Cholecystectomy in cirrhotic patients: pitfalls and reasonable recommendations

Cholecystectomy in cirrhotic patients remains a high risk procedure. The recent literature was reviewed in the objective to elaborate (evidence-based) recommendations for therapeutic decision. In patients with Child Pugh A or B cirrhosis, the laparoscopic approach should be preferred as it is associated with reduced morbidity and mortality as compared with open surgery (level B). In patients with decompensated Child Pugh C cirrhosis, the scarcity of literature data renders much more hazardous the definition of robust recommendations. In these patients, two options have to be considered beyond early laparoscopic cholecystectomy: first, a delayed surgery, in order to improve the preoperative patient's general condition and namely the coagulation, and second, a percutaneous drainage in very severe cases (level C).

Five years of Telemedicine in Cystic Fibrosis Disease

AIMS

We studied the effect of Telehomecare (THC) in a group of Cystic Fibrosis (CF) patients, with the aim to early recognize the relapses of pulmonary infections. Data obtained with Vivisol (OXYTEL) instrumentation were collected from 2001 to 2005.

MATERIALS AND METHODS

The study has involved 17 patients (11 f, 6 m) affected by CF, treated with THC, in addition to the usual therapeutic protocol, for an average period of 29.6 months +/- 13.5. The mean age for THC enrollment was 15.74 years +/- 5.8. As controls, the study has involved the same patients during the 12 months prior to THC start-up and 28 patients affected by CF treated at our Unit (13 f, 15 m; average age 14.77 +/- 5.22).

RESULTS

The results show a statistically significant decrease of outpatient accesses and increase of therapy cycles, and a trend of higher stability of the respiratory function, in THC treated subjects compared to controls.

CONCLUSIONS

Our study suggests that THC programs may not be optimally accepted by CF patients, and that its use seems to increase in general the rate of access to health care without demonstrating any clear effect of pulmonary function.

Exhaled 8-isoprostane and prostaglandin E(2) in patients with stable and unstable cystic fibrosis

We measured 8-isoprostane, a biomarker of oxidative stress, and prostaglandin (PG) E(2) in exhaled breath condensate in 36 stable and 14 unstable cystic fibrosis (CF) patients, and in 15 healthy age-matched controls. We studied the relationships of these eicosanoids with clinical, radiological, and systemic inflammatory parameters. Compared with controls [15.5 (11.5-17.0) pg/ml] exhaled 8-isoprostane was increased in stable CF patients [30.5 (25.3-36.0) pg/ml, P<0.001]. Unstable CF patients had higher exhaled 8-isoprostane levels [47.5 (44.0-50.0) pg/ml, P<0.001] than stable CF patients. Unlike PGE(2), exhaled 8-isoprostane was negatively correlated with FEV(1) (r=-0.67; P<0.0001; r=-0.63; P<0.02) and Shwachman score (r=-0.43, P=0.012; r=-0.58, P=0.031) and positively correlated with Chrispin-Norman score (r=0.51, P<0.002; r=0.56, P=0.039) in stable and unstable CF patients, respectively. No correlation was observed with C-reactive protein. Compared with controls [41.0 (29.0-50.0) pg/ml], exhaled PGE(2) was also elevated in stable [72.0 (64.3-81.8) pg/ml, P<0.001) and, to a greater extent, in unstable CF patients [83.0 (74.3-91.3) pg/ml, P<0.001). In patients with CF, exhaled 8-isoprostane and PGE(2) could be a useful marker of disease severity.

Peripheral cholangiocarcinoma with endoluminal tumor thrombus in main bile duct mimicking a Klatskin tumor

BACKGROUND

Peripheral cholangiocarcinoma with endobiliary thrombus could be confused with Klatskin tumor, eventually leading to inappropriate therapeutic decision.

CASE REPORT

A 56-year-old man presented with an obstructive jaundice. Preoperative magnetic resonance imaging (MRI) showed a segment 7 liver tumor associated with a complete stop at the biliary bifurcation compatible with a Klatskin tumor. Surgical exploration revealed that biliary obstruction was caused by endobiliary tumor-related thrombus. A right hepatectomy was performed, allowing complete endobiliary thrombus extraction. At pathology, a T2N0 intrahepatic cholangiocarcinoma was demonstrated. No adjuvant chemotherapy was given and currently, 22 months after surgery, the patient remains disease free.

DISCUSSION

This case underlines the fact that intraductal growth of peripheral cholangiocarcinoma does not represent a contraindication for surgical treatment. MRI could be useful to differentiate such presentation of peripheral cholangiocracinoma from Klatskin tumor and orientate the surgical treatment.

Liver transplantation for acute liver failure in adults

Acute liver failure is a challenging clinical condition, associated with high morbidity and mortality. In well-selected patients, LT (LT) is the only therapeutic which has been demonstrated to improve patient survival. Clichy and King's College criteria are the two mains scoring systems used to select the patients for liver transplantation. Both models achieve high specificity but remain associated with limited negative predictive value. Several other predictive factors have been evaluated, but none of them have been strongly validated so far. Globally, whole LT appears as the procedure of choice for patients within Clichy and/or King's College criteria. Due to the severity of the disease and its multisystemic consequences, the results of LT for fulminant liver failure remain inferior to those obtained in elective indications. Accord-ing to local conditions, namely expected waiting time before urgent transplantation and surgical expertise, living donor transplantation and auxiliary transplantations appear as valuable alternatives. These techniques have the respective potential advantages to limit the waiting period before transplantation and to avoid the need for lifelong immunosuppression when native liver recovers, but overall results remain inferior to those obtained with whole LT.

A pilot trial on safety and efficacy of erythrocyte-mediated steroid treatment in CF patients

BACKGROUND

Chronic neutrophil inflammation of the respiratory tract tissues plays a key role in the pathogenesis and in prognosis of cystic fibrosis (CF). It is evident that an anti-inflammatory therapy represents an important step in the treatment of CF patients. Corticosteroids and ibuprofen have been proven to slow down the impairment of the pulmonary function in CF patients but their use is limited by the frequency of adverse events. A novel strategy for delivering low doses of steroids for long periods through the infusion of autologous erythrocytes loaded with dexamethasone has been recently set up. A recent study suggested the feasibility of therapy with low doses of corticosteroids delivered through engineered erythrocytes in CF patients. This study presents a further analysis of safety and efficacy of this therapy.

METHODS

The treatment group was not randomised and the assignment was based on the patient's consent. Patients entered the study if they had a forced expiratory volume in 1 second (FEV1) <70%, puberty development completed, pancreatic insufficiency, and chronic pulmonary infection requiring frequent cycles of intravenous antibiotic therapy. Patients were excluded if they underwent systemic corticosteriod therapy in the three months preceding the experimental treatment or were on therapy with non-steroidal anti inflammatory drugs (NASDs), or if they had liver CF disease, allergic bronchopulmonary aspergillosis, or positive tuberculin test. Controls were patients who followed a standard treatment, who fulfilled the enrollment criteria, and who were matched to the experimental group by gender, age, and severity of the disease.

RESULTS

Nine patients in the experimental group received the treatment once a month for a period of 24 month. Patients did not develop diabetes, cataract, or hypertension, or other typical side effects of steroid treatment during the follow up period. There was a constant improvement of FEV1 in patients undergoing the experimental treatment compared to a gradual decrease of the same parameter in the standard therapy group (P = 0.04). The average of clinic and radiological indexes did not vary. The number of infective relapses that have required antibiotic intravenous therapy was not different in the two groups, although the average of these episodes was slightly higher in the experimental therapy group.

CONCLUSION

Intraerythrocyte corticosteroid treatment may stabilize the respiratory function in CF patients but is often considered too invasive by patients. The results obtained by our study may help planning an experimental, controlled, randomised study. A sample size of 150 patients per group would be sufficient for demonstrating such a difference with a 95% confidence interval and a power of 90%.

Clinical effects of early treatment with insulin glargine in patients with cystic fibrosis and impaired glucose tolerance

Diabetes mellitus is an increasing complication of cystic fibrosis (CF), as a result of the improved life expectancy. There is clear association between diabetes and increased morbidity and mortality. Lung function and clinical status deteriorate up to 2-4 yr before the diagnosis of CF-related diabetes (CFRD). The aim of our study was to evaluate the effects, on glucose homeostasis and clinical status, of the early treatment with insulin glargine in CF patients with impaired glucose tolerance (IGT). We selected six subjects with IGT diagnosed at oral glucose tolerance test (OGTT). Median age was 18.12 yr (range 9.2-27.8). Insulin glargine was administered at the median dosage of 0.3 U/kg/day (range 0.2-0.5). After the initial adjustment of the dosage, no patient manifested hypoglycemia during treatment. Median glycosylated hemoglobin (HbA1c) did not show any significant variation during treatment: it was 5.9% at baseline (range 5.5-6.2) and 6.1% (range 5.0-6.7) at the end of follow-up (p=0.496). Median body mass index (BMI) z-score significantly increased during treatment, from -0.95 (range -3.2-+0.6) at baseline to -0.5. (range -3.0-+0.9) at the end of follow-up (p=0.026). Lung function, measured by median forced expiratory volume in the first second (FEV1%), showed a mild but significant improvement during insulin treatment. It was 72.7% at baseline (range 41.5-98.4) and 76.7% (range 42.0-106.8) at the end of follow-up (p=0.027). No significant variation was found between the number of hospitalizations for clinical exacerbation (no./patient/yr) in the last 2 yr before treatment and during follow-up. Median number at baseline was 1.95/patient/yr (range 1-3) and 2.0/patient/yr (range 1-3) at follow-up (p=0.715). Our data seem to indicate that early insulin therapy can be safe, no patient manifested hypoglycemia or other adverse effects during treatment. Insulin is an anabolic hormone implicated in both lipid and protein metabolism. The appearance of IGT out of infections can indicate an early insulin deficiency, with a potential impact on the nutritional and clinical status of the patient, even before the appearance of overt diabetes. Larger controlled trials are necessary to verify if early insulin therapy is able to reduce the deterioration of nutritional status and lung function associated with the onset of IGT.

[Intra-hepatic cholangiocarcinoma]

Intra-hepatic cholangiocarcinoma (IHCC) is a rare tumor which arises from the epithelial cells of the intra-hepatic bile ducts; it may develop in a healthy liver and bile ducts or in bile ducts with malignant predisposition (Caroli's syndrome, primary sclerosing cholangitis). It has the worst prognosis of any tumor arising in the liver. Unlike hepatocellular carcinoma, no predisposing factors or high-risk populations have been demonstrated for cholangiocarcinoma other than intraphepatic choledocholithiasis such as is seen in east Asian populations. The most common clinical sign is a palpable tumor mass emphasizing that the tumor is usually detected at an advanced stage. CT scanning yields much clinical information but ultrasound-guided needle biopsy is necessary for diagnosis. Aggressive surgical resection is the only treatment modality which has afforded even slight prolongation of survival; hepatic resection must be large with uninvolved resection margins. When an IHCC is deemed resectable (localized tumor without hepatic metastases or intrahepatic or extrahepatic lymph node spread), pre-operative tumor embolization may be useful; when jaundice is present, percutaneous drainage of the dilated biliary system of the liver to be spared may also be necessary. Neither adjuvant nor neo-adjuvant chemotherapy or radiotherapy have shown proof of efficacity. Cholangiocarcinoma complicates sclerosing cholangitis in 10-15% of cases and is very difficult to diagnose. IHCC may also develop in Caroli's syndrome, where it is commonly found incidentally on pathologic examination of a resection specimen after surgery for a complication of the disease.

Usefulness of a program of hospital-supervised physical training in patients with cystic fibrosis

Exercise is an important part of normal childhood, but the ability to exercise may be impaired in chronic lung diseases such as cystic fibrosis (CF). Improving exercise performance by training is very attractive. The aim of the present study was the evaluation of the effects of a physical aerobic training program, performed in the Children's Hospital and Research Institute "Bambino Gesù" (Rome, Italy) in outpatient CF children, supervised by a physician. Twelve patients (mean forced expiratory flow in 1 sec (FEV1), 71%), age range 12-24 years (16.7 +/- 4.4 years), were enrolled. They performed a maximal exercise stress test on the treadmill (modified Bruce protocol) with breath-by-breath determination of oxygen consumption (VO2) to maximum at end-exercise; we measured time of exercise (TE), maximal heart rate (Hrmax) in beats per minute (bpm), and maximal systolic blood pressure (SBPm) in mmHg. The program consisted of 12 weeks of training twice a week. Each training session consisted of walking or running on the treadmill for 30 min at the speed that allowed the child to attain 60% of the maximal heart rate obtained during a baseline stress test for 4 weeks, 70% in the following 4 weeks, and 80% in the last 4 weeks, under strict medical supervision. HR was continously monitored. There was no change in FEV1 and forced vital capacity after the treatment period. Hrmax and SBPm also remained the same (P = 0.37 and P = 0.25, respectively). There was a significant increase in TE (P < 0.002), VO2, VO2/kg, and pulmonary ventilation (VE) (P < 0.0001, P < 0.001, and P < 0.001, respectively). This pilot study showed that a simple training program improves short-term cardiopulmonary fitness in children with CF. Further studies with a larger sample and for a more prolonged time are necessary to assess if sport can have a long-term effect on lung function or survival in CF patients.

Molecular analysis using DHPLC of cystic fibrosis: increase of the mutation detection rate among the affected population in Central Italy

BACKGROUND

Cystic fibrosis (CF) is a multisystem disorder characterised by mutations of the CFTR gene, which encodes for an important component in the coordination of electrolyte movement across of epithelial cell membranes. Symptoms are pulmonary disease, pancreatic exocrine insufficiency, male infertility and elevated sweat concentrations. The CFTR gene has numerous mutations (>1000) and functionally important polymorphisms (>200). Early identification is important to provide appropriate therapeutic interventions, prognostic and genetic counselling and to ensure access to specialised medical services. However, molecular diagnosis by direct mutation screening has proved difficult in certain ethnic groups due to allelic heterogeneity and variable frequency of causative mutations.

METHODS

We applied a gene scanning approach using DHPLC system for analysing specifically all CFTR exons and characterise sequence variations in a subgroup of CF Italian patients from the Lazio region (Central Italy) characterised by an extensive allelic heterogeneity.

RESULTS

We have identified a total of 36 different mutations representing 88% of the CF chromosomes. Among these are two novel CFTR mutations, including one missense (H199R) and one microdeletion (4167delCTAAGCC).

CONCLUSION

Using this approach, we were able to increase our standard power rate of mutation detection of about 11% (77% vs. 88%).

Segregation analysis in cystic fibrosis at-risk family demonstrates that the M348K CFTR mutation is a rare innocuous polymorphism

OBJECTIVE

Cystic fibrosis (CF; OMIM# 219700) is caused by mutation in the CF transmembrane regulator (CFTR) gene. We investigate whether the (paternal) M348K mutation is a benign polymorphism or a disease-causing mutation in a patient clinically affected with CF, with the second (maternal) CFTR allele identified as N1303K.

METHODS

The patient and his father were studied for the presence of mutations in the CFTR gene using the DHPLC system to analyze all CFTR exons. Amplicons showing an abnormal elution profile were sequenced.

RESULTS

The CFTR gene from the healthy father has two mutations, M348K and G1244E. The affected son inherited only the G1244E paternal mutation from his father, and hence the two paternal mutations are trans and do not occur in the same CFTR gene. The patient's genotype is G1244E(paternal)/N1303K(maternal). This information was used to study an ongoing pregnancy of the couple, where the fetus inherited the same genotype as the affected proband and therefore is affected.

CONCLUSION

M348K in the CFTR gene is not a mutation causing CF, but a rare polymorphism. These data are important for genetic counseling and prenatal diagnosis and illustrate the importance of full sequence data when studying rare mutations.

Circadian rhythm of hunger sensation in patients affected by cystic fibrosis

OBJECTIVE

The aim of this study was to investigate the daily pattern of hunger sensation (HS) in patients affected by a non-advanced form of cystic fibrosis (CF) in order to detect how the orectic stimulus (OS) behaves in fibrocystic patients (FP) who are obliged to eat frequently because of their pancreatic exocrine insufficiency.

MATERIALS AND METHODS

The study involved 27 out-patients (13 males and 14 females; mean age 18 +/- 4 years; mean BMI 18.77 +/- 2.17 kg/m2) with a non-advanced form of CF, and 19 clinically healthy subjects (CHS, 9 males and 10 females; mean age 24 +/- 2 years; mean BMI 21.00 +/- 1.70 kg/m2). The FP were used to eating frequent small meals between the three main meals of breakfast, lunch and dinner. All of the participants were asked to compile an "orexigram"' which was chrono-biometrically analysed by means of: 1) conventional statistical methods; 2) rhythmometric analysis of circadian rhythm (CR); and 3) spectral analysis of the harmonic structure substantiating the within-day variability of HS.

RESULTS

HS in FP had 1) a significantly increased daily mean level; 2) a well-established CR, with a significantly increased oscillatory mesor and amplitude; and 3) a modified orexigram power spectrum affecting the ultradian harmonic components.

CONCLUSIONS

Our results suggest that the orectic perception of CF patients is characterised by "daily hyperorexia", with the maintenance of HS CR. This condition seems to be a structured abnormality insofar as there are visible changes in the orexigram spectral resolution, particular in the ultradian harmonic components whose oscillatory frequency is responsible for the diurnal pattern of HS. The hyperorexia of the investigated FP indicates that their frequent small meals are not sufficient to satisfy their HS, which may cause a vicious circle leading to progressively disrupted mealtime behaviour.

The impact of cystic fibrosis on neonatal intestinal obstruction: the need for prenatal/neonatal screening

To determine the incidence of cystic fibrosis (CF) in neonates with intestinal obstruction (NIO) secondary to meconium ileus (MI), jejunoileal atresia (JA), meconium plug syndrome (MPS), volvulus (V), and meconium peritonitis (MP) and analyze the correlation of ultrasonographic (US) signs with CF in NIO with a prenatal diagnosis of intestinal anomaly, a prospective analysis of different types of NIO from 1990 to 1998 was undertaken. Immunoreactive trypsin measurement, genetic studies, and sweat tests were performed to confirm or rule out CF. Cases with prenatal diagnosis were analyzed for gestational age, dilated bowel, ascites, hyperechoic bowel, and calcifications. Of 80 neonates, 19 (24%) had CF: 2/33 (6%) JA, 6/14 (43%) MPS, 1/14 (7.1%) MP, 10/10 (100%) MI, and 0/9 V. Thirty (37.5%) had a prenatal diagnosis of an intestinal anomaly. The overall incidence of CF in NIO with a prenatal diagnosis of intestinal anomaly was 4/30 (13%), or 333 times the estimated risk of CF in the general population. A hyperechoic pattern with dilated bowel was associated with higher specificity for CF: 3/3 cases (100%), followed by hyperechoic bowel with ascites: 3/4 cases (75%). All babies with any type of NIO should thus be screened for CF. Prenatal screening for CF should be indicated in all pregnancies with US patterns of specific intestinal disorders.

High risk of surgical intervention in hereditary pancreatitis

Background

The aim of the study was to quantify the risk of surgical intervention in families with hereditary pancreatitis referred to the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer (EUROPAC).

Methods

Recruitment to EUROPAC started in 1997; families were considered if two or more members had chronic pancreatitis of unknown aetiology. Families were tested for protease serine 1 (PRSS1) mutations using polymerase chain reaction restriction digestion, sequencing the PRSS1 gene-screened negative families. Clinical information about surgical intervention was obtained from family members and referring clinicians, and the cumulative incidence of surgical intervention in the N291 and R122H mutation groups was determined with the Kaplan–Meier method.

Results

Forty-four families had the R122H mutation, 21 the N291 mutation, and 31 were negative for both. Some 14 (35 per cent) of 40 patients (median age 26·5 (95 per cent confidence interval (c.i.) 21·5–36·3) years) with the N291 mutation had an operative procedure for complications of pancreatitis, compared with 21 (25 per cent) of 83 patients (median age 24 (95 per cent c.i. 13·8–35·8) years) with the R122H variant. This resulted in a cumulative lifetime risk for surgical intervention of 0·6 (95 per cent c.i. 0·5–0·8) for the R122H mutation and 0·6 (0·5–0·8) for the N291 mutation (P = 0·11, log rank test).

Conclusion

Hereditary pancreatitis carries a significantly increased risk of surgical intervention in this cohort of patients, which equates to an estimated lifetime risk of around 60 per cent. The risk of surgery appears to be independent of PRSS1 mutation type.

Idiopathic chronic pancreatitis in children: MR cholangiopancreatography after secretin administration

PURPOSE

To assess the accuracy of dynamic magnetic resonance (MR) cholangiopancreatography after secretin administration in detecting pancreatic duct abnormalities typical of early-onset idiopathic chronic pancreatitis in children with recurrent episodes of idiopathic acute pancreatitis.

MATERIALS AND METHODS

Fifteen children (mean age, 11.3 years; range, 6-17 years) with at least three recurrent episodes of idiopathic acute pancreatitis prospectively underwent MR cholangiopancreatography before and after secretin administration. Image analysis included visualization of side branches, ductal narrowing, endoluminal filling defects, irregular ductal contour, cavities, and pancreas divisum. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP).

RESULTS

Dilated side branches were detected in three (20%) of 15 patients on MR cholangiopancreatograms obtained before secretin administration and in seven (47%) of 15 patients on images obtained after secretin administration. Ductal narrowing was detected in one (7%) of 15 patients on images obtained before secretin administration and in two (13%) of 15 patients on images obtained after secretin administration. Endoluminal filling defects in one (7%) of 15 patients were observed on MR cholangiopancreatograms obtained both before and after secretin administration. Irregular contour of the main pancreatic duct was present in four (27%) of 15 patients on MR cholangiopancreatograms obtained before secretin administration and in five (33%) of 15 patients on images obtained after secretin administration. Cavities and pancreas divisum were detected in one (7%) of 15 patients and in two (13%) of 15 patients, respectively, only on MR cholangiopancreatograms obtained after secretin administration.

CONCLUSION

Secretin improves the sensitivity of MR cholangiopancreatography in diagnosing early-onset idiopathic chronic pancreatitis.

Acute pancreatitis in children. An Italian multicentre study

AIM

To evaluate the clinical, morphological and aetiological aspects of acute pancreatitis in children in Italy.

PATIENTS

The hospital records of 50 consecutive patients with acute pancreatitis observed in 5 Italian Pediatric Departments were reviewed.

RESULTS

A total of 25 males and 25 females (median age 10.5 years, range 2-17) were studied. Of these patients, 48 (96%) had abdominal pain. The pancreatitis was associated with biliary disease in 10 patients (20%); it was due to viral infection in 6 patients (12%), pancreatic duct abnormalities in 4 (8%, familial chronic pancreatitis in 3 (6%), trauma in 5 (10%) and other causes in 5 (10%); the pancreatitis was of unknown origin in 17 patients (34%). Previous attacks of the disease had occurred in 14 patients. A diagnosis of mild pancreatitis was made in 41 patients (82%) and of severe disease in 9 (18%). One patient with severe pancreatitis died from multiorgan failure. Patients with severe pancreatitis had significantly higher serum concentrations of C-reactive protein than patients with mild pancreatitis. Hospital stay was similar for patients with the mild form and those with the severe form of the disease.

CONCLUSIONS

In Italian children, acute pancreatitis is of unknown origin in about one-third of the children and is recurrent in 28% of the cases. The disease is severe in 18% of the cases.

Resting energy expenditure in young patients with cystic fibrosis receiving antibiotic therapy for acute respiratory exacerbations

BACKGROUND

patients with cystic fibrosis commonly have severe malnutrition and growth retardation. Among possible causes of these manifestations are low caloric intake, loss of nutrients and increased resting energy expenditure. This study was designed to assess the influence of antibiotic therapy for infectious exacerbations on resting energy expenditure in young patients with cystic fibrosis.

METHODS

We studied 17 patients with cystic fibrosis (mean age, 13.6 years). All were hospitalized to receive intravenous antibiotic therapy (mean duration, 2 weeks) for acute respiratory exacerbations. At the beginning of therapy and after it ended, all patients underwent blood chemical tests, anthropometrical measures, determination of body composition by bioelectrical impedance, spirometry, and indirect calorimetry.

RESULTS

Antibiotic therapy led to a significant improvement in biochemical, spirometric variables and in estimated calorimetry measurements expressed in relation to fat-free mass. These findings suggest that infective exacerbations are among the causes of increased resting energy expenditure in young patients with cystic fibrosis.

CONCLUSIONS

Indirect calorimetry may prove useful in the diagnosis of infective exacerbations and in monitoring the effect of antibiotic therapy in patients with cystic fibrosis.

[Tridimensional (3D) reconstruction in the osteoarticular area]

Three-dimensional reconstruction techniques have been used since the development of computed tomography. In skeletal radiology they have been used to better visualize fractures and spatial relationships between fragments in maxillo-facial surgery. Aim of this paper is to illustrate the most important reconstruction techniques and their application in skeletal radiology. Images can be obtained by means of a Spiral CT scanner with the following parameters: collimation/pitch/reconstruction interval 2/1/1. Acquired images are sent to a workstation with a software running on a Window NT platform Vitrea 2.01 (Vital Images, USA) equipped with Volume Rendering algorithm. SSD as well as MPR and curved reformatted reconstruction algorithms is available at the CT console. Three-dimensional reconstruction have been shown to be useful for the diagnosis and for a preoperative planning. Other applications of three-dimensional reconstruction techniques are prosthesis engineering and biomechanic research. 3D images help the communication between radiologist and surgeons. Technical advances in acquisition methods and in reconstruction algorithms are needed to improve image quality and use in skeletal radiology.

Towards the pharmacogenomics of cystic fibrosis

Cystic fibrosis (CF) is the most common lethal recessive genetic disease affecting children in Europe and the US. CF is a multiorgan disease and may present a variety of clinical symptoms, like chronic obstructive lung disease, exocrine pancreatic insufficiency (PI) and elevated sweat chloride concentration. CF mutations have also been found in other related clinical diseases such as congenital bilateral absence of the vas deferens (CBAVD), disseminated bronchiectasis and chronic pancreatitis. These clinical overlaps pose etiopathogenetic, diagnostic and therapeutic questions. Despite stunning advances in genomic technologies and drug discovery, drug therapy often improves disease symptoms but does not cure the disease. One of the main causes of this failure in CF cure may be attributable to genetic variability and to the scarce knowledge of CF biochemistry. Therefore, knowing the genotype of a patient might help improve drug efficacy, reduce toxicity and suggests innovative genomic-based therapy approaches.

Pancreatic cystosis in cystic fibrosis: case report

We describe a 19-year-old cystic fibrosis patient, with pancreatic insufficiency since the age of 4 who presented at the age of 13 with postprandial abdominal pain. Ultrasonography and computed tomography showed several pancreatic cysts that progressively increased in diameter over 6 years. The lack of association with clinical and biochemical signs of acute pancreatitis is highlighted.

Diagnostic accuracy of fecal elastase 1 assay in patients with pancreatic maldigestion or intestinal malabsorption: a collaborative study of the Italian Society of Pediatric Gastroenterology and Hepatology

Several reports have indicated that fecal elastase-1 (EL-1) determination is a new, sensitive, and specific noninvasive pancreatic function test; however, very few patients with malabsorption due to small intestine diseases have been included in the previous studies. The aim of the study was to compare the diagnostic accuracy of fecal EL-1 and fecal chymotrypsin (FCT) in distinguishing between pancreatic maldigestion and intestinal malabsorption. Three groups of subjects were studied: group A included 49 patients with known cystic fibrosis (25 males, median age 5 years); group B included 43 subjects with various small intestine diseases (17 males, median age 6 years); and group C included 45 children without any history of gastrointestinal disease (22 males, median age 5 years). In all patients, stools were collected for 72 h on a standard diet and fecal EL-1, FCT, and steatocrit tests were performed. Both EL-1 and FCT were below normal limits in all CF patients with pancreatic maldigestion not treated with pancreatic enzyme (100% sensitivity for both assays); El-1, but not FCT, was also below normal in all the CF patients with pancreatic maldigestion treated with pancreatic extracts. Both EL-1 and FCT values in the CF group were significantly lower than in subjects with various small intestinal diseases and in children without any history of gastrointestinal disease (P < 0.0001). FCT, but not EL-1, values showed an inverse statistically significant correlation with steatocrit values in the whole CF group (P < 0.001); FCT was below normal in three of four CF patients with steatorrhea on pancreatic enzyme therapy. Both EL-1 and FCT had 100% specificity when calculated in children without any history of gastrointestinal disease; in contrast, specificity was 86% for EL-1 and 76% for FCT if we considered the control group with small intestinal diseases: low EL-1 was observed in two cases of intestinal giardiasis, two cases of short bowel syndrome, one case of celiac disease, and one case of intestinal pseudobstruction; FCT was abnormal in four cases of intestinal giardiasis, three cases of celiac disease, one case of short bowel syndrome, one case of Crohn's disease, and one case of intestinal pseudobstruction. Diagnostic accuracy was 92% for fecal EL-1 and 82% for FCT. Steatocrit values were over the normal limit in 11 patients with small intestine diseases; in 7/11 of these patients at least one of the pancreatic test results was below the normal limit. In conclusions, in patients with CF, fecal EL-1 determination is not more sensitive than FCT in identifying pancreatic maldigestion; however, fecal EL-1 assay is more specific than FCT determination in distinguishing pancreatic maldigestion from intestinal malabsorption.

Nocturnal oximetry in infants with cystic fibrosis

AIM

To investigate whether children with cystic fibrosis under 3 years of age have disordered breathing and episodes of oxygen desaturation during sleep.

METHODS

We studied 19 infants (9 boys and 10 girls) with cystic fibrosis, mean age 13.1 months (range 3-36 months) and 20 age and sex matched healthy subjects. Patients and controls underwent an overnight polysomnographic study and respiratory function testing on the following morning.

RESULTS

Seven patients with ongoing respiratory tract inflammation had disordered breathing and episodes of oxygen desaturation during sleep. Pulse oximetry showed a significantly lower mean oxygen saturation (SaO(2)) and a higher percentage of total sleep time spent with SaO(2) less than 93% in symptomatic children than in controls.

CONCLUSION

Results suggest that infants and young children with cystic fibrosis and mild airways inflammation (rhinitis, cough, red throat) have episodes of oxygen desaturation during sleep.

Phenotype/genotype correlation and cystic fibrosis related diabetes mellitus (Italian Multicenter Study)

BACKGROUND

A genotype/phenotype correlation between early onset cystic fibrosis related diabetes (CFRD) and the N1303K mutation of the CF gene was previously identified in a small series of 28 CFRD patients, out of 313 CF patients.

PATIENTS AND METHODS

In order to confirm the observation, data of 141 CFRD patients out of 1,229 CF patients attending 14 Italian CF centers were collected. All patients were older than 10 years and had been genotyped.

RESULTS

DeltaF508 was the most frequent mutation (147/282 alleles: 52%) and N1303K the second most frequent mutation (18/282 alleles: 6.3%) in CFRD patients, without significant difference as compared with CF patients without DM (52% vs 48.6% and 6.3% vs 5.1%, respectively). W1282X was the third most frequent mutation in CFRD patients, more frequent than in CF patients without DM (5.3% vs 2%; p<0.001).

CONCLUSIONS

Unlike the previous study, we did not find a higher frequency of the N1303K mutation in CFRD patients; moreover, data from this large CF series showed a significant correlation between the W1282X mutation and CFRD.

Comparison of two enteric coated microsphere preparations in the treatment of pancreatic exocrine insufficiency caused by cystic fibrosis

BACKGROUND

Pancreatic exocrine insufficiency is a common condition in patients with cystic fibrosis. Large amounts of pancreatic enzyme supplements are required to reduce malabsorption but patient compliance is not always optimal.

AIMS

To compare patients' preference and the efficacy of two enteric coated microsphere preparations in patients with cystic fibrosis.

PATIENTS

Patients with pancreatic exocrine insufficiency due to cystic fibrosis.

METHODS

Patients were assigned to the crossover treatment with Creon or Pancrease for 1 week and then to the alternative treatment. Patients had to follow a fixed diet (at least 2 g fat/kg) and had to assume 1000 units lipase/g fat. The evaluation parameters were: patients' preference, acceptance of therapy, stool fat excretion, stool weight, gastrointestinal symptoms, and tolerance.

RESULTS AND CONCLUSIONS

Of the 33/60 patients who expressed a preference for one of the two treatments, 30 preferred Creon while only 3 patients preferred Pancrease (p<0.001). No difference between the two treatments was observed regarding stool characteristics, gastrointestinal symptoms and tolerance. The mean number of capsules taken daily was reduced by 35% with Creon. The results of this study showed a preference in favour of Creon probably due to the reduction of daily capsule intake of 35%, supporting digestion as well as Pancrease.

[Injuries of the cruciate ligament of the knee: diagnostic contribution of MR and spiral CT]

Lesions of cruciate ligament are common after knee trauma of different degree of gravity. Lesions evaluation is possible thanks to CT and MRI. Our purpose is to verify their value in diagnosis of cruciate ligaments lesions. We retrospectively evaluated 160 patients (80 CT and 80 MRI) with subsequent diagnosis of cruciate ligaments injury. CT and MRI were performed in the acute phase and in the subacute phase within 2-3 weeks from trauma. On the basis of our results CT and MRI shown a reduced sensitivity in acute phase owing to the intraarticular haemorrhage; in this phase MRI gives more information about fibres interruption. In subacute or chronic phase, both methods are correct in recognising the lesions but MRI is more sensitive and accurate. It is a real wish that, with more MRI machines diffusion, this method will be preferred in the study of cruciate ligaments both in acute phase and subacute-chronic phase.

Wolman's disease diagnosed by intestinal biopsy

We describe a fatal case of Wolman's disease in a 5-month-old Italian infant with severe gastrointestinal symptoms in whom the diagnosis was made from intestinal biopsy findings at the age of 3 1/2 months. Abdominal CT scan, elevated blood acid phosphatase levels and histologic findings confirmed the diagnosis.

[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.

[Surgical rehabilitation of stomal disease]

The Authors report their experience in the surgical rehabilitation of patients with complicated ileo- or colostomy. Mechanical and psychosocial implications as well as different rehabilitative methods are discussed. The results of a surgical protocol in the treatment of stomal diseases observed in 63 patients are herein reported. In 14 patients the surgical treatment was performed in general anaesthesia, while in 49 local anaesthesia was used. The latter was better tolerated by the patients. In conclusion, surgery should play a major role in this rehabilitation protocol, either in terms of prevention or definitive treatment.