EUS-guided biliary drainage with placement of a new partially covered biliary stent for palliation of malignant biliary obstruction: a case series.

Endoscopic ultrasonography-guided biliary drainage (EUS-BD) has been developed as an alternative drainage technique in patients with obstructive jaundice where endoscopic retrograde cholangiopancreatography (ERCP) has failed. Between July 2008 and December 2009, 16 patients (9 men; median age 79 years) with biliopancreatic malignancy, who were candidates for alternative techniques of biliary decompression because ERCP had been unsuccessful, underwent EUS-BD with placement of a transmural or transpapillary partially covered nitinol self-expandable metal stent (SEMS). EUS-assisted cholangiography was successful in all patients, with definition of the relevant anatomy, but biliary drainage was successfully performed in only 12 (75 %) of the 16 patients (9 choledochoduodenostomies with SEMS placement and 3 biliary rendezvous procedures with papillary SEMS placement), with regression of the cholestasis. No major complications and no procedure-related deaths occurred. There was one case of pneumoperitoneum which was managed conservatively. The median follow-up was 170 days. During the follow-up, eight patients of the 12 patients in whom biliary draining was successful died; four are currently alive. None of the patients required endoscopic reintervention. This series demonstrated that EUS-BD with a partially covered SEMS has a high rate of clinical success and low complication rates, and could represent an alternative choice for biliary decompression.

Carbon dioxide insufflation versus air insufflation during endoscopic retrograde cholangiopancreatography under general anesthesia.

AIM: The aim of this paper was to evaluate the effect of carbon dioxide (CO2) vs. air insufflation on post-endoscopic retrograde cholangiopancreatography (ERCP) abdominal pain and distension. In addition, we investigated the changes in the partial pressure of end-tidal CO2 (PetCO2) and the partial pressure of arterial CO2 (PaCO2). METHODS: From October 2009 to January 2010, all patients admitted to our centre for ERCP were screened for enrollment; the patients recruited were randomised to CO2 or air insufflation. The patients were asked to rate their abdominal pain intensity and distension using a 100-mm Visual Analogue Scale (VAS) before, in the recovery room and at 1, 3, 6 and 24 hours after the ERCP. All anesthesiological and endoscopic details and complications were evaluated. RESULTS: We included 76 patients, 39 in the Air group and 37 in the CO2 group. The groups were similar for age, gender, indications and duration of the procedure. Post-procedure mean values of pain (in the recovery room and at 1, 3 and 6 hours) and distension (at recovery room, and at 1 and 3 hours) according to the VAS were significantly reduced in the CO2 group as compared to the Air group. At baseline, the PetCO2 values were similar between the two groups while, during the ERCP, they increased significantly in CO2 group as compared to the Air group; these values were reduced by simply increasing the ventilation. CONCLUSION: CO2 insufflation during ERCP significantly reduces post-procedural abdominal pain and distension. Increased PetCO2 and PaCO2 values remained within acceptable or readily controllable ranges.

Short- and long-term outcomes of self-expanding metal stent placement as a bridge to surgery for acute left-sided colorectal cancer obstruction.

AIM: The aim of this study was to evaluate the short- and long-term outcomes of self-expanding metal stent (SEMS) insertion as a bridge to surgery (BTS) in patients presenting with acute left-sided colorectal cancer obstruction (LCCO). METHODS: All patients with acute LCCO who underwent endoscopic SEMS placement as a BTS between January 2005 and December 2010 were reviewed and included in the study. RESULTS: Thirty-six patients (19M and 17F; mean age 68.5) were included. The most frequent location was the sigmoid colon (47.2%). Technical success was achieved in 91.6% and clinical success in 88.9%. Technical failure was related to the location of the stricture at the rectosigmoid junction (P=0.03). There were four SEMS-related complications: one fecal obstruction, one haemorrhage treated with APC and two silent perforations which were noted during surgical resection. The mean time between SEMS insertion and surgical treatment was 19 days (range 6-80 days) and the most frequent intervention was a left hemicolectomy (46.9%). No intraoperative mortality and morbidity, or postoperative mortality were observed. The postoperative morbidity rate was 18.8% (two wound infections, one deep venous thrombosis, one case of pneumonia and one anastomotic dehiscence). Finally, after discharge from hospital, a total of 29 patients (90%) were stoma free. At the end of the follow-up period, 24 patients are still alive and the mean survival rate was 37.3±18 months (range 9-72). CONCLUSION: In our experience, SEMS placement as a BTS is a safe and effective strategy for the treatment of patients with acute LCCO.

The Po Delta is restarting progradation: geomorphological evolution based on a 47-years Earth Observation dataset.

From the 1950s, the Po delta, one of the largest anthropogenic world deltas, has been subjected to a fast degradation and shoreline retreat due a marked reduction of sediment supply, mainly controlled by human impacts/factors, including subsidence. Through the interpretation of satellite images, coupled with the analysis of the flow discharge, and of the annual frequency of marine storms, we show that recently (>2010) the Po River has resumed delta progradation, especially in its northern portion. This happens after decades of erosion, followed by alternating regrowth and degradation phases, indicating conditions of substantial stability (1970-2000). Today the delta shows aggradation of new mouth-bars at the main distributary mouth, a clear evidence of active constructive processes. The ongoing trend marks a countertendency compared to many deltas worldwide.

Three-year retrospective analysis of the incidence of Toxoplasma gondii infection in pregnant women living in the Greater Romagna Area (northeastern Italy).

The aim of this study was to assess the incidence of Toxoplasma gondii infection in a population of pregnant women living in the Romagna area of the Emilia-Romagna region. From 1 January 2012 to 31 December 2014, 36 876 pregnant women were tested to evaluate the IgG- and IgM-specific anti-T. gondii response. The average incidence was 0.192%, underlining the need for an appropriate and active screening for toxoplasmosis during pregnancy.

Effects of early ductal decompression in human biliary acute pancreatitis.

It was recently demonstrated in experimental models that, after pancreatic outflow obstruction, serum amylase levels first increase and then progressively decline regardless of whether the obstruction was maintained or relieved. Furthermore, early decompression of the ductal biliary system may prevent the progression of the disease. This finding prompted us to look for a similar pattern in patients with obstructive acute pancreatitis due to biliary stones. Forty-two patients with biliary acute pancreatitis were prospectively studied. Twenty-one patients underwent urgent endoscopic sphincterotomy (ES), and 21 received conservative medical treatment (CMT). The two groups were comparable for sex, age, onset of pain, and severity. Serum amylase and lipase were determined in all patients on admission and 24 h later. The percentage variation of serum amylase and lipase was calculated considering, for each patient, the concentrations of the two enzymes assayed on admission and 24 h later. On admission, all patients had elevated serum concentrations of amylase (mean +/- SEM: ES, 2,560+/-473 U/L; CMT, 1,783+/-481 U/L) and lipase (ES, 3,037+/-574 U/L; CMT, 3,179+/-724 U/L). The serum amylase variation (mean +/- SEM) was -65.6+/-5.5% in the ES and -47.2.1+/-8.1% in the CMT patients. The serum lipase variation was -59.1+/-7.7 and -33.1+/-18% in the same groups, respectively. These differences were not statistically significant. Acute pancreatitis worsened in one patient in the ES group and in seven in the CMT group; this difference was statistically significant (p < 0.02). The mean length of hospitalization was 8.9 days in the ES group and 19.7 days in the CMT group (p < 0.001). Serum pancreatic enzymes determination is not useful to evaluate the results of the early decompression of biliary duct in human acute pancreatitis. Indeed, early endoscopic sphincterotomy may result in a substantial improvement in the outcome of biliary acute pancreatitis.

Circulating lymphocyte subsets in human acute pancreatitis.

We investigated peripheral lymphocyte subsets in 34 consecutive acute pancreatitis patients (21 males, 13 females; mean age, 57 years; range, 16-85 years) studied within 48 h of pain onset and for 5 consecutive days to understand better the immunological response during the course of the disease. The diagnosis was based on characteristic abdominal pain associated with a twofold increase in serum lipase and confirmed by imaging techniques in all patients. Acute pancreatitis was of biliary origin in 25 patients, due to alcohol abuse in 5, due to pancreas divisum in 1, and of unknown origin in 3. Fifteen patients had severe illness and 19 had mild disease. In all patients, total lymphocyte and lymphocyte subset counts were carried out on admission, as well as on the third and fifth day of hospitalization, using a flow cytometric analysis. Twenty-three patients (13 with severe illness and 10 with mild disease) also had a repeat count 1 month after recovery. Twenty-five healthy subjects and 27 patients with nonpancreatic acute abdomen comparable for sex and age were studied as controls. On the first day of the study, the leukocyte number was significantly higher in patients with acute pancreatitis and in those with nonpancreatic acute abdomen with respect to healthy subjects, whereas the number of total and CD4+, CD8+, CD3+ DR-, and CD3- DR+ lymphocytes was significantly lower in acute pancreatitis patients than in healthy subjects or in patients with nonpancreatic acute abdomen. These subject counts persisted on the third and fifth days of the study.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum creatinine and chest radiographs in the early assessment of acute pancreatitis.

BACKGROUND: We previously identified serum creatinine values >2 mg/dL (176.8 micromol/L) and pathological chest radiographs due to the presence of pleural effusions or pulmonary densifications as two early prognostic factors of life-threatening acute pancreatitis (AP). The aim of the present study was to validate their prognostic efficacy in combination. METHODS: We analyzed as prognostic factors only the data obtained within 24 hours of admission in 539 cases of AP, including 163 patients (30.2%) with acute necrotizing pancreatitis (NP). Eleven patients (2%) presented with infected pancreatic necrosis, and 20 patients (3.7%) died. RESULTS: One hundred and nine cases (20.2%) presented pathological chest radiographs: 32 (5.9%) pulmonary densifications and 77 (14.3%) pleural effusions (18 right, 25 left, 34 bilateral). Fifty-one patients (9.5%) had serum creatinine values >2 mg/dL. Pathological chest radiographs and serum creatinine values >2 mg/dL were significantly associated both with mortality risk (P <0.00001), with a diagnosis of NP (P <0.00001), and with risk of developing infected necrosis (P <0.0001). Considering positivity of either or both tests, the mortality risk sensitivity was 90% (95% confidence interval [CI] 70.7 to 98.3) with a specificity of 76% (CI 72.5 to 79.8), for the NP diagnosis the sensitivity was 60% (CI 52.5 to 67.4) and the specificity 88% (CI 85.0-91.5), whereas for the risk of infected necrosis the sensitivity was 73% (CI 42.2 to 92.6) and specificity 75% (CI 70.1 to 78.4). These data are comparable to those obtained with the Ranson or Glasgow scores at 24 hour in this patient group, with a cut-off > or =3. CONCLUSIONS: Serum creatinine and chest radiographs are two indices capable of identifying, within 24 hour of admission, a subgroup of acute pancreatitis patients with a more severe or adverse clinical course.

Relapses of biliary acute pancreatitis in patients with previous attack of biliary pancreatitis and gallbladder in situ.

AIM: To evaluate relapse of acute pancreatitis in patients with biliary pancreatitis in whom coexisting diseases or patient refusal have excluded cholecystectomy. PATIENTS AND METHODS: Forty-seven patients presenting a first episode of biliary acute pancreatitis underwent urgent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES). RESULTS: ERCP with ES was successful in all but one patient (97.8%) who was then cholecystectomised. Complications related to the endoscopic procedure were reported in five patients (10.6%). During the follow-up period (median time 12 months; range 1-84 months), 10 patients (21%) suffered from biliary complications. Three patients (6.4%), all with lithiasis of the gallbladder, had relapses of acute pancreatitis, two of them within 2 months of the previous episode, and one about a year later after ingestion of a rich meal and alcoholic beverages. The first two were cholecystectomised. Two patients died during the follow-up period from unrelated diseases. CONCLUSIONS: In subjects who are at high risk for anaesthesia, endoscopic procedures may be utilised.

Silent myocardial ischemia induced by hypoglycemia.

Hypoglycemia is known to produce various EKG changes, including arrhythmias. Although these changes have been rarely documented, their presence may pose diagnostic and therapeutic problems in an emergency situation. We report the case of a 81-year-old man with insulin-dependent diabetes mellitus who showed electrocardiographic features of acute myocardial ischemia during an episode of hypoglycemia; these alterations disappeared after glucose administration.

The use of the peripheral leukocyte count and chest X-rays in early assessment of the severity of acute pancreatitis in comparison with the Ranson score system.

BACKGROUND: To evaluate the efficacy of the peripheral leukocyte count and chest X-rays as an index which could be used in the early assessment of the severity of acute pancreatitis in an Emergency Room. METHODS: We prospectively evaluated the peripheral leukocyte count and the findings of chest X-rays in 181 consecutive patients (102 males, 79 females, mean age 61 years, range 16-97) who were admitted to our Emergency Department with acute pancreatitis. One hundred twenty six patients had mild pancreatitis and 55 had severe pancreatitis. The peripheral leukocyte count and the chest X-rays were evaluated in all patients upon admission. The Ranson criteria were also assessed. RESULTS: Using a cut off value of 13,000/mm3, 45% of the patients with severe pancreatitis and 17% of those with mild acute pancreatitis had a peripheral leukocyte count greater than 13,000/mm3. Pleural or pulmonary alterations observed on chest X-ray were found in 66% of patients with severe pancreatitis and in 2% of those with mild acute pancreatitis. A peripheral leukocyte count greater than 13,000/mm3 and/or pleural or pulmonary alterations present on chest X-ray were found in 78% of the patients with severe pancreatitis and in 19% of those with mild pancreatitis. The Ranson criteria greater than or equal to three were found in 45% of the patients with severe acute pancreatitis and in 16% of those with the mild form of the disease. The positive predictive value was 92% for the presence of alterations on the chest X-rays, 64% for the alteration of at least one of the abnormal findings on the chest X-ray and a peripheral leukocyte count greater than 13,000/mm3, 56% for a peripheral leukocyte count greater than 13,000/mm3, and 54% for the presence of Ranson criteria greater than or equal to three. The negative predictive values were similar. CONCLUSIONS: The presence of pleural or pulmonary alterations on chest X-rays may be useful in the Emergency Room for the early identification of patients with severe acute pancreatitis.

Serum lipase assay. A test of choice in acute pancreatitis.

We evaluated the clinical accuracy of an automated turbidimetric assay for serum lipase determination in order to screen for acute pancreatic damage. Seventy patients with pancreatic and thirty with nonpancreatic digestive diseases were studied. Fifty-two healthy subjects were also studied as controls. Serum lipase concentrations were abnormally high in all patients with acute pancreatitis and in 3 (10%) in the group of 30 patients with nonpancreatic acute abdomen. In the 35 patients with chronic pancreatitis studied during clinical remission, serum lipase levels were abnormally high in 8 (23%), and abnormally low in 3 (9%). In the 9 patients with pancreatic cancer, 4 (44%) had abnormally elevated serum lipase values and 1 (11%) abnormally low. The results indicate that serum lipase determination is useful in the emergency diagnosis of acute pancreatic damage because of its high sensitivity and specificity. In patients with chronic pancreatitis and in patients with pancreatic carcinoma serum lipase determination is of limited value.

Severity of acute pancreatitis: relationship with etiology, sex and age.

BACKGROUND/AIMS: To correlate the severity of acute pancreatitis with the etiology, age and sex of the patients. METHODOLOGY: 158 consecutive acute pancreatitis patients (92 males, 66 females; mean age 59.7+/-18.1 years; mean+/-SD) who were admitted to our Emergency Department between January 1991 and March 1995 were included in this study. The diagnosis of acute pancreatitis was made on the basis of the characteristic abdominal pain associated with hyperamylasemia and hyperlipasemia and was further confirmed by ultrasonography and/or computed tomography findings. RESULTS: Acute pancreatitis was associated with biliary disease in 112 patients (70.9%), due to alcohol abuse in 26 patients (16.5%), due to other causes in 8 (5.1%), and was of unknown origin in 12 (7.6%). On the basis of the Atlanta criteria, 110 patients (69.6%) were diagnosed as having mild acute pancreatitis and 48 (30.4%) as having the severe form of the disease. The age of the males was significantly lower than that of females; the age of patients with biliary pancreatitis was significantly higher than that of the overall population, whereas the age of patients with acute pancreatitis due to other causes was significantly lower. A significantly higher frequency of acute biliary pancreatitis was found in females (97.0%) as compared to males (52.2%), while alcoholic pancreatitis and pancreatitis due to other causes was present only in males (28.3% and 8.7%, respectively). CONCLUSIONS: An age greater than 55 years, the male sex, pancreatitis of unknown origin and alcoholic pancreatitis were positively associated with the severity of the disease.

Electrocardiographic abnormalities in acute pancreatitis.

It has been reported that electrocardiographic abnormalities may be associated with acute pancreatitis. However, the data are lacking or sketchy. The aim of this study was to assess the frequency and type of electrocardiographic abnormalities present in patients with acute pancreatitis. Fifty-six consecutive patients with acute pancreatitis and without previous history of heart disease were studied. Eleven patients had arterial hypertension. Forty-one patients had mild pancreatitis and 15 had the severe form of the disease. On admission, all patients underwent a standard 12-leads electrocardiogram and a serum electrolyte determination. Nineteen healthy subjects were also studied as controls. Twenty-seven patients (48.2%) (10 with severe pancreatitis and 17 with mild pancreatitis) had a normal electrocardiogram. In the remaining 29 patients (51.8%), one patient with severe pancreatitis had atrial extrasystoles and eight had bradycardia (less than 60 beats/minute) (two with severe pancreatitis and six with mild pancreatitis); 14 patients had changes of the T-wave and/or the ST-segment (two with severe pancreatitis and 12 with mild pancreatitis); seven patients showed disturbances of the intraventricular conduction (one with severe pancreatitis and six with mild pancreatitis): four had left anterior hemiblock, two had complete left bundle branch block and one had left anterior hemiblock and incomplete right bundle branch block; one patient with mild pancreatitis had atrioventricular block (first degree). No differences in heart rate, RR interval, PR interval and QT interval were found when patients with acute pancreatitis were compared with healthy subjects, nor when patients with severe pancreatitis were compared with those having the mild form of the disease. Seventeen of the 29 patients with electrocardiographic abnormalities (52.6%) also had serum electrolyte alterations. More than 50% of the patients with acute pancreatitis had electrocardiographic abnormalities and electrolyte alterations were also present in about one-half of these.

[Management of vaccination practices in adults: the influenza vaccination campaign in Lazio region, Italy]. / Modelli organizzativi di profilassi vaccinale nell'adulto: l'esperienza della campagna di vaccinazione antinfluenzale nella regione Lazio.

This paper focuses on key issues of the organizational model of the influenza vaccination campaign in Lazio region, Italy, started during the 1999-2000 season. The following crucial features of the model are emphasized: a strong support given by Regional Health Agency; a high level of commitment of local health authorities; a considerable involvement of general practitioners; the appropriation of economical incentives related to different levels of coverage; an "ad hoc " information system. The model resulted in a remarkable increase of the number of vaccinations among elderly population (from about 420,000 in the 2000-2001 vaccination campaign to about 560,000 in the successive campaign) and of the correspondent levels of coverage (from 45.7% in the 2000-2001 vaccination campaign to 59.2% in the successive campaign). Nevertheless, further efforts should be provided to better identify population at risk, and to reach the most disadvantaged groups. Moreover, actions are to be performed to assess health and economic benefits of vaccination campaign, in order to improve the efficiency of health care planning programs.

Serum amylase and lipase concentrations and lipase/amylase ratio in assessment of etiology and severity of acute pancreatitis.

We studied the behavior of serum amylase and lipase in 66 consecutive patients with acute pancreatitis in order to assess the ability of these tests and of the serum lipase-amylase ratio to establish the etiology and predict the severity of acute pancreatitis. Forty-two patients had biliary acute pancreatitis, 14 had alcoholic acute pancreatitis, and the remaining 10 nonbiliary, nonalcoholic (NBNA) acute pancreatitis. Serum amylase and lipase were abnormally high in all patients. The elevations of both serum amylase and lipase were significantly lower in patients with alcoholic pancreatitis than in those with biliary pancreatitis, although a considerable overlap was observed between the two groups. No statistically significant differences were found between NBNA patients and those with either biliary or alcoholic forms of the disease. The serum lipase-amylase ratios in patients with alcoholic pancreatitis ranged from 0.2 to 5.6, in those with biliary pancreatitis from 0.1 to 7.9, and in those with NBNA pancreatitis from 0.1 to 4.4. These differences were not statistically significant. No differences in serum enzyme levels were observed among patients without apparent imaging signs of acute pancreatitis (N = 20), those with signs of pancreatic edema (N = 36), and those with necrotizing pancreatitis (N = 10). The results indicate that serum amylase and lipase concentrations are not able to establish either the etiology or to predict the severity of acute pancreatitis as assessed by imaging techniques. Furthermore, the serum lipase-amylase ratio is not useful in distinguishing acute episodes of alcoholic from nonalcoholic acute pancreatitis.

Serum interleukin-10 in human acute pancreatitis.

Interleukin 10 (IL-10) recently emerged as an antiinflammatory cytokine that inhibits the secretion of proinflammatory cytokines by monocytes and/or macrophages and the release of free oxygen radicals. It has been reported that treatment with IL-10 decreases the severity of experimental pancreatitis, mainly by inhibiting cellular necrosis. The aim of this study was to evaluate the behavior of serum IL-10 in patients with acute pancreatitis and to explore the possibility of a relationship between this cytokine and severity of the disease. Forty-five patients with acute pancreatitis were studied. Acute pancreatitis was of biliary origin in 30 patients, due to alcohol abuse in 10, due to pancreas divisum in 1, and of unknown origin in the remaining 4. According to the Balthazar criteria, 19 patients had scores of A, B, or C and 25 had scores of D or E. Twelve healthy subjects were also studied as controls. Serum IL-10 was determined in all subjects on admission, and in acute pancreatitis patients also daily for the following four days using a commercial kit. Healthy subjects had no detectable serum levels of IL-10. In acute pancreatitis patients, serum IL-10 levels were increased on the first day of the disease and then progressively decrease in the following days. On the first day of the acute pancreatitis, patients with the mild disease had serum levels of IL-10 significantly higher than those with severe disease, whereas in the following days, no statistically significant difference was observed between the two groups. The elevation of IL-10 on the first day of the illness is more marked in patients with mild acute pancreatitis than in those with the severe form of the disease. The finding of low values of serum IL-10 in severe acute pancreatitis suggests that there may be altered down-regulation of the immune system response in these patients.