Endoscopic ultrasound-fine needle aspiration (EUS-FNA) for pancreatic lesions: effectiveness in clinical practice.

BACKGROUND: Diagnosis of pancreatic masses is often difficult. Endoscopic ultrasound-fine needle aspiration has been proposed as the best single-step strategy. AIMS: To prospectively evaluate feasibility, effectiveness and safety of endoscopic ultrasound-fine needle aspiration of pancreatic masses in a consecutive study of unselected patients. METHODS: Two hundred ninety-three patients were enrolled in two referral Hospitals in Northern Italy. All patients were referred either due to the presence of imaging test abnormalities (suspected or evident masses, or features indirectly suggesting the presence of a mass) or due to clinical or biochemical findings suggesting pancreatic cancer in the absence of positive imaging. All patients underwent linear array endoscopic ultrasound and, when indicated, fine needle aspiration. All procedures were recorded prospectively. The final diagnosis was established at the end of follow-up or when the patients underwent surgery or died. RESULTS: Fine needle aspiration was indicated in 246 of 293 cases (84%), considered technically feasible in 232 of 246 cases (94%) and gave adequate samples for histopathological diagnosis in 204 of 232 cases (88%). Endoscopic ultrasound sensitivity, specificity and accuracy were 79, 60 and 72%, respectively; the corresponding figures for endoscopic ultrasound-fine needle aspiration were 80, 86 and 82%. There was good agreement with final diagnosis for endoscopic ultrasound-fine needle aspiration (kappa 0.673, 95%CI 0.592-0.753), greater than that for endoscopic ultrasound alone (kappa 0.515, 95%CI 0.425-0.605). There was one case of intracystic haemorrhage and one case of transient hyperthermia (0.3%). CONCLUSIONS: Endoscopic ultrasound-fine needle aspiration of pancreatic masses seems to be feasible, effective and safe in this consecutive study of patients.

Short communication: Effect of stearoyl-coenzyme A desaturase polymorphism on fatty acid composition of milk.

The effect of the stearoyl-CoA desaturase (SCD) gene on milk fatty acid composition was tested. Cows of 3 breeds of northern Italy, Piedmontese, Valdostana, and Jersey, were genotyped at exon 5 of the SCD gene. This has been suggested as a primary candidate gene to change the proportion of saturated vs. unsaturated fatty acids in milk, wherein a single nucleotide polymorphism (C/T) gives rise to a different AA codon. It was possible to ascribe a reduced desaturase activity to the T allele only in the case of caproleic and myristoleic fatty acids. In contrast with the findings of SCD effects on carcass fat, it was not possible to confirm the higher desaturation activity of this single nucleotide polymorphism on long-chain fatty acids, due to the different pathways that originate milk fatty acids of different carbon length; long-chain fatty acids are highly influenced by the complex metabolic events that affect the ingested nutrients during their transfer to milk fat.

Therapeutic ERCP in paediatric patients.

BACKGROUND: Major limitations of endoscopic retrograde cholangiopancreatography in paediatric populations are a low incidence of biliopancreatic disease among children, the equipment dimensions (size of endoscopes and devices) and the increasing role of MR-cholangiopancreatography in the field of diagnostic indications. Aim of this study was to evaluate the diagnostic and therapeutic yields of endoscopic retrograde cholangiopancreatography for biliopancreatic diseases in a paediatric population. METHODS: Between 1996 and 2002, 48 endoscopic retrograde cholangiopancreatographies were performed in 38 children aged 4 weeks to 17 years as part of the diagnostic evaluation for suspected pancreatic or biliary tract disease. Endoscopic retrograde cholangiopancreatography was carried out under general anaesthesia, using prototype paediatric duodenoscopes or standard duodenoscopes in children younger or older than 18 months, respectively. RESULTS: The indications to perform endoscopic retrograde cholangiopancreatography were common bile duct stones (14 children), biliopancreatic abnormalities (8), primary sclerosing cholangitis (2), Wirsung disruption (1), biliary leakage (1), cholestasis (4) and pancreatitis (8). Cannulation was successful in all patients but one. Sphincterotomy together with stone extraction or stent insertion was performed in 30/38 patients. Immediate complications were mild and treated conservatively. CONCLUSIONS: Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography can be used safely and effectively in the management of biliopancreatic diseases in childhood as well. Indications, endoscopic techniques and complications are similar to those reported for adult patients.

Effectiveness of Helicobacter pylori eradication treatments in a primary care setting in Italy.

AIM: To evaluate the choice and relative effectiveness of Helicobacter pylori eradication regimens in a primary care setting. PATIENTS AND METHODS: Patients referred to our department, who had been treated for H. pylori infection during the preceding 6 months, were enrolled between September 1998 and July 1999. H. pylori status was assessed by urea breath test. Information on the drugs administered, compliance and side-effects was recorded. RESULTS: The mean eradication rate was 72% in patients receiving their first course of treatment (1863 cases; 45% male; mean age, 53 +/- 14 years); a double therapy regimen was prescribed to 14% of patients, triple therapy to 85% and quadruple therapy to 1%. Maastricht Consensus proton pump inhibitor-based regimens were prescribed in 80% of cases, with a mean eradication rate of 73%. No statistically significant correlation was found between eradication failure and sex, age, endoscopic findings or administered treatment. CONCLUSIONS: In Italy, in a primary care setting, first-line H. pylori eradication therapies reflect international guidelines. The efficacy of such regimens is lower than that reported by controlled trials. These results are relevant when making pharmacoeconomic evaluations of H. pylori management.

Ultrasonic monitoring of Wirsung duct following secretin in controls and in chronic pancreatitis patients.

Ultrasonic monitoring of the pancreas following secretin stimulation has shown to cause a marked dilatation of Wirsung duct; whether this phenomenon is due to the stimulation of pancreatic secretion and/or to the effect of secretin on the sphincter of Oddi (SO) motility is unknown. In the present study pancreatic scan after secretin was performed in 11 patients with nonpancreatic diseases after premedication with glucagon (inhibition of both pancreatic secretion and SO motility) or tyropramide (inhibition of SO motor function) and in patients with different degrees of pancreatic insufficiency. Serum immunoreactive trypsinogen (IRT) levels were measured in all the subjects during the test. Premedication with glucagon completely abolished both Wirsung enlargement and serum IRT increase, while tyropramide significantly reduced, but did not abolish, the response to secretin. These results suggest that both stimulation of pancreatic secretion and the increase of SO pressure are prerequisites for a full-blown occurrence of the secretin-induced modifications of Wirsung. Within chronic pancreatitis patients, the response to secretin was exaggerated in those with a still preserved pancreatic function and it was lacking in those with severe pancreatic insufficiency.

Increased serum pancreatic enzymes in uremia: relation with treatment modality and pancreatic involvement.

Increased levels of pancreatic enzymes have been reported in patients with renal insufficiency and ascribed either to impaired urinary excretion or, in a few studies, to the presence of pancreatic damage. In the present study serum total amylase, pancreatic amylase, and lipase were evaluated in 63 patients with chronic renal insufficiency (CRF), in 98 patients on hemodialysis (HD), in 28 patients on continuous ambulatory peritoneal dialysis (CAPD), in 23 patients with renal transplantation (RT), and in 34 normal volunteers (C). Serum parathyroid hormone and triglyceride levels were also measured in the majority of patients. Ultrasound examination of the pancreas was performed in a select number of cases. Mean values of pancreatic enzymes were significantly higher in all the study groups in comparison with controls, but values exceeding three times the upper normal limit were detected only in HD patients, who also showed amylase and lipase levels significantly highly than those of CAPD and CRF subjects. Negligible amounts of pancreatic enzymes were detected in peritoneal fluid of CAPD patients. Significant correlations were found with serum creatinine in CRF, with parathyroid hormone in HD and CAPD, and with duration of treatment in HD. No pancreatic abnormalities were detected by ultrasound. In conclusion, very high levels of pancreatic enzymes are seen mainly in HD patients and might be related more to the metabolic derangement of long-term dialysis treatment than to the occurrence of acute pancreatic damage.

Discrepancy between Helicobacter pylori stool antigen assay and urea breath test in the detection of Helicobacter pylori infection.

BACKGROUND: The reference diagnostic methods available for detection of Helicobacter pylori infection are either invasive (histology) or expensive and highly sophisticated (Urea Breath Test). A new enzyme immunoassay, which can be easily performed in any laboratory, has been developed to detect Helicobacter pylori in stool specimens (HpSA-Meridian Diagnostics, Cincinnati, USA). Aim of the study was to compare HpSA to Urea Breath Test. PATIENTS AND METHODS: A total of 125 patients (52 never treated for Helicobacter pylori infection and 73 after Helicobacter pylori eradication therapy) referring to our Department, underwent both tests within two weeks. RESULTS: Contrasting results between the two tests were found in 30% of cases: in 19% of the untreated patients and in 37% of the treated patients (p<0.001). The main discrepancy consisted in positive HpSA associated with negative Urea Breath Test. Mean HpSA value in such conditions was 0.273 optical density, while in patients with both positive tests, it was 1.192 optical density. In untreated, but not in treated patients, raising the HpSA cut off value significantly decreased the percentage of conflicting results. CONCLUSIONS: Some disagreement was detected between HpSA and Urea Breath Test results, especially in treated patients. Possible explanations for our findings are a low HpSA cut off value together with the identification of Helicobacter pylori coccoid forms by the immunoassay but not by the urease based Urea Breath Test. The higher percentage of discrepancy detected in treated patients might support this hypothesis.

Detection of anti-Saccharomyces cerevisiae antibodies in Crohn's disease: is it a reliable diagnostic and prognostic marker?

BACKGROUND: In the past few years, serologic markers have been proposed in inflammatory bowel disease. Anti-Saccharomyces cerevisiae antibodies showed high specificity for Crohn's disease. A prognostic role for serology has also been hypothesised. AIMS: To evaluate anti-Saccharomyces cerevisiae antibody distribution in an unselected Italian inflammatory bowel disease population. To analyse whether anti-Saccharomyces cerevisiae antibody status (positive/negative) and/or anti-Saccharomyces cerevisiae antibody titres are associated with clinical variables and outcome measures in Crohn's disease patients. PATIENTS AND METHODS: A series of 299 inflammatory bowel disease patients were evaluated; serum samples were taken and a short clinical history was recorded. anti-Saccharomyces cerevisiae antibodies IgG enzyme-linked immunosorbent assay Medilab (Milan, Italy) kit was used in order to determine anti-Saccharomyces cerevisiae antibody status. RESULTS: Sensitivity, specificity and likelihood ratio for positive test in the differential diagnosis of inflammatory bowel disease was 59%, 89%, 8.1, respectively. Clinical variables significantly associated with anti-Saccharomyces cerevisiae antibody status in logistic regression were found to be ileal location (p=0.01) and earlier age at diagnosis (p<0.01). Among ileal Crohn's disease patients, there was a trend in concordance between anti-Saccharomyces cerevisiae antibody titres and higher number of surgical procedures which was not statistically significant applying more complex statistics. CONCLUSIONS: In an Italian inflammatory bowel disease population, anti-Saccharomyces cerevisiae antibodies status showed characteristics similar to those previously reported. Anti-Saccharomyces cerevisiae antibody positivity is associated with ileal involvement and with earlier onset of Crohn's disease.

Plasma hormones and metabolites in Piedmontese cows during late pregnancy: relationships with calf birth weight.

Relationships among plasma hormonal and metabolic variables in the last trimester of gestation in 59 Piedmontese dams (n = 15 heifers, n = 44 cows) and the calf birth weight (BWT) class of their offspring were investigated in seven herds. The BWT data were categorized as follows: > 50 kg (BWT-A), 46 to 50 kg (BWT-B), 41 to 45 kg (BWT-C), and < 41 kg (BWT-D). Blood samples were collected at 33, 36, and 39 wk of gestation. Packed cell volume (PCV) and plasma concentrations of insulin, estrone sulfate (E1SO4), NEFA, and creatinine were determined and correlated to BWT class. Creatinine: E1SO4 ratio also was calculated. Duration of gestation was greater for dams producing a BWT-A calf than for the other BWT classes, and calf BWT was heavier (P < 0.001) for calves in the BWT-A vs. BWT-D class. The heaviest calf in BWT-A was associated with the highest calving difficulty score. Insulin and PCV values were not affected by week of gestation, whereas plasma E1SO4, NEFA, and creatinine content increased (P < 0.001) and creatinine:E1SO4 decreased (P < 0.001) during late gestation. Calf BWT class did not affect PCV value. Plasma E1SO4 concentrations were lower (P < 0.01) in BWT-D dams than the other dams, showing the greatest difference at 39 wk of gestation. At 36 and 39 wk of gestation, dams bearing BWT-C and BWT-D calves had a higher (P < 0.01) plasma insulin concentration than those bearing BWT-A and BWT-B calves. Plasma NEFA concentrations at 39 wk of gestation were higher (P < 0.05) in dams of calf BWT-A than in the other dams. We conclude that plasma E1SO4 level is a variable that can be used to monitor problems related to a small size calf. Conversely, the forthcoming birth of a calf with a heavy BW seems to be preceded by a pronounced increase in plasma NEFA level in the dam just a few days before calving.

Modality of treatment and outcome of Helicobacter pylori infection in primary care. An Italian experience.

BACKGROUND: Aim of the present study was to evaluate the selection and the relative efficacy of H. pylori eradication regimens in primary care setting. METHODS: Patients referred to our Department, treated for H. pylori infection during the last 6 months, were enrolled during September 1998-July 1999. H. pylori status was assessed by urea breath test and recorded together with information about administered drugs, compliance, side effects. RESULTS: In patients undergone the first treatment course (1863 cases, 45% M, mean age 53+/-14 yrs) the mean eradication rate (ER) was 72%: a double therapy was prescribed in 14% of cases, a triple therapy in 85% and a quadruple in 1%. Maastricht Consensus PPI-based regimens were prescribed in 80% of total cases with a mean ER of 73%. No statistical significant correlation was found between eradication failure and sex, age or administered treatment. CONCLUSIONS: In Italy, in primary care setting: 1) first line H. pylori eradication therapies reflect international guidelines; 2) the efficacy of such regimens is lower than the one reported by controlled trials: such data should be kept in mind when pharmacoeconomic evaluations of H. pylori management are drawn.

Impact of urea breath test (UBT) in the management of H. pylori infection in a primary care setting.

BACKGROUND: Aim of the present study was to evaluate the use of UBT in a primary care setting. METHODS: From September 1998 to July 1999 we studied 2810 consecutive patients, referred to the Department of Gastroenterology, Mauriziano Hospital, Torino. A structured questionnaire was used to record information on demographic characteristics and clinical history. 13C-UBT was performed by means of isotope ratio mass spectrometer. RESULTS: The results shown that: 1) the main indication to perform UBT was the evaluation of treatment success (72% of cases); 2) in patients aged less than 45 years and never assessed before for H. pylori infection, UBT was used as first line procedure in 68% of cases: this finding stand for an initial adoption of the ''test and treat'' strategy; 3) first line H. pylori eradication therapies reflect international guidelines. CONCLUSIONS: The effectiveness of therapeutic regimens results to be decreased when translated into routine clinical practice.

Multiple sampling 13C-urea breath test: improvement of diagnosis in postgastrectomy patients.

AIM: Partial gastrectomy and Helicobacter pylori (H. pylori) infection are considered 2 risk factors for gastric cancer development. False negative urea breath test (UBT) results have been described in patients with gastric surgery, due to rapid gastric emptying of urea solution from the stomach. On the other hand, a rapid 10-minute 14C-UBT proved to be highly reliable for diagnosis of H. pylori infection when delaying test meal was omitted. Aim of this study was to improve the diagnostic accuracy of 13C-UBT in patients with gastric resection. METHODS: UBT was performed in 100 gastrectomised patients with breath collection at 0, 10, 15, 20, 25 and 30 minutes (multi-UBT) after 100 mg 13C urea ingestion and 100 ml of marketed fruit juice. In 28 cases contemporary histological data from biopsy specimens (within 1 month, in absence of treatment) were also available. RESULTS: Multi-UBT was persistently negative or positive in all the samplings in 34% and 25% of cases, respectively. Positivity only at 30 minutes was found in 10% of cases, while 19% of subjects were positive at 15-25 minutes but not at 30 minutes. In 12% of cases the test was positive only at 10 minutes. CONCLUSIONS: Multi-UBT offers a not negligible diagnostic improvement over the standard UBT: at least 19%, and up to 31% if positivity at ''10-minute only'' is taken into account. This method can be useful when accurate diagnosis of H. pylori infection is required in gastrectomised patients.

Long-term ranitidine treatment for the maintenance of duodenal ulcer healing.

The purpose of the present trial was to verify the efficacy and safety of long-term ranitidine treatment (150 mg at bedtime for 1 year) for the maintenance of duodenal ulcer healing in 22 patients following a successful short-term course of therapy with ranitidine at the full dose of 300 mg per day. Of the 16 patients who completed the trial - there were 6 drop-outs - 4 suffered relapses during the year of treatment (25% cumulative recurrence rate), while remission persisted in the remaining 12 patients (75%). Biochemical tests revealed no statistically significant differences in mean fasting serum pepsinogen and trypsinogen as compared to mean basal values. Mean fasting serum gastrin showed a statistically significant rise from 156 +/- 27 S.D. to 258 +/- 110 S.D. pg/ml (p less than 0.01) only at the 12th month of therapy and rapidly returned to normal (162 +/- 34 S.D.) as soon as therapy was discontinued. No side-effects of any consequence were observed.

Trypsin-like immunoreactivity in the diagnosis of acute pancreatitis.

Elevated serum and urine amylase and serum lipase values are not always diagnostic of an acute pancreatitis, on the account of the extrapancreatic production of these enzymes. A diagnostic improvement can be made by using the CAm/CCr ratio, but this index too is abnormal in some non pancreatic diseases. Since trypsin measurement seems to be more specific in the evaluation of pancreatic condition, serum trypsin-like immunoreactivity has been measured in 28 patients with acute pancreatitis, 95 patients with a wide spectrum of gastroenterological diseases and in 30 patients with severe chronic renal failure. 85 normal subjects were used as controls. Abnormally high serum trypsin-like immunoreactivity (TLI) values were detected in 100% of patients with acute pancreatitis, without any overlap with normal controls. TLI values above the upper normal limit were also found in 70% of patients with severe renal damage, while none of the patients with liver disease, biliary disease, peptic ulcer an inflammatory bowel disease had elevated TLI levels. In 29 patients with hyperamylasemia due to extra-pancreatic diseases serum trypsin-like immunoreactivity was always within the normal range. It is concluded that the determination of serum TLI is a sensitive and reliable tool in the diagnosis of an acute pancreatic inflammation, providing that a severe renal failure is excluded.

Effects of replacing palm oil with maize oil and Curcuma longa supplementation on the performance, carcass characteristics, meat quality and fatty acid profile of the perirenal fat and muscle of growing rabbits.

An experiment has been conducted to study the effects of the inclusion of plant oil in rabbit diets. This study was aimed at evaluating the beneficial effects of the inclusion of maize oil (MO), rich in unsaturated fatty acids (UFAs), compared to palm oil (PO) containing saturated fatty acids (SFAs), on the meat fatty acid (FA) profile. As UFAs are susceptible to rancidity, Curcuma longa (CL), which is known for its antioxidant properties, was also added (3 g/kg) to the diet with two plant oils. CL contains curcuminoids, volatile oils, sugars, proteins, resins and polyunsaturated fatty acids (PUFAs). We also evaluated the influence of CL inclusion in the diet on the FA profile of the meat. Furthermore, the possibility of using these oil-enriched diets and the ability to assimilate CL in rabbits was evaluated by analysing the performance, carcass characteristics and meat quality. At the end of the experiment, there were no significant differences between the groups concerning the live weight, live weight gain, feed consumption, feed efficiency, carcass yield or the percentages of edible organs. The hind legs, forelegs, loins and abdominal wall, breast and ribs, skin and limbs and head were not affected by the oil type or by the inclusion of CL. The chemical composition, pH and oxidative status of the Longissimus dorsi muscle of the rabbits fed the experimental diets were not affected by the oil source or by the CL supplementation. Conversely, it has been shown that it is possible to modify the FA profile of rabbit meat and fat by dietary means. The SFA/PUFA ratio significantly decreased from -18% to -16% in the meat and from -25% to -23% in the perirenal fat of the rabbits fed diets containing MO without or with CL supplementation, respectively, compared to same tissues of the rabbits fed diets containing PO without or with CL supplementation, respectively. Similar trends were found for the atherogenic index, which decreased from -20% to -17% in the meat and from -26% to -23% in the perirenal fat, respectively, and the thrombogenic index, which decreased from -19% to -24% in the meat and from -24% to -23% in the perirenal fat, respectively. CL increased the α-Linolenic acid and PUFA n-3 contents and reduced the vaccenic acid content and the n-6/n-3 ratio in the meat of the rabbits fed the PO or MO diets.

Epidural plus general anesthesia vs general anesthesia alone for elective aortic surgery: effects on gastric electrical activity and serum gastrin secretion.

BACKGROUND: The aim of this study was to evaluate differences in electrogastrographic activity and serum gastrin secretion in patients subjected to general anesthesia (GA) vs blended anesthesia (BA = GA plus epidural analgesia) for abdominal aortic surgery. METHODS: Thirty-four patients (all males: 28 with abdominal aorta aneurysm, 6 with obstructive aorto-iliac disease; mean age: 68+/-7 years) were randomly assigned either to GA (N.=17) or to BA (N.=17) for abdominal aortic surgery. Each patient was evaluated for serum gastrin secretion at the time of electrogastrography (EGG) 24 h before and after surgery, using ambulatory equipment. Gastrin levels were tested under fasting conditions and after a standard meal. EGG shows gastric electrical activity that parallels gastric motor activity. RESULTS: Before surgery, no significant difference was found for any of the EGG parameters or the serum gastrin integrated value (area under the curve [AUC]) between the two groups of patients. After surgery, an increased frequency of electrical waves (tachygastria) was observed in 22% of those undergoing GA and in 5% of patients undergoing BA. The power ratio (postprandial/fasting total power) was exceedingly high (>4) in 53% of the GA patients and in 11% of the BA patients (P<0.05). The gastrin AUC was 263+/-58 pg/mL in the GA group and 179+/-92 pg/mL in the BA group (P<0.01). CONCLUSIONS: An excess of EGG activity and serum gastrin secretion was observed in patients undergoing GA vs those submitted to BA. Thus, the latter procedure seems to affect gastric function less than GA alone.