Proposal of a new method for the use of the Rydel-Seiffer tuning fork in the screening of diabetic polyneuropathy. A pilot study.

We investigated the usefulness of a new examiner-independent method based on the duration of vibration sensation following the placement of the Rydel-Seiffer tuning fork over the dorsum of the interphalangeal hallux joint. This method demonstrated the same diagnostic efficacy as the Rydel-Seiffer method coupled with greater ease of use.

Neuroendocrine tumors diagnosed at the Antonio Cardarelli hospital (Naples, Italy) between 2006-2009: a single-institution analysis.

Neuroendocrine tumors (NETs) are rare, with an incidence of about 5 per 100,000 inhabitants. As no study on NETs has ever been specifically conducted on the population of Campania, we performed a retrospective analysis of all newly diagnosed NETs at the Antonio Cardarelli hospital between 2006-2009. A search of the registry of the Pathology Department of the Antonio Cardarelli hospital was carried out to retrieve available data on all newly diagnosed NET cases. Two hundred and ninety-nine NET tumors were diagnosed at our Institution from January, 2006 to December, 2009. Globally, 121 patients (40% of the population) had a lung NET, while 92 patients (30% of the population) presented a GEP-NET. The most common primary tumor site varied by sex, with female patients being more likely to have a primary NET in the lung, breast or colon, and male patients being more likely to have a primary tumor in the lung. Also, twenty-three cases of breast NETs were identified, and clinical information regarding therapy and response was available for 22 patients. Our study represents a pioneering effort to provide the medical community in Campania with basic information on a large number of patients with different types of NETs. The Antonio Cardarelli hospital could greatly benefit from cooperation with other hospitals in order to become a highly specialized center for NETs in the region and Southern Italy.

[Spinning-induced rhabdomyolysis: importance of MRI for patient's outcome. A case report]. / Su un caso di rabdomiolisi da spinning: valore prognostico della RMN.

The first Italian case of spinning-induced exertional rhabdomyolysis is presented here. The spinning is an expanding fitness activity which uses a stationary bike, that in some rare cases described in literature can induce rhabdomyolysis. In our patient, through magnetic resonance imaging, we detected a clear-cut temporal dissociation between clinical-biochemical healing and anatomical recovery. In fact we found that the improvement of magnetic resonance picture was much slower than the vanishing of myalgias and normalization of serum myoglobin and enzymes. This observation could be useful to understand the timing for exercise resumption without any risk for the patient.

Pancreatic functional impairment following acute necrotizing pancreatitis: long-term outcome of a non-surgically treated series.

OBJECTIVES: Patients who survive an episode of acute necrotizing pancreatitis may develop endocrine and exocrine pancreatic functional impairment; often these patients have undergone pancreatic surgery during the acute episode. Aim of this study is to report the results of a long-term follow-up of patients recovering from an episode of acute necrotizing pancreatitis which had not been treated surgically during the index hospital admission. DESIGN AND SUBJECTS: Sixty-five consecutive patients enrolled between January 1990 and December 1993, prospectively followed through December 2006. RESULTS: Median follow-up period was 179.5 months (range 156-203). 40 patients (61.5%) who completed follow-up were analysed. Endocrine function: 2 patients (5%) were diabetic before the pancreatitis episode, and 6 (15.7%) developed overt diabetes; diabetes appeared within the 3rd year after acute pancreatitis in 2 patients, between the 3rd and 4th year in 2 patients, and between the 5th and 6th year in the last 2 patients. Exocrine function: 9 patients (22.5%) showed fecal elastase impairment; in all patients ultrasound was normal and fecal elastase returned above the normal limit during follow-up. CONCLUSIONS: After an episode of acute necrotizing pancreatitis treated without surgery, the endocrine and exocrine function is not frequently impaired after long-term follow-up. Reduction in exocrine function is transient and complete recovery is achieved in all patients within a few years.

Antioxidant treatment in hereditary pancreatitis. A pilot study on three young patients.

BACKGROUND: Abdominal pain is the most challenging symptom of hereditary pancreatitis. No specific and proven therapy is yet available; analgesics, often in large doses, are required also in children and young patients. PATIENTS AND METHODS: We performed an open-label, pilot study on three young patients, coming from the same kindred, with hereditary pancreatitis. The study period lasted two years (July 1997-July 1999) and was divided into four sub-periods of six months each. In the first and third period the patients took only oral analgesics, if necessary; in the second and fourth period, an antioxidant regimen per os was added. This treatment consisted of sulphadenosyl-methionine (800 mg per day), Vitamin C (180 mg per day), Vitamin E (30 mg per day), Vitamin A (2,400 microg per day), and selenium (75 microg per day). RESULTS: Compliance of patients to the treatment schedule was satisfactory and no important side-effects were observed. Antioxidant treatment led to a significant reduction (p<0.05) in the number of days with abdominal pain experienced by the three patients and this was verified for both periods of treatment. Albeit, consumption of analgesics was lower in the antioxidant treatment periods. CONCLUSIONS: Oxidative stress may be one of the principle contributors to pain in hereditary pancreatitis and orally administered antioxidant treatment appears to be effective for control of the condition, in young patients, suffering from this rare disease.

[Somatostatin analogues for the treatment of gastro-entero-pancreatic neuroendocrine tumours]. / Ruolo degli analoghi della somatostatina nel trattamento dei tumori neuroendocrini gastroenteropancreatici.

Somatostatin has represented a significant breakthrough in the treatment of patients with hormone-acting, neuroendocrine gastro-intestinal-pancreatic (NEGEP) neoplasms, even if its short half-life made it impractical in the clinical practice. Over the last recent years new long-acting formulations have been developed from the native peptide. Octreotide, lanreotide and vapeotide are octapeptides with similar biological activity, remarkable stability and longer half-life; an extended-release formulation of octreotide (Octreotide-LAR) and lanreotide (Lanreotide-SR) have been more recently developed by incorporating the peptide in microspheres of a biodegradable polymer. This formulation was conceived to provide patients with the convenience of a once-a-month or twice-a-month injection and to ensure a stable serum concentration between injections and good clinical control of NEGEP tumours symptoms. Nowadays, somatostatin long-acting analogues represent the first treatment option in those patients who doesn't underwent radical surgery; in addition, these substances present no important side effects, ameliorate the prognosis and can exert some degree of tumour growth control.

Chronic pancreatitis: relation to acute pancreatitis and pancreatic cancer.

The relationship between chronic pancreatitis (CP) and other pancreatic diseases, such as acute pancreatitis (AP) and pancreatic cancer (PK), remains a fairly debated question. The progression from alcoholic AP to CP is controversial, and some long-term epidemiological studies suggest that alcoholic CP might be the result of recurrent alcoholic AP (necrosis-fibrosis sequence) and a subgroup of alcoholics may present recurrent AP without progression to CP. Other predisposing factors (genetic, nutritional, environmental) seems to be important in inducing different outcomes of pancreatic damage due to alcohol. However, recurrent episodes of AP are clearly involved in pathophysiology of CP in patients with hereditary pancreatitis. A relationship between CP and subsequent PK development has long been suspected, but we actually don't know whether this association is direct or is the result of confounding factors, such as alcohol intake or cigarette smoking. Many issues should be considered as indicators of a causal association, and several of them are not fulfilled. Nonetheless, epidemiological studies (case-control or cohort studies) showed that the risk of PK is increased in patients with CP; the risk is significantly higher in tropical calcifying CP and hereditary pancreatitis. Studies on growth factors, oncogenes, tumor-suppressor genes, and angiogenesis suggest that the sequence PC-KP is plausible from the biological standpoint.

Flumazenil in the treatment of acute hepatic encephalopathy in cirrhotic patients: a double blind randomized placebo controlled study.

AIMS: The aim of this study was to evaluate the effects of flumazenil on hepatic encephalopathy in patients with liver cirrhosis. PATIENTS AND METHODS: . In the double blind randomized, placebo controlled study, 54 patients with hepatic encephalopathy grade III-IV were randomly assigned to receive either flumazenil 2 mg iv (group A) or placebo (group B); conventional treatment with branched-chain amino acid, saline, glucose, and lactulose was administered in both groups. A 24-hour observation period was established. Clinical improvement was defined as a 3 point decrease in the Glasgow coma score at any time within 24 hours. RESULTS: Clinical improvement was obtained in 22/28 patients in group A and in 14/26 in group B (p<0.05); improvement was observed within the first six hours in 21/22 patients in group A and only in 3/14 in group B. Mortality rate was not different between group A and B; however, all 6 non-responders in group A and only 5 out of 12 in group B died within 24 hours. Among patients with post-bleeding encephalopathy, 11 out of 17 in group A and only 2 out of 14 in group B improved (p<0.001). CONCLUSIONS: Flumazenil may exert a beneficial effect in a subset of patients with acute hepatic encephalopathy; encephalopathy associated with bleeding is more likely to respond to flumazenil; responders to the treatment usually improve within the first 6 hours while lack of response usually represents a bad prognostic sign.

Neopterin serum levels in pancreatic adenocarcinoma.

CONCLUSIONS: Activation of the immune system in pancreatic cancer is demonstrated by increased serum levels of neopterin, soluble Interleukin 2 receptor (sIL-2R), and Interleukin 6 (IL-6). Determination of these parameters does not provide benefit in the diagnosis of pancreatic cancer. BACKGROUND: The aim of the study was to define the diagnostic value of serum neopterin, an in vivo marker of macrophage activity, in pancreatic cancer. METHODS: Thirty-four patients with pancreatic cancer were studied. According to the UICC TNM classification 6 were in stage I, 9 in stage II, 6 in stage III, and 13 in stage IV. Twenty-four patients with chronic pancreatitis, 72 healthy blood donors, and 20 patients with jaundice resulting from gallstones were used as control groups. Neopterin, tumor necrosis factor (TNF), sIL-2R, and IL-6 were measured in serum in the different groups; Ca 19-9 was also measured in cancer and pancreatitis. RESULTS: Serum levels of neopterin, sIL-2R, and IL-6 were higher in cancer than in pancreatitis and healthy donors, and in pancreatitis higher than in donors. Serum TNF was similar in the three groups. Serum levels of neopterin, TNF, sIL-2R, and IL-6 were not related to the tumor stage or to Ca 19-9 levels. A positive correlation was found between sIL-2R and neopterin levels. Neopterin levels in obstructive jaundice were similar to those of pancreatitis. Ca 19-9 at the recommended cutoff of 37 U/mL showed the best sensitivity and specificity (88.2 and 87.5%, respectively). At the selected cutoff neopterin, TNF, sIL-2R, and IL-6 showed low sensitivity and specificity in differentiating cancer from pancreatitis.

Serum creatinine and chest radiographs in the early assessment of acute pancreatitis.

BACKGROUND: We previously identified serum creatinine values >2 mg/dL (176.8 micromol/L) and pathological chest radiographs due to the presence of pleural effusions or pulmonary densifications as two early prognostic factors of life-threatening acute pancreatitis (AP). The aim of the present study was to validate their prognostic efficacy in combination. METHODS: We analyzed as prognostic factors only the data obtained within 24 hours of admission in 539 cases of AP, including 163 patients (30.2%) with acute necrotizing pancreatitis (NP). Eleven patients (2%) presented with infected pancreatic necrosis, and 20 patients (3.7%) died. RESULTS: One hundred and nine cases (20.2%) presented pathological chest radiographs: 32 (5.9%) pulmonary densifications and 77 (14.3%) pleural effusions (18 right, 25 left, 34 bilateral). Fifty-one patients (9.5%) had serum creatinine values >2 mg/dL. Pathological chest radiographs and serum creatinine values >2 mg/dL were significantly associated both with mortality risk (P <0.00001), with a diagnosis of NP (P <0.00001), and with risk of developing infected necrosis (P <0.0001). Considering positivity of either or both tests, the mortality risk sensitivity was 90% (95% confidence interval [CI] 70.7 to 98.3) with a specificity of 76% (CI 72.5 to 79.8), for the NP diagnosis the sensitivity was 60% (CI 52.5 to 67.4) and the specificity 88% (CI 85.0-91.5), whereas for the risk of infected necrosis the sensitivity was 73% (CI 42.2 to 92.6) and specificity 75% (CI 70.1 to 78.4). These data are comparable to those obtained with the Ranson or Glasgow scores at 24 hour in this patient group, with a cut-off > or =3. CONCLUSIONS: Serum creatinine and chest radiographs are two indices capable of identifying, within 24 hour of admission, a subgroup of acute pancreatitis patients with a more severe or adverse clinical course.

Acute pancreatitis in adult type IV congenital cyst of bile ducts: report of two cases.

Type IV congenital cyst of bile duct represents about 10% of all bile duct congenital cysts in adulthood. Clinical presentation is usually related to recurrent jaundice and abdominal pain. No cases of type IV bile duct cyst presenting with acute pancreatitis have been described so far. We herein report two cases of such association; both patients recovered from acute pancreatitis. The relevant world literature is reviewed.

Does endoscopic digital pancreatography constitute an advance in pancreatic imaging?

BACKGROUND: From a technological viewpoint, there have been few advances in retrograde pancreatography since the inception of ERCP despite remarkable advances in other radiographic techniques such as CT and magnetic resonance imaging. We describe a new method of pancreatographic imaging, endoscopic digital pancreatography, based on digital image intensification. METHODS: Thirty-two nonconsecutive patients with various pancreatic diseases were entered into the study. Pancreatography was performed using standard technique with a non-ionic, low osmolarity contrast medium. In addition to conventional pancreatographic x-rays, digital images were acquired and then processed by means of computer-assisted technical modalities. Both pancreatograms were evaluated by two independent investigators. RESULTS: Digital pancreatography was rated as superior to conventional pancreatography in terms of overall quality as well as specific parameters. X-ray dosage was significantly higher and fluoroscopy time significantly longer for conventional pancreatography. CONCLUSION: Endoscopic digital pancreatography represents a significant advance, one with several important advantages compared with conventional pancreatography.

The incidence of main pancreatic duct disruption in severe biliary pancreatitis.

BACKGROUND: Little is known regarding the incidence of main pancreatic duct disruption in patients suffering from acute necrotizing pancreatitis and whether the occurrence of this disruption may contribute to the decision to intervene surgically. The aim of this prospective study was to assess these findings in a group of patients with acute necrotizing biliary pancreatitis. PATIENTS AND METHODS: Seventy-five consecutive patients with necrotizing acute pancreatitis and suspected biliary etiology underwent endoscopic retrograde cholangiopancreatography within the first week upon admission. Biliary pancreatitis (common bile duct stones or endoscopic features probative for recent transpapillary stone migration in patients with gallstones) was confirmed in 70 patients. Imaging not only of the biliary tract but also of the pancreatic ducts was pursued. Fifty-one patients (72.8%) were conservatively treated, 19 (27.1%) underwent surgery: indication for surgery was infection of necrosis in 15 cases, pseudocysts in 3 cases, and fistula in 1 case. RESULTS: Satisfactory visualization of the main pancreatic duct was achieved in 59 cases (84.3%). Disruption of the main pancreatic duct was observed in 18 cases (30.5%), ie, 5 of the 17 patients who underwent surgery and 13 of the 42 patients who were nonoperatively managed (NS). CONCLUSIONS: Our results suggest that the loss of integrity of the main pancreatic duct, as verified with endoscopic pancreatography, constitutes quite a frequent event in acute biliary pancreatitis, and it should not be considered as an absolute indication for surgery in patients with sterile necrosis. Most of these patients can be safely managed without surgery.

Influence of advanced age and related comorbidity on the course and outcome of acute pancreatitis.

BACKGROUND AND AIMS: Aging process and comorbidity have been held to influence the course and outcome of acute pancreatitis in elderly patients. The aim of the present study was to investigate this issue in a large series of patients > or = 70 years of age suffering from acute pancreatitis. PATIENTS AND METHODS: A retrospectively study was carried out on 439 patients with a first episode of AP. The patients were divided into two age groups: < or = 69 years (n = 340) and > or = 70 years (n = 99). Differences in general characteristics, aetiological factors, blood tests and laboratory data, severity of the disease and outcome were evaluated. The presence of intercurrent diseases was also investigated in the two age groups. RESULTS: No significant difference was observed in the distribution of the various aetiological factors in the two age groups considered. The percentage of patients with necrotizing forms of AP, Ranson prognostic score for severity, local and systemic complications, the number of patients requiring surgical intervention or endoscopic sphincterotomy, as well as length of hospital stay were similar in the two groups. Considering the patients suffering from necrotizing acute pancreatitis, a significant increase (p = 0.01) in mortality was observed in > or = 70-year-old patients (25.8 vs 7.8%). Associated diseases were significantly more frequent in advanced age (63.6 vs 41.4%; p = 0.0004), but comorbidity did not correlate with the presence of pancreatic necrosis, the need for surgery or endoscopic sphincterotomy, and with mortality. CONCLUSIONS: The results of this study suggest that advanced age and related comorbidity have only a limited influence on the course and outcome of acute pancreatitis.

Serum interleukin-6 in acute pancreatitis due to common bile duct stones. A reliable marker of necrosis.

In a prospective clinical study we have assessed the value of serum interleukin-6 in comparison with C-reactive protein in discriminating necrotizing from oedematous acute pancreatitis due to common bile duct stones in the first hours of disease. The study comprised 36 patients with acute biliary pancreatitis; inclusion criteria were admission in hospital within 48 hours from the onset of symptoms, availability of contrast enhanced CT scan within 72 hours from admission and presence of common bile duct stones at early ERCP. A sample of serum was taken at hospitalization and interleukin-6 and C-reactive protein were measured. Interleukin-6 levels were significantly higher in necrotizing pancreatitis, being closely related to the extension of necrosis. C-reactive protein showed low efficacy in detecting necrotizing forms, although its levels were higher than in oedematous. We conclude that serum interleukin-6 is a very reliable marker of necrosis in the first 48 hours of acute biliary pancreatitis.

Endoscopic sphincterotomy and recurrence of acute pancreatitis in gallstone patients considered unfit for surgery.

The aim of the present prospective study was to investigate whether endoscopic sphincterotomy may be useful in preventing recurrence of acute pancreatitis in patients with gallstones and a high anesthesiological risk of cholecystectomy. Twenty-six elderly patients with severe cardiopulmonary, hepatic, and renal diseases were considered. Endoscopic sphincterotomy was successful in 19 cases (group A: mean age, 78.4 years; range, 71-87) and failed in 7 patients (group B: mean age, 79.8 years; range 73-85). In the follow-up period biliary pain without an increase in pancreatic serum enzymes occurred in six patients in group A and in all patients in group B (p = 0.002); recurrence of acute biliary pancreatitis with a need for hospitalization occurred in one patient in group A and in four patients in group B (p = 0.01). These results suggest that endoscopic sphincterotomy may be considered a very useful option in reducing the recurrence of acute biliary pancreatitis in elderly patients with gallstones and a high anesthesiological risk of cholecystectomy.

Neopterin in acute pancreatitis.

BACKGROUND: Activation of the cellular immune system may play a role in the pathogenesis of acute pancreatitis (AP); it has recently been proposed that excessive leukocyte stimulation may lead to the most severe forms of AP. The aim of this study was to investigate serum neopterin, a useful in vivo marker of macrophage activation, in mild and severe AP and its relationship with other markers of leukocyte activation, such as interleukin-6 (IL-6) and tumor necrosis factor (TNF). METHODS: Serum levels of neopterin (mmol/ml), IL-6 (pg/ml), and TNF (pg/ml) were measured on the 1st and 7th day of hospitalization in 17 patients with severe AP and 24 with mild AP. Severe AP was defined in accordance with the Atlanta criteria: all patients have necrosis at contrast-enhanced computerized tomography scan. RESULTS: Day 1: Neopterin and IL-6 levels were significantly higher in severe than in mild AP and normal controls; mild AP values were also significantly higher than in normal controls. The best neopterin cutoff level we obtained (30 mmol/ml) reached a specificity of 76% and a sensitivity of 46% in distinguishing severe from mild AP. Day 7: Neopterin was significantly higher in severe AP than in mild AP and in normal controls; no difference was seen between mild AP values and normal controls; neopterin serum levels were significantly higher on day 7 than on day 1 in severe AP but not in mild AP; in both groups of patients IL-6 was significantly higher on day 1 than on day 7. Using a neopterin cutoff level of 40 mmol/ml, we found specificity and sensitivity value of 92% in differentiating severe from mild AP. With regard to TNF values, no difference was seen on day 1 and 7 in the two groups of patients in comparison with normal controls. Neopterin serum values did not correlate with IL-6 and TNF on either day. CONCLUSIONS: These results confirm the activation of the cellular immune system in AP. Initially enhanced NEOP and IL-6 serum levels reflect the severity of the disease; neopterin may be considered a reliable prognostic indicator also at a distance from AP onset because its levels increase during the 1st week of AP in patients with severe forms only.