Alpha-galactosidase versus active charcoal for improving sonographic visualization of abdominal organs in patients with excessive intestinal gas.

UNLABELLED: Intestinal gas is a frequent cause of poor visualization during gastrointestinal ultrasound (US). The enzyme alpha-galactosidase may reduce intestinal gas production, thereby improving abdominal US visualization. We compared the efficacies of alpha-galactosidase and active charcoal in improving US visualization in patients with previous unsatisfactory abdominal US scans caused by excessive intestinal gas. MATERIALS AND METHODS: 45 patients with poor visualization of at least one target organ: pancreas, hepatic lobes (score 0-2) or common bile duct (CBD) (score 0-1) were enrolled in a prospective randomized, crossover, observer-blinded study. The patients received alpha-galactosidase (Sinaire Forte, Promefarm, Milan, Italy) 600 GalU t.i.d. for 2 days before abdominal US plus 900 GalU the morning of exam or active charcoal 448 mg t.i.d., for 2 days before the exam plus 672 mg the morning of the exam. Visualization was graded as follows: 0 = none (complete gas interference); 1 = severe interference, 2 = moderate interference, 3 = mild interference; 4 = complete (no gas interference). RESULTS: 42 patients completed the study. Both alpha-galactosidase and active charcoal improved the visualization of target organs. Visualization of the right hepatic lobe, CBD and pancreatic tail was significantly improved (vs. baseline) only by alpha-galactosidase (p < 0.01). Scores ≥3 for all parts of the pancreas and both hepatic lobes were achieved in only 12.5% of the patients after both treatments. Both products were well tolerated. CONCLUSION: Alpha-galactosidase and active charcoal can improve US visualization of abdominal organs in patients whose scans are frequently unsatisfactory due to excessive intestinal gas. Visualization of the pancreatic tail and right hepatic lobe was significantly improved only by alpha-galactosidase. However, both treatments allowed adequate visualization of all target organs during the same examination only in a few patients.

Evaluación de la respuesta al sildenafil 50 mg en pacientes con disfunción eréctil sin tratamientos previos en la práctica cotidiana / Evaluation of the response to sildenafil 50 mg in patients with erectil dysfunction without previous treatment during the current practice

Nuestro estudio corrobora la elevada eficacia del Sildenafil para el tratamiento de la Disfunción Sexual Eréctil en el contexto de la práctica diaria de consultorio. El Sildenafil mostró ser un fármaco seguro, aun en pacientes con patologías concomitantes, debiendo pocos pacientes suspender la medicación por efectos secundarios severos. El Sildenafil mejoró no sólo la actividad sexual de los pacientes sino también su calidad de vida.

Transient small-bowel intussusceptions in adults: significance of ultrasonographic detection.

AIM: To investigate the frequency, clinical significance, and outcome of small-bowel intussusceptions in adults detected using ultrasound in an outpatient setting. PATIENTS AND METHODS: In two different retrospective (January 2001 to April 2003) and prospective (May 2003 to June 2005) periods, 33 small-bowel intussusceptions were found in 32 patients (13 females; mean age: 38.1 years) with known or suspected intestinal disease. Patients underwent diagnostic work-up to assess any organic disease. Patients with self-limiting intussusception were submitted to clinical and ultrasonographic follow-up. RESULTS: Of the 32 patients with small-bowel intussusception, 25 were identified in the prospective series of 4487 examinations (0.53%) and seven in the retrospective series of 5342 examinations (0.15%; p=0.002). Four patients had persistent and 28 self-limiting intussusceptions. Self-limiting intussusceptions were idiopathic in 11 patients (39%) or associated with organic diseases in 17 (Crohn's disease in 11 patients, celiac disease in three, ulcerative colitis in one patient, and previous surgery for cancer in two). Self-limiting intussusceptions were asymptomatic in 25% of patients. CONCLUSION: Small-bowel intussusceptions in adults are not rare and are frequently self-limiting, idiopathic, or related to organic diseases, mainly Crohn's disease and coeliac disease.

Sex steroid receptors, secondary bile acids and colorectal cancer. A possible mechanism of interaction.

AIM: The aim of the work was to study in colon-rectum cancer mucosae the binding charateristics, as sex steroid receptors. METHODS: Specific androgen (AR), estrogen (ER) and progesterone (PgR) receptors were measured in the tissue samples of 35 patients (15 males, 20 females) undergoing colectomy or coloproctectomy for adenocarcinoma. The characteristics of androgen receptor (AR, DHT-R: dihydrotestosterone receptor) were also investigated using competitive activity of cyproterone acetate, cortisol, aldosterone and steroid-like substances such as deoxycholic and lithocholic acid, present in the milieu of the considered organ. Binding assays and competition tests were conducted using a charcoal dextran method. RESULTS: When present (50%), ER and PgR receptors showed very low levels and no difference was noted between cancerous and the surrounding healthy mucosa. AR were found in all samples from both neoplastic and non neoplastic surrounding mucosa, with no significant difference. Androgen receptor however exhibited an altered binding activity in cancer specimens. Cyproterone acetate did not displace DHT from AR while significant displacing activity was elicited by DHT, testosterone, as well as by lithocholic acid, but not by deoxycholic acid. CONCLUSION: In cancerous large bowel mucosa, androgen receptors show altered binding characteristics. The selective binding of lithocholic acid to AR supports the hypothesis that diet-related endoluminal substances may play a role in cancer development model where molecular alterations such as DNA damage or mutation is the 1st event.

Locally recurrent rectal cancer.

Local recurrence (LR) varies from less than 4% to greater than 50%; several tumor factors and operative techniques may influence rate of LR. Of greatest interest has been the considerable inter-surgeon variation, even within the same institution. An LR rate of less than 10% has been consistently reported by those who use total mesorectal excision even without any form of adjuvant therapy, either preoperatively or postoperatively. These findings raise important questions about surgical technique, subspecialty teaching, place of adjuvant therapy and quality assurance. The management of LR by a multispecialty team and multimodality treatment including preoperative chemoradiation, surgical resection and intraoperative radiotherapy provides encouraging results in terms of better local control and prolonged survivorship in carefully selected patients. These uncontrolled results justify further evaluation of these salvage operations in a more controlled manner that should include repercussions on the quality of life of the patients.

Secondary and tertiary hyperparathyroidism: causes of recurrent disease after 446 parathyroidectomies.

OBJECTIVE: To determine, in a series of patients with secondary and tertiary parathyroid hyperplasia, whether the type of parathyroidectomy (subtotal, total with autotransplantation, or total), the histologic pattern of the parathyroid tissue, or the proliferative index, as determined by Ki-67 analysis, could predispose patients to recurrent hyperparathyroidism. SUMMARY BACKGROUND DATA: Recurrent hyperparathyroidism appears in 10--70% of the patients undergoing surgery for secondary or tertiary hyperparathyroidism. The incidence could be related to the type of operation (Rothmund) but also depends on the histologic pattern of the glands removed (Niederle). METHODS: The retrospective investigation was performed on 446 patients undergoing parathyroid surgery. They were also studied in relation to the possibility of renal transplantation. In this population, two homogeneous groups were subsequently identified (23 patients with clear signs of recurrence and 27 patients apparently cured); they were studied from the histologic and immunohistochemical point of view using antibody to Ki-67 antigen. RESULTS: Subtotal parathyroidectomy, total parathyroidectomy with autotransplantation, and total parathyroidectomy produced similar results when considering the regression of osteodystrophy, pruritus, and ectopic calcification. As one could anticipate, total parathyroidectomy increased the incidence of hypoparathyroidism. The percentage of recurrence was 5% to 8% after subtotal parathyroidectomy, total parathyroidectomy with autotransplantation, and total parathyroidectomy, and only after incomplete parathyroidectomy did this percentage climb to 34.7%. In the recurrence group, the nodular form was more common and the proliferative fraction detected by Ki-67 was 1.9%; it was 0.81% in the control group. CONCLUSIONS: Because more radical procedures were not more effective, the authors favor a less radical procedure such as subtotal parathyroidectomy. Histologic patterns and proliferative fraction could be useful indices of a recurrence, and these patients should be watched closely after surgery.

Recurrence after first cerebral infarction in young adults.

OBJECTIVE: We have investigated recurrence of stroke in a consecutive series of young adults, aged 16 to 45 years, after a first cerebral infarction. METHODS: From January 1, 1988 to December 31, 1996 we submitted those patients to a diagnostic protocol including angiographic, cardiological, and haematological investigations. The patients were followed at 6 month intervals up to December 31, 1998. RESULTS: We have evaluated and followed-up 135 patients, 71 men and 64 women, who were 3.99% of all the admitted stroke patients. At 12 months after stroke, 83 patients had returned to work, 40 patients were mildly to moderately handicapped, 4 were using a wheel-chair, and 8 had died. Follow-up was 26 to 123 months (mean 68.8). Recurrence of stroke, always of ischaemic nature, was seen in 15 patients (11.1%), 3 to 76 months after the first stroke (mean 27.4), for an annual incidence of 2.26%. Recurrence was significantly associated with Partial Anterior Circulation Syndrome and Haematological subtype of first stroke (respectively, P = 0.0209 and P = 0.0135, chi2 test), but not with age (< or = or > 35 years) or risk factors. Repetition of stroke was never fatal, but it caused heavy disability in 13 patients, 8 of whom had completely or nearly completely recovered after the first event. CONCLUSIONS: Our data suggest that recurrence of stroke is a major clinical problem also for the patients aged less than 45 years and that it might be more frequent with specific clinical syndromes and etiologic subtypes of first stroke.

Benefits of laparoscopic-assisted colectomy for colon polyps: a case-matched series.

OBJECTIVE: To clarify the true benefits of laparoscopic-assisted colectomy by comparing clinical outcomes from a series of laparoscopic right colectomies with matched open colectomies, all performed for the singular indication of polyp not amenable to colonoscopic removal. PATIENTS AND METHODS: A retrospective case-matched study was performed of consecutive patients undergoing laparoscopic-assisted right hemicolectomy for polyps between January 1992 and July 1997. Each case was matched to a control undergoing the equivalent open procedure for the same indication during the same time period. RESULTS: Thirty-eight patients undergoing laparoscopic-assisted right hemicolectomy for polyps were identified, and matches were found. The conversion rate was 18.4% (7/38), 21.4% early in the series and 10% in later experience. Operative times were longer for laparoscopic-associated colectomy (median, 208 minutes vs 150 minutes, P < .001). Laparoscopic-assisted colectomy resulted in shorter postoperative ileus (time to flatus, 3.0 vs 4.0 days, P < .001; time to bowel movement, 3.5 vs 5.0 days, P < .001) and in earlier tolerance of regular diet (3.5 vs 6.0 days, P < .001). Fewer days of narcotic administration were required by the laparoscopic group (3.0 vs 4.5 days, P < .001). This resulted in a significantly shorter length of hospital stay (4.0 vs 7.0 days, P < .001). There was no significant difference in the incidence of postoperative complications. CONCLUSIONS: Laparoscopic right hemicolectomy has significant patient benefits. These benefits are apparent when procedures of equal complexity and equivalent indications are compared. Laparoscopic-assisted resection has become our preferred approach for polyps not amenable to colonoscopic polypectomy.

Primary myocutaneous flap closure following resection of locally advanced pelvic malignancies.

BACKGROUND: Perineal wounds, created at the time of extended resection for locally advanced malignancy and following chemoradiation, are at risk of serious complications. METHODS: To determine whether immediate myocutaneous flap closure prevents complications, 57 patients treated with multimodality therapy and proctectomy (35 perineal wounds) or sacrectomy (22 posterior wounds) were studied. Patients were categorized according to whether they underwent primary skin and pelvic closure (group 1; ,n = 20); primary skin and omental pelvic closure (group 2; n = 24); or immediate myocutaneous flap closure (group 3; n = 13). RESULTS: Groups were similar with respect to age and sex; however, group 1 had more primary tumours and required less radical surgery and chemoirradiation than groups 2 and 3. Groups 1 and 2 experienced more complications overall (eight of 20, nine of 24 and three of 13 patients in groups 1, 2 and 3 respectively), more acute wound complications (seven of 20, nine of 24 and two of 13), delayed wound healing (three of 20, six of 24 and one of 13) and more reoperations for perineal wound problems (five of 20, seven of 24 and zero of 13). Patients in group 2 had a significantly longer hospital stay than those in group 1. Flap closure (group 3) did not increase the length of stay. The routine use of primary flap closure reduced overall wound complications (eight of 31 versus ten of 26 patients) and length of hospitalization (13 versus 17 days). CONCLUSION: Complete wound healing was achieved in all patients; however, immediate myocutaneous flap closure reduced the need for readmission and reoperation.

Prognosis in myocardial infarction survivors with left ventricular dysfunction is predicted by electrocardiographic RR interval but not QT dispersion.

OBJECTIVES: The aim of the study was to assess if QT dispersion and RR interval on the standard 12-lead electrocardiogram (ECG) predict cardiac death and late arrhythmic events in postinfarction patients with low left ventricular ejection fraction (LVEF). QT dispersion on a standard electrocardiogram (ECG) is a measure of repolarization inhomogeneity, but its prognostic meaning in myocardial infarction (MI) survivors is unclear, especially in patients with left ventricular dysfunction. RR interval has been shown to predict mortality in post-MI patients, but its prognostic power has not been compared with other noninvasive risk factors. METHODS: Retrospective cohort study. Ninety patients were identified, from a series of 547 consecutive postinfarction patients admitted to our institution for phase II cardiac rehabilitation, as having a LVEF of <0.40 at two-dimensional echocardiography (mean LVEF 0.35+/-0.04; range 0.20-0.39). QT dispersion and RR interval were analyzed on the admission 12-lead electrocardiogram, 20+/-10 (range 8-45) days after MI, using specially designed software. Additional risk markers were collected from clinical variables, signal-averaged ECG and Holter recording. RESULTS: During 24+/-18 (range 1-63) months of follow-up, 10 of 90 patients (11%) died, all from cardiac causes, and there were 18 late arrhythmic events, defined as sudden death or the occurrence of a sustained ventricular arrhythmia > or =5 days after the index MI. QT interval and dispersion were not significantly prolonged in patients who died compared to survivors and not significantly different between patients with and without arrhythmic events. Mean RR interval from standard ECG was significantly shorter in patients with both cardiac death (682+/-99 vs. 811+/-134 ms; P=0.004) and arrhythmic events (720+/-100 vs. 818+/-139 ms; P=0.006). A Cox proportional hazards model identified RR interval from standard ECG (P<0.001) and a history of more than one MI (P=0.002) as significant predictors of cardiac death independent of thrombolytic therapy, LVEF, filtered QRS complex duration at signal-averaged ECG, mean RR and its standard deviation at 24-h Holter monitoring. CONCLUSIONS: Measurement of QT interval and dispersion 3 weeks after MI has no prognostic power in patients with LV dysfunction after a recent MI. RR interval on standard 12-lead ECG is as good a prognostic indicator as other, more expensive, noninvasive markers. These findings may be relevant in this era of limited health care resources.

Accuracy of computed tomography in determining resectability for locally advanced primary or recurrent colorectal cancers.

AIM: To determine the accuracy of computed axial tomography (CT) in determining tumor resectability in patients with locally advanced primary (T4) or locally recurrent colorectal cancer. METHODS: Computed tomography scans of 84 patients with "resectable" locally advanced primary rectal cancer (n = 12) or recurrent colorectal cancer (n = 72) were compared with the operative findings to assess the accuracy of abdominal and pelvic CT in determining extent of disease and resectability. RESULTS: At surgery, disease was confined to the pelvis in 63 patients, the abdomen in 7, and involved both the pelvis and abdomen in 14. Computed tomography correctly identified these anatomic sites of tumor in 87% of patients, with 89% and 80% accuracies for pelvic and abdominal disease, respectively. Tumor resection was performed in 71 patients (85%), but was not in 13 patients because of locally unresectable disease in 8 and metastatic disease in 5. The accuracy of predicting tumor-related operability was 85%. With regard to adjacent organ resection, CT was accurate in determining the need for sacrectomy or hysterectomy, but overestimated the need for urinary organ resection. Based on histological examination of resection margins, CT correctly staged (n = 45) or overstaged (n = 9) 54 patients (64%) and understaged the remaining 30. The ability of CT to preoperatively predict a locally advanced tumor after preoperative radiation therapy as not being fixed was 30%, fixed but resectable 75%, and fixed but not resectable 25%. CONCLUSIONS: Computed tomography is generally reliable at identifying disease as being confined to one region, and for predicting the need for adjacent organ resection. It is less discriminating for predicting local tumor resectability.

Ileal pouch-anal anastomosis in patients with colorectal cancer: long-term functional and oncologic outcomes.

UNLABELLED: When colorectal cancer complicates chronic ulcerative colitis or familial adenomatous polyposis, the role of ileal pouch-anal anastomosis is uncertain because of concerns that the procedure may compromise oncologic therapy and that oncologic therapy may compromise ileal pouch-anal anastomosis function. AIM: This study was undertaken to investigate the impact both of ileal pouch-anal anastomosis on cancer outcomes and of cancer treatments on ileal pouch-anal anastomosis function. PATIENTS AND METHODS: Of 1,616 patients undergoing ileal pouch-anal anastomosis for chronic ulcerative colitis or familial adenomatous polyposis (1981-1994), 77 patients were identified with adenocarcinoma of the colon (56), rectum (17), or both (4). Data were obtained from an ileal pouch-anal anastomosis registry, case notes, and postal and telephone surveys. RESULTS: Mean age of the 77 index patients was 37 (range, 13-60) years. Stage distribution was as follows: Stage 0, 9; Stage I, 31; Stage II, 15; Stage III, 22 patients. Twelve patients died with systemic disease (6 with a local component) after a mean follow-up of 6 (range, 2-15) years. Twenty-two patients received adjuvant therapy (chemotherapy, 16; radiotherapy, 2; both, 4 patients). Chemotherapy complications requiring dose reduction or interruption occurred in three (15 percent) patients. One patient developed radiation enteritis (17 percent). Pouch failure occurred in 16 percent of cancer patients, compared with 7 percent for the overall registry. There were no differences between cancer and non-cancer groups in operative complications, median stool frequency, incontinence, pad usage, or pouchitis. CONCLUSIONS: Although pouch failure is more common, ileal pouch-anal anastomosis can be performed in the setting of colorectal cancer without significant impact on oncologic outcome or long-term ileal pouch-anal anastomosis function.

Computerized patient record for a department of respiratory rehabilitation.

A computerized patient record (CPR) system plays an essential support role in the efficient functioning of the clinical and research services of a medical centre. We report the experience gained in developing a CPR for the Respiratory Rehabilitation Department (RRD) of the Tradate Medical Center of the Salvatore Maugeri Foundation, with specific reference to Out-patient (OP) and In-patient (IP) Units. The CPR was developed locally under the guidance of the Bioengineering Department. Several items implemented and strategies adopted are described and grouped in relation to broader objectives, such as the improvement of health-care quality, the enhancement of personnel productivity and reduction in costs, the support of clinical and health service research and the accommodation of future developments. In particular, we describe the design and implementation of anamnestic, physical and admission data collection, specifically orientated to respiratory diseases. Daily use of the CPR in the OP and IP units and its potential outcome for research and management support are also studied in detail. On the basis of our experience (1,251 out-patient examinations, 650 in-patient clinical admission cards), the computerized patient record seems a useful way of providing better health-care and a more comprehensive coverage of the rehabilitation process of patients in a Respiratory Rehabilitation Department.

Anticardiolipin antibodies in acute non-hemorrhagic stroke seen within six hours after onset.

INTRODUCTION: We have undertaken a prospective study to measure anticardiolipin antibodies of IgG isotype within the first few hours of an acute non-hemorrhagic stroke. MATERIAL AND METHODS: We have collected blood samples at entry from one hundred patients (53 men and 47 women), mean age 67.4 years, referred within 6 h of a first-ever non-hemorrhagic stroke, and from an equal number of age- and gender-matched control patients. RESULTS: IgG anticardiolipin antibodies were > or = 10 GPL in 26 patients and in 5 controls (p < 0.0001, X2 test). After logistic regression analysis, increase of IgG anticardiolipin antibodies remained independently associated with stroke (p = 0.0034), together with hypertension (p = 0.0009) and atrial fibrillation (p = 0.0238). CONCLUSION: Our data suggest that the occurrence of elevation of IgG anticardiolipin antibodies in stroke patients should antedate stroke onset and might be a risk factor per se.

[The electrocardiographic anomalies and 2D-echocardiographic findings during the recovery phase of the stress test in the postinfarct patient]. / Anomalie elettrocardiografische e reperti ecocardiografici 2D durante la fase di recupero del test ergometrico nel post-infarto.

BACKGROUND: The appearance or the increase of repolarization abnormalities in the EKG during post exercise (ET) recovery phase (R) is considered a marker of ischemia. METHODS: In order to evaluate the real meaning of these changes we compared the EKG data with eventual modifications of left ventricular kinesis analyzed by 2D-ECHO. 10 male patients with previous myocardial infarction, mean age 50 +/- 4.8 y, underwent exercise testing on a treadmill (Bruce's protocol) and continuous 2D-ECHO observation from the end of exercise along the whole R. Patients were divided in two groups: Group A (6 patients) and Group B (4 patients), all free of symptoms. RESULTS: Group A showed ischemic EKG markers during exercise which increased during R; Group B showed ischemic EKG markers only during R. The 2D-ECHO showed in Group A an impairment of left ventricular kinesis at peak exercise without increase or extension during R (WMSI at rest 1.32; peak ET 1.60; R 1.60); in Group B the kinetic alterations appeared only in R (WMSI at rest 1.33, peak ET 1.42; R 1.80), strictly related to EKG markers. CONCLUSIONS: The data suggest : 1) that the increase of EKG abnormalities already present during exercise do not seem to imply more severe ischemia; 2) that EKG changes appearing during R are markers of ischemia which occur in the R.

Blood coagulation changes in nude mice bearing human colon carcinomas.

We studied several blood coagulation parameters and tumor tissue procoagulant activity (PCA) in nude mice bearing human colorectal carcinomas (HCC). In a control group of 51 tumor-free nude mice, platelet number was 1.2 +/- 0.03 x 10(6)/microliters, thrombotest activity 90% +/- 2.6 and fibrinogen 172 +/- 11 mg/dl. The same parameters were studied in nude mice (n = 71) bearing 7 different HCC lines subcutaneously (s.c.). The results did not significantly differ from those in control mice but there was broad variability among groups of mice injected with different HCC lines, ranging from 0.36 to 2.55 x 10(6)/microliters for platelets, from 100 to 28% for thrombotest activity and from 42 to 460 mg/dl for fibrinogen. The results were significantly (p less than 0.05) different from those in the tumor-free group when each group of HCC-bearing animals was analyzed individually. A malignant HCC line that grew in the liver of nude mice (n = 24) significantly (p less than 0.001) reduced thrombotest activity (58% +/- 5.9). The PCA of tissue extracts from tumors grown s.c. in nude mice was assayed. All the HCC xenografts expressed PCA which differed significantly for the various tumor lines (from 25.5 +/- 1.9 to 2.8 +/- 0.6 unit/mg in tumor tissue). Cancer procoagulant (CP), a cysteine proteinase with a direct factor-X-activating effect, was present in different amounts (84.7 +/- 4.3 to 59.5 +/- 9.0%) in the tumors. Our results indicates that the nude mouse is a suitable model for evaluating the hemostatic changes induced by human tumors and may represent a tool for investigating the underlying biochemical mechanisms.

[Radiological study of the thorax. Evaluation of efficacy-efficiency of a large-field image intensifier in mass screening]. / Studio radiologico del torace. Valutazione dell'efficacia-efficienza dell'intensificatore di brillanza a grande campo nelle indagini di massa.

Chest X-ray is the most frequent examination in radiology and accounts for a considerable portion of total population radiation exposure, mostly in screening programs. The ideal radiographic system is the one providing the best image quality together with the lowest dose to the patient, at a low cost. In this paper the authors analyze the potentials of a new chest X-ray examination unit equipped with a large-screen image intensifier (TS 57-Siemens). Two-thousand subjects were examined with this unit. The technical aspects of everyday practice are analyzed from the radiologist's point of view, together with the dose to the patient, image quality, and costs.