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.

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.

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.

Nonsurgical treatment of acute necrotizing pancreatitis.

Our objective was to analyze conservative management in a large series of acute necrotizing pancreatitis (ANP) patients in a specialized center for pancreatic disease in the Internal Medicine and Emergency Department of a 1,500-bed hospital. One hundred ninety-nine patients with ANP were considered (mean age, 55.4 +/- 18.2 years; biliary etiology, 60.3%). Identification of necrotizing forms of acute pancreatitis was obtained by ultrasonography, computed tomography scan, and surgery (53 cases). Exclusion of infection of the necrosis was based on clinical findings and percutaneous aspiration with bacteriological sampling. Medical treatment was started in all cases; 37 patients required ICU treatment; 87 patients underwent early endoscopic cholangiopancreatography (ERCP), and endoscopic sphincterotomy was performed in 61 cases; and percutaneous guided aspiration of necrosis and fluid collections was performed in 78 cases and in 9 patients with acute pseudocysts. Fifty-three patients (26.6%) underwent surgery; all patients (n = 30) with infected necrosis were in this group. One hundred forty-six patients were unoperated (73.3%): clinical resolution of ANP and biochemical normalization was achieved in 132 cases (66.3%) at discharge. Ultrasonographic follow-up documented morphological resolution of necrosis and fluid collections in 84 cases (57.5%) at different periods from the onset of ANP (range, 2.2-63.5 weeks); 16 patients dropped out and seven patients are still being followed. Spontaneous regression of acute pseudocysts was observed in 59.2%; percutaneous/endoscopic aspiration was successful in 33.3%. Mortality was 9.5%, significantly lower than the mortality observed in operated patients (28.3%; p = 0.002). Conservative treatment of ANP with sterile necrosis may allow healing in most cases, independent of the extent of necrosis or its association with major complications.

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.

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.

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.

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.

[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.

[Serum pancreatic enzymes in patients with chronic renal failure on hemodialysis and in transplant patients]. / Enzimi pancreatici sierici in pazienti con insufficienza renale cronica in trattamento emodialitico ed in pazienti trapiantati.

OBJECTIVE: The aim of this study was to evaluate which of serum pancreatic enzymes was less influenced by chronic renal failure (CRF). MATERIALS AND METHODS: 40 patients with CRF undergoing hemodialysis (A group) and 24 renal transplant patients (B group) were considered. None of these patients showed clinical and instrumental findings of exocrine pancreas disease. Total amylase (T Amy), pancreatic isoamylase (P Amy), lipase (L) and Elastase-1 (E-1) were measured (in A group immediately before hemodialysis). RESULTS: In A group T Amy and P Amy showed a significant correlation with serum creatinine level. In A group T Amy serum levels were increased in 65% of cases, P Amy in 72.5%, L in 47.5%, E-1 in 10%; in B group T Amy serum levels were increased in 41.6%, P Amy in 20.1%, L in 8.3% and E-1 in 4.1%. Statistical comparison showed a significantly lower percentages in B group considering P Amy (p < 0.001) and L (p = 0.003). CONCLUSIONS: Our data suggest that E-1 is the only pancreatic enzyme whose specificity is not limited by CRF and thereby may be of value in the diagnosis of the exocrine pancreatic disease in patients with CRF on hemodialysis.

Soluble interleukin-2 receptor: a new marker in pancreatic adenocarcinoma?

An increase in soluble Interleukin-2 receptor has been observed in several lymphoproliferative diseases and in certain solid neoplasms. Little is known, however, of the serum levels of this marker in pancreatic cancer. We studied the behaviour of the soluble Interleukin-2 receptor in 32 patients with pancreatic cancer versus 17 patients with alcoholic chronic pancreatitis and 24 healthy controls. The results obtained showed a significant statistical difference (Student's "t"-test and Mann Whitney U test) between pancreatic cancer on one hand and chronic pancreatitis plus healthy controls on the other (p < 0.0001).

Early prediction of aetiology and severity of acute pancreatitis by serum amylase and lipase assays.

OBJECTIVE: To evaluate whether simple pancreatic enzyme assays are useful in the early assessment of aetiology and prognosis of acute pancreatitis. DESIGN: A retrospective clinical study. SETTING: Department of Internal Medicine with a Pancreatic Disease Centre. PATIENTS: The study included 246 patients with acute pancreatitis admitted to our Unit within the first 24 hours from the onset of disease. Amylase and lipase serum levels and lipase/amylase ratio were evaluated. RESULTS: Serum amylase was higher in patients with necrotizing pancreatitis than oedematous and biliary pancreatitis than alcoholic (p < 0.009 and p < 0.05 respectively), but a high degree of overlap between values was found. No differences were noted in lipase serum levels. Lipase/amylase ratio was not different between patients with alcoholic and nonalcoholic pancreatitis. CONCLUSIONS: Evaluation of serum amylase and lipase is not useful for assessing aetiology and severity of acute pancreatitis, although amylase may be higher in severe and biliary forms.

[The clinical, histological and ultrastructural findings in a case of acute steatosis of pregnancy with a severe cholestatic syndrome]. / Rilievi clinici, istologici e ultrastrutturali in un caso di steatosi acuta gravidica con grave sindrome colestatica.

A case of acute steatosis in pregnancy featuring unusually severe cholestasis is discussed with details of the successful outcome for mother and foetus. The correspondence between clinical picture, histological and ultrasound findings is reported together with a detailed review of the latest reports in the literature and what they reveal about the true incidence of the disease, the variability of the clinical picture, whether and when it is better for both mother and child to interrupt.

[Predictive evaluation of acute necrotizing pancreatitis: results of a prospective study]. / Evaluation prédictive de la pancréatite aiguë nécrosante: résultats d'une étude prospective.

OBJECTIVES: The aim of this study has been to evaluate the prognostic efficiency of some indexes based on biochemical and clinical criteria and computed tomography (CT) findings in the early phase of necrotizing acute pancreatitis. METHODS: Prospective evaluation of 53 patients selected in two groups: a) 21 cases with severe prognosis (11 deaths and 10 patients with a complicated clinical outcome of more than 3 months) and b) 32 cases with lighter prognosis (clinical recovery within 3 months and no deaths). The prognostic indexes we considered were: CT-scan score, simplified prognostic criteria, modified Glasgow criteria, Hong-Kong criteria and C-reactive Protein serum value. RESULTS: The best values of sensitivity were obtained by C-reactive protein (100%) and CT findings (90.4%), the best values of specificity by Hong-Kong criteria (87.5%) and of efficiency by CT (85.1%). As concerns sensitivity, the statistical comparison (McNemar test) showed a significantly lower Hong-Kong level versus all the other indexes and a significantly greater level C-reactive protein versus simplified prognostic criteria and modified Glasgow score. The comparison of the specificity results showed a significantly greater level of CT, Hong-Kong and simplified prognostic criteria versus C-reactive protein and versus modified Glasgow score. Associating CT-score with Hong-Kong improved the value of specificity (90.3%) and efficiency (90.3%). CONCLUSIONS: Contrast enhancement CT-scan score showed the most valuable prognostic efficiency early during a severe form of necrotizing acute pancreatitis: the association with a simple biochemical index like Hong-Kong criteria (based on blood urea and glucose) yields an even greater accuracy in prognostic evaluation.

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.

Gabexate mesilate in the treatment of acute pancreatitis.

Despite controversial experimental and clinical findings, the use of Aprotinin (A) in the treatment of acute pancreatitis (AP) is still widespread in our country. Compared to A, Gabexate Mesilate (FOY) should have the following advantages: lack of antigenicity, low molecular weight with better cellular penetrance, wide inhibitory spectrum (against phospholipase A2 too) and good tolerability. In order to verify the efficacy of FOY versus, we decided to carry out a prospective multicenter (34 centers) randomized double blind trial in moderate-severe AP with FOY 3g/day versus A 1,500,000 U.I.K./day infused for 7 days with central venous line. Based on standard clinical, biochemical and radiological data, 199 patients suffering from AP were enrolled to the study from January 1989 to December 1990. The main admission criteria were: onset of the disease from no more than 72 hours, at least 2 Ranson positive criteria and C.T. evidence of acute pancreatic damage. Seventeen no protocol patients were excluded. The Etiology in the 182 analyzed patients (106 male, 76 female; mean age 57.6 years, range 21-91) were: biliary 102 (56%), alcohol 47 (25.8%), post-operative 13 (7.1%), unknown causes 13 (7.1%) and others 7 (3.8%). Median Ranson's Score was 3. CT examination showed 66 AP with edema, while 116 cases (63.7%) were recognized as severe forms with pancreatic necrotic involvement of 30% of the gland in 71 (61.2%), 50% in 31 (26.7%), and more than 50% in 14 (12.1%). Out of 182 patients, 91 were treated with A and 91 with FOY. The two groups were comparable regarding the main prognostic factors.(ABSTRACT TRUNCATED AT 250 WORDS)

Early prognostic assessment of acute pancreatitis with sterile necrosis. A perspective clinical study.

In an attempt to early assess the prognosis of acute pancreatitis with sterile necrosis, we have perspectively studied 40 patients with necrotizing acute pancreatitis and sterile necrosis in the first 48 hours of disease. As prognostic parameters, we have considered the computed tomography score according to Balthazar, simplified prognostic criteria according to Agarwal, Glasgow criteria and C reactive protein. Patients were divided in A group, 5 patients who died, and B group, 35 patients who survived. Computed tomography score, simplified prognostic criteria and Glasgow criteria were significantly higher in A group than B (9.5 +/- 1 vs 6.3 +/- 1.9, 3.6 +/- 0.5 vs 1.2 +/- 1.2 and 5.4 +/- 1.7 vs 2.7 +/- 1.9 respectively); conversely, C reactive protein serum levels did not show significantly difference in the two groups. We conclude that the extension of pancreatic and extrapancreatic necrosis, as measured by computed tomography, as well as the failure of extrapancreatic organs and the development of systemic and metabolic complications, as assessed by simplified prognostic score and Glasgow criteria, are the most important determinant of prognosis in necrotizing acute pancreatitis with sterile necrosis.

[The role of clinical, biochemical and echographic data in identifying the biliary pathogenesis of acute pancreatitis]. / Ruolo dei dati clinici, biochimici ed ecografici nella identificazione della patogenesi biliare della pancreatite acuta.

The role of clinical (biliary pain and/or jaundice), laboratory (discriminant function (DF) calculated using AST, ALT, AlkPh and GGT serum values) and ultrasonographic (US)(dilation and/or stone of common bile duct (CBD)) findings in identification of the biliary etiology of acute pancreatitis (AP) was studied in 60 patients. AP biliary etiology was defined by ERCP executed in the early phase of the disease (lithiasis and/or stenosis of CBD; endoscopic features of forced papilla in patients with gallstone). US showed the best values of sensitivity (84.6%) and diagnostic efficacy (76.7%); DF showed the best results of specificity (62.5%) and of test positive predictive value (92.8%). The statistical evaluation (McNemar test) showed a significant increase of sensitivity for US vs clinical findings and of specificity for DS vs clinical findings (p less than 0.05). The sensitivity, specificity, accuracy, test negative and positive predictive value were improved to 96.1, 87.5, 96.6, 77.1 and 92% by the combination of US and DF. Therefore the association of US and DF can provide the best non invasive method in rapidly detecting CBD pathology as an etiological factor in AP and then the enough accurate indication to early operative ERCP.

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.