Plasma pentraxin 3 in idiopathic inflammatory myopathies: a possible new biomarker of disease activity.

Pentraxin-3 (PTX3) is a component of humoral innate immunity with essential functions both in promotion and resolution of inflammation. We aimed to study the PTX3 in the plasma and in the muscle of patients with idiopathic inflammatory myopathies (IIM) and whether PTX3 may correlate with disease activity. Plasma PTX3 levels were assessed in 20 patients with IIMs, 10 dermatomyositis (DM), and 10 polymyositis (PM), compared to 10 patients with rheumatoid arthritis (RA) and 10 healthy donors (HDs) aged, sex, and body mass index matched. Disease activity in IIMs was assessed by Myositis Disease Activity Assessment Visual Analog Scale (MYOACT), while disease activity score on 28 joints (DAS28) was used for RA patients. Muscle histopathology and immunohistochemical (IHC) analyses were also performed. Mean plasma PTX3 levels were significantly higher in IIM patients than HDs (518 ± 260 pg/ml vs. 275 ± 114 pg/ml, P = 0.009). Linear regression analysis adjusted for age, sex, and disease duration showed a direct correlation between PTX3 and CPK levels (ß: 0.590), MYOACT (ß: 0.759), and physician global assessment of disease activity (ß: 0.832) in IIMs. No association between PTX3 levels and DAS28 was found in RA. Global PTX3 pixel fraction was higher in IIM than HDs muscle, but a lower PTX3 expression was found in perifascicular areas of DM and in myofibers with sarcolemmal staining for membrane attack complement. PTX3 plasma levels were increased in IIMs and correlated with disease activity suggesting a possible role as biomarker of disease activity. PTX3 showed a different distribution in DM or PM muscle.

Intestinal occlusion by stenotic neuroendocrine tumours of left colon and concomitant association with small bowel gastrointestinal stromal tumours: A case report.

INTRODUCTION: The association between Gastrointestinal Stromal Tumours (GIST) and Neuroendocrine Tumours (NET) is very rare. These tumours have various clinical expressions and sometimes are asymptomatic. Synchronous NETs and GISTs have been already described in literature in few case reports. On the other hand, there is no mention of concomitant presence of discending colon NEC-G3 and small intestinal GIST. PRESENTATION OF CASE: we presented a case of a patient with clinical evidence of intestinal occlusion and radiological and intraoperative aspects of an adenocarcinoma of the left colon with a single metastasis on small bowel. The pathology analysis of the tumour showed a stenotic left colon NEC-G3 and a small bowel GIST. DISCUSSION: In this case report GIST was surgically treated as a small bowel ripetitive lesion and NET as a left colon adenocarcinoma. These tumours may have a similar presentation in terms of symptoms, endoscopic findings and imaging results. CONCLUSION: Concomitant NEC and GIST is rare but it is important to investigate patients before surgery in order to distinguish these from other tumours because of the different prognosis.

"Syndrome in syndrome": Wernicke syndrome due to afferent loop syndrome. Case report and review of the literature.

Wernicke syndrome is a rare neurological pathology due to a deficit in vitamin B1. The syndrome is common among alcohol abusers, patients with malignant tumor or gastrointestinal diseases, those who undergo hemodialysis or long-term peritoneal dialysis, pregnant women with hyperemesis, women who breast-feed, patients with hyperthyroidism or anorexia nervosa or gastric or jejunal-ileal bypass surgery for obesity, patients submitted to gastric surgery or prolonged total parenteral nutrition or prolonged intravenous therapy. We report a case of Wernicke syndrome due to afferent loop syndrome characterized by incoercible vomiting.

[The role of palliation in peri-ampullar tumors in the elderly]. / Il ruolo della palliazione nei tumori periampollari in età geriatrica.

Authors wonder about the actual part of the palliative practices in periampullar cancers of the geriatric age, and the choice criteria of the different surgical options that are practicable. They reaffirm that the common radical operation is the pancreaticoduodenectomy, even if, as it is verifiable in the relevant literature and in our series of cases, it is practicable only a few times. The necessity of amending the toxic-septic condition of the neoplastic cholestasis, which certainly is more unfavourable during the geriatric age, gives to the palliative procedures a better role, because few patients could be treated with a curative intention. Authors report their experience and their results about the icterus regression, mortality, morbidity and the average survival rate. About the surgical palliative options of the bilio-digestive shunts, they give the same importance to the gallbladder jejunostomy and to the common bile duct jejunostomy, granting to the first their preference in the geriatric age for the simplest and rapid execution. They point out the necessity of the gastrojejunostomy in all the present or incipient jejuno's obstruction, because of the surgical action importance, and to avoid another operation. They give, even in the geriatric age, their preference to the surgical palliative treatments, proposing to reserve the endoscopic and radiologic practices to the patient undergoing an operation for the precarious general state, for the high operating risk and the modest residual life. In fact, the non surgical treatments are suitable to amend the neoplastic cholestasis, but they aren't equivalent to the surgical palliative, that is more effective for the greater survivals, a better life's quality, a smaller mortality and morbidity.

Microsatellite instability and mutation analysis among southern Italian patients with colorectal carcinoma: detection of different alterations accounting for MLH1 and MSH2 inactivation in familial cases.

BACKGROUND: Microsatellite instability (MSI) is due to defective DNA mismatch repair (MMR) and has been detected at various rates in colorectal carcinoma (CRC). The role of MSI in colorectal tumorigenesis was assessed further in this study by both microsatellite analysis of two CRC subsets [unselected patients (n = 215) and patients <50 years of age (n = 95)], and mutation screening of the two major MMR genes MLH1 and MSH2 among familial CRC cases. PATIENTS AND METHODS: PCR-based microsatellite analysis was performed on paraffin-embedded tissues. In CRC families, MLH1/MSH2 mutation analysis and MLH1/MSH2 immunostaining were performed on germline DNA and MSI+ tumour tissues, respectively. RESULTS: The MSI+ phenotype was detected in 75 (24%) patients, with higher incidence in early-onset or proximally located tumours. Among 220 patients investigated for family cancer history, MSI frequency was markedly higher in familial [18/27 (67%)] than in sporadic [32/193 (17%)] cases. Three MLH1 and six MSH2 germline mutations were identified in 14 out of 36 (39%) CRC families. Prevalence of MLH1/MSH2 mutations in CRC families was significantly increased by the presence of: (i) fulfilled Amsterdam criteria; (ii) four or more CRCs; or (iii) one or more endometrial cancer. While MSH2 was found mostly mutated, almost all [8/9 (89%)] familial MSI+ cases with loss of the MLH1 protein were negative for MLH1 germline mutations. CONCLUSIONS: Both genetic (for MSH2) and gene-silencing (for MLH1) alterations seem to be involved in CRC pathogenesis.

[Early colorectal reoperation: risk factors]. / Reinterventi precoci in chirurgia colorettale: fattori di rischio.

The aim of the study was to analyse the risk factors in colorectal reoperation. Over the period from January 1987 to December 1999, 371 patients (191 male and 180 female, aged from 16 to 88 years) underwent colorectal surgery. Eighteen reoperations (12 male, 6 female, aged from 20 to 74 years; median age: 52.6 years) were performed. These included reoperations performed within 30 days of the first operation (or patient admission). The overall incidence of reoperation after colorectal surgery was 4.8% (18/371). In 14 of 18 patients (77%) anastomotic dehiscence was the indication for reoperation. In our experience, the mortality rate was 16.6% (3/18), in agreement with other reports in the literature. Analysis of risk factors in colorectal reoperation poses several methodological problems because we have no randomized multicentre studies that analyse risk factors in colorectal reoperation and the related surgical mortality.

[Palliative treatments in obstructive jaundice due to periampullary neoplasms]. / I trattamenti palliativi dell'ittero ostruttivo da neoplasie periampollari.

OBJECTIVE: The evaluation of the palliative procedures, surgical and endoscopical or radiological, in the treatment of patients affected by obstructive jaundice resulting from periampullary tumors. SUBJECTS: Patients with jaundice by periampullary tumors undergoing to surgery or to endoscopical or radiological procedures from january 1987 to april 1998. RESULTS: Jaundice has come down in all patients after surgery. Mortality after surgery was 5.2% (5.9% in geriatric patients); morbidity 15.8% (17.6% in geriatric patients) survival 10.4 months after surgery (8.8 months in geriatric patients) versus 3.1 months after non surgical procedures. DISCUSSION: In all patients periampullary tumors are more frequent than hepatic hilum and common bile duct tumors. We have performed surgical and not surgical palliative procedures more frequently than curative resection (DCP), especially in geriatric patients (94.5% versus 79%). In geriatric patients we have chosen, between bile-digestive by-passes, the cholecysto-jejunal anastomosis because it is easier and faster to carry out than choledochojejunal anastomosis with the same results as well as from literature data. We have always performed a gastroenteric anastomosis in association with palliative surgical procedures to prevent or to solve a duodenal obstruction. This additional treatment didn't show an increasing of mortality and morbidity as well as from literature data. CONCLUSIONS: We have reserved the palliative non surgical procedures only to high surgical risk patients. In the other cases we have chosen palliative surgery for better long-term results and quality of life in the general series patients as well as in geriatric patients.

A catastrophic complication of systemic lupus erythematosus: massive mesenteric infarction.

The AA reports a case of a 64-year-old female patient affected for 3 years by systemic lupus erythematosus who developed a massive perforating mesenteric infarction. An immediate surgical treatment with resection of the small bowel and right colon followed by a side-to-side primary anastomosis between the remaining jejunum and transverse colon were performed. The patient died 15 days after surgery due to recurrence of a mesenteric and pulmonary thromboembolia.

[Primary non-Hodgkin's lymphoma of the stomach (a rare case of extensive spread to the entire organ)]. / Linfoma non-Hodgkin primitivo dello stomaco (su un raro caso di estesa diffusione all'intero viscere).

Primary gastric lymphoma is the most frequent extra nodal primary site for non-Hodgkin's lymphoma (NHL) and is itself uncommon. Moreover, a massive infiltration of all stomach (from cardias to antrum) simulating a linitis plastica, it's rare. We present a case report of this atypical presentation of primary gastric NHL in a 73 year old females. The patient came to our observation complaining of dyspepsia, epigastric pain and vomiting from 7 months associated with weight loss and asthenia. Physical examination revealed an epigastric palpable mass. Computed tomographic findings has been necessary to confirm that the massive infiltration of gastric wall (from cardias to pylorus) was ascribed to lymphoma. Dawson's criteria was respected to define primary gastric NHL and was performed a total gastrectomy with systematic lymphadenectomy. The histopathological evidences have confirmed clinical diagnosis of primary gastric NHL. Preoperative diagnosis to clarify the nature of lesions (primary or not) and accurate staging of neoplasm before the operation are indispensable for a correct therapeutic approach; in according to the Ann Arbor classification modified by Musshoff our cases was stage IIE and radical gastrectomy with systematic lymphadenectomy was performed. Surgical resection is generally considered to have a definitive role in the treatment of primary gastric lymphoma specially for the stage IE and IIE.

[Our directions for the treatment of colorectal cancer]. / Nostri indirizzi nel trattamento del cancro colo-rettale.

Authors make a review of personal experience in colorectal surgery from 1998 to 1997 (18 year) and indicate the own opinion about oncological principle of colorectal surgery. Colo-rectal cancer is the most frequent tumor in West Countries (United States 156,000 new case/year, Europe 58,300 deaths/year). A Medline analysis using terms "colon and rectal cancer" prove a progressive increasing of interest about many problems regard prevention, diagnosis, prognosis and therapy of colorectal cancer. Prognosis of colorectal cancer depend on correct and complete stadiation. The most used classifications are Dukes classification, modified from Astler-Coller, and TNM classification of UICC. In the past years oncologic al principle of colorectal surgery was modified from a new debated concept of oncological radicality. The authors analyze own experience in comparison to Literature about the "no touch isolation technique", the principle of vascular ligation at the origin of vessels, lymphectomy extension, total mesorectal excision, surgical decision about advanced loco-regional cancer, surgical decision of complicated colorectal cancer (perforation and occlusion), the role of bilateral prophylactic ovariectomy, surgical treatment of liver metastasis, correct indication of T.E.M. and finally the role of laparoscopic surgery for the treatment of colorectal cancer.

[The indications and surgical treatment in the complications of colonic diverticular disease]. / Indicazioni e trattamento chirurgico nelle complicanze della malattia diverticolare del colon.

In this work the authors describe the different stages of diverticulosis and analyze the pathogenetic principal factors. During the period from 1979 to 1998 they observed 420 patients affected by diverticular disease (224 M; 196 F), 42 (10%) of them were operated on for complications. Fifteen patients operated on in elective time underwent a one stage procedure of resection and anastomosis with derivative colostomy; 27 patients were operated on in emergency: 6 patients had one stage procedure of resection and anastomosis with derivative colostomy, 16 patients Hartmann's procedure, 3 patients Mikulicz's procedure and 2 patients colostomy and peritoneal drainage. Two patients died from septic shock. There was absence of postoperative complications for the patients operated on in elective time, while 8 cases (29.6%) showed peritoneal sepsis and 4 cases (14.8%) infection of wound in the patients operated on in emergency. The Authors describe the different surgical options in the treatment of colonic complicated diverticular disease and conclude that the surgical treatment is not definite. A tendency is to make a one-stage procedure of resection and anastomosis and to reduce the Hartmann's procedure or the simple colostomy with drainage of abdominal cavity.

[Cell-mediated immunity and delayed hypersensitivity study in splenectomy patients: a comparative evaluation between IFN-gamma and skin tests]. / Studio dell'immunità cellulo-mediata e dell'ipersensibilità ritardata negli splenectomizzati: valutazione comparativa fra IFN gamma e skin tests.

The authors of this paper attempt to indicate a feasible, easy-to-use and inexpensive instrument for daily assessing and monitoring of splenectomized subjects to see if they are immunocompromised. Skin tests which are considered easy and inexpensive, may be useful for immunological investigation if their effectiveness is considered equal to that of more difficult and expensive methods. They have also assessed the effectiveness of ST in the study of specific cell-mediated immunity in general and also in cases of delayed hypersensibility, comparatively to serum IFN gamma dosage. The latter is produced by Th1 lymphocytes and Natural Killer cells and is considered a reasonable indicator of cell-mediated immunity and Th1-related delayed hypersensibility. The results of this study confirm that ST is effective in 100% of all splenectomized patients compared to positivity of 60% for the compromise of the immunocompetent system revealed by serum IFN gamma dosage in the same sample of patients. In addition, the fundamental role of other cytokines was confirmed. These include IL-2 which is produced by Th1 lymphocytes and whose lack of results in splenectomized patients are immunocompromised. This is revealed not only by IFN gamma dosage but also by ST.

[Appendiceal carcinoid. Clinical observations and therapeutic considerations]. / Il carcinoide dell'appendice. Osservazioni cliniche e considerazione terapeutiche.

The Authors report 3 cases of carcinoid of the appendix discussing the difficult preoperative diagnosis and the different therapeutical options. Between May 1998 and August 1999 36 appendicectomies were performed, in 18 males and 18 females (age 14-89 years; m. a.: 51.5 years). In 3 cases histological response was positive for carcinoid of the appendix. No postoperative mortality or morbility was reported. In one case, the malignancy of histological response made a second operation of typhlectomy necessary, without postoperative complications. The Authors analyze the biological peculiarities and the prognostic factors of appendiceal carcinoid tumors, as size of the tumor and the lymphatic or vascular infiltration of the mesoappendix (and the relative more aggressive surgical treatments) and recommend an appropriate postoperative follow-up since synchronous or metachronous bowel carcinomas are likely to occur.

[Th1-Th2 cytokine correlates (INF-gamma and IL-4) in splenectomized patients]. / Studio delle citochine Th1-Th2 correlate (IFN gamma e IL-4) negli splenectomizzati.

This paper attempts to explain if immunodepression in patients who had undergone a splenectomy may be due to altered balance between Th1-Th2 lymphocyte subpopulations, as shown in several studies on phagocyte and lymphocyte cells. This was achieved by dosing serum levels of IFNg, produced by Th1 lymphocytes and IL-4, produced by Th2 lymphocytes. Final analysis showed immunodepression in splenectomized patients but also emphasized that in 70% of all cases, there is functional damage of T-lymphocytes that continues for several years after the surgery involving both cellular and humoral immunity. Immunoglobulin dosage allows the increase of IgE to be seen in 50% of the splenectomized patients studied, all with allergic symptoms that appeared after the operation. The production of IgE is stimulated by Th2 lymphocytes. This leaves one to believe that splenectomy may favour the persistence of allergens in the blood, the appearance of allergic symptoms and the increase of IgE serum levels in patients with normal Th2 functioning and consequently, with normal or increased IL-4 serum levels.

[Diverticula of the small intestine: the authors' own experience]. / I diverticoli dell'intestino tenue: contributo d'esperienza.

The Authors report the experience acquired in the management of small bowel diverticula at the Emergency Surgical Department of the University of Bari, from 1987 to 1993. After a brief illustration of the few cases observed, the Authors discuss the problems of this rare pathology, which as all types of bowel diverticula, is diagnosed with difficulty. In fact, only in case of complications, with a specific check-up, the lesions may be discovered. Although rarely, emergency surgery may be needed when complications such as bleeding or occlusion occur. Usually the treatment of minor complications (dyspepsia, gripes, steatorrhoea, constipation and diarrhoea) consists of dietetic indications and symptomatic drugs.

[Intrahepatic cholangiojejunostomy on the third segment in non-operable neoplasms of the hepatic hilum]. / La colangiodigiunostomia intraepatica al III segmento nelle neoplasie inoperabili dell'ilo epatico.

The authors report their experience in 19 cases of primitive or secondary tumor of the hilus of the liver which couldn't benefit from radical operation. Palliative treatments--to resolve the jaundice (which is often the only responsible for a short-term exitus)--include surgical (intrahepatic bilio-digestive derivations) and non surgical procedures (PTDB, percutaneous transtumoral intubation). Considering the ephemeral results of the latter, the Authors take peripheral derivative operations into account and particularly the Soupault and Couinaud technique (intrahepatic colangiojejunostomy) performed in 7 patients with satisfying results. It is an easy and quick technique--because of constant anatomical situation of the left intrahepatic biliary distribution and of the superficial location of the duct of the III segment--which allows a lasting biliary decompression with a good residual life.

[The rationale in surgery of hepatic echinococcosis: total pericystectomy and resections. Personal experience]. / Il "razionale" nella chirurgia della echinococcosi epatica: la pericistectomia totale e le resezioni. Esperienza personale.

The Authors report their fifteen years experience in the surgical treatment of hepatic hydatid cysts. They emphasize the difference in the incidence of radical procedures (pericystectomy and hepatic resections) registered in the two periods examined (1980-83 and 1987-93), stressing the role of current diagnostic imaging techniques and improved surgical procedures which allow to perform standard operations for a radical treatment of hepatic hydatid cysts. Total pericystectomy is considered the procedure of choice; rarely it can't be performed (high vascular risk in central cysts located between portal and hepatic veins) and consequently subtotal pericystectomy or conservative treatment are the only possible procedures. Hepatic resection is preferred in case of multiple cysts involving the same lobe or when a giant hydatid cyst replaces the lobe. A further therapeutical resource--in radical procedures--is offered by the use of antihelminth drugs with marked antiparasitic action (albendazole).