[Percutaneous transhepatic biliary drainage. Complications and their treatment]

In the present series of 296 PTBDs in 281 patients, 103 complications of different degree developed (34.7%). Early complications directly connected to the procedure (32/296 = 10.8%) and late complications generally due to malfunctioning of the catheter or progression of the disease (71/296 = 23.9%) are analyzed. Caveats to prevent complications, therapeutic procedures to resolve them, as well as obtained results are reported. On the whole, major complications directly related to the procedure are present in a small percentage and the procedure appears well tolerated also in patients with poor general conditions.

Genetic conditions among Canadian Mennonites: evidence for a founder effect among the old colony (Chortitza) Mennonites

Distinctive disease patterns exist among Canadian Old Colony (Chortitza) Mennonites. This religious and genetic isolate is of 16th century Dutch/German ancestry. The group originated in the Netherlands, then settled in the Vistula delta area of western Prussia for 200 years. A small number of founding families later migrated to Chortitza, the "Old Colony", in the Ukraine in the late 18th/early 19th century, where they remained a distinct genetic isolate. This group has come to Canada over the past 100 years. The more conservative Canadian Mennonites of Chortitza descent practice strict endogamy, have a large family size and live predominantly in rural public health subdistricts in the four western provinces, and in southern Ontario. The world's largest reported familial aggregations of insulin-dependent diabetes mellitus, of autoimmune diseases and of Tourette syndrome were initially ascertained in a small northern Alberta public health subdistrict. Clusterings of malformations, inborn errors of metabolism, and other conditions were also found in the subdistrict, and in group descendents living in other provinces. A founder effect, or genetic drift, accounts for the familial aggregations of autosomal recessive and dominant conditions, some diseases of multifactorial determination, and other inherited conditions in Canadian kinships descending from this ancestral group. The medical literature on genetic conditions among Canadian Mennonites is reviewed and re-evaluated in the light of this information. There is biochemical, serologic, and molecular biologic evidence in favour of genetic homogeneity amongst patients with certain inherited conditions in this special population group. This genetic isolate offers potential for the study of the genetic epidemiology and molecular biology of inherited diseases. A computerized genealogic data base on about 1400 group members, as well as a cryopreserved lymphocyte/DNA bank on over 100 individuals with genetic conditions has been established in this special population group.

[Cholangitis and percutaneous biliary drainage]

The binomial PTBD-cholangitis often stands under different and sometimes even opposite relations. Among its indications the procedure lists, the treatment of cholangitis which, on the other hand, may be itself a complication of biliary drainage. The present work proposes a critical review of cholangitis-PTBD correlations, from an ordinary clinical-radiological point of view. Different pathogenetic hypothesis of cholangitis (inflammation, cholestasis, surgical manipulation) are discussed together with risk factors (impaired macrophagic-phagocytic system, immunosuppression, wide neoplastic liver involvement, multiple intrahepatic ductal obstructions, chronic liver diseases, aged patients, etc.). The authors also report about prevention and treatment of septic complications which must be carried out following technical and therapeutic strategies, such as chemoprophylaxis and focused antibiotic therapy according to bile culture samples, slow injection of small amounts of contrast medium, peripheral branches approach, gentle handling of catheters and guidewires, flushing with saline solutions and brushing of the catheter itself, and finally use of large gauge catheters in the presence of bile sludge.

[Radiologic examination in assessing the response to chemoradiotherapy of esophageal spinocellular carcinoma]

Squamous cell carcinoma represents more than 90% of esophageal cancers; its prognosis is still extremely severe. A treatment consisting in the combined use of preoperative chemotherapy and radiotherapy is now in course of experimentation at Istituto Nazionale Tumori, Milan. Over a period of 28 months (July 1985 to October 1987), 21 patients with 22 lesions (stage III) underwent a double contrast study of the esophagus, both before and after therapy. The radiological evaluation of the lesions after treatment was compared with the pathological diagnosis. Radiological diagnosis has been confirmed in 86.3% of cases (19/22 lesions) as far as mucosal detailing was concerned. On the contrary, radiological evaluation has proven unreliable as far as submucosal layers were concerned. No radiological false positives have been observed.

[Postoperative radiologic follow-up of rectocolonic anastomoses. The visualization of fistulous passages after evacuation]

The early postoperative study of colo-rectal anastomoses is a common diagnostic procedure with symptomatic patients which is extended to asymptomatic patients by some authors. Eighty-eight anastomotic fistulas were early diagnosed after intervention in 316 patients who underwent a water-soluble contrast enema. Four out of these fistulas (4.5%) could not be demonstrated at complete filling on X-ray, but were only opacified on radiographs taken after the spontaneous evacuation of contrast medium. The increase in endoluminal pressure due to the evacuation and the lack of balloon catheter probably play a role in allowing these fistulas to be visualized.

Inherited diseases in North American Mennonites: focus on Old Colony (Chortitza) Mennonites

The patterns of migration and the genetic disorders occurring among North American Mennonites are reviewed, and inherited conditions recently recognized in a religious and genetic isolate, the Old Colony (Chortitza) Mennonites, are described. Old Colony Mennonites are of Dutch/German origin and descend from approximately 400 founding families who settled in the Old Colony, Chortitza (the Ukraine, USSR) in the late 1700s, and then migrated to Canada and Central and South America in the past century. We investigated over 6 generations of a Canadian Old Colony kindred in which there was extensive intermarriage, and in whom 28 individuals developed diabetes mellitus. Insulin-dependent diabetes mellitus (IDDM) occurred in 14 affected individuals in 10 closely related sibships; the 11 living IDDM patients were all concordant for the immunogenetic marker HLA-DR4. Fourteen close relatives had other disorders of carbohydrate metabolism, including gestational diabetes and non-insulin-dependent diabetes mellitus. Other close relatives had autoimmune diseases, including rheumatoid arthritis, hyper- and hypothyroidism, multiple sclerosis, and red cell aplasia. Other inherited diseases, including Alport syndrome, congenital defects, and inborn errors of metabolism were also found in the kindred. In the almost exclusively (99%) Old Colony Mennonite public health district in which the kindred was ascertained, there were multiple cases of Tourette syndrome, of malformations (including congenital heart defects and cleft lip +/- palate), and familial clusters of inborn errors of metabolism. We report this Old Colony (Chortitza) Mennonite isolate because 1) there are large familial aggregations of tissue-specific autoimmune diseases, malformations, inborn errors of metabolism, and of some other conditions whose genetic basis is still unknown; 2) there are multiple cases of rare genetic conditions, 3) we have established a computerized genealogic data base on over 1,000 kindred members as well as a cryopreserved lymphocyte/DNA bank on over 100 closely related individuals with various genetic conditions; and 4) this religious isolate, which extends across North, Central, and South America, offers an excellent opportunity for studying the epidemiology and molecular genetics of both common and rare inherited diseases.

Double contrast barium enema combined with non-invasive imaging in peritoneal mesothelioma

Mesotheliomas are rare tumors arising from serosal linings of the major serous cavities. Five patients with peritoneal mesothelioma underwent a double contrast barium enema (DCBE) and ultrasonography (US) (2 patients), computed tomography (CT) (3 patients) and/or magnetic resonance imaging (MRI) (3 patients). The diagnosis was confirmed at laparotomy. The radiologic pattern at DCBE is unspecific and consists of compression and dislocation of bowel loops by extrinsic masses. Mesenteric retraction and segmental stenosis may be present. In one patient DCBE was normal. US, CT and MRI findings are also unspecific but when combined with information obtained from DCBE the site and abdominal extension of the disease are well defined.

[Gastrointestinal interventional radiology. Technics and preliminary results]

Gastrointestinal interventional radiology allows the positioning of feeding tubes in difficult situations, as well as the balloon dilatation of stenoses and the transintestinal drainage of fistulas and collections, with some advantages over endoscopic and surgical procedures. In the present series feeding tubes were positioned in 26 patients, both to get over the strictures in the upper gastrointestinal tract and to exclude fistulous tracts or anastomotic leaks from alimentary transit. Balloon dilatation was performed in 10 patients with stenoses of different aetiologies, at different levels of the gastrointestinal tract: in all cases the clinical symptoms diminished. All the 7 non-neoplastic stenoses were successfully treated (follow-up 6-27 months). The draining of abscesses through the enteric fistulous tract did allow the reduction/resolution of all collections in a short time. These procedures are simple and safe, and help to reduce the interval between diagnosis and therapy. Their failure does not prevent the use of other therapeutic procedures.

[Diagnostic imaging and interventional radiology in abdominal abscess formations]

Abdominal abscesses as a complication of laparotomic surgery have a high mortality rate. The authors reviewed the diagnostic and therapeutic procedures of 36 patients who developed intra-abdominal abscesses after surgical treatment for abdominal neoplasias. The first-step diagnostic procedures (plain film of the abdomen and chest, CT and US) showed a sensibility of 78%. In 25/36 patients (69.5%) two interventional radiology procedures were performed: fine needle aspiration and catheter drainage of the abscess. In 16% of patients fine needle aspiration led to a complete evacuation of the abscess cavity and guaranteed the recovery. In 84% of cases a drainage catheter was positioned into the cavity and left indwelling. This case review is aimed at stressing how plain film of the abdomen is still a diagnostic procedure with high sensibility and specificity for this pathology, even though it is currently considered as a second-choice diagnostic step--US and CT being assessed as the methodologies of choice. The latter techniques can both provide a more accurate imaging when interventional radiology procedures are to be performed.

Unusual clustering of diseases in a Canadian Old Colony (Chortitza) Mennonite kindred and community

We investigated a large Old Colony (Chortitza) Mennonite kindred with branches across Canada. Six generations of the kindred were traced. There was intermarriage among numerous family members. Insulin-dependent diabetes mellitus (IDDM) was identified in 10 members; all 7 living patients were found to carry the immunogenetic marker HLA-DR4. Nine other close relatives had disorders of carbohydrate metabolism, including gestational diabetes mellitus and non-insulin-dependent diabetes mellitus progressing to insulin use. Ten other relatives had autoimmune diseases, including rheumatoid arthritis, hyperthyroidism, hypothyroidism and multiple sclerosis. Cases of Alport's syndrome, congenital malformations, inborn errors of metabolism and unusual malignant diseases were also found in the kindred. In the small Alberta community in which the kindred was ascertained there were people of Old Colony Mennonite descent with genetic conditions such as Gilles de la Tourette's syndrome and congenital malformations, including congenital heart disease. This kindred represents the largest reported familial aggregation of IDDM. This disease and other disorders of carbohydrate metabolism occur in the context of a strong familial predisposition to autoimmune disease. Study of this family may permit empiric testing of proposed models of inheritance of diseases of complex origin such as IDDM. We report this Old Colony (Chortitza) Mennonite community because it is one of the settlements populated by this religious and genetic isolate, which extends across Canada and Central and South America and affords opportunities for the study of both common and rare inherited diseases.

Sensitivity of Hemoccult test for large bowel cancer in high-risk subjects

From 1979 to 1982, 1233 symptom-free subjects at high risk for colon cancer because of family history and/or personal history of bowel neoplasia (cancer or adenomatous polyp) were examined with a guaiac test (Hemoccult II) for occult blood in stools. The test was positive (H+) in 98 subjects (7.9%). Endoscopy was subsequently performed on 86% of the H+ and on 64% of the H- subjects. Of 20 in invasive cancers found, 15 had been H+ [75.0%; 95% confidence interval (CI), 54.3-91.0%]. Of 96 patients with adenoma(s), 23 were H+ (24%; 95% CI, 16.0-33.0%). However, the sensitivity for adenomas was higher in patients with multiple adenomas or with a single adenoma measuring 2 cm or more in its largest diameter (37.5%; 95% CI, 21.8-54.7%). Of 699 subjects free of neoplastic lesions at endoscopy, 47 had been H+, ie, false positive (6.7%; 95% CI, 5.0-8.7%). Adjusting for differential compliance of H+ and H- subjects to endoscopy, a corrected estimate for sensitivity would be 69% for cancer and 19% for adenomas; the corrected estimate for the false-positive rate would be 5%.

The occurrence of cholangitis after percutaneous biliary drainage: evaluation of some risk factors

Sepsis of the biliary tract is often reported after percutaneous transhepatic biliary drainage (PTBD) and is considered a life-threatening condition. The authors studied 39 patients with biliary stenosis (35 with neoplastic stricture and four with benign disease) with the purpose of identifying some factors possibly associated with a higher risk of cholangitis. None of the patients complained of biliary sepsis at the first clinical examination. Several factors were taken into account and were statistically tested according to Miettinen rate ratios to differentiate patients in whom cholangitis would consequently develop: nature, site and extent of basic disease, type and functioning of PTBD, skin contamination at puncture site of PTBD, and bile contamination at PTBD and at follow-up. The presence of bacteria in the first bile (31.5%) was not related to a higher risk. All subjects showed bile contamination after PTBD, but cholangitis developed in only 15 patients, and it was always supported by enteric microorganisms. When we compared patients with cholangitis and subjects without infection, it was possible to demonstrate a statistically significant association of cholangitis and the following: nature of the stricture, presence of multiple intrahepatic biliary obstruction, neoplastic invasion or compression on the duodenum, and presence of Staphylococcus aureus on the skin at puncture site at drainage.

[Proposal for a radiological classification of multiple adenomatosis of the colon]

The double contrast enemas of 47 patients with multiple adenomatosis of the colon and rectum were analyzed. According to the density and the distribution of polyps on the mucosal surface, the radiological patterns were classified into three different groups: sporadic, dense and confluent adenomas. Radiographic patterns of each patient were related to the clinical and pathological data collected during the diagnosis and the follow-up. The clinical and pathological features and the evolution of the disease appear to be different in each group of patients (identified by the radiological classification). The occurrence of cancer at the time of the diagnosis of polyposis is closely correlated either to the number of polyps or to their size and the age of patients. The occurrence of metachronous cancer is correlated only to the number of polyps, not to their size, nor to the surgical treatment of the polyposis. If these data are confirmed on a wider number of patients, the role of radiological survey might become a more prominent one, not only in diagnosing, but also in therapy planning, as well as in the prognostic evaluation of multiple adenomatosis of colon.

A New Set for Transhepatic Insertion of Large Caliber Catheters for Biliary Drainage: Technical and Clinical Report

An original set for percutaneous insertion of large caliber (12-16 French) biliary drainages is described. The results obtained in the 70 patients submitted to biliary drainage with late complications due to malfunction of the standard 8.3 or 10 F catheters show the advantage of the set described. The correction of unsatisfactory levels of bilirubinemia was obtained in 100% of cases, the resolution of recurrent cholangitis in 84.2% and of bile leakage on the skin in 46.7%. The large caliber and the large side holes of the catheter, together with its length and its easy handling, allow resolution of many different problems of insufficient drainage present in patients with neoplastic involvement of bile ducts.

Structural and evolutionary implications of the packaging of DNA for differentiation and proliferation in the lymphocyte

During the differentiation of the clonally distributed lymphocytes of mouse and man into mature resting B and T cells, their DNA becomes tightly packed into dense heterochromatin masses and exhibits very little transcriptional activity; it also becomes extensively nicked, containing some 3000-4000 single-strand breaks per diploid genome. The nuclear matrix is sparse and poorly organized and there are but trace amounts of the matrix-linked enzyme DNA topoisomerase II; the nucleus of these small cells is surrounded by a thin rim of cytoplasm. The resting cell can thus be considered (by analogy to a sperm cell) as a vector for transporting tightly packed and relatively inert genetic information to all parts of the body. When the lymphocyte is stimulated to enter a proliferative cycle by binding of appropriately presented antigen or mitogen to relevant membrane receptors, the cell enlarges, due to increased synthesis of protein; the dense heterochromatin is pulled out into very small clumps, as a result of an enormous growth in size as well as complexity of the nuclear matrix, and a great increase in transcriptional activity occurs. We have identified four nuclear matrix antigens that are very widely conserved in the evolution of eucaryotes and that occupy distinctive domains in interphase nuclei. Of particular interest is antigen P1, detected in organisms ranging from algae to mammals. By virtue of its location at the interface between nuclear envelope and chromatin, we propose that it plays a major and evolutionarily conserved role in chromatin organization and orientation in all eucaryotic cell types.(ABSTRACT TRUNCATED AT 250 WORDS)

[Structuring and use in clinical research of a software for the diagnosis and features of polypoid lesions of the colorectum]

Double contrast enema and endoscopy are very important in the diagnosis of adenomas and early cancer of the colon and rectum. These exams can not only detect the presence, but also suggest the histologic diagnosis, of polypoid lesions of the colon. An Olivetti M24 Personal Computer was used to create a software to study the results obtained by double contrast enema, and to compare them with endoscopy and pathology. The data base is formed by 7 files: one anagraphic, 3 collecting the characteristics of the diagnosis--namely the radiologic, the endoscopic and the pathologic one-- and 3 multiple files featuring each lesion, as defined by the three diagnostic techniques. The software allows to evaluate the different lesions that can be detected by the three techniques in the same patient and to compare the diagnosis of presence to the morphologic features of each lesion. False negatives and false positives of each technique are easily recognized. It is also possible to characterize the single morphologic feature leading the radiologist and/or the endoscopist to express an opinion about the histologic diagnosis of each lesion and to compare them with pathological features. The first experience in clinical use of the software, in the analysis of the characters of 336 lesions in 218 patients, is described.

Increase in intracellular Na+: transmembrane signal for rejoining of DNA strand breaks in proliferating lymphocytes

Two early events in the mitogen-induced entry of murine splenocytes into proliferation are (a) a rapid rise in influx of Na+, causing its total internal concentration to increase by 42 +/- 7% within 2 h of culture with concanavalin A (Con A), and (b) rejoining of some 3000 DNA strand breaks per diploid genome within the same period. Con A did not induce rejoining in low Na+ (less than 9 mM) medium, but the process began directly when Na+ was added, at its usual concentration, to the growth medium. Incubation of cells with ouabain, an inhibitor of the Na+K+-ATPase, or monensin, a Na+ ionophore, caused an increase in the internal Na+ concentration in normal, but not in low, Na+ medium. In the former (but not in the latter) medium, both ouabain and monensin caused rejoining of the DNA strand breaks to occur in resting lymphocytes, i.e., in the absence of mitogen. Stimulation of splenocytes with Con A also resulted in a rapid but transient increase in the level of intracellular free Ca2+. This effect was also observed in the absence of extracellular Na+; however, deprivation of extracellular Ca2+ completely abolished this effect. Moreover, the intracellular free Ca2+ level was significantly higher in cells suspended in Na+-free buffer or medium. Since the Con A-induced rejoining of DNA strand breaks occurred in the absence of extracellular Ca2+ and removal of extracellular Na+ had no inhibitory effect on the Con A-induced increase in the level of intracellular free Ca2+, the Con A-stimulated repair could not have been mediated by the initial increase in Ca2+ influx. The early mitogen-induced increase in the internal Na+ concentration is a necessary and sufficient signal for the rejoining of breaks, an event that must occur before the proliferating lymphocytes can replicate their DNA.

Esophageal carcinoma. Radiologic appearance of minimal lesions

Twelve minimal lesions were found over a period of 18 months at the Istituto Nazionale Tumori of Milan at the end of the radiologic, endoscopic and histologic procedures. Eleven lesions were radiologically detected, and a radiologic diagnosis of malignancy was perspectively made in 10 of the identified lesions. The radiologic aspects of minimal lesions are described. Double contrast study of the esophagus allows excellent mucosal detail and good reproduction of lesions. Simplicity and minimal discomfort for the patient justify it as a first diagnostic step for detection of neoplastic pathology.

Sodium ion influx in proliferating lymphocytes: an early component of the mitogenic signal

Stimulation of pig peripheral blood lymphocytes with concanavalin A (Con A) provoked a rapid increase (two- to threefold) in the rate of ouabain-inhibitable K+ uptake observable within 3-10 min of stimulation with mitogen. At least two phases can be distinguished in the activation of the Na+/K+ pump: the early phase (till 3 h) is characterized by an unaltered number of ouabain binding sites and the later phase (noted at 5 h) by an increased number of such sites. Both K+ efflux and influx increased to the same extent, thereby maintaining [K+]i at the same level as in resting cells (120 mM). Within 3 min of addition of mitogen, the rates of total and amiloride-inhibitable Na+ uptake went up two- and fourfold, respectively, thus resulting in rapid increase in [Na+]i from 20 to about 50 mM. Activation of the Na+/K+ pump was not observed when the cells were stimulated with Con A in low Na+ medium (9 mM), nor did the usual rise in [Na+]i occur. When monensin (30 microM), a Na+/H+ ionophore, was added to resting cells, an increase in both [Na+]i and active K+ uptake occurred in normal medium but not when cells were suspended in low Na+ isotonic buffer. Amiloride (500 microM), on the other hand, prevented both the Con A-induced increase in [Na+]i and the activation of the Na+/K+ pump. Despite complete inhibition of the Na+,K+-ATPase in the presence of ouabain (1 mM), Con A activated the amiloride-inhibitable Na+ uptake in the usual way. In mouse splenocytes stimulated with Con A, there was also a parallel rise in both [Na+]i and active K+ uptake but this took considerably longer to occur than was the case in pig peripheral blood lymphocytes. Increase in both ionic fluxes, the former passive and the latter active, is essential to the entry and maintenance of the cells in proliferative cycle.

Regulation of the number of Na+,K+-pump sites after mitogenic activation of lymphocytes

The early activation of Na+,K+-ATPase-mediated ion fluxes after concanavalin A (ConA) stimulation of pig lymphocytes is caused by an increase in intracellular Na+ concentration. A second mechanism of regulation of Na+,K+-ATPase activity becomes apparent between 3 and 5 h after mitogenic stimulation, but prior to onset of increase in cell volume; this consists of an increase (about 75%) in the number of ouabain-binding sites (from 35 X 10(3) +/- 12 X 10(3)/cell in resting to 60 X 10(3) +/- 27 X 10(3)/cell in activated lymphocytes). The increase in ouabain binding was attributed to an increase in the number of active Na+,K+-ATPase molecules, based on the following evidence: there was an increase in the Vmax of ouabain binding, without variation in the Km; the increase in ouabain binding was accompanied by a proportional increase in K+ influx, when the assay was performed in the presence of the Na+ ionophore monesin, which was used to eliminate the difference in intracellular Na+ concentration between resting and activated cells; there was proportionality between ouabain-inhibitable ATPase activity in permeabilized cells and the number of ouabain-binding sites in resting and activated lymphocytes. The ConA-induced increase in ouabain-binding sites was influenced neither by amiloride nor by incubation in low Na+ medium, under conditions which prevented both increase in intracellular Na+ concentration and K+ influx. Increase in intracellular Na+ concentration was ineffective in altering the number of active pump molecules in resting cells. During incubation with ConA, the presence of ouabain did not affect the increase in ouabain-binding sites; thus, regulation of the number of pump sites is independent of the regulation of their activity. The ConA-induced increase in number of ouabain-binding sites did not require protein synthesis; indeed, cycloheximide, anisomycin, and puromycin, under conditions in which they inhibited protein synthesis by by 95%, induced the increase to approximately the same extent as did ConA. This suggests the presence in resting lymphocytes of a rapidly turning over protein that either prevents the ATPase subunits from assembling or from integrating into the membrane.