Dietary macronutrient intake during the first 10 years of life in a cohort of Italian children.

OBJECTIVE: To describe the longitudinal pattern of dietary energy and macronutrient intakes during the first 10 years of life in a sample of healthy Italian children. PATIENTS AND METHODS: Sixty-one healthy children were followed from birth to 10 years of age. At 1, 5, 8, and 10 years of age, anthropometric measurements were taken and nutritional habits evaluated using a standardized food frequency questionnaire. RESULTS: Compared to the Italian recommended dietary allowances, the children's diet was high in protein at any age, high in lipids from age 5 onward, and high in calories at 5 years of age. At 1 year, mean (SD) protein, carbohydrate, and lipid intake, expressed as percentage of total energy, was 20% (3%), 48% (7%), and 34% (5%), respectively. Afterward, the corresponding mean value ranged around 14% to 15%, 57% to 60%, and 29% to 32%. The mean glycemic load and overall glycemic index ranged around 143 to 150 and 58 to 59, respectively. A difference between boys and girls was found in the longitudinal pattern for the intake of energy (P < 0.0001) and glycemic load (P < 0.0001). The individual longitudinal dietary pattern varied over time for the intake of total energy (P < 0.0001), any macronutrient (P < 0.0001), and overall glycemic index (P = 0.05). CONCLUSIONS: Although the amount of energy intake was in accordance with the Italian recommended dietary allowances, children consumed a high-protein and high-lipid diet. Early and continuous dietary education of children and parents may provide support for adequate nutritional habits throughout their childhood.

[Management of "complicated" work fitness judgements among health care workers]. / La gestione delle "idoneità difficili" negli operatori della sanità.

The occupational physician, performing health surveillance within a hospital, may face to some difficulties due to the variety and complexity of the tasks and the health risk factors of the health care workers. One of the hardest issue for occupational physician is to provide judgement on worker's fitness. Moreover, this task could be more complicated when a impaired worker could represent an hazard for his patients and colleagues. The authors will illustrate three critical clinical cases examined in Occupational Health Unit of Luigi Sacco Hospital, Milan; furthermore, the authors will show the difficulties and the applied solutions in order to provide the judgement on worker's fitness.

Dietary glycemic load and macronutrient intake in healthy Italian children.

The objective is of this study is to examine the relationship of dietary glycemic load (GL) and overall glycemic index (OGI) with macronutrients intake, body mass index (BMI) and insulin sensitivity in healthy children. The subjects comprised of 105 healthy non-obese eight-years old children, 60 boys and 45 girls. A Food Frequency Questionnaire (FFQ) evaluating dietary habits, GL and OGI. Insulin sensitivity was evaluated by the homeostatic model assessment (HOMA). GL was positively associated with dietary total (correlation coefficient, r=0.57) and starch (r=0.67) carbohydrates, daily consumption of pasta and white bread, cooked potatoes, bakery products and cookies, and negatively with dietary fats (r=-0.52). OGI was positively associated with daily consumption of white bread and cookies, and negatively associated with soluble carbohydrates (r=-0.35), and consumption of fibres, proteins, fruit, legumes and carrots. No significant association was found of GL or OGI with BMI or insulin sensitivity. In healthy children, GL and OGI may represent a useful indicator of quality of diet.

Extrahepatic biliary stenoses after hepatic arterial infusion (HAI) of floxuridine (FUdR) for liver metastases from colorectal cancer.

Hepatic arterial infusion of floxuridine is an effective treatment for unresectable hepatic metastases from colorectal cancer. Despite its pharmacological advantage of higher tumor drug concentration with minimal systemic toxicity, hepatic arterial infusion of floxuridine is characterized by regional toxicity, including hepatobiliary damage resembling idiopathic sclerosing cholangitis (5-29% of treated cases). Unlike previous reports describing biliary damage of both intrahepatic and extrahepatic ducts, a case series of extrahepatic biliary stenosis after hepatic arterial infusion with floxuridine is herein described. Between September 1993 and February 1999, 54 patients received intraarterial hepatic chemotherapy based on continuous infusion of floxuridine (dose escalation 0.15-0.30 mg/kg/day for 14 days every 28 days) plus dexamethasone 28 mg. Twenty-seven patients underwent laparotomy to implant the catheter into the hepatic artery, the other 27 patients receiving a percutaneous catheter into the hepatic artery through a transaxillary access. Five patients (9.2%) developed biliary toxicity with jaundice and cholangitis (3 cases), alterations of liver function tests and radiological features of biliary tract abnormalities. They received from 9 to 19 cycles (mean 14.5 +/- 6.3 cycles) of floxuridine infusion with a total drug delivered dose ranging from 20.3 to 41.02 mg/kg (mean: 31.4 +/- 13.5 mg/kg). Extrahepatic biliary sclerosis was discovered by computed tomography scan and ultrasound, followed by endoscopic retrograde cholangiopancreatography and/or percutaneous cholangiography in 3 cases. Radiological findings included common hepatic duct complete obstruction in 1 case, common hepatic duct stenosis in 2 cases, common bile duct obstruction in 1 case, and intrahepatic bile ducts dilation without a well-recognized obstruction in 1 case. Two patients were treated by sequentially percutaneous biliary drainage and balloon dilation while 1 patient had an endoscopic transpapillary biliary prosthesis placed. Percutaneous or endoscopic procedures obtained the improvement of hepatic function and cholestatic indexes without subsequent jaundice or cholangitis. In two patients suppression of floxuridine infusion allowed the improvement of hepatic function. The present series suggests that in some patients receiving hepatic arterial infusion of floxuridine extrahepatic biliary stenosis may represent the primary event leading to a secondary intrahepatic biliary damage that does not correlate with specific floxuridine toxicity but results from bile stasis and infection, recurrent cholangitis and eventually biliary sclerosis. Aggressive research for extrahepatic biliary sclerosis is advised, since an early nonsurgical treatment of extrahepatic biliary stenosis may prevent an irreversible intrahepatic biliary sclerosis worsening the prognosis of metastatic liver disease.

Renal arterial stenosis: prospective comparison of color Doppler US and breath-hold, three-dimensional, dynamic, gadolinium-enhanced MR angiography.

PURPOSE: To compare color Doppler ultrasonography (US) with fast, breath-hold, three-dimensional, gadolinium-enhanced magnetic resonance (MR) angiography in detecting renal arterial stenosis. MATERIALS AND METHODS: Forty-five patients with clinical suspicion of renovascular disease were prospectively examined with intra- and extrarenal color Doppler US and breath-hold, gadolinium-enhanced MR angiography. Digital subtraction arteriography (DSA) was the standard of reference in all patients for the number of renal arteries and degree of stenosis. RESULTS: DSA depicted 103 arteries and 52 stenoses. Color Doppler US was nondiagnostic in two examinations. Significantly more of 13 accessory renal arteries were detected with MR angiography (n = 12) than with color Doppler US (n = 3; P <.05). For assessing all stenoses, the sensitivity and accuracy were 94% and 91%, respectively, for MR angiography and 71% and 76%, respectively, for US (P <.05). The sensitivity was higher for MR angiography (100%) than for US (79%; P <.05) in diagnosing stenoses with at least 50% narrowing. The specificity, accuracy, and negative predictive value in diagnosing stenoses of at least 50% narrowing were 93%, 95%, and 100% for MR angiography and 93%, 89%, and 90% for US. CONCLUSION: Breath-hold, gadolinium-enhanced MR angiography is superior to color Doppler US in accessory renal artery detection. Although the specificity of MR angiography is similar to that of color Doppler US, MR angiography has a better sensitivity and negative predictive value in depicting renal arterial stenoses.

Pre-operative chemoembolization of hepatocellular carcinoma in cirrhotic patients.

BACKGROUND/AIMS: The aim of the study was to evaluate clinical and pathological effects of transcatheter arterial chemoembolization (TACE) before surgical resection for hepatocellular carcinoma (HCC) in cirrhosis (55 patients); results were compared with a group of 45 patients undergoing surgical resection without TACE. METHODOLOGY: From March 1989 to December 1997, 55 cirrhotic patients, affected by surgically resectable HCC not larger than 5 cm with unifocal or bifocal tumor lesions, underwent TACE pre-operatively. RESULTS: Massive necrosis was observed in 26%, necrosis > 50% in 38% of lesions. Neoplastic cells were found in 47% of cases within the capsule or in the pericapsular tissue. Satellite nodules showed a low rate of necrosis. Mortality and morbidity in the pre-operative TACE group were 1.8% and 29%, respectively, and 4.4% and 33%, respectively, in the control group. One-, 3- and 5-year patient survival rates were 87%, 70% and 39%, respectively, versus 79%, 38% and 19%, respectively (p<0.02), in the control group. Disease-free survival was 40% and 28% at 3 years and 5 years with pre-operative TACE versus 20% and 11% (p<0.05). CONCLUSIONS: Pre-operative TACE can be performed with low morbidity. TACE can necrotize the main lesion and temporarily arrest portal diffusion of neoplastic cells by acting on microvascular infiltration. No evident effect on satellites and pericapsular neoplastic foci was observed. The long-term patients and disease-free survival rates were improved upon.

[Embolization of iatrogenic renal vascular lesions with coaxial catheters and microcoils]. / Embolizzazione delle lesioni vascolari renali iatrogene mediante sistema di cateteri coassiali e microspirali.

INTRODUCTION: We report our experience with the superselective embolization of iatrogenic vascular injuries. We used new coaxial catheters and new microcoils to assess their technical features and efficacy. MATERIALS AND METHODS: Diagnostic angiography by catheterization of the main renal artery was performed in 7 patients with suspected renal vascular injury to detect injury presence and site. After super-selective catheterization of the feeding arteries with a coaxial catheter (Tracker 18), we performed embolization with platinum microcoils inserted using a coil pusher. The procedure efficacy was assessed at angiography and by comparing serum hemoglobin and hematocrit levels before and after embolization; posttreatment renal function was also studied. RESULTS: Selective embolization permitted complete occlusion of the arteries feeding the vascular injury in all patients, preserving as much parenchyma as possible. Hemoglobin and hematocrit levels were improved or unchanged after the maneuver (average hemoglobin level before embolization: 9.01 mg/dl versus 9.95 mg/dl after embolization; average hematocrit level before embolization: 27.3% versus 30.06% after embolization). We had no difficulty during microcoil insertion and the coaxial catheter was always stable. CONCLUSION: Superselective embolization of iatrogenic vascular injuries is an effective and definitive treatment. We recommend it in the patients with renal bleeding due to iatrogenic vascular injury after percutaneous diagnostic or therapeutic procedures.

Color Doppler imaging in the assessment of vascular involvement by pancreatic carcinoma.

OBJECTIVE: The aim of our study was to assess the accuracy of color Doppler imaging in diagnosing the involvement of peripancreatic vessels by pancreatic carcinoma. SUBJECTS AND METHODS: We prospectively evaluated the color Doppler images of 61 patients with pancreatic carcinoma. Our evaluations occurred before surgery and focused on vascular involvement. Absence of contact or a short contiguity (< or = 2 cm) between tumors and peripancreatic vessels was considered to be a sign of resectability on color Doppler imaging; a long contiguity (> 2 cm), compression, encasement, or thrombosis was considered to be a sign of unresectability. In all patients, the sonographic diagnosis was compared with the surgical results. RESULTS: With color Doppler imaging, we detected signs of vascular involvement in 26 of 33 patients in whom vascular involvement was found at surgery. We detected no vascular involvement in 25 of 28 patients in whom no vascular involvement was found at surgery. No false-positive diagnoses occurred when vascular encasement was revealed by color Doppler imaging. For diagnosis of vascular involvement, the sensitivity, specificity, and overall accuracy of color Doppler imaging were 79%, 89%, and 84%, respectively; positive and negative predictive values were 89% and 79%, respectively. CONCLUSION: Color Doppler imaging is a sensitive and highly specific technique in assessing vascular involvement by pancreatic cancer when absence of contact or vascular encasement is seen. When vascular encasement is detected by color Doppler imaging, a definitive diagnosis of unresectability can be made, and further diagnostic procedures can be avoided. When sonography is used in the initial evaluation of pancreatic cancer, color Doppler imaging can improve the selection of patients for further diagnostic examinations or surgical exploration.

Renal artery stenosis: value of screening with three-dimensional phase-contrast MR angiography with a phased-array multicoil.

PURPOSE: To evaluate screening with three-dimensional (3D) phase-contrast magnetic resonance (MR) angiography with a phased-array multicoil to detect renal artery stenosis. MATERIALS AND METHODS: Fifty consecutive patients suspected of having renovascular disease were prospectively examined with 3D phase-contrast MR imaging with a phased-array multicoil. Findings were correlated with those at intra-arterial digital subtraction angiography (DSA) as the standard of reference for grade of stenosis. RESULTS: MR angiography depicted 101 of 103 renal arteries depicted at intraarterial DSA; the two missed arteries were an accessory artery outside the imaging volume and an artery with a stent. At intraarterial DSA, a stenosis was found in 31 of 101 arteries. On the basis of findings at 3D phase-contrast MR angiography, the presence of any degree of stenosis was correctly depicted in 29 of 31 cases and the absence of stenosis was correctly depicted in 66 of 70 cases (accuracy, 94%; sensitivity, 94%; negative predictive value, 97%). Overall accuracy was 97% for correct depiction of severe renal artery stenosis (> 50%). CONCLUSION: 3D phase-contrast MR angiography with a phased-array multicoil was an accurate noninvasive screening technique in patients with suspected renal artery stenosis.

Plain and gadolinium-DTPA-enhanced MR imaging of hepatocellular carcinoma treated with transarterial chemoembolization.

BACKGROUND: To assess unenhanced and gadolinium-enhanced magnetic resonance (MR) imaging patterns of hepatocellular carcinoma (HCC) treated with transarterial chemoembolization (TACE). METHODS: Thirty-two patients with 48 HCC lesions underwent MR imaging before and 15 days after TACE. Fifteen lesions were then surgically resected. The remaining 33 lesions were not removed and were followed up with MR imaging at 3, 6, 12, and 18 months after treatment. Spin echo (SE) T1- and T2-weighted and gadolinium-enhanced SE T1-weighted sequences were employed. Qualitative evaluation of signal intensity pattern of the treated lesions was performed in all cases. Histological evaluation and selective hepatic arteriography were considered the gold standard of the study for the 15 resected lesions and the 33 unresected lesions, respectively. RESULTS: On follow-up enhanced T1-weighted images of the 15 resected lesions, seven showed no area of enhancement corresponding to complete necrosis at histologic examination. The remaining eight resected lesions showed areas of enhancement; in six of these cases, viable tumor tissue was found at histology; in the other two lesions, histologic examination revealed the presence of complete tumor necrosis. In the group of resected lesions, T2-weighted images showed no pattern characteristic of necrosis. In 24 of 33 unresected lesions, loss of enhancement on follow-up enhanced T1-weighted images was a characteristic finding, which correlated to devascularization at arteriography. Of these 24 lesions, 17 were completely hypointense on follow-up T2-weighted images; the remaining seven showed small foci of hyperintensity. The other nine unresected lesions showed enhanced portions on follow-up enhanced T1-weighted images, which corresponded to hyperintense areas on T2-weighted images. These findings correlated to persistence of hypervascular areas at arteriography. CONCLUSION: Gadolinium-enhanced T1-weighted MR imaging is a reliable method for evaluating the outcome of TACE treatment and is more accurate than unenhanced T2-weighted MR imaging.

[Conservative treatment of postoperative pancreatic fistula. Role of interventional radiology]. / Trattamento conservativo della fistola pancreatica postoperatoria. Ruolo della radiologia interventistica.

OBJECTIVE: To assess the role of interventional radiology in the conservative treatment of postoperative pancreatic fistula. CASE REPORT: A case of a high flow mixed entero-bilio-pancreatic fistula caused by dehiscence of pancreatic-jejunal anastomosis after duodenocephalopancreasectomy for endocrine neoplasm of the head of the pancreas, SETTING: General Surgery Division and Diagnostic Radiology. CONCLUSIONS: Conservative treatment represents at the time being, due to the current possibilities in assisting critical patients and in controlling pancreatic secretory activity, the first choice in pancreatic fistula treatment. The effectiveness of this treatment depends on the severity of inflammatory disease of the pancreas. Clinical (Ranson, Glasgow, APACHE II) and radiological (Balthazar, Vernacchia) parameter evaluation is a critical step in therapeutic choice. Surgery should be used in patients with severe pancreatitis. Conservative treatment represents the first choice in stable and critical patients with mild pancreatitis.

[Ocular color Doppler echography: the examination technic, identification and flowmetry of the orbital vessels]. / Eco color Doppler oculare: tecnica d'esame, identificazione e flussimetria dei vasi orbitari.

We studied the main ocular and retrobulbar vessels with color-Doppler US and report on examination technique, detectability of the vessels and their flow characteristics to define the normal ranges of Doppler spectra for each artery and vein. We comparatively examined both eyes of 20 healthy subjects. Of each eye we studied the ophthalmic artery, the central retinal artery, the ciliary artery, the central retinal vein and the superior ophthalmic vein. The following flow parameters were considered: peak systolic velocity, end-diastolic velocity and resistive index for arteries; maximum and minimum velocity for veins. The examination lasted about 10 minutes per eye--20 minutes for each subject. In all subjects the five investigated vessels were identified in both eyes, and adequate Doppler spectra were obtained. The average peak systolic velocities of ophthalmic, central retinal and ciliary arteries were respectively about 35, 12 and 10 cm/s, with low resistance patterns (resistive index: 0.75, 0.72 and 0.68, respectively). The venous flow, which is usually continuous, may be sometimes influenced by cardiac and respiratory activities: the maximum velocities of superior ophthalmic and central retinal veins were about 6 and 5 cm/s, respectively. Color-Doppler US noninvasively visualizes both ocular and retrobulbar vessels, providing major hemodynamic information from different flow parameters; the knowledge of these parameters in normal conditions can be the basis of hemodynamic studies in many abnormal orbital conditions.

Social organization and space use in California voles: seasonal, sexual, and age-specific strategies.

We intensively monitored space use and movement in Microtus californicus over a 2-year period that included 1 year of high density (maximum 618/ha) and one of low (minimum 5/ha); historically this population has exhibited cycles of 2 or 4 years. Adults of both sexes dispersed at the start of the breeding season, culminating in the establishment of intrasexually exclusive territories. In females, these territories persisted throughout life, except that many young females recruiting during the breeding season established contiguous, overlapping, or adjacent home ranges with their mothers. This female philopatry explains the conclusion of previous workers that females of this species are non-territorial. In the dry (non-breeding) season, females had smaller ranges that often overlapped and were clustered. Adult males moved breeding territories at a modal interval of 6 weeks; this is consistent with their avoidance of inbreeding with philopatric daughters. Ranges overlapped 1-4 adult females at any one time, and a cohort of 7 long-lived males overlapped an average of 16.4 females during their tenure on the grid. The period of maximum overlap with adult females varied among individual males, and did not correlate with the time of maximum body weight. Ranges of males in the dry season overlapped extensively, with persistent associations among some individuals. In the lowdensity year, ranges of some adults failed to overlap intersexually. Juvenile males dispersed gradually between 3 and 13 weeks of age (half before 9 weeks), with some leaving after reaching sexual maturity; a few remained philopatric. Of juvenile females, 47% remained philopatric with the rest disappearing before 9 weeks of age. New understanding of vole social behavior, dispersal, and space use is achieved by focusing on the seasonal dynamics of spatial relationships among individuals with respect to age, sex, and relatedness.

[Role of magnetic resonance in the follow-up o hepatocarcinoma treated with percutaneous ethanol injection (PEI) or transarterial chemoembolization (TACE)]. / Ruolo della Risonanza Magnetica nel follow-up dell'epatocarcinoma trattato con alcolizzazione percutanea (PEI) o chemioembolizzazione (TACE).

The purpose of this study was to assess Magnetic Resonance Imaging (MRI) patterns of hepatocellular carcinoma (HCC) treated with percutaneous ethanol injection (PEI) or Transarterial Chemoembolization (TACE) and, consequently, the potential role of MR Imaging in the follow-up of these lesions. HCC treated with PEI. Thirty-one patients with a single small HCC lesion underwent MR Imaging at 0.5 T before and after PEI. In all cases before and after treatment contrast enhanced Computed Tomography (CT) and US-guided fine-needle biopsy were performed. Twenty-seven of 31 HCC lesions in which complete tumor necrosis was obtained with PEI showed homogeneous hypointensity on SE T2-weighted MR images. This feature corresponded to an unenhanced and low-attenuation area on follow-up contrast-enhanced CT scans. All these lesions were negative for malignant cells at fine-needle biopsy follow-up. In four HCCs, high-signal areas on SE T2-weighted images and high-attenuation areas on contrast-enhanced CT scans were observed, suggesting the presence of residual tumor tissue; these lesions were positive for malignant cells at 6-month fine-needle biopsy. In each case, incomplete tumor necrosis was confirmed at pathologic examination of the surgical specimen. HCC treated with TACE. Twenty-one patients with a total of 36 HCC lesions underwent plain and Gadolinium-enhanced MR Imaging before and after TACE. 10 HCC lesions were later surgically resected; 26/36 lesions underwent MR, CT and angiographic follow-up. At short-term follow-up exams (15-30 days), hypointensity was present on enhanced SE T1 weighted sequences in those lesions (5/10) in which complete tumor necrosis was histologically confirmed. In the remaining 5/10 HCC lesions, persistent viable tumor portions were found at pathology. These areas corresponded to areas on hyperintensity of Gadolinium-enhanced SE T1-weighted images. Hypointensity on both SE T2-weighted and enhanced SE T1-weighted images was a characteristic pattern on long-term follow-up MR images in 21/26 unresected lesions; this finding was correlated with devascularization at angiography; the presence of hyperintense areas on SE T2 weighted and enhanced SE T1-weighted images corresponded to the persistence of hypervascular (viable) areas at angiography.

[Magnetic resonance: preoperative assessment of abdominal aortic aneurysms. Comparison with surgical findings in 80 cases]. / Risonanza magnetica: valutazione preoperatoria degli aneurismi dell'aorta addominale. Confronto con i reperti operatori in 80 casi.

This work was aimed at assessing Magnetic Resonance (MR) accuracy in the preoperative investigation of abdominal aortic aneurysms, with a view to suggesting MRI as the method of choice for surgical planning, replacing other relatively invasive investigation techniques like angiography and enhanced CT. In the last 3 years 80 patients with abdominal aortic aneurysms identified with US or CT were examined with 0.5-T MRI and underwent surgical repair within 15 days. Spin-echo (SE) T1-weighted axial, sagittal and coronal sequences were always performed. In 18 patients gradient-echo (GE) flow sequences were also acquired; SE T2-weighted sequences were used to study parietal thrombi in 10 patients and finally Gd-DTPA T1-weighted sequences were obtained in inflammatory aneurysms (3 patients). MR images were blindly evaluated by 2 radiologists. The following variables which are useful for surgical planning were considered for each patient: aneurysm extent, characteristics of parietal thrombi, dissections, fixurations, inflammation signs, involvement of renal arteries, vena cava, ureters, duodenum, the presence of retroaortic renal vein or of other anomalies or associated conditions. MR images were always compared with intraoperative findings, since surgery was considered as the gold standard. MR findings were in agreement with surgical findings in the evaluation of cranio-caudal aneurysm extent (78/80), parietal thrombus features (80/80), dissection (1/1) and fixuration signs (8/9), origin of renal arteries (80/80), inferior vena cava involvement (3/3), other anatomical anomalies or conditions (6/6). Inflammation signs were overestimated (14/8) as well as adhesion between aneurysm and duodenum (17/13). The presence of distal renal polar arteries was underestimated (2/4). In conclusion, MRI proves to be a highly sensitive method to demonstrate abdominal aortic aneurysms and is therefore suggested as the examination of choice before surgery.