Healthcare-associated Clostridium difficile infection: role of correct hand hygiene in cross-infection control

INTRODUCTION

Clostridium difficile (CD) is the most common cause of health-care-associated infectious diarrhea with increasing incidence and severity in recent years. The main cause of hospital's acquired cross infections can be attributed to incorrect hand hygiene. We described the epidemiology of CD infection (CDI) in a teaching hospital in Southern Italy during a two years surveillance period and evaluated the health-care workers compliance to hand hygiene.

METHODS

CDI Incidence rates were calculated as the number of patients with positive C. difficile toxin assay per 10,000 patient-days. Compliance with hand hygiene was the ratio of the number of performed actions to the number of opportunities observed. Approximately 400 Hand Hygiene (HH) opportunities/year /ward were observed. We finally checked out if any correlation could be found.

RESULTS

From January 2015 to December 2016 a total number of 854 CD determinations were performed in patients with clinical symptoms of diarrhea. The search for toxins A and B was positive in 175 cases (21,2%), confirming the diagnosis of CDI. Compliance to hand hygiene was significantly inversely associated with the number of CDIs: the lower the compliance of health-care workers with hand hygiene the higher was the number of cases of CDIs (p = 0.003).

CONCLUSIONS

According to our results proper handwashing of health-care workers appears to be a key intervention in interrupting CD cross infections regardless of age and type of department in which the patient is admitted.

Evaluation of health status in patients with hepatitis c treated with and without interferon

Background

The evolution of technology in healthcare has increased the health care’s costs and, the universal healthcare systems, in developed countries, need to ensure proper allocation of resources. Thus, the major issue is assessing the effectiveness of new medical technologies. The evaluation of quality of life in response to new treatments has become a key indicator in chronic conditions for which medical interventions are evaluated not only in terms of increasing the number of expected life years but also in terms of increasing quality of life. The aim of this observational study was to verify whether a simple instrument (EQ-5D-5 L) can capture variations in health-related quality of life (HRQoL) and allow us to evaluate the impact of different drug treatment protocols in patients with hepatitis C virus (HCV) on daily activities.

Methods

Sixty six patients with HCV were consecutively enrolled in the Hepatology Unit at the University Hospital of Catania “G. Rodolico”. Sixteen patients received new direct-acting-antiviral agents (DAAs) plus pegylated alpha interferon (Peg-α-IFN) protocol (Group A) and 50 DAAs IFN free protocol (Group B).

The EQ-5D-5 L® questionnaire and visual analog scale (VAS) were given to both groups to calculate coefficient’s utility. We used the EQ-5D-5 L Crosswalk Index Value Calculator to obtain the utility EQIndex and both parametric and non parametric tests for the statistical analysis.

Results

The biopsy taken at the beginning of treatment showed comparable cell damage in both groups. The difference in the VAS results was negative for patients who received protocols containing IFN (indicating decreased quality of life),whereas it was positive in patients treated with IFN-free protocols. The baseline EQIndex did not reveal any differences between the two treatment groups. The post-treatment EQIndex was statistically better in the groups that received IFN-free therapy.

Conclusions

When innovative treatments are introduced into clinical practice, assessing quality of life is mandatory to determine their benefits. The instruments used in the present study are effective in detecting the areas in which improvement has occurred. These instruments can be easily managed by general practitioners for follow up of progression of the disease and referred to the specialist.

Recirculating HIV-target T lymphocytes at the mucosal surface of the female genital tract are associated with progesterone increases during the menstrual cycle (MUC2P.938)

The Female Genital Tract (FGT) provides a means of entry to opportunistic infections, including HIV, yet immune cell populations at this mucosal surface are poorly defined. We initiated a study of 20 healthy women to characterize resident T cell populations in the lower FGT from lavage and patient-matched blood samples. Surprisingly, we report FGT T cells were primarily CCR7hi memory CD4 T cells (P=<0.0001), consistent with a central memory phenotype and known HIV reservoir. FGT CCR7hi T cells exhibited more frequent expression of HIV susceptibility markers CCR5 and CD38 compared to blood (0.6% vs. 13.6%, P=0.0017), yet retained the ability to migrate to CCR7 ligands, suggesting these cells could migrate from the genital tract into afferent lymphatics. Finally, we demonstrate the frequency of FGT CCR7hi target cells increased during the luteal phase of the menstrual cycle (51.7-72.7), and correlated to progesterone from patient-matched blood (r=0.5176, P=0.0024). These data show that a majority of CD4 T cells at the surface of the FGT in humans do not express canonical resident memory T cell markers, but are primarily a central memory T cell phenotype with the ability to traffic across the mucosal epithelium into underlying tissue. Our findings suggest HIV may directly infect recirculating memory CD4 T cells that traffic virus across the FGT mucosal barrier and progesterone changes throughout the menstrual cycle may predict availability of these cells HIV target cells.

Long-term maintenance of sustained virological response in liver transplant recipients treated for recurrent hepatitis C

BACKGROUND

The recurrence of hepatitis C viral infection is common after liver transplant, and achieving a sustained virological response to antiviral treatment is desirable for reducing the risk of graft loss and improving patients' survival.

AIM

To investigate the long-term maintenance of sustained virological response in liver transplant recipients with hepatitis C recurrence.

METHODS

436 Liver transplant recipients (74.1% genotype 1) who underwent combined antiviral therapy for hepatitis C recurrence were retrospectively evaluated.

RESULTS

The overall sustained virological response rate was 40% (173/436 patients), and the mean follow-up after liver transplantation was 11±3.5 years (range, 5-24). Patients with a sustained virological response demonstrated a 5-year survival rate of 97% and a 10-year survival rate of 93%; all but 6 (3%) patients remained hepatitis C virus RNA-negative during follow-up. Genotype non-1 (p=0.007), treatment duration >80% of the scheduled period (p=0.027), and early virological response (p=0.002), were associated with the maintenance of sustained virological response as indicated by univariate analysis. Early virological response was the only independent predictor of sustained virological response maintenance (p=0.008).

CONCLUSIONS

Sustained virological response achieved after combined antiviral treatment is maintained in liver transplant patients with recurrent hepatitis C and is associated with an excellent 5-year survival.

A Bayesian methodology to improve prediction of early graft loss after liver transplantation derived from the liver match study

BACKGROUND

To generate a robust predictive model of Early (3 months) Graft Loss after liver transplantation, we used a Bayesian approach to combine evidence from a prospective European cohort (Liver-Match) and the United Network for Organ Sharing registry.

METHODS

Liver-Match included 1480 consecutive primary liver transplants performed from 2007 to 2009 and the United Network for Organ Sharing a time-matched series of 9740 transplants. There were 173 and 706 Early Graft Loss, respectively. Multivariate analysis identified as significant predictors of Early Graft Loss: donor age, donation after cardiac death, cold ischaemia time, donor body mass index and height, recipient creatinine, bilirubin, disease aetiology, prior upper abdominal surgery and portal thrombosis.

RESULTS

A Bayesian Cox model was fitted to Liver-Match data using the United Network for Organ Sharing findings as prior information, allowing to generate an Early Graft Loss-Donor Risk Index and an Early Graft Loss-Recipient Risk Index. A Donor-Recipient Allocation Model, obtained by adding Early Graft Loss-Donor Risk Index to Early Graft Loss-Recipient Risk Index, was then validated in a distinct United Network for Organ Sharing (year 2010) cohort including 2964 transplants. Donor-Recipient Allocation Model updating using the independent Turin Transplant Centre dataset, allowed to predict Early Graft Loss with good accuracy (c-statistic: 0.76).

CONCLUSION

Donor-Recipient Allocation Model allows a reliable donor and recipient-based Early Graft Loss prediction. The Bayesian approach permits to adapt the original Donor-Recipient Allocation Model by incorporating evidence from other cohorts, resulting in significantly improved predictive capability.

Abstract P6-10-01: Evaluation of post-progression survival (PPS) in advanced breast cancer (ABC) according to treatment line: Correlation with PFS and OS in an unselected population

Background: MBC remains an incurable disease with a median survival of 2-3 years despite the use of new drugs. The validation of PPS as surrogate endpoint and its correlation to PFS and OS is matter of debate.

Methods: From 2006-2012 we analyzed retrospectively consecutive 192 pts treated for MBC outside of clinical trials, 103 with at least 3 lines CT, in order to evaluate post-progression survival (PPS) according to treatment line and its relation to PFS and OS. Moreover we evaluated the gain of benefit after CT3 and predictive factors of response to multiple lines of therapy.

Results: Median age at M+ diagnosis was 59 years (30-89), median site of disease was 2 (1-6), 67% visceral, HER-2 + pts 32%, median number of anti-Her-2 treatment was 2 (0-6); median number of treatment was 3 (1-8). Median OS for all pts was 45.6 (95% CI: 36.5-54.7). Median OS for CT > = 3 vs CT < 3 was respectively 52.5 (95% CI: 43.3-61.7) and 32.3 (95% CI: 23.6-41.2) P = 0.007. Multivariate Cox analysis showed that OS is related with ER/Pgr status (positive versus negative p<0.0001) number of lines (>3 vs ≤3) p = 0.001 and number of metastatic sites (>2 vs ≤2) p<0.0001. We evaluated the relation between PFS and OS and between PPS and OS until the 6th line of therapy with a linear regression model.

 Median PFS (95% c.i.)Median PPS (95% c.i.)Median OS from M+ diagnosisCorrelation OS-PPSCorrelation OS-PFS1st line11.0 (9.5-12.5)29.9 (18.2-41.6)Not reachedP<0.0001 OS-PPS1P<0.0001 OS-PFS12nd line7.0 (5.8-8.2)20.9 (11.7-30.0)29.1 (17.5-40.7)P<0.0001 OS-PPS2P<0.0001 OS-PFS23rd line5.6 (4.5-6.7)19.5 (14.9-24.1)41.9 (15.5-68.2)P<0.0001 OS-PPS3P<0.0001 OS-PFS34th line5.7 (4.0-7.4)15.3 (13.4-17.2)50.4 (27.4-73.4)P<0.0001 OS-PPS4P<0.0001 OS-PFS45th line3.9 (3.1-4.7)11.2 (7.8-14.5)65.9 (20.8-112.2)P = 0.004 OS-PPS5P<0.0001 OS-PFS56th line3.3 (2.6-4.0)8.2 (2.2-14.2)56.8 (48.7-64.9)P = 0.36 OS- PPS6P = 0.002 OS-PFS6

Conclusion: These results supported the use of chemotherapy after CT3. PFS and PPS are related to OS until the 6th line of treatment. The utility of PPS as surrogate endpoint of OS is a valid hypothesis that could be evaluated in prospective trials of MBC.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-10-01.

Plasma concentrations but not serum concentrations of brain-derived neurotrophic factor are related to pro-inflammatory cytokines in patients undergoing major abdominal surgery

OBJECTIVES

To investigate peripheral brain-derived neurotrophic factor (BDNF) concentrations in the perioperative period, their relationship with transforming growth factor-β1 (TGF-β1 tumour necrosis factor-α (TNF-α), interleukin-6 (IL-6) and IL-6 genetics.

DESIGN AND METHODS

Prospective, observational study. BDNF, TGF-β1, IL-6 and TNF-α were analysed at baseline (T0), 5 h (T1), 24 h (T2) and 5 days (T3) after surgery, in 21 patients. The IL-6 -174 G/C polymorphism was genotyped.

RESULTS

Serum BDNF concentrations decreased (P=0.048), correlated with TGF-β1 (r=0.610 at T1, r=0.493 at T2, r=0.554 at T3). Plasma BDNF concentrations raised (P=0.049), correlated with IL-6 and TNF-α at T1 (r=0.495 and r=0.441, respectively). BDNF response was predictable from TNF-α and IL-6 concentrations and the IL-6 -174 G/C genotype.

CONCLUSION

Serum and plasma BDNF concentrations could relate to platelet activation and inflammatory response, respectively. IL-6 genetics played a role in the BDNF acute response.

Balancing donor and recipient risk factors in liver transplantation: the value of D-MELD with particular reference to HCV recipients

Donor-recipient match is a matter of debate in liver transplantation. D-MELD (donor age × recipient biochemical model for end-stage liver disease [MELD]) and other factors were analyzed on a national Italian database recording 5946 liver transplants. Primary endpoint was to determine factors predictive of 3-year patient survival. D-MELD cutoff predictive of 5-year patient survival <50% (5yrsPS<50%) was investigated. A prognosis calculator was implemented (http://www.D-MELD.com). Differences among D-MELD deciles allowed their regrouping into three D-MELD classes (A < 338, B 338-1628, C >1628). At 3 years, the odds ratio (OR) for death was 2.03 (95% confidence interval [CI], 1.44-2.85) in D-MELD class C versus B. The OR was 0.40 (95% CI, 0.24-0.66) in class A versus class B. Other predictors were hepatitis C virus (HCV; OR = 1.42; 95% CI, 1.11-1.81), hepatitis B virus (HBV; OR = 0.69; 95% CI, 0.51-0.93), retransplant (OR = 1.82; 95% CI, 1.16-2.87) and low-volume center (OR = 1.48; 95% CI, 1.11-1.99). Cox regressions up to 90 months confirmed results. The hazard ratio was 1.97 (95% CI, 1.59-2.43) for D-MELD class C versus class B and 0.42 (95% CI, 0.29-0.60) for D-MELD class A versus class B. Recipient age, HCV, HBV and retransplant were also significant. The 5yrsPS<50% cutoff was identified only in HCV patients (D-MELD ≥ 1750). The innovative approach offered by D-MELD and covariates is helpful in predicting outcome after liver transplantation, especially in HCV recipients.

Balancing donor and recipient risk factors in liver transplantation: the value of D-MELD with particular reference to HCV recipients

Donor-recipient match is a matter of debate in liver transplantation. D-MELD (donor age × recipient biochemical model for end-stage liver disease [MELD]) and other factors were analyzed on a national Italian database recording 5946 liver transplants. Primary endpoint was to determine factors predictive of 3-year patient survival. D-MELD cutoff predictive of 5-year patient survival <50% (5yrsPS<50%) was investigated. A prognosis calculator was implemented (http://www.D-MELD.com). Differences among D-MELD deciles allowed their regrouping into three D-MELD classes (A < 338, B 338-1628, C >1628). At 3 years, the odds ratio (OR) for death was 2.03 (95% confidence interval [CI], 1.44-2.85) in D-MELD class C versus B. The OR was 0.40 (95% CI, 0.24-0.66) in class A versus class B. Other predictors were hepatitis C virus (HCV; OR = 1.42; 95% CI, 1.11-1.81), hepatitis B virus (HBV; OR = 0.69; 95% CI, 0.51-0.93), retransplant (OR = 1.82; 95% CI, 1.16-2.87) and low-volume center (OR = 1.48; 95% CI, 1.11-1.99). Cox regressions up to 90 months confirmed results. The hazard ratio was 1.97 (95% CI, 1.59-2.43) for D-MELD class C versus class B and 0.42 (95% CI, 0.29-0.60) for D-MELD class A versus class B. Recipient age, HCV, HBV and retransplant were also significant. The 5yrsPS<50% cutoff was identified only in HCV patients (D-MELD ≥ 1750). The innovative approach offered by D-MELD and covariates is helpful in predicting outcome after liver transplantation, especially in HCV recipients.

Randomized clinical trial of radiofrequency-assisted versus clamp-crushing liver resection

BACKGROUND

Surgical resection remains the treatment of choice for primary and secondary liver cancer. Complications are mainly related to blood loss. Radiofrequency-assisted liver resection (RF-R) has been proposed for parenchymal division as an alternative to clamp crushing in order to reduce blood loss.

METHODS

Fifty patients (median age 62 (range 30-82) years) undergoing hepatectomy were randomized to RF-R (24 patients) or the clamp-crushing method (26). In the RF-R group the resection plane was precoagulated by multiple insertion of a planar triple-cooled radiofrequency ablation needle, and then the parenchyma was sectioned using a scalpel.

RESULTS

The two groups were well matched in terms of age, sex, liver disease and type of resection. There were no deaths. Eight in the RF-R group developed complications (abscess in six, biliary fistula in three and biliary stenosis in one) compared with none of those who had resection by the crush method (P < 0.001). Two patients with cirrhosis in each group developed decompensation. Blood transfusion was required in eight of 24 patients in the RF-R group and 13 of 26 in the clamp-crushing group (P = 0.079).

CONCLUSION

RF-R allows parenchymal resection in a clean surgical field but is associated with a higher rate of postoperative complications than the clamp-crushing technique.

Single hepatocellular carcinoma ranging from 3 to 5 cm: radiofrequency ablation or resection?

BACKGROUND

The optimal therapy for hepatocellular carcinoma (HCC) is transplantation. For all those patients not eligible for transplantation (or on the waiting list) among the treatments of choice used more frequently in recent years are resection (RES) and radiofrequency ablation (RFA). RFA is less efficacious for HCC ranging over 3 cm. The aim of this study was to compare RFA to RES in a restricted cohort of patients with a single naive HCC ranging from 3 to 5 cm in size and without end-stage liver disease. PATIENTS AND METHODS. A total of 102 patients who had never been treated before were enrolled. Those patients whose HCC position would have required too much parenchymal loss at RES (central or close to main vascular structures) were treated with RFA (n=60), and the others underwent RES (n=42). The two groups were similar for HCC size and liver disease status. The outcome was considered in terms of overall survival (OS) and disease-free survival (DFS) calculated by the Kaplan-Meier method. Differences among groups were validated by log-rank test.

RESULTS

The RES group seemed to present a better long-term OS (91%, 57%, and 43% vs 96%, 53%, and 32% at 1, 3, and 5 years, respectively) and DFS (74%, 35%, and 14% vs 68%, 18%, and 0%, respectively) but there was no statistical significance. Age, gender, virus etiology, HCC size and alpha-fetoprotein levels did not correlate with survival. Patients with recurrence within the first 12 months after treatment showed a worse long-term survival (p=0.011). Patients in Child-Pugh class B had poor prognoses compared with those in class A (p=0.047).

CONCLUSION

Even if RES seemed to promise better long-term results, in the medium term this difference had no statistical significance. Survival in this series was more closely related to the stage of the underlying liver disease than to treatment (RES/RFA).

[Smoking habits in health care workers: experience in two general hospitals of Eastern Sicily]

PURPOSE

The aim of our study was to assess the smoking habits in health care workers.

MATERIALS AND METHODS

In concomitance with a medical examination for Health Care Surveillance requested by the Italian Laws (D. Lgs. 626/94), our operative units interviewed 2,000 persons (47.9% males, 52.1% females, mean age = 45 yrs (SD+/-9.41 yrs) working in two General Hospitals of Eastern Sicily.

RESULTS

The prevalence of smokers was found to be higher in men (34.5%) than in women (33.6%), in Health Care Operators (36.4%) and professional nurses (36.2%) than in medical doctors (27.7%), in night-time workers (34,5%) then in day-time-workers (28,7%). The compliance with smoking restriction was found to be poor; in fact, 60% out of smokers declared to smoke during the working hours.

CONCLUSIONS

This investigation has revealed the significant prevalence of tobacco smoking among the health care workers in general. We think that the inclusion of an anonymous questionnaire on smoking habits within the Services of Sanitary Surveillance may help in the national campaign against cigarette smoking.

Lipoprotein(a), lipids and proinflammatory cytokines in patients undergoing major abdominal surgery

Background

The aims were to investigate whether surgical stress can induce a positive or negative lipoprotein(a) acute response, to determine any association with apolipoprotein(a) phenotypes, and to establish whether any such response is dependent on changes in lipids and proinflammatory cytokines. In addition, the impact of interleukin (IL) 6 genetic variability on the cytokine response to surgery was examined.

Methods

This prospective, observational study included 41 patients with cancer referred for abdominal surgery. Preoperative (T0) plasma concentrations of lipoprotein(a), IL-6, tumour necrosis factor α, and serum concentrations of transforming growth factor β1 and lipids, were compared with values obtained 5 h (T1), 24 h (T2) and 5 days (T3) after surgery. Apolipoprotein(a) Kringle IV (KIV)-VNTR (variable-number tandem repeat) and IL-6 − 174 G/C polymorphisms were analysed.

Results

Lipoprotein(a) was found to act as a negative acute-phase reactant (30·0 per cent reduction at T2) (P = 0·009). Surgery had a more profound impact on subjects with low KIV-VNTR. After surgery, lipoprotein(a) correlated significantly with corrected low-density lipoprotein (LDL)-cholesterol (r = 0·408 at T2). IL-6 inversely correlated with lipoprotein(a) (r = −0·321 at T1) and LDL-cholesterol (r = −0·418 at T1). The IL-6 response could be predicted from a combination of the surgical severity and −174 G/C genotype.

Conclusion

Although temporal associations did not indicate causality, these data provide a hypothesis to explain the inverse relationship between lipoprotein(a) and IL-6.

MELD Predictive Value of Alterations of Brain Perfusion During Liver Transplantation

INTRODUCTION

The systemic circulation of patients with liver failure is characterized by low vascular resistance and a compensatorily increased cardiac output. In addition, some patients show functional loss of the autoregulation system for cerebral blood flow, creating enhanced risk during orthotopic liver transplantation (OLT), a possible cause of the high incidence of central nervous system complications after OLT.

PATIENTS AND METHODS

Sixteen consecutive patients undergoing OLT were enrolled and characterized by the Child-Pugh (CTP), the MELD, and the HCC-adjusted-MELD score before surgery. OLT was performed with the "piggyback" technique. Brain perfusion and oxygenation was monitored by NIRO300 by Hamamatsu. This instrument detects concentration changes in oxygenated hemoglobin (DeltaHbO(2)), deoxygenated hemoglobin (DeltaHHb), and total volume of hemoglobin (DeltaHbT). It also calculates the tissue oxygenation index (TOI), namely HbO(2)/HbT expressed as a percentage, and the tissue hemoglobin index (THI).

RESULTS

The lowest levels of brain perfusion were recorded at the washout, DeltaHbO(2) = -13.95 (-20/-5.3) micromol L(-1) and TOI = 51.5 (35.2/70.7)%, while immediately after, at reperfusion, the highest peaks were observed: DeltaHbO(2) was 0.16 (16.9/13) micromol L(-1); DeltaHbT was 1.1 (22.3/11.8) mumol L(-1); and TOI was 73.6 (78.1/65.3)%.

CONCLUSIONS

Patients with more severe liver deficiency scores showed higher levels of brain perfusion and oxygenation during surgery. Both the MELD and the CTP score predict alterations in brain perfusion.

[Essential levels of care and mode of admission: a trial of cost-volume contracts]

Within a research project funded by the Ministry of Health, the purpose of this work was to define the procedures of a contract for the provision of health services (hospital admissions), between the regional health administration (the "buyer") and the University teaching hospital (the "provider"), with the aim of improving efficiency. The contract concerned a few DRGs, among those identified as being "at risk of inappropriateness", in the national decree on "essential levels of care" (LEA). The contract defined production levels (number and percentage of admissions in day hospital), financing rules and methods for evaluation of results and improvement of performance within the hospital. This trial, even if run for a limited time and for demonstration purposes, showed that some results can be attained, provided some organizational adjustments are made.

Solutions for Organ Perfusion and Storage: Haemorheologic Aspects

BACKGROUND

The hydroxyethyl starch (HES) contained in University of Wisconsin (UW) solution causes erythrocyte aggregation. The effect of UW on red blood cell (RBC) deformability is still unclear. HES-free preservation solutions, Celsior (CS) and Custodiol (CU) are available. In this study we evaluated whether they really showed a reduced aggregating and stiffening effect on RBCs when compared with UW. We was also evaluated the effect of these solutions on cellular membranes by measuring acetylcholinesterase (AChE), which is a marker of RBC membrane integrity.

METHODS

The determination of RBC aggregation and deformability was performed by a laser-assisted optical rotation cell analyzer (LORCA). AChE measurement was performed with a spectrophotometric technique.

RESULTS

The mean RBC aggregation index (AI) measured in pure blood control samples was 28.00 +/- 0.73%. The AI measured samples containing UW was 38.82 +/- 1.58%. In samples with CS, it was 13.307 +/- 0.64% and in samples with CU the mean AI was 12.47 +/- 0.42%. Also the RBC aggregating time was quicker in presence of UW compared with controls. AChE concentration in blood was 3.043 +/- 0.4 nmol. CS and UW did not produce any significant change; a significant reduction was found when CU was added to blood, namely 1.975 +/- 0.1 nmol (P < .05). The use of UW or CS or CU did not result in any significant change in RBC deformability.

DISCUSSION

CS and CU solutions do not aggregate erythrocytes, whereas Wisconsin does massively. CU causes an alteration of RBC cellular membrane as demonstrated by depletion of AChE.

[Gene expression of the MAGE-1, -3, and -6 antigens in hepatic carcinoma]

MAGE is a family of genes specifically associated to human melanoma, but also found in hepatocellular carcinoma (HCC). In this study we evaluated the expression of such genes in 41 HCC patients, their correlation with pathological and clinical aspects of cancer, and the impact on prognosis. MAGE are expressed in most of HCC samples (28/41), no correlation was found with type and stage but they may be used as potential target for IT.

[Anatomical hepatic resection using radiofrequency thermoablation in the treatment of primary or secondary liver tumors]

Radiofrequency thermoablation (RFA) in performing parenchymal liver section has been tested. Eleven patients with primary cancer or colorectal cancer metastasis underwent anatomical major liver resection after vascular control. Parenchymal section was performed by knife after coagulative necrosis. No deaths, clinical or technical complications or blood losses occurred. Such technique is feasible and effective.

Premenopausal women affected by sexual arousal disorder treated with sildenafil: a double-blind, cross-over, placebo-controlled study

OBJECTIVE

To verify whether sildenafil is effective in young premenopausal women affected by arousal disorder.

DESIGN

A double-blind cross-over study.

SETTING

Centre for Sexological Research, Department of Microbiological and Gynaecological Science, University of Catania, Italy.

SAMPLE

Fifty-three volunteer women aged 22-28 years affected by arousal disorders.

METHODS

The study consisted of three 4-week periods: sildenafil, washout, placebo, by six possible sequences. sildenafil was used at 25 mg or 50 mg.

MAIN OUTCOME MEASURES

Efficacy was assessed at baseline and once monthly by the Personal Experiences Questionnaire based on the 5-point Likert scale. The questionnaire quantified subjective arousal (primary endpoint), and orgasm, enjoyment, sexual frequency, and the number of sexual fantasies.

RESULTS

Fifty-one women completed the study. Mean (SD) usage of sildenafil 25mg and 50mg was, respectively, 2.8 (0.8) and 2.7 (1.3) times weekly, while mean usage of placebo was 2.8 (1.6) times weekly. During both sildenafil dosages, arousal and orgasm improved with respect to placebo (P < 0.001). Therapeutically significant differences were not noted during the treatment with both 50 mg and 25 mg of sildenafil for arousal and orgasm. The frequency of sexual fantasies and of sexual intercourse, and enjoyment, improved in the women treated with sildenafil (P < 0.05).

CONCLUSIONS

Our study suggests that sildenafil may improve sexual performance of women affected by sexual difficulties such as arousal disorder, and may indirectly improve other aspects of sexual life. Moreover, further studies need to define the use of PDE type 5 inhibitors in this sexual pathophysiology.

Antiviral and antiproliferative activity in vitro of some new benzimidazole derivatives

The antiviral and antiproliferative activity of new compounds having n-benzenesulphony 1-2 (2 or 3-pyridylethyl) benzimidazole as a base structure were studied in vitro. Their antitumour activity against human chronic myeloid leukaemia cells was evaluated and compared with that of equimolar doses of daunorubicin. Only compound 7a, with the presence of both the pyridyl moiety bound at the ethylenic bridge in C-2 of benzimidazole and the nitro-group in the benzene ring, displays a selective antiproliferative effect against certain leukaemia cells and a good antiviral activity especially towards the Coxsackie B5 virus. However, it should be noted that, in the case of hydroxybenzyl-benzimidazole, resistance also builds up to compound 7a, the Coxsackie B5 virus developing resistance to it after about ten runs. Cytotoxicity tests show that many of these substances are well tolerated by the VERO cells. The mechanism of action is still unclear.

Accuracy of exercise testing in the assessment of the severity of myocardial ischemia as determined by means of technetium-99m tetrofosmin SPECT scintigraphy

BACKGROUND

The separation of patients with suspected or known coronary artery disease into low- and high-risk subgroups by means of noninvasive testing is highly relevant in the selection of patients who require further diagnostic or therapeutic investigation. We evaluated whether exercise electrocardiographic variables during exercise testing might be a means of predicting the severity of myocardial ischemia as assessed with myocardial scintigraphy.

METHODS AND RESULTS

We retrospectively reviewed 816 consecutive patients (mean age, 57+/-10 years) who underwent exercise technetium-99m tetrofosmin single photon emission computed tomography (SPECT) for the assessment of suspected or known coronary artery disease. Eight independent significant predictors of the extent and severity of reversible perfusion defects (ischemic perfusion score), which when integrated in a diagnostic algorithm satisfactorily discriminated patients with no reversible perfusion defects (sensitivity, 75%; specificity, 80%) and patients with severe impaired myocardial perfusion (> or =11 ischemic perfusion score; sensitivity, 77%; specificity, 82%), were identified by means of stepwise discriminant analysis. However, patients with mildly to moderately impaired myocardial perfusion (> or =21 but <11 ischemic perfusion score) were poorly discriminated (sensitivity, 50%; specificity, 78%). The set of variables that were significant (P<.0001) for prediction included sex, myocardial infarction, exercise angina, the maximal amount of ST segment depression, rate-pressure product threshold criteria, slope of ST segment depression, ST/heart rate index, and peak exercise heart rate.

CONCLUSIONS

The results of the use of clinical and electrocardiographic exercise variables satisfactorily agrees with the results from scintigraphy only for patients with no reversible perfusion defects and with severely impaired myocardial perfusion. However, it fails as an approach with universal applicability.

Cytotoxicity and probable mechanism of action of sulphimidazole

Sulphimidazole (1-methyl-2((4-aminophenyl)-sulphonyl)-amino-5-nitroimidazole) is a new compound in which a p-aminobenzenesulphonamide radical has been attached at position 2 of the 5-nitroimidazole ring. It possesses a useful spectrum of activity in vitro against various anaerobic microorganisms and its action against aerobic and facultative bacteria is synergically enhanced in association with trimethoprim. In the present study, we determined the cytotoxicity in vitro of sulphimidazole and trimethoprim, both alone and in combination, and analysed the viability of Vero cells and the protein content of their cell lysate in the presence of increasing concentrations of these drugs. Also, in order to verify the hypothesis that the action of sulphimidazole against aerobic and facultative bacteria is mediated by the sulphonamide component of the molecule, while that against anaerobic bacteria depends on the action of the nitro group of the 5-nitroimidazole ring, we studied the mechanism of action of the new compound both indirectly, by means of microbiological techniques, and directly, by determining its oxidoreduction potential with respect to that of metronidazole. The results show that sulphimidazole is only slightly toxic in vitro for Vero cells, either alone or in association with trimethoprim, and that the combination of the two functional groups in a single molecule not only maintains its structure-activity relationship intact but also broadens its antibacterial spectrum.

Immune responses to administration of a vaccine against Haemophilus influenzae type B in splenectomized and non-splenectomized patients

OBJECTIVES

we investigated the cause of hypo-responsiveness to vaccines in splenectomized subjects.

METHODS

we evaluated the immune responses to a Haemophilus influenzae type b vaccine and the sizes of lymphocyte subpopulations in 25 splenectomized and 45 non-splenectomized thalassaemic patients, in 12 individuals who had been splenectomized after trauma and in 20 controls.

RESULTS

the immune response in the controls was significantly higher (P < 0.001) than in splenectomized patients after trauma and in both, the response was higher (P < 0.001) than in thalassaemic patients. In asplenic subjects after trauma, percentages of CD3 and CD4 cells were lower (P < 0.001) than in patients in the other groups; the controls had higher percentages of CD8 cells (P < 0.001) than patients in the other groups. The natural logarithm of the mean percentage of (CD19 showed a quadratic trend from thalassaemic patients through asplenic subjects to controls (P < 0.001). Levels of CD16+ natural killer (NK) cells were higher (P < 0.001) only in asplenic subjects after trauma.

CONCLUSIONS

the significant decrease in the immune response of the splenectomized thalassaemic patients vs. non-splenectomized thalassaemic patients may, in part, be due to their basic immunological condition. Thus, the best strategy for protecting these subjects is to vaccinate them before the splenectomy.

Synthesis and antiproliferative activity of some N-sulphonated-2-substituted benzimidazoles and imidazo[4,5-b]pyridines

Some N-sulphonated-2-substituted benzimidazoles and imidazo[4,5-b]-pyridines were synthesized and tested in vitro for antiviral and antiproliferative activity. None of the compounds had antiviral properties. However, three of them inhibited the proliferation of leukaemia and lymphoma cell lines at micromolar concentrations. The maximum potency of antiproliferative activity is correlated with the presence of an ethylenic spacer between the two heterocycles.

Outcome of differentiated thyroid cancer in Graves' patients

The clinical behavior and outcome was evaluated in 21 nonoccult differentiated thyroid carcinomas occurring in Graves' patients during the period 1982-94 and compared with that of matched tumors occurring in euthyroid controls (n = 70). At surgery, patients with Graves' disease showed distant metastases more frequently than euthyroid patients (3/21 = 14.3% vs. 1/70 = 1.4%, P = 0.0556). Graves' patients also showed a significantly higher cumulative risk of recurrent/progressive distant metastases or total adverse events (odd ratios = 3.14 and 2.07, respectively) as compared with euthyroid patients. At the last follow-up visit, persistence of distant metastases was also more frequent in the Graves' group (P = 0.007), although the cumulative individual dose of radioiodine administered was higher than in the control group (median dose = 805 mCi vs. 350 mCi). Two patients died in the Graves' group vs. none in the control group. Circulating thyroid stimulating antibodies were present in all patients but one and persisted as long as signs of disease were evident. These findings indicate that differentiated thyroid carcinomas in patients with Graves' disease are more aggressive than those occurring in matched euthyroid controls and should, therefore, be managed accordingly.

Postoperative changes in serum interleukin-2 concentrations

OBJECTIVE

To evaluate the postoperative changes in circulating interleukin-2 (IL-2) concentration according to the severity of the surgical injury and other postoperative variables that could influence IL-2 production.

DESIGN

Prospective observational study.

SETTING

University hospital, Italy.

SUBJECTS

43 patients about to undergo major operations (gastric and colo-rectal resection for cancer), intermediate operations (open cholecystectomy or mastectomy for cancer), and minor operations (hernia repair or breast lump); 24 healthy age and sex matched controls.

MAIN OUTCOME MEASURES

Postoperative changes in serum concentrations of IL-2 after different degrees of surgery on the 1st, 3rd and 8th postoperative days correlated with changes in in vivo cellular mediated immunity (skin tests), duration of operation, blood transfusion or postoperative H2-blockers and antiprostaglandins.

RESULTS

There were no significant variations in IL-2 serum concentrations postoperatively on ANOVA, and when the data were normalised, there were no significant changes in the median postoperative values after minor and intermediate operations. There was a slight but not significant increase in IL-2 concentrations after major operations. Neither blood transfusion nor duration of operation correlated with postoperative changes in IL-2, while postoperative antiprostaglandins and H2-blockers seemed to provide slight but not significant protection against a reduction in IL-2 concentrations.

CONCLUSIONS

Circulating IL-2 does not necessarily correlate with reported in vitro postoperative production of IL-2 and therefore seems to be of little use in monitoring immunosuppression in surgical patients.

[Blood flow assessment with Doppler color ultrasonography in primary and secondary tumors of the liver]

Our study was aimed at measuring hemodynamic changes in liver perfusion in patients with HCC and hepatic metastases using color Doppler US, a noninvasive investigation technique. Eighty-seven patients were examined: 14 of them had HCC and 34 had metastases; the control group consisted of 39 people. Blood flow was measured in the common hepatic artery and portal vein and the ratio of hepatic arterial to total liver blood flow (HPI = hepatic perfusion index) and the ratio of hepatic arterial to portal venous blood flow (A/V ratio) were calculated. HPI and A/V values were changed in HCC patients (HPI = 0.23, range: 0.16-0.35; A/V = 0.32, range: 0.19-0.55) as a consequence of reduced portal venous blood flow (9.76 +/- 2.51 cm3/s) and of increased hepatic arterial flow (2.78 +/- 0.46 cm3/s). HPI and A/V values were significantly changed also in the patients with hepatic metastases (HPI = 0.24, range: 0.11-0.38; A/V = 0.34, range: 0.12-0.61) compared with the control group. These changes were correlated with increased hepatic arterial blood flow (3.16 +/- 1.35 cm3/s) and decreased portal venous blood flow (10.39 +/- 3.81 cm3/s). These results prove the role of color Doppler US in the study of primary liver cancer and metastases. Additional examinations are nevertheless necessary to assess the diagnostic value of color Doppler US in the early detection of and discrimination between benign and malignant tumors.

The "proximal isovelocity surface area" method in assessing mitral valve area in patients with mitral stenosis and associated aortic regurgitation

BACKGROUND

This study compares the mitral valve area determined by Doppler color mapping of the proximal isovelocity surface area (PISA) and by Doppler pressure half-time with that obtained by two-dimensional planimetry in patients affected by mitral stenosis, with and without associated aortic regurgitation. Pressure half-time frequently overestimates the mitral valve area in patients with mitral stenosis and associated aortic regurgitation. PISA is an alternative method for determining mitral valve area in mitral stenosis and is not influenced by regurgitant lesions.

METHODS

We studied 76 patients with mitral stenosis; aortic regurgitation > or = 2 was present in 24 patients. The PISA was recorded from the apex and the transmitral maximal flow rate, Q (ml/s), was calculated using the hemispheric equation Q = 2 pi R2 x AV x alpha/180, where R (cm) is the maximal radius of the PISA, AV (cm/s) is the aliasing velocity and alpha/180 is a correction factor accounting for the alpha inflow angle formed by the mitral leaflets. Mitral valve area, A (cm2), was calculated by continuity equation A = Q/V, where V (cm/s) is the peak transmitral flow velocity measured by continuous wave Doppler.

RESULTS

The mitral valve area by two-dimensional planimetry (range 0.5-2.4 cm2; mean 1.33 +/- 0.41 cm2) was consistent with both PISA (r = 0.83; SEE 0.23 cm2) and pressure half-time (r = 0.79; SEE 0.25 cm2) methods. Similar agreement was found for the 36 patients with mitral regurgitation and for the 30 patients in atrial fibrillation. However, in patients with aortic regurgitation > or = 2, pressure half-time overestimated two-dimensional and PISA determined mitral valve areas by 0.24 +/- 0.25 cm2 (p < 0.01).

CONCLUSIONS

In patients with mitral stenosis and significant aortic regurgitation, the PISA method is more accurate than pressure half-time in assessing mitral valve area. This method may be a reliable alternative when pressure half-time is affected by aortic regurgitation and two-dimensional planimetry images are unsuitable for anatomic evaluation.

Cold thyroid nodule reduction with L-thyroxine can be predicted by initial nodule volume and cytological characteristics

In a previous study we demonstrated that a 1-yr treatment with L-T4 induces substantial nodule volume reduction (> or = 50%) in approximately 40% of patients with a benign solitary cold thyroid nodule. The present prospective study investigated whether it is possible to identify, before starting L-T4 treatment, nodules with a high probability to shrink in response to L-T4. We recorded several clinical and cytological features in a continuous series of 42 patients with a cold nodule and related them to the nodule volume response to 1-yr treatment with L-T4. Fisher discriminant analysis showed that a combination of some cytological features (colloid, degenerative changes, cellular hyperplasia, and fibrosis) and initial nodule volume can be used for predicting nodule volume reduction. In fact, although only 33% of all nodules shrank, 62% of colloid nodules and 57% of small degenerative nodules shrank. None of the hyperplastic or fibrotic nodules shrank. These results were validated in a different retrospective series of 46 patients and allowed us to predict nodule reduction in over 80% of the cases.

Improved accuracy of computed tomography in local staging of rectal cancer using water enema

A new technique in the preoperative staging computed tomography of rectal cancer using a water enema to promote full distension of the rectum was compared with standard CT in a non-randomised blind study. One hundred and twenty-one patients were enrolled. There were 57 in the water enema CT group and 64 in the standard group. The stage of the disease was assessed following strict criteria and tested against the pathological examination of the resected specimen. Water enema CT was significantly more accurate than standard CT with an accuracy of 84.2% vs. 62.5% (Kappa: 0.56 vs. 0.33: Kappa Weighted: 0.93 vs. 0.84). The diagnostic gain was mainly evident in the identification of rectal wall invasion within or beyond the muscle layer (94.7 vs. 61). The increased accuracy was 33.7% (CL95: 17-49; P < 0.001). The results indicate that water enema CT should replace CT for staging rectal cancer and may offer an alternative to endorectal ultrasound.

Reduction of postoperative immunosuppression with ranitidine in patients with cancer of the stomach or large bowel

OBJECTIVE

To assess the effect of ranitidine on cellular immune response (and postoperative infective morbidity) in a homogeneous group of patients.

DESIGN

Prospective randomized controlled trial.

SETTING

University hospital, Italy.

SUBJECTS

42 patients about to undergo curative resection for carcinoma of the colon, rectum, or stomach.

INTERVENTIONS

Cell mediated immunity was tested 3 days before, and 4 days after, operation by reactions to 7 recall antigens (Multitest, Merieux). 21 patients were randomly allocated to receive ranitidine 100 mg twice daily intravenously from the day before operation until the third postoperative day.

MAIN OUTCOME MEASURES

Comparison of the number of reactive patients and number of positive antigens before and after operation; and correlation between reactivity and incidence of postoperative infective complications.

RESULTS

The median (range) skin test scores preoperatively were: ranitidine group 8.5 (0-17), and control group 10 (0-19). The postoperative figures were 7 (0-28) and 4.5 (0-15.5) respectively. The corresponding numbers of positive antigens were 1 (0-4) and 3 (0-4) compared with 1 (0-5) and 1 (0-3). The changes in the scores did not seem to be influenced by blood transfusion, serum albumin concentration, age of the patient, or type of tumour. Two patients died in the ranitidine group (pulmonary embulus, n = 1, necrotising pancreatitis, n = 1) and there were 4 wound infections. There were no deaths in the control group, one intra-abdominal abscess, and 8 wound infections. Median hospital stay was similar, 10 (8-16) in the ranitidine group, and 11 (5-20) in the control group.

CONCLUSION

Ranitidine had a beneficial effect on cell-mediated immunity as it seemed to prevent the usual postoperative reduction in reactivity, but there was no significant difference in the incidence of infective complications though it was lower in the ranitidine group.

Levothyroxine and potassium iodide are both effective in treating benign solitary solid cold nodules of the thyroid

OBJECTIVE

To determine the effectiveness of levothyroxine and potassium iodide in treating patients with benign solitary cold thyroid nodules.

DESIGN

Randomized controlled study.

SETTING

Outpatient clinic at a university hospital.

PATIENTS

80 patients with solitary solid cold thyroid nodules found to be benign at cytologic examination were randomly assigned to no treatment, suppressive levothyroxine (thyroid-stimulating hormone level, < 0.3 mU/L), or low-dose potassium iodide (2 mg every 2 weeks). Seventy patients completed the 1-year study. After 1 year, patients receiving treatment discontinued drug therapy and were re-evaluated 4 months later; patients receiving no treatment were given levothyroxine and were followed for a second year.

MEASUREMENTS

Nodule volume was measured by ultrasonography at 4-month intervals by an observer masked to treatment assignment.

RESULTS

Mean nodule volume decreased by 40% of the basal volume in the 23 patients receiving levothyroxine (P < 0.001) and by 23% of the basal volume in the 25 patients receiving potassium iodide (P = 0.053). Volume slightly increased in the 22 untreated patients (P = 0.085). A clinically relevant reduction in nodule volume (> or = 50%) was observed in 9 of 23 patients treated with levothyroxine, in 5 of 25 patients treated with potassium iodide, and in none of 22 untreated patients (P = 0.004). Only nodules with a volume of 10 mL or less were reduced; nodules with volumes of 5 mL or less shrank most frequently. Nodule volume did not relevantly increase in treated patients but did increase in 3 of the 22 untreated patients. Drug withdrawal resulted in an increased mean nodule volume (P = 0.004) after 4 months.

CONCLUSIONS

Levothyroxine and, to a lesser extent, potassium iodide are effective in arresting the growth or in reducing the volume of benign solitary solid cold thyroid nodules, especially small ones; discontinuation of therapy may result in resumed nodule growth.

Immune status and immune response to diphtheria-tetanus and polio vaccines in allogeneic bone marrow-transplanted thalassemic patients

We evaluated the immune status against diphtheria (D), tetanus (T) and polio viruses (PV) and the immune response to re-administration of the respective vaccines in a series of 23 transplanted homozygous beta-thalassemic patients, aged 5-17 years (mean age 12.1 +/- 3.1 years). They had been given compulsory DT toxoids and types 1, 2 and 3 PV vaccine in infancy and had been successfully submitted to allogeneic BMT 2-6 years previously. Prior to revaccination, a high percentage of subjects (from 48% for type 2 PV to 83% for D) had antibody levels below the protective levels and low geometric mean titers (GMTs). After revaccination (three doses of DT toxoids and of inactivated PV vaccine) the percentage of subjects with protective levels of antibodies rose to 86-100% and the GMTs increased markedly. We conclude that: (1) the protection afforded by compulsory DT and PV vaccines administered in infancy is almost entirely lost in beta-thalassemic patients for several years after BMT, (2) revaccination is necessary in these subjects, and (3) at least three doses of DT and PV vaccines must be administered to recover adequate protection.

Reliability of clinical judgement in evaluation of the nutritional status of surgical patients

The ability of surgeons to make a reproducible and reliable evaluation of the nutritional status of patients was assessed. Three independent observers assigned 64 patients to one of four nutritional states--normal nourishment, and mild, moderate and severe malnutrition--using a questionnaire and clinical examination. Interobserver variability was analysed using the kappa statistic and reliability by assessing the correlation between the assigned class and total serum protein, haemoglobin, albumin, transferrin and cholesterol levels, weight loss and the results of immunological skin tests. Concordance was observed in 49 of the 64 judgements (77 per cent) and partial agreement in the remainder (kappa = 0.74, P < 0.001). Clinical judgement correlated significantly with albumin, transferrin and cholesterol levels and weight loss (R2 = 0.73, P < 0.001). Surgeons are able to assess nutritional status using clinical judgement.

Cancer risk in patients with cold thyroid nodules: relevance of iodine intake, sex, age, and multinodularity

PURPOSE

We evaluated the frequency of thyroid cancer in patients with cold thyroid nodules in relation to iodine intake, sex, age, and multinodularity in a consecutive series of patients with nodular thyroid diseases.

PATIENTS

In the period from 1980 to 1990, 5,637 patients were studied: 4,176 patients were from an iodine-sufficient area (ISA) and 1,461 from an adjacent iodine-deficient area (IDA). Surgery was performed in 792 patients on the basis of a suspicious or malignant finding at fine-needle aspiration biopsy.

RESULTS

The overall thyroid cancer frequency was 4.6% (259 patients had cancer). Iodine intake affected the cancer rate in patients with cold nodules. The frequency of cancer in patients with cold thyroid nodules was 5.3% in the ISA and 2.7% in the IDA. This difference, however, was significant only in females. Sex had a major influence on the malignant rate of cold nodules; although female patients were more frequently observed (n = 5,028) than male patients (n = 609), the frequency of cancer was significantly lower in female patients with cold nodules (4.2%) than in males (8.2%). Age was an important factor in both sexes. The proportion of nodules that were malignant was smallest in patients of the 4th decade and was greatest in patients younger than 30 years or older than 60 years. Multivariate analysis showed that sex and age interact in determining the cancer risk in patients with thyroid nodules. Finally, the frequency of thyroid cancer in patients with a solitary nodule was not different from the frequency in patients with multiple nodules.

CONCLUSION

Our study indicates that thyroid cancer risk in a patient with a nodular goiter varies markedly according to iodine intake, sex, and age but not in relation to multinodularity, as assessed by clinical examination. The knowledge of these epidemiologic aspects of thyroid cancer may increase the accuracy of the preoperative selection of patients with cold nodules of the thyroid.

Relation between steroid receptor status and body weight in breast cancer patients

Obesity is known to adversely affect breast cancer prognosis. Since obesity is associated with increased oestrogen levels, and oestrogens are growth stimulators of oestrogen receptor (ER)-positive breast carcinomas, we evaluated the relationship between the ER and progesterone receptor (PR) status of the neoplastic tissue and obesity in a series of 615 breast cancer patients. Both ER and PR concentrations were significantly and positively correlated with obesity by multiple regression analysis. Furthermore, the estimated probability of having an ER+/PR+carcinoma was significantly higher in obese patients (odds ratio 2.65, 95% confidence interval 1.56-4.48). This association between receptor-positive status and obesity was observed both in premenopausal and postmenopausal patients. Our data suggest, therefore, that obesity plays a role in determining the ER status of breast cancer and raise the possibility that ER presence in breast carcinomas occurring in obese patients is not indicative of a favourable prognosis.

Rectal carcinoma: CT staging with water as contrast medium

Computed tomography (CT) was used to study 42 patients with rectal carcinoma. Water was used as a contrast medium for studying the local extent of tumor in all patients. Scans were read prospectively without knowledge of the histologic staging and then compared with pathologic specimens. CT depicted the tumor in all patients. Comparison of CT and histologic results (following the Dukes classification) showed that disease was correctly staged as A in three of four patients, as B in eight of 12, as C in 15 of 17, and as D in nine of nine. Overall, carcinoma was correctly staged with CT in 35 of 42 patients (diagnostic accuracy, 83.3%). The accuracy in the assessment of local invasion was 97.6% (41 of 42). In the detection of lymph node involvement, the accuracy was 78.6% (sensitivity, 88%; specificity, 64.7%). CT is recommended in the preoperative staging of rectal carcinoma and as an aid in choosing the appropriate therapy. The use of water enema and complete distention of the rectum are reliable techniques for improving the accuracy of CT in the assessment of local invasion by cancer.

[Epidemiological survey of dental caries in 937 middle school students in Gravina, Catania]

The AA. have carried out a transversal epidemiologic investigation on 937 children attending the school of Gravina. The age of the subjects range from 10 to 14 years. In these young subjects dental decays percentage, DMF/dmf were evaluated and compared to age and oral hygiene. Oral hygiene has been expressed with values ranging from 1 to 3, the point 1 showed the best situation and 3 the worst. It has been evaluated also the number of subjects with dental decay that have been cured by the dentist. No correlation between dental decay and weight has been found infact X analysis was not significative.

Protective colostomy closure: the hazards of a "minor" operation

A retrospective study of 87 patients, subjected to colostomy closure between 1976 and 1987, was conducted in order to evaluate the role of 8 potential risk factors on morbidity and mortality. Possible risk factors were age greater than 65 years, presence of hypoalbuminaemia (less than 3.0 gr%), anaemia (Hb less than 10 gr%), operative technique, duration of colostomy, site of colostomy, underlying disease and presence of subcutaneous drainage. Apart from hypoalbuminaemia, no clear risk factor was identified, although an interval of more than 90 days between construction and closure of colostomy appears to be safer than shorter intervals. A comparison was also made between two different periods from 1976 to 1982 and from 1983 to 1987 which resulted in important changes in patient management in the second period including: type of antibiotic prophylaxis, type of anastomosis and suture material, site of colostomy and mean duration of colostomy. Four post-operative deaths (4.6%) (two for myocardial insufficiency and two for sepsis), 11 major (13%) and 25 (29%) minor complications were recorded. The analysis of the two different periods showed a strong reduction in both mortality and morbidity in the second period, which could be related to a better management of this type of patient. In conclusion, the incidence of mortality and morbidity in colostomy closure cannot be underestimated and therefore the same skill and meticulous approach are required for this operation as for any major surgical procedure on the colon.

Prediction of mortality by logistic regression analysis in patients with postoperative enterocutaneous fistulae

The contrasting results of treatment of patients with postoperative enterocutaneous fistulae reflect the heterogeneity of the disease and depend on the patient's condition and the characteristics of the fistulae. For this reason, the use of a prognostic index, which enables such patients to be classified according to their risk of death, could be useful. In this study we propose a prognostic index based on a logistic regression analysis, obtained by using two (APACHE II score and serum albumin concentration) of the eight risk factors that have been retrospectively analysed in a series of 70 patients with postoperative enterocutaneous fistulae treated in our surgical department since 1981. The logistic regression equation indicates that patients with a probability of dying of less than 0.35 have a good prognosis, with a sensitivity of 90 per cent, a specificity of 90 per cent, a negative predictive value of 79 per cent, a positive predictive value of 96 per cent and an accuracy of 90 per cent. The predictive performance of the index has also been evaluated in a group of 17 patients studied prospectively, and this confirms the sensitivity and specificity of the model. This postoperative enterocutaneous fistulae index could be a helpful tool in clinical trials and surgical audit.

Epidemiology of acute diarrhea in children living in Sicily

A longitudinal survey (February 1984 - January 1985) on the incidence of acute diarrhea episodes in a sample of 8,164 children (aged 0-12 years) living in southeastern Sicily was carried out by means of weekly telephone interviews with doctors practising in the territory. The incidence rate was 0.479 (0.472-0.485 95% C.I.) per child per year and the frequency of episodes was significantly higher (p less than 0.001) in children aged 0-4 years (0.86). Diarrhea was more frequent in industrial areas than in rural ones, and almost half (45.1%) of the total episodes had a mild course. No death from diarrhea occurred and admission to hospital was reported for 8.4% of all cases.