Feasibility and outcome of laser CO2conization performed within the 18th week of gestation

The purpose of this study is to evaluate the feasibility, safety, and potential therapeutic benefit of laser CO2conization of the cervix forin situand minimally invasive carcinoma diagnosed during pregnancy. Twenty-six pregnant patients with biopsy-proven carcinomain situ/cervical intraepithelial neoplasia III but colposcopically suspicious for invasion underwent laser CO2conization during the 18th week of gestation in an outpatient setting under local anesthesia. No major intraoperative or postoperative complications occurred, and cervical cerclage was not required in any case. Two cases (7.7%) of occult FIGO stage IA1 minimally invasive cervical cancers with free surgical margins were diagnosed. Both patients delivered vaginally at term and were free of disease at postpartum follow-up. Median length of gestation was 39.1 weeks with a median birth weight of 3450 g. All 1-min Apgar scores were 8 or greater. Twenty patients (76.9%) delivered vaginally, while six patients underwent cesarean section for indications not related to the prior conization. After a mean postpartum follow-up of 18 months (range 3–42), 92.3% of patients continued to have both cytologic and colposcopic evaluations negative for persistent or recurrent disease. Two cases of persistent intraepithelial disease were successfully managed by reconization. In summary, our data suggest that laser CO2conization performed within the 18th week of gestation is safe for both the patient and the fetus, provides reliable histologic diagnosis, and can be curative. Further studies are required to confirm the favorable risk–benefit ratio of laser CO2conization in the management of non-reassuring cervical lesions observed in the first half of pregnancy.

Prognosis of stage II colon cancer by non-neoplastic mucosa gene expression profiling

We have assessed the possibility to build a prognosis predictor (PP), based on non-neoplastic mucosa microarray gene expression measures, for stage II colon cancer patients. Non-neoplastic colonic mucosa mRNA samples from 24 patients (10 with a metachronous metastasis, 14 with no recurrence) were profiled using the Affymetrix HGU133A GeneChip. Patients were repeatedly and randomly divided into 1000 training sets (TSs) of size 16 and validation sets (VS) of size 8. For each TS/VS split, a 70-gene PP, identified on the TS by selecting the 70 most differentially expressed genes and applying diagonal linear discriminant analysis, was used to predict the prognoses of VS patients. Mean prognosis prediction performances of the 70-gene PP were 81.8% for accuracy, 73.0% for sensitivity and 87.1% for specificity. Informative genes suggested branching signal-transduction pathways with possible extensive networks between individual pathways. They also included genes coding for proteins involved in immune surveillance. In conclusion, our study suggests that one can build an accurate PP for stage II colon cancer patients, based on non-neoplastic mucosa microarray gene expression measures.

Complete radiological response of colorectal liver metastases (LM) after chemotherapy: Does it mean cure?

3501

Background: Most of patients with colorectal LM receive systemic chemotherapy. Complete response on imaging is considered a good indicator of the efficacy of chemotherapy. Whether complete radiological response is correlated to complete pathological response is not well known. The objective of this study was to determine the significance of complete radiological response of LM after chemotherapy. Methods: Between 1998 and 2004, 586 patients were treated in one institution for colorectal LM. 38 with the following criteria were included in the study: less than 10 LM before chemotherapy, disappearance of one or several LM on helical CT scan and ultrasound after chemotherapy, surgery with liver examination and intraoperative ultrasound within 4 weeks after imaging, no extra-hepatic disease, follow-up at least one year after surgery. Results: Overall, 66 LM disappeared on imaging after chemotherapy (38 patients). In 9 patients, persistent macroscopic disease was observed at surgery at the site of 20/66 (30%) LM although there were considered in complete response on imaging. In 15 patients, with no remnant disease at surgery, the sites of 15 initial LM were resected. Pathological examination of theses sites of LM considered in complete response showed the presence of viable tumor cells in 12/15 cases (80%). In 14 other patients, the sites of 31 initial LM, which were not visible at surgical exploration were left in place during surgery. After one year of follow-up, 23/31 (74%) LM considered in complete response had recurred in situ (11/14 patients). Overall, persistent macroscopic or microscopic residual disease or early recurrence in situ were observed in 55/66 LM (83%) with complete radiological response (32/38 patients). Conclusions: Complete radiological response in patients who have received chemotherapy is a useful tool to evaluate the effect of chemotherapy but it does not mean cure in most patients. This should be taken into account when considering multimodality treatment including chemotherapy and surgery.

No significant financial relationships to disclose.

[Cerebral aneurysm related to pediatric AIDS. Case report]

INTRODUCTION

Aneurysms, described in pediatric AIDS, are related with bad prognosis with high mortality in 5 months. The twenty reports found in literature were considered late (mean age 9.97 years old) and associated with severe immunological involvement. The mean CD-4 count was 79.17 cells and mean viral load 222,662 copies/mL. Some authors consider this complication associated to the human immunodeficiency virus (HIV), to an opportunistic agent (citomegalovirus and Mycobacterium avium) or due to inflammatory mechanisms related with the immunological improvement.

CASE REPORT

This paper present a 9 years old girl with severe AIDS (C-3) and with transient amaurosis related to transient ischemic attacks on ophthalmic artery during her immunological improvement on viral load and CD-4 counts. Necropsy showed aneurysm due to atypical micobateriosis.

CONCLUSION

This report highlights the occurrence of this rare but severe HIV complication witch was associated with an opportunistic etiology during an immunological recovery, when inflammatory mediators could play a role.

Treatment strategy for patients with colorectal cancer and synchronous irresectable liver metastases

BACKGROUND

The aim of this case-matched study was to determine the best treatment strategy for patients with asymptomatic colorectal cancer and irresectable synchronous liver metastases.

METHODS

Between 1997 and 2002, 27 patients with asymptomatic colorectal cancer and irresectable synchronous liver metastases were treated by chemotherapy without initial primary resection (chemotherapy group). These 27 patients were compared with 32 patients matched for age, sex, performance status, primary tumour location, number of liver metastases, nature of irresectable disease and type of chemotherapy, but who were treated initially by resection of primary tumour (resection group).

RESULTS

The 2-year actuarial survival rate was 41 per cent in the chemotherapy group and 44 per cent in the resection group (P = 0.753). In the latter group, the mortality and morbidity rates for primary resection were 0 and 19 per cent (six of 32 patients) respectively. In the chemotherapy group, intestinal obstruction related to the primary tumour occurred in four of 27 patients. The mean overall hospital stay was 11 days in the chemotherapy group and 22 days in the resection group (P = 0.003).

CONCLUSION

Systemic chemotherapy without resection of the bowel cancer is the option of choice because, for most patients, it is associated with a shorter hospital stay and avoids surgery without a detrimental effect on survival.

[The mesorectum: an anatomical entity that is difficult to evaluate with MRI]

The preoperative assessement by magnetic resonance imaging (MRI) of mesorectum involvement could improve the treatment strategy for patients with rectal cancer. However, the anatomical definition of the mesorectum remains controversial and consequently the accurracy of its analysis by preoperative imaging workup is still unsatisfactory. The aims of this study were to define the mesorectum anatomically and to assess whether it could be evaluated accurately by MRI. Total mesorectal excision was performed in 37 patients with rectal cancer. The mesorectum was inked for anatomical analysis, which was performed before and after fixation in formalin. The mesorectal thickness was measured anteriorly, posteriorly and laterally. Mesorectal involvement was defined by the shortest distance from the outermost part of the tumour to the lateral mesorectal margin. The anatomical measures were compared to those evaluated by preoperative MRI. In middle rectum, the anatomical analysis showed that the maximal mesorectal thickness was 60 and 20 mm posteriorly and anteriorly, respectively. In low rectum, the mesorectum was very thin and its maximal thickness was less than 10 mm anteriorly and posteriorly in all cases. The mesorectal involvement was less than 2 mm in 23% of cases. In terms of mesorectal involvement, there was good agreement between anatomical analysis and MRI for middle rectum. In contrast, the agreement was fair for low rectum. This anatomical analysis could explain the poor performance of MRI in the assessement of mesorectum involvement in low rectum.

Endothelial cytochrome P450 contributes to the acetylcholine-induced cardiodepression in isolated rat hearts

AIMS

Acetylcholine (ACh) is known to reduce the contractility of the heart by acting on myocardial muscarinic M2 receptors. ACh induces also an endothelial-dependent vasodilatation by causing the release of nitric oxide (NO), prostacyclin and endothelium-derived hyperpolarizing factors from the vascular endothelium. It has been proposed that ACh elicits a hyperpolarization of the coronary endothelial cells which may be accompanied by the activation of cytochrome P450 (CYP) and the resulting release of epoxyeicosatrienoic acids (EETs). The study aims at investigating whether endothelial CYP is involved in the cardiodepression by ACh.

METHODS AND RESULTS

In isolated rat hearts, cardiodepression by ACh (i.e. 25-30% reduction of developed left ventricular pressure) was partially attenuated either by inhibition of CYP with 1-aminobenzotriazole (ABT) or by endothelial dysfunction obtained with Triton X-100. No attenuation of cardiodepression was seen after nitric oxide synthase and cyclooxygenase inhibition by L-nitro-arginine methyl ester and indomethacin, respectively.

CONCLUSION

The results suggest that the negative inotropic effect of ACh depends not only on a direct myocardial effect but also on the endothelial CYP activation.

Loss of heterozygosity on 10q and mutational status of PTEN and BMPR1A in colorectal primary tumours and metastases

We investigated the possible role of chromosome 10q losses in colorectal cancer metastasis by carrying out an allelic imbalance study on a series of microsatellite instability-negative (MSI−) primary tumours (n=32) and metastases (n=36) from 49 patients. Our results demonstrate that 10q allelic losses are associated with a significant proportion (25%) of MSI− colorectal tumours, but are not involved in the metastatic process. PTEN and BMPR1A, two genes located in the common deleted region, were screened for mutations in samples with loss of heterozygosity. The absence or low frequency of mutations indicates that the inactivation of these genes by deletion of one allele and mutation of the other one plays only a minor role in MSI− tumours.

Surgery and local treatments of liver metastases from colorectal cancer: how to improve results

Over the last 30 years, the benefits of surgical resection for liver metastases have been established. Actually, surgical resections are feasible with a very low mortality and a 5-year survival that approaches 40 %. However, even if progresses in surgery and anaesthesiology now render possible extensive resections with removal of large, numerous or bilateral lesions, only 10 to 20 % of patients are candidate to surgery. The others gain benefit from chemotherapy with more and more active drugs. To improve this overall picture, efforts have been made to increase the number of patients that could be candidates for surgery. Shrinkage of tumours after administration of preoperative chemotherapy and availability of ablative techniques now permit to treat with curative intent metastases initially considered as non-resectable.

Fatty acids are important for the Frank-Starling mechanism and Gregg effect but not for catecholamine response in isolated rat hearts

In some pathophysiological conditions myocardial metabolism can switch from mainly long chain fatty acid (LCFA) oxidation to mainly glucose oxidation. Whether the predominant fatty acid or glucose oxidation affects cardiac performance has not been defined. In a buffer perfused isovolumetrically contracting rat heart, oxidation of endogenous pool LCFA was avoided by inhibiting carnitine-palmitoyl-transferase I (CPT-I) with oxfenicine (2 mM). In order to restore fatty acid oxidation, hexanoate (1 mM), which bypasses CPT-I inhibition, was added to the perfusate. Three groups of hearts were subjected to either an increase in left ventricular volume (VV, +25%) or an increase in coronary flow (CF, +50%), or inotropic stimulation with isoproterenol (10(-8) and 10(-6) m). The increase in VV (the Frank-Starling mechanism) increased rate-pressure product (RPP) by 21 +/- 2% under control conditions, but only by 6 +/- 2% during oxfenicine-induced CPT-I inhibition. The contractile response to changes in VV recovered after the addition of hexanoate. Similar results were obtained in hearts, in which an increase in CF was elicited (the Gregg phenomenon). Isoproterenol caused a similar increase in contractility regardless of the presence of oxfenicine or hexanoate. In all groups, a commensurate increase in oxygen consumption accompanied the increase in contractility. The fatty acid oxidation is necessary for an adequate contractile response of the isolated heart to increased pre-load or flow, whereas the inotropic response to adrenergic beta-receptor stimulation is insensitive to changes in substrate availability.

[Cervical myomectomy by laser CO2. Report of two cases]

Cervical localization of uterine fibroids is an uncommon event and vaginal surgery by cold knife is the current therapeutic approach. Two patients with cervical fibroids underwent laser CO2 excision under colposcopic guidance, using local anesthesia and in outpatient setting. The absence of intra- and post-surgical complications and the successful therapeutical results prove that laser CO2 surgery could be an alternative treatment in selected cases.

[Cervical cytologic reports of ASCUS and LSIL. Cyto-histological correlation and implication for management]

BACKGROUND

The purpose of this retrospective study is to evaluate the appropriate management of ASCUS and LSIL pap smears by correlating the histological findings obtained by punch biopsy or excised specimens.

METHODS

The study group included 584 women with abnormal pap smear: 358 with ASCUS and 226 with LSIL cytological abnormalities. All patients underwent colposcopy and, if necessary, directed-punch biopsy. In case of biopsy-proven dysplasia a destructive or excisional treatment was performed, as indicated.

RESULTS

The prevalence of HPV-CIN histological lesions in ASCUS patients was 36.3% and in LSIL patients was 67.7%. High grade CIN was observed in 15.7 and 20.8% respectively. In one ASCUS patients an invasive lesion was diagnosed on punch biopsy and two LSIL patients showed stromal invasion on the final histopathologic report on excised specimens.

CONCLUSIONS

Patients with ASCUS or LSIL pap smear exhibit a wide spectrum of histological findings ranging from no pathologic abnormality to frequent high grade CIN and invasive carcinoma in rare cases. Because of the histological assessment by directed-punch biopsy and its therapeutical indications, colposcopic examination is recommended for all women with a cytologic diagnosis of ASCUS and LSIL.

Prolonged survival after resection of pancreatoblastoma and synchronous liver metastases in an adult

Pancreatoblastoma is an uncommon pediatric neoplasm with distinct acinar and squamoid cell differentiation. Pancreatoblastoma is exceedingly rare in adults with only ten reported cases. Pancreatoblastoma in adults has a poor prognosis and no survival without recurrence exceeding 30 months has been reported. We report the first adult case of pancreatoblastoma revealed by gastric bleeding due to segmental hypertension. On computed tomography scan, the tumor appeared lobulated and extended from the splenic hilum to the portal vein. Two hypervascular centimetric hepatic metastases were observed in segments III and VII. The patient was operated and a distal pancreatectomy with splenectomy associated with two hepatic wedge resections was performed. The diagnosis of pancreatoblastoma was made on immunohistochemical examination. The patient received 6 cycles of adjuvant therapy. After three years of follow-up, the patient was well with no sign of recurrence on computed tomography scan. This case suggests that in the presence of pancreatic tumor of unknown origin, aggressive management including complete surgical resection and adjuvant chemotherapy should be attempted even in the presence of synchronous liver metastases.

Antimicrobial activity of Argentine plants used in the treatment of infectious diseases. Isolation of active compounds from Sebastiania brasiliensis

Different extracts of Sebastiania brasiliensis, Sebastiania klotszchiana, Polygonum punctatum, Lithraea molleoides and Myrcianthes cisplatensis, all plants growing in Entre Ríos Province and traditionally used as antiseptics, were tested against a set of Gram positive and Gram negative bacteria and fungi. All the species, with the exception of M. cisplatensis, presented activity against some of the microorganisms tested. A 50% hydroalcoholic extract of S. brasiliensis was selected for bioguided fractionation. Two antimicrobial compounds identified as methylgallate (MIC 128 microg/ml) and protocatechuic acid (MIC 128 microg/ml) were isolated apart from quercetin, kaempferol, quercitrin and gallic acid.

No evidence of somatic FGFR3 mutation in various types of carcinoma

Germline specific point mutations in the gene encoding fibroblast growth factor receptor 3 (FGFR3) are associated with autosomal dominant human skeletal dysplasia and craniosynostosis syndromes. Mutations identical to the germinal activating mutations found in severe skeletal dysplasias have been identified in certain types of cancer: at low frequency in multiple myeloma and cervix carcinoma and at high frequency in bladder carcinoma. We analysed, by SSCP and sequencing, the prevalence of FGFR3 mutations in 116 primary tumours of various types (upper aerodigestive tract, oesophagus, stomach, lung and skin). The regions analysed encompassed all FGFR3 point mutations previously described in severe skeletal dysplasia and cancers. No mutations were detected in the tumour types examined, suggesting that FGFR3 mutations are restricted to a few tumour types, the evidence to date suggesting that they are very specific to bladder carcinomas.

Surgical management of hepatic metastases from colorectal malignancies

Liver metastasis represents the major cause of death of patients who have been treated for colorectal adenocarcinoma. Spontaneous survival rarely exceeds two years. Surgery can offer long-term survival and resection should be considered when liver metastases can be totally resected with clear margins and when there is no non-resectable extra-hepatic disease. The choice between anatomical or wedge resection depends on the number and the location of the metastases but does not influence survival. Clamping methods limit blood loss. Operative mortality is generally less than 5%. The five-year survival rate after surgical resection varies from 20% to 45% according to several prognostic factors. The longer survival is observed in patients with fewer than four lesions, with lesions smaller than 4 cm, without extra-hepatic disease, with lesions that appeared more than two years after the resection of a stage I or II colorectal cancer and whose CEA level is normal. After resection, follow-up can detect hepatic recurrence that can be treated with repeat hepatectomy. The efficacy of systemic chemotherapy using new agents can increase the number of patients amenable to surgery. Regional therapies with cryotherapy or radiofrequency ablation can help to treat unresectable or non-totally resectable lesions and may improve survival. The effects on survival of adjuvant treatments, including pre- or postoperative systemic or postoperative intra-arterial chemotherapy, are currently under evaluation.

"Side" effects of HAART: decreasing and changing occupational exposure to HIV-infected patients

To investigate percutaneous exposures to HIV in the highly active antiretroviral therapy (HAART) era, we performed an analysis of all percutaneous exposures reported from January 1994 to December 1998 in 18 Italian acute-care hospitals. Frequency and rate per 100 prevalent AIDS cases of HIV exposures decreased by 40% (from 4.3% to 2.6%, and from 1.0% to 0.6%, respectively; p<0.001), which were mainly those related to the insertion/manipulation of peripheral vascular access devices (from 7.2% to 4.8%; p=0.05). We conclude that the benefits of HAART have changed the complexity of care required and therefore, the number and type of procedures performed on HIV patients that place the HCW at risk of injury.

Comparison between the effects of pentobarbital or ketamine/nitrous oxide anesthesia on metabolic and endothelial components of coronary reactive hyperemia

Barbiturates induce reduction of myocardial contractility and metabolism, whereas ketamine exerts a sympathomimetic effect that can mask its direct depressant effect on contractility. However, it is unclear whether barbiturates, which interfere with the cytochrome P-450 pathway, or ketamine, which inhibits nitric oxide synthesis, also alter the responsiveness of the coronary vessels to vasodilator stimuli. We hypothesized that the parameters of coronary reactive hyperemia (CRH), which reflect both the degree of myocardial metabolism and vascular reactivity, could be modified by the type of anesthesia used. In two groups of goats, anesthesia was induced either using ketamine plus nitrous oxide or pentobarbital alone. To record coronary flow an electromagnetic flow-probe was placed around the left circumflex coronary artery. In the ketamine group (n = 14) and in the pentobarbital group (n = 16) CRH was studied using the indices of myocardial metabolism and vascular dilator responsiveness. In the pentobarbital group all of the indices of myocardial metabolism were lower than in the ketamine group (i.e. the excess to debt flow ratio was 2.3+/-0.8 vs. 4.6+/-2.4; p< 0.001). Yet, some indices of vascular responsiveness (time derivative of coronary flow and the peak to basal flow ratio) were not different in the two groups. Moreover, the duration of the reactive hyperemia was shorter in the ketamine than in the pentobarbital group (118+/-47 vs. 153+/-45 s, p<0.05). It is suggested that pentobarbital decreases the indices of CRH related to metabolic activity, whereas ketamine reduces the duration of the hyperemic response, which suggests an impairment of endothelial function.

Cytochrome P-450 metabolite of arachidonic acid mediates bradykinin-induced negative inotropic effect

This study focused on the mechanisms of the negative inotropic response to bradykinin (BK) in isolated rat hearts perfused at constant flow. BK (100 nM) significantly reduced developed left ventricular pressure (LVP) and the maximal derivative of systolic LVP by 20-22%. The cytochrome P-450 (CYP) inhibitors 1-aminobenzotriazole (1 mM and 100 microM) or proadifen (5 microM) abolished the cardiodepression by BK, which was not affected by nitric oxide and cyclooxygenase inhibitors (35 microM NG-nitro-L-arginine methyl ester and 10 microM indomethacin, respectively). The CYP metabolite 14,15-epoxyeicosatrienoic acid (14,15-EET; 50 ng/ml) produced effects similar to those of BK in terms of the reduction in contractility. After the coronary endothelium was made dysfunctional by Triton X-100 (0.5 microl), the BK-induced negative inotropic effect was completely abolished, whereas the 14,15-EET-induced cardiodepression was not affected. In hearts with normal endothelium, after recovery from 14,15-EET effects, BK reduced developed LVP to a 35% greater extent than BK in the control. In conclusion, CYP inhibition or endothelial dysfunction prevents BK from causing cardiodepression, suggesting that, in the rat heart, endothelial CYP products mediate the negative inotropic effect of BK. One of these mediators appears to be 14,15-EET.

The seroepidemiology of varicella in Italy

We conducted a seroepidemiological study to evaluate the potential impact of mass varicella vaccination on the transmission of varicella-zoster virus (VZV) in Italy, where vaccination is not mandatory. We tested 3179 serum samples, collected from September 1996 to October 1997, for specific anti-VZV antibodies using a commercially available ELISA. The results confirmed that varicella typically involves children (82.1% seroprevalence among 10- to 14-year-olds) and that the mean age of acquiring the infection seems to be increasing. The results also revealed that southern Italy, compared to the rest of the country, has a greater circulation of VZV and an earlier age of acquisition. The potential impact of mass vaccination among 12- to 18-month-old children on the epidemiological trend of the infection must be carefully considered, in that failure to reach high levels of coverage could lead to an increase in the mean age of acquisition, which is already occurring in Italy.

Role of NO and PAF in the impairment of skeletal muscle contractility induced by TNF-alpha

The role of platelet-activating factor (PAF) and nitric oxide (NO) as mediators of the effects of tumor necrosis factor-alpha (TNF-alpha) on skeletal muscle contractility was studied in guinea pig extensor digitorum longus (EDL) muscle. TNF-alpha (5-10 ng/ml) reduced contractility at every stimulation frequency (1-200 Hz) and shifted the force-frequency relationship to the right. The role of NO and PAF as mediators of TNF-alpha was suggested by the protective effect of N(G)-nitro-L-arginine methyl ester (L-NAME; 1 mM), but not of N(G)-nitro-D-arginine methyl ester (D-NAME; 1 mM), and by the inhibitory effect of the PAF-receptor antagonist WEB-2170 (3 microM). TNF-alpha increased the production of PAF and NO. Similar to TNF-alpha, both S-nitroso-N-acetylpenicillamine (0.5-1 microM), an NO-generating compound, and PAF (10-20 nM) reduced EDL contractility. L-NAME, but not D-NAME, blocked the negative effect of PAF. Blockade of phospholipase A(2), which is required for PAF synthesis, significantly reduced the effects of TNF-alpha. WEB-2170 inhibited NO synthesis induced by TNF-alpha and PAF-stimulated NO production. These results suggest that both PAF and NO contribute to the development of the mechanical alterations induced by TNF-alpha and that NO production is downstream to the synthesis of PAF.

[Established data and practical recommendations concerning pre- and postoperative chemotherapy of rectal cancer]

Adjuvant chemotherapy appears to be active in stage II-III rectal cancers; the NSAPB R01 trial demonstrated a survival advantage for patients receiving chemotherapy using the MOF protocol and 3 meta-analyses are in favor of the efficacy of adjuvant chemotherapy in rectal cancer. Three randomized trials have also demonstrated that combinations of radiation and chemotherapy are superior to surgery alone or adjuvant radiotherapy and demonstrated the major role of systemic chemotherapy combined with radiotherapy. However this efficacy of adjuvant chemotherapy alone or combined with radiation therapy is still debated and specific trials must be conducted to test the value of chemotherapy using more active regimens than those previously tested and taking into account the quality of surgery and radiotherapy; such trials are in progress, especially the trial conducted by the EORTC and the FFCD. The efficacy of neoadjuvant chemotherapy has never been clearly demonstrated, although a combination of radiotherapy and chemotherapy as first-line treatment for locally advanced rectal cancer and in the case of synchronous metastasis seems to facilitate surgical resection. It is a reasonable and tolerable approach with manageable toxicity which gives substantial results in 2/3 of patients. This strategy also allows better selection of patients likely to benefit from surgical resection of their primary tumor and in some cases of their synchronous metastases. However, the efficacy of perioperative treatments should not decrease the quality of the surgical resection and especially mesorectal excision as well as the need for high quality pathological examination which must be very thorough with analysis of a sufficient number of lymph nodes. The efficacy of combined treatment in advanced rectal cancers is a major argument in favor of the multidisciplinary coordination required for optimal treatment of patients with rectal cancer.

Pattern of susceptibility to measles in Italy. Serological Study Group

On the basis of seroprevalence and incidence data we describe the distribution of individuals susceptible and immune to measles in Italy in 1996-97. In regions where vaccination coverage was at least 70%, approximately 10% of 3-year-old children were susceptible to measles, whereas 40% were in this category in regions with lower vaccination coverage. Seroprevalence among children older than 4 years was similar for the two groups of regions; in the age group 20-39 years it was approximately 95%. During 1990-96 in the regions with lower vaccination coverage the incidence was highest among children aged 4-6 years, and the median age of cases was 7 years; in the regions with higher vaccination coverage, however, the incidence remained at around 5% for the age group 4-16 years, and the overall median age was 10 years. These data confirm the partial reduction in measles incidence in Italy, although transmission has still not been interrupted. The size and geographical distribution of the current pool of susceptible individuals can be expected to present an obstacle to measles elimination if appropriate vaccination strategies, such as catch-up campaigns, are not adopted.

Restorative proctocolectomy for distal ulcerative colitis

BACKGROUND

Chronic distal colitis may cause troublesome symptoms and alter quality of life. When medical treatment fails to control symptoms, patients and doctors are often reluctant to consider surgical resection because of the relatively small portion of the large bowel affected by the disease.

AIM

To assess the outcome of restorative proctocolectomy (RP) in patients with distal colitis who required surgery for chronic debilitating symptoms and failed medical management.

PATIENTS/METHODS

From 1986 to 1996, of 263 patients receiving RP for ulcerative colitis, 27 (16 men) were operated on for distal ulcerative colitis limited to the rectum and sigmoid colon. Bowel function and quality of life were compared before and one year after RP.

RESULTS

The mean (SD) duration of ulcerative colitis was 11 (6) years. RP was performed at a mean age of 46 (10) years. All the pouches were J-shaped, and a diverting loop ileostomy was always performed. Mean (SD) hospital stay was 25 (10) days. Seven complications occurred in six patients. Previously unknown severe dysplasia was discovered on the colectomy specimen in two patients. After RP there was a significant decrease in mean (SD) daytime stool frequency (8.2 (4) v 4.7 (2), p<0.05), night-time stool frequency (2 (2) v 1 (1), p = 0.05), and the number of patients with urgency to defecate (26/27 v 1/27, p<0.001). Sex life was improved in eight patients, social life in 26, and professional life in eight. Twenty six patients were satisfied with the results, and 25 wished that they had received surgery earlier in the course of their disease.

CONCLUSION

RP can improve bowel function and quality of life in patients with disabling chronic symptoms of distal ulcerative colitis.

The effects of ischemic preconditioning on resting coronary flow and reactive hyperemia: involvement of A1 adenosine receptors

During the myocardial protection induced by ischemic preconditioning a reduction in myocardial metabolism occurs due to activation of the A1 adenosine receptors. This study investigates whether preconditioning changes both resting coronary flow and the magnitude of coronary reactive hyperemia and whether A1 adenosine receptors are involved in the observed changes. Experiments were performed in 14 goats (30-50 kg body weight). After the animals were anesthetized with ketamine, an electromagnetic flow-probe was used to record blood flow in the left circumflex coronary artery. Distal to the probe, an occluder was placed to produce ischemic preconditioning and reactive hyperemia. Preconditioning was obtained with two periods of 2.5 min of coronary occlusion separated from each other by 5 min of reperfusion. Coronary reactive hyperemia was obtained with 15 s of occlusion of the artery before and after preconditioning. In a group of goats before preconditioning 0.2 mg kg(-1) of 8-cyclopentyl-dipropylxanthine (CPX), an A1 adenosine receptor blocker, were given intravenously. In all animals ischemic preconditioning did not alter resting coronary flow, but, in the absence of A1 adenosine receptor blockade, reduced the reactive hyperemic response. The total hyperemic flow and the excess/debt flow ratio were reduced by about 25% and 30% respectively. The A1 adenosine receptor blockade "per se" did not cause any change in the resting flow and in the parameters of the reactive hyperemia. Unlike what observed in the absence of blockade, after CPX ischemic preconditioning was unable to reduce total hyperemic flow and the excess/debt flow ratio. The results suggest that ischemic preconditioning reduces the coronary hyperemic response by decreasing the myocardial metabolism through the activation of the A1 adenosine receptors.

Role of nitric oxide and platelet-activating factor in cardiac alterations induced by tumor necrosis factor-alpha in the guinea-pig papillary muscle

OBJECTIVE

Tumor necrosis factor-alpha (TNF-alpha), a proinflammatory cytokine with negative inotropic properties, is implicated in several pathophysiological events. To clarify the mechanism of action of TNF-alpha on myocardium, we investigated the possible role of platelet-activating factor (PAF) and nitric oxide (NO) as secondary mediators of the depressant effect of this cytokine.

METHODS

Isometric twitches and intracellular action potentials were recorded from guinea pig papillary muscles. The effects of TNF-alpha (1-10 ng/ml) were studied in controlled conditions and after treatment with 0.5% Triton X-100, to destroy the endocardial endothelium NG-nitro-L-arginine methyl ester (L-NAME), D-NAME (1 mM) and the two different PAF-receptor antagonists WEB 2170 (3 microM) and CV 3988 (5 microM) were used to study the role of NO and PAF in cardiac depression induced by TNF-alpha. To study the role of NO in cardiac alterations induced by PAF, papillary muscles were pretreated with L-NAME or D-NAME and then challenged with PAF (0.1-1 microM). Nitrite production by papillary muscles challenged with TNF-alpha alone. TNF-alpha in the presence of WEB 2170 or CV 3988, or PAF was studied with the Greiss reagent method. PAF production by papillary muscles stimulated by TNF-alpha was studied by a bioassay method.

RESULTS

TNF-alpha induced an initial, transient positive inotropic effect, then reduced the contractility and the action potential duration in a concentration-dependent manner. Treatment of papillary muscle with Triton X-100 did not modify the response to TNF-alpha, suggesting that the effect of TNF-alpha is not mediated by endocardial endothelial cells. Pretreatment with indomethacin reduced the negative effect of TNF-alpha, while propranolol abolished the initial increase of contractility. The role of PAF and NO as mediators of TNF-alpha was suggested by: (1) the protective effect of L-NAME, but not of D-NAME, on electrical and mechanical alterations; (2) the stimulatory effect of TNF-alpha on nitrite production; (3) the inhibitory effect of WEB 2170 and CV 3988, on both the electromechanical alterations and the nitrite production; (4) the synthesis of PAF induced by TNF-alpha. L-NAME blocked the negative effect of PAF and PAF enhanced nitrite production by papillary muscle.

CONCLUSIONS

The present results suggest that in cardiac muscle: (1) the release of PAF triggered by TNF-alpha may account for the stimulation of NO production; (2) both PAF and NO contribute to the development of the electrical and mechanical alterations induced by TNF-alpha; (3) NO production was down-stream to the synthesis of PAF.

Mycobacterium paratuberculosis and Mycobacterium avium subsp. silvaticum DNA cannot be detected by PCR in Crohn's disease tissue

BACKGROUND

The etiology of Crohn's disease remains unknown. A putative mycobacterial cause of the disease is still controversial.

AIMS

To assess the mycobacterial hypothesis in Crohn's disease using a polymerase chain reaction technique.

PATIENTS AND METHODS

Nested polymerase chain reaction with primers on the 16S-rRNA coding region (16S-rDNA) and with primers specific both to the insertion sequences (IS) 900, and IS 901/902 were used to amplify Mycobacterium paratuberculosis or Mycobacterium avium subsp. silvaticum DNA in frozen endoscopic intestinal biopsies or surgical resection specimens from patients with Crohn's disease (n = 47: 25 endoscopic biopsies and 22 surgical resection samples, +/- lymph nodes), ulcerative colitis (n = 27), and non inflammatory bowel diseases (n = 20: colonic tumors and diverticulitis). Positive as well as negative controls were used throughout the study.

RESULTS

All strains of Mycobacterium paratuberculosis and Mycobacterium avium subsp. silvaticum tested were positive for both primer systems. Of the 94 biopsies tested, 5 (2 Crohn's disease, 1 ulcerative colitis and 2 controls) were positive with the 16S-rDNA primers but did not correspond to Mycobacterium paratuberculosis or Mycobacterium avium subsp. silvaticum. None of the specimens was positive with the IS primers.

CONCLUSION

These results do not support the hypothesis that Mycobacterium paratuberculosis, or Mycobacterium avium subsp. silvaticum play a role in Crohn's disease.

Surgical treatment of severe duodenal polyposis in familial adenomatous polyposis

BACKGROUND

Patients with familial adenomatous polyposis (FAP) are at risk for adenomas and cancers in the duodenum but the ideal management of duodenal polyposis remains uncertain.

METHODS

The outcome of surgical resection was analysed in 18 patients with FAP who had severe duodenal polyposis.

RESULTS

Duodenotomy and clearance of duodenal adenomas was performed seven times in six patients. There were two duodenal leaks and, after a mean follow-up of 53 (range 36-72) months, duodenal adenomas recurred in all patients and five had severe polyposis. Pancreatoduodenectomy was performed in seven patients with severe duodenal polyposis. Histology of the specimens revealed two unsuspected duodenal carcinomas at an early stage. After a mean follow-up of 42 months all patients were alive and well, and there was no case of jejunal polyposis. Pancreatoduodenectomy was attempted in five patients with duodenal cancer and only one survived more than 4 years.

CONCLUSION

Surgical excision of duodenal adenomas should be discussed before carcinoma occurs. Surgical polypectomy fails to guarantee a polyp-free duodenum and carries a risk of postoperative complications whereas pancreatoduodenectomy eliminates the risk of duodenal cancer with an acceptable morbidity rate. Pancreatoduodenectomy could be offered to some patients with large or multiple villous duodenal adenomas repeatedly showing severe dysplasia.

Modulation of guinea-pig cardiac L-type calcium current by nitric oxide synthase inhibitors

1. Electrophysiological (whole-cell clamp) techniques were used to study the effect of NO synthase (NOS) inhibitors on guinea-pig ventricular calcium current (ICa), and biochemical measurements (Western blot and citrulline synthesis) were made to investigate the possible mechanisms of action. 2. The two NOS inhibitors, NG-monomethyl-L-arginine (L-NMMA, 1 mM) and NG-nitro-L-arginine (L-NNA, 1 mM), induced a rapid increase in ICa when applied to the external solution. D-NMMA (1 mM), the stereoisomer of L-NMMA, which has no effect on NOS, did not enhance ICa. 3. Western blot experiments gave no indication of the presence of inducible NOS protein (iNOS) in our cell preparation, neither immediately after dissociation nor after more than 24 h. Statistically, there was no significant difference between electrophysiological experiments performed on freshly dissociated cells and experiments performed the next day. Moreover cells prepared and kept in the presence of dexamethasone (3 microM), to inhibit the expression of iNOS, gave the same response to L-NMMA as control cells. 4. The stimulatory effect of L-NMMA (1 mM) on basal ICa was reversed by competition with higher doses (5 mM) of externally applied L-arginine, the natural substrate of NOS. The effect of L-NMMA was also eliminated by L-arginine in the patch pipette solution. 5. Intracellular perfusion with GDP beta S (0.5 mM), which stabilizes the G-proteins in the inactive state, did not affect the L-NMMA-induced stimulation of ICa. 6. Carbachol (1 microM) reduced the ICa previously stimulated by L-NMMA, and intracellular cGMP (10 microM) prevented L-NMMA enhancement. 7. Simultaneous treatment with L-NMMA and isoprenaline (1 microM) induced a non-cumulative enhancement of ICa that could not be reversed by carbachol (1 microM). 8. NO synthesis, measured by the formation of [3H]citrulline from L-[3H]arginine during a 15 min incubation, showed a relatively high basal NO production, which was inhibited by L-NMMA but not affected by carbachol. 9. These results suggest that inhibitors of NOS are able to modulate the basal ventricular ICa in the absence of a receptor-mediated pathway, and that NO might be required for the muscarinic reduction of ICa under isoprenaline stimulation, even if NO production is not directly controlled by the muscarinic pathway.

Differential effects of paclitaxel and derivatives on guinea pig isolated heart and papillary muscle

Paclitaxel (Taxol) is an anticancer agent with clinical activity against various human cancer types. Paclitaxel blocks cell division by stabilizing microtubules, a mechanism that also underlies its major side effects (neutropenia and neurotoxicity). Paclitaxel can also alter cardiac function, and to elucidate the mechanism of this activity, we tested the mechanical and electrical effects of paclitaxel and a series of analogs (docetaxel, taxol B, taxol C and N-methyltaxol C; 5-20 microM) on two different cardiac preparations, the isolated coronary perfused heart and the papillary muscle of the guinea pig. Paclitaxel and N-methyltaxol C induced conduction arrhythmias and reduced coronary flow and left ventricular systolic pressure in the isolated heart, whereas the other taxol derivatives tested had no significant effect. Moreover, paclitaxel blocked the vasodilator effect of bradykinin in the isolated heart. Paclitaxel and N-methyltaxol C produced a positive inotropic effect in papillary muscle, without alterations in the action potential. In the latter preparation, no significant variations were observed after treatment with the other taxol derivatives. The in vitro cardiodepressant and arrhythmogenic activity of paclitaxel is similar to that reported after its clinical administration and might be due to coronary vasoconstriction. The precise role of microtubules as modulators of intracellular calcium in cardiac and smooth muscle cells is at present unclear, because docetaxel and other taxol analogs, though they exhibited similar activity on tubulin, lacked cardiac effects.

[Colorectal cavernous hemangiomatosis treated by total coloproctectomy and ileo-anal anastomosis]

A diffuse cavernous hemangioma of the colon and rectum was made in a 20-year-old man. Treatment consisted of total colectomy with ileorectostomy. A proctectomy was mandatory four years later because of massive rectal bleeding. A sphincter-saving operation was possible and bowel continuity was restored with an ileal "J" pouch-anal anastomosis. Cavernous hemangioma generally affects the rectosigmoid and colo-anal sleeve anastomosis is the treatment of choice. When cavernous hemangioma affects the colon and rectum or when the colon has been removed for an other reason, an ileo-anal anastomosis, although technically difficult, can be performed in order to prevent recurrent bleeding while preserving continence and allowing acceptable bowel function.

Femorodistal bypass using cryopreserved venous allografts for limb salvage

Critical ischemia due to extensive femoropopliteal occlusive disease often leads to amputation in patients in whom an autologous vein is unavailable for reconstruction. The purpose of this nonrandomized prospective study is to evaluate the usefulness of cryopreserved venous allografts (CPVA) as an arterial substitute in these cases. Between October 1990 and March 1993, long bypass to a tibial or a foot artery using a CPVA was performed in 25 consecutive patients with ulcerations or gangrene. There were 19 women and six men with a mean age of 72 years (range: 51-90). The indication for allograft reconstruction was absence (17 cases) or unsuitability (eight cases) of an autologous vein graft. Greater saphenous vein allografts were harvested from multiple organ donors and frozen at -80 degrees C with 12% dimethylsulfoxide (DMSO). Sixteen patients had undergone one or more previous unsuccessful limb salvage attempts. The plantar arch was absent or incomplete in 16 patients (64%). Patients were followed up prospectively for a mean of 21 months (range: 3-32). One patient died early (32 days) and three patients died late with patent bypasses. Cumulative survival rate was 77% at 1 year and 72% at 2 years. Cumulative secondary patency rate (Kaplan-Meier) was 88% at 1 months, 72% at 6 months, and 52% at 1 year. The cumulative limb salvage rate was 78% at 2 years. When an autologous vein is unavailable, long bypass using a CPVA is a simple, quick, minimally traumatic, economical, and effective method to achieve limb salvage in patients with severe distal arterial occlusive disease. However, CPVA causes immunoreaction and there is a risk of proximal postanastomotic stenosis. Doppler ultrasound surveillance of a subcutaneous graft allows accurate assessment and repair of the abnormalities with no increase in mortality or morbidity.