Intimal-medial thickness of the carotid artery in nondiabetic and NIDDM patients. Relationship with insulin resistance.

OBJECTIVE: The aim of this study was 1) to compare intimal-medial thickness (IMT) of the carotid artery in nondiabetic and NIDDM patients and 2) to evaluate the association of this early marker of atherosclerosis with several cardiovascular risk factors, including plasma insulin and insulin resistance. RESEARCH DESIGN AND METHODS: A total of 58 nondiabetic and 56 NIDDM patients, randomly selected among those attending the outpatient Diabetes Clinic or the Clinic for Internal Medicine were examined. BMI, waist-to-hip ratio (WHR), blood pressure, glycohemoglobin (HbA1c), and fasting concentrations of plasma glucose, serum lipids (total and HDL cholesterol, triglycerides), and serum insulin were measured. Insulin resistance was assessed by computing glucose disappearance rate from plasma after intravenous insulin injection (Kitt). IMT of the carotid artery was measured by ultrasonography. RESULTS: IMT was significantly higher in diabetic patients, and the difference remained highly significant after adjusting for sex, age, BMI, WHR, presence of hypertension and dyslipidemia, and smoking status (1.39 vs. 1.24 mm, common SD 0.12, P < 0.001). Univariate regression analyses showed that IMT was negatively correlated with Kitt in either nondiabetic (r = -0.348, P < 0.01) or diabetic patients (r = -0.492, P < 0.001). However, multiple regression analyses showed that IMT was independently associated with age and WHR in nondiabetic subjects, whereas in diabetic patients, IMT was independently predicted by Kitt and hypertension. These two variables explained approximately 62% and approximately 35% of the variability of IMT in nondiabetic and diabetic patients, respectively. Plasma insulin was not independently associated with IMT in either groups. CONCLUSIONS: These results indicate that 1) diabetes is characterized by a greater thickness of the carotid artery independently of other established risk factor of atherosclerosis, 2) early atherosclerosis is independently associated with insulin resistance in diabetic but not in nondiabetic patients, 3) central adiposity is an independent predictor of IMT in nondiabetic individuals.

High serum levels of angiotensin-converting enzyme in untreated Addison's disease.

Serum angiotensin-converting enzyme (ACE) in four patients with untreated Addison's disease was significantly higher [79.7 +/- 17.5 (SD) nmol min-1 ml-1] than in normal subjects (37.7 +/- 8.9 nmol min-1 ml-1, P less than 0.02). During corticosteroid hormone replacement therapy the enzyme levels returned within the normal range (44.0 +/- 7.6 nmol min-1 ml-1). In two additional patients the enzyme was assayed only while they were receiving therapy and found normal (38 and 52 nmol min-1 ml-1, respectively). In one of them, an increase ACE level (70 nmol min-1 ml-1) was found after therapy was reduced by 50%. Primary adrenal insufficiency is another disease in which ACE levels may be increased.

Elevated plasma levels of soluble receptors of TNF-alpha and their association with smoking and microvascular complications in young adults with type 1 diabetes.

The purposes of this study were 1) to compare soluble tumor necrosis factor-alpha receptors, which are thought to reflect the degree of TNF-alpha activation, in nondiabetic subjects and type 1 diabetic patients, and 2) to evaluate the effects of smoking and microvascular complications on soluble tumor necrosis factor-alpha receptor levels in type 1 diabetic individuals. Plasma soluble tumor necrosis factor-alpha receptor levels (R1 and R2) were measured in 50 young type 1 diabetic patients without clinical macroangiopathy and in a matched group of 20 healthy volunteers. When diabetic patients were grouped according to smoking and microvascular complication status, the groups of patients had similar values of age, sex, body mass index, blood pressure, lipids, creatinine, and glycometabolic control. Nevertheless, soluble tumor necrosis factor-alpha receptor-R1 levels but not R2 levels, were markedly elevated (P < 0.05 or less) in complicated vs. uncomplicated (2.40 +/- 0.3 vs. 1.80 +/- 0.1 ng/ml) patients and in smokers vs. nonsmokers (2.66 +/- 0.4 vs. 1.76 +/- 0.1 ng/ml). In a two-factor ANOVA, both smoking (P < 0.01) and microvascular complications (P < 0.05) were independent predictors of soluble tumor necrosis factor-alpha receptor-R1. Soluble tumor necrosis factor-alpha receptor levels of diabetic patients who did not smoke or without complications were similar to those of healthy controls. In conclusion, smoking and microvascular complications seem to exert an additive and deleterious impact on TNF-alpha activation, as reflected by levels of soluble tumor necrosis factor-alpha receptors, in young adults with type 1 diabetes.

Early hilar lung cancer--clinical aspects and long term survival. Identification of a subgroup of stage IA patients with more favorable prognosis.

Twenty-nine patients out of 2018 operated on for a non-small-cell lung cancer from 1987 to February 1998 met the criteria proposed by the Japan Lung Cancer Society (JLCS) for the definition of early hilar lung cancer (EHLC). Twenty-six patients were symptomatic and 20 had a radiologically visible lesion. All cancers were located and diagnosed by bronchoscopy and all patients were resected. At histology, all tumors were squamous in nature. The five-year cumulative survival rate was 96%--a second primary lung cancer (2nd Pr.) developed in 4 patients (13.8%). The definition of EHLC proposed by the JLCS allows the selection of a subgroup of stage I patients with a very good prognosis. Nevertheless, a close follow-up is mandatory because more than 10% of these patients develop a 2nd Pr.

Partial characterization of cytosol and membrane-bound protein kinases in hereditary spherocytosis erythrocytes.

The protein kinase activity located in the cytosol of hereditary spherocytosis erythrocytes is due to multiple forms which can be resolved by Sepharose 6B filtration at high ionic strength into two fractions phosphorylating the whole casein on different sites. The membrane-bound protein kinases, solubilized by 0.7 M NaCl, display an elution volume from Sepharose column and a phosphorylation behaviour towards casein quite similar to those of the more retarded fraction of hemolysate. When compared with the multiple protein kinase forms from normal human erythrocytes, no significant difference has been found.

Endogenous phosphorylation of membrane proteins in normal and in hereditary spherocytosis erythrocytes.

The phosphorylation state of the proteins in hereditary spherocytosis erythrocyte membranes, incubated in the presence of [gamma-32P]ATP, appears to be different from that in normal ones. This is indicated by the finding that in the two types of erythrocyte membranes the ratios between the 32P-labeling of their phosphorylserine and phosphorylthreonine residues were different.

Procollagen III peptide and fibronectin in alcohol-related chronic liver disease: correlations with morphological features and biochemical tests.

In order to clarify the significance of procollagen III peptide (PIIIP) and fibronectin (FN) blood concentration in alcohol related chronic liver disease (ALD), we have investigated their relationships with histological liver features and biochemical liver tests in 44 ALD patients. PIIIP was measured in serum by radioimmunoassay whereas FN was determined in plasma using an immunonephelometric method. In each liver biopsy, steatosis, portal infiltrate, lobular necro-inflammation, portal fibrosis and lobular fibrosis were semiquantitatively assessed by scoring from 0 to 3. A close correlation of PIIIP was found with morphological features of fibrosis (both of lobular and portal type), but not with necro-inflammation or steatosis. PIIIP was also positively correlated with ALP and GGT and exhibited a good diagnostic value in liver fibrosis. On the contrary, FN did not distinguish between normals and patients and was not correlated with any morphological liver feature or biochemical liver test. We also conclude that serum NP3P effectively reflects liver fibrosis, whereas plasma FN seems not related to any of the main histological aspects of liver damage in ALD.

Does extended pancreaticoduodenectomy increase operative morbidity and mortality vs. standard pancreaticoduodenectomy?

The poor prognosis of pancreatic carcinoma after resection is related to distant metastases and local recurrence that is characterized by a strong tendency to infiltrate the retroperitoneal tissue and spread along the neural plexuses and lymph nodes. Thorough clearance of these tissues around the celiac and mesenteric axes, aorta, and inferior vena cava from the diaphragm to the inferior mesenteric artery (extended pancreaticoduodenectomy may lower the rate of local recurrence, but the procedure has been criticized for its higher morbidity and mortality. Our aim was to compare extended pancreaticoduodenectomy (EPD) with standard pancreaticoduodenectomy (SPD) in terms of postoperative morbidity and mortality. Data from 47 patients who underwent either EPD (n=24) or SPD (n=23) between November 1992 and October 1995 were retrospectively analyzed. Preoperative laboratory findings, operative risk (according to the American Society of Anesthesiologists classification), type of operation (classic Whipple vs. pylorus-preserving Whipple), operative time, intraoperative blood and plasma transfusion, postoperative morbidity and mortality, and postoperative hospital stay were scrutinized. The results showed that all of the parameters considered were similar in the EPD and SPD groups (intraoperative blood transfusion 800+/-490 ml vs. 700+/-586 ml, postoperative mortality 0% vs. 4.3%, overall morbidity 45.8% vs. 47.8%, surgical morbidity 37.5% vs. 34.7%, and postoperative hospital stay 16+/-8.1 days vs. 17+/-13.1 days. These two groups differed only in the operative time, which was significantly longer for EPD than for SPD (360+/-68.9 minutes vs. 330=66.9 minutes, P=0.02). Although the operative time is increased with EPD, there does not appear to be an increase in intraoperative complications, postoperative morbidity and mortality, or postoperative hospital stay with this procedure. However, definitive confirmation of these results can only be provided by a prospective randomized study.

Mastectomy and immediate breast reconstruction: oncological considerations and evaluation of two different methods relating to 88 cases.

The authors consider 88 cases of mastectomy and immediate breast reconstruction mainly performed using the skin expander plus prosthesis method or latissimus dorsi myocutaneous flaps. At the same time, 53 patients underwent contralateral mastopexy for symmetry. The mean follow-up was 21 months (range 2-102). Progressive disease was observed in nine cases: one patient presented scar relapse, one axillary relapse, two contralateral tumor, two contralateral tumor and distant metastasis, three distant metastases and one death from distant metastasis. Reconstruction complications were capsular contracture in 12 cases, infection in nine, skin necrosis in two, skin expander breakage in three and implant dislocation in one. The final result was judged good in 54 cases, fair in nine, poor in 11 and unevaluable in 14. In conclusion immediate breast reconstruction does not seem to interfere with the disease or oncological therapy. After analysing separately, and comparing the results and complications of the two main techniques used, latissimus dorsi seems to be the most reliable method in the majority of cases but skin expanders can be a good technique in patients with small and firm breasts and without complicating risk factors.

Completion pneumonectomy for non-small cell lung cancer: experience with 59 cases.

OBJECTIVE: The objective of this study was to assess the results of completion pneumonectomy performed for non-small cell lung cancer, classified as second primary or recurrence/metastasis. METHODS: From 1982 to 2000, 59 patients underwent completion pneumonectomy for lung cancer, classified second primary or recurrence/metastasis according to a modified form of Martini's criteria, after a mean interval from first resection of 60 months for second primary lung cancers and 19 months for recurrences/metastases. RESULTS: Operative mortality was 3.4% and complications occurred in 30% of patients. Five-year survival rate for completely resected patients was 25% (median 20 months). No significant difference in long-term survival was detected between second primary and recurrent tumors; survival was not adversely affected by a resection interval of less than 2 years or less than 12 months. CONCLUSIONS: Completion pneumonectomy for non-small cell lung cancer is a safe surgical procedure in experienced hands; long-term survival is acceptable and the best results are obtained for stage I lung cancer. Distinction between second primary lung cancer and recurrence failed to demonstrate a prognostic value.

Sleeve lobectomy for non-small cell lung cancer and carcinoids: results in 160 cases.

OBJECTIVE: To assess operative mortality (OM), morbidity and long-term results of sleeve lobectomies performed for non-small cell lung cancer (NSCLC) and carcinoids during a 35-year period. METHODS: A retrospective review of patients who underwent a sleeve lobectomy for NSCLC and carcinoids was undertaken, univariate and multivariate analyses of factors influencing early mortality in NSCLC were performed and for this purpose the series was split into an early and a contemporary phase, the Kaplan-Meier method was used to calculate the cumulative survival rate, and statistical significance was calculated with the log-rank test. Causes of death were evaluated in relation to the stage of the disease. RESULTS: OM for NSCLC was 14.6% in the early phase and 6% in the contemporary one; late stenosis occurred in 7.7% of NSCLC patients in the early phase and in 2% in the contemporary one. No OM or late stenosis occurred in carcinoid patients. Three, 5 and 10-year survival rates excluding carcinoids were 77, 62 and 31% for stage I(A-B), 45, 34 and 27% for stage II(A-B), 33, 22 and 0% for stage III(A-B). The 10-year survival rate for carcinoids was 100%. There was no significant difference in long-term survival between stages II and III, while the difference between stage I and stages II and III was significant (P<0.001). When survival was analyzed in relation to nodal status, 3, 5 and 10-year survival rates were 71, 57 and 33% for N0 disease, 42, 33 and 22% for N1 disease, and 34 and 19% with the last observation at 82 months of 19% for N2 disease; there was no significant difference in survival between N1 and N2 disease. A second primary lung cancer occurred in six patients (3.7%) who underwent resection. Late mortality was not related to cancer in most stage I patients while in stages II and III patients it was related to local and distant recurrences. CONCLUSIONS: Sleeve lobectomy is a valid alternative to pneumonectomy: careful patient selection and surgical technique make it possible to achieve a mortality rate comparable to or lower than that for pneumonectomy along with a better quality of life. In addition, it allows further lung resection, if necessary.

Alternative pathway for complement activation triggered by human liver plasma membranes.

Liver plasma membranes (LPM) prepared from normal hepatocytes by centrifugation in sucrose discontinuous gradient, are capable of haemolysing PNH-like cells in the presence of complement or complement plus EGTA or MG2+ ions. In contrast, EDTA or Ca2+ ions inhibit the lysis. The total complement lytic activity is reduced by some 40% when fresh serum is incubated with LPM, whereas the total amount of C4 remains constant. The cross-immunoelectrophoresis studies of fresh serum incubated with LPM demonstrate the appearance of C3 breakdown products, which suggests the activation of the alternative complement pathway. In contrast, the sucrose test, which proceeds mainly through the classical complement pathway, is inhibited by LPM. The possible role of complement in liver disease is discussed.

[Ataxia telangiectasia. Description of a case with multiple cerebral hemorrhages and liver cirrhosis]. / Atassia-teleangiectasia. Descrizione di un caso con emorragie cerebrali multiple e cirrosi epatica.

Clinical history and morbid anatomy findings of a new case of ataxia-telangiectasia are reported. A 26 years old man, with overt signs of the disease since the age of 8, died for decompensated cirrhosis; in the last year he suffered for cerebral haemorrhage; post-mortem examination showed venous angiectasias in cerebral white matter that caused two macroscopical areas of haemorrhagic infarction and multiple pin-pointed haemorrhages. We suggest that longer survival of patients with A.T., due to better management of infectious complications, permits the appearance of vascular abnormality not only in skin and mucosae, but also in deep organs, generally protected from environmental damages.

[Lung resection after pneumonectomy for bronchogenic carcinoma]. / Resezioni polmonari dopo pneumonectomia per carcinoma broncogeno.

METHODS: Four patients who previously underwent pneumonectomy for lung cancer, underwent a new contralateral resection for a metachronous cancer. Functional evaluation of these patients was not different from the standard one and included ECG, spirometry, blood gas analysis and a careful clinical evaluation. A femoro-femoral bypass was used in 2 patients to work on a collapsed lung, High Frequency Jet Ventilation was used in 1 while the last patient was hyperoxygenated and then ventilation was discontinued for the time required for the resections. RESULTS: Each method was free of complications. Operative mortality was nil. Two patients are alive free of disease at 66 and 14 months, two died for metastatic disease at 4 (N2 paratracheal nodes) and 12 months. CONCLUSIONS: Patients with a single lung should not be denied a further resection on contralateral lung. A routine evaluation of cardiopulmonary function may be sufficient but a more sophisticated evaluation including exercise oxygen consumption test, cardiac catheterization, lung perfusion scan, should be used when there is some doubt on the possibility of the patients to sustain the resection. Due to the high operative risk of this kind of patients mediastinoscopy should be performed even if preoperative CT scan of the chest shows minimally enlarged mediastinal nodes.

[Diagnosis and treatment of traumatic diaphragmatic hernia with delayed presentation]. / Diagnosi e trattamento dell'ernia traumatica del diaframma a tardiva presentazione.

AIM: To evaluate the clinical picture, diagnostic techniques and most appropriate treatment in traumatic diaphragmatic hernia with delayed presentation on the basis of personal experience and in the light of other published studies. EXPERIMENTAL DESIGN: Review of cases treated. SETTING: Patients treated in University General Surgery wards. PATIENTS: Those patients in whom diagnosis was made some time after trauma and after the acute event were selected from a group of patients with traumatic diaphragmatic hernia. SURGERY: All patients underwent surgery to reduce hernia and repair the diaphragmatic lesion. MEASUREMENTS: All clinical findings were examined together with the tests performed and the type of treatment carried out. RESULTS: The diagnosis was made between 3 months and 3 years after the injury. Three patients presented manifest symptoms of high intestinal occlusion on entry. Radiological alterations were present in standard chest X-rays in all patients and digestive tract contrast radiography was positive for the diagnosis of hernia in 3 out of 4 cases in which it was performed; a preoperative diagnosis of hernia was obtained in 4 cases. Patients were operated using a thoracotomy (3 cases) or combined laparothoracotomy access (2 cases); the diaphragmatic lesion, localised in all cases in the cupula of the left hemidiaphragm, was repaired using separate sutures in non-reabsorbable material without the use of grafts. One patient died postoperatively owing to septic complications. CONCLUSIONS: traumatic diaphragmatic hernia with delayed presentation involves severe complications that increase morbidity and operating mortality.

[Thoracoplasty today. Review of a technique of the past]. / La toracoplastica oggi. Rivisitazione di una tecnica del passato.

Thoracoplastic operations had ruled the field in the past as treatment of choice in the surgical antituberculous collapse therapy; they have had a notable revival during the last years as an efficient therapeutic modality in the treatment of chronic empyemas of the most various etiologies. They are thoracoplasties done with particular modalities, imposing, setting out case by case to suppress the infected pleural space. It is usually joined with a thoracotomy and it permits also the execution of other surgical intrathoracic manoeuvres such as decortications, treatment of fistulas, myoplasties. Situations such as chronic empyemas, without any solution before, have found a brilliant solution by the use of this operation.

[Surgical resection for pancreatic neoplasms in the past 20 years]. / La chirurgia resettiva per neoplasie pancreatiche negli ultimi venti anni.

Over the last 20 years there has been substantial progress in histopathological and biological understanding of pancreatic tumours. This has allowed surgical removal to be planned according to the aggressiveness and natural history of the tumours with benign (cystoadenomas, insulinomas) or low grade tumours (borderline mucin producing tumours, cystic papillary tumours), the trend towards cost effective surgery (conservative pancreatectomy) may be linked to the neighbouring organs (spleen, stomach, duodenum) in an attempt to bring about more rapid functional recovery for the patient and an improvement in the quality of life. On the other hand, the drastic reduction in operative mortality, which is currently less than 5% of cases following duodeno-pancreatectomy, has encouraged a more aggressive surgical technique in order to increase radical resectability for malignant tumours. Moreover, for highly malignant tumours such as ductal adenocarcinoma, the role of pancreatic resection for palliative purposes, in order to improve the quality of life with an acceptable operative risk, has been confirmed. It is foreseeable that as a result of a more accurate selection and grading of patients for surgery, there may in the future be improvements in survival even in those patients operated on for ductal adenocarcinoma. Until now, these patients have received no significant benefit from the undoubted progress achieved in diagnostic and operative techniques.

[Iatrogenic rupture of the esophagus: presentation of several cases]. / Le rotture iatrogeniche dell'esofago: presentazione di alcuni casi.

Four cases of iatrogenic rupture of the oesophagus are presented. The site of the lesion was in the cervical tract in 1 case and in the thoracic tract in the other 3 cases. Their etiology was pneumatic endoscopic dilatation for achalasia in 2 cases, endoscopic insertion of a Celestin tube for carcinoma of the thoracic tract of the oesophagus in 1 case, and diagnostic endoscopy in the last one. Instrumental findings were relevant in all cases. All patients underwent surgery. In the patients suffering from achalasia, the rupture was repaired by a patch of the gastric fundus. The patient suffering from carcinoma underwent an oesophageal resection, the one with cervical perforation underwent a mediastinal drainage. There were no deaths or considerable post operating complications. In a patient suffering from achalasia gastro-oesophageal reflux was demonstrated after some months following the operation.

[Hemorrhoidal thrombosis and perianal hematoma: diagnosis and treatment]. / Trombosi emorroidaria ed ematoma perianale: diagnosi e trattamento.

Thrombosed haemorrhoids and anal haematomas are very usual in patients with haemorrhoids. Conservative treatment and surgery are effective by the features and time of presentation. Authors refer about pathological and clinical findings and discuss the treatment.

[Thymoma, aplastic anemia, hypogammaglobulinemia and malignant pulmonary neoplasm: a case report]. / Timoma, anemia aplastica, ipogammaglobulinemia e neoplasia polmonare maligna: presentazione di un caso.

A 67 year old man presented with non-invasive thymoma, associated aplastic anemia and important hypogammaglobulinemia; the postoperative course has been characterized, three months later, by thrombocytopenia (kept under control with steroid therapy) and, two years later, by squamous lung cancer, not susceptible of surgical treatment. The patient died five years after operation because of progression of the lung cancer. Anemia improved only partially after operation; there where no effects on hypogammaglobulinemia. Thymoma has been reported in literature in 50% of patients with aplastic anemia, 7-13% of adult patients with hypogammaglobulinemia is affected by thymoma, in 21% of patients that presented with thymoma other tumors have been discovered through clinical history.