Self-expanding plastic stent to palliate symptomatic tissue in/overgrowth after self-expanding metal stent placement for esophageal cancer.

Self-expanding metal stents (SEMS) are used to treat obstructive malignancies of the esophagus or esophagogastric junction; however, a potential complication is recurrent dysphagia because of tissue in/overgrowth. The placement of a second SEMS is one strategy to re-establish patency of the esophageal lumen. We evaluated the safety and efficacy of an alternative and likely less costly approach: placing a self-expanding plastic stent (SEPS) to manage relapsing dysphagia in patients previously treated with a partially covered SEMS. From December 2007 to January 2009, 13 patients previously treated with a SEMS for malignant dysphagia underwent treatment by inserting a SEPS to palliate relapsing dysphagia, as a result of tissue in/overgrowth. Stenosis was located in the upper esophagus in one patient, in the middle in four patients, and in the lower esophagus in eight patients. Clinical evaluation was performed at the time of stent placement, after 1 week, and then, monthly until death. The SEPS was successfully placed in a single treatment session for all patients. No preliminary dilation was required, and no further treatment was necessary for any patient. Before stenting, the median dysphagia score was 4 (range 3-4), and 1 week later the score was 0 for all patients. The resolution of dysphagia persisted until patient death (from tumor progression). The mean survival after the SEPS insertion was 4 months (range 3-8). This case series supports the use of a SEPS to palliate dysphagia from tissue in/overgrowth of a SEMS. Future clinical trials with larger patient samples are warranted.

Acute gastric anisakiasis: an Italian experience.

Anisakidosis is a parasitic disease of the human gastrointestinal tract caused by ingestion of larvae of marine nematodes such as Anisakis spp. or, rarely, Pseudoterranova spp., present in raw or undercooked fish. We report the first series of gastric Anisakis infection (anisakiasis) from a single centre in Italy. In our department, we observed 3 cases, all in women who were urgently hospitalized following intense epigastric pain and vomiting, developed after the ingestion of raw fish. The patients underwent urgent gastroscopy within a few hours. In each, a worm was extracted from the gastric mucosa by means of biopsy forceps. This was followed by prompt clinical improvement. The worm was identified by its macroscopic and microscopic characteristics as an Anisakis spp. larva (L3). In 2 cases, laboratory tests revealed marked leukocytosis and eosinophilia in the peripheral blood 3-4 days after ingestion of the raw fish. The diagnosis of anisakiasis can be made by endoscopy, radiology and abdominal ultrasound, but is often made only at surgery. In the gastric form of the disease, urgent gastroscopy has both a diagnostic and a therapeutic role, because the worm can be removed by means of biopsy forceps.

Association between coffee or tea drinking and Barrett's esophagus or esophagitis: an Italian study.

BACKGROUND/OBJECTIVES: Only a few papers have treated of the relationship between Barrett's esophagus (BE) or erosive esophagitis (E) and coffee or tea intake. We evaluated the role of these beverages in BE and E occurrence. SUBJECTS/METHODS: Patients with BE (339), E (462) and controls (619) were recruited. Data on coffee and tea and other individual characteristics were collected using a structured questionnaire. RESULTS: BE risk was higher in former coffee drinkers, irrespective of levels of exposure (cup per day; ⩽1: OR=3.76, 95% CI 1.33-10.6; >1: OR=3.79, 95% CI 1.31-11.0; test for linear trend (TLT) P=0.006) and was higher with duration (>30 years: OR=4.18, 95% CI 1.43-12.3; TLT P=0.004) and for late quitters, respectively (⩽3 years from cessation: OR=5.95, 95% CI 2.19-16.2; TLT P<0.001). The risk of BE was also higher in subjects who started drinking coffee later (age >18 years: OR=6.10, 95% CI 2.15-17.3). No association was found in current drinkers, but for an increased risk of E in light drinkers (<1 cup per day OR =1.85, 95% CI 1.00-3.43).A discernible risk reduction of E (about 20%, not significant) and BE (about 30%, P<0.05) was observed in tea drinkers. CONCLUSIONS: Our data were suggestive of a reduced risk of BE and E with tea intake. An adverse effect of coffee was found among BE patients who had stopped drinking coffee. Coffee or tea intakes could be indicative of other lifestyle habits with protective or adverse impact on esophageal mucosa.

Endoscopic surveillance of Barrett's Esophagus. Personal experience.

BACKGROUND: The possible progression of Barrett's Esophagus (BE) to carcinoma is well established: the incidence of cancer in BE is about 1.9-10% or 1/52-1/441 patients/year with a risk up to 30-125 times the normal population. Endoscopic surveillance can detect esophageal adenocarcinomas when they are early and curable. The purpose of endoscopic and histologic surveillance in patients with BE is to follow its evolution in order to characterize possible affiliation to a neoplastic risk group. METHODS: From 1998 to 2000 we have endoscopically identified 12 patients with EB, histologically confirmed: 9 males and 3 females, with a M/F ratio of 3:1 and an average of 45.25 years. RESULTS: During the endoscopic and histologic follow-up have observed the sequence from intestinal metaplasia with a low-grade dysplasia in one patient, confirmed after 2 months of treatment with double-dose pump inhibitor (PPI), to intestinal metaplasia with a high-grade dysplasia on biopsy samples done after vital staining with Lugol. So the patient had an endoscopic mucosal ablation, because he rejected esophagectomy. In the other patients without dysplasia, we used prokinetic drugs and PPI and we involved them in a follow-up every 2/3 years. CONCLUSIONS: Histological grading of dysplasia is currently the most important parameter used to follow-up patients with EB: the guidelines suggest a periodic endoscopic surveillance, from six months to 2 or 5 years, according to higher or lower risk of carcinoma arising, because there is no medical or surgical therapy able to decrease cancer risk.

[Colorectal cancer screening: comparison among strategies]. / Screening del cancro del colon-retto. Metodiche a confronto.

Colorectal cancer (CCR) screening is justified since CCR is 2nd leading cause of death for malignancy: most colorectal cancers arise from preexisting adenomatous polyps that remain clinically silent until presentation, often with advanced and incurable malignant disease. The merits and cost-effectiveness of screening for colorectal cancer are evident because the detection and removal of early carcinomas and adenomatous polyps reduces colorectal cancer mortality. Several screening methods are available, each of them presenting advantages and limits. Conventional colonoscopy is considered as the gold standard for the study of colon and, at present, it is the method of screening with the highest effectiveness in reducing CCR morbidity and mortality. However, the use of colonoscopy as the most important screening strategy is limited, because it causes major complications, it has a low compliance, and there are few specialized structures and few specialists to carry out a high number of colonoscopies as screening methods. The screening strategies used at present are described and their advantages and limits are compared.

[Rare causes of serious digestive hemorrhages]. / Le gravi emorragie digestive da cause rare.

The rare causes of massive hemorrhage in the gastrointestinal tract are not completely classifiable. They are characterized by high variability, as shown in several isolated reports. In our experience of 17 cases, clinical and endoscopic features were sometimes typical of a rare pathology, others were referable to common pathologies and exactly diagnosed only by angiography or surgery. Our experience points out the difficulties in the surgical prescription and timing, when the endoscopic diagnosis was lacking or unsure, or when a massive haemorrhagic recurrence forced diagnostic laparatomy. The role of endoscopy and the advantages of intraoperative enteroscopy have been compellingly demonstrated. Diagnostic and therapeutic angiography has been the main method in vascular hemorrhage.

[Hartmann's operation in acute perforated diverticulitis]. / L'intervento di Hartmann nella diverticolite acuta perforata.

Acute perforated diverticulitis of the colon is still a serious clinical event that requires an emergency treatment which is based upon clinical staging and pathological characteristics. Surgical treatment, performed in Hinchey's stages III and IV, is correlated with the presence of infection in the peritoneal cavity: it is always necessary to remove the septic focus, but there are different reconstruction strategies. The resection of the diseased colonic segment can be performed with primary anastomosis or Hartmann's operation with reconstruction in a later time. In our experience, based on 97 patients (33 of which, Hinchey's III and IV, underwent emergency surgical treatment) we preferred Hartmann's operation which carries a low risk of mortality in seriously ill patients.

Cytosine to uracil conversion through hydrolytic deamination of cytidine monophosphate hydroxy-alkylated on the amino group: a liquid chromatography--electrospray ionization--mass spectrometry investigation.

A novel pathway for cytosine to uracil conversion performed in a micellar environment, leading to the generation of uridine monophosphate (UMP), was evidenced during the alkylation reaction of cytidine monophosphate (CMP) by dodecyl epoxide. Liquid chromatography-electrospray ionization - ion trap - mass spectrometry was used to separate and identify the reaction products and to follow their formation over time. The detection of hydroxy-amino-dodecane, concurrently with free UMP, in the reaction mixture suggested that, among the various alkyl-derivatives formed, CMP alkylated on the amino group of cytosine could undergo tautomerization to an imine and hydrolytic deamination, generating UMP. Interestingly, no evidence for this peculiar conversion pathway was obtained when guanosine monophosphate (GMP), the complementary ribonucleotide of CMP, was also present in the reaction mixture, due to the fact that NH(2)-alkylated CMP was not formed in this case. The last finding emphasized the role played by CMP-GMP molecular interactions, mediated by a micellar environment, in hindering the alkylation reaction at the level of the cytosine amino group.

Barrett's esophagus, esophageal and esophagogastric junction adenocarcinomas: the role of diet.

Identification of modifiable risk factors is an attractive approach to primary prevention of esophageal adenocarcinoma (EAC) and esophagogastric junction adenocarcinoma (EGJAC). We conducted a review of the literature to investigate the association between specific dietary components and the risk of Barrett's esophagus (BE), EAC and EGJAC, supposing diet might be a risk factor for these tumors. Consumption of meat and high-fat meals has been found positively associated with EAC and EGJAC. An inverse association with increased intake of fruit, vegetables and antioxidants has been reported but this association was not consistent across all studies reviewed. Few studies have examined the association between diet and BE. Additional research is needed to confirm the aforementioned association and clarify the mechanisms by which dietary components affect the risk of developing EAC and EGJAC. Future studies could advance our knowledge by emphasizing prospective designs to reduce recall bias, by using validated dietary intake questionnaires and biological measures and by considering important confounders such as gastro-esophageal reflux disease (GERD) symptoms, tobacco and alcohol use, biometrics, physical activity, and socioeconomic factors.

Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE), endorsed by the European Society for Radiotherapy and Oncology (ESTRO), the European Society of Digestive Endoscopy (ESDO), and the European Society for Clinical Nutrition and Metabolism (ESPEN). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations for malignant disease 1 ESGE recommends placement of partially or fully covered self-expandable metal stents (SEMSs) for palliative treatment of malignant dysphagia over laser therapy, photodynamic therapy, and esophageal bypass (strong recommendation, high quality evidence). 2 For patients with longer life expectancy, ESGE recommends brachytherapy as a valid alternative or in addition to stenting in esophageal cancer patients with malignant dysphagia. Brachytherapy may provide a survival advantage and possibly a better quality of life compared to SEMS placement alone. (Strong recommendation, high quality evidence.) 3 ESGE recommends esophageal SEMS placement as the preferred treatment for sealing malignant tracheoesophageal or bronchoesophageal fistula (strong recommendation, low quality evidence). 4 ESGE does not recommend the use of concurrent external radiotherapy and esophageal stent treatment. SEMS placement is also not recommended as a bridge to surgery or prior to preoperative chemoradiotherapy. It is associated with a high incidence of adverse events and alternative satisfactory options such as placement of a feeding tube are available. (Strong recommendation, low quality evidence.) Main recommendations for benign disease 1 ESGE recommends against the use of self-expandable stents (SEMSs) as first-line therapy for the management of benign esophageal strictures because of the potential for adverse events, the availability of alternative therapies, and costs (strong recommendation, low quality evidence). 2 ESGE suggests consideration of temporary placement of SEMSs as therapy for refractory benign esophageal strictures (weak recommendation, moderate evidence). Stents should usually be removed at a maximum of 3 months (strong recommendation, weak quality evidence). 3 ESGE suggests that fully covered SEMSs be preferred over partially covered SEMSs for the treatment of refractory benign esophageal strictures, because of their lack of embedment and ease of removability (weak recommendation, low quality evidence). 4 For the removal of partially covered esophageal SEMSs that are embedded, ESGE recommends the stent-in-stent technique (strong recommendation, low quality evidence). 5 ESGE recommends that temporary stent placement can be considered for treating esophageal leaks, fistulas, and perforations. The optimal stenting duration remains unclear and should be individualized. (Strong recommendation, low quality evidence.) 6 ESGE recommends placement of a SEMS for the treatment of esophageal variceal bleeding refractory to medical, endoscopic, and/or radiological therapy, or as initial therapy for patients with massive esophageal variceal bleeding (strong recommendation, moderate quality evidence).

Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system 1 2 was adopted to define the strength of recommendations and the quality of evidence. Main Recommendations: 1 ESGE recommends endoscopic en bloc resection for superficial esophageal squamous cell cancers (SCCs), excluding those with obvious submucosal involvement (strong recommendation, moderate quality evidence). Endoscopic mucosal resection (EMR) may be considered in such lesions when they are smaller than 10 mm if en bloc resection can be assured. However, ESGE recommends endoscopic submucosal dissection (ESD) as the first option, mainly to provide an en bloc resection with accurate pathology staging and to avoid missing important histological features (strong recommendation, moderate quality evidence). 2 ESGE recommends endoscopic resection with a curative intent for visible lesions in Barrett's esophagus (strong recommendation, moderate quality evidence). ESD has not been shown to be superior to EMR for excision of mucosal cancer, and for that reason EMR should be preferred. ESD may be considered in selected cases, such as lesions larger than 15 mm, poorly lifting tumors, and lesions at risk for submucosal invasion (strong recommendation, moderate quality evidence). 3 ESGE recommends endoscopic resection for the treatment of gastric superficial neoplastic lesions that possess a very low risk of lymph node metastasis (strong recommendation, high quality evidence). EMR is an acceptable option for lesions smaller than 10 - 15 mm with a very low probability of advanced histology (Paris 0-IIa). However, ESGE recommends ESD as treatment of choice for most gastric superficial neoplastic lesions (strong recommendation, moderate quality evidence). 4 ESGE states that the majority of colonic and rectal superficial lesions can be effectively removed in a curative way by standard polypectomy and/or by EMR (strong recommendation, moderate quality evidence). ESD can be considered for removal of colonic and rectal lesions with high suspicion of limited submucosal invasion that is based on two main criteria of depressed morphology and irregular or nongranular surface pattern, particularly if the lesions are larger than 20 mm; or ESD can be considered for colorectal lesions that otherwise cannot be optimally and radically removed by snare-based techniques (strong recommendation, moderate quality evidence).(AU)

Alkylation of complementary ribonucleotides by 1,2-dodecyl-epoxide in a micellar environment: a liquid chromatography-electrospray ionization-sequential mass spectrometry investigation.

Alkylation of a pair of complementary ribonucleotides, adenosine monophosphate (AMP) and uridine monophosphate (UMP), was accomplished by 1,2-dodecyl-epoxide (DE) in a oil-in-water microemulsion based on the cationic surfactant Cetyl-trimethyl-ammonium-bromide, providing a suitable catalytic interface for the reagents. Several, often isomeric, alkylation products, bearing one or two hydroxy-dodecyl moieties on their structures, were identified in the reaction mixtures by high-performance liquid chromatography coupled to electrospray ionization ion trap mass spectrometry. In particular, mass spectrometry (MS)/MS spectra, implemented by extracted ion chromatograms obtained for peculiar MS/MS product ions, indicated alkylation to occur on uracil and on uracil/phosphate OH groups in singly and doubly alkylated UMP, respectively. Adenine NH2 group and phosphate or ribose OH groups were found to be involved as such (single alkylation) or in combination, in the case of alkylated derivatives of AMP. The reaction of both endocyclic N and C=O groups (tautomerized to C-OH groups) of uracil and the predominance of nucleophilic attack to the more accessible carbon of the DE epoxydic bridge (the only exception being the reaction by the NH2 group of adenine) were inferred from MS3 spectra with the help of extracted ion chromatograms for specific fragment ions, after their structural characterization. Interestingly, alkylation on one of the uracil C=O groups and, partially, on the adenine NH2 group, both potentially involved in AMP/UMP base pairing in the micellar environment, were found to be hindered when both ribonucleotides were present in the reaction mixtures.

Novel surfactant-based adsorbent material for groundwater remediation.

Many surfactants aggregate spontaneously in aqueous media to form small spherical structures called micelles. Among the numerous technical applications it is known that micelles have the ability to dissolve in their hydrophobic part significant amounts of water-insoluble organic compounds. In this study we investigated through UV-vis spectroscopy the micellar solubilization of 2,4,5-trichlorophenol (Tcp), an intermediate product of the microbial degradation of the broad-leaf herbicide 2,4,5-trichlorophenoxyacetic (2,4,5-T). Our results show that in the presence of the anionic surfactant sodium dodecylsulfate SDS the water solubility of Tcp increases six-fold whereas with cationic CTAB and nonionic Triton-X 100 the partition of chlorinated compound is not efficient. After the excess amount of the pollutant solubilized in SDS-micelles has been precipitated with CaCl2 the remaining fraction of Tcp has been successfully reduced within the toxicological limit for drinkable water through a cocurrent multistage operation. Finally, potential use in the decontamination of wastewater or soils of the new adsorbent material has been compared with the most commonly used activated carbon and silica gel.

Psychometric properties of an Italian version of the Barratt Impulsiveness Scale-11 (BIS-11) in nonclinical subjects.

To assess the psychometric properties of the Italian translation of the Barratt Impulsiveness Scale-11 (BIS-11), the scale was administered to 763 college undergraduates. Based on analyses using item-total correlations and t-tests for differences between the top and the bottom total score quartiles, all items from the English version of the BIS-11 were retained in the Italian version. Cronbach's alpha for internal consistency was.79 and two-month test-retest reliability was.89. An exploratory principal-components analysis replicated the six first-order factors and three oblique second-order factors, consistent with the number identified in the English version. However, subfactor item loadings differed between the English and Italian versions. The overall item pool was consistent in being a homogeneous measure of impulsiveness. The BIS-11 total score was correlated significantly with aggression and ADHD measures. The BIS-11 also significantly differentiated between high and low levels of binge eating, alcohol consumption, and cigarette smoking.

The retrospective assessment of childhood attention deficit hyperactivity disorder in adults: reliability and validity of the Italian version of the Wender Utah Rating Scale.

To assess the reliability and validity of the Wender Utah Rating Scale (WURS), 759 Italian undergraduate students were administered the Italian version of the WURS. In this sample, the WURS showed good internal consistency reliability (Cronbach alpha =.888). Both 1-week (r =.981, P <.001) and 2-month (r =.924, P <.001) retest reliabilities were satisfactory. The mother/subject agreement on the WURS total score was large: intraclass r =.883, P <.001. The principal component (PC) analysis showed the presence of three positively correlated first-order PCs, and one second-order PC. This PC structure of the WURS was replicated in an independent sample of 300 consecutively admitted psychiatric inpatients and outpatients. Finally, in a sample of 132 secondary school students, the WURS showed a moderate correlation with the Conners Abbreviated Parent and Teacher Questionnaire (CAPTQ): r =.307, P <.001. In this sample, the WURS total score was negatively correlated with school performance (rho = -.460, P <.001) and conduct (rho = -.293, P <.005) indexes.