St John's wort, a herbal antidepressant, activates the steroid X receptor

St John's wort (SJW), an extract of the medicinal plant Hypericum perforatum, is widely used as a herbal antidepressant. Recently, this agent has been found to adversely affect the metabolism of various coadministered drugs. Steroid X receptor (SXR), an orphan nuclear receptor, induces hepatic cytochrome P450 gene expression in response to diverse endogenous steroids, xenobiotics and drugs. Here, we report that, when coexpressed with SXR, a reporter construct derived from the cytochrome P450 3A promoter is activated by St John's wort. A GAL4-SXR ligand binding domain (LBD) fusion mediates concentration-dependent transactivation by SJW, whereas a mutant GAL4-SXR fusion, containing substitutions in key residues in a transactivation domain, is inactive. SJW recruits steroid receptor coactivator-1 to SXR in a two-hybrid assay and competes with radiolabelled ligand in binding studies, suggesting it interacts directly with the receptor LBD. Of two constituents of SJW, we find that hyperforin, but not hypericin, mediates both transactivation and coactivator recruitment by SXR. Our observations suggest that SXR activation by St John's wort mediates its adverse interaction with drugs metabolised via the CYP 3A pathway. Future development of SJW derivatives lacking SXR activation, may enable its antidepressant and drug-metabolising properties to be dissociated.

Effect of interleukin-2 on generation of natural killer cells: role of major histocompatibility complex class I in B6 and TAP-1-/- mice

Long-term bone marrow cultures were used to investigate the effect of IL-2, a cytokine widely used in immunotherapy, on natural killer cell differentiation. Specifically, the role of MHC was evaluated by comparing normal B6 and class I-deficient TAP-1-/- mice. The number of cells generated after a 13-day culture was the same in cell cultures from TAP-1-/- or B6 mice but the relative number of natural killer cells, identified as NK-1.1+CD3- cells by flow cytometry analysis, was increased in TAP-1-/- compared to B6 cultures (74.4% and 63.9%, respectively). Addition of an anti-class I mAb determined a strong inhibition of natural killer cell generation in B6 cultures, and its effect was specific since no effect was seen in TAP-1-/- cell cultures. TAP-1-/- natural killer cells or the few natural killer cells escaping the inhibitory effect of anti-class I mAb, were less cytotoxic than total B6 natural killer cells against target cell lines of different haplotype.

Simple and complicated acute appendicitis. Indications for a correct diagnosis

BACKGROUND

In this retrospective investigation the symptoms, signs, and laboratory findings collected in 2 groups of patients with simple and complicated acute appendicitis, respectively, have been observed in order to give some indication for a correct diagnosis and surgical treatment.

METHODS

A total of 103 consecutive patients affected by simple and complicated acute appendicitis submitted to surgical operation have been studied.

RESULTS

Data collected show statistically significant differences between clinical presentation of simple and complicated acute appendicitis.

CONCLUSIONS

The conclusion is draws in that anamnesis and clinical examination of the patients affected by acute appendicitis are the best indications for an exact diagnosis and to select patients who need an immediate operation.

A dominant-negative peroxisome proliferator-activated receptor gamma (PPARgamma) mutant is a constitutive repressor and inhibits PPARgamma-mediated adipogenesis

The nuclear receptor peroxisome proliferator-activated receptor gamma (PPARgamma) promotes adipocyte differentiation, exerts atherogenic and anti-inflammatory effects in monocyte/macrophages, and is believed to mediate the insulin-sensitizing action of antidiabetic thiazolidinedione ligands. As no complete PPARgamma antagonists have been described hitherto, we have constructed a dominant-negative mutant receptor to inhibit wild-type PPARgamma action. Highly conserved hydrophobic and charged residues (Leu(468) and Glu(471)) in helix 12 of the ligand-binding domain were mutated to alanine. This compound PPARgamma mutant retains ligand and DNA binding, but exhibits markedly reduced transactivation due to impaired coactivator (cAMP-response element-binding protein-binding protein and steroid receptor coactivator-1) recruitment. Unexpectedly, the mutant receptor silences basal gene transcription, recruits corepressors (the silencing mediator of retinoid and thyroid receptors and the nuclear corepressor) more avidly than wild-type PPARgamma, and exhibits delayed ligand-dependent corepressor release. It is a powerful dominant-negative inhibitor of cotransfected wild-type receptor action. Furthermore, when expressed in primary human preadipocytes using a recombinant adenovirus, this PPARgamma mutant blocks thiazolidinedione-induced differentiation, providing direct evidence that PPARgamma mediates adipogenesis. Our observations suggest that, as in other mutant nuclear receptor contexts (acute promyelocytic leukemia, resistance to thyroid hormone), dominant-negative inhibition by PPARgamma is linked to aberrant corepressor interaction. Adenoviral expression of this mutant receptor is a valuable means to antagonize PPARgamma signaling.

Dominant negative mutations in human PPARgamma associated with severe insulin resistance, diabetes mellitus and hypertension

Thiazolidinediones are a new class of antidiabetic agent that improve insulin sensitivity and reduce plasma glucose and blood pressure in subjects with type 2 diabetes. Although these agents can bind and activate an orphan nuclear receptor, peroxisome proliferator-activated receptor gamma (PPARgamma), there is no direct evidence to conclusively implicate this receptor in the regulation of mammalian glucose homeostasis. Here we report two different heterozygous mutations in the ligand-binding domain of PPARgamma in three subjects with severe insulin resistance. In the PPARgamma crystal structure, the mutations destabilize helix 12 which mediates transactivation. Consistent with this, both receptor mutants are markedly transcriptionally impaired and, moreover, are able to inhibit the action of coexpressed wild-type PPARgamma in a dominant negative manner. In addition to insulin resistance, all three subjects developed type 2 diabetes mellitus and hypertension at an unusually early age. Our findings represent the first germline loss-of-function mutations in PPARgamma and provide compelling genetic evidence that this receptor is important in the control of insulin sensitivity, glucose homeostasis and blood pressure in man.

Three novel mutations at serine 314 in the thyroid hormone beta receptor differentially impair ligand binding in the syndrome of resistance to thyroid hormone

The syndrome of resistance to thyroid hormone is associated with diverse mutations in the ligand-binding domain of the thyroid hormone beta receptor, localizing to three clusters around the hormone binding cavity. Here, we report three novel resistance to thyroid hormone mutations (S314C, S314F, and S314Y), due to different nucleotide substitutions in the same codon, occurring in six separate families. Functional characterization of these mutant receptors showed marked differences in their properties. S314F and S314Y receptor mutants exhibited significant transcriptional impairment in keeping with negligible ligand binding and were potent dominant negative inhibitors of wild-type receptor action. In contrast, the S314C mutant bound ligand with reduced affinity, such that its functional impairment and dominant negative activity manifest at low concentrations of thyroid hormone, but are more reversible at higher T3 concentrations. The degree of functional impairment of mutant receptors in vitro may correlate with the magnitude of thyroid dysfunction in vivo. Modelling these mutations using the crystal structure of thyroid hormone receptor beta shows why ligand binding is perturbed and why the phenylalanine/tyrosine mutations are more deleterious than cysteine.

Attitudes of Italian doctors to euthanasia and assisted suicide for terminally ill patients

Among Italian hospital physicians and general practitioners, 17.9% endorsed euthanasia or assisted suicide for terminally ill patients and 79.4% endorsed withholding or withdrawal of treatment. Need for attention to quality of life and pain control also emerged.

Cloning and expression of a short Fas ligand: A new alternatively spliced product of the mouse Fas ligand gene

The Fas/FasL system mediates apoptosis in several different cell types, including T lymphocytes. Fas ligand (FasL), a 40-kD type II membrane protein also expressed in activated T cells, belongs to the tumor necrosis factor ligand family. We describe a new alternative splicing of mouse FasL, named FasL short (FasLs), cloned by reverse transcriptase-polymerase chain reaction. FasLs is encoded by part of exon 1 and part of exon 4 of FasL gene. The protein encoded by FasLs mRNA has a putative initiation code at position 756 and preserves the same reading frame as FasL, resulting in a short molecule lacking the intracellular, the transmembrane, and part of the extracellular domains. RNase protection and immunoprecipitation analysis showed that FasLs is expressed in nonactivated normal spleen cells and in hybridoma T cells and that it is upregulated upon activation by anti-CD3 monoclonal antibody (MoAb). Moreover, FasLs-transfected cells expressed soluble FasLs in the supernatant and became resistant to apoptosis induced by agonist anti-Fas MoAb. Thus, FasLs, a new alternative splicing of FasL, is involved in the regulation of Fas/FasL-mediated cell death.

Cisternography in combination with single photon emission tomography for the detection of the leakage site in patients with cerebrospinal fluid rhinorrhea: preliminary report

The site of leakage in a patients with rhinorrhea of various origin may be difficult to identify. The aim of our paper is to evaluate the contribution of cisternography in combination with single photon emission tomography (SPECT) to identify the fistulous track. From 1/1/1992 to 30/11/1997 we studied 20 patients with rhinorrhea posing a challenging diagnostic problem as to identification of the leakage site. Two mls of Indium DTPA (In 111) were injected into the subarachnoid space by the lumbar route. The tracer was followed by planar scintigraphy until it reached the cranial base and subsequently the SPECT acquisition started. A fistula was demonstrated in all of our cases including patients with no active leakage at the time of examination, patients with no bone defects on thin sliced CT scanning or patients with a normal MRI. At surgery the fistulous track was confirmed in all but two cases when a bilateral fistula was operatively identified only on one side. In conclusion whenever a CT scanning fails to demonstrate significant bone defects and MRI does not localize a fistulous track, SPECT cisternography via the lumbar route proved in our experience to be a reliable examination for a precise diagnosis.

A role for helix 3 of the TRbeta ligand-binding domain in coactivator recruitment identified by characterization of a third cluster of mutations in resistance to thyroid hormone

Resistance to thyroid hormone (RTH) has hitherto been associated with thyroid hormone beta receptor (TRbeta) mutations which cluster in two regions (alphaalpha 310-353 and alphaalpha 429-461) of the hormone-binding domain and closely approximate the ligand-binding cavity. Here, we describe a third cluster of RTH mutations extending from alphaalpha 234-282 which constitute a third boundary of the ligand pocket. One mutant, T277A, exhibits impaired transactivation which is disproportionate to its mildly reduced ligand affinity (Ka). T3-dependent recruitment of coactivators (SRC-1, ACTR) by mutant receptor-RXR heterodimers was reduced in comparison with wild-type. Cotransfection of SRC-1 restored transactivation by T277A. In the TRbeta crystal structure this helix 3 residue is surface-exposed and is in close proximity to residues L454 and E457 in helix 12 which are known to be critical for coactivator interaction, suggesting that they all constitute part of a receptor-coactivator interface. The transcriptional function of other mutants (A234T, R243W/Q, A268D, Delta276I, A279V, R282S) in this cluster correlated with their reduced Ka and they inhibited wild-type TRbeta action in a dominant negative manner. DNA binding, heterodimerization and corepressor recruitment were preserved in all mutants, signifying the importance of these attributes for dominant negative activity and correlating with the absence of natural mutations in regions bordering the third cluster which mediate these functions.

Detection of a new de novo mutation at codon 251 of exon 8 of thyroid hormone receptor beta gene in an Italian kindred with resistance to thyroid hormone

Resistance to thyroid hormone (RTH) is almost invariably associated with mutations of the thyroid hormone (TH) receptor beta (hTR beta) gene and is inherited as an autosomal dominant disease. Mutations of hTR beta identified in patients affected by RTH cluster generally at two spots of the ligand binding domain. We investigated whether an Italian kindred with RTH had a mutation in the thyroid hormone (TH) receptor beta gene. Blood samples were obtained from the available family members for biochemical and genetic analyses. Thyroid function tests in basal conditions, and in the case of the propositus also following incremental doses of T3, were performed. Exon 4 to 10 of hTR beta gene were amplified using the polymerase chain reaction (PCR) and the mutation was identified by direct sequence analysis. The affinity constant of this mutated receptor for T3 was measured by in vitro transcription-translation and was then compared with that of wild type. We identified a heterozygous G to A transition at nucleotide 1037 of exon 8 at codon 251, resulting in a glycine (G) to glutamic acid (E) substitution (G251E) in the patient affected by RTH and in his affected offspring, but not in the normal family members. This novel mutation represents a de novo mutation since both parents of the index case were unaffected and did not have this genomic mutation. When expressed in vitro, the mutant protein (G251E) showed a marked decrease of the affinity for T3, suggesting an impaired ligand-dependent transactivation activity of this mutant receptor. In vivo studies with incremental doses of L-T3 demonstrated a reduced sensitivity to TH in the index case, in particular at the pituitary level where the thyrotrophs' activity was not completely inhibited even by 200 micrograms/day of L-T3. G251E mutation represents the fourth mutation described up to now in exon 8 of hTR beta among the subjects affected by RTH. A third cluster of mutations of the c-erbA beta gene located proximally with respect to the other two so far described begins to emerge in RTH patients.

[A case of a urachal fistula]

The authors report a case of urachal fistula diagnosed after repeated omphalitis, this disease was associated with coronal hypospadias. Diagnosis was done thanks to a fistulography; subsequently, during the operation, to evidence the fistula, this was injected with methylene blue, this expedient showed that the fistula was longer than that disclosed from fistulography. To carry out a complete extirpation of the fistula the authors were bound to make a cystotomy. The course after operation was good and the patient discharged after a few days. After 5 years the patient is in perfect health. This case allowed some anatomic, clinical and semeiotic considerations.

Identification and characterization of a novel de novo mutation (L346V) in the thyroid hormone receptor beta gene in a family with generalized thyroid hormone resistance

We have investigated an Italian family with generalized resistance to thyroid hormone (RTH), consisting of two individuals with elevated serum thyroid hormones (TH) and a non-suppressed TSH, together with unaffected family members, for a mutation in the thyroid hormone receptor beta gene (hTR beta). We have identified a single nucleotide substitution (1321 CTT to GTT) corresponding to a leucine to valine substitution at codon 346 (L346V) in the predicted protein. The index case and her affected child are heterozygous for the receptor defect, with normal sequence in unaffected family members. Furthermore, both parents of the index case were unaffected, suggesting that the mutation had arisen de novo. When expressed in vitro, the L346V mutant receptor showed a marked reduction in its affinity for tri-iodothyronine (T3), impaired ligand-dependent transactivation and potent dominant negative activity. Its functional impairment could not be alleviated, even at supraphysiological concentrations of T3, suggesting that the mutation might interfere with the intrinsic ligand-dependent transactivation function (AF-2) located in the hormone binding domain of hTR beta. Finally, the presence of the L346V mutation in the son of the propositus, who died from complications associated with congenital heart disease, raises the possibility that RTH might have contributed to the pathogenesis or severity of the latter.

Prognostic value of persistent thallium-201 defects that become reversible after reinjection in patients with chronic myocardial infarction

BACKGROUND

The presence of defects at stress-redistribution thallium-201 scintigraphy is related to a higher risk of cardiac events. However, the prognostic value of defects that become reversible after reinjection is not known. In this study we evaluated the prognostic contribution of stress-redistribution-reinjection with special regard to 3-hour fixed defects that become reversible after reinjection.

METHODS AND RESULTS

We studied 122 patients with chronic myocardial infarction (>2 months) and suspected or known residual ischemia, with stress-redistribution-reinjection planar scintigraphy. Thallium scans were analyzed by three observers (three segments per view, 5-point score) and classified as normal, fixed, and reversible. The lung/heart ratio was also calculated. At a median follow-up of 47 months, 10 patients had hard events (four deaths and six myocardial infarctions) (group I), 12 patients had unstable angina (group II), 12 patients underwent planned coronary artery bypass grafting or percutaneous transluminal coronary angioplasty (group III), and 86 patients had no events (group IV). The presence of fixed defects that became reversible after reinjection did not identify patients at higher risk. The number of reversible defects at 3 hours was significantly higher only in patients who underwent revascularization. Unstable angina was not predicted by any scintigraphic pattern. The variables that were statistically related to hard events by univariate analysis were increased lung uptake, reversible cavity dilation, and the number of fixed defects that remained fixed after reinjection. By Cox multivariate analysis, the strongest predictor of hard events was the presence of more than three fixed defects that remained fixed after reinjection as a marker of irreversible myocardial damage.

CONCLUSIONS

(201)Tl reinjection is a useful approach for not only detecting viable myocardium but also risk stratification in patients with chronic myocardial infarction.

[Nursing aspects in men with urinary catheters at the Nursing Service of the District of Trento]

The whole male population with indwelling catheter of the Trento health district has been included in a survey of the quality of the home nursing services. The epidemiological and in depth analysis of the characteristics and motivation of the high degree of heterogeneity of medical prescribing behaviors and of the nursing practices suggest that an important effort of rationalization (on the basis of pre adopted protocols) is both needed and possible.

The association between rhabdomyolysis and acute renal failure in patients undergoing cardiopulmonary bypass

OBJECTIVE

The authors describe 9 cases of rhabdomyolytic acute renal failure (ARF) as a complication of cardiopulmonary bypass.

EXPERIMENTAL DESIGN

Retrospective research between June 1992 and March 1994.

SETTING

Department of Cardiac Surgery.

PATIENTS

931 consecutive patients undergoing major cardiac surgery.

INTERVENTIONS

Patients affected by rhabdomyolytic ARF were treated with pharmacological therapy and/or plasmapheresis/continuous arteriovenous hemofiltration. In seven patients indirect cannulation of the femoral artery was used.

MEASURES

Incidence, risk factors of syndrome results obtained with pharmacological treatment, CAVH and plasmapheresis were evaluated. Statistical analysis was performed with ANOVA, Tukey Kramer test and chi2 test (p<0.05 as significant).

RESULTS

The syndrome occurred in 0.96% (9/931 patients) of the total cases; 11.3% (6/53 -p<0.0000) in patients undergoing a direct femoral artery cannulation for cardiopulmonary bypass and 9.5% (2/21, p<0.01) in patients in which the aortic balloon pump was used. Six patients develop acute anuric renal failure and underwent plasma exchange and hemodialysis (1 case) or CAVH (5 cases); 3 patients underwent early medical treatment and developed developed acute renal failure (ARF) with preserved diuresis. Early medical therapy appeared to prevent the evolution towards anuric ARF. The indirect cannulation of the femoral artery does not seem to produce a rhabdomyolytic ARF syndrome. In patients with direct femoral artery cannulation risk factors appear to be: arteriopathy (p<0.001), prolonged extra corporeal circulation (p<0.001), low cardiac output syndrome (p<0.001), continuous i.v. infusion of epinephrine (p<0.0001).

CONCLUSIONS

Rhabdomyolytic acute renal failure is a severe complication, early identification of patients ¿at risk¿ is most important. The preventive measures and the therapy adopted proved efficient.

[Traumatic rupture of the chordae tendineae in acute tricuspid insufficiency. Early detection with transesophageal echocardiography]

An uncommon case of traumatic rupture of chordae tendineae with tricuspid regurgitation is described. The early diagnosis, in a patient with polydistrectual injuries, was done by transesophageal echocardiography. This technique allowed accurate diagnosis of the type of lesion suggesting the opportunity to perform an echocardiogram, possibly transesophageal, in all patients with blunt thoracic trauma, even in the absence or with subtle clinical manifestations of cardiovascular involvement.

[Predictive value of the shunt-to-infarct size ratio as a surgical risk factor in patients with decompensated post-ischemic interventricular septal rupture]

Postischemic septal rupture has always been evaluated, in respect of surgical indication, as regards the time lapse between infarct and rupture, interval between rupture and operation, extension of myocardial damage and general risk factors such as age, sex and associated pathologies. But in fact the surgeon is dealing with a two sided problem, the MI and the rupture, and thus surgical results depend upon both the residual ventricular function after MI and the consequences of volume overload on a damaged muscle. Surgical indication could not be based on a single criterion only. Extension of the MI alone is not fully predictive of operative mortality because, aside the reperfusion injury, the repair further jeopardizes viable myocardium and alters ventricular geometry; although the shunt appears unrelated to mortality it certainly interferes with operative outcome at least because of the time elapsed between rupture and repair. So far an index which could correlate the extension of myocardial damage and the entity of the shunt with each other was not available. Patients with septal rupture follow an emergency protocol and are often insufficiently investigated but every patients has a least one echo-Doppler evaluation or even a ventriculography while one or more ECGs are always available. With the presumption that the Qp/Qs is roughly indicative of the right ventricular volume overload and that ecg signs of myocardial infarct are always reliable, we have reviewed among our 24 patients with septal rupture those where a full ecg tracing and a quantitative Echo or angiographic evaluation of the shunt were available.(ABSTRACT TRUNCATED AT 250 WORDS)

The "fully no-touch" technique for the internal thoracic-coronary artery anastomosis

Extreme technical accuracy is crucial in coronary artery surgery. Although late graft patency depends mostly upon the patient's own biochemical status in chronic ischemic patients who have undergone elective surgery, graft disease is certainly promoted by an inaccurate technique or by careless arterial harvesting, which may cause both intimal lesions and anastomotic strictures. We describe a technique of internal thoracic-coronary artery anastomosis that fully prevents contact between vessels and surgical instruments. In order to enable the suturing of a fully dilated vessel, intracoronary papaverine is injected into the clamped aortic root while the heart is still beating and before systemic cooling begins. The suturing technique applies some microvascular principles, the chief being a high number of stitches incorporating the least amount of tissue, to avoid bulk.

Genetic polymorphism in the Garfagnana population (Tuscany)

Blood group systems ABO, KEL, MN, RH, secretor status for ABH blood group substances, red cell enzymes ACP1, ESD, AK1, 6-PGD, PGM1 subtypes, serum markers GC, TF, PI, AHSG, ORM1 and chromosomal heteromorphism Q, C, DA/DAPI were examined in a population sample of the Garfagnana, a semi-isolated mountainous area in the province of Lucca (Tuscany, Italy). The total sample was subdivided and analysed according to the more recent historical events which have occurred in Garfagnana. The observed phenotype and gene frequencies were discussed in the context of other population samples from the same province and of the same region. As a whole, the results concur in pointing out a certain degree of heterogeneity within the area and a high differentiation from the rest of Tuscany. Such peculiar genetic features of the population have to be related to the historical, geographic and cultural isolation of the Garfagnana.

Variability of DA/DAPI and C heterochromatic regions: a population study

DA/DAPI and C chromosomal heteromorphic sites (1q, 9q, 15p, 16q, Yq) in a sample of 136 unrelated individuals from the Garfagnana valley (Tuscany, Italy) have been analyzed quantitatively and qualitatively. The variations in length, between-homolog heteromorphisms, and intensity of fluorescence of the heterochromatic bands have been compared in two subsamples of the population (upper and middle valley) individualized according to geodemographic criteria. DA/DAPI heterochromatin differed significantly from C heterochromatin, showing a lower average amount and a higher variability at each site. This suggests a differential staining of DNA of the two banding systems. Furthermore, DA/DAPI heterochromatin was less uniformly distributed in the population than C heterochromatin and the regions 16q and Yq discriminated better between subsamples. The variations of DA/DAPI fluorescence at the 15p site demonstrated an excess of homomorphic individuals in the upper valley, which could be related to the mating structure of the population living in this area.

Ten years of surgery of aortic dissections and aneurysms. Clinical experience and original contributions

From January '82 to April '91, 117 patients with aortic disease were operated upon at our University Hospital in Genoa, Italy. Thirty-seven had arch dissections or aneurysms; 66 had acute aortic dissection type A and 14 had aortic dissections or aneurysms type B, acute and chronic. Patients with arch or type B aortic pathology but without surgical indication and cases of post-traumatic aortic transections are not included. There were 84 male and 33 female patients with a mean age of 52 (6 min and 74 max). In the acute patients, the mean interval between clinical onset and surgery was 34 hours (6 min-72 max). All patients with primary arch disease had surgical repair with the aid of deep hypothermia and circulatory arrest (17-96 min). Type A dissections were treated with standard CPBP at 28 degrees C. Surgical techniques included direct suture of intimal tear alone, direct suturing of the two aortic stumps; interposition of Dacron tubular prosthesis; Bentall repair; separated valve and aortic replacement; an original aortic bulb aortoplasty with valve repair; arch replacement with resuturing of one or more aortic trunks. Human fibrin glue (Tissucol) was employed either as haemostatic agent, widely spread over the suture lines or as tissue adhesion agent between dissected aortic layers. Human fibrin glue is adopted because it gathers high glueing capacity and maintenance of the elastic property of the vessel wall. Hospital mortality (30 days) has been 25% in ascending aortic dissections (16/66 patients) and 50% in patients with arch disease (18/37 patients) who needed circulatory arrest. Late mortality 5/83 (6%). Reoperations for aortic valve insufficiency or re-dissection have been 7 (8.4%). Early diagnosis (increasing reliability of 2D-Echo and CT scans), aggressive surgery, meticulous myocardial and cerebral protection and introduction in clinical use of biological glues seem to be the milestones of present and further improvements in surgical results.

Arterial shunt with pump infusion line for the treatment of chronic thoracic aortic aneurysms: the "modified shunt of Gott"

Dissection of the aneurysm is the most dangerous step during graft replacement of the descending thoracic aorta. Sudden hemorrhage may follow wall rupture or disruption of major collaterals before the aorta can be clamped. A simple modification of the classic Gott is illustrated, which makes the shunt work also as a partial bypass if needed, with rapid reinfusion of blood losses. Nineteen of 25 patients requiring resection of descending aortic aneurysms from 1982 to 1990 were treated with this method with no mortality.

[Peritonitis caused by jejunal perforation resulting from metastasis of pulmonary carcinoma]

The Authors report a case of peritonitis due to perforation of a single small bowel metastasis in a woman affected by right upper lobar lung carcinoma still with neck's lymphnodes and cerebellar metastasis. They underline the rarity of the finding and analyze its clinical, therapeutic, prognostic problems.

[Acute surgically-treated complications of myocardial infarct. Clinical experience and discussion of surgical indications]

Post-infarction free-wall, papillary muscle and septal myocardium rupture yields a lowering mortality, not only due to the improved surgical technique but also to a more careful selection of surgical candidates. The value of pericardial decompression in cases of free-wall rupture is discussed. Echocardiographic evidence of blood in the pericardium after a myocardial infarction is not a direct indication for a diagnostic sampling, decompression or surgery. Pericardiocentesis is not a risk-free procedure and should be limited to patients with life-threatening acute tamponade. Clinical results of 34 patients operated upon for myocardial rupture, regardless of adopted technique or timing of surgery, confirm that the decision about a patient's operability should follow a careful evaluation of the following risk factors in this order: infarct size, age, cardiogenic shock, multiorgan failure, rupture site, cardiac failure and associated diseases.

Immunoscintigraphy of primary and metastatic colorectal cancers with radiolabelled monoclonal antibodies anti-CEA

Thirteen patients with a diagnosis of primary colorectal tumour and 68 patients previously operated for colon cancer underwent an immunoscintigraphy carried out with monoclonal antibodies anti-CEA F(ab')2, labelled with 131I or 111In. These studies led to the detection of all primary tumours and of most of their associated lesions (7/8). In this group 15 neoplastic deposits previously undetected were demonstrated, allowing an improvement in the patient staging before the operation. In the group of the 68 operated patients, immunoscintigraphy succeeded in imaging 96 out of 121 known lesions: the best outcomes were obtained for abdominal and pelvic recurrences as well as for lymph nodes lesions. The lowest levels of sensitivity were observed for liver metastases. An enhancement of the immunoscintigraphy sensitivity was obtained when the radiopharmaceutical was injected intraperitoneally. In 50 patients, this alternative administration route was successful in detecting 91/107 cancer deposits and, in particular, liver metastases were found out in 36/42 cases.

[Primary resection in occlusions caused by cancer of the left colon]

Based on a survey of 47 cases of left colonic occlusive cancer operated on at the Emergency Surgery Department-University of Rome "La Sapienza", the authors concluded that in such condition, when the patient is not seriously ill, the Hartmann procedure is a valid alternative to the anastomosis-resection because: a) it solves intestinal obstruction in a short time with consequent improvement of general conditions; b) it allows to perform the second oncologically radical operation early with less risk of neoplastic spread. The latter procedure, therefore, is carried out under better conditions, relative to the stage of the disease and the status of the patient.

Locoregional immunotherapy of human ovarian cancer: preliminary results

Ten patients with advanced ovarian carcinoma (5 in FIGO stage III and 5 in stage IV), following the failure of repeated chemotherapy courses, were submitted to i.p. radioimmunotherapy (RIT). Several antibodies (HMFG1, HMFG2, H17E2, B72.3) were employed. The antibody choice was made on the basis both of immunohistochemistry and immunoscintigraphy results. The mean dose administered in each single course was 17 mg, 3 patients underwent two treatments and 2 patients were injected three times. The isotope employed was 131I (mean dose 92 mCi). The early or late untoward effects were negligible. All patients developed anti-mouse antibodies (HAMA) which reduced, during the further RIT, the MoAbs' effective half-life. The estimated radiation dose delivered to the tumour ranged from 2910 to 11,000 cGy. Both wholebody and liver radiation burden resulted in tolerable limits while the thyroid irradiation was high. In 3 patients the RIT result was ineffective; in 2 cases a temporary ascitis staunch was obtained. In 2 cases the tumour growth was slower than expected and in 3 patients instrumental evidence of partial tumour reduction, still lasting after 4-11 months, was observed.

Improved immunoscintigraphy by subcutaneous injection of 99mTc or 111In labelled F(ab')2 fragments of an anti-melanoma monoclonal antibody

Technetium-99m and/or 111In labelled F(ab')2 fragments of a melanoma associated MoAb 225.28S were injected i.v. in 80 patients affected by stage I to IV malignant melanoma. Seventy five percent of metastatic lesions already documented by other methods were detected by immunoscintigraphy, which was also capable of detecting a certain number of unknown metastases. However, we observed a lower percentage of positive scans in liver, lung and skin because of the poor tumour to background ratio. In some patients, subcutaneous (s.c.) injection allowed us to visualize documented metastases undetected by i.v. administration. An equal amount of non-specific F(ab')2 fragments (MoAb 4C4) injected s.c. as a negative control showed no positive scans. Clinical studies and chromatographic patterns of patient serum samples suggest that the s.c. route of administration offers, with respect to the i.v. route, the advantage of reducing vascular background and aspecific accumulation in liver, probably because of retention of possible contaminants by the lymphatic system.

Plasma levels of lactoferrin in children suffering from cystic fibrosis

Plasma levels of lactoferrin (LF) have been found to be increased in a few patients with cystic fibrosis (CF). This study was aimed at investigating plasma LF levels in children with CF (26 cases) and in controls (C) (19 cases). Plasma LF was measured by a radioimmunoassay method. Plasma LF levels were not significantly different in CF and in C, even though 10 CF patients showed LF levels above the mean + 2 SD value of the controls. Neither the duration of the disease nor the age of the controls was correlated with LF or with the exocrine pancreatic capacity. A significant relationship between the presence of an acute lung inflammation and LF levels was found. This study shows that LF is increased in CF only in the presence of an acute inflammatory state. Further studies are necessary to establish the usefulness of an LF assay as an index of the presence of an acute inflammatory process.

BT-Paba test in the diagnosis of pancreatic exocrine insufficiency in cystic fibrosis: urinary and serum determinations compared

Urinary recovery and serum determination of Paba were carried out in 48 control children (C) and 53 paediatric patients with cystic fibrosis (CF) divided into three classes by age. Ninety and 120 min after the ingestion of 15 mg/kg of BT-Paba and of a standard meal, serum Paba was determined. In the same subjects the percentage Paba recovery was measured in the urine collected during an 8 h period after the same administration of BT-Paba. Correlation between urinary and serum Paba values was higher in the older children in respect to the 0-2-year-old infants. A urinary Paba test was less sensitive and specific than a serum Paba test in the evaluation of exocrine pancreatic function. The best discrimination between C and children with CF, using the maximal value of serum Paba at 90 or 120 min (peak), was obtained in the younger infants (0-2 years old). BT-Paba test with serum Paba peak determination is recommended as a substitute for the classical urinary Paba test in the evaluation of exocrine pancreatic function in paediatric patients, especially in the younger infants.

Serum and sputum concentrations of azlocillin, cefoperazone and ceftazidime in patients with cystic fibrosis

Single-dose pharmacokinetics of azlocillin, cefoperazone and ceftazidime were studied in 17 patients with cystic fibrosis (CF). All patients had broncho-pulmonary infections caused by Pseudomonas aeruginosa. Three groups of five, six, and six patients were treated with azlocillin, cefoperazone, or ceftazidime, respectively. The size of the single dose was 133 mg/kg for azlocillin, 66.7 mg/kg for ceftazidime and 66.7 mg/kg for cefoperazone. The clearance values for the three antibiotics calculated from the single-dose data were, on the average, higher than the values previously reported for normal subjects. After the first dose, the patients received a repeated-dose treatment with the same antibiotic. During the first 5 days of therapy, a complement postural drainage of sputum was obtained four times a day for each patient. Cefoperazone could be measured in 47 (39.2%) of the 120 sputum samples assayed while ceftazidime was shown to be present in all 120 sputum samples examined. Azlocillin was not detected in any of the 100 sputum samples assayed.

Alternative antibiotics for the treatment of Pseudomonas infections in cystic fibrosis

We have investigated the effectiveness of seven new beta-lactam antibiotics, azlocillin, piperacillin, ceftazidime, cefsulodin, cefoperazone, latamoxef (moxalactam), and cefotaxime, against acute pulmonary exacerbations caused by Pseudomonas aeruginosa in cystic fibrosis. Three hundred and fifty-five strains of Ps aeruginosa isolated from 310 sputum cultures (190 cystic fibrosis patients) were tested for susceptibility to the drugs by determination of minimal inhibitory concentrations (MIC). The highest activity was shown by ceftazidime (6% resistant strains) followed by cefsulodin and piperacillin (15 and 16% resistant strains); very low activity was found for cefotaxime and latamoxef (moxalactam). Ceftazidime was the most active drug against 32 pseudomonas isolates that were resistant to both carbenicillin and aminoglycosides (78% susceptible). A randomized, double-blind trial of azlocillin, piperacillin, ceftazidime, cefsulodin or cefoperazone was performed in 111 cystic fibrosis patients with predominant and susceptible pseudomonas in their sputum. Results were evaluated by a clinical, radiological and bacteriological scoring system: the best results were obtained with ceftazidime, followed by cefsulodin and piperacillin. However, pseudomonas was eradicated in only 22 (23%) of the cases with the most active drugs and persisted or reappeared in all the cases 1 to 3 months later. Ceftazidime always eradicated Staph. aureus and Haemophilus influenzae associated with pseudomonas. Similar eradication occurred nearly always with cefsulodin but rarely with the other drugs. No serious drug reaction occurred but a later fever and rash with piperacillin, transient diarrhoea with cefoperazone, vomiting with cefsulodin, and very frequent eosinophilia with ceftazidime should be mentioned. These five drugs offer, in varying degree, alternatives to traditional anti pseudomonas antibiotics in cystic fibrosis pulmonary infections, but they should be used only against well-proven resistant strains. Ceftazidime is best and cefotaxime and latamoxef (moxalactam) least useful.