The familial adenomatous polyposis region exhibits many different haplotypes

In the present study, we used five different polymorphic markers to construct the haplotype at the adenomatous polyposis coli (APC) locus in families with familial adenomatous polyposis (FAP) and in the normal Italian population. Non-ambiguous haplotypes were reconstructed from 246 normal chromosomes and 65 FAP chromosomes. In the control population, the four polymorphisms intragenic to APC gave rise to 16 haplotypes, the most common of which (II and XV) accounted for over 50% of all chromosomes. In FAP patients, 13 haplotypes were found but their distribution was not statistically different from normal subjects. Eighty complete chromosomal haplotypes (many fewer than the theoretical maximum of 208) for the five polymorphic sites assayed were observed in the control population, 35 being found in the FAP patients. We compared the distribution of these haplotypes within the two groups; no statistically significant differences between normal and FAP chromosomes were found. The elevated heterogeneity of FAP chromosomes was clearly confirmed by the observation that 19 patients who carried one or other of the two most common APC mutations (nt 3183 and nt 3927) showed 18 different haplotypes. On the basis of these results, we were not able to identify a founder FAP chromosome. Various mechanisms are presented to explain this observation.

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.

Vaginal repair of rectocele after dynamic graciloplasty for fecal incontinence due to imperforate anus

A 35-years-old woman developed obstructed defecation due to a large (6 cm) non-emptying rectocele one year after successful electrostimulated gracilis neosphincter operation for correction of fecal incontinence after surgery for imperforate anus. Surgical correction of the rectocele was performed by a trans-vaginal approach due to the poor elasticity of the neoanus and avoidance of possible damage to the neosphincter. After physiological investigations, including defecography, the patient had a resection of the posterior vaginal mucosal wall, a double layer plication of the muscular wall with non-absorbable suture and a longitudinal mucosal suture. The postoperative course was uneventful. Defecography, performed 3 and 6 months later, showed a marked reduction of the rectocele (2 cm) which corresponded to clinical improvement. Occurrence of disabling rectocele can be considered a possible long term complication after successful electrostimulated neosphincter procedure in patients at risk for developing a rectocele; a successful repair can be obtained using trans-vaginal approach without the risk of neosphincter damage. Transvaginal repair of rectocele in similar clinical situations may be recommended.

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.

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.

Increased production of procoagulant activity (tissue factor) by human peripheral blood monocytes after intralipid® infusion

Intralipid can produce functional and structural changes in the mononuclear phagocyte system. We have investigated the effect of Intralipid on the capacity of peripheral blood human monocytes to produce procoagulant activity when incubated in short term cultures. Twenty-three patients were studied before and after a single infusion of Intralipid 10%. Procoagulant activity was measured on isolated mononuclear cells after incubation (4 h at 37 degrees C) with and without endotoxin, using a one-stage clotting assay. Mononuclear cells obtained after Intralipid infusion produced significantly increased procoagulant activity as compared to their pre-infusion control samples (p < 0.005). Similar results were obtained when freshly collected whole blood was incubated with and without endotoxin (4 h at 37 degrees C) and procoagulant activity was measured on subsequently isolated mononuclear cells (p < 0.005). In all instances procoagulant activity was identified as tissue factor. Patients in the need of Intralipid are often at increased risk for thromboembolic complications and/or disseminated intravascular coagulation because of malignant disease, surgery or infection and there is evidence that the procoagulant activity of mononuclear phagocytes could play a major role in these processes. Our findings suggest that Intralipid might cause a further accentuation of the thrombotic tendency as a result of increased procoagulant activity.