Massive plexiform neurofibroma with associated meningo-encephalocoele and occipital bone defect presenting as a cervical mass

The commonest skull manifestations in neurofibromatosis involve the orbit, with very few reports about occipital defects. We report a rare case of a 54-year-old lady with a massive plexiform neurofibroma extending from the auricular region down her left neck and into her shoulder, with an associated large left occipital and left petrous bone defect and extensive cerebellar meningo-encephalocoele, which presented with a relatively asymptomatic cervical mass and was treated with resection of the neurofibroma and advancement and rotational skin flaps.

Review article: prevention of postsurgical relapse and recurrence in Crohn's disease

After first resection in Crohn's disease at 1 year 60-80% of patients have endoscopic recurrence, 10-20% have clinical relapse, and 5% have surgical recurrence.1, 2 This review focuses on the actual evidence on the prevention of recurrence and relapse dealing with risk factors and with drugs. Smoking is the only risk factor for Crohn's disease, that has been shown to be related to both endoscopic and surgical recurrence and relapse. Among the different drugs evaluated, some (Mesalamine and Metronidazole) have been shown to be effective, whereas others (immunosuppressive) need to be evaluated in further, new trials.

Nodal metastatic melanoma in the neck of a 4-year-old girl after diagnosis of Spitz nevus of the cheek

A 4-year-old girl was referred to the plastic surgery unit with metastatic malignant melanoma diagnosed in a cervical lymph node. She had previously undergone excision of a Spitz nevus of the cheek at age 18 months. The management of this patient is discussed along with a review of the literature relating to Spitz nevi and malignant melanoma in childhood.

A comparison of three methods of repairing the hard palate

OBJECTIVE

To compare growth, speech, and nasal symmetry outcomes of three methods of hard palate repair.

PATIENTS

Consecutive available records of children born with unilateral bony complete cleft lip and palate over the period 1972 to 1992.

INTERVENTIONS

Identical management of lip, nose, alveolus, and soft palate. Hard palate repair by Cuthbert Veau (CV) from 1972 to 1981, von Langenbeck (vL) from 1982 to 1989, or medial Langenbeck (ML) from 1989 to 1991.

OUTCOME MEASURES

For growth: GOSLON yardstick or 5-year model index. For speech: articulation test. Nasal anemometry. For nasal symmetry: Coghlan computer-based assessment. All these measures were developed during the period of data collection but not for this project.

RESULTS

There was a strong trend toward more favorable anteroposterior maxillary growth with the change from CV to vL to ML techniques. This fell short of statistical significance because of the small sample size. There was a significant reduction in cleft-related articulation faults (p =.01) considered to be related to improved arch form. In the absence of improved rates of velopharyngeal insufficiency or nasal symmetry, increased surgical experience was discounted as a significant contribution to improved growth and articulation outcomes.

CONCLUSIONS

Reduced periosteal undermining and residual exposed palatal shelf from CV to vL to ML improved incisor relationships and articulation.

[Treatment with chimeric monoclonal antitumor necrosis factor (infliximab) of patients with active steroid-dependent/resistant Crohn's disease and fistulas]

30 patients--13 with active steroid-dependent/resistant Crohn's disease (CD), 8 with active steroid-dependent/resistant disease complicated by fistulas and 9 with fistulas only (perianal or abdominal)--were treated with infliximab. "Clinical response or remission" were defined as the reduction by 70 or more points or below 150 points of the CDAI score, respectively. As regards fistulas, "response" was defined as the reduction of 50 percent or more from baseline in the number of draining fistulas or of the quantity of drainage, "remission" as their closure. At 8 weeks 13/21 (61.9%) patients treated for active disease went on remission and 6/21 (28.5%) had a clinical response; 6/17 (35.2%) patients treated for fistulas went on remission and 8/17 (47%) had a response, while 3/17 (17.6%) didn't have any response. At 24 weeks, 9/12 (75%) patients treated for active disease and 13/16 (81.25%) treated for fistulas had a recurrence in a median time of 18.3 weeks (range, 1-36 weeks) after the first infusion.

[Opinions and attitudes on oral cancer in a sample of students attending a state secondary school in Rome. A pilot study]

BACKGROUND

This study aimed to evaluate knowledge and awareness in a group of secondary school students on the subject of risk factors and strategies used in the prevention of oral cancer.

METHODS

The study took the form of a questionnaire which was filled in by a group of 106 secondary school students. The questionnaire was divided into 3 sections: the first analysed the general characteristics of the sample population; the second investigated their knowledge on the specific subject of this study; the last regarded exposure to risk factors and the role played by the dentist and family doctor in the prevention of oral cancer.

RESULTS

Of the 106 students taking part in the study, 42% were male and 58% female. 30% of the group felt it was not possible to prevent cancer in general. 6% associated cigarette smoking with oral cancer, whereas 15% identified alcohol as a risk factor for the same pathology. 30% of the group thought that it was not possible to prevent oral cancer. In the event of a suspected oral lesion, 44% would consult the family doctor, 25% would go to the dentist and 3% to a dental technician.

CONCLUSIONS

This study highlights the need improve knowledge of prevention methods in oral cancer. Although young people do not have a high risk of developing oral cancer, they represent a means of conveying information in a social and familial context, thus enabling an early diagnosis, and they also represent the preferred target for primary prevention activities.

Prevalence of cytomegalovirus infection in severe refractory ulcerative and Crohn's colitis

OBJECTIVES

Cytomegalovirus infection has been reported as a cause of refractory inflammatory bowel disease, but no data are available on its prevalence in severe colitis. The aim of this study was to evaluate the prevalence and outcome of cytomegalovirus infection in a consecutive series of patients with severe steroid refractory colitis admitted to our department from 1997 to 1999.

METHODS

Among 62 patients with severe colitis, 55 with ulcerative colitis and seven with Crohn's disease, 19 (30%) were resistant to intravenous steroids and bowel rest. In all of them, rectal biopsies were examined for cytomegalovirus (the flexible proctoscopy being performed without air insufflation and limited to the first 10 cm). Buffy coat preparation on leukocytes was also performed to detect systemic infection. If cytomegalovirus was not detected, cyclosporine was started.

RESULTS

In seven (five with ulcerative colitis and two with Crohn's disease) out of 19 (36%) patients with refractory disease, cytomegalovirus was diagnosed in the rectal specimens as well as by buffy coat preparation. Five patients went into remission after antiviral treatment (three with ganciclovir and two with foscarnet). One patient did not respond and was operated on. In one patient, cytomegalovirus was found in the surgical specimen.

CONCLUSIONS

Cytomegalovirus infection is a frequent cause of severe refractory colitis. Rectal biopsy should always be performed in severe steroid-resistant colitis.

Lack of changes in serum prolactin, FSH, TSH, and estradiol after melatonin treatment in doses that improve sleep and reduce benzodiazepine consumption in sleep-disturbed, middle-aged, and elderly patients

An open pilot study on the safety and efficacy of melatonin in the treatment of insomniac patients was conducted in 22 subjects (16 females), mean +/- S.D. age 60.1 +/- 9.5 years. All patients received 3 mg of gelatin melatonin capsules per os daily for 6 months, 30 min before expected sleep time. Twenty of 22 patients were on benzodiazepine treatment and they continued this treatment for part of or for the entire melatonin administration period. Serum concentrations of prolactin, follicle-stimulating hormone (FSH), thyroid-stimulating hormone (TSH), or estradiol were measured by radioimmunoassay (RIA) in morning samples at the beginning and after 6 months of melatonin administration, and standard clinical laboratory tests for blood components were performed. Urinary 6-sulphatoxymelatonin (aMT6s) excretion was measured by RIA before treatment. Serum concentrations of prolactin, FSH, TSH, or estradiol did not exhibit changes after 6 months of melatonin administration, nor were any indications of hematologic or blood biochemistry alteration found. Melatonin augmented significantly the quality and duration of sleep, and decreased sleep latency and the number of awakening episodes, as assessed from sleep logs filled by the patients (first 21 days) and from structured interviews performed by incumbent physicians (up to 6 months). Estimates of next-day function (i.e., alertness in the morning and during the day) also improved significantly during melatonin treatment. The observed effect lasted for the entire period examined (up to 6 months), with 22 out of 22 patients showing improved sleep at the end of treatment. The urinary excretion of aMT6s before starting administration of melatonin correlated negatively and significantly with age, but not with the intensity of sleep the disorder or the outcome of treatment. In 13 of 20 patients taking benzodiazepines together with melatonin, benzodiazepine use could be stopped, and in another four patients, benzodiazepine dose could be decreased to 25-66% of the initial dose. The results of this open, subacute administration trial indicate that melatonin is a safe and useful treatment for sleep disturbances in middle-aged or elderly patients, either by itself or together with benzodiazepines.

Treatment of small hepatocellular carcinoma with percutaneous ethanol injection: a validated prognostic model

OBJECTIVE

Percutaneous ethanol injection may prolong the survival of patients with small hepatocellular carcinoma associated with cirrhosis. The aim was to identify prognostic factors of survival and of local recurrence, as well as separate new lesions.

METHODS

We performed Cox regression analysis in 115 consecutive patients with hepatocellular carcinoma (81 Child-Pugh class A, 34 Child-Pugh class B) treated by percutaneous ethanol injection. The validity of the model was tested by comparing predicted and observed survival in 105 independent patients from an external series.

RESULTS

Overall survival rates were 89%, 63%, and 43% at 1, 2, and 3 yr, respectively. The 1-, 2-, and 3-yr survival rates were 96%, 78%, and 63%, respectively, for Child-Pugh class A patients and were 73%, 35%, 12%, respectively, for Child-Pugh class B. The albumin level was the only independent variable significantly associated with survival (p < 0.0001). The 3-yr rate of appearance of separate new lesions and local recurrence were 41% and 23%, respectively. The survival predicted by the model agreed with that observed in the independent patients.

CONCLUSIONS

Survival of patients with hepatocellular carcinoma treated by percutaneous ethanol injection is related to baseline albumin level. The high rate of recurrence (both local and distant) points out the palliative role of this therapy.

Basal cell carcinoma in aplasia cutis congenita

A case of multilocal basal cell carcinoma in a 45-year-old man is reported.

Modification of the Koken nasal splint

Koken nasal splints have been found effective postoperatively in treating cleft-lip nose deformity. In our experience, their retention has been poor, so reducing the molding effect. This paper presents a modification designed to overcome the problem of retention.

Mortality and causes of death in celiac disease in a Mediterranean area

No data on mortality in celiac disease are currently available in southern Europe. Our aim was to evaluate mortality and the cause of death in adult celiac disease in a Mediterranean area. In all, 228 adults with celiac disease were histologically diagnosed in our department from 1980 to 1997. Full information on their state of health was obtained in 216 of 228 patients. A tabulation of patient-years at risk was constructed in terms of age at diagnosis and the interval from diagnosis. Standardized mortality ratio was calculated by dividing the number of observed deaths by the number of expected deaths. Twelve deaths were observed, whereas 3.12 deaths were expected (SMR = 3.8; 95% CI 2-7). The increased mortality was mainly observed within four years from diagnosis (8 observed; 1.4 expected) (SMR = 5.8; 95% CI 2.5-11.5). Twelve tumors were observed (six lymphomas). In conclusion, mortality from adult celiac disease in our geographical area is increased compared with the general population, and this increased risk seems due to non-Hodgkin's lymphoma.

Beclomethasone dipropionate enemas versus prednisolone sodium phosphate enemas in the treatment of distal ulcerative colitis

AIM

To compare beclomethasone dipropionate 3 mg/60 mL enema (BDP) and prednisolone sodium phosphate 30 mg/60 mL enema (PP) once daily in patients with active distal ulcerative colitis.

METHODS

One hundred and fifty-seven patients were enrolled in a multicentre, 4-week, randomized, double-blind trial. Patients were assessed at baseline, 2 and 4 weeks.

RESULTS

Both treatment groups showed statistically significant improvement of clinical activity after 2 and 4 weeks. Endoscopy and biopsy showed a reduction in the activity score at the end of the treatment period in both groups. No statistically significant difference was observed between the two treatment groups. After 4 weeks, 29% of patients in the BDP group and 25% in the PP group were considered to be in clinical remission; an improvement was observed in 40% of patients on BDP and in 47% on PP. Mean morning plasma cortisol levels showed a slight but significant reduction in the PP group, while the ACTH test showed that neither drug interfered with the hypothalamic-pituitary-adrenal (HPA) axis function. No significant changes were observed in the laboratory tests. Finally, there was a low incidence of adverse events in both groups.

CONCLUSIONS

It is concluded that, in the topical treatment of active distal ulcerative colitis, BDP 3 mg enemas are as efficacious as PP 30 mg enemas, without interference with the HPA axis.

Treatment of small hepatocellular carcinoma associated with cirrhosis by percutaneous ethanol injection. A trial with a comparison group

BACKGROUND

Ethanol injection has been reported to be effective in the treatment of hepatocellular carcinoma, but no controlled randomized trials have been performed. We therefore performed a trial comparing ethanol injection with an untreated, matched historical comparison group in the treatment of hepatocellular carcinoma.

METHODS

From 1992 to 1993, 35 patients (14 Child's A and 21 Child's B cirrhosis) with small (< 4 cm) hepatocellular carcinoma associated with cirrhosis were treated by ethanol injection. Each patient was matched with an untreated case (followed up during the period 1984-89) for variables known to have independent prognostic value (age, Child's classification, number of lesions, alpha-fetoprotein, and modality of diagnosis).

RESULTS

The 1-, 2-, and 3-year survival rates of ethanol-treated patients were 86% (95% confidence interval (CI), 69-94), 53% (95% CI, 34-68), and 33% (95% CI, 15-52), whereas the survival rates of the comparison group were 75% (95% CI, 56-85), 26% (95% CI, 13-41), and 14% (95% CI, 5-27) (P = 0.01). The 1-, 2-, and 3-year survival rates of Child's A were 100%. 87% (95% CI, 30-97), 71% (95 CI, 33-90), 71% (95% CI, 33-90) in the ethanol-treated patients and 92 (95% CI, 59-99), 43% (95% CI, 23-73), and 21% (95% CI, 23-72) in untreated patients. The 1-, 2-, and 3-year survival of Child's B patients were 76% (95% CI, 59-97), 32% (95% CI, 13-53), and 9% (95% CI, 0.8-33) in the treated group and 61% (95% CI, 40-83), 14% (95% CI, 3-32), and 9% (95% CI, 1-26) in the treated group.

CONCLUSIONS

These data suggest that ethanol injection prolongs the life of patients with hepatocellular carcinoma associated with Child's A cirrhosis but seems not to influence the survival of Child's B patients.

[Role of free radicals, telomeres, and telomerases in aging and cancerogenesis]

After a rapid examination of a few basic concepts concerning cellular aging and programmed cell death, the aging of the tissues and organs, the authors discuss the principal theories on senescence. They underline that it is necessary to agree in considering the various genetic and epigenetic, endogenous and exogenous mechanisms that lead to the complex aging phenomenon multiple and interrelated. In particular they stress the hypothesis that senescence can be due to a sum of molecular damages caused by free radicals, and to the loss of telomeric DNA. Radical reactions can cause mutations, inactivation or a decrease in the turnover of mitochondrial DNA which is more vulnerable than the nuclear genoma to the attack of mutagenic agents, acting also as a continuous source of initial and/or promoting factors of the carcinogenetic process. The somatic cells become senescent because during cell division, they lose the mechanisms for the lengthening of the telomere. The telomerase prevents the shortening of telomeres in neoplastic cells and therefore renders them immortal. Paradoxically the protection of the telomere is exactly what must be avoided in the case of tumor cells. Recently the demonstration that telomerase is not always involved in the restoration of telomere length shows the complexity of the problems connected to the cause of senescence.

[Increase of oxygen free radicals and their derivatives in chemo- and radiation treated neoplasm patients]

BACKGROUND

Radical oxygen species (ROS) are known to mediate cytotoxic anticancer activity by modifying the cellular homeostatic redox balance. The aim of the study is to evaluate whether cancer patients show more ROS after radio/chemotherapy.

METHODS

ROS were evaluated in 32 oncologic untreated patients. Blood samples were collected both before and after the end of radio/chemotherapy. Spectrophotometric detection of ROS was performed by using d-ROMs test (Diacron).

RESULTS

After therapy all patients showed a marked increase in ROS (378 +/- 35 U Carr) compared to values measured before therapy (269 +/- 62 U Carr, p < 0.0001). This result was more evident during the first course of therapy. No significant differences were observed between patients who received radio or chemotherapy.

CONCLUSIONS

In conclusion both radio and chemotherapy induce oxidative stress by increasing radical oxygen species, exceeding the antioxidative capacities of cancer patients. This is useful for therapeutic purposes but may enhance the cytotoxicity induced by therapy.

Relationship between site of disease and familial occurrence in Crohn's disease

Concordance in the extent of disease among the family members of patients with Crohn's disease has not been widely investigated. Furthermore, the relationship between the site of the disease and familial occurrence has never been studied. Our aim was to evaluate the familial occurrence of Crohn's disease in the various sites. Nine hundred thirty-four patients with Crohn's disease, observed consecutively in two gastrointestinal departments, were investigated to determine first-degree familial incidence (in both Crohn's disease and ulcerative colitis). Whenever two or more members were attending the same clinic, only one was regarded as a propositus. The analysis, therefore, was carried out on 882 patients. The exact site of the disease was determined in all patients either at diagnosis or during the follow-up by colonoscopy and by small bowel enema. The rate of concordance in the extent of disease and familial occurrence in the various sites was evaluated and the difference was calculated by chi-square test. Sixty-one propositi were identified among all the patients. Forty-nine had familial occurrence for the same disease (concordant patients), whereas 12 had at least one relative with ulcerative colitis (discordant patients). In 44 propositi with only one relative affected, the rates of concordance in the extent of the disease were 84, 68, 18, and 0% respectively, for the ileum, the ileum-right colon, the ileum-total colon, and the colon. The number of propositi in the various sites was as follows: 4 of 162 (2.4%) patients with the disease located in the colon, 1 of 9 (11%) with the jejunum site, 24 of 380 (6.3%) with the ileum site, 16 of 165 (9.7%) with the ileum and right colon site, and 16 of 164 (9.7%) with the ileum and total colon site. The chi-square values of propositi distribution among other sites and the colon was, respectively, as follows: jejunum, 2.2 (N.S.); ileum, 3.4 (P = 0.06); ileum and right colon, 7.4 (P = 0.006); and ileum and total colon, 7.4 (P = 0.006). This study shows a pronounced concordance in the site of the disease for family members with Crohn's disease and suggests that familial occurrence in Crohn's disease is less frequent when the disease is located in the colon rather than elsewhere.

Factors associated with hypotension and bradycardia after epidural blockade

In order to identify patient-, anesthesia-, and surgery-related factors influencing the probability of hypotension and bradycardia after epidural blockade, an observational study was conducted on 1050 nonpregnant patients. Backward stepwise logistic regression was performed on the variables hypotension (systolic blood pressure < 90 mm Hg) and bradycardia (heart rate < or = 45 bpm). Hypotension and bradycardia occurred in 158 and 24 patients, respectively. The probability of hypotension increased when epidural fentanyl was administered (odds ratio [OR] = 2.18; 95% confidence interval [CI] = 1.16-4.11), with body weight and spread of epidural analgesia, and decreased when a tourniquet was used (OR = 0.01, CI = 0.01-0.02) and bupivacaine instead of carbonated lidocaine was administered (OR = 0.28, CI = 0.14-0.60). Sensitivity and specificity of the model were 89% and 88%, respectively. The probability of bradycardia was less in women (OR = 0.05, CI = 0.01-0.41) and when a tourniquet was used (OR = 0.04, CI = 0.02-0.09). Sensitivity and specificity were 50% and 97%, respectively. In conclusion, our analysis can contribute to identification of patients at high risk to develop hypotension and bradycardia after epidural blockade. If bupivacaine instead of carbonated lidocaine is used and epidural fentanyl is not administered a decrease in the incidence of hypotension may be anticipated.

[Treatment of acute a steroid-resistant ulcerative colitis with continuous venous infusion of cyclosporine]

Aim of this open study is to evaluate the efficacy and safety of a low-dose treatment of continuous intravenous infusion of cyclosporine. We treated twelve patients with severe active ulcerative colitis, that did not respond to high doses of intravenous steroid for at least ten days. We used a dose of 2 mg/kg/day for 15 days. After this period, if patients improved, cyclosporine was administered orally at the dose of 6 mg/kg/day for six months. The response rate to acute phase therapy was 92.8%. The mean response time was 5.8 days. Sixty-nine percent of patients responded within the first week. No adverse reaction was observed. The first five patients responding to acute phase therapy relapsed during or at the end of maintenance phase. Because of that, azathioprine was associated in the successive patients. Only 4 out of 12 patients (33%) were operated on.

CONCLUSIONS

continuous intravenous infusion of cyclosporine at dosage of 2 mg/kg/day is a highly effective and safe therapy that may avoid or defer colectomy to eligible conditions.

Early upregulation of medium neurofilament gene expression in developing spinal cord of the wobbler mouse mutant

Homozygous wobbler mouse mutants develop a progressive paralysis due to spinal motoneuron degeneration. To understand the molecular aspect underlying the genetic defect we have studied the embryonic (from E13) and postnatal expression of the three neurofilament and choline acetyltransferase genes in each member from several wild-type (wt) and wobbler (wr) progenies. There are no variations among wt littermates at all ages studied. In contrast, analyses of neurofilament mRNA reveals a 3-4-fold increase of medium neurofilament (NFM) mRNA in wobbler mice (wr/wr). The pattern of increased NFM mRNA during development, prior to the appearance of the wobbler phenotype, among littermates (from heterozygous carriers) conforms to a mendelian inheritance of a single gene defect 1:2:1 (wr/wr:wr/+:+/+). Light and heavy neurofilament mRNA levels are also increased later in development exclusively in those individuals with high NFM mRNA values indicating that increase of the latter is associated with increase of the light and heavy subunit expression. Also NF proteins are increased. Expression of choline acetyltransferase gene is instead always comparable to normal control. Our study provides novel insights into the nature of the wobbler defect, strengthening the hypothesis that neurofilament accumulation plays a pivotal role in the etiopathogenesis of motoneuron degeneration.

Mortality in patients with Crohn's disease

BACKGROUND

No data on mortality for Crohn's disease are available from southern Europe.

METHODS

Five hundred and thirty-one patients with Crohn's disease were observed in our unit between 1973 and 1993. In 325 patients the first diagnosis was made in our hospital. In this consecutive incidence series, in which the follow-up was 99% complete, the standardized mortality rate (SMR) was calculated.

RESULTS

Nine deaths were observed, against 9.25 expected. The SMR was 0.97 (95% confidence interval (CI), 0.4-1.8). The relative risk of dying was significantly higher in the female group in the first 5 years after diagnosis (SMR, 10.3; 95% CI, 2.30-30.2). There was an excess of deaths from tumors of the digestive organs (1 observed, 0.37 expected).

CONCLUSIONS

These results show that in our geographic area the mortality from Crohn's disease was not increased as shown in other community studies.