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

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

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

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

Degradation of soluble collagen by ozone or hydroxyl radicals.

Collagen exposed to ozone or hydroxyl radicals was degraded in a time- and dose-dependent manner. This degradation was inhibited by free radical scavengers. Furthermore, lower levels of these oxidants did not degrade the molecule, but caused it to become susceptible to proteolytic degradation. We suggest an alternative mechanism by which oxygen-derived free radicals participate in the destruction of extracellular matrix observed during acute lung injury by oxidant gas, in addition to the commonly accepted proteinase-antiproteinase theory of lung injury.

Stimulation of human polymorphonuclear leukocyte superoxide anion radical production by tumor promoters.

Comparison was made of the ability of the potent tumor promoter phorbol myristate acetate (PMA), as well as less active PMA analogs and non-phorbol ester tumor promoters, to stimulate superoxide anion radical (O-.2) production by human polymorphonuclear leukocytes (PMN). The rate of O-.2 production was found to correlate with the tumor-promoting activity of the phorbol esters as opposed to their inflammatory activity. Mezerein and telocidin B were slightly better stimulators of O-.2 production than PMA. Acetic acid was inactive. These data are discussed in terms of a possible role for O-.2 and other reactive oxygen species in tumor promotion.

Inhibition by reactive aldehydes of superoxide anion radical production from stimulated polymorphonuclear leukocytes and pulmonary alveolar macrophages. Effects on cellular sulfhydryl groups and NADPH oxidase activity.

Alpha,beta-unsaturated aldehydes such as acrolein (ACR) and crotonaldehyde (CRO) have been shown previously in our laboratory to inhibit the production of superoxide anion radical (O2-) by stimulated phagocytic cells in vitro in a dose-related manner. Based on the known reactivity of these compounds towards cellular sulfhydryls (SH), the present studies were aimed at investigating cellular SH status in relation to O2- production. Plasma membrane surface SH groups were measured using carboxypyridinedisulfide and monitoring the resultant formation of mixed disulfides through assay of thione released into the supernatant fraction. Intracellular non-protein sulfhydryls were measured using 5,5'-dithiobis-2-nitrobenzoic acid. In both human polymorphonuclear leukocytes (PMN) and rat pulmonary alveolar macrophages (PAM) there was a dose-related decrease in surface SH and soluble SH after ACR and CRO treatment. Propionaldehyde, a three-carbon saturated aldehyde, was without effect. The decrease in surface SH was greater than the decrease in soluble SH. In addition, in PMN and PAM preincubated with 5-40 microM ACR, there was a dose-related inhibition in the rate of O2- production with no effect on the lag time as measured by cytochrome c reduction. In stimulated PMN, there was a dose-related decrease in the rate after addition of 5-40 microM ACR. These data suggest that changes in SH status by reactive aldehydes can modulate the activity of the plasma membrane NADPH oxidase responsible for O2- production.

Noninvasive detection of vascular dysfunction in alcoholic patients.

Vasodilation is impaired in various conditions, such as hypercholesterolemia and tobacco use. We evaluated brachial artery flow-mediated vasodilation (FMD) after blood pressure (BP) cuff occlusion using high-resolution B-mode ultrasound in 20 alcoholics, without any coexisting conditions such as smoking, hypertension, or cholesterolemia, after a 3-month period of abstinence. They were compared with a control group of 20 alcohol-free healthy subjects. We measured the diameter of the brachial artery under baseline conditions, during reactive hyperemia (with increased flow causing endothelium-dependent dilatation), and after administration of sublingual glyceryl trinitrate (GTN), an endothelium-independent dilator. We performed an echocardiographic study (Esaote Au3) according to guidelines of the American Society of Echocardiography to assess left ventricular mass (LVM), wall thickness, systolic stress, and diastolic function changes. FMD (% diameter change) was significantly less in the alcoholic patients than in the controls (6.03+/-3.67 v 13.7+/-4.65; P < .05), whereas no difference was noted after GTN administration (13.7+/-7.97 v 16.0+/-5.12, P = NS). Echocardiographic study showed no differences between the study group for LVM, wall thickness, and systolic stress; diastolic function expressed as E/A ratio inversion was significantly impaired. These data demonstrate an impairment of endothelial-dependent vasodilatation in chronic alcohol abusers, which may contribute to the excess prevalence of cardiovascular diseases in these individuals.

Evaluation of the genetic toxicity of middle distillate fuels.

Petroleum middle distillate (PMD) fuels are mixtures of hydrocarbons that distill between approximately 170-370 degrees C. Commercial products that fall into this category include kerosine, diesel fuel, jet fuel, and home heating oil. These products contain both saturated (paraffins and cycloparaffins) and aromatic species, but because of the boiling range normally contain very small amounts of the 3-6 ring polycyclic aromatic hydrocarbon (PAH) constituents, which are considered to be carcinogenic. Nevertheless, there is evidence of weak tumorigenic activity when these materials are repeatedly applied to mouse skin. In the current studies representative products were tested in two commonly used, short-term assays for genetic toxicity, the Salmonella/mammalian microsome mutagenicity assay and the mouse bone marrow micronucleus test. All samples were inactive in the micronucleus assay, and three were clearly inactive in the Salmonella test. Of the remaining two, one was marginally active in the Salmonella assay, and one was equivocal. The marginally active sample contained detectable levels of PAH due to the use of catalytically cracked materials as blending stocks. The results indicated that PMDs that do not contain cracked material were not mutagenic. Thus they may produce tumors via nongenotoxic processes. Those products that do contain cracked stocks may have sufficient PAH to be mutagenic in the Salmonella assay, and in those cases the PAH might also contribute to tumor formation.

Inhibition by reactive aldehydes of superoxide anion radical production in stimulated human neutrophils.

alpha,beta-Unsaturated aldehydes were investigated in vitro for their ability to inhibit superoxide anion radical (O2-.) production in stimulated human polymorphonuclear leukocytes (PMN). The aldehydes investigated were (i) trans-4-hydroxynonenal and malonaldehyde (MDA), two toxic lipid peroxidation products; (ii) acrolein and crotonaldehyde, two air pollutants derived from fossil fuel combustion; (iii) trans,trans-muconaldehyde, a putative hematotoxic benzene metabolite. Preincubation of PMN with reactive aldehydes followed by stimulation with the oxygen burst initiator phorbol myristate acetate (PMA) resulted in a dose-dependent inhibition of O2-. production. The concentration at which 50% inhibition (IC50) was observed was 21 microM for acrolein, 23 microM for trans,trans-muconaldehyde, 27 microM for trans-4-hydroxynonenal and 330 microM for crotonaldehyde. A similar inhibitory effect by these aldehydes was observed in digitonin- and concanavalin A-stimulated PMN. MDA inhibited O2-. production in PMA-stimulated PMN by 100% at 10(-2) M but gave no inhibition at 10(-3) M. The standard aldehyde propionaldehyde did not inhibit O2-. production at 10(-3)-10(-6) M. Preincubation of PMN with acrolein in the presence of cysteine completely protected against the inhibitory effect of this reactive aldehyde. The results indicate that the ability of toxic aldehydes to inhibit O2-. production in stimulated PMN correlates directly with their alkylation potential which is a function of the electrophilicity of the beta carbon.

Enhancement of rat and human phagocyte superoxide anion radical production by cadmium in vitro.

The mechanism by which cadmium produced oxidizing effects in vivo is unknown. We show that cadmium enhances the production of superoxide anion radical (O-(2) .), a reactive oxygen species, in digitonin-stimulated phagocytes from man and rat. Cadmium concentrations ranging from 3.6 X 10(-2)M to 3.6 X 10(-4)M inhibited O-(2) . production in rat alveolar macrophages or human granulocytes. However, when activated in the presence of 3.6 X 10(-5)M cadmium, the production of O-(2) . was increased by a factor of 2.11 +/- 0.25 above control levels in human granulocytes and 3.6 +/- 0.62 above control levels in rat alveolar macrophages. This effect by levels of cadmium within the range of those occurring during in vivo toxicity might provide an explanation for the oxidizing effects of this metal ion.

Assessment of the utility of the micronucleus test for petroleum-derived materials.

The micronucleus test is a commonly used in vivo assay for chromosomal damage and is an integral part of many mutagenicity testing strategies. The present report describes an assessment of the micronucleus test for the detection of mutagenic potential of petroleum-derived materials. To this end, studies were conducted with catalytically cracked clarified oil (CCCO). This material contains high levels of polycyclic aromatic constituents (PAC) and is a very potent inducer of mouse skin tumors. CCCO is also active in the Salmonella assay and other in vitro tests. As CCCO is the most potent of the various petroleum-derived materials in other assays, it was assumed to be the most easily detectable in the micronucleus test. CCCO was tested in standard mouse micronucleus tests utilizing oral and intraperitoneal injection for test material administration. All of these studies were negative, although DMBA, tested at roughly equivalent levels based on potency in the Salmonella assay, produced statistically significant increases in micronucleus frequency. In a second series of studies, aromatic fractions of CCCO were prepared and tested at up to acutely toxic levels. Results of these studies were also negative. Finally, another petroleum-derived material which is carcinogenic and contained PAC was tested in the micronucleus assay. It also produced negative results. Thus, it was concluded that petroleum-derived materials do not produce clastogenic effects in vivo in the mouse micronucleus test, despite the fact that some pure polycyclic aromatic hydrocarbons are quite active in this assay.

Activation of neutrophil collagenase by cathepsin G.

Collagenase is secreted from neutrophils as a latent or proenzyme. In an effort to understand the mechanism of collagenase activation in inflammation, human peripheral neutrophils (PMNs) were isolated and incubated with the tumor promotor, phorbol myristate acetate (PMA), which induces the neutrophils to degranulate and secrete proteinases. Neutrophil media were then treated with various activators or inhibitors of collagenase and other proteinases, and the collagenase activity was measured. A serine proteinase secreted from neutrophils, cathepsin G, was found to activate latent collagenase, but it was also found to require activation itself. Both hypochlorous acid (HOCl) and oxidized glutathione (GSSG) were tested for their collagenase-activating ability and were found to be successful only in the presence of active cathepsin G. A specific cathepsin G inhibitor (0.5 mM Z-Gly-Leu-Phe-CH2Cl) prevented the activation of latent collagenase by HOCl. To confirm these results, purified neutrophil cathepsin G was incubated with a neutrophil proteinase mixture which contained latent collagenase. The collagenase was shown to be activated upon incubation with purified cathepsin G. These results indicate that cathepsin G is a key mediator in neutrophil collagenase activation.

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

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

Is hepatitis G virus a real risk for haemodialysis patients?

Haemodialysis patients are at high risk of developing liver disease due to blood-borne viral agents. At present hepatitis C virus (HCV) is the most common cause of infection in these patients. A new RNA virus of the Flaviviridae family, hepatitis G virus (HGV) has recently been cloned. HGV prevalence in haemodialysis patients ranges from 3.1% to 57.5%. The aim of this study has been to detect HGV-RNA in our haemodialysis patients in order to evaluate the prevalence of HGV and to correlate the viral presence to liver disease. A total of 79 patients, on haemodialysis for a mean of 52 months, were tested. 3 patients (3.8%) were HBsAG positive and 19 patients (24%) were HCV positive. 24 of the 79 (30%) patients had been transfused. Only 2 of the 79 patients (2.5%) were HGV positive. These patients were HBsAG and anti HCV negative, both had been previously transfused and showed no signs of liver disease.

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

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

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

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

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

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

[Hemorrhagic emergency due to esophagogastric varices in the portal hypertension patient]. / L'urgenza emorragica da varici esofagogastriche nel paziente iperteso portale.

High gastrointestinal hemorrhage represents the more frequent (12-71.1%) and heavy complication of hepatic cirrhosis and correlates to portal hypertension; it is weighed by global mortality which sways from 30 to 50%. High gastrointestinal hemorrhage gives, therefore, a serious of diagnostic and therapeutic problems not easy to guide for at least 3 reasons: numerous causes of bleeding; hepatic failure; the marigold possible therapies. Aim of this work is to clarify some diagnostic and therapeutic features about high gastrointestinal hemorrhage in cirrhotic patient, because such eventuality often presents dramatic aspects, which endangers the patient's life. Our experience shows a casuistry referred to the period of time which goes from 1987 to 1998 and that comprehend 143 examined patients: 91 of them have been submitted to medical treatment (endoscopic sclerotherapy, glupressin e/o somatostatin); in 52 cases it has been possible to realize a surgical treatment, different from the elective therapy (33 pz) and emergency therapy. Immediate hemostatic effect obtained in both the conditions, has been satisfying with best results at a distance of three years and five years given by devascularization. As matter stands our preference of the devascularization surgical treatment, it seems appropriate to pay attention to the operation of mesocaval anastomosis which, either in our very brief experience (3 cases) or by international literature, seems to offer encouraging results.

[Acute pancreatic necrosis complicated by infection and gastro-intestinal translocation: pathogenesis correlation and therapeutic implication]. / Necrosi pancreatica acuta infetta e translocazione batterica intestinale: correlazioni patogenetiche e implicazioni terapeutiche.

The authors define pathogenetics correlations as a acute necrotizing pancreatitis complicated by infection and bacterial translocation. Acute necrotizing pancreatitis infection occurs for gastrointestinal bacterial translocation due to structural and functional modifications of intestinal mucosa. These modifications are results of mucosa ischemic-reperfusion system caused by systemic emodynamic instability in micro- and macro-circulation of splanchnic district. Emodynamic systemic instability has a central role in different multiple physiopathologic phenomena (ipovolemic shock; pancreatic shock, SIRS), which is caused by acute pancreatic necrosis and carries to common way established by severe systemics emodinamics modifications; these changes promote growth of adverse events which conduce by means of process previously described to bacterial translocation and infection of acute pancreatic necrosis. Indeed, emodynamic systemic instability of any etiology, can determine for one way bacterial translocation and on the other acute ischemic pancreatitis; both phenomena concur lead to cause beginning of acute necrotizing pancreatitis complicated by infection. The authors confirm that improved knowledge of acute pancreatic necrosis complicated by infection and own pathogenetic correlations with bacterial translocation, allows the realization of therapeutic measures aimed to prophylaxis of infection of acute pancreatic necrosis. Central emodynamic stability regularization of splanchnic perfusion and antibiotic prophylaxis, have a central role in prophylaxis of infection of acute pancreatic necrosis. Antibiotic is given by systemic (imipenem e.v.) and selective decontamination of gastrointestinal tract (SDD). SDD provides for oral antibiotic prophylaxis (PTA protocol) and systemic antibiotic prophylaxis (cefotaxime and gentamicin), in addition to microbiologic and gastrointestinal monitoring. If on the one hand the role of SDD about mortality reduction is not clear, however, on the other it is well recognized capacity of reduction the intercurrents and pulmonary infections. Other Authors think that SDD is insignificant on early mortality, whereas, is a good option to reduce late and overall mortality of acute pancreatic necrosis complicated by infection.

[Emergencies in gastroesophageal varices hemorrhage in the patient with portal hypertension]. / L'urgenza emorragica da varici esofago-gastriche nel paziente iperteso portale.

High gastrointestinal hemorrhage represents the more frequent (12-71.1%) and heavy complication of hepatic cirrhosis and correlates to portal hypertension; it is weighed by global mortality which sways from 30 to 50%. High gastrointestinal hemorrhage gives, therefore, a serious of diagnostic and therapeutic problems not easy to guide for at least 3 reasons: numerous causes of bleeding; hepatic failure; the marigold possible therapies. Aim of this work is to clarify some diagnostic and therapeutic features about high gastrointestinal hemorrhage in cirrhotic patient, because such eventuality often presents dramatic aspects, which endangers the patient's life. Our experience shows a casuistry referred to the period of time which goes from 1987 to 1998 and that comprehend 143 examined patients: 91 of theme have been submitted to medical treatment (endoscopic sclerotherapy, glupressin e/o somatostatin); in 52 cases it has been possible to realize a surgical treatment, different from the elective therapy (33 pz) and emergency therapy. Immediate hemostatic effect obtained in both the conditions, has been satisfying with best results at a distance of three years and five years given by devascularization. As matter stands our preference of the devascularization surgical treatment, it seems appropriate to pay attention to the operation of mesocaval anastomosis which, either in Our very brief experience (3 cases) or by international literature, seems to offer encouraging results.

[The dehiscence of colorectal anastomoses: the risk factors]. / Le deiscenze nelle anastomosi colo-rettali: fattori di rischio.

OBJECTIVE: To evaluate the results of emergency and elective colorectal resective surgery; to identify general and local factors that influence the anastomotic leak rate. MATERIAL AND METHOD: 200 selected consecutive patients (115 males and 85 females, medium age 50.6 years, range 16-87) underwent resective colorectal surgery between 1990 to 1997. 154 (77.0%) were operated in elective surgery and 46 (23.0%) in urgency, for carcinoma, diverticular disease, mesenteric infarction, chronic intestinal disease, dolicosigma, anastomotic leakage, familiar polyposis or lesions by firearm. The operations consisted in 58 right colectomy, 28 left colectomy, 6 resection of the transverse and 29 of the sigmoid colon, 40 anterior resection, 12 total colectomy, 19 closing of colostomy, 6 by-passes. Anastomoses were performed in 88 cases by manual and in 110 by mechanical sutures. RESULTS: We observed 12 (6%) anastomotic leakages. Mortality rate was 1.0%. 13%.0 of these patients were underwent before to emergency and 3.9% to elective surgery; 5.7% by manual and 6.4% by mechanical suture. Diagnosis of leakage was made by clinical features, blood vessel examinations and abdominal TC scan. DISCUSSION: The risk factors of anastomotic leakage are general or local. Chronic obstructive pulmonary disease, perioperative transfusion, level of serum albumin, use of corticosteroid in the first group and sepsis, bowel obstruction, anastomotic level and tension and poor blood supply in the second, appear the most important causative factors in the development of anastomotic leaks. CONCLUSION: The incidence of dehiscence in colo-rectal surgery was seen significatively lower when anastomoses were performed in ideal circumstances than in the presence of one or more unfavorable factors. Healing remains a process depending more on the patient than on any aspect of the surgical technique.