Laparoscopic nerve-sparing complete excision of deep endometriosis: is it feasible?

BACKGROUND: Little is known about the morbidity associated with laparoscopic complete excision of endometriosis in terms of urinary, digestive and sexual function. METHODS: We performed a prospective non-randomized study in 45 patients with laparoscopic complete excision of all detectable foci of endometriosis with segmental bowel resection using a non nerve-sparing technique (control group-group A n=20) and a nerve-sparing technique (case group-group B n=25). At initial gynaecological evaluation, and at follow-up details on dysmenorrhoea, pelvic pain, dyspareunia and dyschezia were evaluated using an interview-based questionnaire (10-point analogue rating scale: 0=absent, 10=unbearable). RESULTS: The mean (+/-SD) follow-up period was 15.3+/-10 months (range, 8.8-23 months) for group A and 3.5+/-2.1 months (range, 0.3-5.2 months) for group B. In the immediate postoperative course, in group A three women required blood transfusion vs seven women in group B (P=0.003). The median time to resume the voiding function was significantly shorter in group B (12.5 vs 3.0 days; P<0.01). At the time of follow-up a higher proportion of patients in group B were 'very satisfied' than those in group A (87.7% vs 59.0%, P=0.013). CONCLUSIONS: Laparoscopic nerve-sparing complete excision of endometriosis seems to be feasible and offers good results in terms of bladder morbidity reduction with apparently higher satisfaction than classical technique. Larger series with longer follow-up are needed to confirm our results.

Prevalence of urinary incontinence in women with cystic fibrosis.

OBJECTIVE: To determine the prevalence of urinary incontinence (UI) in female patients (aged > or = 15 years) attending a cystic fibrosis (CF) centre, in whom stress UI could be common, as chronic coughing and sputum production are frequent symptoms associated with progressive lung disease in these patients. PATIENTS AND METHODS: An anonymous questionnaire was completed by 176 women with CF (mean age 24.6 years, SD 5.8) during routine assessments as outpatients. RESULTS: In all, 72 patients (41%) were classified as never incontinent; occasional UI was reported in 61 women (35%). Regular UI, occurring twice or more a month for at least two consecutive months in the last year, was reported in 43 patients (24%). Regular UI was associated with increasing age and a lower mean (SD) forced expiratory volume/s (of that predicted) than in women with no urinary symptoms, at 26.9 (6.5) years and 53.5 (23.5)%, and 23.1 (5.4) years and 65.5 (23.2)%, respectively (P < 0.01 and P < 0.05, respectively). All incontinent women recorded stress UI; coughing, laughing and physical activity were associated with UI in 92%, 33% and 21% of the patients, respectively. CONCLUSION: Stress UI is a common symptom in women with CF. As urine loss can be under-reported to the healthcare providers, women should be asked about incontinence as part of their routine follow-up. Pelvic floor muscle exercises are effective in treating stress UI and should be considered for those with CF and regular UI.

Preoperative autologous blood donation by elderly patients undergoing orthopaedic surgery.

BACKGROUND AND OBJECTIVES: To assess the feasibility of a programme of predeposit in elderly patients undergoing elective orthopaedic surgery. PATIENTS AND METHODS: We retrospectively studied 789 elderly patient candidates (> 65 years of age) for orthopaedic surgery (total hip and knee replacement and spinal surgery), who were undergoing a programme of preoperative autologous blood donation (PABD) in our city hospital between January 1990 and December 1998. RESULTS: Six hundred and eighty-eight patients (87.2%) were transfused with autologous blood; 128 (16.2%) also received allogeneic blood. Hip arthroplasty revision was characterized by the greatest blood consumption. The predeposit programme was discontinued in 96 patients (12.2%) because of the following complications: the onset of anaemia (11.0%); vasovagal reactions (0.5%); lack of venous access (0.4%); or cardiac complications (0.2%). No episodes of reaction to autologous transfusion were recorded. CONCLUSIONS: Our study confirms the feasibility of PABD in elderly patients undergoing elective orthopaedic surgery.

Neonatal screening for cystic fibrosis: long-term clinical balance.

BACKGROUND/AIMS: Very few studies have been performed on the long-term clinical advantages of neonatal screening programs for cystic fibrosis (CF) and these have been inconclusive. This is a preliminary report of two observational cohort studies on this subject. METHODS: In the first study, CF patients born between 1973 and 1981 in northeastern Italy were split into 4 groups according to the modality of diagnosis: screening by meconium test (58 patients); meconium ileus (45 patients); symptoms and pancreatic insufficiency (PI; 75 patients), or symptoms and pancreatic sufficiency (PS; 19 patients). The patients were followed for up to 26 years by three CF centers sharing common treatment protocols. In the second study, two cohorts of CF patients born between 1983 and 1992 were compared. Patients from one cohort (126 patients) were born in the Veneto region, where a neonatal screening program had been established based on immunoreactive trypsinogen. Patients from the other cohort (152 patients) were born in Sicily, where an intensive program of early diagnosis by symptoms was implemented. The cohorts were comparable for CF incidence, CFTR genotypes, gender proportion and common treatment protocols. Statistical analyses were performed by Kaplan-Meier survival curves, a Cox proportional hazard model for survival and cross-sectional comparisons by 2-year periods for weight z score, height z score and body mass index. RESULTS: In the first study, the patients detected by newborn screening (PI) showed better survival and nutritional status compared to patients diagnosed through meconium ileus or symptom presentation with PI. PS patients diagnosed by symptoms showed the best outcome, but most of them had a mild genotype. In the second study, the Veneto cohort showed better outcome with regard to survival and nutritional status over 16 years of follow-up. CONCLUSIONS: Observational cohort studies cannot give definitive evidence of the clinical benefit of neonatal CF screening; however, data have been accumulated which strongly suggest a better clinical outcome for CF patients born in an area where a screening program is performed.

Reliability of sweat-testing by the Macroduct collection method combined with conductivity analysis in comparison with the classic Gibson and Cooke technique.

UNLABELLED: This study was to ascertain the reliability of sweat-testing by the Macroduct collection method combined with conductivity analysis (MCS) compared with the Gibson and Cooke technique (GCT). Sweat stimulation by pilocarpine iontophoresis was identical for both procedures, sweat being collected for 30 min on a filter paper on one forearm and in the coil of the Macroduct collector on the other. Chloride, sodium and potassium concentrations were chemically analysed both on paper-eluted and tube-collected sweat; the latter was also analysed using a conductivity analyser. Chemical analyses were compared with conductivity analyses. This prospective study was carried out on 318 subjects with MCS (118 CFs, 200 controls) and on 305 of them with the GCT (113 CFs, 192 controls). The pilocarpine iontophoresis produced adequate sweat in 96.4% of collections with GCT and in 90.9% with the MCS. Sensitivity and specificity of the Macroduct/conductivity system were comparable to the GCT. No patient detected by the GCT technique was considered negative by conductivity, but one GCT positive was "borderline" with the MCS. Six non-CF subjects identified as negative by the GCT (3.3%) were in the borderline range with the MCS. CONCLUSION: Sweat-testing by the MCS has acceptable sensitivity and specificity when performed by trained CF sweat-testing technicians. Additional studies will be required to find out if these results can be confirmed in small clinics and hospitals where testing is done infrequently. Wherever the MCS is used all positive or borderline results should be confirmed by the GCT at a reference Cystic Fibrosis Center.

Cardiac troponin I as diagnostic and prognostic marker in severe heart failure.

BACKGROUND: Cardiac cell death has been shown to occur in heart failure and has been implicated as one of the mechanisms responsible for progression of the disease. Cardiac Troponin I (cTnI) represents a highly sensitive marker for myocardial cell death. Based on previous studies reporting that cTnI may be detected in patients with heart failure, we evaluated the clinical correlates and prognostic implications of detectable cTnI in a consecutive series of patients with severe heart failure. METHODS: Thirty-four patients were examined. Upon admission, we measured serum levels of cTnI by conventional immunoenzymatic assay (Stratus Dade II). According to the results of this assay, patients were divided into 2 groups, based on the presence (cTnI+) or absence (cTnI-) of detectable cTnI. These 2 groups were compared by non-parametric analysis for their clinical characteristics, instrumental findings, and short-term outcome. RESULTS: The cTnI+ group included 10 patients (29%) with a mean serum cTnI of 0.7 +/- 0.3 ng/ml. Compared with the cTnI- group, these patients had significantly lower left ventricular ejection fractions (20% +/- 5% vs 26% +/- 7%, p = 0.023) and a trend for higher systolic pulmonary artery pressure (59 +/- 17 mm Hg vs 49 +/- 13 mm Hg, p = 0.08). In cTnI+ patients, the correlation between cTnI levels upon admission and ejection fraction was r = -0.530 (p = 0.11). We found ischemic etiology was equally present in the 2 groups, whereas we never found histologic signs of acute myocarditis. Other clinical characteristics (functional class, daily diuretic dose, need for intravenous inotropes) were not statistically different in the 2 groups. In cTnI+ patients who improved after admission, cTnI became undetectable after a few days; in patients with refractory heart failure who were hospitalized until death, cTnI persisted in detectable levels throughout the observation period. Using the Cox proportional hazard model, a positive cTnI was the most powerful predictor of mortality at 3 months (p = 0.013; hazard ratio 6.86; 95% confidence interval 1.32 to 35.4). CONCLUSIONS: These observations suggest that cTnI is detected in the blood of 25% to 33% of patients with severe heart failure; its presence may help to identify a high-risk sub-group who faces very poor short-term prognosis.

The extent of regional wall motion abnormalities identifies patients at risk of extensive left ventricular remodeling: implications for the design of post myocardial infarction trials.

BACKGROUND: The FAMIS (Fosinopril in Acute Myocardial Infarction Study) was a multicenter, placebo-controlled, double-blind trial designed to evaluate the safety and the efficacy of fosinopril in reducing left ventricular enlargement after acute anterior myocardial infarction. We evaluated the echocardiographic examinations performed during the trial in order to assess the trend of the remodeling process over time and to evaluate the role of infarct size in identifying patients at risk of progressive left ventricular dilation. METHODS: A complete echocardiographic examination was performed on admission, before discharge and three months later. Patients undergoing coronary bypass surgery or PTCA had a further examination prior to the procedure. The echocardiograms were analyzed at a central laboratory, and the end-diastolic and end-systolic left ventricular volumes were computed by using a modified Simpson's rule technique. Regional wall motion was evaluated using the centerline method, analyzing the left ventricular boundary along 100 chords perpendicular to the centerline constructed midway between the end-diastolic and the end-systolic contours. A quantitative infarct-size index was then computed according to the number of chords with a fractional shortening equal to or less than 5%. RESULTS: Left ventricular end-diastolic and end-systolic volume index significantly increased over time (p < 0.0001); as a result, the stroke volume increased (p < 0.0001) but the ejection fraction did not change. Patients were then divided according to the three-month infarct-size index. For both end-diastolic and end-systolic volume, not only did larger infarcts had higher volumes, but there was also a greater increase from baseline to 3 months. Moreover, larger infarcts had a lower ejection fraction, with a further reduction over the three months, while smaller infarcts had higher values and an increase over time. An infarct-size index of 25 or larger allowed prospective identification at the baseline examination of patients at risk of subsequent left ventricular dilation. CONCLUSIONS: In conclusion, patients at greatest risk of left ventricular dilation, namely those with larger infarct size, constitute a group that is worth considering for any therapeutic effort for reducing the remodeling process. These patients could in fact benefit from therapeutic strategies aimed at the reduction of left ventricular remodeling and should be studied in clinical trials.

Carrier testing program in a high-risk cystic fibrosis population from northeastern Italy. Active recruitment of relatives via probands' parents.

OBJECTIVE: To assess the practicability and monitor the results of an active carrier testing program among relatives of cystic fibrosis (CF) patients. METHODS: Parents of CF patients in the Veneto and Trentino regions of northeastern Italy were asked to help recruit relatives aged between 18 and 45 years for CF mutation testing. RESULTS: Of 409 enrolled CF parents, 59.6% agreed to send to the CF Center family composition data of relatives up to the third degree, and 28.8% recruited relatives to carrier testing, providing names and addresses of those who, being contacted, expressed a willingness to be tested. The participation of parents was higher if they were young and had a child recently diagnosed with CF. Recruiting parents indicated 333 close relatives (59%) for testing. When contacted by the CF Center, 170 of these 333 (51%) attended for testing. The percentage of close relatives who spontaneously asked for the test was 5.4% before the carrier testing program started; it rose to 25.3% following the introduction of the active strategy. CONCLUSIONS: The participation of the parents of CF patients is an important factor affecting the utilization of testing by relatives. Besides this, the influence of a favorable medical and cultural context (participation of gynecologists and family doctors in testing programs, genetic education of the general population) has to be considered.

High- versus low-lipase acid-resistant enzyme preparations in cystic fibrosis: a crossover randomized clinical trial.

High-strength pancreatic enzyme preparations have recently come into widespread use in some countries for treatment of pancreatic insufficiency in cystic fibrosis. However, the therapeutic equivalence of these preparations to the standard acid-resistant microsphere preparations, under the same lipase dosage, has not been demonstrated by appropriate clinical trials; they are also considered responsible for severe colonic stricture. In a randomized crossover study, 20 adolescent or adult cystic fibrosis patients were treated in hospital with both low-lipase (A) and high-lipase (B) enteric-coated microsphere preparations. The fat excretion coefficient, evaluated over two 72-h fat balance periods (measured fat intake, 1.43 to 3 g/kg/day according to age), was the main response variable, secondary variables being stool wet and dry weight, fecal nitrogen output, and energy loss. With both preparations, patients were given a daily dose of 1,500-2,000 lipase BP U/g fat ingested, distributed across four meals. The low-strength preparation was divided into three doses during each meal, while the high-strength preparation was taken as a single dose in the middle of each meal. The considerable variability of results did not provide conclusive evidence of equivalence or significant differences between the two preparations in terms of steatorrhea and other variables. However, mean differences between the two treatments and their 95% confidence intervals showed less satisfactory results with the high-lipase preparation. A high-strength preparation is thought to release relatively less enzyme activity in the small intestine, forcing patients to increase their dosage and possibly creating a dangerous enzyme hyperconcentration in the large intestine. For this reason, the occasional occurrence of colonic stricture should be borne in mind, as must the possible scope for division of dosage during each meal.

Short-term effects of three chest physiotherapy regimens in patients hospitalized for pulmonary exacerbations of cystic fibrosis: a cross-over randomized study.

The aim of our study was to compare the short-term efficacy of three different chest physiotherapy (CPT) regimens (PD, postural drainage; PEP, positive expiratory pressure physiotherapy; HFCC, high-frequency chest compression physiotherapy) on patients with cystic fibrosis (CF) hospitalized for an acute pulmonary exacerbation. Sixteen patients with CF, 8 males, 8 females, aged 15-27 years (mean, 20.3 +/- 4), met the inclusion criteria: 1) age over 14 years; 2) mild or moderate airway obstruction; 3) sputum volume > 30 mL/day; 4) being proficient in PD and PEP CPT. Patients at admission had (mean +/- SD) forced volume in 1 second (FEV1) 52.2 +/- 21.9 percent predicted; Shwachman-Kulczycki clinical score 65.1 +/- 11 points; Chrispin-Norman chest radiography score 18.6 +/- 4.3 points. The three CPT regimens and a control-treatment (CONT) were administered in a random sequence, each patient receiving each treatment twice a day (in 50 minute sessions) for 2 consecutive days. During CONT and for 30 minutes after each session only spontaneous coughing was allowed. Wet and dry weight of sputum were recorded during the 50-minute sessions and 30 minutes afterward. Lung function was measured before and 30 minutes after each session. For each treatment a score was given by the patient for efficacy, and by both the patient and the physiotherapist for tolerance. Wet and dry weights of sputum collected during the sessions were greater for all CPT regimens than for CONT (P < 0.001, P < 0.0001). No significant differences between the three CPT regimens for both wet and dry weights were found when the number of coughs was taken into account.(ABSTRACT TRUNCATED AT 250 WORDS)

Determinants of maximal transdiaphragmatic pressure in adults with cystic fibrosis.

To investigate whether diaphragmatic strength could be reduced in cystic fibrosis (CF), and to examine possible mechanisms leading to diaphragmatic weakness, we measured transdiaphragmatic pressure (Pdi), together with lung mechanics, including dynamic "intrinsic" positive end-expiratory pressure (PEEPi,dyn), ventilation, lung volumes, and nutritional status in 15 adult patients with CF in stable clinical condition. Diaphragmatic strength was assessed as the maximum Pdi (Pdimax). Nutritional assessment included the calculation of weight as a percentage of ideal weight for height (Wt/Ht). On average, our 15 CF patients had airway obstruction (FEV1 = 59 +/- 28% predicted) and a small PEEPi,dyn (1 +/- 0.7 cm H2O). Functional residual capacity average 52 +/- 9% of the predicted total lung capacity. The Wt/Ht was normal on average (95%), but with a large range from malnutrition to a good nutritional status (76 to 109%). We found that Pdimax decreased with increasing FRC/TLC percent predicted (r = 0.55, p < 0.05), but more significantly with decreasing Wt/Ht (r = 0.76, p < 0.001). The multiple linear regression analysis for these factors was significant (R2 = 0.70, p < 0.05); however, the partial regression coefficient was significant only for Wt/Ht (p < 0.01). These results suggest that in CF patients, diaphragmatic strength decreases with the progression of the disease, increasing lung volume and worsening nutritional status, and that malnutrition is the strongest determinant of diaphragmatic weakness.

Portal hypertension and esophageal varices in cystic fibrosis. Unreliability of echo-Doppler flowmetry.

To investigate the role of echo-Doppler flowmetry in evaluating patients with cystic fibrosis and portal hypertension at risk of esophageal varices, we studied 26 subjects divided in 3 groups: 9 with portal hypertension and esophageal varices, 8 with chronic liver disease without varices, and 9 without chronic liver disease. Spleen size, diameter, blood velocity, and flow rate of portal, splenic, and superior mesenteric veins were recorded. In patients without chronic liver disease Doppler measurements were repeated on 2 different days to assess intraobserver variability. Significant differences among the three groups were found for mean values of spleen size and diameters of portal, splenic, and superior mesenteric veins. Nevertheless, a considerable overlapping of individual data was observed. No differences were observed in mean hemodynamic measurements, except for blood velocity in portal vein and flow rate in splenic vein. The intraobserver variability for repeated Doppler measurements was clinically unacceptable for most of the variables studied. Echo-Doppler assessment of splanchnic flow seems to be an unreliable tool in the management of cystic fibrosis patients with portal hypertension at risk of esophageal varices.

Modification of some markers of inflammation during treatment for acute respiratory exacerbation in cystic fibrosis.

An objective approach for monitoring the treatment of acute pulmonary exacerbation in cystic fibrosis was evaluated. Eleven biochemical markers of inflammation (erythrocyte sedimentation rate, neutrophil count, C-reactive protein, alpha-1 antitrypsin, haptoglobin, ceruloplasmin, fibronectin, alpha-1 glycoprotein, alpha-2 macroglobulin, C3, granulocyte elastase and anti-Pseudomonas IgG) were measured in blood serum and plasma from 46 cystic fibrosis patients with chronic Pseudomonas aeruginosa colonization before and after treatment. The overall outcome in each patient was evaluated by means of a pondered sum of clinical, chest X-ray and lung function scores. Biochemical markers were related to the overall clinical improvement: haptoglobin, ceruloplasmin, fibronectin and alpha-1 glycoprotein showed a good sensitivity (64-70%), specificity (60-70%) and positive predictive value (86-89%). Granulocyte elastase showed a similar sensitivity (67%) and positive predictive value (85%) but a lower specificity (33%). The negative predictive value was generally poor (32-39%). Our data suggest that the combined measurement of some markers of inflammation and of conventional clinical parameters, may help in evaluating the efficacy of anti-infective treatment in cystic fibrosis.

A more objective approach to the evaluation of antimicrobial therapy in cystic fibrosis.

Thirteen biochemical markers of infection and inflammation were measured during anti-Pseudomonas therapy in cystic fibrosis (CF) patients with respiratory exacerbation. The assessment of some of these markers is thought to be helpful in the evaluation of efficacy of antibiotic therapy in CF.

Two-dimensional echocardiographic evaluation of mitral valve calcification. Sensitivity and specificity.

The effectiveness of two-dimensional echocardiography in assessing mitral valve calcification was compared to radiography of the surgically excised valves in 43 patients affected by rheumatic disease of the mitral valve. Mitral valve calcification was graded as absent or present if single thin or multiple dense conglomerate echoes defined the valvular orifice in short axis view, provided the sensitivity of the instrumentation was adequately optimized. The radiograph of the excised valve was similarly graded. The interobserver reproducibility for both two-dimensional echocardiography and radiography was 100 percent. There were 14 true positives, 19 true negatives, 10 false positives and no false negatives, thus giving, for two-dimensional echocardiography, a sensitivity of 100 percent and a specificity of 65 per cent. It is concluded that two-dimensional echocardiography is an extremely sensitive method for assessing mitral valve calcification, and is prospectively useful also in planning reconstruction versus replacement in mitral valve surgery. Nevertheless, the consistent number of false positives affecting two-dimensional echocardiography represents a definite limit to the specificity of the technique.

[M.-mode and two-dimensional echocardiographic diagnosis of pseudoaneurysm of the left ventricle (author's transl)]. / Diagnosi ecocardiografica mono e bidimensionale di un caso di pseudoaneurisma del ventricolo sinistro.

The echocardiographic features of a case of postinfarction pseudoaneurysm of the left ventricle are described. M-mode echocardiography displayed an echo-free space behind the posterior left ventricular wall and two-dimensional echocardiography defined the saccular contour of the pseudoaneurysm and its probable communication with the ventricular cavity. A second echocardiographic examination--a week later--revealed a marked enlargement of the pseudoaneurysm and a characteristic fast backward early systolic motion of the ventricular wall interposed between left ventricular cavity and the saccular aneurysm; this motion is interpreted as a passive displacement of the ruptured wall during ventricular systole, and allows a differential diagnosis with similar echocardiographic M-mode aspects, due to pericardial effusion, pleural effusion or pericardial cysts. Echocardiography findings were confirmed by angiocardiography and the surgery. Echocardiography seems to be a safe method for early non-invasive diagnosis of left ventricular pseudoaneurysm.