Inter-Observer Variability in the Interpretation of Mammograms

Inter-observer agreement was tested in the interpretation by 8 radiologists of mammograms from 45 women (for a total of 180 films per radiologist). The radiologists were representative of the whole range of those involved in mammography in the town of Torino, with a number of films read per year ranging from 100 to 4000. Out of the 45, 9 women were affected by breast cancer (histologically proved), 25 had benign disease (diagnosed with fine-needle aspiration) and 11 had normal breasts. Weighted kappa values were in the range 0.27–0.82 (median 0.60) for parenchymal patterns; 0.33–0.67 (0.48) for diagnosis in five categories; and 0.22–0.57 (0.38) for indications for further diagnostic tests. These values are comparable with those reported from other investigations.

HOMA-IR and non-HDL-C as predictors of high cholesteryl ester transfer protein activity in patients at risk for type 2 diabetes

BACKGROUND AND AIMS

Metabolic syndrome (MS) and type 2 diabetes are highly associated with an abnormal lipoprotein profile, which may be generated and accentuated by high cholesteryl ester transfer protein (CETP) activity. Given the difficulty in measuring CETP activity, the aim was to identify simple biochemical predictors of high CETP activity.

DESIGN AND METHODS

Eighty five subjects at risk for type 2 diabetes were classified according to the presence of MS. Lipoprotein profile, HOMA-IR and endogenous CETP activity were evaluated.

RESULTS

As expected, MS patients presented higher concentration of glucose, insulin, triglycerides and non-HDL-C and lower HDL-C levels. Moreover, MS patients exhibited increased HOMA-IR and CETP activity. Employing a ROC curve for MS, high CETP activity was defined as >250%ml⁻¹ h⁻¹. The predictive variables of high CETP were non-HDL-C≥160mg/dl (OR=11.1;95%IC=3.3-38.2;p<0.001) and HOMA-IR>2.1 (OR=4.4;95%IC=1.3-14.8;p<0.05).

CONCLUSIONS

High non-HDL-C and insulin resistance were predictors for increased CETP activity which measurement is not accessible for clinical laboratories.

Assessment of the multiple components of the variability in the adenoma detection rate in sigmoidoscopy screening, and lessons for training

BACKGROUND AND STUDY AIMS

The determinants of the observed variability of adenoma detection rate (ADR) in endoscopy screening have not yet been fully explained.

PATIENTS AND METHODS

Between November 1999 and November 2006 13 764 people (7094 men, 6670 women; age range 55-64) underwent screening flexible sigmoidoscopy at five hospital endoscopy units in Turin. To study the determinants of the ADR for distal adenomas, accounting for patient, examiner, and hospital characteristics, we applied a multivariate multilevel regression model.

RESULTS

Average ADRs for all adenomas and for advanced adenomas (size > or = 10 mm, villous component > 20 %, high grade dysplasia) were 13.5 % (range 5.2 %-25.0 %) and 6.4 % (3.1 %-10.7 %) for men, and 8.0 % (2.5 %-14.0 %) and 3.7 % (0.2 % - 7.4 %) for women. In multivariate analysis, increased ADR of advanced adenomas was associated with male gender (odds ratio [OR] 1.78, 95 %CI 1.49 - 2.11), self-report of one first-degree relative with colorectal cancer (CRC) (1.44, 1.11-1.86), or of recent-onset rectal bleeding (1.73, 1.24-2.40). Adjusting for these variables, a significantly lower ADR was found for endoscopists with either a lower rate of incomplete sigmoidoscopy (< 9 %; OR 0.59, 95 %CI 0.41-0.87) or a higher rate (> 12 %; 0.64, 0.45-0.91), or with low activity volume (< 85 sigmoidoscopies/year; 0.66, 0.50-0.86). Residual variability explained by the endoscopy center effect was about 1 % and statistically significant.

CONCLUSIONS

Endoscopist performance in flexible sigmoidoscopy CRC screening is highly variable. Low volume of screening activity independently predicts lower ADR, suggesting that operators devoting more time to screening sigmoidoscopy may perform better. Variability among pathologists in adenoma classification might explain part of the residual variability across endoscopy units.

Barrett's oesophagus: long-term follow-up after complete ablation with argon plasma coagulation and the factors that determine its recurrence

BACKGROUND

Argon plasma coagulation seems to be a promising technique for ablation of Barrett's oesophagus, yet few long-term efficacy data are available.

AIM

To report on a long-term follow-up and the factors that determine the recurrence of intestinal metaplasia in a cohort of patients with non dysplastic, intestinal type Barrett's oesophagus, after complete ablation of the metaplastic mucosa with argon plasma coagulation.

METHODS

Ninety-six patients underwent endoscopic argon plasma coagulation with adequate acid suppression obtained through a continuous omeprazole therapy (50 patients) or through laparoscopic fundoplication (46 patients). Complete ablation was achieved in 94 patients who underwent follow-up. Endoscopic and histological examinations were performed every 12 months.

RESULTS

The median follow-up of the patients was 36 months (range 18-98). A recurrence of intestinal metaplasia was found in 17 patients (18%), with an annual recurrence rate of 6.1%. Neither dysplasia, nor adenocarcinoma were found during the follow-up. Through the use of logistic regression analysis, previous laparoscopic fundoplication was associated with a reduced recurrence rate of intestinal metaplasia (odds ratio 0.30, 95% confidence interval 0.10-0.93).

CONCLUSIONS

The long-term recurrence of intestinal type Barrett's oesophagus was low after complete ablation with argon plasma coagulation. The control of oesophageal acidity acid exposure with laparoscopic fundoplication seems to reduce the recurrence rate.

Metastases outside the abdomen (MOA) are associated with initial high tumor burden (TB) in gastrointestinal stromal tumors (GIST)

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Background: In GIST MOA are rare events (8–10%) with a prognostic and predictive impact (JCO 2005;23:5795). To stage GIST, NCCN recommends either CT or abdominal MRI + chest imaging, suggesting PET scan only if early response assessment is needed. Therefore, MOA may be missed by standard work up. We evaluated if TB (largest tumor diameter > 12 centimetres) at diagnosis was associated to a higher incidence of MOA. Methods: From 01/02 to 12/05, 66 pts affected by GIST were either treated or followed-up at our hospital. Routine initial work up consisted in: chest CT + CT or MRI abdominal scan. Pet scan was performed if: uncertainties after standard imaging, to monitor “neoadjuvant” therapy or within clinical trials. Identified MOA if unique, would be considered for fine needle biopsy whilst multiple MOA would be monitored by most appropriate imaging technique. Results: Twenty-three pts (34%) had TB between 13 and 31 centimetres. At diagnosis 10 pts (15%) had MOA located in: lung (7 pts), bone (2 pts) subcutaneous tissue (1 pts). In this unfavourable group 9 pts (14%) were affected by tumors larger than 12 cm. Pts without MOA were 56 (85%) of whom 14 (21%) had TB. The association between initial TB and MOA was statistically significant (p<0.001). Conclusions: In this small series, high tumor burden is positively correlated to MOA. If these data should be confirmed, initial diagnostic work up could usefully include both chest CT and PET scan in abdominal mass beyond 12 centimetres wide. A precocious recognition of MOA would allow to better control therapeutic response and to better identify high-risk patients.

No significant financial relationships to disclose.

Predictive value of rectal bleeding for distal colonic neoplastic lesions in a screened population

The aim of this study was to determine the diagnostic value of rectal bleeding for distal colorectal cancer (CRC), or large (> or =10 mm) adenomas among an average-risk population. A cross-sectional survey was conducted among individuals aged 55-64 years, who attended sigmoidoscopy (FS) screening in the context of a multicentre randomised trial of FS screening for CRC. Sensitivity, specificity and positive predictive value (PPV) of rectal bleeding for large distal adenomas or CRC were calculated. Rectal bleeding was reported by 8.8% of 8507 patients examined (15% of those with large adenomas and 29% of those with CRC). The risk of CRC was increased when bleeding was associated with an altered bowel habit: odds ratio (OR)=10.42; 95% Confidence Interval (CI): 4.08-26.59; the corresponding OR for isolated bleeding was 5.29 (95% CI: 2.28-12.30). Rectal bleeding carries an increased risk of distal neoplastic lesions. However, most lesions are detected among asymptomatic subjects. This finding suggests that screening represents the optimal strategy to detect CRC or large adenomas in the distal colon in the targeted age range.

[Ultrastructural behavior of interstitial cells innervation during the differentiation of the chick embryo ovary cultured with 17-beta-estradiol]

In a previous work we demonstrated the relationship between nerve fibers and nerve endings and interstitial cells (estrogen-producing cells) from the atrophic right ovary and the medulla in the left functioning ovary during embryogenesis in the chick, in ovo. Besides, the local production of neurotrophins by steroidogenic cells is probably involved in the control of ovarian innervation. The objective of the present study was to analyze ultrastructurally the innervation during the differentiation of chick ovary cultured with 17-beta-estradiol. Explants of right and left ovaries from seven to nineteen days in ovo development were cultured separately for 4 days in MEM (controls) or in the presence of 17-beta-estradiol (problems). In controls the electron microscopic examination of the innervation explants from chick embryo ovaries revealed that the interstitial cells are well innervated. Nerve fibres and nerve endings were observed in close contact with steroid-producing cells, a similar pattern of innervation that those of the fifteen days ovaries in ovo development. Problems cultured from seven days showed nerve fibres and nerve endings at difference to controls. These results in vitro suggest that innervation of the ovaries is controlled by indirect mechanism via the hypothalamic-pituitary system and local production factors. More experiments are necessary to confirm this results.

Endoscopic ablation of Barrett's esophagus using argon plasma coagulation (APC) following surgical laparoscopic fundoplication

BACKGROUND

Barrett's esopagus (BE) is considered a risk factor for the development of esophageal carcinoma. Recently, partial restoration of squamous mucosa after ablation of BE with endoscopic techniques has been described.

METHODS

From November 1996 to November 1999, 23 patients with histologically proven BE have been treated by endoscopic argon plasma coagulation (APC) following suppression of gastro-esophageal reflux by laparoscopic fundoplication. Histological follow-up after completed ablation ranged from 16 to 45 months (mean, 31.9 months).

RESULTS

Histologically, complete squamous reepithelialization was observed in 20/23 patients, whereas a regrowth of a mixed squamous and gastric type mucosa was observed in 1 patient. Small islands of intestinal metaplasia were observed under the neosquamous epithelium in two patients (9%) during follow-up.

CONCLUSION

The success rate of APC ablation following laparoscopic antireflux surgery in our series may be as high as 91%. Nevertheless, small islands of intestinal metaplasia under the new squamous epithelium may persist in some patients. In these circumstances, the authors recommend that endoscopic ablation of BE should be confined to controlled clinical trials.

[Differential diagnosis in fibro-osseous lesions of facial bones: report of a case of ossifying fibroma and review of literature]

Ossifying fibroma is a relatively rare, benign neoplasm of non-odontogenic origin, affecting the facial bones, and prevalently localized in the mandible, but which can also appear in the maxilla, paranasal sinuses and peripheral bones. Its growth is generally very slow and it is usually asymptomatic, for which it often manages to reach a considerable size. An incidental diagnosis during orthopantography, on the other hand, is not infrequent. The diagnosis, which is fundamentally made by utilizing conventional x-rays and CT and NMR scans, may present several controversial aspects and is not to be disjointed from the clinical and anatomopathological aspects, for which close interdisciplinary collaboration is required in many cases. In effecting a differential diagnosis, the possibility of inflammatory lesions, other fibrous-osseous lesions (in particular, fibrous dysplasia) and benign or malignant neoplasms must be taken into consideration. The present work presents a case of ossifying fibroma of the maxilla that is emblematic in its clinical, radiological and histopathological aspects. It also discusses problems connected with classification and differential diagnosis, in particular with respect to fibrous dysplasia, which are important in determining the proper therapeutic approach.

Prognostic indicators of local recurrence in patients operated for rectal cancer

BACKGROUND/AIMS

To identify subgroups of patients at high risk of local relapse after curative surgery for rectal cancer.

METHODOLOGY

Thirty-five variables of 216 patients observed from January 1987 to December 1995 were retrospectively analyzed according to univariate and multivariate methods. Median follow-up was 38 months.

RESULTS

High and moderate grade (P = 0.0001), Size > or = 5 cm (P = 0.013), lymph nodes involvement (P = 0.002) and patients with locally advanced rectal cancer underwent extensive surgery and postoperative radiation significantly increased local relapse; whereas surgical procedure and experience of surgeons had no influence.

CONCLUSIONS

The above-mentioned prognostic factors of rectal cancer that show a risk of local relapse 2- to 3.5-times higher than comparative conditions could be useful in identifying subgroups of patients at high risk for local recurrence. These patients should undergo a careful selection according to risk factors of relapse in order to increase local control of disease performing "optimal" primary surgery, effective postoperative radiation and tailored follow-up.

Role of magnetic resonance imaging in the staging of gastrointestinal neoplasms

A concise review is presented of the current applications and techniques of magnetic resonance imaging (MRI) in the field of diagnostic imaging of oncologic disease of the gastrointestinal tract, with a summary of the diagnostic possibilities of MRI in the various types of tumor pathology of the gastrointestinal tract. We conclude with a review of the specific situations in which MRI presents distinct advantages over other diagnostic imaging methods (such as computed tomography and ultrasound).

Risk factors for the development of gallstone recurrence following medical dissolution. The British-Italian Gallstone Study Group

OBJECTIVE

To assess risk factors for gallstone recurrence following non-surgical treatment.

DESIGN

A prospective follow-up of a multicentre cohort of post-dissolution gallstone patients.

SETTING

Six gastroenterology units in the UK and Italy.

PARTICIPANTS

One hundred and sixty-three patients with confirmed gallstone dissolution following non-surgical therapy (bile acids or lithotripsy plus bile acids), followed up by ultrasound scan and clinical assessment at 6-monthly intervals for up to 6 years (median, 25 months; range, 6-70 months).

OUTCOME MEASURES

Subject-related variables (sex, age, height, weight, body mass index), gallstone-related variables (number, diameter, presence of symptoms, months to complete stone clearance), treatment modalities (bile acid therapy, extracorporeal shock wave lithotripsy) and follow-up related variables (weight change, use of non-steroidal anti-inflammatory agents, statins, pregnancies and/or use of oestrogens) were assessed by univariate and multivariate analysis as putative risk factors for gallstone recurrence.

RESULTS

Forty-five gallstone recurrences were observed during the follow-up period. Multiple primary gallstones and length of time to achieve gallstone dissolution were the only variables associated with a significant increase in the recurrence rate. Appearance of biliary sludge during follow-up was also significantly related to development of gallstone recurrence. Use of statins or non-steroidal anti-inflammatory agents did not confer protection against recurrence.

CONCLUSIONS

Patients with primary single stones are the best candidates for non-surgical treatment of gallstones, because of a low risk of gallstone recurrence. The positive association of recurrence with biliary sludge formation and time to dissolution of primary stones may provide indirect confirmation for the role of impaired gallbladder motility in the pathogenesis of this condition.

[Richter's hernia: a clinical case and the clinico-therapeutic considerations]

The authors report a case of Richter's hernia. They underline main clinical and therapeutic patterns, emphasizing the need of an early diagnosis and surgery. This is a hernia of abdominal wall with partial entrapment of bowel wall (antimesenteric site) through a small ring. The incidence increased in the last years because of diffusion of laparoscopic techniques. Richter's hernia could be asymptomatic for a long time or show vanish sign. Sometimes this hernia can be diagnosed during surgery. The clinical signs are conclamated if hernia is complicated by strangulation. High mortality is justified by performing too late diagnosis and operation.

Is intensive follow-up really able to improve prognosis of patients with local recurrence after curative surgery for rectal cancer?

BACKGROUND

Because more than 90% of local recurrences after curative surgery for rectal cancer appear within the first 36 months after surgery, an intensive and strict follow-up program during this period could improve early diagnosis and, thus, prognosis of patients.

METHODS

Of the 216 patients who underwent surgery for rectal cancer, 127 entered an intensive follow-up program (median follow-up: 42 months); the clinical outcome of the remaining 89 patients was reconstructed with the help of their general practitioners.

RESULTS

Fifty eight (26.8%) of the 216 patients who were treated with curative surgery alone developed a local recurrence; pelvic recurrences were prevalent. Eleven (30.5%) of the 36 patients who had recurrence during follow-up, and 6 of the 22 who had not undergone follow-up, had a reoperation with curative intent; the median survival was 19 months vs. 8 months, respectively (P = ns). Four (44.4%) curative reoperations were performed on the 9 asymptomatic patients and in 13 (26.5%) of the 49 cases with symptomatic local recurrences. Median survival was 15 months vs. 14 months, respectively (P = n.s). All patients except one (living after 42 months from reoperation) died within 48 months.

CONCLUSIONS

In our study, adherence to a strict follow-up program unfortunately proved to be ineffective for improving long-term survival for patients who underwent reoperation with curative intent.

Gastroesophageal reflux disease: relationship between clinical and histological features. GOSPE. Gruppo Operativo per lo Studio delle Precancerosi dell'Esofago

Our purpose was to evaluate the relationship between the clinical and histological features in a cohort of patients who had gastroesophageal reflux-related lesions diagnosed after upper digestive endoscopy. In all, 589 patients scheduled for elective endoscopy in a multicentric prospective study were evaluated. Multiple biopsies from the distal esophagus showing aspects of esophagitis or metaplastic epithelium were taken. Esophagitis was histologically detected in 25.6%, gastric-type Barrett's esophagus in 36.2%, and specialized columnar epithelium in 33.1%. The frequency of esophagitis was constant across age decades. Patients with specialized columnar epithelium were significantly older (P = 0.01) and had a greater extent of metaplastic epithelium (P<0.0001). Specialized columnar epithelium was observed in 15% of patients with only distal esophagitis. In conclusion, endoscopic esophagitis was constant across age strata. The presence of specialized columnar epithelium was associated with older age and with longer segments of Barrett's esophagus. Short areas of esophagitis should be biopsied in view of their potential for holding areas of specialized columnar epithelium.

Local control after curative surgery for cancer of the extraperitoneal rectum. Twenty years of experience

A retrospective study was carried out in 264 patients with low rectal cancer surgically treated with curative intent from January 1975 to December 1995 to analyze the influence of stapling devices on surgical and disease outcome. Patients were classified as follows: group 1 underwent surgery from 1975 to 1980, when staplers were not employed, and group 2 from 1981 to 1995, when stapling devices were routinely used. The use of stapling devices determined a corresponding increase in low anterior resection (LAR) and a decrease in postoperative mortality. A statistically significant difference in local recurrence rate between abdominoperineal resection (APR) patients and LAR sutured cases of group 1 was observed. In T3, N+ cases local recurrence rate was comparable in APR patients and LAR cases with stapled anastomosis. Improved local control occurred in stapled group 2 patients which was independent of the distal clearance. Although APR still plays an important role in treatment of lower rectal cancer, results indicated that a similar outcome after stapled LAR can also be expected in locally advanced carcinoma of the distal rectum, if accurate excision of perirectal tissue is carried out.

[Renal hemangiopericytoma. Anatomo-pathologic and clinico-therapeutic considerations. A case report]

The Authors report a case of renal hemangiopericytoma, whose interest is related to the extreme rarity (24 cases reported until today), its insidious growth, the late in diagnosis, its uncertain clinical-biological evolution, not always predictable. Considering chemotherapy and radiotherapy ineffectiveness, an adequate treatment for such a neoplasm requires the surgical therapy, which must be followed by a careful follow-up.

[Adenocarcinoid of the appendix: a case report and anatomo-pathological and clinico-therapeutic considerations]

The Authors underline the most important pathological, clinical and therapeutic aspects of appendiceal adenocarcinoid. Appendiceal adenocarcinoid is quite a rare tumor, presently considered as a single entity; it differs from typical carcinoid of the appendix because of its well definite histology, its aggressive behaviour and its poorer prognosis. There are no precise prognostic and therapeutic criteria to direct the operative choice between appendectomy and hemicolectomy. In particular the tumor diameter is of no use since the tumor often present diffuse rather than nodular growth. According to most Authors appendectomy is not sufficient in the following cases: liver lymph-node or retroperitoneal metastases; cecal meso-appendiceal or peritoneal spreading; histological poorly differentiated tumors, with nuclear atypia and high mitotic count. Some Authors performed hemicolectomy and bilateral oophorectomy in all case with peritoneal involvement since the ovaries are a frequent site of metastases.

Incidence of Barrett's adenocarcinoma in an Italian population: an endoscopic surveillance programme. Gruppo Operativo per lo Studio delle Precancerosi Esofagee (GOSPE)

BACKGROUND

Barrett's oesophagus is a premalignant condition leading to adenocarcinoma. The incidence of adenocarcinoma of the oesophagus and the gastrooesophageal junction is rapidly increasing in the USA, northern and central Europe. Data from southern Europe are still unavailable.

OBJECTIVE

To evaluate the incidence of oesophageal adenocarcinoma in a large cohort of Italian patients with Barrett's oesophagus.

METHODS

A total of 344 patients (253 males and 91 females, age range 19-75 years) with histologically proven Barrett's oesophagus (length of metaplasia > or = 3 cm) were enrolled from November 1987 to June 1995. Endoscopic and histological examinations were scheduled at yearly intervals.

RESULTS

One hundred and eighty-seven patients complied with the follow-up. The mean duration of the follow-up period was 36 months (total follow-up 562 patient-years; range 12-90 months). Low grade dysplasia was found in five patients at the initial examination. During the surveillance period, dysplasia increased in frequency as well as in severity and was found exclusively in the intestinal type of Barrett's oesophagus. In all, dysplastic changes were found in seven patients (five low grade and two high grade) and adenocarcinoma developed in three patients during the follow-up. In a single case, both adenocarcinoma and specialized columnar epithelium developed without any evidence of dysplasia or intestinal metaplasia at the previous follow-up examination. This prospective study shows an incidence of adenocarcinoma in Barrett's oesophagus of 1/187 patient-years. When only patients with specialized columnar epithelium were considered, the risk of adenocarcinoma was 1/88 patient-years.

CONCLUSION

The present report shows that the incidence of adenocarcinoma in Italian Barrett's oesophagus patients is in the range of that reported from other Western countries.

[Hepatic cysts: a case report and anatomicopathological and clinico-therapeutic considerations]

The recent observation of a case of non-parasitic cyst of the liver brought the authors to a literature review. A 62 year old male, affected by type 2 diabetes and hypertension, after a CT scan and ETG, underwent resection and "capitonnage" of the cyst. Three months after surgery a CT scan showed a complete repletion of the cavity previously occupied by the cyst as a consequence of regeneration and reorganization of the hepatic parenchyma. In conclusion, hepatic cysts are rare and clinically relevant only when huge. The diagnosis is possible with the use of ETG and CT scan of the abdomen, however, in some cases angiography is also useful. The intervention of choice is the "capitonnage" of the cyst.

Screening for colorectal cancer by once only sigmoidoscopy: a feasibility study in Turin, Italy

OBJECTIVES

To assess the impact on compliance of three invitation methods, as well as the acceptability and efficacy of two bowel preparation regimens, for endoscopic screening in the general population.

METHODS

1170 subjects (men and women aged 55 to 59, in the rosters of a sample of general practitioners (GPs) in Turin), were randomly allocated to one of three invitation groups (A: personal letter, signed by GP, with a pre-fixed appointment; B: same as for A + letter supporting the study by a well known scientist; C: letter signed by the study coordinator, NS) and two preparation regimens (i: one enema, self administered at home two hours before the test; ii: two enemas, administered the night before and two hours before the test). A postal reminder was mailed to non-attenders. A sample of non-responders was contacted for a telephone interview by a trained nurse. Written consent was obtained from all subjects undergoing the test.

RESULTS

A total of 278 subjects attended for sigmoidoscopic screening. An invitation from the GP alone produced the highest response rate (compliance: A = 29.3%; B = 24.9%; C = 26.8%). A single enema was as effective as two enemas in achieving satisfactory preparation for the test: the proportion of subjects invited to repeat the test was 8.1% in the single enema group, and 9.6% in the group receiving two enemas.

CONCLUSIONS

Compliance with this screening procedure tends to be low. One enema, self administered two hours before sigmoidoscopy, can ensure a satisfactory bowel preparation.

[Carotid surgery and its monitoring in our experience]

Carotid endarterectomy (CEA) is the elective surgical procedure to prevent stroke due to stenosis of the carotid bifurcation. During a period of 17 years the Authors performed 215 operations on the carotid arteries of 168 patients. The average age was 64.6 and the male/female ratio was 3/1. Patients were symptomatic in 75.8% of cases and asymptomatic in the remaining 24.2%. Preoperative investigations consisted of echo-Duplex scanning, arteriography, cerebral CT or MRI. Indications for surgery were: stenosis wider than 70% in 173 cases, ulcerated or "high-risk" stenosis in symptomatic patients in 37 cases, and carotid malformation in 5 cases. The intraoperative use of shunt (12% of the operations) was selective, depending from the results of our monitoring system: stump pressure and transcranial Doppler (TCD) of the middle cerebral artery (MCA) ipsilateral to the procedure. The global major stroke/mortality rate was 3.3% (7/215), the minor morbidity was 8.8% (19/215). Mortality rate was 0.5% (1/215). The major stroke/mortality rate for symptomatic patients was 4.2% and for asymptomatic patients was 0%. The average follow up was 58 months (range 1-192) for 200/215 patients, with 15/215 patients (7%) lost. The postoperative incidence of stroke after 4 years was 8.5% (17/200), with an annual mortality rate of 1.6% (min. after 2 months, max. 118, average 55 months). CEA is a safe procedure to prevent cerebral infarctions, but it still carries an operative risk. A better monitoring would allow to understand the mechanisms of clamp-induced ischaemia and prevent it, therefore decreasing the operative risks and extending the surgical indications to a higher ratio of asymptomatic subjects. TCD is becoming essential for our goal: it is useful in deciding to insert an intraoperative shunt, check the carotid flow, recognize embolic events, and also during the initial phase of carotid preparation.

Bile acid conjugation in early stage cholestatic liver disease before and during treatment with ursodeoxycholic acid

The efficiency of bile acid conjugation before and during therapy with 600 mg/day of ursodeoxycholic acid was measured in seven adult patients with early chronic cholestatic liver disease (6 with primary biliary cirrhosis; 1 with primary sclerosing cholangitis). Duodenal bile samples were obtained by aspiration and the proportion of unconjugated bile acids was determined using lipophilic anion exchange chromatography to separate bile acid classes, followed by analysis of individual bile acids by gas chromatography-mass spectrometry. The proportion of conjugated bile acids was determined by high-performance liquid chromatography. Use of a (99m)Tc-HIDA recovery marker permitted the absolute mass of unconjugated bile acids in the gallbladder to be calculated. Unconjugated bile acids comprised 0.4% of total biliary bile acids before and 0.2% during ursodeoxycholic acid therapy, indicating highly efficient conjugation of bile acids. During therapy, percentage unconjugated ursodeoxycholic acid significantly increased from (mean +/- S.D.) 13 +/- 13% to 54 +/- 12%; P < 0.002. When the unconjugated and conjugated fractions of bile acids were compared, there was an enrichment in unconjugated fraction for cholic acid and ursodeoxycholic acid and a depletion for chenodeoxycholic acid both in basal condition and during ursodeoxycholic acid therapy, suggesting that hydrophilic bile acids were conjugated less efficiently. During therapy, the conjugation efficiency significantly increased for cholic acid and ursodeoxycholic acid. The pretreatment mass of total unconjugated bile acids in the gallbladder was (mean +/- S.D.) 4.4 +/- 3.2 mumol, and was not significantly changed by ursodeoxycholic acid therapy (6.2 +/- 3.5 mumol). However, ursodeoxycholic acid therapy caused a significant increase in the mass of unconjugated ursodeoxycholic acid. It is concluded that endogenous bile acids and exogenous ursodeoxycholic acid when given at the usual dose are efficiently conjugated in patients with early cholestatic liver disease. Despite showing increased biliary unconjugated ursodeoxycholic acid during its oral administration, our data do not lend support to the occurrence of hypercholeresis due to cholehepatic shunting of bile acids.

[Adenocarcinoma of the small intestine. A case report and the clinico-therapeutic considerations]

Adenocarcinoma of the small bowel is a rare tumor. The diagnosis is often tardy and surgical treatment is still palliative in most cases. A major interest toward this kind of tumor as well as an early diagnosis may give the opportunity to perform a radical operation allowing better results in terms of survival.

[Massive intestinal hemorrhage caused by leiomyoma of the jejunum. Report of a case]

Small-bowel leiomyoma is a rare tumour. The authors report a case complicated by severe bleeding. Esophagus-gastro-duodenal endoscopy was not decisive enough, while TC was the most reliable instrumental investigation. Because of dimensions basic than 10 cm, the presence of a pseudocapsule end the absence of cariokinetic figures, the histopathologic test supports the hypothesis that it was a benign disease. One year follow-up, negative for relapse, confirm that the lesion is benign.

The Angelchik prosthesis in the surgical therapy of reflux oesophagitis. Short and long term results

The authors report the results acquired from 1981 to 1985 using the Angelchik prosthesis in 22 patients with reflux oesophagitis resisting medical therapy for more than 6 months. Clinical evaluation has been done using Visick scale, as modified by Deakin. Clinical and instrumental controls have been done at 1 month, 12 months and 5-10 years after the operation. Intraoperative mortality and morbidity were zero. Complications directly related to the operation were: transitory dysphagia in 4 cases, persistent dysphagia in 3 cases, transitory gas bloat syndrome in 1 case and persistent gas bloat syndrome in another, persistent stenosis in 1 case and prosthesis dislocation in 6 cases. Clinical results were satisfactory (success rate: 90.9%) only in patients with a short term follow-up (30 days). The full rate of success has come down to 84.2% and 66.6% in patients having follow-ups respectively of 1 year and 5-10 years. The results are truly disappointing and the authors conclude that this procedure is not to be employed.

[Obstructive jaundice caused by residual and/or recurrent choledochal lithiasis: endoscopic and surgical treatment]

Results of surgical and endoscopic treatment in 79 patients (58 females and 21 males, age 40-89, mean 62), affected with jaundice, due to secondary choledochal lithiasis, are reported. Thirty-four patients (43%) underwent surgical operation: choledochotomy and T-tube 12, choledocho-jejunostomy 4, choledochoduodenostomy 3, papillosphincteroplasty 15. In 45 patients (57%) EST has been performed. Comparison of results has been obtained after 30 days and after 3-105 months (mean 49). Optimal results have been achieved in 94.9% of patients: 100% after surgery and 94.1% after EST. Morbidity and mortality outcomes in patients who underwent EST (11.1% and 0% after 30 days respectively, 8.1% and 8.1% after several months) are better compared to those ones after surgical treatment (17.6% and 5.8% after 30 days, 20% and 16% after several months). We conclude that EST is nowadays the therapy of choice in patients with jaundice due to choledochal lithiasis, either relapsing or residual.

Effect of plant density on yield and rubber accumulation in guayule (Parthenium argentatum) in south-eastern Queensland

Guayule (Parthenium argentatum) was grown as a rainfed and an irrigated crop on an oxisol in south-eastern Queensland for 36 months, to assess its potential as a source of rubber. The rainfed experiment consisted of 3 cultivars (N565, 11591, 11619) grown at 4 densities (0.9, 1.8, 3.6, 5.2 plants/m2). The irrigated experiment compared cultivars N565 and 11591 at densities of 1.8, 3.6, and 5.2 plants/m2. In both trials, harvests were taken at 4-monthintervals. Dry matter yields of stems and roots, and rubber concentration in stems and roots, showed a near linear increase with time. Stem dry matter yields at 36 months approached 8.0 t/ha, with a rubber concentration of 13%. Rubber concentration and rubber yield increased with plant density. Total rubber yield in stems plus roots after 36 months was about 1.2 t/ha. The low productivity of this crop was associated with poor root development in the soil profile, a low leaf area index, and subsequent low light interception. A main inhibitor to root growth was the high incidence of a Fusarium sp. root pathogen.

[The clinical importance of physiopathological studies of the bile salts performed using the gamma-emitting bile acid SeHCAT]

The availability of the gamma-labelled bile acid 75SeHCAT, that allows a non-invasive assessment of the enterohepatic circulation of bile acids, has prompted in the last 10 years the implementation of several studies involving wide series of normal subjects and patients with various organic and functional bowel disorders. The clinical indications for performing a SeHCAT test have been clearly defined: the test can identify with high accuracy, in the setting of the irritable bowel syndrome, the patients with bile acid malabsorption that can be confidently and successfully treated with cholestyramine; it can also assess whether, and to what extent, the diarrhoea presenting in patients with intestinal organic disorders is due to bile acid malabsorption, permitting an optimal therapeutic strategy to be designed. The parameters of the hepatic handling of SeHCAT after bolus intravenous administration have been characterized in normals, and studies on various chronic hepatic disorders are now in progress. Interesting results are emerging from studies performed in patients with chronic non-obstructive cholestatic disease, where a specific defect in the excretion rate of SeHCAT is present: these studies may cast more light on the abnormalities of bile secretion and on the mechanism of action of drugs used to treat this condition, forming the rationale for the use of intravenous SeHCAT for hepatobiliary dynamic scintigraphy as a sophisticated liver function test. In conclusion, the SeHCAT test has become an important diagnostic tool for the gastroenterologist studying the diarrhoea, and awaits more studies to be used also by the hepatologist. The relatively long physical half-life of 75Se (180 days), preventing a wider use of the test, could theoretically be overcome by the synthesis of a similar gamma-labelled bile acid with a shorter half-life.

Inhibition of the sodium transport by pentachlorophenol (PCP) in toad skin (Pleurodema thaul)

1. The effects of pentachlorophenol (PCP) were studied in vitro on an active ionic transporting epithelium. Ussing's technique was applied on the isolated Pleurodema thaul skin. 2. Concentrations of PCP in the range 0.003-0.043 mM caused an irreversible dose-dependent inhibition in both the short-circuit current and the potential difference. 3. Parameters of an electrical equivalent circuit were calculated applying the Isaacon's amiloride test. 4. It was also shown that PCP produced a significant increase in the O2 consumption of the skin. 5. The inhibitory action of PCP on active sodium transport in terms of the equivalent electrical circuit and the increased oxygen consumption points to an uncoupling action of PCP on the oxidative phosphorylation.

Measurement of bile acid half-life using [75Se]HCAT in health and intestinal diseases. Comparison with [75Se]HCAT abdominal retention methods

The diagnostic values in detecting terminal ileum dysfunction using [75Se]HCAT have been assessed for two different scintigraphic techniques in 58 subjects. The measurement of [75Se]HCAT T1/2 in the enterohepatic circulation by daily gallbladder scintigraphy showed 78% sensitivity, 96% specificity, 96% positive predictive value, and 78% negative predictive value at the optimal cutoff level of 2.0 days; lower--but not significantly different--figures were observed for [75Se]HCAT total abdominal retention four and seven days after isotope administration, at the optimal cutoff levels of 40% and 22%, respectively. [75Se]HCAT T1/2 was then evaluated in 60 patients with various intestinal diseases. Sixty-nine percent (9/13) of patients with diarrhea of obscure origin showed abnormal [75Se]HCAT T1/2. Bile acid malabsorption using [75Se]HCAT can be investigated by the noninvasive measurement of its enterohepatic T1/2 and may play a pathogenetic role in patients with diarrhea of obscure origin.

[Leiomyosarcomas of the small intestine]

The main clinical and anatomico-pathological aspects of small bowel leiomyosarcomas are stressed. These are rarely observed malignant tumours, which sometimes prove difficult to diagnose and have a poor prognosis. Also characteristic is the substantial difficulty often encountered in defining the malignancy grade histologically.

[Diagnosis of bacterial contamination of the small intestine using the 1 g [14C] xylose breath test in various gastrointestinal diseases]

The prevalence of the small intestine bacterial overgrowth syndrome has been assessed in 109 in-patients affected by various gastrointestinal disorders using the 1 g [14C]-xylose breath test; 18 healthy subjects acted as a control group: none of them showed abnormal results (100% specificity). None of 14 patients with colonic disease had abnormal results, whereas in 44 patients with ileal diseases the test was positive in 12% to 39% of the cases. Abnormal results were found in 46% of patients who underwent partial gastric resection greater than 20 years before, 29% of patients with irritable bowel syndrome without diarrhoea (faecal wet weight less than or equal to 600 g/72 h), 56% of those with diarrhoea of obscure origin, and 25% of celiac patients. Eight out of 8 patients with altered results showed normalization of the test after antibiotic therapy. Despite its high diagnostic value in the setting of clinical research, the 1 g [14C]-xylose breath test cannot as yet be proposed as a routine investigation.

[A case of small-cell carcinoma of the rectum]

A case of oat-cell carcinoma of the rectum prompted the authors to undertake a review of the literature. The main histological aspects allowing an accurate diagnosis are stressed. This is a rare form of highly malignant neoplasm of uncertain origin (probably similar to that of carcinoids) with a very marked tendency to metastasize, even to distant organs; it is characterized by substantial cellular polymorphism with small-sized elements, very little cytoplasm, a large hyperchromic nucleus, barely visible nucleoli and histochemical reactions typical of neuroendocrine cells.

[The ileocecal valve as a prognostic factor in extensive resection of the small intestine]

The aim of the study was to examine the role of the ileocaecal valve in relation to the nature and extent of symptoms following extensive bowel resection (EBR) in 13 patients with short bowel syndrome (SBS) referred to our department over the period 1962-1988. The results obtained do not allow us to assess the effective role of the ileocaecal valve in determining the severity of SBS. The factors conditioning the extent of the aftermath of EBR and effectively affecting prognosis are, in fact, multiple and act in various interrelated ways, thus making it difficult to define the precise role of any one of them. The ileocaecal valve, however, does play a substantial role, in that, on the one hand, it performs sphincter and barrier functions against ileocolic reflux of bacteria, while, on the other, its removal involves excision of the right colon (reserve area for reabsorption of water and ions) and of the terminal ileum (a site specialized in absorption of vitamin B12 and bile salts).

[Human lingual organogenesis: histochemical and ultrastructural aspects]

The structural, ultrastructural and histochemical studies of tongues of human fetuses of 8 to 32 weeks development, were carried out to evaluate the possible chronologic coincidences in the differentiation process of the histologic components during organogenesis. From week 8 to 32, the epithelium increased its cellular layers, becoming flat, stratified, with parakeratinized areas, abundant desmosomes, tonofilaments and scarse intracellular granules. Chorionic fibers increased concomitantly, decreasing mucosubstances. Rudimentary papillae appeared on the dorsal surface of the tongue at 8 weeks, the fungiform ones being evident at 12 weeks. Glycoproteins in the basament layer became evident along with the papillary differentiation, reaching their definitive form at 20 weeks. Myoblasts were observed at 20 weeks. Glandular buds were noticed at the early age studied as were rich in glycogen inclusions and transversal striations were at 20 weeks the structural and ultrastructural differentiated acini, with PAS positive, metachromatic and alcianophilic secretions. The cytochemical changes observed are indicative of the cell differentiation process and tissues participating in the histogenesis present a similar rhythm of differentiation and growth.

[A case of leiomyosarcoma of the small intestine. Clinical and anatomopathologic considerations]

Leiomyosarcoma of the small intestine is a malignant mesenchymal tumour composed of smooth muscle cells from the muscular coat or, rarely, from muscularis mucosae, which in the majority of cases is characterised by a clinically silent development and by an unfavorable prognosis. The considerable difficulty of obtaining a histological definition of the degree of malignancy of the leiomyosarcoma is also typical. The paper reports a clinical case and summarises its main clinical and anatomopathological aspects. In particular, the difficulties of clinical and histological diagnosis of the degree of malignancy are underlined, together with the fact that these have a considerable influence on the possibilities and results of surgical therapy and survival rates.

[Treatment of recurrent or residual calculosis of the choledochus. A comparison of the technics]

The results of treating residual or recurrent calculosis of the choledochus for the purpose of obtaining elements for deciding whether or not to carry out a given operation in a particular group of patients are reported. Although they do not offer elements of certainty, the results still make it possible to arrive at an indication for endoscopic papillotomy in elderly patients in poor general condition with one or a few calculi and non-dilated choledochus, for choledochotomy in patients with choledochus of normal diameter and with multiple calculi, or for an intervention of biliodigestive drainage (particularly choledochojejunostomy) in patients with multiple calculosis and with dilated choledochus. In cases in which the apparatus of Oddi is the site of an irreversible inflammatory process and has lost its function, transduodenal papillosphincterotomy is justified.

[Results of endoscopic treatment of choledochal calculosis and cicatricial stenosis of the papilla]

The results obtained with endoscopic papillo-sphincterotomy in the treatment of gallstones and cicatricial stenosis of the papilla are reported. The treatment proved effective in 91.3% of patients with papillary stenosis and the incidence of side-effects (cholangitis, pancreatitis, bleeding, perforation) was 7.5%. Endoscopic PST hitherto restricted to cases judge inoperable due to serious concomitant pathologies may be a valid alternative to surgery wherever total sphincter dysfunction can be ascertained.