The juvenile fibromyalgia syndrome (JFMS): a poorly defined disorder.

Juvenile fibromyalgia syndrome (JFMS) is a chronic condition characterized by symptoms of chronic diffuse musculoskeletal pain and multiple painful tender points on palpation. It is often accompanied by fatigue, disorders of sleep, chronic headaches, irritable bowel syndrome, and subjective soft tissue swelling. The complexity of the presenting clinical picture in JPFS has not been sufficiently defined in the literature. Similarities to adult fibromyalgia syndrome in JFMS are often difficult to compare, because many of the symptoms are "medically unexplained" and often overlap frequently with other medical conditions. However, a valid diagnosis of JFMS often decreases parents' anxiety, reduces unnecessary further investigations, and provides a rational framework for a management plan. The diagnostic criteria proposed by Yunus and Masi in 1985 to define JFMS were never validated or critically analyzed. In most cases, the clinical diagnosis is based on the history, the physical examination that demonstrates general tenderness (muscle, joints, tendons), the absence of other pathological conditions that could explain pain and fatigue, and the normal basic laboratory tests. Research and clinical observations defined that JFMS may have a chronic course that impacts the functional status and the psychosocial development of children and adolescents. This paper briefly reviews the existing knowledge on JFMS focusing on the diagnosis, clinical and the epidemiological characteristics in children and adolescents for better understanding of this disorder.

[Screening for colorectal cancer in high-risk and intermediate-risk subject: what's the best tool?]. / Screeening per la prevenzione del cancro del colon nei soggetti ad alto rischio ed in quelli a rischio intermedio. Qual e la migliore opzione?

Although several screening tests are now available, at present none of them has been proven the best one. Colonoscopy is usually used in high-risk subjects (family history of either colorectal cancer [CRC] or adenomas). In intermediate-risk subjects, fecal occult blood test (FOBT) is preferred, and colonoscopy is performed only when FOBT results positive. The aim of this study is to better define the role of colonoscopy in a screening program. Three groups of subjects were retrospectively reviewed. RSP (Regional Screening Program), FDR (First Degree Relatives), and Control-groups included 362, 581, and 300 subjects, respectively. Adenoma or carcinoma were more frequent in RSP-group than in FDR- and Control-group (53%, 23.7%, and 20%, respectively; p < 0.001). CRC rate was 11.6% in RSP-group, 2.2% in FDR-group (p < 0.001), 6% in Control-group (p < 0.05). Adenoma rate was 41.4% in RSP-group, 21.5% in FDR-group (p < 0.05), 14% in Control-group (p < 0.01). Our results showed that colonoscopy probably can not be regarded as a first-line tool for the screening of CRC in FDR of patients with CRC or adenoma. Some stratification or scoring system for the risk of CRC should be adopted. As an alternative, FOBT could be used also in these subjects.

Subcapsular liver tumors treated with percutaneous radiofrequency ablation: a prospective comparison with nonsubcapsular liver tumors for safety and effectiveness.

PURPOSE: To assess the safety and effectiveness of percutaneous radiofrequency (RF) ablation of subcapsular liver tumors. MATERIALS AND METHODS: The study protocol was approved by the institutional review board, and all patients gave written informed consent. One hundred eighty-one patients (79 men, 102 women; age range, 36-85 years) underwent ultrasonographically (US) guided percutaneous RF ablation of 361 primary or secondary (metastatic) liver tumors. Forty-four patients had one or more subcapsular nodules (group 1), and 137 had nonsubcapsular nodules only (group 2). Overall, 80 nodules were subcapsular and 281 were nonsubcapsular. The completeness of the ablation was assessed with contrast material-enhanced computed tomography (CT) 1 month after RF ablation. If residual tumor was documented, RF ablation was repeated. All patients in whom the ablation was complete after the first or second ablation session were monitored with CT or contrast-enhanced US every 3 months. Major complication, complete ablation, and local tumor progression rates were compared by using the chi(2) test or Fisher exact test. RESULTS: Three (7%) major complications (intraperitoneal bleeding, skin burn, and tumor seeding) occurred in group 1, and two (1.5%) cases of tumor seeding occurred in group 2 (P = .093). No RF ablation-related deaths occurred. The complete ablation rate was 98% (43 of 44 patients) in group 1 and 98.5% (135 of 137 patients) in group 2 (P = .756). The local tumor progression rate after a median follow-up of 25 months (range, 13-54 months) was 16% (seven of 43 patients) in group 1 and 9.6% (13 of 135 patients) in group 2 (P = .355). CONCLUSION: The difference in major complication rate between the subcapsular and nonsubcapsular liver tumors was not significant. The safety of RF ablation of subcapsular tumors seems acceptable, and the effectiveness is comparable to that of RF ablation of nonsubcapsular tumors.

[Physicians working in internal medicine's ward: a survey on their role in the management of the gastrointestinal endoscopy services in Emilia Romagna]. / L'Internista nei Servizi di Endoscopia Digestiva: indagine sugli Ospedali pubblici dell'Emilia Romagna.

We carried out a survey on the role played by the Wards of Internal Medicine in the management of the Gastrointestinal Endoscopy (G.E.) Services operating in Emilia Romagna. 45 G.E. Services were censored, for a total of 225 endoscopists: 105 out of them (46.7%) were gastroenterologists and 84 (37.3%) were surgeons, whereas just 35 (15.6%) were working in Internal Medicine's Ward and 1 (0.4%) was working in a Division of Geriatrics. A significant difference was observed analyzing the composition of the G.E. staffs on the basis of the size and activity of G.E. Services (p < 0.001). Physicians working in Wards of Internal Medicine represented 9.2% and 24.5% of the endoscopists in the hospitals with or without a Gastroenterology Unit, respectively (p = 0.003). Based on these results, the physicians working in Internal Medicine's Ward seem to play a secondary role in G.E. Services. Their role is greater in small hospitals, but they are often compelled to operate under suboptimal circumstances.

Diagnostic accuracy of a rapid fecal test to confirm H pylori eradication after therapy: prospective comparison with a laboratory stool test.

AIM: To investigate the clinical performances of rapid stool test (ImmunoCard STAT HpSA, Meridian Diagnostic Inc.) in the evaluation of eradication therapy of H pylori and to compare it with a well-known and validated laboratory stool test (Amplified IDEA Hp StAR, Dako). METHODS: Stool samples of 122 patients were evaluated after eradication therapy of H pylori. H pylori status was assessed by 13C-urea breath test (UBT). Stool specimens were tested using either the rapid immunoassay kit or the laboratory immunoassay kit. RESULTS: Forty-three patients were infected and 79 non-infected. Sensitivity and specificity of ImmunoCard STAT and Hp StAR were 58.14% and 76.4%, and 97.47% and 98.73%, respectively (P > 0.05). Overall agreement between the two tests was 92.6% (113 of 122 cases). CONCLUSION: ImmunoCard STAT seems to have rather low performances, and it cannot be regarded as a reliable tool in the post-treatment setting. Also Hp StAR cannot be recommended to confirm H pylori eradication after treatment.

[A peculiar case of hypomagnesemia]. / Un singolare caso di ipomagnesemia.

An old man with previous resections of small intestine for infarction and sigmoid for adenocarcinoma presented vomit, vertigo, visual impairment, fatigue, serum non detectable, reduced cellular magnesium, no ECG alterations. For the lack of symptoms proportionate to this alteration, an adaptation to progressive decrease in cellular magnesium is hypothesized.

Unsedated ultrathin upper endoscopy is better than conventional endoscopy in routine outpatient gastroenterology practice: a randomized trial.

AIM: to compare the feasibility and patients' tolerance of esophagogastroduodenoscopy (EGD) using a thin endoscope with those of conventional oral EGD and to determine the optimal route of introduction of small-caliber endoscopes. METHODS: One hundred and sixty outpatients referred for diagnostic EGD were randomly allocated to 3 groups: conventional (C)-EGD (9.8 mm in diameter), transnasal (TN)-EGD and transoral (TO)-EGD (5.9 mm in diameter). Pre-EGD anxiety was measured using a 100-mm visual analogue scale (VAS). After EGD, patients and endoscopists completed a questionnaire on the pain, nausea, choking, overall discomfort, and quality of the examination either using VAS or answering some questions. The duration of EGD was timed. Blood oxygen saturation (SaO2) and heart rate (HR) were monitored during EGD. RESULTS: Twenty-one patients refused to participate in the study. The 3 groups were well-matched for age, gender, experience with EGD, and anxiety. EGD was completed in 91.1% (41/45), 97.5% (40/41), and 96.2% (51/53) of cases in TN-EGD, TO-EGD, and C-EGD groups, respectively. TN-EGD lasted longer (3.11 +/- 1.60 min) than TO-EGD (2.25 +/- 1.45 min) and C-EGD (2.49 +/- 1.64 min) (P<0.05). The overall tolerance was higher (P<0.05) and the overall discomfort was lower (P<0.05) in TN-EGD group than in C-EGD group. EGD was tolerated "better than expected" in 73.2% of patients in TN-EGD group and 55% and 39.2% of patients in TO-EGD and C-EGD groups, respectively (P<0.05). Endoscopy was tolerated "worst than expected" in 4.9% of patients in TN-EGD group and 17.5% and 23.5% of patients in TO-EGD and C-EGD groups, respectively (P<0.05). TN-EGD caused mild epistaxis in one case. The ability to insufflate air, wash the lens, and suction of the thin endoscope were lower than those of conventional instrument (P<0.001). All biopsies performed were adequate for histological assessment. CONCLUSION: Diagnostic TN-EGD is better tolerated than C-EGD. Narrow-diameter endoscope has a level of diagnostic accuracy comparable to that of conventional gastroscope, even though some technical characteristics of these instruments should be improved. Transnasal EGD with narrow-diameter endoscope should be proposed to all patients undergoing diagnostic EGD.

Accuracy of transthoracic sonography in detection of pneumothorax after sonographically guided lung biopsy: prospective comparison with chest radiography.

OBJECTIVE: The purpose of this study was to prospectively evaluate the accuracy of transthoracic sonography in the detection of pneumothorax after transthoracic sonographically guided lung biopsy. SUBJECTS AND METHODS: Transthoracic sonography was performed on 285 patients after transthoracic sonographically guided lung biopsy. Disappearance of the sliding lung and comettail artifacts and appearance of reverberation artifacts were considered evidence of pneumothorax. Upright chest radiography was performed within 30 minutes of transthoracic sonography. If a discrepancy between transthoracic sonographic and chest radiographic findings occurred, CT was performed. When it was diagnosed, pneumothorax was sonographically monitored. After visualization of resolution of pneumothorax, chest radiography was performed to confirm the resolution. RESULTS: Pneumothorax occurred in eight (2.8%) of the patients. Transthoracic sonography depicted all cases of pneumothorax and excluded pneumothorax in the other cases. Chest radiography did not depict one case of pneumothorax, which was confirmed on CT. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were all 100% for transthoracic sonography and 87.5%, 100%, 100%, 99.6%, and 99.6%, respectively, for chest radiography. The 95% confidence intervals (CI) of the differences in sensitivity, negative predictive value, and overall accuracy were -10% to 35%, -0.1 to 0.9%, and -0.1 to 0.9%. Transthoracic sonographic visualization of resolution of pneumothorax was always confirmed with chest radiography. CONCLUSION: These preliminary results suggest that transthoracic sonography is as effective as chest radiography in the detection of pneumothorax after transthoracic sonographically guided lung biopsy and may become the method of choice for excluding, diagnosing, and monitoring pneumothorax after transthoracic sonographically guided biopsy. Chest radiography may be needed only for assessment of the extent of pulmonary collapse after transthoracic sonographic diagnosis of pneumothorax or in the presence of discrepancy between transthoracic sonographic findings and clinical presentation.

[Primary biliary cirrhosis and autoimmune hepatitis overlap syndrome. An early case]. / Sindrome di overlap tra epatite autoimmune e cirrosi biliare primitiva. Un caso precoce.

A 21-year old asymptomatic woman had accidental report of increased transaminases. Serologic tests were negative, autoimmune profile was positive for anti-nuclear, antimitochondrial antibodies and rheumatoid factor. Histology of the liver biopsy showed severe necro-inflammatory activity both in biliary epithelium and in intralobular area, suggesting primary biliary cirrhosis/autoimmune hepatitis overlap syndrome.

[Stool antigen test for diagnosis of Helicobacter pylori infection. Merely a research opportunity, or an effective diagnostic tool?]. / Test fecale per la diagnosi di infezione da Helicobacter pylori: argomento di ricerca o realtà?

Since Helicobacter pylori (H. pylori) infection was recognized as a major cause of peptic ulcer disease and an important risk factor for gastric malignancy, several strategies have been used to diagnose it. These methods are split up along two lines: 1) direct detection of the bacteria, and 2) detection of antigen-antibody assay against H. pylori, or anyhow detection of H. pylori by indirect methods. In this review of literature about the methods to diagnose H. pylori infection, we focused in particular on the non-invasive tests based on H. pylori antigens detection in faeces. Some meta-analyses showed that immunoenzymatic stool tests can be considered reliable in untreated patients, whereas further confirmations are needed before extending their use also in anti-H. pylori treated patients. As it concerns cost-analysis, immunoenzymatic stool test is the most cost-effective among the tests today available. Finally, a newly developed office-based stool test has been evaluated. It does not require laboratory assay, and the results are available within 10 minutes. Preliminary data about its clinical usefulness are promising, but further and wider confirmations are needed, as it has been put on the market quite recently.

Degradation of polyurethane gastrostomy devices: what is the role of fungal colonization?

The aim of this study was to evaluate polyurethane percutaneous endoscopic gastrostomy (PEG) tube degradation and the role played by fungi. The inner surfaces of 20 used polyurethane tubes were brushed, and the brushing end was incubated for 7 days in Saburaud broth and cultured if fungal growth occurred. Three tubes used for 12 (sample 12w), 17 (sample 17w), and 96 (sample 96w) weeks and two new tubes were cut to produce several 4-cm-long equal halves. Six samples from the new tubes were considered control samples (Co sample), seven were incubated in Saburaud broth (Co sample + Sa.), and seven in the broth supplemented with Candida albicans (Co sample + Sa. + Ca). All samples underwent morphological examination by electron microscopy and differential scanning calorimetry measurements (DSC). All tubes had fungal colonization. DSC showed deterioration in all tubes including the new ones; adding Candida albicans had no additional effects. Morphological examination by electron microscopy showed a regular pattern in the Co sample, and thick biofilm, holes, and crevices in samples 12w, 17w, and 96w. The more the tubes had been used, the more severe were the changes. The Co sample + Sa and the Co sample + Sa + Ca showed no changes in the inner surface, but cryogenically fractured surfaces had holes and crevices. Yeasts constantly colonize PEG tubes and are likely to contribute to polyurethane deterioration. The impairment of new PEG tubes incubated in Saburaud broth suggests that other factors also play a role in polyurethane deterioration.

Upper gastrointestinal endoscopy: are preparatory interventions or conscious sedation effective? A randomized trial.

AIM: The fears and concerns are associated with gastroscopy (EGD) decrease patient compliance. Conscious sedation (CS) and non-pharmacological interventions have been proposed to reduce anxiety and allow better execution of EGD. The aim of this study was to assess whether CS, supplementary information with a videotape, or presence of a relative during the examination could improve the tolerance to EGD. METHODS: Two hundred and twenty-six outpatients (pts), scheduled for a first-time non-emergency EGD were randomly assigned to 4 groups: Co-group (62 pts): throat anaesthesia only; Mi-group (52 pts): CS with i.v. midazolam; Re-group (58 pts): presence of a relative throughout the procedure; Vi-group (54 pts): additional information with a videotape. Anxiety was measured using the "Spielberger State and Trait Anxiety Scales". The patients assessed the overall discomfort during the procedure on an 100-mm visual analogue scale, and their tolerance to EGD answering a questionnaire. The endoscopist evaluated the technical difficulty of the examination and the tolerance of the patients on an 100-mm visual analogue scale and answering a questionnaire. RESULTS: Pre-endoscopy anxiety levels were higher in the Mi-group than in the other groups (P<0.001). On the basis of the patients' evaluation, EGD was well tolerated by 80.7% of patients in Mi-group, 43.5% in Co-group, 58.6% in Re-group, and 50% in Vi-group (P<0.01). The discomfort caused by EGD, evaluated by either the endoscopist or the patients, was lower in Mi-group than in the other groups. The discomfort was correlated with "age" (P<0.001) and "groups of patients" (P<0.05) in the patients' evaluation, and with "gender" (females tolerated better than males, P<0.001) and "groups of patients" (P<0.05) in the endoscopist's evaluation. CONCLUSION: Conscious sedation can improve the tolerance to EGD. Male gender and young age are predictive factors of bad tolerance to the procedure.

Sonographically guided small-bore chest tubes and sonographic monitoring for rapid sclerotherapy of recurrent malignant pleural effusions.

OBJECTIVE: To evaluate the role of sonographically guided small-bore chest catheters and sonographically based monitoring of fluid evacuation in rapid sclerotherapy of malignant pleural effusions. METHODS: In 50 patients with recurrent malignant pleural effusions, a 9F catheter was inserted into the pleural space under sonographic guidance. When sonography documented complete fluid evacuation, bleomycin (0.75 mg/kg) was injected via the tube. Fluid drainage was monitored for 12 hours; if fluid output was less than 100 mL, the pleural catheter was removed; otherwise, a second dose of bleomycin was administered after 24 hours. If loculations or fluid reaccumulations due to tube malfunctioning were detected, they were evacuated by sonographically guided thoracentesis, and bleomycin (1.5 mg/100 mL of fluid) was injected through the thoracentesis needle. All patients were monitored for fluid recurrence with thoracic sonography. RESULTS: Twenty-nine patients received 1 dose of bleomycin, and 21 received 2 doses. In 11 patients with residual loculations, sonographically guided thoracentesis was performed, and bleomycin was injected into the loculations. In 29 patients, pleurodesis was completed within 24 hours; in 21, it was completed within 48 hours. The 30-day response was 84%; the long-term response was 60%. No complications or serious side effects were observed. CONCLUSIONS: Rapid pleurodesis can be accomplished within 24 to 48 hours, with good short- and long-term responses. Thoracic sonography plays a pivotal role. It guides placement of the pleural catheter and is valuable in the monitoring of fluid evacuation for determining the right time for sclerosing agent administration and in the detection and treatment of loculations or residual pleural fluid due to tube malfunctioning.

Prospective randomized trial of intrapleural bleomycin versus interferon alfa-2b via ultrasound-guided small-bore chest tube in the palliative treatment of malignant pleural effusions.

PURPOSE: To compare bleomycin pleurodesis and immunotherapy with intrapleural interferon alfa-2b (IFN) in the palliation of malignant pleural effusions. PATIENTS AND METHODS: One hundred sixty patients with rapidly recurrent malignant pleural effusion were randomly assigned to intrapleural bleomycin (83 patients) or IFN (77 patients). A 9-French intrapleural catheter was placed under sonographic guidance, and pleural effusion was completely drained before starting the treatment. Bleomycin 0.75 mg/kg was administered as a single dose. An additional dose was given if daily fluid output did not drop to less than 100 mL/d within 3 days. IFN 1 million units/10 kg was administered for six courses at 4-day intervals. Thirty-day and long-term responses were evaluated under the intention-to-treat principle. RESULTS: Thirty-day response was 84.3% in the bleomycin arm and 62.3% in IFN arm (P =.002). Median time to progression was 93 days (range, 12 to 395 days) in bleomycin group, and 59 days (range, 7 to 292 days) in the IFN group (P <.001). Median survival was 96 days (range, 15 to 395) and 85 days (range, 16 to 292) in the bleomycin and IFN groups, respectively. Twenty-three patients received two doses of bleomycin, as their daily fluid output remained higher than 100 mL after the first dose. Thirteen of them had complete response, which lasted until death. CONCLUSION: Intrapleural bleomycin is more effective than IFN and is a valid option for the palliative treatment of massive, rapidly recurrent malignant pleural effusions. The administration of a second dose of bleomycin to patients not responding to the first one can remarkably improve the overall outcome of the treatment.

Comparison of magnesium concentration in serum, erythrocytes and gastric tissue in two groups of patients affected by chronic gastritis, Helicobacter pylori negative and positive.

UNLABELLED: Magnesium seems to be an important factor both for acid gastric secretion regulation (together with Ca2+) and for Helicobacter pylori survival and virulence. It can therefore be useful to evaluate if Helicobacter pylori (HP) infection is accompanied by variations in the host Mg availability. In this study serum, erythrocytary and gastric tissue Mg concentration was measured in 36 patients affected by chronic antral gastritis. Based on the presence of Helicobacter pylori infection, the patients were subdivided in two groups: group A: Helicobacter pylori negative, n = 23; group B: Helicobacter pylori positive, n = 13. RESULTS: While no differences were found between the two groups for serum Mg (group A 0.81 +/- 0.07 mm/L, group B 0.81 +/- 0.11 mm/L), both erythrocytary Mg (EMg) and gastric tissue Mg were found significantly lower in the HP positive subjects (erythrocytary Mg: 2.14 +/- 0.55 vs. 1.81 +/- 0.34 mm/L; gastric tissue Mg: 729.2 +/- 333.8 vs. 510.6 +/- 178.8 microg/g of dried tissue for group A and B respectively, p < 0.001 for both determinations). Erythrocytary Mg reduction is a clue of the whole body reduction in Mg availability (and consequently in gastric cells as well); the erythrocytary Mg reduction detected in the present paper for Helicobacter pylori positive patients can weaken gastric cells by impairing their metabolism. The hypothesis submitted is to impair Mg utilization in Helicobacter pylori, in order to improve eradication treatment, and in the meantime to preserve Mg homeostasis in infected cells.