[Appropriate hospital utilization in emergency surgery: application of the Appropiatness Evaluation Protocol]. / Uso appropriato della struttura ospedaliera in chirurgia d'urgenza: applicazione dell'Appropriateness Evaluation Protocol.

UNLABELLED: The Authors developed and tested a new version of the Appropriateness Evaluation Protocol (AEP) to review 160 clinical records of the Emergency Surgery Department of Policlinico Umberto I-Rome. The modifications to the AEP also allow to evaluate the appropriate ward of hospitalization of acute patients (Surgery, Orthopedics, Head & Neck, Burns). RESULTS: 26 (16%) out 160 admissions failed the AEP criteria; 85 of the remaining admissions were judged appropriate in the Emergency Surgery Department (53% of the whole sample), 14 (9%) in the Head & Neck Department, 10 (6%) in the Orthopedic Department, 25 (16%) not in an Emergency Surgery Department. Only 63% of the appropriate admissions has been judged adequate in the Emergency Surgery Department. The Authors conclude that it is necessary to improve the primary "filter" of the hospitalization (the ambulatory care component of the National Health System). Finally, this version of the AEP was shown to be reliable, an useful tool in the hands of trained physicians.

[Differential diagnostic problems between nodular fasciitis and soft-tissue sarcomas. A review of the literature and a case report]. / Problemi diagnostici differenziali tra fascite nodulare e sarcomi dei tessuti molli. Revisione della letteratura e descrizione di un caso.

After a review of literature and the report of a case with intrathoracic location, the authors consider present criteria for a correct diagnosis of low grade soft tissue sarcoma, when the possibility of nodular fasciitis is under evaluation. Nodular fasciitis is a benign pathology up to day not well characterised from the clinical and pathological point of view. The authors conclude that differential diagnosis between low grade soft tissue sarcoma and nodular fasciitis is frequently possible only on the basis of clinical course evaluation; otherwise the management may be inadequate.

[Genetic factors and colorectal cancer: a new approach to clinical experimentation]. / Fattori genetici e cancro del colon-retto: una nuova frontiera per la sperimentazione clinica.

The Authors point out the basis for a better characterisation of colo-rectal cancer and precursory lesions. In fact the etiology of familial adenomatous polyposis (FAP), aberrant crypt foci (ACF), hereditary non polyposis colon cancer syndrome (HNPCC) seems to be correlated to molecular pathology. Therefore the Authors review colo-rectal cancer natural history which frequently appears to be not related to clinical evolution.

Intratumoral heterogeneity in colorectal carcinoma: trucut sampling for DNA ploidy analysis.

BACKGROUND: Solid tumors, such as colorectal carcinomas, consist of cell subpopulations that differ both genetically and in their clinical behavior. Many authors have examined cell kinetics and DNA content in colorectal tumors in correlation to clinical and pathological variables with different results. The interpretation of those results present some difficulties related to tumor heterogeneity that to date are unsolved. Our study is based on a new method of colon cancer sampling for DNA content determination. The aim of this work was to reduce the risk of incorrect DNA evaluation due to tumor heterogeneity. MATERIAL AND METHODS: Our study was based on eleven selected cases of T3 colorectal carcinoma. Fresh surgical specimens from the primary tumor site were taken during surgery. For each case at least four samples were taken using a 23 gauge trucut from the outside of the serosa through the tumor to the lumen of the colon. The specimens were stained according to a modified Feulgen method and DNA content was measured by image analysis. Three parameters were evaluated: DNA index, ploidy and proliferation level (considered as the sum of elements corresponding to the S and G2 phases). RESULTS: One of the eleven (9.1%) tumors showed a diploid pattern; four out of eleven (36.4%) cases showed a tetra/polyploid pattern and six out of eleven (54.5%) cases showed an aneuploid pattern. Three tumors were monoclonal (27.3%), one diploid and two aneuploid. Eight were polyclonal (72.7%). Considering the single specimen, seven out of sixty-eight specimens (10.3%) were inadequate because of scanty material. Twenty-five out of the sixty-one adequate specimens (41%) were monoclonal and thirty-six (59%) were polyclonal. Five tumors (three monoclonal and two polyclonal) showed the same cell clones on all the examined samples. The remaining six tumors showed interregional variability. The six of the eight polyclonal cases (75%) multiple stem lines were evident, analyzing only one sample taken close to colon serosa, while in one case (25%) it was necessary to examine two samples in order to see the polyclonality of the lesion. When samples taken close to mucosa where analyzed, however, one sample was not enough to show tumor polyclonality in five of the eight polyclonal examined cases. Proliferation level varied greatly in different parts of the same carcinoma and did not correlate to the site from which the sample was taken. CONCLUSION: In the present study, we demonstrated that DNA ploidy differences may exist between the superficial and the deep part of the same neoplasia and that tumor samples show a greater variability in the deeper layers. Using trucut samplings, it was possible to point out the majority of aneuploid cell populations close to the serosa. In conclusion, trucut biopsy permits full thickness sampling of the tumoral mass and allows, from few samples, to evaluate the multiple DNA stemlines present in different parts of a colorectal tumor.

[Desmoids associated with multiple familial polyposis: description of a clinical case]. / Desmoidi associati alla poliposi familiare multipla: descrizione di un caso clinico.

The Authors report a case of great desmoid tumor of the abdominal wall with intestinal adhesions and enterocutaneous fistula, in a patient with Gardner's syndrome, who underwent total colectomy with ileorectal anastomosis. The patient was treated at first with non steroidal antiinflammatory drugs, then with local chemotherapy. The Authors performed a second surgical procedure resecting the tumor and opening a temporary ileostomy. Despite of these treatment patient showed a local recurrence. Desmoid tumor is a neoplastic benign lesion arising from aponeurotic muscle tissue. Local infiltration and post-operative recurrence are very common. Several surgical and medical treatments are proposed, but they are not totally effective. Surgical treatment might be radical, with wide resection to reduce local recurrences. Radiotherapy and chemotherapy are second choice treatments.

[Acute hepatic necrosis in a patient treated with cyproterone acetate]. / Necrosi epatica acuta in paziente sottoposto a terapia con ciproterone acetato.

The Authors report a case of prostatic carcinoma in a 84 year old male, treated with cyproterone acetate (CPA), complicated by a fatal fulminant hepatitis. He was admitted with a mixed jaundice followed by a derange of all liver function tests. Serological markers for hepatitis were negative. Ultrasonography and CT revealed no hepatic abnormality but gallstones and dilatation of principal bile duct with a terminal stricture. By the endoscopic retrograde cholangiography and sphincterotomy we put an external drain tube. He died 9 days after admission. Fatal hepatis due to CPA is a very rare complication but all patients on anti-androgenic drugs should have liver function closely monitored. CPA must be discontinued immediately at the first derange of liver function tests.

[Is it possible to consider intranuclear DNA imaging analysis as a new parameter in the staging of colorectal cancer?]. / E possibile considerare l'analisi per immagine del DNA intranucleare come un nuovo parametro per la stadiazione del cancro colo-rettale?

Intranuclear DNA imaging may be considered as a marker of the biological behaviour of neoplasias. However, some questions fundamentally related to the interpretation of cytometric data, to the correlation with other histomorphological parameters and to tissue sampling concerning staging and prognostic evaluation of colon cancer patients are still unsolved. A way to solve this problem may be to perform multiple full thickness samplings.

[Clinical-experimental models for the identification of immunologic parameters to be integrated in traditional staging systems of colorectal neoplasms]. / Modelli clinico-sperimentali per la definizione di parametri immunologici da integrare ai sistemi di stadiazione tradizionali delle neoplasie colo-rettali.

The Authors evaluate new possible models for the staging of colorectal cancer based on clinico-morphological, histo-pathological and bio-immunological parameters. Particularly, they evaluate the possibility of studying host's immunological response against tumor spread by the examination of the "in situ" cellular responses. This study was performed by cytotoxic test and immunohistochemical evaluation of the lymphocytes. The latter seems to give better results compared to the first in the evaluation of the host's immunological response.

[Evaluation of the effect of H2-histamine antagonists in the natural history of stomach cancer]. / Valutazione dell'influenza degli antagonisti H2-istaminici nella storia naturale del carcinoma gastrico.

On a study population of 131 patients the Authors evaluate possible differences related to the use of H2 blockers. Patients were divided in 2 groups: one (70 cases) studied before the introduction of H2 blockers and the other (61 cases) treated with H2 blockers. The influence of endoscopy for the early diagnosis of gastric cancer was also considered. The Authors conclude that H2 blockers do not have a negative influence from a surgical point of view, however the correct diagnosis may often be delayed and this is not acceptable for an era in which early diagnosis is feasible.

[A case of multiple intestinal perforations due to TBC in a female patient with HIV-1 infection]. / Su di un caso di perforazioni intestinali multiple da TBC in una paziente con infezione da HIV-1.

The authors report a case of HIV-1 infection, primary miliary tuberculosis of the lung and secondary intestinal tuberculosis complicated with multiple intestinal perforations. The surgical emergency therapy, supported by specific antitubercular drugs, antibiotics, and total parenteral nutrition, consisted in suturing seven perforative sites of the small and large intestine. The Authors stress the possibility that in the future tubercular complications up till now considered atypical may become more and more frequent because of the HIV-1 infection association.

Evaluating bronchial hyperreactivity tests in epidemiology.

The aim of this study is to assess the value of the most common tests which can be used in epidemiological surveys to identify asthmatic children. We reviewed anamnestic information from a self-administered questionnaire, bronchial reactivity by means of exercise-test, bronchodilation-test with trimethochinol, carbachol-test (PD20 FEV1 was reported), cutaneous reactivity monitored by prick-test. (Data from a polycentric epidemiological study). We conclude that, while these tests are very useful in the initial study and in the further follow-up of the asthmatic child, providing also information about the possibilities of management of bronchoconstriction and its pharmacologic prevention, they show a limited value in the absolute diagnosis of asthma.

[Measurement of the metabolic response to physical exercise in children. Influence of training and bronchospasm]. / La misura della risposta metabolica all'esercizio fisico nei soggetti in età pediatrica. Influenza dell'allenamento e del broncospasmo.

A treadmill incremental exercise test was performed on 30 children. They were 18 healthy subjects (17 males, 1 female, age 7-16 years) and 12 asthmatic subjects (10 males, 2 females, age 9-19 years). The latter were characterized by exercise induced asthma (E.I.B.) and underwent a second test after the administration of Beta 2-adrenergic drug. During the test, while increasing the work-load, measurements were made of ventilation, O2 uptake CO2 production and heart-rate. No significant difference was found comparing the performances of the healthy subjects with those of the asthmatic patients. On the contrary trained subjects (both healthy and asthmatic) showed a better performance when compared to untrained subjects. In the presence of E.I.B. only untrained asthmatic children had their performances diminished. It is concluded that adequate information is required in order to avoid the negative consequences of exercising in the asthmatic subjects: physical exercise can be freely practised by children with asthma but they should be educated to recognize the limitations the bronchospasm can possibly represent for them.