[Bochdaleck diaphragmatic hernia in adults. Case report]. / Ernia diaframmatica di Bochdaleck nell'adulto. Storia di un caso clinico.

The case of a 27-year-old woman, admitted to our surgical ward with symptoms of epigastric-ache, postmeal vomiting and significant weight loss, is reported. Clinical and radiographic suspicion of mesenterium commune, with duodenal compression due to bands, requested an explorative laparatomy that confirmed the mesenterium commune presence with left caecum and colon adhesion and left Bochdaleck hernia, which is rare in adult age.

Net1 stimulates RNA polymerase I transcription and regulates nucleolar structure independently of controlling mitotic exit.

The budding yeast RENT complex, consisting of at least three proteins (Net1, Cdc14, Sir2), is anchored to the nucleolus by Net1. RENT controls mitotic exit, nucleolar silencing, and nucleolar localization of Nop1. Here, we report two new functions of Net1. First, Net1 directly binds Pol I and stimulates rRNA synthesis both in vitro and in vivo. Second, Net1 modulates nucleolar structure by regulating rDNA morphology and proper localization of multiple nucleolar antigens, including Pol I. Importantly, we show that the nucleolar and previously described cell cycle functions of the RENT complex can be uncoupled by a dominant mutant allele of CDC14. The independent functions of Net1 link a key event in the cell cycle to nucleolar processes that are fundamental to cell growth.

Characterization of the Net1 cell cycle-dependent regulator of the Cdc14 phosphatase from budding yeast.

In the budding yeast Saccharomyces cerevisiae, the multifunctional protein Net1 is implicated in regulating the cell cycle function of the Cdc14 protein phosphatase. Genetic and cell biological data suggest that during interphase and early mitosis Net1 holds Cdc14 within the nucleolus where its activity is suppressed. Upon its transient release from Net1 at late anaphase, active Cdc14 promotes exit from mitosis by dephosphorylating targets in the nucleus and cytoplasm. In this paper we present evidence supporting the proposed role of Net1 in regulating Cdc14 and exit from mitosis. We show that the NH(2)-terminal fragment Net1(1-600) directly binds Cdc14 in vitro and is a highly specific competitive inhibitor of its activity (K(i) = 3 nm) with five different substrates including the physiologic targets Swi5 and Sic1. An analysis of truncation mutants indicates that the Cdc14 binding site is located within a segment of Net1 containing residues 1-341. We propose that Net1 inhibits by occluding the active site of Cdc14 because it acts as a competitive inhibitor, binds to a site located within the catalytic domain (residues 1-374), binds with reduced affinity to a Cdc14 C283S mutant in which an active site Cys is replaced, and is displaced by tungstate, a transition state analog known to bind in the catalytic site of protein-tyrosine phosphatases.

Biliopancreatic diversion.

Biliopancreatic diversion (BPD) has made reacceptable the malabsorptive approach to the surgical treatment of obesity. The procedure, in a series of 2241 patients operated on during a 21-year period, caused a mean permanent reduction of about 75% of the initial excess weight. The indefinite weight maintenance appears to be due to the existence of a threshold absorption capacity for fat and starch, and thus energy, and the weight loss is partly due to increased resting energy expenditure. Beneficial effects other than those consequent to weight loss or reduced nutrient absorption included permanent normalization of serum glucose and cholesterol without any medication and on totally free diet in 100% of cases, both phenomena being due to a specific action of the operation. Operative mortality was less than 0.5%. Specific late complications included anemia, less than 5% with adequate iron or folate supplementation (or both); stomal ulcer, reduced to 3.2% by oral H2-blocker prophylaxis; bone demineralization, increasing up to the fourth year and tending to decrease thereafter, with need of calcium and vitamin D supplementation; neurologic complications, totally avoidable by prompt vitamin B administration to patients at risk; protein malnutrition, which was reduced to a minimum of 3% with 1.3% recurrence, in exchange with a smaller weight loss, by adapting the volume of the gastric remnant and the length of the alimentary limb to the patient's individual characteristics. It is concluded that the correct use of BPD, based on the knowledge of its mechanisms of action, can make the procedure an effective, safe one in all hands.

Biliopancreatic diversion for obesity at eighteen years.

BACKGROUND: Surgical attempts to treat obesity began because of the discouraging results of conservative medical treatment, which successfully achieved initial weight loss but failed to maintain it. Gastric restrictive procedures, currently the most popular surgical methods for obesity therapy, have proved to be effective in initiating weight loss, but some concerns regarding their long-term efficacy in weight maintenance have arisen. METHODS: Of a total of 1968 obese patients who underwent biliopancreatic diversion since 1976, the last consecutive 1217 underwent the "ad hoc stomach" type of diversion with a 200 cm alimentary limb, a 50 cm common limb, and a gastric volume varying between 200 and 500 ml. Mean age was 37 years old (11 to 69 years), and mean excess weight was 117%. Maximum follow-up was 115 months with nearly 100% participation. RESULTS: In the last half of the series, operative mortality was 0.4% with no general complications and with early surgical complications of wound dehiscence and infection (total, 1.2%) and late complications of incisional hernia (8.7%) and intestinal obstruction (1.2%). Mean percent loss initial excess weight (IEW) at 2, 4, 6, and 8 years was 78 +/- 16, 75 +/- 16, 78 +/- 18, and 77 +/- 16 in the patients with IEW up to 120% and 74 +/- 12, 73 +/- 13, 73 +/- 12, and 72 +/- 10 in those with IEW more than 120%. A group of 40 patients who underwent the original "half-half" biliopancreatic diversion maintained a mean 70% reduction of IEW during a 15-year follow-up period. Specific late complications included anemia (less than 5%), stomal ulcer (2.8%), protein malnutrition (7% with 1.7% requiring surgical revision by common limb elongation or by restoration). Clinical problems from bone demineralization were minimal in the short term and almost absent in the long term. CONCLUSIONS: Biliopancreatic diversion is a very effective procedure but is potentially dangerous if used incorrectly.

Pregnancies in an 18-Year Follow-up after Biliopancreatic Diversion.

BACKGROUND: 239 pregnancies occurred in 1136 women who had undergone biliopancreatic diversion (BPD). METHODS: There were 73 abortions, and 14 pregnancies are presently in their course. The 152 term pregnancies (six twins) occurred in 129 women 2-173 months (mean 42.7) after BPD. Mean age and current excess weight were 31.4 years (20-42) and 29.1%(- 6.9-78.2), and mean excess weight loss was 72.9%(30.4-110.5). RESULTS: Mean weight gain during pregnancy was 6.2 kg (-21-25). In 32 patients (21%), parenteral nutritional support was needed. In all the other patients (79%), the usual supplementations were given. Of the newborns, 122 were delivered at term (84.7%) with a mean weight of 2842.4g (1760-4600g) and a mean length of 48.S cm (43-59 cm), while the 22 preterm babies (15.3%) weighed 2151.1 g (1400-3850 g) and had a length of 44.6 cm (33-56 cm). Forty infants (27.8%) were small for gestational age but 17 of them weighed more than 2500 g. Eleven twins (one, abortion at 26th week) were also delivered, with a mean weight of 2088.6 g (1200-3100 g) and a mean length of 45.6 cm (35-50 cm). Delivery was spontaneous in 85 instances (56%), while vacuum extractor was used in one, and 66 cesarean sections were performed. There were two birth malformations, one infant died after surgery for meconium obstruction and two died from unknown causes. Of the 129 women, 35 had been infertile before BPD. CONCLUSIONS: Disappearance of infertility and decrease of pregnancy risk are to be considered among the beneficial effects of weight reduction following BPD.

Body composition in subjects with surgically obtained stable body weight normalization.

The body composition of lean control subjects was compared with that of subjects following biliopancreatic diversion for morbid obesity, when their excess weight had been stabilized at under 40 per cent of the ideal body weight value for over two years. Lean body mass, body cell mass and fat were indirectly calculated from total body water and total body sodium, measured by isotope dilution technique. The body composition in the two groups of subjects was essentially normal, as was indicated by the percentage values of the body composition parameters and by the linear correlations between body weight and the lean body compartments size.

Etiological factors of protein malnutrition after biliopancreatic diversion.

Protein malnutrition is the main early problem with biliopancreatic diversion; gastric volume greatly influences the incidence of protein malnutrition.

Surgical revision of biliopancreatic diversion.

Biliopancreatic diversion is a very effective method for weight reduction. In some instances it is too effective and needs to be revised.

Body composition after 'very-little-stomach' biliopancreatic bypass.

The nutritional status prior to and 3 months and 1 year after biliopancreatic bypass surgery was evaluated. The common nutritional indexes (serum albumin and transferin concentrations, daily urinary creatinine excretion and delayed hypersensitivity) were determined. The body compartments were derived from total body water (TBW) and total body sodium (TBNa), measured by dilutional technique, and total body potassium (TBK), calculated from TBW, TBNa, and the ratio of the sodium plus potassium content divided by the water content in a sample of whole blood. Before surgery, obese patients showed a dilatation of both fat an lean compartments with a normal lean body mass (LBM) qualitative composition, as indicated by TBNa/TBW, and TBNa/TBK ratios not greater than those measured in controls. Three months following very-little-stomach biliopancreatic bypass (VLS BPB), a consistent reduction of body weight and body fat were observed. The body cell mass value fell and reached a level closely similar to that found in lean control subjects. LBM showed only a slight decrease. A sharp increase of TBNa/TBW and TBNa/TBK ratios demonstrated a dilatation of the extracellular space. This malnutritional status was not detected by the usual nutritional parameters. One year after VLS BPB surgery, the patients' body composition became very similar to that of lean subjects, though a TBNa greater than that of controls suggested that a slightly expanded extracellular space was still present.

In vivo evaluation of postoperative immunosuppression by means of Multitest system.

The Multitest System, a new standardized method for evaluating delayed hypersensitivity and cell mediated immunity was carried out before surgery and throughout the postoperative care in subjects undergoing gastrointestinal surgery. In all patients significantly depressed cutaneous reactions were found in the first day after operation. Immunosuppression lasted more than four days when postoperative infection has set up, while in uneventful patients delayed hypersensitivity has returned to preoperative values from the fourth day. It would be suggested that Multitest System data in fourth postoperative day could identify subjects with uneventful recovery after surgery.

[Evaluation of blood flow using a reservoir flowmeter of several types of arteriovenous fistulas in chronic hemodialysis treatment]. / Valutazione del flusso ematico di alcuni tipi di fistole artero venose per il trattamento emodialitico cronico mediante "flussi metria a pozzetto".

Blood flow of nine end to end and eight side to side arteriovenous fistulas (AVF) at distal forearm for maintenance hemodialysis, was measured by blood flowmeter inserted in the arterial line between the pump and the dialyzer. The mean flow of the end to end and the side to side fistulas was 386.6 +/- 69.6 ml/min and 345 +/- 45 ml/min (p 0.01) respectively. Since, in addition, the end to end flow seems to be better than the side to side flow as regards local and general effects, we advocate the use of end to end fistulas.