Association between global longitudinal strain and myocardial fibrosis biomarkers in patients with end-stage chronic kidney disease

Introduction

Myocardial fibrosis represents a landmark characteristic of uremic cardiomyopathy, leading to a high burden of arrhythmias, diastolic dysfunction (DD) and ultimately heart failure in this population. Collagen-derived biomarkers (Procollagen type I carboxy-terminal propeptide (PICP), Procollagen type III N-terminal peptide (P3NP)) and Galectin-3 (Gal-3) are associated with the extent of myocardial fibrosis on myocardial biopsy. Global longitudinal strain (GLS) as assessed by two-dimensional speckle tracking echocardiography (2D-STE) has been shown to detect subclinical myocardial dysfunction in various populations. The correlation between GLS and the serum level of these biomarkers has not been studied so far.

Purpose

The aim of this study was to evaluate the association between the left ventricular GLS measured by 2D-STE and the serum level of three biomarkers (PICP, P3NP, Gal-3) known to be associated with the presence of myocardial fibrosis, in patients with end-stage renal disease (ESRD), not on dialysis.

Methods

We conducted a cross-sectional study that included 135 patients with an eGFR (CKD-EPI) <15 ml/min/1.73 m2, stable, asymptomatic, not on dialysis. We performed a complete transthoracic echocardiography with 2D-STE and determined serum levels of PICP, P3NP and Gal-3 by ELISA. Patients in atrial fibrillation, with a permanent pacemaker or with a poor acoustic window were excluded.

Results

The mean age was 59.2±15.5 (median 61 years), 44% of the patients were males, 33% were diabetic, 11% had a history of myocardial infarction and 14% were smokers. The average volumetric ejection fraction (EF) was 54.4±9.8% (median 55%), with only 6.3% of the patients having an EF <40%. The majority of the patients (86.6%) had at least grade I DD, with only 5.3% having a restrictive pattern (grade III DD). The mean GLS was −16.8% ± 0.1 (median −17%). The average serum levels of PICP, P3NP and Gal-3 were 440.2±139.6, 244.9±380.1 and 10.8±6.7, respectively. After regression analysis, GLS was correlated with PICP, P3NP and Gal-3 levels (p=0.005, r=0.88; p=0.001, r=0.75; and p=0.006, r=0.81 respectively). Additionally, GLS was inversely correlated with the severity of DD (p=0.0001, r=0.84). In multiple regression analysis of a model consisting of GLS, PICP, P3NP and Gal-3, the serum level of PICP counted for 34% of the variance of GLS (R2=0.559, p=0.002, F=32.39).

Conclusions

In conclusion, this study proves that although stable and asymptomatic, patients with ESRD have lower values of GLS, a high proportion of DD and higher values of PICP, P3NP and Gal-3, when compared with the general population, in spite of a normal EF. Our study is the first to demonstrate that these biomarkers correlated with GLS in patients with ESRD, suggesting that GLS could represent an important tool for estimating the amount of fibrosis and risk stratification in this population.

Funding Acknowledgement

Type of funding sources: None.

The impact of COVID-19 on right ventricular function in chronic kidney disease patients

Introduction

In chronic kidney disease (CKD) patients, the case fatality rate caused by the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) is higher than in the general population [1]. In patients hospitalised with COVID 19, right heart dysfunction is present in 20% of the cases, associated with an increased risk of all-cause death [2].

Purpose

CARDIO-SCARS in CKD is a currently ongoing multi-center observational match controlled trial that aims to assess the cardiovascular (CV) risk in a CKD (stages 3 to 5), dialysis and kidney transplant population, following SARS-CoV-2 infection, by using clinical evaluation, various techniques and novel biomarkers (ClinicalTrials.gov Identifier NCT05125913). We hereby report the main baseline echocardiographic parameters that assess the right ventricular (RV) function.

Methods

We conducted a cross-sectional study that included 263 patients with CKD (dialysis, transplantation or eGFR <60 ml/min/1.73 m²). For assessing RV function, 5 parameters were measured: fractional area change (FAC, %), tricuspid annular plane systolic excursion (TAPSE, mm), tricuspid S' wave (S tric, cm/s), Tei index and right ventricular free wall longitudinal strain (RVFWLS, %). Patients in atrial fibrillation, with a permanent pacemaker or with a poor acoustic window were excluded.

Results

Our study included 263 patients with CKD, divided in two groups: 168 patients post COVID-19 (94 in dialysis, 38 post kidney transplantation and 36 with CKD) and 95 patients in the control group (57 in dialysis, 30 post kidney transplantation and 8 with CKD).The mean age was 57.3±15.4 years (median 60 years old), 55.2% of the patients were males, 24% were diabetic and 9.5% were smokers. The mean duration of dialysis in the COVID-19 group was 63.8 months vs. 62.6 months in the control group. In the COVID group, the echocardiography was performed at a mean distance of 2.2±2.1 months after testing positive for SARS-CoV-2.All the parameters of RV function were better in the control group (FAC (%): 43.6±11 vs. 41.3±11; TAPSE (mm): 23.2±6.9 vs. 21.4±4.9; S tric (cm/s): 13.4±3.4 vs. 13±3.1; Tei index: 0.5±0.2 vs. 0.6±0.2; RVFWLS (%): −20.1±3.8 vs. −18.6±5.1. After performing a two-sample t-Test, statistical significance was reached only for TAPSE, Tei index and RVFWLS (0.008, 0.0001 and 0.006, respectively).

Conclusions

Our study is the first to describe echocardiographic alterations post-COVID in a CKD population. All CKD patients had lower values of RV parameters than those reported in the general population. Still, the CKD COVID group had lower values than CKD control group, with the same magnitude as the changes reported in the general population [3,4]. The evolution of these parameters and their prognostic significance is of interest, regarding long-term CV sequelae of COVID-19.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Ministry of Research and Innovation, CNCS-UEFISCDI

Silica nanoparticles: preparation, characterization and in vitro/in vivo biodistribution studies

BACKGROUND

The current progress in pharmaceutical nanotechnology field has been exploited in the design of functionalized radiolabelled nanoparticles that are able to deliver radionuclides in a selective manner to improve the outcome of diagnosis and treatment. Silica nanoparticles (SNPs) have been widely developed for biomedical applications due to their high versatility, excellent functional properties and low cost production, with the possibility to control different topological parameters relevant for multidisciplinary applications.

PURPOSE

The aim of the present study was to characterize and evaluate both in vitro, by microscopy techniques, and in vivo, by scintigraphic imaging, the biodistribution of silica nanostructures derivatives (Cy5.5 conjugated SNPs and (99m)Tc radiolabelled SNPs) to be applied as radiotracers in biomedicine.

METHODS

SNPs were synthesized by hydrolysis and condensation of silicon alkoxides, followed by surface functionalization with amino groups available for fluorescent dye and radiolabelling possibility.

RESULTS

Our data showed the particles size distribution (200-350 nm), the surface charge (negative for bare and fluorescent SNPs and positive for amino SNPs), polydispersity index (broad distribution), the qualitative composition and the toxicity assessments (safe material) that made the obtained SNPs candidates for in vitro/in vivo studies. A high uptake of fluorescent SNPs in all the investigated organs was evidenced by confocal microscopy. The (99m)Tc radiolabelled SNPs biodistribution was quantified in the range of 12-100% counts/g organ using the scintigraphic images.

CONCLUSIONS

The obtained results reveal improved properties, namely, reduced toxicity with a low level of side effects, an improved biodistribution, high labelling efficiency and stability of the radiolabelled SNPs with potential to be applied in biomedical science, particularly in nuclear medicine as a radiotracer.

Set-up and statistical validation of a new scoring system for obstructed defaecation syndrome

OBJECTIVE

There is no objective means to assess the obstructed defaecation syndrome (ODS), to allow evaluation of outcome or to compare the efficacy of treatment including surgery. The study aimed to validate a disease-specific index to quantify severity to allow assessment of the results of treatment in clinical trials, to permit comparison between them.

METHOD

Seventy-six patients with ODS and 30 healthy controls entered the study after proctologic and ano-rectal physiological investigation. Hirschsprung's disease and slow transit constipation were excluded. An eight-item questionnaire with four or five possible answers was administered by two independent researchers at two different times. The ODS score was the sum of all points with a maximum possible of 31 points. Agreement between the two operators was evaluated by the Kappa coefficient for each single item. The coefficient of repeatability (CR) was assessed by the Bland and Altman plot. The internal consistency was evaluated by the Crohnbach-alpha test. A cluster analysis was carried out on each clinical finding. The Mann-Whitney U-test was used to compare median ODS score between patients and controls.

RESULTS

The ODS score of the two operators was normally distributed and strongly correlated (r = 0.89). The correlation coefficient between the score assigned to each item by two operators ranged from 0.79 to 0.98. The degree of agreement between the operators was good and the two methods were reproducible (CR = 3.13). There was a significant difference between the mean ODS score for patients and controls (t = 20.70, P < 0.001). The Crohnbach alpha value for internal reliability was +0.513. Cluster analysis showed a different profile between cluster 1 (a nonhomogenous group including rectocoele, intussusception or perineal descent), and cluster 2 (pelvic dysynergia).

CONCLUSION

The ODS score offers a validated severity of disease index in grading the severity of disease and monitoring the efficacy of therapy.

Reinterventions after complicated or failed stapled hemorrhoidopexy

BACKGROUND

Stapled hemorrhoidopexy has become increasingly popular over the past five years, mainly because of the assumption that it is associated with less pain. However, persistent tags and recurrence might represent a problem, because piles are not excised and severe complications requiring surgery have been occasionally reported. The aim of the present study is to analyze the causes for and the outcome of reintervention following either severely complicated or failed stapled hemorrhoidopexy.

METHODS

A total of 232 primary stapled hemorrhoidopexies and 65 reinterventions after stapled hemorrhoidopexy were performed by the authors in five centers devoted to colorectal surgery. Twelve patients of the latter group had the stapled hemorrhoidopexy performed in one of these centers. Thirty-five were males and 30 were females. The mean age was 50 (range, 29-81) years. In all cases the primary indication for stapled hemorrhoidopexy was either third-degree or fourth-degree symptomatic hemorrhoids. In all patients submitted to reoperation the diagnosis of either severely complicated or failed stapled hemorrhoidopexy was made. The clinical history of all of these patients was carefully studied and all underwent inspection, digital exploration, and proctoscopy. After the reintervention, proctoscopy was performed in 61 patients (92 percent) after a median follow-up of 5.5 (range, 1-36) months.

RESULTS

Our reoperation rate after stapled hemorrhoidopexy was 11 percent. The most frequent indications for reintervention were persistent, severe anal pain (visual analog pain score higher than 7) in 29 patients (45 percent), severe postoperative bleeding in 20 (31 percent), anal fissure in 16 (21 percent), prolapsing piles in 12 (18 percent), rectal polyp in 11 (16 percent), anorectal sepsis in 11 (16 percent), and fecal incontinence in 7 (11 percent). Thirteen different types of reintervention were needed. Excisional hemorrhoidectomy, removal of staples, and fissurectomy and/or internal sphincterotomy were the most frequent operation (n = 41). A decrease in anal pain, as measured by visual analog pain score, was observed one month after reintervention, compared with that measured preoperatively (from 5.6 +/- 3.6 to 3.0 +/- 2.9) (P < 0.001). Bleeding requiring treatment occurred in six cases (10 percent), anal stricture requiring dilation occurred in three (5 percent), and fecal incontinence in three (5 percent). Proctoscopy showed no recurrences in 52 cases (80 percent) after the reintervention.

CONCLUSION

Pain and bleeding mostly caused by piles, fissures, and retained staples were the most frequent causes for reoperation after stapled hemorrhoidopexy. Reintervention was associated with a high bleeding and soiling rate, but was effective in treating pain and other symptoms in the majority of patients. Because of the wide spectrum of different interventions required, a failed or complicated stapled hemorrhoidopexy might be better treated by an experienced colorectal surgeon.

Disappointing long-term results of the artificial anal sphincter for faecal incontinence

Long term results of ABS disappointing

Bleeding, incontinence, pain and constipation after STARR transanal double stapling rectotomy for obstructed defecation

BACKGROUND

The STARR double stapling procedure (DSP), i. e. transanal anteroposterior rectotomy, has been recently reported as a low-morbidity and effective operation for the treatment of rectocele and internal rectal mucosal prolapse (R-IMP) causing obstructed defecation. We report the postoperative complications and recurrence of symptoms following this novel operation.

PATIENTS AND METHODS

Fourteen chronically constipated women with RIMP, aged 36-72 years, presented with either severe complications or recurrence of symptoms following DSP performed by means of two circular staplers. All were followed for a median period of 12 months (range, 2-24) after DPS.

RESULTS

Severe rectal bleeding occurred in two cases postoperatively. Persistent severe anal pain was reported by seven patients, all presenting with anxiety. Four of them were multiparous. Three patients had fecal incontinence, both had vaginal deliveries. R-IMP recurred in six, obstructed defecation in seven cases. Four patients needed reintervention, one for suturing the bleeding area, one excising the recurrent prolapse, one for colpocele and one for rectal stricture. Four patients required biofeedback training for non-relaxing puborectalis and two needed psychotherapy.

CONCLUSION

Parity, spastic floor syndrome and psychoneurosis seem to be the risk factors predisposing to failure of DSP, which may be followed by severe complications and early recurrence of symptoms requiring reoperation.

Complications after stapled hemorrhoidectomy: can they be prevented?

Stapled hemorrhoidectomy (SH), a new approach to the treatment of hemorrhoids, removes a circumferential strip of mucosa about four centimeters above the dentate line. A review of 1,107 patients treated with SH from twelve Italian coloproctological centers has revealed a 15% (164/1,107) complication rate. Immediate complications (first week) were: severe pain in 5.0% of all patients, bleeding (4.2%), thrombosis (2.3%), urinary retention (1.5%), anastomotic dehiscence (0.5%), fissure (0.2%), perineal intramural hematoma (0.1%), and submucosal abscess (0.1%). Bleeding was treated surgically in 24%, with Foley insertion 15%; and by epinephrine infiltration in 2%; 53% of patients with bleeding received no treatment and 6% needed transfusion. One patient with anastomotic dehiscence needed pelvic drainage and colostomy formation. The most common complication after 1 week was recurrence of hemorrhoids in 2.3% of patients, severe pain (1.7%), stenosis (0.8%), fissure (0.6%), bleeding (0.5%), skin tag (0.5%), thrombosis (0.4%), papillary hypertrophy (0.3%) fecal urency (0.2%), staples problems (0.2%), gas flatus and fecal incontinence (0.2%), intramural abscess, partial dehiscence, mucosal septum and intussusception (each <0.1%). Recurrent hemorrhoids were treated by ligation in 40% and by Milligan-Morgan procedure in 32%. All hemorrhoidal thromboses were excised. Anal stenoses were treated by dilatation in 55% and by anoplasty in 45%. Fissure was treated by dilatation in 57%. Most complications (65%) occurred after the surgeon had more than 25 case experiences of stapled hemorrhoidectomy. The most common complication in the first 25 cases of the surgeon's experience was bleeding (48%). Even though SH appears to be promising, we feel that a multicenter randomized study with a long-term follow-up comparing SH and banding is necessary before recommending the procedure. Most complications can be avoided by respecting the rectal wall anatomy in the execution of the procedure.

Multicentre retrospective analysis of the outcome of artificial anal sphincter implantation for severe faecal incontinence

BACKGROUND

A new prosthetic device, the Action artificial anal sphincter, has recently been introduced for treating severe faecal incontinence. The results of this procedure in 28 patients are presented.

METHODS

The patients underwent operation for severe faecal incontinence in four Italian university hospitals and patients were reviewed after a median follow-up of 19 (range 7-41) months.

RESULTS

Early infections occurred in four patients, requiring removal of the device in three. Dehiscence of the perineal wound occurred in nine patients. After activation of the device, the cuff had to be removed in a further four patients (for rectal erosion in two, anal pain in one and late infection in one). The cuff was accidentally broken in one patient. A new anal cuff was repositioned successfully in two patients. Overall, five patients had complete removal of the device and two removal of the cuff only. Twenty-one patients available for long-term evaluation had a major improvement in faecal continence. Median resting anal pressure increased from 27 mmHg before surgery to 32 mmHg after operation. Preoperative squeeze pressure was 42 mmHg while maximum postoperative anal pressure with the activated device was 67 mmHg. The median American Medical System incontinence score decreased significantly from 98.5 to 5.5 (P < 0.001). Similar figures were observed using the Continence Grading Scale (from 14.9 to 2.6; P < 0.001). Twelve patients developed symptoms of obstructed defaecation while two patients complained of anal pain.

CONCLUSION

Improved continence was achieved after neosphincter implantation in three-quarters of the patients. Early infection and rectal erosion, together with difficulty in evacuating, are still major concerns with this technique.

Neuromodulation for fecal incontinence: outcome in 16 patients with definitive implant. The initial Italian Sacral Neurostimulation Group (GINS) experience

PURPOSE

Sacral nerve modulation appears to offer a valid treatment option for some patients with fecal incontinence and functional defects of the internal anal sphincter or of the striated muscle.

METHODS

Sixteen patients with fecal incontinence (4 males; mean age, 51.4 (range, 27-79) years) with intact or surgically repaired (n = 1) anal sphincter underwent permanent sacral nerve stimulation implant. Cause was traumatic in two patients, and associated disorders included scleroderma (2 patients) and spastic paraparesis (1 patient); eight (50 percent) of the patients also had urinary incontinence, and two (12.5 percent) had nonobstructive urinary retention. All patients were selected on the basis of positive findings from at least one peripheral nerve evaluation. The stimulating electrode was positioned in the S2 (1 patient), S3 (14 patients), or S4 (1 patient) sacral foramen.

RESULTS

Mean follow-up was 15.5 (range, 3-45) months. Mean preimplant Williams score decreased from 4.1 +/- 0.9 (range, 2-5) to 1.25 +/- 0.5 (range, 1-2) (P = 0.01, Wilcoxon test), and the number of incontinence accidents for liquid or solid stool in 14 days decreased from 11.5 +/- 4.8 (range, 2-20) before implant to 0.6 +/- 0.9 (range, 0-2) at the last follow-up. Important manometric data were an increase in mean maximal pressure at rest of 37.7 +/- 14.9 mmHg (implantable pulse generator 49.1 +/- 18.7, P = 0.04) and in mean maximal pressure during squeeze (prestimulation 67.3 +/- 21.1 mmHg, implantable pulse generator 82.6 +/- 21.0, P = 0.09).

CONCLUSIONS

Neuromodulation can be considered an option for fecal incontinence. However, an accurate clinical and instrumental evaluation and careful patient selection are required to optimize outcome.

[Sclerotherapy and elastic ligation of hemorrhoids]

In the treatment of haemorrhoids all procedures may have good results, if indications are correct. Injection treatment has the best indication for I and II degree bleeding piles, the rubber band ligation for II and III degree piles; this procedure is very effective when associated to cryosurgery. All operations for haemorrhoids must be avoided in Crohn disease.

Does surgery resolve outlet obstruction from rectocele?

In order to ascertain whether plastic surgery for rectocele is of value in the treatment of outlet obstruction, a retrospective study was made of 21 women complaining of difficulty in expelling faeces: 13 patients (group A) underwent surgery with transanal longitudinal plication of the anterior rectal wall (Block's technique), and 8 patients (group B) had colpoperineoplasty which, in 2, was associated with bladder-neck suspension following the Raz-Peyrera technique for urinary incontinence. The mean follow-up was 24.2 +/- 18.7 and 36.8 +/- 17.8 months respectively. In 11 group A patients (80.9%) and 6 group B patients (75%) cure, or an improvement, was achieved. Of the remaining 4 patients (19%), recurrent rectocele was found in 2 (one group A and one group B) and intestinal transit time tests detected colonic constipation in one group A and in one group B patient. It is concluded that surgery can resolve outlet obstruction from rectocele, but Block's technique is preferable because it is more straight-forward and easier.

Does acetylsalicylic acid interfere with stimulated pancreatic secretion? An experimental study in the rat

To evaluate the effect of the prostaglandin inhibitor acetylsalicylic acid (ASA) on rat exocrine pancreas secretion, three groups of rats were administered ASA by infusion: Groups 1-3, 50, 100, and 200 mg/kg body wt, respectively; Group 4 received saline. Twenty minutes later these ASA-pretreated groups were given intraarterial secretin (18 CU/kg) and cholecystokinin (CCK) (18 micrograms/kg). In an additional three groups of seven rats each, saline solution rather than secretin-CCK was given after ASA pretreatment. Pancreatic juice was collected every 10 min by means of a chronic pancreatic fistula. Bicarbonate and protein concentrations were measured and variations in outputs observed. No significant variations were found in the bicarbonate concentrations and outputs of rats with different types of pharmacological treatment, while protein concentrations and outputs were found to vary with time and type of experiment. There was, however, no interaction between these two variables. At lower ASA dosages, the bicarbonate and protein concentrations and outputs of secretin-CCK-stimulated rats were higher than the basal values and the levels of rats without hormonal stimulation. At higher dosages, no difference was found between the two groups. In conclusion, ASA seems to interfere with stimulated pancreatic exocrine secretion of proteins, even when its effect on bicarbonate concentration is factored in, and its effect seems to be present at the highest dosages considered in the study. Among the various hypotheses that may explain this phenomenon, an antagonizing effect of ASA on secretin-CCK action should be the first to be considered.

Can proctological procedures resolve perianal pruritus and mycosis? A prospective study of 23 cases

Twenty-three patients with pruritus ani associated with anal mycosis underwent primary treatment of a concurrent anal disorder. The anal disorders included haemorrhoids (n = 9), fissure (n = 8), anal spasm without fissure (n = 5), and occult mucosal prolapse (n = 1). Pretreatment investigation of faeces for parasites was negative. The glucosal tolerance test and white blood cell count were normal in all cases. Culture of skin smears from the perianal region was positive for Candida only in 16 patients, Dermatophytes only in 6 and a combination of both in 1 patient. Following the appropriate proctological procedure, pruritus resolved or markedly improved in 20 patients. The remaining three patients required antifungal treatment with econazole. Two of these, however, continued to complain of pruritus. It is suggested that in patients with pruritus ani associated with perianal mycosis, antimycotic therapy should be used only if fungal infection persists after treatment of the underlying proctological disease.

Disposable torch-lit anoscope

A disposable torch-lit anoscope is described. Its bevelled end facilitates therapeutic procedures, while the fact that it does not need an external light source makes its use on the ward or in the patient's home more straight-forward.

[Functional evaluation of the anorectal region]

Defecography is a method allowing the morphodynamic evaluation of the anorectal region. The technique we employed needs two complementary times: "phase" defecography and dynamic defecography. In our series of patients affected with severe constipation, 2 groups could be identified. Group A included those patients (mean age: 38.7 years) in whom no significant changes were observed in anorectal angle and in the distance of anorectal angle from pubococcygeal line in comparison with normal subjects (Student's t-test). Group B included those patients (mean age: 63.3 years) in whom significant reduction was observed in anorectal angle on straining, together with increased distance of anorectal angle from pubococcygeal line on squeezing in comparison with normal subjects (Student's t-test). In constipated patients narrowed anal canal was observed (60%), together with rectocele (42.6%), mucosal prolapse (27.8%), rectal prolapse (18%) and solitary ulcer (14.7%). In idiopathic incontinence patients (mean age: 63.3 years), increased distance was observed of anorectal angle from pubococcygeal line on squeezing and, in the most severe cases, even at rest, with the patient sitting (Student's t-test). In incontinent patients larger anal canal was observed (67.6%), together with rectocele (36.7%), mucosal prolapse (14.7%), and rectal prolapse (11.7%).

Failure of secretin to exert an ameliorative effect on acute reflux pancreatitis in the rat

This study was undertaken to evaluate the possible ameliorative effect of secretin on acute reflux pancreatitis in the rat. Thirty days after the performance of a gastrojejunal anstomosis, in all rats (36 Sprague-Dawley, mean weight 250 g) acute pancreatitis was induced by creating a closed duodenal loop for 12 h. In the subsequent 12 h group A (14 rats) received continuous intra-arterial infusion of secretin (5 CU/kg/h); group B (22 rats) received equal volumes of saline solution. Serum amylase and pancreatic histology were evaluated. In group B a mild form of pancreatitis was observed, since the mean values of haemorrhage, necrosis and steatonecrosis, indices of severe disease, were found to be low. Group A presented similar results. No difference was documented between the two groups for both the histological findings and serum amylase. We can conclude that despite the reported protective and ameliorative effects of secretin in cerulein-induced acute pancreatitis in the rat, our data do not support a similar action of secretin in the closed duodenal loop model.

Role of proctography in severe constipation

As referred to in the literature, patients complaining of constipation may have a spastic or, in the case of chronic staining, weak pelvic floor. Twenty-two severely constipated patients who did not improve after a high fiber diet were submitted to whole gut transit time (TT), proctographic, and anorectal manometric studies. A control group consisting of five subjects for TT, five subjects for proctogram, and ten subjects for manometry was also studied. Transit time was delayed (P less than 0.001) in all patients. Manometry in the constipated group showed a high rectal threshold (64.1 vs. 17.1 ml of air, P less than 0.01), but no other significant difference. Proctograms in 10 of 22 patients (Group A) showed no differences in the anorectal angle (ARA) and in its distance from the pubococcygeal line (DLPC) in respect to the control group; 12 of 22 patients (Group B) had a paradoxical closure of the ARA at straining in respect to resting position (101.2 degrees vs. 120.1 degrees), and a higher DLPC than Group A and the control group in all positions studied. There was no difference in TT for rectal stasis of radiopaque markers between the two pathologic groups. Patients in Group B were older than patients in Group A (55.3 vs. 42.9 years, P less than 0.05). In conclusion, proctograms showed alterations of the pelvic floor, but there was no correlation between protographic data and rectal or colonic stasis of the radiopaque markers, or clinic severity of constipation, but a correlation between ages did exist.

Does bile play a fundamental role in inducing and influencing acute reflux pancreatitis in rat?

Acute pancreatitis by closed duodenal loop in two groups of rats, with or without biliary diversion, was induced to ascertain any role that bile might have in codetermining and influencing the disease. Both the histological findings and the serum amylase levels showed the presence of mild acute pancreatitis in both groups. The histological and/or biochemical findings and the survival rates were similar for rats with and rats without biliary diversion. We may therefore conclude that the closed duodenal loop causes acute pancreatitis of a mild degree in the rat; bile did not appear to play a fundamental role in inducing or in influencing the outcome of the acute pancreatic inflammation in this experimental model.

Lipid metabolism in lipoatrophic diabetes

Some aspects of lipid metabolism were studied in 4 patients with a congenital lipoatrophic diabetes (LAD) associated to a type IV hyperlipoproteinemia. The analysis of lipoprotein composition, expressed as mg/dl, demonstrates a significant increase of VLDL mass and a significant reduction of HDL mass. The analysis of lipoprotein composition, expressed as per cent of total mass demonstrates an increase of the triglyceride content in all fractions and a significant reduction of the cholesterol and phospholipid content in HDL2 particles. Apo C-II, C-III0, C-III1 and C-III2 levels in lipoprotein fractions were normal in LAD patients. Lipoprotein lipase activity in omental adipose tissue, collected during laparoscopy in one patient was undetectable. The serum of this patient did not fully activate the lipoprotein lipase eluted from normal adipose tissue. In all patients the adipose tissue lipoprotein lipase activity in post-heparin plasma was blunted or near absent. Thus a reduced peripheral clearance of triglyceride-rich lipoprotein could be an important determinant of lipoprotein abnormalities in lipoatrophic diabetes.

[Radiologic diagnosis of anal fistulae with radio-opaque markers]

Fistulography classifies anal fistulas in low-below puborectalis muscle-, high-above puborectalis muscle-, and middle. This classification increases the scope and accuracy of radical surgery. In order to improve the diagnostic reliability of anal fistulography the authors point out the importance of radio-opaque markers for anatomical definition of the anorectal region. Thirty patients (25 males and 5 females; mean age: 47 years) were studied by anal fistulography using radiopaque markers: a Foley's 22 Fr catheter, with distal balloon filled of idrosoluble radiopaque contrast medium, was placed in the anal canal; a metal marker was fixed to the anus. In order to demonstrate the relationship between fistula and puborectalis muscle, we subdivided the anal canal in 3 equal segments: high, middle and low. The idrosoluble contrast medium for fistulography is injected through a pediatric Foley's catheter 8 Fr when external opening is large enough, and through a K7072 endovenous catheter when the opening is small. Fistulous tract was visible in all patients: internal fistulous opening in 23/90 cases, and relationship of fistulous tract to puborectalis muscle in 25/30 (83.3%). In demonstrating either secondary fistulous tracts or abscesses, fistulography with radiopaque markers was correct in 60% of cases; in 20% of patients some of the above-mentioned complications were demonstrated, and in the 20% no complications at all were detected.

Combined determination of serum CA 19-9 and tissue polypeptide antigen: why no improvement in pancreatic cancer diagnosis?

CA 19-9 and tissue polypeptide antigen (TPA) were determined in the sera of 28 control subjects, 29 patients with pancreatic cancer, 26 with chronic pancreatitis and 62 with benign and malignant extra pancreatic diseases in order to compare their usefulness in diagnosing pancreatic cancer, to verify whether the combined assessment of the two indices could improve the results given by a single parameter and to speculate on the role of liver dysfunction in increasing their serum levels. The sensitivity, specificity and accuracy of CA 19-9 and TPA in diagnosing pancreatic malignancy were: 76, 85 and 61% for CA 19-9 and 79, 52 and 32% for TPA. The receiver-operating characteristic curves showed that CA 19-9 and TPA similarly discriminate pancreatic cancer from controls and chronic pancreatitis, while CA 19-9 is more useful than TPA in differentiating pancreatic malignancy from benign and malignant extra pancreatic abdominal diseases. TPA did not seem to add further information as compared to CA 19-9 alone when both markers were combined. Liver dysfunction may contribute to increasing serum levels of both markers.

[2 cases of psychogenic pruritus ani in the same family]

The authors present two cases of idiopathic pruritus ani in the same family in which psychological factors seem to play an etiological role.

Hot or cold in anal pain? A study of the changes in internal anal sphincter pressure profiles

In 26 volunteers without anorectal complaints, and in 31 patients with anorectal problems such as hemorrhoidal disease, anal fissure, and proctalgia fugax, baseline resting anal canal pressures were recorded manometrically for 5 minutes at room temperature (23 degrees C). In 16 volunteers (Group A) and 21 patients (Group B) anorectal manometry was then performed while the anus was immersed in water at varying temperatures (5 degrees C, 23 degrees C, and 40 degrees C). In ten volunteers (Group A') and ten patients (Group B') resting pressures were recorded for an additional 30 minutes following immersion for 5 minutes at 40 degrees C. In all subjects (at least P less than 0.01), resting anal canal pressures diminished significantly from baseline after immersion at 40 degrees C, but remained unchanged in all subjects after immersion at 5 degrees C and 23 degrees C. In Group A', anal canal pressures remained significantly reduced for 15 minutes (P less than 0.02). In Group B', significant reduction in resting pressure lasted 30 minutes (P less than 0.02). Wet heat applied to the anal sphincter apparatus significantly and reproducibly decreased resting anal canal pressures over time, and therefore was likely to benefit patients after anorectal operations and those with anorectal pain.

An improved technique of local anal anesthesia

A four-needle anesthetic injector has been developed for perianal anesthesia in minor proctologic procedures. This technique obviates the need for multiple separate anesthetic injections.

Psychological findings in chronic anal pain

The psychological characteristics of 21 patients suffering from chronic anal pain were studied. They underwent a clinical interview and completed the Eysenck personality questionnaire, the Zung self-rating depression scale and an analogue scale for the assessment of perceived pain. Data derived from the self-rating scales were compared with those obtained from a matched control group afflicted with fissure-in-ano. The pain patients reported higher scores for neuroticism, psychoticism, depression and perceived pain than the controls. Fifty percent of the experimental group had suffered prior to the onset of pain from depressive disturbances, and 11 subjects reported at the clinical interview somatic symptoms which usually accompany depression. These results support the hypothesis that the pain symptom in some patients with chronic anal pain could represent the manifestation of an underlying depressive disturbance.

The mycotic flora in proctological patients with and without pruritus ani

The perianal mycotic flora was studied in proctological patients with and without pruritus ani, as well as in control subjects. Four groups of patients underwent perianal mycoculture. In Group 1, 53 patients with anal pruritus were treated for benign anorectal disease. In Group 2, 24 patients with no underlying disease presented with anal pruritus. Both of these groups underwent concomitant chemical and parasitical examination of the faeces and an oral glucose tolerance test. In Group 3, 50 patients without pruritus ani at present or in the past were treated for benign anorectal diseases. In Group 4, 47 surgical patients without pruritus ani were treated for benign (9) and malignant (38) non-proctological diseases. In Group 1 the mycoculture was positive in 24/53 patients (Candida albicans 14, dermatophytes 10). In Group 2 fungal infections were seen in 16/24 patients (C. albicans 7, dermatophytes 9). No parasites or diabetes were found in either group. In Group 3 C. albicans was isolated in 14/50 patients. In Group 4 C. albicans was found in 11/47 cases (2 in benign, 9 in malignant diseases). Infection by C. albicans was observed in all groups studied, independent of the presence of disease or anal pruritus. The presence of dermatophytes was always associated with pruritus ani.

Exocrine pancreatic function in diabetic rats treated with intraportal islet transplantation

Streptozotocin-diabetic rats with chronic pancreatic fistula show severe impairment of secretin-stimulated pancreatic secretion while the action of pancreozymin remains unchanged. Intrahepatic transplantation of islets of Langerhans restores the response of ductal cells to secretin; physiological control of insulin secretion appears to be essential for exocrine function.

The relaxing effect of caerulein on isolated human internal anal sphincter

In the attempt to find a pharmacological treatment for the spasm of the internal anal sphincter, usually associated with anal fissures, the activity of caerulein on human internal and sphincter was investigated in vitro and in vivo. In the isolated distal part of the internal and sphincter, caerulein (0.61 microM) depressed resting muscle tone and caused marked relaxation of norepinephrine-contracted preparations. The effect of caerulein was reduced by atropine and increased by physostigmine, suggesting that it was largely due to the release of acetylcholine. In vivo, intravenous infusion of caerulein, both to healthy volunteers and to subjects affected by anal fissures and anal sphincter hypertone, did not modify the values of internal anal sphincter pressure. The lack of spasmolytic effect of caerulein in vivo may have been due to the relatively unimportant influence of cholinergic neurons on the control of internal anal sphincter tone. Alternatively, the presence of fibrosis caused by anal fissures could hinder sphincter relaxation.

Usefulness of transhepatic portal catheterization in the treatment of insulinomas

Twenty-four per cent of beta-cell tumours require more than one operation to control the hypoglycaemic syndrome. Almost all of them are small insulinomas undetectable by palpation of the pancreas. Arteriography is too insensitive to detect non-palpable tumours. Transhepatic catheterization of the splenic and portal veins (TPC) can detect the position at which there is an abrupt increase in insulin level indicating the site of the tumour. Routine use of TPC allowed us to locate all 9 insulinomas in which this technique was employed, whereas of 15 patients not studied by TPC only 12 tumours were located at first operation, 2 of which were found by blind resection of the tail of the pancreas. We believe that routine application of TPC to all cases of suspected insulinoma would reduce the incidence of surgical failures, unsuccessful blind resections and lengthy trials of medical therapy before laparotomy.

Effect of cimetidine on steroid experimental peptic ulcers

Cimetidine, a H2-receptor inhibitor was able to prevent the development of gastric ulcers induced in rats by chronic administration of prednisolone and hydrocortisone associated to fasting. The results suggest that cimetidine may be used in patients under long term steroid treatment.

Effect of a synthetic analogue of PGE2 on exocrine and endocrine pancreatic function in the rat

The effect of 16,16-dimethyl PGE2-methyl-ester (di-M-PGE2, a long-acting synthetic analogue of PGE2) on exocrine and endocrine pancreatic secretion was studied in rats with chronic pancreatic fistulas. Under basal conditions as well as after stimulation with secretin and OP-CCK, pancreatic exocrine secretion was inhibited markedly by intravenous injection of di-M-PGE2 at 10 microgram/kg and 100 microgram/kg. Secretory volumes and bicarbonate and protein outputs decreased within 10 minutes after the administration of di-M-PGE2, and this inhibitory effect persisted throughout the following 40 minutes. The smaller dose of di-M-PGE2 (10 microgram/kg) inhibited the volume of pancreatic secretion by an average of 47.7% and decreased bicarbonate and protein output by 41.1% and 70.5%, respectively. The larger dose (100 microgram/kg) caused a mean 48.3% inhibition of pancreatic secretory volume and decreased bicarbonate and protein outputs by 41.7% and 64.5%, respectively. Plasma insulin levels were lowered markedly after injection of di-M-PGE2 under basal conditions (mean inhibition 63.1% by PG-10 and 55.3% by PG-100) as well as after secretin stimulation (mean inhibition 89.5% by PG-10 and 82.4% by PG-100). These observations document that di-M-PGE2 is a potent inhibitor of pancreatic exocrine and endocrine function in the unanesthetized rat. In these actions the PGE2-analogue antagonized the stimulatory effects of both secretin and OP-CCK.

[Current value of diagnostic laparatomy with splenectomy in Hodgkin's disease (critical evaluation of 188 cases)]

Diagnostic laparotomy with splenectomy was performed in 188 patients with Hodgkin's disease. Preoperative assessment by means of conventional methods of examination was confirmed in 118 cases (62.9%) and had to be modified in the remainder. Post-operative complications were observed in 12 cases (6.5%). One subject died of myocardial infarct. It is felt that the procedure is useful in establishing the stage of the disease and in planning treatment. It must not be applied indiscriminately, however, and is primarily useful insofar as it results in a modification of the therapeutic programme.