Segmental duodenal resection: indications, surgical techniques and postoperative outcomes.

INTRODUCTION: Segmental duodenal resections (DR) have been increasingly performed for the treatment of primary duodenal tumours. The aim of the study is to review the indications for, clinical and operative details, and outcomes of patients undergoing elective DR. MATERIAL AND METHODS: We retrospectively reviewed all patients who underwent elective segmental DR for the treatment of primary duodenal tumours, at a single institution between January 2007 and December 2013. Demographic data, clinical presentation, preoperative investigations, operative details, postoperative complications/mortality and histopathological results were recorded. RESULTS: In the study period, 11 duodenal resections were performed (7 male, median age 61 years). Thirty-six percent of the patients presented with anaemia. Surgical resection included two or more segments in seven patients. The most frequently resected part of the duodenum was segment 3 (n = 7). Median operative time was 191 min and blood loss was 675 ml. End-to-end and end-to-side anastomoses were performed in equal numbers. The pathology of resected specimens included adenocarcinoma (n = 4), gastrointestinal stromal tumour (GIST) (n = 1), adenoma (n = 5) and lymphoma (n = 1). Median hospital stay was 14 days. Overall, 30-day morbidity rate was 82% (78% Clavien 2 or less). CONCLUSIONS: Segmental duodenal resection is a safe and effective surgical technique for the resection of primary duodenal tumours.

Extreme heatstroke causing fulminant hepatic failure requiring liver transplantation: a case report.

INTRODUCTION: Exertional heatstroke with liver involvement is a rare and potentially fatal condition. In this setting, fulminant hepatic failure (FHF) occurs as a result of severe hypoxic hepatitis. CASE REPORT: We report the case of a young male athlete who developed exertional heatstroke associated with rhabdomyolysis and hypoxic hepatitis while running the final stages of an ultra-marathon (62 km). The patient rapidly developed multiorgan failure, including fulminant hepatic failure, requiring intensive care admission for mechanical ventilation, hemodialysis, and inotropic support. He failed to improve with supportive measures and underwent an emergency hepatectomy followed by orthotopic liver transplant, after which he recovered completely. CONCLUSIONS: We discuss the rationale for liver transplantation in this setting, possible alternative treatments, and the pathophysiology of fulminant liver failure in this rare case.

Role of robotic surgery in colorectal resections for cancer.

In recent years, robotic surgery is becoming a valid alternative in colorectal diseases treatment to laparoscopic and traditional open surgery. The most relevant reported technical advantages of the robotic surgery are 3D-view, tremor-filtering, seven degree-free motion and a higher comfortable setting for the surgeon. Both case series and comparative studies available in Literature report only short and mid-term outcomes. These studies are able to demonstrate that robotic surgery is as safe and feasible as laparoscopic surgery regarding perioperative outcomes. Trials with long term follow up are needed to establish the real safety and effectiveness of the robotic surgery especially concerning resections for cancer. The robotic surgery could be considered a promising surgical field. The high costs represent one of the most relevant drawbacks.

[Intravitreal Ranibizumab Injection for the Treatment of Occult and Classic CNV in Exsudative AMD]. / Ranibizumab intravitreal zur Behandlung okkulter und klassischer choroidaler Neovaskularisation (CNV) bei AMD.

BACKGROUND: Double-blind, randomised, placebo-controlled and multicentre studies have proven an increase in visual acuity in one-third of the patients receiving Ranibizumab (0.5 mg) injections, who suffer from exsudative AMD. The purpose of this study was to evaluate the early effects of intravitreal Ranibizumab therapy in patients with mainly occult neovascular AMD in clinical applications. PATIENTS AND METHODS: In a retrospective cohort study, 91 eyes with occult and classic neovascular AMD were treated with intravitreal injections of Ranibizumab (0.5 mg) at 30-day intervals. The treatment effects were evaluated according to best corrected visual acuity, optical coherence tomography (OCT) and intraocular pressure at baseline as well as 1, 3 and 6 months after the beginning of therapy. Furthermore, fluorescein angiography (FLA) was performed at baseline as well as 3 and 6 months after therapy. RESULTS: 74 % of the patients lost fewer than 15 letters on the EDTRS-scale 6 months after the beginning of therapy. Visual acuity improved by more than 15 letters in 11 % of the patients. Central retinal thickness, measured by OCT, decreased statistically significantly in each control compared to baseline (1 month: p = 0.045; 3 months: p = 0.001; 6 months: p = 0.006). Leakage and membranes, evaluated in FA, worsened in 31 % of the patients; in 67 % the findings were stable. No increase in intraocular pressure was detected. CONCLUSIONS: Intravitreal application of Ranibizumab was safe and well tolerated. In the clinical situation, visual acuity was stabilised in the short term. As opposed to phase-III studies, no improvement in visual acuity could be accomplished. Cental retinal thickness decreased and findings in fluorescein angiography were stable within a 6-month follow-up period. It is necessary to perform monthly controls and proceed with VA- and OCT-based injections in order to maintain the therapeutic effect. Futher clinical evaluations of Ranibizumab will be necessary to evaluate its long-term treatment effects.

[Ocular motility disorders in a patient with Fabry's disease]. / Augenbewegungsstörungen bei einem Patienten mit Morbus Fabry.

Fabry's disease (FD) is a rare lysosomal storage disorder. Early cerebral manifestations are a major and often life-threatening burden of the disease. We present a 38-year-old male FD patient with a prior history of six different episodes of stroke and newly developing ocular disorders. He presented with nystagmus with different wave forms and directions and blepharospasm as well as cornea verticillata.

[Photodynamic therapy with verteporfin combined with intravitreal injection of ranibizumab for occult and classic CNV in AMD]. / Photodynamische Therapie mit Verteporfin kombiniert mit intravitrealer Injektion von Ranibizumab zur Behandlung okkulter und klassischer choroidaler Neovaskularisationen bei AMD.

PURPOSE: The aim of this study is to discuss the effect and outcome of a combined photodynamic therapy and intravitreal injection of ranibizumab (0.5 mg) in occult CNV with recent disease progression and in classic choroidal neovascularization (CNV) due to AMD. METHODS: In a pilot study in 28 patients (17 classic, 11 occult CNV) an intravitreal injection of ranibizumab was administered within 12 to 24 hours after standard PDT, followed by 2 injections of ranibizumab after 1 and 2 months. Before as well as 3 and 6 months after treatment visual acuity, OCT examinations (retinal thickness) and fluorescein angiography were performed. RESULTS: Mean visual acuity was significantly improved compared to baseline after 3 months (VA baseline 20/80, after 3 months 20/50, and 20/63 after 6 months). We found no choroidal hypoperfusion and no RPE rip. OCT and fluorescein angiography in patients with occult and classic choroidal neovascularisation after the combination therapy showed a reduced retinal thickness (baseline: 307 microm, after 1 month: 210 microm, after 3 months: 228 microm and after 6 months 281 microm) and a reduction of leakage compared to baseline. CONCLUSIONS: Photodynamic therapy combined with injection of intravitreal ranibizumab was well tolerated and is effective. We found a stabilisation of VA in 96% of patients. Our short-term results are very promising. Further studies are necessary to show the long-term effect of the PDT and anti-VEGF combination therapy.

[Intravitreal injection of bevacizumab for exsudative AMD with occult or minimal classic choroidal neovascularisation (CNV)]. / Bevacizumab intravitreal zur Behandlung okkulter und minimal klassischer choroidaler Neovaskularisation (CNV) bei AMD.

PURPOSE: Systemic anti-VEGF therapy with bevacizumab was effective in neovascular AMD in the SANA study. Intravitreal bevacizumab has the advantage that a high concentration can be achieved in the eye with a low dose. First clinical studies showed a good therapeutic effect. METHODS: In a clinical study 93 patients with occult or minimal classic CNV due to neovascular AMD were treated with intravitreal injections of Bevacizumab (1.25 mg). Before, 1, 3 and 6 months after treatment visual acuity, intraocular pressure measurement, angiography and OCT examination were performed. After one day and after one week an eye examination was done and the intraocular pressure was measured. RESULTS: Bevacizumab was well tolerated and we had no complications. Mean visual acuity was 20 / 80 at baseline. Visual acuity was stabilised but not significantly improved after 1, 3 and 6 months (20 / 80). 70 (75 %) patients showed reduced leakage in fluorescein angiography after 6 month. In OCT retinal thickness was reduced significantly after 1, 3 and 6 months (OCT: mean 323 microm at baseline, 260 microm after 1, 290 microm after 3 and 275 microm after 6 months). CONCLUSIONS: Intravitreal therapy with bevacizumab was safe and well tolerated. It is a therapeutic option in treating occult choroidal neovascularisations and minimal classic CNV. Six months after intravitreal administration of bevacizumab mean visual acuity was stabilised. Retinal thickness and leakage were more reduced after 1 month than after 3 and 6 months. According to our results, a monthly injection schedule could give more favourable results.

[Photodynamic therapy with verteporfin combined with intravitreal injection of bevacizumab for occult and classic CNV in AMD]. / Photodynamische Therapie kombiniert mit intravitrealer Injektion von Bevacizumab zur Behandlung okkulter und klassischer choroidaler Neovaskularisationen bei AMD.

PURPOSE: The aim of this study is to discuss the effect and outcome of a combined photodynamic therapy and intravitreal injection of bevacizumab (1.25 mg) in occult and classic choroidal neovascularisation (CNV) due to AMD. Especially cases of occult CNV with pigment epithelium detachment (PED) are not likely to respond positively to standard photodynamic therapy, often ending up in PED enlargement or tearing of the RPE. METHODS: In a pilot study involving 23 patients, intravitreal injections of bevacizumab were administered within 12 to 24 hours after standard PDT to reduce the post-PDT increase of proangiogenic and inflammatory factors. Before and at 1, 3 and 6 month after treatment visual acuity and OCT examinations (retinal thickness) were performed. RESULTS: Mean visual acuity was significantly improved compared to baseline. (VA baseline 20/125, after 1 month 20/80, after 3 months 20/80, and 20/80 after 6 months) and an enlargement of the PED in occult CNV was prevented. We found no RPE rip. OCT findings in patients with occult and classic choroidal neovascularisation 1, 3 and 6 months after combination therapy showed a reduced retinal thickness compared to baseline. CONCLUSIONS: Photodynamic therapy combined with injection of intravitreal bevacizumab tends to be more effective compared to PDT monotherapy by reducing the post-PDT increase of vascular growth and inflammatory factors. Our short-term results are very promising. Further studies are necessary to show the long-term effect of PDT and anti-VEGF combination therapy.

Multi-scale analysis of the toraymyxin adsorption cartridge. Part II: computational fluid-dynamic study.

Extracorporeal endotoxin removal by means of the Toraymyxin device is based on the ability of polymyxin B to bind endotoxins with a high specificity. The endotoxins/polymyxin molecular interactions were computationally analyzed in a parallel work (Part I). In this paper we investigate with a multi-scale approach the phenomena involving blood and plasma fluid dynamics inside the device. The macro- and mesoscale phenomena were studied by means of 3D models using computational fluid dynamics. The flow behavior in the sorbent material was focused, modeling the sorbent as a homogeneous porous medium at the macroscale level, or accounting for the realistic geometry of its knitted fibers at the mesoscale level. A microscale model was then developed to analyze the behavior of endotoxin molecules subjected to the competition of flow drag and molecular attraction by fiber-grafted polymyxin B. The macroscale results showed that a very regular flow field develops in the sorbent, furthermore supplying the peak velocity to be input in the lower-scale model. The mesoscale analysis yielded the realistic range for wall shear stresses (WSSs) acting on fiber walls. With WSS values in the entire range, the results of the microscale analysis demonstrated that the capability of polymyxin B to capture endotoxin molecules from the flow extends at distances one order of magnitude greater than the characteristic distance of the stable intermolecular bond. We conclude that the use of an integrated, multi-scale analysis allows for a comprehensive understanding of the complex mechanisms involved in endotoxin sorption phenomena with immobilized polymyxin B.

The C(-260)>T gene polymorphism in the promoter of the CD14 monocyte receptor gene is not associated with acute myocardial infarction.

CD surface molecules mediates cell activation and signaling. In particular, CD14 on blood monocytes mediate monocyte/macrophage activation by lipopolysaccharide. Lipopolysaccharide and its receptor, CD14, have been implicated in atherogenesis. It has been recently shown that a C(-260)T polymorphism in the promoter of the CD14 receptor may be a risk factor for coronary artery disease. Recently this association has been questioned because no increased risk was found with the T allele, even in the homozygous state. In the present study we investigated a possible association between the C(-260)T polymorphism in the CD14 promoter and acute myocardial infarction. Two hundred and thrteen patients with and acute myocardial infarction 213 healthy controls were included in the study. Genotype frequencies of the C(-260)T polymorphism in the CD14 promoter were determined by polimerase chain reaction and the amplified product was cleaved with HaeIII. The frequency of the T allele was not significantly different in patients compared with controls. In this study we were not able to detect differences of frequency of the allele T (-260) in the promoter of the CD14 receptor gene in survivors of myocardial infarction and controls.

Two Italian kindreds carrying the Arg136-->Ser mutation of the Apo E gene: development of premature and severe atherosclerosis in the presence of epsilon 2 as second allele.

BACKGROUND AND AIMS: Type III hyperlipoproteinemia, or dysbetalipoproteinemia, is commonly associated with apolipoprotein E2 homozygosity (Cys112, Cys158). Apo E2-Christchurch (Arg136-->Ser), a rare mutation of the Apo E gene, located in the receptor-binding domain of the protein, has been found to be associated in the vast majority of cases of dysbetalipoproteinemia. METHODS AND RESULTS: This is the first report of two Italian kindreds carrying the Arg136-->Ser mutation. One family is a four-generation kindred from Genoa (Liguria, Italy) with a high rate of mortality due to coronary artery disease: the proband was a 51-year-old woman with previous myocardial infarction and residual angina, severe carotid atherosclerosis, peripheral arterial vascular disease and arterial hypertension. The other family was identified in Palermo (Sicily, Italy): the proband was an overweight 62-year-old man with a mixed form of hyperlipidemia. The mutation, which was identified by means of Apo E genotyping followed by direct sequencing, co-segregated with the same haplotype in the two families. CONCLUSIONS: The family histories and clinical examinations of these subjects clearly show that the Apo E Arg136-->Ser variant fully expresses a type III phenotype in association with a second allele coding for Apo E2, and only partially in association with a second allele coding for Apo E4.

Autosomal recessive hypercholesterolemia in a Sicilian kindred harboring the 432insA mutation of the ARH gene.

We describe a Sicilian family presenting a recessive form of hypercholesterolemia harboring a mutation of the autosomal recessive hypercholesterolemia (ARH) gene. In two of the three sibs, a 26-year-old male and a 22-year-old female, a severe hypercholesterolemia was diagnosed with very high levels of plasma cholesterol (15.9 and 12.2 mmol/l, respectively); tendon xanthomatas and xanthelasms were present and in the male proband was documented a diffuse coronary atherosclerotic disease with a rapid and fatal progression. Both the parents had normal or slightly increased levels of plasma cholesterol. All causes of secondary hypercholesterolemia were ruled out as well as an involvement of the LDL receptor or apoB genes. Beta-Sitosterol plasma levels were in the normal range. Cultured fibroblasts from skin biopsy from parents and the two probands displayed a normal ability to bind and degrade 125I-LDL. Direct sequencing of ARH gene demonstrated the presence of a 432insA mutation in homozygosis in the two probands; parents were heterozygotes for the same mutation. This mutation is the first report of a mutation of the ARH gene responsible for recessive forms of hypercholesterolemia in Sicily.

Effectiveness of screening for known mutations in Sicilian patients with "probable" familial hypercholesterolemia.

BACKGROUND AND AIM: More than 750 mutations in the low-density lipoprotein (LDL) receptor gene are currently known to cause familial hypercholesterolemia (FH), but the array of mutations varies considerably in different populations. The definition of essentially all the LDL receptor gene mutations in a population is therefore a prerequisite for the implementation of nation-wide genetic testing for FH. METHODS AND RESULTS: In this study, a screening strategy based on PCR-enzymatic digestion and PCR-allele specific hybridisation procedures was used to evaluate the frequency distributions of 11 known mutations in a cohort of 214 unrelated subjects meeting the diagnostic criteria of "probable" FH. We identified 20 mutation carriers (9.3%). One mutation (FH Palermo-1) occurred with a relatively high frequency, accounting for 7% of the entire study cohort. We also report the first observation of the receptor-negative mutation V408M (Afrikaner-2) in Italy. CONCLUSIONS: Our screening approach is not effective and, at least in our area, it is not a suitable alternative to the more expensive and time-consuming sequencing approach. However, our data suggest that it is possible to identify the molecular defect in about 10% of Sicilian patients with a clinical diagnosis of "probable FH" using a rapid laboratory diagnostic mutation panel. Four mutations were responsible for all of the diagnosed cases, and it could be reasonable to use this 4-mutation panel as a preliminary step before adopting a more complex laboratory approach.

Regulated Ran-binding protein 1 activity is required for organization and function of the mitotic spindle in mammalian cells in vivo.

Ran-binding protein (RanBP) 1 is a major regulator of the Ran GTPase and is encoded by a regulatory target gene of E2F factors. The Ran GTPase network controls several cellular processes, including nucleocytoplasmic transport and cell cycle progression, and has recently also been shown to regulate microtubule nucleation and spindle assembly in Xenopus oocyte extracts. Here we report that RanBP1 protein levels are cell cycle regulated in mammalian cells, increase from S phase to M phase, peak in metaphase, and abruptly decline in late telophase. Overexpression of RanBP1 throughout the cell cycle yields abnormal mitoses characterized by severe defects in spindle polarization. In addition, microinjection of anti-RanBP1 antibody in mitotic cells induces mitotic delay and abnormal nuclear division, reflecting an abnormal stabilization of the mitotic spindle. Thus, regulated RanBP1 activity is required for proper execution of mitosis in somatic cells.

The human per1 gene: genomic organization and promoter analysis of the first human orthologue of the Drosophila period gene.

Per genes encode components of the circadian clocks controlling metabolic and behavioural rhythms. The human Per1 cDNA, RIGUI, was previously isolated and mapped on chromosome 17p12 (Sun, Z.S., Albrecht, U., Zhuchenko, O., Bailey, J., Eichele, G., Lee, C.C., 1997. RIGUI, a putative mammalian orthologue of the Drosophila period gene. Cell 90, 1003-1011). We have now isolated the entire genomic locus containing the human Per1 gene, in a search for genes associated with CpG-rich sequences. The hPer1 gene spans 15kb of human genomic DNA and is composed of 23 exons, flanked by 5' and 3' regulatory regions. Comparison of the hPer1 genomic clone with the dbEST database revealed homologies with putative alternative transcripts. Functional mapping within the 5' CpG-rich regulatory region enabled us to locate the hPer1 promoter core in a 510bp-long sequence centred around a TATA box, which supports high levels of hPer1 transcription. A second regulatory region was formally identified in intron 1, which appears to exert a negative role in transcriptional control of hPer1. These regions may be differentially involved in tissue-specificity, and/or circadian regulation, of the human hPer1 gene transcription.

Asthma hospitalizations in Wisconsin: a missed opportunity for prevention.

Asthma is the most common chronic disease of children and the third leading cause of preventable hospitalizations in the United States. To assess the impact of this disease on Wisconsin, we examined 1996-1998 state-wide and county-specific asthma hospitalization rates and compared these rates to Wisconsin 1990-1992 rates, national rates, and United States Healthy People 2010 asthma target objectives. Wisconsin's average asthma hospitalization rate has decreased from 13.4/10,000 during 1990-1992 to 12.1/10,000 during 1996-1998. Wisconsin children 0-4 years of age had the highest asthma-related hospitalization rate (38.0/10,000) of all age groups, during 1996-1998. Wisconsin African American residents had an average asthma hospitalization rate 6.6 times higher than whites (58.5 vs. 8.8 per 10,000, respectively) during 1996-1998. Milwaukee County had the highest county-specific asthma hospitalization rate in the state (26.4/10,000). Unless significant reductions are achieved, Wisconsin will not reach the Healthy People 2010 target objectives. Interventions should be directed to preventing asthma hospitalizations, especially among Wisconsin's youth and African American population.

Cytosine methylation transforms an E2F site in the retinoblastoma gene promoter into a binding site for the general repressor methylcytosine-binding protein 2 (MeCP2).

The CpG-rich promoter of the retinoblastoma tumor suppressor gene (Rb-1) is normally unmethylated. However, aberrant methylation of CpG dinucleotides within the Rb-1 promoter has been depicted in certain tumors, which determines transcriptional inactivity of the gene and absence of the pRb retinoblastoma protein. Here we have concentrated on an E2F-binding site in the Rb-1 promoter. We show that the E2F site is required for cell-cycle regulated Rb-1 transcription in non-transformed cells. The function of the E2F site is associated with its ability to interact with several activating factors of the E2F family. In contrast, in vitro methylation of two tandemly arranged CpGs in the E2F recognition site prevents binding by E2F factors, and determines instead the recruitment of the general repressor methylcytosine-binding protein 2 (MeCP2). These results suggest that the interaction of MeCP2 with the methylated version of the E2F site may represent a step towards Rb-1 promoter inactivity in tumor cells.

Two E2F sites control growth-regulated and cell cycle-regulated transcription of the Htf9-a/RanBP1 gene through functionally distinct mechanisms.

The gene encoding Ran-binding protein 1 (RanBP1) is transcribed in a cell cycle-dependent manner. The RanBP1 promoter contains two binding sites for E2F factors, named E2F-c, located proximal to the transcription start, and E2F-b, falling in a more distal promoter region. We have now induced site-directed mutagenesis in both sites. We have found that the distal E2F-b site, together with a neighboring Sp1 element, actively controls up-regulation of transcription in S phase. The proximal E2F-c site plays no apparent role in cycling cells yet is required for transcriptional repression upon growth arrest. Protein binding studies suggest that each E2F site mediates specific interactions with individual E2F family members. In addition, transient expression assays with mutagenized promoter constructs indicate that the functional role of each site is also dependent on its position relative to other regulatory elements in the promoter context. Thus, the two E2F sites play opposite genetic functions and control RanBP1 transcription through distinct molecular mechanisms.

Interactions with single-stranded and double-stranded DNA-binding factors and alternative promoter conformation upon transcriptional activation of the Htf9-a/RanBP1 and Htf9-c genes.

The murine Htf9-a/RanBP1 and Htf9-c genes are divergently transcribed from a shared TATA-less promoter. Transcription of both genes is initiated on complementary DNA strands and is controlled by cell cycle-dependent mechanisms. The bidirectional promoter harbors a genomic footprint flanking the major transcription start site of both genes. Transient promoter assays showed that the footprinted element is important for transcription of both genes. Protein-binding experiments and antibody assays indicated that members of the retinoid X receptor family interact with the double-stranded site. In addition, distinct factors interact with single DNA strands of the element. Double-stranded binding factors were highly expressed in liver cells, in which neither gene is transcribed, while single-stranded binding proteins were abundant in cycling cells, in which transcription of both genes is efficient. In vivo S1 analysis of the promoter depicted an S1-sensitive organization in cells in which transcription of both genes is active; S1 sensitivity was not detected in conditions of transcriptional repression. Thus, the same element is a target for either retinoid X receptor factors, or for single-stranded binding proteins, and form distinct complexes in different cellular conditions depending on the DNA conformation in the binding site.