Evaluation and management of chronic anorectal and pelvic pain syndromes: Italian Society of Colorectal Surgery (SICCR) position statement.

Chronic pelvic pain is a hidden issue which needs to involve many different usually uncoordinated specialists. For this reason there is a risk that treatments, in the absence of well-defined pathways, common goals, and terminology, may be poorly effective. The aim of the present paper is to summarize the evidence on anorectal pelvic pain, offering useful evidence-based practice parameters for colorectal surgeons' daily activity. Analysis of chronic anorectal and pelvic pain syndromes, the diagnostic and clinical optimal needs for evaluation, and the innumerable low evidence treatments and therapeutic options currently available suggests that a multimodal individualized management of pain may be the most promising approach. The limited availability of dedicated centers still negatively affects the applicability of these principles.

Transanal irrigation in functional bowel disorders and LARS: short-term results from an Italian national study.

PURPOSE: To evaluate the potential benefits associated with the short-term (6 months) treatment with transanal irrigation (TAI) in patients suffering from functional constipation (FC), functional fecal incontinence (FI), and low anterior resection syndrome (LARS). METHODS: A multicenter observational study (12 centers; 369 patients) was conducted to assess the following primary and secondary objectives: to evaluate the level of satisfaction regarding bowel control and quality of life (QoL); to evaluate bowel symptoms severity and dropout frequency and reason. To this aim, validated questionnaires were provided to the patients at baseline (T0) and after 6 months of TAI treatment (T6) performed with the medical device Peristeen® Plus (Coloplast A/S, Denmark). Statistical analyses were conducted to compare the outcomes obtained at T0 and T6. RESULTS: A 6-month treatment with TAI enabled a statistically significant (p < 0.05) improvement of QoL scores, satisfaction scores regarding bowel control, and severity indexes of disorder-related symptoms in patients suffering from FC, FI, and LARS. Globally, 8.0% of patients discontinued the treatment after 6 months as a result of occurrence of symptoms (2.4%) or other justifications (3.8%) such as personal reasons. None of the dropouts were due to treatment inefficacy. CONCLUSION: Results of the present study suggest that short-term TAI treatment is beneficial for patients suffering from functional bowel disorders and LARS. Future analysis of prospective data will focus on the clinical outcomes associated with the long-term use (up to 24 months) of TAI when dealing with these types of medical conditions.

Food stress, but not experimental exposure to mercury, affects songbird preen oil composition.

Mercury is a global pollutant and potent neurotoxic metal. Its most toxic and bioavailable form, methylmercury, can have both lethal and sublethal effects on wildlife. In birds, methylmercury exposure can disrupt behavior, hormones, the neuroendocrine system, and feather integrity. Lipid-rich tissues and secretions may be particularly susceptible to disruption by lipophilic contaminants such as methylmercury. One such substance is feather preen oil, a waxy secretion of the uropygial gland that serves multiple functions including feather maintenance, anti-parasitic defense, and chemical signaling. If methylmercury exposure alters preen oil composition, it could have cascading effects on feather quality, susceptibility to ectoparasites, and mate choice and other social behaviors. We investigated whether exposure to methylmercury, either alone or in association with other stressors, affects preen oil chemical composition. We used a two-factor design to expose adult song sparrows (Melospiza melodia) to an environmentally relevant dietary dose of methylmercury and/or to another stressor (unpredictable food supply) for eight weeks. The wax ester composition of preen oil changed significantly over the 8-week experimental period. This change was more pronounced in the unpredictable food treatment, regardless of dietary methylmercury. Contrary to our prediction, we found no main effect of methylmercury exposure on preen oil composition, nor did methylmercury interact with unpredictable food supply in predicting the magnitude of chemical shifts in preen oil. While it remains critical to study sublethal effects of methylmercury on wildlife, our findings suggest that the wax ester composition of preen oil is robust to environmentally relevant doses of this contaminant.

Evaluation and management of perianal abscess and anal fistula: SICCR position statement.

Perianal sepsis is a common condition ranging from acute abscess to chronic anal fistula. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. Surgery is the main treatment and several procedures have been developed, but the risks of recurrence and of impairment of continence still seem to be an unresolved issue. This statement reviews the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

Non cross-linked equine collagen (Salvecoll-E gel) for treatment of complex ano-rectal fistula.

BACKGROUND: Fistula-in-ano is one of the most commonly presenting anorectal diseases. Sphincter sparing treatment options should be considered in patients with complex fistulas. Salvecoll-E gel is a native collagen deantigenated and purified, non-cross-linked equine dermal extract, with an amino acid composition identical to human collagen. METHODS: The multicentric trial study was a prospective, single-arm observational clinical study with the objective to assess the efficacy of Salvecoll-E gel for anal fistula repair in 70 patients. All patients had undergone preliminary surgical treatment consisting of positioning of a draining loosing seton that was maintained for a period of 4-6 weeks. After seton removal, a gentle debridement and washing of the fistula track was performed. The scar tissue was removed from the internal orifice. Internal opening was covered by a side-to side mucosal suture. Salvecoll-E was injected through the external opening into the fistula track, the external opening it has been opened. RESULTS: Twelve months after surgery, 55 patients demonstrated a clinically healed fistula (78,5%), 15 patients have a recurrence (21,5%). Most of the recurrences were observed in the first 6 months of treatment (13/15, 86.6%). We don't observe any worsening in CCF score. The results obtained at 1 year certainly seem satisfactory and in line with the best results published in literature using mini-invasive techniques. CONCLUSION: Salvecoll-E gel is a promising non-invasive technique for conservative treatment of anal fistulas, it's well tolerated by the patients and, in case of recurrence, reinjection or all other known techniques are feasible.

Evaluation and management of perianal abscess and anal fistula: a consensus statement developed by the Italian Society of Colorectal Surgery (SICCR).

Perianal sepsis is a common condition ranging from acute abscess to chronic fistula formation. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. The key to successful treatment is the eradication of the primary track. As surgery may lead to a disturbance of continence, several sphincter-preserving techniques have been developed. This consensus statement examines the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

Curriculum survey on tobacco education in European dental schools.

BACKGROUND AND AIM: Dental professionals need adequate education in tobacco use prevention and cessation skills. The aim of this study was to identify the level of integration of tobacco education in undergraduate curricula of European dental schools. METHOD: In 2009, a total of 197 European dental schools were identified through web-based searches. An e-mail survey, containing 20 questions, was sent to each head of school/director of education with up to five follow-up e-mails to non-responders. RESULTS: Dental schools from 21 European countries responded to the survey. The overall return rate was 68 out of 197 schools (35%). In 14 (21%) dental schools, the students were requested to be tobacco free, 14 (21%) asked their students to quit tobacco use and 21 (31%) offered students cessation assistance. All responding schools reported that patients were asked about their tobacco use; 59% by taking an oral history, 75% using a general medical history form and 10% using a specific tobacco use history form. A total of 34% of the schools referred smokers to an external counselling clinic, 13% referred to a telephone counselling, and dental students provided brief counselling in 11 schools (16%). Forty-five (67%) dental schools reported to have tobacco education implemented in their curriculum, of these 30 (67%) stated their tobacco curriculum was mandatory. Theoretical education on tobacco culture and its impact on oral health were implemented in 45 (66%) dental schools. However, only 18 (40%) schools have introduced practical skills training to their students. Dental schools assessed their students' theoretical knowledge (27%) and practical training (4%), respectively. CONCLUSION: Even though theoretical tobacco education appears to be acknowledged by many European dental schools, further practical training of undergraduate dental students in tobacco prevention and cessation skills should be encouraged.

Multicentre observational study of the natural history of left-sided acute diverticulitis.

BACKGROUND: The natural history of acute diverticulitis (AD) is still unclear. This study investigated the recurrence rate, and the risks of emergency surgery, associated stoma and death following initial medical or surgical treatment of AD. METHODS: The Italian Study Group on Complicated Diverticulosis conducted a 4-year multicentre retrospective and prospective database analysis of patients admitted to hospital for medical or surgical treatment of AD and then followed for a minimum of 9 years. The persistence of symptoms, recurrent episodes of AD, new hospital admissions, medical or surgical treatment, and their outcome were recorded during follow-up. RESULTS: Of 1046 patients enrolled at 17 centres, 743 were eligible for the study (407 recruited retrospectively and 336 prospectively); 242 patients (32·6 per cent) underwent emergency surgery at accrual. After a mean follow-up of 10·7 years, rates of recurrence (17·2 versus 5·8 per cent; P < 0·001) and emergency surgery (6·9 versus 1·3 per cent; P = 0·021) were higher for medically treated patients than for those treated surgically. Among patients who had initial medical treatment, age less than 40 years and a history of at least three episodes of AD were associated with an increased risk of AD recurrence. There was no association between any of the investigated parameters and subsequent emergency surgery. The risk of stoma formation was below 1 per cent and disease-related mortality was zero in this group. The disease-related mortality rate was 0·6 per cent among patients who had surgical treatment. CONCLUSION: Long-term risks of recurrent AD or emergency surgery were limited and colectomy did not fully protect against recurrence.

p27Kip1 is inactivated in human colorectal cancer by cytoplasmic localization associated with activation of Akt/PKB.

p27Kip1 is a nuclear member of the Kip/Cip family of cyclin-dependent kinase inhibitors and is a negative cell cycle regulator that is thought to play a role in tumour suppression. Reduced levels of p27Kip1 are frequent in human cancers and these have been associated with poor prognosis. We have analysed p27Kip1 expression and intracellular localization in 70 human colorectal cancers by western blotting and immunohistochemistry and the results related to Akt expression and clinical pathological parameters. p27Kip1 protein expression, as evaluated by western blotting, was absent or reduced in about 63% of colorectal cancers compared with both peritumoral and normal tissue. Cytoplasmic p27Kip1 was detected, by immunohistochemical analysis, in 30% (21 of 70) of cases indicating that translocation of p27Kip1 protein into the cytoplasm may be responsible for p27Kip1 inactivation. The analysis of phosphorylated Akt by western blotting indicated that it was expressed in 38% (8 of 21) of tumours showing cytoplasmic p27Kip1. Patients whose cancer presented accumulation of cytoplasmic p27Kip1 showed poorer outcomes for cancer-related relapse and survival. These results suggest that cytoplasmic p27Kip1 localization, associated or not with Akt activation, may contribute to colorectal tumorigenesis and metastasis and it may be useful as a negative prognostic factor for the outcome of patients with colorectal cancer.

Proctalgia in a patient with staples retained in the puborectalis muscle after STARR operation.

Stapled transanal rectal resection (STARR) is a novel surgical technique for the treatment of intussusception and rectocele causing obstructed defecation. In this procedure, a double full-thickness rectal resection is performed transanally using two circular staplers. We describe the case of a patient complaining of persistent pain, tenesmus and fecal urgency after STARR. The patient also had an external rectal prolapse requiring an Altemeier rectosigmoid resection; during this operation we found and removed several staples that had stuck to the puborectalis muscle during STARR. Some degree of muscle inflammation was found at histological analysis. The patient recovered fully after this reintervention. Among the complications reported after STARR, the present one had not previously been described. The retained staples might have caused proctalgia in this patient.

The rectal pocket syndrome after stapled mucosectomy.

OBJECTIVE: Stapled rectal mucosectomy (SM) is less painful than manual haemorrhoidectomy but may be followed by unusual complications which may require reinterventions. The aim of the present study was to report on a particular postoperative complication, the rectal pocket syndrome (RPS). METHODS: Six patients, four females and two males, five with severe proctalgia and signs of intermittent sepsis and one with faecal soiling following SM, underwent clinical examination, proctoscopy (n = 5) anal manometry and ultrasound (n = 4) revealing a painful rectal intramucosal pocket with an endoluminal orifice at the level of the suture line. Four of them underwent a reintervention. RESULTS: At surgery, a faecolyth was found to be entrapped in the rectal pocket with an underlying chronic abscess in four patients. The cavity was laid open and curetted in all cases. One of the females needed a fistulotomy of a low intersphincteric track after one year. In none of the others did endorectal pocketing and abscess or prostatitis recur after a mean follow up of 25 months (range 2-60 months). The male patient still had moderate postevacuation pain and prostatitis possibly via a bacterial translocation after two months. Overall, the incidence of the post mucosectomy RPS at our Units was 2.5%. CONCLUSIONS: The RPS can occur after SM, is likely to be due to a failure of either the purse-string or of the staples causing a suture defect leading to an intramural sinus, and may be successfully treated by a transanal lay-open in most cases.

Which surgical approach for rectocele? A multicentric report from Italian coloproctologists.

The most effective surgical technique for rectocele has not yet been clearly established. A retrospective multicentric study was carried out to compare the long-term results of 3 endorectal techniques (Block, Sarles and stapled) and the perineal levatorplasty, alone and in association, in a series of patients with symptomatic rectocele. From January 1992 to December 1999, 2212 patients with defecation disorders were referred to 5 Italian coloproctology units. An anterior rectocele was clinically diagnosed in 1045 patients and confirmed with defecography. On the basis of clinical and radiological parameters, 317 patients (312 women; mean age, 52.4+/-20.1 years) were selected for surgery. Group 1 consisted of 141 patients (136 women; mean age, 50.4+/-18.8 years) who were submitted to endorectal operations. Group 2 consisted of 126 women (mean age, 52.5+/-19.7 years) who received perineal levatorplasty. Finally, 50 women (mean age, 54.3+/-21.9 years) in Group 3 received endorectal operations associated with perineal levatorplasty. A total of 269 patients were followed postoperatively (mean period, 24.2+/-3.1 months, 27.5+/-5.4 months and, 22.8+/-2.8 months, respectively) with the same questionnaire and clinical examination. Three months after surgery, a defecography examination and anorectal manometry were performed in 136 and 132 patients, respectively. Operative time, hospital stay and time to return to work were significantly higher in Group 3 (p<0.001). There was one death in Group 3 due to severe sepsis. Main postoperative complications were: in Group 1, hemorrhage (7.8%, all Sarles), dehiscence of the endorectal suture (5.0%, all Block), distal rectal stenosis (2.1%, 1 stapled, 2 block), and rectovaginal fistula (1.4%, all Sarles); in Group 2, delayed healing of the perineal wound (16.4%); in Group 3 delayed healing of the perineal wound (22.0%), hemorrhage (6%, all Sarles), dehiscence (4.0%), stenosis (2.0%). 17.3% of patients of Group 2 and 22.5% of Group 3 complained of dyspareunia. Postoperative defecography showed a complete absence of the rectocele in 44.1% of patients and reduction of size in the others, without significant differences among the three groups. Manometric pattern was not significantly modified by surgery. Significant symptoms recurred in 5.9% of the patients in Group 1, 6.4% in Group 2, and 5.0% in Group 3. Perineal levatorplasty did not significantly improve obstructed defecation, as it did not allow to excise the rectal mucosal prolapse, and was followed by an high incidence of delayed healing of the perineal wound and dyspareunia. Sarles procedure achieved better control of mucosal prolapse but carried a higher complication rate compared to the others. The association of the perineal levatorplasty with an endorectal technique required significantly longer operative time, and led to a longer hospital stay and time to return to work. In conclusion, the investigated techniques showed different patterns of postoperative complications: bleeding after Sarles, dehiscence after Block, dyspareunia after perineoplasty and fatal gangrene after stapled, but non of them showed a clear superiority over the others in term of clinical or functional results 2 years after surgery.

Glyceryl trinitrate for chronic anal fissure--healing or headache? Results of a multicenter, randomized, placebo-controled, double-blind trial.

PURPOSE: Internal anal sphincterotomy for treating chronic anal fissure can irreversibly damage anal continence. Reversible chemical sphincterotomy may be achieved by anal application of glyceryl trinitrate ointment (nitric oxide donor), which has been reported to heal the majority of patients with anal fissure by inducing sphincter relaxation and improving anodermal blood flow. This trial aimed to further clarify the role of glyceryl trinitrate in the treatment of chronic anal fissure. METHODS: A total of 132 consecutive patients from nine centers were randomly assigned to receive 0.2 percent glyceryl trinitrate ointment or placebo twice daily for at least four weeks. The severity of pain and maximum anal resting pressure were measured before and after one week of treatment. Anodermal blood flow was measured before and after application of glyceryl trinitrate or placebo in ten patients. RESULTS: The study was completed by 119 patients (59 glyceryl trinitrate and 60 placebo), matched for gender, age, duration of symptoms, duration of treatment, site of fissure, previous attempts to treat, pain score, and maximum anal resting pressure. Twenty-nine patients (49.2 percent) healed after glyceryl trinitrate and 31 patients (51.7 percent) healed after placebo (P = not significant). Pain score fell significantly in both groups, in addition to maximum anal resting pressure. Anodermal blood flow improved significantly in seven patients receiving glyceryl trinitrate, but not in the three receiving placebo. Twenty-three patients (33.8 percent) experienced headache and 4 (5.9 percent), orthostatic hypotension after glyceryl trinitrate. CONCLUSION: This trial fails to demonstrate any superiority of topical 0.2 percent glyceryl trinitrate treatment vs. a placebo, although the effects of glyceryl trinitrate on anodermal blood flow and sphincter pressure are confirmed. This finding, together with the high incidence of side-effects, should discourage the use of this treatment as a substitute for surgery in chronic anal fissure.

Relationship between folate-binding protein expression and cisplatin sensitivity in ovarian carcinoma cell lines.

It has been suggested that sensitivity of ovarian carcinomas to cisplatin is in part related to an endogenous folate deficiency. In this work, we investigated whether overexpression of the folate-binding protein (FBP), a receptor involved in folate transport, might be associated with cisplatin sensitivity. The results obtained on a panel of ten ovarian carcinoma cell lines that overexpress different levels of the FBP showed a statistically significant relationship between FBP overexpression and cisplatin responsiveness, with the most sensitive cell lines expressing higher FBP levels on their membrane than the less sensitive ones. The relationship was observed both in cells growing in standard medium-containing high-folate concentrations (2.3 microM) and in cells adapted to growth in low-folate (20 nM) medium. Analysis of two cisplatin-resistant cell lines derived from the cisplatin-sensitive IGROV1 ovarian carcinoma cell line indicated that resistance was associated with a significant decrease in FBP expression. However, the receptor does not appear to be directly responsible for drug sensitivity per se as different cell lines transfected with FBP cDNA did not become more sensitive to the drug. Together, the data suggest the possible predictive value of FBP in ovarian carcinoma, as higher levels of expression can be indirectly but significantly associated with increased drug sensitivity.

Growth of ovarian-carcinoma cell lines at physiological folate concentration: effect on folate-binding protein expression in vitro and in vivo.

Ovarian-carcinoma cell lines (OVCAR3, IGROVI, OVCA432, SW626 and SKOV3), grown in standard medium containing supra-physiological (2.3 microM) folate concentration, display different levels of reactivity with the anti-folate-binding-protein (FBP) monoclonal antibody MOv18, which recognizes the alpha-isoform of the protein. Gel-filtration and absorption experiments indicated that on IGROVI cells this molecule accounts for all folic-acid binding at nanomolar concentrations. The aim of the study was to investigate the effect of extracellular folate levels on cells adapted to grow in medium containing physiological folate concentration (20 nM). By the ternary complex assay, all cell lines showed a marked depletion of intracellular reduced folates, compared with those in standard folate medium. The monitoring of FBP by MOv18 showed on IGROVI cells a transient up-regulation of the protein, whereas on the other cell lines, except SKOV3, no changes were detected. These data suggest that in these cells further over-expression of the molecule cannot generally be induced by lowering the extracellular folate concentration. On SKOV3, Scatchard analysis of 125I-MOv18 binding, as well as the evaluation of total folate binding capacity, showed a 2- to 3-fold stable increase of FBP expression after long-term growth in low-folate medium. Reverse transcriptase-polymerase chain reaction (RT-PCR) analysis indicated in these cells a 1.5-fold increase in alpha-FBP mRNA. SKOV3 cells, maintained in vitro in medium containing supraphysiological and physiological (i.e., low-folate) concentrations were injected into nude mice. Weight differences, though not statistically significant, were observed in favour of low-folate-derived tumors. Immunohistochemical and immunochemical analysis of the tumor samples showed that in SKOV3 cells the receptor modulation can also be induced by restoring the physiological folate concentration in vivo.

Double flap technique to reconstruct the anal canal after concurrent surgery for fistulae, abscesses and haemorrhoids.

Benign anorectal conditions, such as abscess, fistulas and haemorrhoids may occur in the same patients, requiring wide excision of the diseased tissues. This may result in a large de-epithelized area of the anal canal, and removal of perianal skin, eventually leading to a stricture. A rectal mucosal advancement sutured to the apex of a skin rotation flap has been successfully used in four patients to partially reconstruct the anal canal and prevent the formation of an anal stenosis. Complex anal fistulas may be associated with haemorrhoids requiring a wide local excision. A large wound with loss of skin and epithelium may result, which is likely to heal causing an anal stricture. After simple open haemorrhoidectomy, three muco-cutaneous bridges are usually left by the surgeon at the end of the operation to prevent a stenosis, but this may be impossible to perform following haemorrhoidectomy and fistulectomy, procedures requiring wider tissue excision. A technique to create a muco-cutaneous bridge despite an extensive surgical wound had been successfully adopted in four patients with long standing multiple anal fistulas, pelvirectal abscess and haemorrhoids.

Folate binding protein distribution in normal tissues and biological fluids from ovarian carcinoma patients as detected by the monoclonal antibodies MOv18 and MOv19.

Folate-binding proteins (FBP), which are molecules relevant in folate metabolism, are overexpressed in ovarian carcinomas, as detected by the monoclonal antibodies (MAb) MOv18 and MOv19, which recognise two different epitopes of the gp38/FBP. In this paper, features of the FBP such as the distribution on normal tissues and the release in biological fluids of normal and tumour origin have been investigated. Immunohistochemical analyses on frozen sections of normal tissues showed the presence of the gp38/FBP on some epithelia. The reactivity of both the MAb on Fallopian tubes was intense and comparable to that observed on ovary carcinoma sections. The kidney, bronchial glands, alveolar epithelium of the lung, oesophagus, stomach, pancreas, breast and thyroid showed different levels of staining. By MOv18/MOv19 double-determinant immunoradiometric assay (DDIRMA), the gp38/FBP was found in soluble form in ascitic fluid, serum and urine of nude mice in which the human ovary carcinoma cell line IGROV1 grew as ascitic carcinomatosis. In human biological fluids, the gp38/FBP was detected in ascites of 60% of ovarian carcinoma patients, and in 29% of those with other carcinomas, but not in patients with non-epithelial tumours or with other non-tumoral pathologies. The mean serum arbitrary units (a.u.)/ml values of ovary carcinoma patients were significantly different to those of healthy donors or patients with endometriosis (P < 0.005 and P < 0.01, respectively), but not when compared to the sera of lung carcinoma patients. In addition, the sensitivity of DDIRMA was poor, since only 24% of the ovary carcinoma patients were positive with this assay. When a restricted number of cases selected for the presence of tumour cells in the ascites was examined, the percentage of DDIRMA-positive sera and ascites rose to 41 and 94%, respectively. In the urine, a strong reactivity was observed in the samples of both normal and tumour origin.

Conventional antibodies: requirements and methods for their optimization.

Eighteen years after the discovery of monoclonal antibodies (MAbs), the debate as to whether these reagents have fulfilled their promise must now be addressed. When MAbs were studied as tools for diagnosis and therapy, problems arose regarding the reagents themselves and the recognized target antigens. Because most MAbs are of murine origin, they usually evoke an immune response in human patients, which reduces their effectiveness. Moreover, their bulky size and dispersal via the blood prevent most of the injected antibodies from substantially penetrating solid, poorly vascularized tumors. However, MAbs that are adequately selected and manipulated to circumvent these problems have been found to successfully image tumors and to be therapeutically active.

Polarization of the alpha 6 beta 4 integrin in ovarian carcinomas.

By immunizing a BALB/c mouse with a human ovary-carcinoma cell line (IGROV1), grown intraperitoneally in nude mice, a monoclonal antibody (MAb), designated MAR6, was produced and characterized. Immunofluorescence on the immunizing cell line showed a specific labelling by MAR6 at the cell-to-cell contact points. In addition, MAR6 was found to immunoprecipitate the alpha 6 beta 4 integrin complex. Competition tests with MAbs anti-alpha 6, anti-beta 4, anti-beta 1 sub-units demonstrated that the recognized sub-unit is alpha 6. Indirect immunofluorescence on various cell lines gave MAR6 as positive only on alpha 6-positive lines (IGROV1, OVCAR3, SW626, SKOV3, ME4405, Calu3, N592, MDA468, A431 and HT29). Moreover, on IGROV1 and OVCAR3 ovary-carcinoma cells, which normally grow either adhering to the culture flask or forming clumps in suspension in the medium, MAR6 selectively stained the connection points between the cells in clumps, where, in the same position, the presence of the beta 4 sub-unit, laminin and fibronectin was detected. On the contrary, the beta 1 sub-unit was distributed over the whole cell membrane. The same pattern of labelling by these MAbs was observed in 2 cases of ovarian-carcinoma cells present in ascitic fluids obtained from patients. Immunoperoxidase tests performed on cryosections of various normal tissues showed specific reactivity of MAR6 on basal or basolateral membranes of epithelial cells. On cryosections of ovarian tumors, MAR6 reactivity correlated with the degree of tumor differentiation. Indeed, in benign and well-differentiated tumors, a strong basal or basolateral labelling only of cells surrounding the neoplastic nodules was found. On the contrary, on undifferentiated tumors the inner part of the tumor nodules was also progressively labelled, whereas the staining on the border was weak and discontinuous as a result of the alpha 6 sub-unit dispersion on the tumor cell surface.

New grading and scoring for anal incontinence. Evaluation of 335 patients.

A grading system of anal incontinence (AI) is described that takes into account both degree and frequency of symptoms. A, B, and C indicate AI for flatus/mucus, liquid stool, and solid stool, respectively; 1, 2, and 3 indicate occasional, weekly, and daily AI. A scoring system, ranging from 0 (continence) to 6 (severe AI, i.e., daily AI for solid stool or C3) also is reported. Three hundred thirty-five patients have been evaluated by this method in our institution: 30 percent had severe AI, graded as C3; only 9 percent had mild symptoms graded as A. Both males and females could not control diarrhea (Grade B) in 44 percent of cases. Nearly half of the 110 patients who underwent surgery had a C3 incontinence before treatment. Positive results were achieved in 75 percent of cases after surgery: e.g., AI score significantly improved from 4.2 +/- 1.6 to 1.5 +/- 1.9 (P less than 0.001) in those with AI and rectal prolapse. Most of the failures were the patients with idiopathic C3 incontinence. In conclusion, this grading and scoring system allowed a satisfactory assessment of patients' AI before and after treatment. It may also be used to achieve an objective comparison between different series.