective and well tolerate drug for the treatment of gastroesophageal reflux disease. In this view we investigated the effects of oral administration of cisapride in 12 children (age range 3-40 months), 7 females and 5 males, suffering from gastroesophageal reflux disease diagnosed on the bases of: clinic criteria, barium swallow radiological examination, 24-hour intraesophageal pH monitoring. After diagnosis a treatment with cisapride (1 mg/kg/die) before feedings for 8 weeks was started in all children. At the end of the trial clinical assessment and 24-hour intraesophageal pH test were performed. Clinical assessment was determined through weight, length and a clinical score calculated using the following parameters: regurgitation, vomiting, irritability, nocturnal weeping, meteorism, respiratory complaints. The total score was evaluated at diagnosis and during the follow-up (1st, 2nd, 4th and 8th week).(ABSTRACT TRUNCATED AT 250 WORDS)

[The predictive value of antigliadin antibodies (AGA) in the diagnosis of non-celiac gastrointestinal disease in children]. / Il valore predittivo degli anticorpi antigliadina (AGA) nella diagnosi di malattia gastrointestinale non celiaca del bambino.

Recent antigliadin antibody (AGA) determination has become an important diagnostic tool in coeliac disease (CD). Although this test has high sensibility for the disease, it is less specific, especially for IgG class, because of its having been found in some acute and chronic common intestinal childhood diseases. We studied the behaviour of AGA, IgA and IgG, in 234 children affected by various gastrointestinal diseases, comparing the results with those obtained in 125 coeliac children and 788 normal children. The intestinal diseases were as follows: irritable bowel syndrome, cow's milk protein intolerance, acute infectious diarrhoea, parasitosis, lactase deficiency, recurrent abdominal pain, cystic fibrosis, chronic constipation, gastroesophageal reflux, intestinal lymphangiectasia, chronic intractable diarrhoea and nodular lymphoid hyperplasia. Our results showed that while AGA-IgA were absent in all children studied, with the exception of 3 cases of acute diarrhoea, a moderate percentage of AGA-IgG was observed in subjects with cow's milk protein intolerance, acute diarrhoea, irritable bowel syndrome, lactase deficiency, chronic intractable diarrhoea and in a low percentage of children with parasitosis, intestinal lymphangiectasia and nodular lymphoid hyperplasia. There was no antibody movement in subjects with cystic fibrosis, gastroesophageal reflux, recurrent abdominal pains and chronic constipation. The different behaviour of the two antibody classes could be explained by the fact that AGA-IgG were detected in diseases where scattered areas of mucosal damage could allow the permeability of the macromolecules inducing passage of gliadin through the mucosal barrier and immune system-induced antibody stimulation.

[The diagnostic approach to and clinical study of 23 children with an obstructive sleep apnea syndrome]. / Approccio diagnostico e studio clinico di 23 bambini affetti da "sindrome di apnea ostruttiva nel sonno".

23 children, aging from 3 to 13 years, affected by chronic upper airway obstruction, were studied. The clinical suspicion was "obstructive sleep apnea" (O.S.A.). In this study was found a significantly different frequency, in O.S.A. group, if compared with controls, of the following symptoms: nocturnal snoring (100%), mouth breathing when awake (69%), and during sleep (91%), abnormal restless movements (69%), behavioral disturbances (60%). Clinical evaluation revealed: pectus excavatum (82%), enlarged tonsils and adenoids (82%), failure to thrive (39%). Chest index was 0.72 +/- 0.07 significantly higher (p < 0.001) than controls. The authors also carried out in all patients and controls pCO2 venous blood determination during sleep, to screen subjects with high risk of cardiopulmonary dysfunction. Data obtained showed that threshold value of pCO2 was 45.6 mmHg.

[Blood beta-carotene after oral administration of carotenoids. A dynamic test of lipid absorption]. / Beta-carotenemia da carico orale di carotinoidi. Prova dinamica di assorbimento dei lipidi.

Authors report a method on the functional investigation of intestinal epithelium, based upon the dosage of serum carotene levels after administration of carotenoids. This test takes advantage of the modality of beta-carotene absorption that it behaves like a lipid. The "beta-carotene test" has demonstrated, as regards to T.A.R.T., great sensibility and specificity over 90%. It doesn't show value overlapping between normal and coeliac children and also it shows good compliance of children and simplicity in laboratory determination. For all these characteristics the Authors suggest the utilization of "beta-carotene test" as screening tool of malabsorption.

[Significance of milk antibodies in cow's milk protein intolerance]. / Significato degli anticorpi antilatte nella intolleranza alle proteine del latte vaccino.

Cow's Milk Protein Intolerance (CMPI) is the most common food intolerance in childhood. The I, III and IV type of the immunological mechanisms are involved in the pathogenesis. Nowadays there are no diagnostic tests with good reliability excluding the IgE-mediated clinical pictures. Recently the evaluation of antibodies (IgA and IgG classes) versus milk proteins has been proposed as reliable test. In order to establish the pattern of antibody response against milk proteins we studied 37 children (17 males and 20 females), aged from 3 months to 6 years, divided as follows: 23 with CMPI of which 16 suffering from gastrointestinal complaints (GI) and 7 from cutaneous ones (CT); 5 children with coeliac disease; 9 normal healthy children without any clinical manifestation. All children at the time of the assessment assuming a diet containing cow's milk proteins. IgA, IgG and IgM antibody classes against cow's milk proteins such as alpha-lactoalbumin (alpha LA), beta-lactoglobulin (beta LG), casein (CAS) and pooled proteins (PPL) were measured using an ELISA method. The results obtained in the various groups were as follows: CMPI-GI group: the percentage of positivity for alpha LA-IgA was 43.8% and alpha LA-IgG 68.7%, for beta LG-IgA was 50% and beta LG-IgG 75%, for CAS-IgA was 43.8% and CAS-IgG 68.7%, for PPL-IgA was 37.5% and PPL-IgG 62.5%. CMPI-CT group: the percentage of positivity for alpha LA-IgA was 42.8% and alpha LA-IgG 57.1%, for beta LG-IgA was 71.4% and beta LG-IgG 42.8%, for CAS-IgA and CAS-IgG was 85.7%, for PPL-IgA was 71.4% and PPL-IgG 57.1%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Megaloblastic anemia: a unusual complication in an infant with double allergy to both cow's milk protein and soy]. / Anemia megaloblastica: singolare complicanza in lattante con doppia allergia alle proteine del latte vaccino ed alla soja.

The authors reported a case of a child suffering from Cow's milk protein allergy, in which a soybean milk was administered for one month. The incorrect preparation of the formula determined a megaloblastic anaemia due to folate deficiency. The observation of very high levels of seric aminoacids during the acute phase of the disease was noteworthy. The therapy with folic acid and the introduction of protein hydrolysated formula milk determined a rapid normalization of the haematological picture. During the follow-up the administration of soybean protein caused anaphylaxis showing the contemporary presence of soybean allergy. The challenge test with cow's milk performed afterwards showed the restoration of the tolerance towards cow's milk protein.

["Qualitative test of fecal fat" and "steatocrit", simple complementary methods for the evaluation of steatorrhea in childhood]. / L'"esame qualitativo dei grassi fecali" e lo "steatocrito", semplici metodi complementari di valutazione della steatorrea nell'infanzia.

The evaluation of fecal fat elimination (steatorrhoea) is of primary importance for diagnosis of gastroenterological disorders. In childhood it is quite difficult to apply the ordinary methods of evaluation, on the other hand it is necessary to make use of them to screen and diagnose maldigestion and/or malabsorption syndromes. In this work "Steatocrit" method by Phuapradit and "Fecal fat qualitative test" (FFQT) on glass, by Jacobson, have been used in a parallel study on stool samples from subjects with suspected gastrointestinal disease. While Steatocrit was determined on 200 samples, FFQT was determined on 1574 samples. Our data show that steatocrit is fully able to detect quantitative steatorrhoea with high significance when compared to controls. Likewise FFQT shows a sensibility of 100% compared to controls and it is able to predict coeliac disease and cystic fibrosis in 85.5% of cases and in 89.9% of cases respectively. We conclude that these two tests are sure and auxiliary each other. They allow, when performed on the same sample, to go toward diagnosis of both malabsorption and maldigestion, furthermore they allow to monitor steatorrhoea under therapy.

[Antigliadin antibodies (AGA) in the various stages of celiac disease in children]. / Gli anticorpi antigliadina (AGA) nelle varie fasi della malattia celiaca del bambino.

Antigliadin antibodies (AGA), both IgA and IgG, were studied in the serum of 84 coeliac children during the various stage (Diagnosis, GFD, Challenge) and in 29 healthy children, with a micro-ELISA technique. The results demonstrated the presence of AGA in the serum of coeliac children and a different behaviour between the two Ig-classes in the various stages of the disease. During acute phase both classes were present at high titre. When gluten was withdrawal from the diet, while the titre of IgA fell rapidly since the first month, the IgG titre decreased slowly and raised the normal limits after six months. If the children didn't observe a corrected GFD, the serum AGA titres remained at high levels. During challenge, while IgG raised since the early days, IgA titres raised later, when the intestinal damage became important. The explanation of this different behaviour could be that AGA-IgA are derived from gut mucosa, on the contrary AGA-IgG are not synthesised in the intestine. We believe that serum AGA seem to be good markers of the immune reaction in the intestine triggered by gluten. Furthermore we conclude that the assay of AGA in the serum of coeliac patients is: 1) high sensible and specific method; 2) the most important screening test for intestinal biopsy; 3) the most important test for diagnosis and follow-up of CD; 4) the test which could substitute 1 or 2 intestinal biopsies of the ESPGAN protocol.

[A case of vascular leiomyosarcoma of the superficial soft tissues]. / Su di un caso di leiomiosarcoma vascolare dei tessuti molli superficiali.

The authors report a case of vascular leiomyosarcoma of the superficial soft tissues, and point out its epidemiologic (rareness of the report), biologic (high degree of malignancy, trend to local relapse and remote conversion into metastases), histopathologic aspects. They consider significant as to prognostic value the appraisal of the "mitotic index" and the opportunity of a radical intervention, followed by radiotherapy. They, moreover, think it useful, in consideration of the frequency of the relapses, to perform a periodic checking of the patient.

[Aneurysm of the superficial femoral artery]. / Aneurisma dell'arteria femorale superficiale.

The authors start from a case of aneurysm of the superficial femoral artery, they had the opportunity to observe, and discuss the etiopathogenetic, diagnostic and clinical problems involved in this disease. Then, they dwell upon the main therapeutical solutions suggested, and declare inclined to endoaneurysmography with interposition of autologous or heterologous grafting.