[Extrarenal retroperitoneal angiomyolipoma: description of a case and review of the literature]

A case of retroperitoneal extrarenal angiomyolipoma is described. The patient, a 61-year-old woman, presented with a large retroperitoneal lipomatous mass. Histologically, it consisted of lipomatous tissue. Focally, there was interstitial and perivascular proliferation of bland oval and epithelioid cells with a large, eosinophilic or clear cytoplasm. Immunohistochemically, these elements were positive for smooth muscle actin and HMB-45. The literature on retroperitoneal extrarenal angiomyolipoma is briefly reviewed. It is important that the pathologist recognize this lesion, even when it is located in the retroperitoneum outside the kidney, and differentiate it from a liposarcoma.

Right ventricular diastolic abnormalities in systemic sclerosis. Relation to left ventricular involvement and pulmonary hypertension

OBJECTIVES

To investigate right ventricular diastolic function in systemic sclerosis (SSc) and its relation to clinical features of the disease.

METHODS

Seventy seven unselected SSc patients and 33 healthy subjects were submitted to echocardiography and echo Doppler study to assess left and right systolic as well diastolic function and to estimate maximal arterial systolic pulmonary pressure (PAP). In addition, the patients were investigated to define the SSc subset and the extent of skin and internal organ involvement.

RESULTS

An abnormal right ventricular filling, as expressed by an inverted tricuspidal (Tr) E/A ratio (Tr E/A ratio <1), was detected in 31 of the 77 SSc patients (40%) and in 0 of the 36 controls ( p<0.001 ). All the 31 patients with an inverted Tr E/A ratio were found to have a PAP > 30 mm Hg. Twenty resulted to have an inverted mitral (Mit) E/A ratio (Mit E/A ratio <1), indicating an abnormal left ventricular filling. In multiple regression analysis, Tr E/A ratio resulted to be independently correlated to both PAP (r= -0.35;p<0. 003) and Mit E/A ratio (r=0.39;p<0.001).

CONCLUSIONS

This study points out an impaired right ventricular filling in a significant percentage of SSc patients whatever the subset. This alteration is independently correlated to both PAP and left ventricular filling abnormalities.

Discriminant power and information content of Ranson's prognostic signs in acute pancreatitis: a meta-analytic study

OBJECTIVE

To determine a meta-analytical definition of the discriminant power of Ranson's signs in the prediction of acute pancreatitis severity and outcome, and of their information content, also compared with clinical judgment.

DATA SOURCES

Two hundred eleven studies since 1974, reporting any predictive system for acute pancreatitis (MEDLINE by various Medical Subject Headings in MEDLARS, Current Contents, Medscape, Virtual Hospital, and other on-line medical services).

STUDY SELECTION

One hundred ten studies reporting clinical use of Ranson's signs were retained. A quality index was calculated for each study. A selection was made according to inclusion criteria, separately for prediction of severity (19 studies; group S) and prognosis (10 studies; group P). Six other studies reporting clinical judgment results were also selected (group C).

DATA EXTRACTION

Sensitivity and specificity values were extracted. Effect sizes were calculated and summarized by the inverse variance-weighted method. Categorical models were studied by analysis of variance. Publication bias was sought by correlation test and analysis of variance. Summary receiver operating characteristic curves were drawn, and the corresponding false-positive rate (FPR) and true-positive rate were calculated for each group. From the total true-positive rate and FPRs, the probabilities of illness for positive and negative results were calculated, for severe pancreatitis prevalence from 0 to 1. Last, the area below the curve and the ratio between this and that of the "perfect test" were calculated as a measurement of information content.

DATA SYNTHESIS

Ranson's signs demonstrated poor discriminant power in both predictions: "d" values were 1.200 (95% confidence interval, 1.083-1.318) and 1.302 (95% confidence interval, 1.046-1.559), respectively. The lack of homogeneity in group S (Q = 58.737; p = .0000032) can be explained by the presence of three outliers. The summary curves showed, for low FPRs, a higher sensitivity of clinical judgment; Ranson's signs reached useful sensitivity only for high FPRs. No differences between groups in the area below the information content curves were found.

CONCLUSIONS

Ranson's signs showed a poor predictive power. The information content did not differ from that of clinical judgment.

Delayed intestinal visualization at hepatobiliary scintigraphy is associated with response to long-term treatment with ursodeoxycholic acid in patients with cystic fibrosis-associated liver disease

BACKGROUND/AIMS

Abnormalities of biliary drainage have been documented at hepatobiliary scintigraphy in many but not all patients studied with cystic fibrosis-associated liver disease. Ursodeoxycholic acid was shown to be beneficial in this disease, mainly by improving biliary secretion. Therefore, patients with impaired biliary drainage are expected to obtain the greatest benefit from this treatment.

METHODS

We evaluated the effects of long-term treatment with ursodeoxycholic acid in 36 patients with cystic fibrosis-associated liver disease, and compared the response in patients presenting a normal (n=18) or delayed time of intestinal visualization (n=18) at baseline hepatobiliary scintigraphy.

RESULTS

The mean treatment duration was 58+/-26 (S.D.) months and 63+/-29 months in the groups with normal or delayed time of intestinal visualization, respectively. The time of intestinal visualization decreased (57+/-23%, p<0.001) from baseline in patients with initially abnormal values and became normal in four (22%). Treatment failure, i.e. lack of sustained normalization of serum liver enzymes or the occurrence of a clinically relevant adverse event, was more frequently observed in patients with a normal time of intestinal visualization at baseline (OR, 5.50; 95% CI, 1.32-22.7). When only clinically relevant adverse events were considered, they occurred in six of the latter patients (liver transplantation in one case, development of ultrasographic or endoscopic signs of portal hypertension in six cases), but in only one patient (development of portal hypertension) in the group with delayed time of intestinal visualization (OR, 10.82; 95% CI, 1.17-100.4).

CONCLUSIONS

Delayed intestinal visualization at hepatobiliary scintigraphy in patients with cystic fibrosis-associated liver disease seems to predict a better response to ursodeoxycholic acid.

[Italian Cystic Fibrosis Registry: 10 years of activity]

Cystic Fibrosis (CF) is a recessive autosomic genetic disease with an incidence in mediterranean countries of about 1:3500 born alive. In Italy the considerable genetic variability makes it difficult to identify all the homozygous subjects and, consequently, to estimate the incidence of the disease in healthy carriers. The disease is evolutive and affects various systems, most of all the respiratory and gastrointestinal systems. Not many years ago, when the clinical definition of CF was first introduced, average survival did not exceed the pediatric age. Nowadays with ever advancing diagnostic and therapeutical techniques many CF patients survive until an adult age. It is therefore necessary to plan adequate health service interventions so as to satisfy as much as possible the needs of both the patients and their families. To this end data collected since 1.1.1988 by the Italian registry for CF (year of birth, sex, region of birth and residence, diagnosis procedures, results of sweat test, pancreatic insufficiency, DNA analysis, status: alive, dead, lost to follow up) of all the patients, diagnosed in the 18 Reference Centres and the 3 local Centres for CF, have proved to be extremely useful. Since the birth of the Registry on 31.12.1997, data relating to 2458 patients alive on 1.1.1988 and 1159 born during the last ten years, for a total of 3617 subjects (1756 females and 1861 males), have been recorded. As already mentioned a considerable increase in life expectancy of CF patients (from 1988 to 1990 the average age of death was 14 years, from 1994 to 1997 it was 19) and a consequent increase in the percentage of adult patients have been observed.

Genome search in celiac disease

Celiac disease (CD), a malabsorption disorder of the small intestine, results from ingestion of gluten. The HLA risk factors involved in CD are well known but do not explain the entire genetic susceptibility. To determine the localization of other genetic risk factors, a systematic screening of the genome has been undertaken. The typing information of 281 markers on 110 affected sib pairs and their parents was used to test linkage. Systematic linkage analysis was first performed on 39 pairs in which both sibs had a symptomatic form of CD. Replication of the regions of interest was then carried out on 71 pairs in which one sib had a symptomatic form and the other a silent form of CD. In addition to the HLA loci, our study suggests that a risk factor in 5qter is involved in both forms of CD (symptomatic and silent). Furthermore, a factor on 11qter possibly differentiates the two forms. In contrast, none of the regions recently published was confirmed by the present screening.

Genetic history of cystic fibrosis mutations in Italy. I. Regional distribution

Earlier analysis of the Italian population showed patterns of genetic differentiation that were interpreted as being the result of population settlements going back to pre-Roman times. DNA disease mutations may be a powerful tool in further testing this hypothesis since the analysis of diseased individuals can detect variants too rare to be resolved in normal individuals. We present data on the relative frequencies of 60 cystic fibrosis (CF) mutations in Italy and the geographical distribution of the 12 most frequent CF mutations screened in 3492 CF chromosomes originating in 13 Italian regions. The 12 most frequent mutations characterize about 73% of the Italian CF chromosomes. The most common mutation, delta F508, has an average frequency of 51%, followed by N1303K and G542X, both with average frequencies around 5%. Multivariate analyses show that the relative frequencies of CF mutations are heterogeneous among Italian regions, and that this heterogeneity is weakly correlated with the geographical pattern of non-DNA 'classical' genetic markers. The northern regions are well differentiated from the central-southern regions and within the former group the western and eastern regions are remarkably distinct. Moreover, Sardinia shows the presence of mutation T338I, which seems absent in any other European CF chromosome. The north-western regions of Italy, characterized by the mutation 1717-1G-->A, were under Celtic influence, while the north-east regions, characterized by the mutations R1162X, 2183AA-->G and 711 + 5G-->A, were under the influence of the Venetic culture.

[Prospective randomized comparative study of laparoscopic hernioplasty and Lichtenstein tension-free hernioplasty]

To compare the laparoscopic transabdominal preperitoneal inguinal hernioplasty (TAPP) and the open Lichtenstein technique, in 1992 a prospective randomized trial was initiated. Until 1995 108 patients with 130 hernias took part in the trial: 64 TAPP (group A) and 66 Lichtenstein (group B). 22 patients had simultaneous bilateral repairs. Laparoscopic approach (group A) was able to expose otherwise-occult controlateral hernias in 3 cases and discovered a complex hernia (a hernia with more than one defect in the wall) in 2 patient in whom a direct hernia had been diagnosed before the operation. Mean operating time for monolateral operations was significantly longer in group A (p < 0.05). The corresponding figures for bilateral operations were longer in group B (p < 0.01). No intraoperative complications, conversions from TAPP to open repair, postoperative deaths. There were not less pain quicker mobility and shorter period of disability in the laparoscopic group (group A). Ten (15.6%) postoperative complications occurred in group A: local hematoma (6 cases, 9.3%), neuralgias (3 cases, 4.7%), urinary retention (1 case, 1.6%). Eight (12.1%) postoperative complications: hematomas (3 cases, 4.5%), urinary retention (3 cases, 4.5%), neuralgias (2 cases, 3%) occurred in group B. Differences were not significant. The current follow-up period is 36 months (15-54) in median. In both groups no recurrences occurred, but 3 patients in group B who were operated on for monolateral hernia (6.5%) discovered to be affected by contralateral hernia. The results of the present report suggest that TAPP does not appear to be associated with better results in terms of complications, pain or period of disability as compared to open tension free hernia repair, but the ability of the laparoscopic approach to expose otherwise-occult defects eliminated the risk of recurrences due to missed hernias.

Corneal curvatures and refractions of central American frogs

We employed neutralizing infrared videophotorefraction and photokeratometry to examine the manifest refractions and corneal curvatures of 21 species of anurans (frogs and toads) in five families (Dendrobatidae, Bufonidae, Centrolenidae, Leptodactylidae, and Hylidae) resident in Central America. We found that all of the anurans exhibited hyperopic refractions in air, but that the observed hyperopia was not totally explained by the small eye artefact (Glickstein & Millodot, 1970). An allometric comparison of the corneal radii of these small anurans with those of a large number of other vertebrates, inferred from ocular axial lengths, showed that their corneal radii increased significantly more rapidly with increasing body size than that of other vertebrates generally (allometric slope constants: anurans: 0.270 +/- 0.032; other vertebrates: 0.151 +/- 0.004). Among the anurans examined, nocturnal Hylids had significantly larger eyes than diurnal Dendrobatid frogs and Bufonid toads.

Diastolic abnormalities in systemic sclerosis: evidence for associated defective cardiac functional reserve

OBJECTIVE

To investigate the pattern of diastolic abnormalities in patients with systemic sclerosis (SSc) and the relationship between impaired ventricular filling and systolic function.

METHODS

Twenty four patients with SSc underwent M-mode and two dimensional echocardiography using echo-Doppler and gated blood pool cardiac angiography, both at rest and after exercise.

RESULTS

An impaired diastolic relaxation of the left ventricle was detected in 10 of the 24 patients with SSc. Left ventricular ejection fraction at rest in these 10 patients with impaired ventricular filling did not differ from that in the remaining 14 patients, but eight of the 10 failed to increase their ejection fraction during exercise, compared with two of the 14 with normal ventricular filling (p = 0.003).

CONCLUSION

Impaired relaxation of the left ventricle is a recently described feature of scleroderma heart disease. Diastolic dysfunction in SSc could depend on myocardial fibrosis or myocardial ischaemia, or both. It was found to be associated with a defective cardiac functional reserve. However, its prognostic significance remains to be clarified.

Short direct repeats at the breakpoints of a novel large deletion in the CFTR gene suggest a likely slipped mispairing mechanism

In the cystic fibrosis conductance transmembrane regulator (CFTR) gene a few small deletions and only a large, complex, 50-kb deletion have been described so far. We report a second large deletion, which had been hypothesized in a patient affected by cystic fibrosis on the basis of an abnormal pattern of inheritance of the intragenic microsatellites IVS17b/TA and IVS17b/CA. Southern blot analysis revealed the presence of an anomalous band in the patient and her father, in the region encompassing exons 13 - 19, approximately 0.6 kb shorten than the one present in normal controls, in addition to the band of the correct size. Cloning and sequencing the DNA fragments spanning the region of interest demonstrated the presence of a 703-bp deletion causing complete removal of exon 17b in the paternal cystic fibrosis chromosome. This analysis revealed the presence of two short direct repeats flanking the breakpoints. The 3' repeat partially overlapped the IVS17b/CA microsatellite and the number of CA repeated units present in the paternal cystic fibrosis allele was the shortest ever found among chromosomes so far analyzed. These data may suggest that the mechanism for the generation of the deletion may have involved a slipped mispairing during DNA replication, which has not previously been described in the CFTR gene.

[Method and application limitations of decision support systems in acute pancreatitis]

Several decision support systems (DSSs) for acute pancreatitis (AP) were analyzed with reference to development methods, procedure limits and operational performances. Almost all the DSSs have been addressed to the early definition of severity, which appears the only decisional point in the approach to the management of AP. None of the three groups of methods, multifactor, scoring and bayesian systems, provides an explicit evidence of effectiveness. The multifactor systems (Ranson and successive) show inadequacy of design and operational limits which involve poor reliability and conflicting indications from the different centers. The scoring systems (APACHE, SAPS) have been projected and developed for clinical situations quite different from the AP at the onset, and seem more properly to be applicable to the monitoring of its complications. The bayesian systems, although the models used until now present important methodological shortcomings, are those which furnished the best results but are lacking in clinical validation and present a form hardly accepted by the clinician. Despite the disappointing operative results and their limited use in the AP, the DSSs probably constitute one of the most effective tools to improve the management of the severe forms, on condition that the methodology of design enad trial is correctly adjusted.

Correction of stress urinary incontinence: laparoscopy combined with vaginal suturing

The authors review the published techniques of laparoscopic colposuspension combined with vaginal suturing. Particular emphasis is given to their own technique, first published in 1992, and to that of Harewood (1993), which is similar. Both involve a Burch-like colposuspension using a technique similar to that of Gittes and Loughlin. This is possible looking inside the pelvis through a laparoscope and using a handle-needle. Published results are similar (about 70% success rate), but the authors point out that the Breda technique is simpler, cheaper, and less time consuming (only one trocar instead of three) and has had a longer follow-up (up to 3 years instead of 19 months). The authors review many other similar techniques reported between 1993 and 1995 with good results but based on rather limited experience. The conclusion is that the laparoscopic technique with vaginal suturing seems a promising way to approach stress urinary incontinence in the female patient.

Laparoscopic nephrectomy: Our personal experience on 39 cases

The authors, six years after the first laparoscopic nephrectomy by Clayman and five years after their own first case in Italy, review the literature and their personal experience in 39 cases. In their opinion, today's situation can be summed up by the conclusion that laparoscopic nephrectomy for benign disease is a safe, reproducible, cost-effective procedure and can be recommended as the procedure of choice for young ladies with a small, afunctional kidney. The same is not true for malignant diseases which, in the authors’ opinion, must be a matter for prospective, randomised and well-controlled clinical trials in reference centres.

Ursodeoxycholic acid for liver disease associated with cystic fibrosis: a double-blind multicenter trial. The Italian Group for the Study of Ursodeoxycholic Acid in Cystic Fibrosis

Liver disease is increasingly recognized as a major cause of morbidity in cystic fibrosis (CF). Preliminary data suggest that ursodeoxycholic acid (UDCA) may be beneficial for treatment of this manifestation. We performed a double-blind, multicenter trial in these patients to establish efficacy and safety of UDCA in terms of the improvement of clinical and nutritional indicators besides standard liver function tests. We also intended to establish whether taurine supplementation has a beneficial effect in patients receiving UDCA. From June to December 1990, we enrolled in 12 centers 55 CF patients with liver disease (39 male subjects; median age, 13.8 years). They were randomly assigned to receive for 1 year one of the following treatments: UDCA (15 mg/kg body weight daily) plus taurine (30 mg/kg body weight daily), UDCA plus placebo, placebo plus taurine, or double placebo. Clinical and laboratory evaluations were performed every 3 months. After 1 year, deterioration of overall clinical conditions, as indicated by the Shwachman-Kulczycki score (SKS), occurred in patients who received placebo but not in those who received UDCA (P = .025). Patients treated with UDCA also showed an improvement in gamma-glutamyl transpeptidase (GGT) (P = .004) and 5'-nucleotidase (P = .006) levels. Treatment with taurine was followed by a significant increase in serum prealbumin levels (P = .053), a trend toward a reduction in fat malabsorption, and no effect on the biochemical profile. No severe side effects occurred with any treatment. Thus, we concluded that UDCA administration improves clinical and biochemical parameters in CF patients with liver disease. Taurine supplementation may be indicated in patients with severe pancreatic insufficiency and poor nutritional status.

Laparoscopy in urology after five years: Urinary incontinence

The authors have reviewed the literature on stress urinary incontinence (SUI) treatment by laparoscopy or pelvioscopy. They report their experience with the pubo-vaginal percutaneous colposuspension assisted by pelvioscopy. Out of 22 patients they had a total correction of incontinence in 15 patients (68.12%) with an average follow-up of 18.6 months. They also report their first experience with the Retzius plasty of Manhes by laparoscopy (average follow-up 13 months, 3/4 patients treated are continent, 1/4 SUI with high stress). They conclude that laparoscopy and pelvioscopy treatments can be a valid alternative to tradizional surgery if performed on selected patients.

[Laparoscopic surgery of stress urinary incontinence in women]

The Authors carried out a literature review on stress urinary incontinence (SUI) treatment using laparoscopy or pelvioscopy. They report their experiences in using a pubo-vaginal percutaneous colposuspension assisted by pelvioscopy. Of 22 treated patients, there was a total correction of the incontinence in 15 patients. (68.12%) with a median follow-up of 18.6 months. They report also their first experience with the Retzius plasty of Manhes by laparoscopy (3/4 patients treated are continent, 1/4 has recurrent SUI during times of stress). They conclude that laparoscopy and pelvioscopy treatment can be valid alternatives to traditional surgery if made on selected patients.

Search for mutations in pancreatic sufficient cystic fibrosis Italian patients: detection of 90% of molecular defects and identification of three novel mutations

A cohort of 31 cystic fibrosis patients showing pancreatic sufficiency and bearing an unidentified mutation on at least one chromosome was analyzed through denaturing gradient gel electrophoresis of the whole coding region of the cystic fibrosis transmembrane conductance regulator gene, including intron-exon boundaries. Three new and 19 previously described mutations were detected. The combination of these with known mutations detected by other methods, allowed the characterization of mutations on 56/62 (90.3%) chromosomes. Among those identified, 17 can be considered responsible for pancreatic sufficiency, since they were found in patients carrying a severe mutation on the other chromosome. Among these presumed mild mutations, eight were detected more than once, R352Q being the most frequent in this sample (4.83%). Intragenic microsatellite analysis revealed that the six chromosomes still bearing unidentified mutations are associated with five different haplotypes. This may indicate that these chromosomes bear different mutations, rarely occurring among cystic fibrosis patients, further underlying the molecular heterogeneity of the genetic defects present in patients having pancreatic sufficiency.