Application of poly-L-lactide screws in flat foot surgery: histological and radiological aspects of bio-absorption of degradable devices.

The flat foot in childhood is a condition frequently observed in orthopedic practice but it is still debated when and in which patients surgical corrective treatment is appropriate; recently, the application of poly-L-lactic-acid (PLLA) screws was proposed. The present study investigates a group of 33 patients treated with PLLA expansion endorthesis in order to evaluate the deformity correction. Clinical and radiological outcomes in patients were correlated with: a) morphological characterization of screws both before and after being removed from patients, when necessary; b) histological and bio-molecular evaluation of degradation processes of the implants, focusing attention on the correlation between the cellular cohort involved in inflammatory reaction and the bio-absorption degree of PLLA screws. Deformity correction was mostly achieved, with minimal need of screw removal; the results obtained clearly show the occurrence of chronic rather than acute inflammation in removed screw specimens. At the histological level, after biomaterial implantation, the sequence of events occurring in the surrounding tissues ultimately ends in the formation of foreign body giant cells (FBGCs) at the tissue/material interface; but the mechanisms which influence the fate of screw implants, i.e. the resolution of acute inflammation rather than the progression towards chronic inflammation, are of crucial importance for biodegradable materials like "polylactic acid". In fact, the FBGC response ensures a long-term mechanism which eliminates the foreign material from the body, but at the same time the implications of prolonged FBGC responses, which generate negative side effects, could significantly impede the healing progress.

MATER protein as substrate of PKCepsilon in human cumulus cells.

High activity of the phosphoinositide 3-kinase/Akt pathway in cumulus cells plays an important role in FSH regulation of cell function and Protein Kinase C epsilon (PKCepsilon) collaborates with these signalling pathways to regulate cell proliferation. Relevant roles in follicular development are played by Maternal Antigen That Embryos Require (MATER) that is a cumulus cell- and oocyte-specific protein dependent on the maternal genome. We recently demonstrated that human MATER localizes at specific domains of oocytes and, for the first time, also in cumulus cells. MATER contains a carboxy-terminal leucine-rich repeat domain involved in protein-protein interactions regulating different cellular functions. Here we investigated the functional role of MATER. Thus, we performed coimmunoprecipitation experiments using HEK293T cells expressing human MATER; a similar approach was then followed in human cumulus/follicular cells. In MATER(+)HEK293T cells, we observed that this protein acts as a phosphorylation substrate of PKCepsilon. Western blot experiments indicate that, unlike oocytes, human cumulus cells express PKCepsilon. Immunoprecipitation and confocal analysis suggest for the first time that MATER protein interacts with this protein kinase in cumulus cells under physiological conditions. Since PKCepsilon is known to collaborate with antiapoptotic signalling pathways, this suggests a novel mechanism for the function of MATER in follicular maturation.

Influence of estrogens and oxytocin on germ cells death in the neonatal mammalian ovary.

During mammalian oogenesis, some processes involve proliferation and others drastic reduction of germ cells. This study reports on the role played by two hormones, estradiol monobenzoate and oxytocin, in the control of the number of germ cells in the neonatal mouse ovary. Female neonatal mice were treated with doses ranging between 0.1 and 1 microg/mouse of estradiol monobenzoate or oxytocin and sacrificed at 5 days of postnatal age. The results showed that in the animals treated with estrogen, follicular development was more advanced than that of controls. Further the number of germ cells in apoptosis was drastically reduced. In the animals treated with oxytocin, the follicular development was arrested at the stage of primary follicles. In addition, the number of apoptotic germ cells increased if compared with that of the controls.

Effects of estrogens and oxytocin on the development of neonatal mammalian ovary.

The preservation and death of germ cells in the neonatal mammalian ovary are linked with the presence of hormones. Estrogens and oxytocin are present at birth in all mammalian vertebrates. The aim of this study was to examine their role in the development of the neonatal ovary and also in the preservation and death of germ cells in the neonatal period: apoptotic phenomena play a fundamental role in the control of their number. Female neonatal mice were treated at birth with estradiol monobenzoate or oxytocin and sacrificed after 5 days. The ovaries were sectioned in toto into semi-thin sections, in order to calculate their volume. Thin sections were also carried out to verify, under the transmission electron microscope (T.E.M.), the cells in apoptosis. The ovaries treated with the greater concentration of estradiol monobenzoate showed a volume that was significantly greater than that of the controls and a reduction of germ cells in apoptosis. The ovaries treated with oxytocin at all degrees of concentration had a volume significantly less than the controls and they also had a higher number of germ cells in apoptosis.

Flexible sigmoidoscopy as a colorectal cancer screening test in the general population: recruitment phase results of a randomized controlled trial in Lombardia, Italy.

UNLABELLED: A two arm multicentre randomized controlled trial is in progress to evaluate the efficacy of flexible sigmoidoscopy (FS) as a screening test for colorectal cancer in the general population. AIMS: To determine the acceptance rate and feasibility of FS as a colorectal cancer screening test in average-risk asymptomatic volunteers. Average-risk, asymptomatic subjects, aged 55-64 years and assisted by 244 general practitioners (GPs) in Lombardy, Italy, were invited by postal questionnaire (PQ) to enter a study for the prevention of colorectal cancer and asked to indicate their interest in, and willingness to undergo, screening: those responding positively were randomized to the intervention or control arms. GPs were trained in colorectal cancer screening and proposed free FS to their patients randomized to the intervention arm. All sigmoidoscopies were performed by experienced endoscopists. Small polyps were removed at FS. Colonoscopy was indicated for high risk polyps (size more than 5 mm, more than two adenomas, villous histology, severe dysplasia or malignancy). 40,945 subjects were invited. 667 PQs were returned undelivered due to postal failure. 7,892 (19.59%) subjects responded, 2,116 of whom (26.81%) were not included, presenting 1 or more exclusion criteria. We randomized 5,778 volunteers and performed 1,582 sigmoidoscopies out of 2,885 subjects in the intervention arm (54.84% acceptance rate). Although the screening procedure had a good attendance rate in the intervention group, involvement of the people invited was lower than expected. Future FS screening programmes will require a keener focus on recruitment strategies, mainly with participation of GPs.

Complications and long-term outcome of 80 oncology patients undergoing needle catheter jejunostomy placement for early postoperative enteral feeding.

Some findings suggest that needle catheter jejunostomy (NCJ) is associated with a significant rate of potentially dangerous complications. The purpose of this study was to prospectively evaluate the rate and type of early and late complications associated with NCJ in patients with surgical treatment of upper gastrointestinal malignancy. Eighty patients underwent NCJ implant at the end of their scheduled surgical procedure. Enteral nutrition programme was started on postoperative day 1 in the surgical ICU. NCJ was always removed in the outpatient clinic after hospital discharge. One case of tube blockage has been observed as single short-term complication in this series. No long-term complications have been detected after a mean follow-up of 12 months. Routine use of NCJ in malnourished patients undergoing major surgical procedures on upper gastrointestinal tract is safe and effective.

Aberrant crypt foci in colorectal carcinogenesis. Cell and crypt dynamics.

Aberrant crypt foci (ACF) have been identified on the colonic mucosal surface of rodents treated with colon carcinogens and of humans after methylene-blue staining and observation under a light microscope. Several lines of evidence strongly suggest that ACF with certain morphological, histological, cell kinetics, and genetic features are precursor lesions of colon cancer both in rodents and in humans. Thus, ACF represent the earliest step in colorectal carcinogenesis. This paper has the main purpose of reviewing the evidence supporting this view, with particular emphasis on cell and crypt dynamics in ACF. ACF have been used as intermediate biomarkers of cancer development in animal studies aimed at the identification of colon carcinogens and chemopreventive agents. Recently, evidence has also shown that ACF can be effectively employed in chemopreventive studies also in humans.

Rare presentation of small bowel leiomyosarcoma with liver metastases.

Intraabdominal sarcomas are rare tumours usually diagnosed at an advanced stage. These lesions at presentation are bulky and symptoms are often related to pressure effects on adjacent organs. This case report describes a rare presentation of a small bowel leiomyosarcoma whose initial presentation was free haemorrhage into the abdominal cavity and concomitant liver metastases. This case report also demonstrates that, even with such a rare presentation, an aggressive surgical approach is indicated in this type of tumour and helps a patient with advanced disease to live a few disease-free months with a good quality of life.

[An experimental study of the use of synthetic meshes in large abdominal eventrations]. / Studio sperimentale sull'applicazione di reti sintetiche in corso di grandi sventramenti addominali.

BACKGROUND: The aim of this study is to evaluate the biocompatibility of Angimesh mesh (polypropilene) in rats, usually used to replace or to strengthen the abdominal fasciae. METHODS: We made an abdominal longitudinal incision of skin and muscles in 20 rats was carried out and two muscular semilunae removed. The incision was occluded with Angimesh mesh fixed by ethilcyanoacrilate glue (first group of rats) or with suture stitches (second group of rats). The animals were sacrificed after 80 days and the stability of the mesh and the presence of endoperitoneal adhesion were evaluated macroscopically, and microscopically the fibrogenesis and inflammation answer. RESULTS: Two rats of the first group and seven of the second group died before 30 days. The mesh was more steady when fixed by suture. Adhesion in the contact sites between the mesh and the peritoneum was found. Histology did not show any inflammation reaction but showed a fibrogenic answer. CONCLUSIONS: The cyanoacrilate non-toxicity has been confirmed also in this application. Angimesh mesh showed good biocompatibility and resulted ideal for the synthesis of large abdominal resections.

Apoptosis in different stages of human oogenesis.

Apoptosis is an active form of cell death characterized by a series of morphological changes that become particularly evident at the ultrastructural level. The majority of ovarian germ cells undergo degeneration during prenatal and reproductive life and only in recent studies has it been demonstred that this drop is due to an apoptotic process. We evaluated this process during human oogenesis in prenatal life and we studied the ultrastructural changes that occur in apoptosis in various phases of the meiotic process. From our observations it is clear that apoptosis involves two main phases of the meiotic process: an earlier one concerning the oogonia and oocytes in the preleptotene stage, and a later one that mainly concerns the oocytes in the pachytene stage.

Scanning electron microscopy of aberrant crypt foci in human colorectal mucosa.

BACKGROUND: Aberrant crypt foci (ACF) are clusters of morphologically altered crypts which can be observed by light or stereomicroscopy on the mucosal surface of the colon after staining with methylene-blue. They probably represent one of the earliest events in human colorectal carcinogenesis. The main purpose of the present study was to observe the surface features of aberrant and normal colonic crypts in humans using scanning electron microscopy (SEM) in order to find and measure differences between aberrant and normal. MATERIALS AND METHODS: Fifteen mucosal specimens containing ACF and 8 with normal mucosa taken from patients operated on for colon cancer were observed under a scanning electron microscope. RESULTS: By SEM ACF were easily observed on the mucosal surface, because they showed a well defined border and were elevated on the mucosal surface. Under higher magnification luminal openings of aberrant crypts had a larger overall average diameter than normal (37.6 microns +/- 13.5, mean +/- SD, vs 15.9 microns +/- 4.9, P = 0.001), though when crypt multiplicity of ACF (number of crypts per ACF) was higher, the diameter of luminal openings tended to be smaller and similar to those of normal crypts, with weak negative correlation between crypt multiplicity of ACF and mean diameter of aberrant luminal openings (r = 0.27). Finally, the mucosal surface among aberrant crypts was flattened because of a loss of microvilli. in conclusion, scanning electron microscopy allows a better definition of the topological features of aberrant crypt foci than light or stereomicroscopy.

Apoptosis of germ cells during human prenatal oogenesis.

During human oogenesis two contrasting processes can be observed: germ cell proliferation and differentiation, and contemporaneous germ cell death. It is well known that apoptosis is a type of physiological cell death that occurs in proliferating and differentiating tissues. The aim of this study is to demonstrate, through ultrastructural and in-situ 3' end labelling observations in intact sections of human fetal ovaries, that germ cell loss during fetal life is due to a phenomenon of apoptosis. We evaluated the presence of programmed cell death in female germ cells in fetal ovaries at 18-20 weeks of postconceptional age. The alterations that occur during apoptosis were detected by the electron microscope and include cytoplasmic condensation, organelle relocalization and compaction, chromatin condensation, and finally, production of membrane-enclosed particles containing intracellular material, known as apoptotic bodies, that are phagocytosed. The fragmentation of DNA, characteristic of apoptotic cells, was detected by the use of the in-situ 3' end labelling procedure on histological sections of ovaries where only some nuclei of germ cells were positively stained. The parallel use of these two methods on human ovaries of 18-20 weeks postconceptional age has allowed us to show that the numerical decrease of human female germ cells during the fetal period is due to an apoptotic phenomenon.

Postoperative enteral feeding does not prevent intestinal bacterial translocation, but reduces the rate of pulmonary infections in pigs undergoing total orthotopic small bowel transplantation.

OBJECTIVE: To assess the effects of a non-elemental liquid diet on nutritional state, composition of bowel flora, intestinal translocation, and pulmonary infections after small bowel transplantation in pigs. DESIGN: Prospective randomised experiment. SETTING: Teaching hospital, Italy. MATERIAL: 32 female Large White pigs. INTERVENTIONS: Group 1 (n = 6) underwent small bowel transplantation, were treated with immunosuppression, and fed on commercial chow. Group 2 (n = 6) were treated similarly except that they were fed with an enteral feed through a tube gastrostomy starting on day 4 postoperatively. Group 3 (n = 6) were treated similarly to group 1 except that they had no immunosuppression, and Group 4 (n = 6) underwent orthotopic small bowel autotransplantation; 8 further pigs underwent a sham operation only to act as controls. MAIN OUTCOME MEASURES: Signs of rejection, graft-versus-host-disease, luminal bacterial overgrowth, bacterial translocation, pneumonia, and the pigs' nutritional state. RESULTS: All animals in group 3 showed signs of acute rejection. There was appreciable overgrowth of aerobic and anaerobic bacteria in all three groups after allotransplantation compared with controls. The counts of anaerobic bacteria were significantly lower in group 2 (enterally fed animals) compared with those given free access to commercial chow [mean (SD) 2.81 (1.39) log CFU/cm2 compared with 4.80 (1.65), p = 0.047]. Bacterial translocation developed to a similar degree after autografts and allografts and pneumonia developed in fewer animals after enteral feeding (1/6) than after conventional feeding (5/6) but the difference was not significant (p = 0.08, odds ratio 25.0, 95% confidence interval of odds ratio 1.20 to 521.13). Enterally fed animals also lost less weight than conventionally fed animals [2.32 (1.23) kg compared with 4.53 (1.74), p = 0.016]. CONCLUSIONS: Enteral feeding for up to a month slightly reduced the rate of pneumonia and resulted in a better nutritional state in pigs after small bowel transplantation. It had no effect on luminal bacterial overgrowth or translocation.

[Feasibility of exeresis. Controversial aspects in the surgery of carcinoma of the pancreas]. / Fattibilità della exeresi. Aspetti controversi nella chirurgia del carcinoma del pancreas.

Pancreatic cancer has a dismal prognosis also after resection with a 5 years' survival of about 5% in operated patients. The main clinical issue in patients with a malignant tumour is to identify the ones that would benefit from a surgical treatment. Resectability of pancreatic cancer has not an absolute value and the possible advantages in terms of prognosis and quality of life should be balanced with surgical mortality and morbidity. For this reason the management of this disease involves a multidisciplinary approach and the surgeon should join with the other specialists in experienced oncology centers. En exhaustive evaluation of the following prognostic factors should be made pre and intra-operatively to better define life expectancy with or without resection: Histotype: endocrine tumours and cystadenocarcinoma have, in general, a better prognosis, Staging: JPS classification has a better prognostic value if compared to the UICC. Completeness of the resection. Biological characteristics of the tumour. The main variables to be considered for the exeresis are: Size and local growth of the tumour (also considering the involvement of vessels, retroperitoneum and pancreatic capsule). Liver or peritoneal metastases: for this laparoscopy has a key role for staging. Histologic confirmation: differential diagnosis with chronic pancreatitis is sometimes difficult and every attempt should be made to have a pre-operative histology. Vascular invasion is one of the main contraindications to surgery and an exhaustive evaluation of vascular involvement should be considered mandatory. Lymph nodal involvement, in general, represents a negative prognostic factor even if Japanese authors claim that a radical resection can be performed in case of positive nodes in the peripancreatic area, if a complete lymphadenectomy is carried out.

Parenteral antibiotics and selective intestinal decontamination do not prevent enteric bacterial overgrowth or translocation observed in a swine model of small bowel transplantation.

Alterations in the luminal microflora and increased intestinal translocation have been reported to occur following experimental and clinical small bowel transplantation (SBT). Selective intestinal decontamination (SID) has been used to prevent luminal overgrowth and bacterial translocation. Despite the wide use of SID in clinical SBT, there are no data supporting its usefulness in this situation. Thus, the aim of this investigation was to examine the effects of cyclosporine A (CsA) and SID upon bacterial overgrowth and translocation in a swine model of SBT. Nineteen Large White female pigs weighing 30 +/- 2 kg underwent a total orthotopic SBT and were randomly allocated to one of the following experimental groups as follows: Group 1 (No. 8) CSA 25 mg/kg body weight (b.w.)/day administered subcutaneously and Cefazolin 2 g/day im. Group 2 (No. 6) received the identical immunosuppression but the Cefazolin 2 g/day im was discontinued on the 5th Postoperative Day (pod) and switched to a SID regimen consisting of Vancomycin, 1 g, Nystatin, 500,000 IU, Colistin, 1,500,000 IU, and Tobramycin, 100 mg, given through a gastrostomy tube. Group 3 (No. 5) received no immunosuppression but antibiotic consisting of Cefazolin 2 g im/day. Group 4 (No. 7) underwent a small bowel autotransplantation. Group 4 received SID as in group 2 but no immunosuppression was given. Finally, 17 normal animals were sham-operated and were used as normal controls (N group). The animals in groups 1, 2, and 4 were sacrificed on the 29th pod. Those in group 3 were sacrificed on the 7th pod.(ABSTRACT TRUNCATED AT 250 WORDS)

Luminal bacterial overgrowth and intestinal translocation in pigs given either cyclosporin A or 15-deoxyspergualin after small bowel transplantation.

OBJECTIVE: To examine the effects of two immunosuppressant regimens on composition of the bowel flora and rate of translocation after transplantation of the small bowel in pigs. DESIGN: Randomised controlled study. SETTING: University hospital, Italy. MATERIAL: 35 female Large White pigs. INTERVENTIONS: 9 Animals were not operated on (normal controls). 19 Animals underwent total orthotopic small bowel allotransplantation and were then randomised to receive: group A (n = 8) cyclosporin A 25 mg/kg subcutaneously and cephazolin 2 g intramuscularly daily; group B (n = 6) 15-deoxyspergualin (15-dos) 3 mg/kg for 7 days then 1.5 mg/kg, cephazolin 2 g intramuscularly daily for 4 days then selective intestinal decontamination with colistin 1.5 million U, tobramycin 100 mg, vancomycin 1 g, and nystatin 500,000 U daily; and group C (n = 5) cephazolin 2 g intramuscularly daily for 8 days. A further group (D, n = 7) underwent orthotopic autotransplantation and received the same antibiotic and selective decontamination regimens as group B. Animals in group C were killed on day 8, and the rest on day 29. MAIN OUTCOME MEASURES: Signs of rejection, graft versus host disease, luminal overgrowth, and evidence of translocation to mesenteric lymph nodes. RESULTS: All animals in group C, and 2 in group B, showed signs of acute rejection. There was a significant overgrowth of both aerobic and anaerobic bacteria in all 3 groups after allotransplantation compared with normal controls. Bacterial translocation was similar in autografted and allotransplanted animals. Mesenteric lymph nodes were colonised in 4/9 controls, 7/8 in group A, 4/4 in group B, 5/5 in group C, and 7/7 in group D. CONCLUSION: Neither cyclosporin A nor 15-dos prevented luminal overgrowth or bacterial translocation to mesenteric nodes up to one month after operation. The rate of translocation was similar in autotransplantation and allotransplantation, suggesting that non-immunological factors (for example, denervation and interruption of lymphatics) may have a role in these alterations.