The Big Game: hunting for retained bullets and foreign bodies in Great War radiology

OBJECTIVES

Searching for retained bullets has always been crucial in war surgery. Aim of this paper is to briefly outline the history of retained bullet identification methods before X-rays discovery and describe the proliferation of the most significant methods of foreign body localization during WWI.

METHODS

Coeval medical journals, reference textbooks, dedicated manuals and documents have been searched and compared in multiple archives and on the internet.

RESULTS

Before radiologic era, probing the wound was the only way to detect the bullet and minimize the need of a large surgical incision (anaesthesia was walking its first tentative steps and antisepsis still to be conceived). Nelaton's probe, specifically designed to detect General Garibaldi's retained projectile, gained popularity. Application of electricity provided further rudimental aids to find retained metals. X-rays discovery made bullet detection easy, but exact localization to guide removal was still difficult. Hundreds of imaginative X-Ray methods for localizing bullets and splinters more precisely in the countless complex wounds flourished during the Great War. Axis intersection, geometric reconstruction and anatomical criteria guided localization. Complex procedures and rudimental localizers to simplify calculations, and a number of compasses and magnetic or electric devices to aid surgical removal were developed, and are here outlined. Intermittent radiology assessment or combined radiology and surgery procedures started to play a role.

CONCLUSIONS

All these methods and tools are the ancestors of modern navigation systems, ensured by images digitalization and miniaturization technologies.

KEY WORDS

Foreign bodies, Mobile Health Units, Radiology, X-Rays, World War I, Wounds and injuries.

Is it possible to reduce recurrences after Altemeier's procedure for complete rectal prolapse? Twenty-year experience in 130 consecutive patients

PURPOSE

In the attempt to understand the reasons for and to find a solution to the high recurrence rate after perineal surgery for complete rectal prolapse, we retrospectively analysed the long-term results of Altemeier's procedure alone, or associated with Trans-Obturator Colonic Suspension (TOCS) in a large series of patients with a median interval of 84 months (range 6-258).

METHODS

Medical records of 110 patients undergoing Altemeier with levatorplasty (group 1) and 20 patients submitted to the same procedure associated with TOCS (group 2) for newly diagnosed complete rectal prolapse were reviewed. All patients had been recruited after preoperative clinical examination, SF-36 quality of life, continence score and colonoscopy.

RESULTS

Mortality was nil. The overall complication and the recurrence rates were 12.3%, and 15.0% (P= 0.769) and 24.6% and 5.0% (P=0.067) in group 1 and 2, respectively. Twelve patients of group 1 with a recurrence were submitted to a redo-Altemeier, 8 to a redo-Altemeier associated with TOCS, and 6 associated with an anterior coloplasty with a mesh. The only patient of group 2 with a recurrence was submitted to a Hartmann's operation. Preoperative vs postoperative mean (SD) continence score was 15.8 (3.1) and 15.6 (3.3) versus 4.1 (1.8) and 3.9 (1.9) in group 1 and 2, respectively (P < 0.001). All parameters of SF-36 improved after surgery (P<0.01) and no differences between the 2 groups were found CONCLUSIONS: Long-term results confirmed the safety and effectiveness of Altemeier's procedure for the treatment of complete rectal prolapse, with the limit of a non-negligible incidence of anastomotic complications and recurrences. The combination of Altemeier with TOCS showed a positive trend to a reduction of the recurrence rate, not worsening morbidity and outcomes.

The Italian mobile surgical units in the Great War: the modernity of the past

Medical services in WWI had to face enormous new problems: masses of wounded, most with devastating wounds from artillery splinters, often involving body cavities, and always contaminated. Tetanus, gas gangrene, wound infections were common and often fatal. Abdominal wounds were especially a problem: upon entering the war the commanders of all medical services ordered to avoid surgery, based on dismal experiences of previous wars. Surgical community divided into non-operative and operative treatment supporters. The problem seemed mainly organizational, as the wounded were rescued after many hours and treated by non-specialist doctors, in inadequate frontline settings or evacuated back with further delay of treatment. During initial neutrality, Italian Academics closely followed the debate, with different positions. Many courses and publications on war surgery flourished. Among the interventionists, Baldo Rossi, to provide a setting adequate to major operations close to the frontline, with trained surgeons and adequate instruments, realized for the Milano Red Cross three fully equipped, mobile surgical hospitals mounted on trucks, with an operating cabin-tent, with warming, illumination and sterilizing devices, post-operative tents and a radiological unit. Chiefs of the army approved the project and implemented seven similar units, called army surgical ambulances, each run by a distinguished surgeon. Epic history and challenges of the mobile units at the frontline, brilliant results achieved on war wounds and epidemics are described. After the war they were considered among the most significant novelties of military medical services. Parallels with present scenarios in war and peace are outlined.

Mucopexy-Recto Anal Lifting (MuRAL) in managing obstructed defecation syndrome associated with prolapsed hemorrhoids and rectocele: preliminary results

Purpose

Treatment of rectocele associated with prolapsed hemorrhoids is a debated topic. Transanal stapling achieved good midterm results in patients with symptoms of obstructed defecation, nevertheless a number of severe complications have been reported. The aim of this study was to evaluate the safety and efficacy of a new endorectal manual technique in patients with obstructed defecation due to the combination of muco-hemorrhoidal prolapse and rectocele.

Methods

Patients enrolled after preoperative obstructed defecation syndrome (ODS) score, defecography and anoscopy were submitted to the novel Mucopexy-Recto Anal Lifting (MuRAL) combined with a modified Block procedure, and followed up by independent observers with digital exploration 3 weeks postoperatively, and digital exploration plus anoscopy at 3, 6, and 12 months. Operative time, hospital stay, numerating rating scale (NRS), ODS, satisfaction scores, and recurrence rate were recorded.

Results

Mean operative time was 35.7 minutes. Fifty-six patients completed 1-year follow-up: 7.1% had acute urinary retention, NRS score was < 3 from the third postoperative day, mean time of daily activity resumption was 12 days, none had persistent fecal urgency, 82% declared excellent/good satisfaction score, significant improvement of 6- and 12-month ODS score, no recurrence of rectocele, and 7.1% recurrence of prolapsed hemorrhoids were observed.

Conclusion

MuRAL associated with modified Block technique gave no severe complications and resulted in a safe and effective approach to symptomatic rectocele associated with muco-rectal prolapse. Further randomized studies, larger series, and longer follow-up are needed.

An incredibly dilated Wirsung mimicking a sero-cystic neoplasm of the pancreatic head

A diabetic patient who at a routine abdominal ultrasounds was found to have a very dilated pancreatic duct. Computed tomography (CT) scan diagnosed a sero-cystic lesion of the pancreatic head. Gastroduodenoscopy discovered a duodenal hyperemic area, which was sampled. Biopsy demonstrated intramucosal vascular emboli from a neuroendocrine carcinoma positive for Chromogranin A and Somatostatin and negative for Gastrin. Cholangio-magnetic resonance imaging revealed that the sero-cystic lesion found at CT, was being mimicked by the enormously dilated pancreatic duct but suggested the possibility of an intraductal or ampullar neoplasm. Blood and urine tests were not helpful and an octreoscan was negative. The patient underwent surgery. Direct exploration confirmed the severe pancreatic duct dilation and a cephalic lesion requiring a pancreatoduodenectomy. Histology confirmed a neuroendocrine tumor infiltrating the duodenum. We conclude that despite modern sophisticated imaging and endoscopic techniques, the evaluation of bilio-pancreatic region can be challenging and can reserve surgical surprises.

Cytogenetic Analysis in 28 Radically Operated Non-Small-Cell Lung Cancer: Preliminary Considerations

Twenty-eight radically operated non-small-cell lung cancer patients were analyzed with regard to chromosomal assessment and DNA content: in 13 cases, different quantitative/ qualitative chromosome alterations were found. In particular, in 12 cases marker chromosomes and cytogenetic abnormalities in euploid cells were demonstrated. The prognostic value of these findings will be aim of further studies.

Mucopexy-recto anal lifting: a standardized minimally invasive method of managing symptomatic hemorrhoids, with an innovative suturing technique and the HemorPex System®

BACKGROUND

Conservative surgery of hemorrhoidal disease is less painful than traditional hemorrhoidectomy, and mucopexy has less risk of serious postoperative complications than stapled hemorrhoidopexy. The aim of this study was to evaluate the safety and effectiveness of a standardized, modified hemorrhoidopexy, named Mucopexy-Recto Anal Lifting (MuRAL) with the HemorPex System (HPS) in patients with symptomatic III and IV degree hemorrhoids.

METHODS

Patients were enrolled from May 2013 to Dec 2015 and operated on with the MuRAL technique, based on arterial ligation and mucopexy at 6 locations, using a standardized clockwise/anti-clockwise rotation sequence of the HPS anoscope. Follow-up controls were carried out by independent observers, as follows: a digital exploration 3 weeks after the intervention, digital exploration plus proctoscopy at 3 and 12 months and repeated at a 12 months interval. Patients who did not strictly follow the postoperative controls were excluded from the study. Primary outcome measurement was the recurrence rate. Secondary measurements were: operative time, hospital stay, postoperative pain, postoperative symptoms and satisfaction score.

RESULTS

We operated on 126 patients (72 males, mean age 53.9, range 29-83): 87 (69.6%) with III degree and 39 with IV degree hemorrhoids; 13 patients had a MuRAL as a revisional procedure of a previous operation for hemorrhoids. Mean duration of follow-up was 554 days (range 281-1219). Four patients were excluded from the study. One-year recurrence rate was 4.1%. The mean duration of the intervention was 29.5 minutes (range 23-60) and 92 patients (73%) were discharged during the same day of the operation. Pain VAS Score in the first, second and third postoperative day was 3.9, 2.5, and 1.9, respectively. Twenty-two patients (18%), all submitted to spinal anesthesia, had postoperative acute urinary retention. Fecal urgency, observed in 18.8% of patients at the first control, disappeared within one year after the operation. Mean time to return to normal activity was 8 days (range 5 -10). The patient satisfaction scores at one-year follow up were 31.1% excellent, 57.4% good, 7.4% fairly good and 4.1% poor. In patients with III degree hemorrhoids operative time was significantly shorter, postoperative pain better and transient fecal urgency lower than in IV degree patients. In our experience the standardization of MuRAL operation with HPS, turned out to be a safe and effective minimally invasive approach in managing symptomatic III and IV degree hemorrhoids, avoiding the risk of severe complications, with the possibility to perform a redo-MuRAL in the event of recurrence.

CONCLUSIONS

In our series up to 88% of the patients reported a good, or excellent one-year satisfaction score. Further comparative randomized studies with longer follow-up period are needed.

The evolution of transanal surgery for obstructed defecation syndrome: Mid-term results from a randomized study comparing double TST 36 HV and Contour TRANSTAR staplers

A randomized study was carried out to compare the mid-term outcome of transanal rectal resection with the CCS-30 TRANSTAR and two TST36 staplers in patients with obstructed defecation syndrome. After selection, patients were randomly assigned to 2 groups:104 underwent a TRANSTAR operation and 104 a transanal rectal resection with two TST36 staplers. Patients were followed up with clinical examination, and defecography. Cumulative complication rate was significantly higher in TRANSTAR operation (P = 0.019). All symptoms and defecographic parameters significantly improved (P < 0.001), without differences. Costs were significantly lower with double TST (P = 0.035). Recurrence rates were 6.2% in TRANSTAR group and 11.4% with double TST (P = 0.206). Two circular TST 36 staplers consent to obtain the same clinical and functional results than the CCS-30, with significantly lower complication rate and costs.

Pulmonary aspiration in adjustable gastric banding carriers undergoing a second surgical procedure. Considerations on personal experience and review of the literature

BACKGROUND

The observation of a relatively high number of pulmonary aspirations (PA) among gastric band (GB) carriers undergoing a second surgery, prompted us to modify our strategy for GB patients candidate to further operation under general anesthesia.

MATERIAL OF STUDY AND RESULTS

In January 2013, following the occurrence of PA at the induction of general anesthesia in 1 GB carrier undergoing a further operation, we reviewed our Data Base between January 2005 and 2013, to explore the rate of pulmonary aspiration in patients GB carriers undergoing a second surgery. Considering the rate (3/172 - 1.7%) too high in comparison with non-GB carriers, we decided to deflate the banding before any further surgery planned under general anesthesia. We then retrospectively reviewed the occurrence of PA after having changed the protocol. Since February 2013, through December 2016, 81 GB carriers underwent a second surgery and not a single episode of PA occurred (0/81).

DISCUSSION

The occurrence of PA in patients with GB seems greater than in non-GB patients. Larger series should be examined to assess the incidence of PA among this specific population. Awareness of the increased risk is important to general anesthesiologists and surgeons, considering the increasing number of GB carriers who may be in need of surgery. Our result after adopting the deflation policy, even though not statistically significant, seems highly suggestive.

CONCLUSION

We believe that, considering the potentially severe consequences of PA, the gastric band should be deflated before any planned procedure requiring general anesthesia. Further data are needed.

KEY WORDS

Adjustable gastric banding, Aspiration Pneumonia, Bariatric surgery, Morbid obesity, Pulmonary Aspiration.

Stapled anopexy versus transanal hemorrhoidal dearterialization for hemorrhoidal disease: a three-year follow-up from a randomized study

BACKGROUND

This randomized study compared the medium-term results of stapled anopexy (SA) and transanal hemorrhoidal dearterialization with anopexy (THD) in 4 homogeneous groups of patients, 2 with third- and 2 with fourth-degree hemorrhoids.

METHODS

Forty patients with third-degree and 30 with fourth-degree hemorrhoids were randomly submitted to SA (N.=20+15) and THD (N.=20+15), respectively. Clinical controls were done every 6 months from 1 to 42 months after the operation, with incidence of recurrent hemorrhoids as primary outcome measure. Operative time, complications, pain, time to return to normal activity, costs, Short Form-36, and overall patient satisfaction were also evaluated.

RESULTS

Frequencies of preoperative obstructed defecation symptoms and prolapse recurrence were higher in patients with fourth-degree hemorrhoids, and SA was more effective than THD in reducing the risk of recurrence at 36±6 months follow-up (P=0.049). Operative time, complications, pain, and time of return to normal activity were similar in the 4 groups. Costs were significantly higher for SA in patients with fourth-degree hemorrhoids (P>0.01). A significant improvement of quality of life was observed in all groups, and no significant difference was found in overall patient satisfaction.

CONCLUSIONS

Both techniques are safe and effective in the mid-term period. SA is more effective in reducing prolapse and obstructed defecation symptoms in fourth-degree hemorrhoids, with the disadvantage of higher costs. Prolapse size and presence of obstructed defecation symptoms could be predictive criteria for choice of the best surgical technique.

Videothoracoscopic approach to stage I non-small cell lung cancer

AIM

Aim of this study is to evaluate the validity of videothoracoscopic staging and treatment in a twenty-year-long series of 286 VATS lobectomies for Clinical Stage I NSCLC.

MATERIAL OF STUDY

We retrospectively reviewed 1549 candidates to resection after conventional staging from November 1991 to December 2013, and routinely submitted to videothoracoscopy immediately before the procedure. Patients deemed operable at videoexploration were resected by thoracoscopy or thoracotomy. Out of 534 VATS resections 286 thoracoscopic lobectomies for clinical stage I cancers were performed with strict indications and standardized technique; more advanced tumours were converted even when thoracoscopically resectable. Impact of preliminary videothoracoscopy and and longterm Kaplan-Meier survival was analyzed.

RESULTS AND DISCUSSION

Out of 1549 patients, videothoracoscopy disclosed inoperability in 62 (4 %), mostly for pleural carcinosis (33pts.-2.1%) or mediastinal infiltration (22pts-1.4%). 534 (34.5%) patients had videothoracoscopic resection (286 lobectomies, 7 pneumonectomies, 241 wedge resections), 919 (59.3%) had thoracotomy resection, 34 (2.2%) had an exploratory thoracotomy (ET). Thoracoscopy had an accuracy rate of 72.4%, was reliable in excluding unresectability (NPV 0.95), and decreased the rate of ETs to 2.1%, ,sparing 596 (38.5%) thoracotomies. There was no intraoperative mortality or recurrence. Stage I patients had 83.8% 3-yr survival and 64.3% 5-yr survival. Five-year survival was significantly better (p=0.004) for T1N0 patients (70%) than T2N0 (55%) and for patients younger than 55 (86.4%) or with lesion < 2 cm (80.8%).

CONCLUSIONS

Preliminary videothoracoscopy reliably assesses tumor resectability and feasibility of thoracoscopic resection, limiting unnecessary thoracotomies. Videolobectomies are safe and survival is comparable to open lobectomy.

KEY WORDS

Lobectomy, Lung cancer, Minimally invasive surgery, Thoracoscopy, VATS.

A new case of familial LCAT deficiency

Twenty-eight patients with familial lecithin:cholesterol acyltransferase deficiency have been reported to date. We report a new Italian case who presents the clinical and biochemical characteristics of the disease. Typical disc-shaped high density lipoproteins (d = 1.063-1.21 g/ml) were detected by electron microscopy. An abnormal distribution of apolipoproteins in the different lipoprotein fractions was found by sodium dodecyl sulphate polyacrylamide electrophoresis.

Affectivity and sexuality in the elderly: often neglected aspects

Sexuality and affectivity constitute a complex phenomenon involving many spheres: biological, psychological and social. To investigate these aspects, we distributed a dedicated questionnaire, followed by an interview, to 130 elderly residents in Milan and 100 in Monza. The answers indicated that the elderly communicate their emotions regarding the affective and sexual sphere, with different levels of desire for physical contact. The main variables were sex, age, marital status, co-morbidity and poly-pharmacotherapy, the perception of health status and of oneself, past experiences, cultural conditioning and social factors.

Thrombosis-related complications and mortality in cancer patients with central venous devices: an observational study on the effect of antithrombotic prophylaxis

BACKGROUND

Recent guidelines do not recommend antithrombotic prophylaxis (AP) to prevent catheter-related thrombosis in cancer patients with a central line.

PATIENTS AND METHODS

This study assessed the management of central lines in cancer patients, current attitude towards AP, catheter-related and systemic venous thromboses, and survival.

RESULTS

Of 1410 patients enrolled, 1390 were seen at least once in the 6-month median follow-up. Continuous AP, mainly low-dose warfarin, was given to 451 (32.4%); they were older, with a more frequent history of venous thromboembolism (VTE), and more advanced cancer. There was no difference in catheter-related thrombosis in patients given AP or not (2.8% and 2.2%, odds ratio 1.29, 95% confidence interval 0.64-2.6). The median time to first catheter-related complication was 120 days. Systemic VTE including deep and superficial thromboses and pulmonary embolism, were less frequent with AP (4% versus 8.2%, P = 0.005). Mortality was also lower (25% versus 44%, P = 0.0001). Multiple logistic regression analysis found only advanced cancer and no AP significantly associated with mortality. No major bleeding was recorded with AP.

CONCLUSIONS

Current AP schedules do not appear to prevent catheter-related thrombosis. Systemic VTE and mortality, however, appeared lower after prophylaxis.

Videolaparoscopic appendectomy: the current outlook

BACKGROUND

Mini-invasive techniques have revolutionized surgery, but the superiority of laparoscopic access for appendectomy is widely debated. The authors analyze their monocentric experience with 1,347 laparoscopic appendectomies.

METHODS

Between October 1991 and December 2002, all the patients with an indication for appendectomy underwent surgery (301 emergency and 1,046 interval appendectomies) using the laparoscopic approach.

RESULTS

For 1,248 patients, appendectomy was performed laparoscopically, whereas for 99 patients (7.3%), it was converted to an open procedure because of technical reasons (90 patients, 6.7%) or intraoperative complications (9 patients, 0.6%). For 59 patients (4.4%), the appendectomy was associated with another procedure. Histology showed "acute" alterations in 261 of the 301 emergency surgeries and in 148 of the 1,046 elective operations. Postoperative complications arose in 37 patients (2.7%), with 5 patients (0.3%) requiring invasive treatment. The mean postoperative stay was 30 h.

CONCLUSIONS

Laparoscopic appendectomy offers unquestionable advantages, but it is not yet considered the "gold standard" for appendiceal pathology. Many centers reserve it for selected patients (e.g., obese patients and women suspected of having other pathologies). No randomized trials or metaanalyses have definitively proved its superiority.

Effect of antithrombotic prophylaxis (AP) on thrombosis-related complications and mortality in cancer patiets (pts) carrying a central venous devices (CVD)

8596

Background: Recent guidelines do recommend against antithrombotic prophylaxis in cancer pts having placed a central line to prevent catheter-related thrombosis. Methods: The present study, which was an observational and prospective one, involved 18 centres in Lombardia (Italy) to assess the management of CVD in pts affected by solid or haematological tumors to evaluate in the current practice the attitude to employ the AP and the clinical evolution as regard to the occurrence of catheter-related and systemic venous thromboses and survival. Results: 1,418 pts entered the study and were followed-up during a median period of 6 months for a total of 24,182 patients-months. Subjects receiving a continuous AP, mainly with mini-warfarin according to Levine, were 439 (31.6%): they were significantly older, with a more frequent history of Venous Thromboembolism (VTE), and with a cancer in a more advanced stage. A trend in favour of those not treated with AP was noticed as regard to catheter-related thrombosis, 3.2 % vs 1.5%, (p=0.058). The median time to the first catheter-related complication was 120 days. The frequency of systemic VTE including deep and superficial vein thromboses in sites other than the venous axis where the CVD had been placed and pulmonary embolism was significantly lower in patients not receiving AP: 1.8% vs 12.4%; OR 0.12 (95% CI: 0.07–0.22; p=.001). Mortality of pts avoiding AP was also significantly lower (23.7% vs 38%), OR 0.5 (95% CI: 0.4–0.6; p=.0001) In the multiple logistic regression analysis only advanced cancer and to be given AP were significantly associated with mortality. No major bleeding was recorded among pts assigned to receive continuous AP. Conclusions: The results of the present study do confirm the current drugs and schedules for AP are unable to prevent not only catheter-related thrombosis but also systemic VTE. Mortality does appear lower in those not treated with AP and the difference still exists after adjustment for age, history of previous VTE and to be given chemotherapy. The attitude to give a continuous AP to pts with central lines presenting with more severe disease or at increased thromboembolic risk seems to be ineffective if not dangerous.

No significant financial relationships to disclose.

Tracheal sleeve pneumonectomy: Long-term outcome

Selected primary lung cancers less than 2cm from the carina or invading the tracheo-bronchial angle, formerly considered inoperable, can be amenable to tracheal sleeve pneumonectomy (TSP). Such a delicate technique, can entail remarkable post-operative morbidity and mortality, and only few clinical series are reported. Purpose of this paper is to examine complications and long-term survival of our personal series and those reported in literature. At our academic department from 1983 to December 2004, out of 99 patients with NSCLC less than 2cm from the carina, 35 (35.4%) were deemed inoperable after conventional staging; the remaining 64 underwent surgery. Since 1993 in every patient with lung cancer we perform a thoracoscopic exploration as the first step of the intervention. Unexpected causes of inoperability were found at thoracotomy in nine patients (14.1%) and at thoracoscopy in two other patients. Of the remaining 53 patients, 52 had a right TSP and one a left TSP. Intraoperative mortality was nil. Perioperative mortality was 7.5%. Major complications occurred in 11.3% of the patients. Thirty (56.6) patients are alive and disease-free 23-97 months after surgery; for 18 (33.4%) of these, more than 5 years have elapsed after the operation. TSP is the only concrete option for treating lung cancer originating less than 2 cm from the carina. The review of our experience and of other reported series suggests that, with careful selection of patients and meticulous surgical technique, operative mortality and complications are acceptable. Long-term survival and prognosis are encouraging.

PIN1 promoter polymorphisms are associated with Alzheimer's disease

In our study, we analyzed the coding and promoter regions of the PIN1 gene in a group of 111 Alzheimer's disease (AD) patients looking for a possible genotype-phenotype correlation. The presence of SNPs - which could affect and modify the clinical phenotype of AD patients was also investigated. We identified two single nucleotide polymorphisms (SNPs) at positions -842 (G-->C) and -667 (C-->T) in the promoter region of the PIN1 gene. Our results evidenced a significantly higher percentage of -842C allele carriers in AD subjects with respect to healthy controls. We found that this allele significantly raised the risk of developing AD (OR 3.044, CI 1.42-6.52). The -842 and -667 SNPs were in linkage disequilibrium and combined to form haplotypes. The CC haplotype conferred a higher risk of developing AD (OR 2.95, confidence interval 1.31-6.82). Finally, protein expression analyses revealed that subjects carrying the -842 CC genotype or the CC haplotype showed reduced levels of the PIN1 protein in peripheral mononuclear cells.

Predictors of high level of burden and distress in caregivers of demented patients: results of an Italian multicenter study

BACKGROUND

Considerable suffering is experienced by carers of patients with dementia. Most existing studies do not consider the coexistence of subjective and objective aspects that cause, interacting to each other, this suffering.

OBJECTIVES

In this study we: (1) define the high-risk group of caregivers on the bases of the scores obtained on the four scales evaluating burden, distress, depression and anxiety (BDDA) taken into account simultaneously and (2) evaluate risk factors related to the high level of BDDA.

SUBJECTS AND METHODS

419 elderly outpatients with dementia and their caregivers were enrolled. Patients were evaluated for their cognitive, neuropsychological and functional impairment and for comorbidity. Caregivers were evaluated with four scales for the assessment of burden, distress related to neuropsychological disturbances, depression and anxiety. Cluster analysis was used to identify the group with the High level of BDDA (HBDDA).

RESULTS

By multiple logistic analysis, disability, specific behavioural disturbances of the patients as well as caregiver's age, type of relationship and living in the south of Italy were observed to be a major risk factor for HBDDA.

CONCLUSION

The targeted use of scales specifically assessing BDDA of the caregiver and the identification of particular patient and caregiver characteristics are able to allow a precise and early definition of caregivers at high risk of burden and distress. This might be helpful in planning the correct social/clinical/rehabilitative approach.

Multimedia article. Video-assisted thoracoscopic major pulmonary resections: technical aspects, personal series of 259 patients, and review of the literature, part 2

BACKGROUND

Although more than 10 years have passed since the first video-assisted thoracoscopic lobectomies, these procedures have not gained widespread acceptance. We discuss the technical aspects and major problems associated with these operations, focusing on their present status and future perspectives. The results of our clinical series are presented and the relevant literature is reviewed.

METHODS

From October 1991 to June 2003, 344 patients were submitted to surgery for an intended video major pulmonary resection.

RESULTS

Of the 344 patients, seven (2.0%) were deemed inoperable at video exploration; 78 (23.1%) required conversion, either for technical reasons (n = 3), anatomical problems (n = 49), oncological conditions (n = 20), or intraoperative complications (n = 6). We carried out 253 video-assisted lobectomies and six pneumonectomies (209 for primary lung tumor, 43 for benign disease, and seven for metastases). There were no intraoperative deaths. Two patients died postoperatively. Complications occurred in 20 patients (7.7%). Global survival at 3 and 5 years was 83.24% (+/-6.9) and 68.87% (+/-9.7), respectively. Patients with T1 N0 cancer had a better survival rate at 3 and 5 years (87.13 +/- 8.3% and 75.12 +/- 12.2%) than those with T2 N0 cancer (78.49 +/- 11.2% and 61.2 +/- 15%).

CONCLUSIONS

Based on our experience and a review of the literature, we conclude that video-assisted thoracoscopic lobectomies offer less postoperative pain, a more rapid recovery, and better cosmetic results than their conventional counterpart. The results at 3- and 5-year follow-up for cancer are attractive. However, because no randomized study has yet proved these benefits definitively, further studies are still needed.

Video-assisted thoracoscopic major pulmonary resections: technical aspects, personal series of 259 patients, and review of the literature

BACKGROUND

Although more than 10 years have passed since the first video-assisted thoracoscopic lobectomies, these procedures have not gained widespread acceptance. We discuss the technical aspects and major problems associated with these operations, focusing on their present status and future perspectives. The results of our clinical series are presented and the relevant literature is reviewed.

METHODS

From October 1991 to June 2003, 344 patients were submitted to surgery for an intended video major pulmonary resection.

RESULTS

Of the 344 patients, seven (2.0%) were deemed inoperable at video exploration; 78 (23.1%) required conversion, either for technical reasons (n = 3), anatomical problems (n = 49), oncological conditions (n = 20), or intraoperative complications (n = 6). We carried out 253 video-assisted lobectomies and six pneumonectomies (209 for primary lung tumor, 43 for benign disease, and seven for metastases). There were no intraoperative deaths. Two patients died postoperatively. Complications occurred in 20 patients (7.7%). Global survival at 3 and 5 years was 83.24% (+/-6.9) and 68.87% (+/-9.7), respectively. Patients with T1 N0 cancer had a better survival rate at 3 and 5 years (87.13 +/- 8.3% and 75.12 +/- 12.2%) than those with T2 N0 cancer (78.49 +/- 11.2% and 61.2 +/- 15%).

CONCLUSIONS

Based on our experience and a review of the literature, we conclude that video-assisted thoracoscopic lobectomies offer less postoperative pain, a more rapid recovery, and better cosmetic results than their conventional counterpart. The results at 3- and 5-year follow-up for cancer are attractive. However, because no randomized study has yet proved these benefits definitively, further studies are still needed.

Long-term Survival After Videothoracoscopic Lobectomy for Stage I Lung Cancer

STUDY OBJECTIVES

The aim of this study was to evaluate our personal experience and survival curves after video-assisted thoracic surgery (VATS) lobectomies for stage I lung cancer, in comparison with the results reported in existing literature.

DESIGN

Retrospective analysis of our experience and an overview of literature.

SETTING

Department of Surgery, San Giuseppe Hospital, University of Milan.

PATIENTS

From October 1991 to December 2001, of 257 patients with clinical stage I lung cancer, 193 patients underwent VATS lobectomy, 7 patients were declared inoperable at thoracoscopic exploration, and 57 patients were converted (18 patients for oncologic reasons and 39 patients for technical reasons).

RESULTS

We observed no intraoperative mortality and no recurrence. Survival data were analyzed with the Kaplan-Meier method along with a log-rank test for statistical significance. The global survival rates at 3 years and 5 years were 77.7% and 63.64%, respectively. T1N0 patients had a better survival curve at 3 years and 5 years (83.50% and 70.21%, respectively) compared to T2N0 patients (71.13% and 56.12%). Patients < 70 years of age had better 3-year and 5-year survival rates (82.37% and 73.32%, respectively) than those > 70 years of age (57.49% and 37.09%). This difference was statistically significant (p < 0.01).

CONCLUSIONS

Our results after the VATS approach match the "best" results reported in literature following conventional surgery. Minimally invasive surgery seems to imply reduced tissue damage and decreased impairment of immunologic function. VATS lobectomy permits radical oncology as accurately as lobectomy by thoracotomy, provided that long-established standards are respected. In spite of technical difficulties, it could therefore become a valid alternative in treating stage I lung cancer.

Second Line Therapy with Weekly Low-dose Docetaxel for Pretreated Non-Small-Cell Lung Carcinoma Patients: A Multicenter Italian Phase II Study

Docetaxel is one of the most active drugs in second-line therapy for non-small-cell-lung-carcinoma (NSCLC). The aim of this multicenter study was to evaluate the safety and efficacy of weekly low-dose docetaxel. Forty-two patients with advanced NSCLC pretreated with cisplatinum-based chemotherapy were enrolled. Docetaxel was administered at a dose of 25 mg/m(2) weekly for 12 consecutive weeks. A total of 386 doses were given with a median number of 10 doses per patient (range: 3-12). Treatment showed low incidence of hematologic toxicity and modest non-hematologic toxicity. An episode of grade 4 thrombocytopenia was reported but no episodes of grade 3 or 4 neutropenia. Most frequent non-hematologic toxicities were asthenia and alopecia. Response rate was 10.5% and median survival time (MST) was 12.8 weeks. Weekly treatment with 25 mg/m(2) docetaxel for 12 consecutive weeks appears to be a feasible and active regimen with mild toxicity in heavily pretreated NSCLC patients.

Non-small cell lung cancer with chest wall invasion: evolution of surgical treatment and prognosis in the last 3 decades

STUDY OBJECTIVES

The treatment of patients with non-small cell lung cancer (NSCLC) that is invading the chest wall is still debated. We aim to illustrate the improvements in treatment results that have occurred over last decade.

DESIGN

Retrospective analysis of our experience and an overview of the literature.

SETTING

Department of Surgery, San Giuseppe Hospital, University of Milan.

PATIENTS

From January 1970 to December 1999, of 2,738 patients with NSCLC, we operated on 146 patients (5.4%) with chest wall invasion by NSCLC. Superior sulcus tumors and tumors invading the diaphragm or mediastinum were excluded. We reclassified all cases according to the current TNM classification.

RESULTS

We registered one postoperative death (0.69%) and five major complications (3.4%). From 1970 to 1979, of 32 patients, 10 underwent an exploratory thoracotomy (ET) and 22 underwent a radical resection (stage IIB disease, 17 patients; stage IIIA disease, 5 patients). The 5-year survival rate was 22.7% (25% for stage IIB disease). From 1980 to 1989, of 67 patients, 11 underwent an ET and 56 underwent a radical resection (stage IIB disease, 34 patients; stage IIIA disease, 12 patients; stage IIIB disease, 5 patients; and stage IV disease, 5 patients). The survival rate following radical resection was 14.1%, ranging between 23.5% for patients with stage IIB disease and 0% (3 years, 14%) for those with stage IIIA disease. From 1990 to 1999, of 47 patients, 2 underwent an ET, 2 underwent an exploratory thoracoscopy, and 43 underwent a radical resection (stage IIB disease, 23 patients; stage IIIA disease, 20 patients). The survival rate was 42.7% (stage IIB disease, 78.5%; stage IIIA disease, 7.2%).

CONCLUSIONS

Considering the low morbidity, mortality, and significant improvement in survival during the last decade, we advocate the performance of radical en bloc resection for the treatment of chest wall invasive NSCLC.

Mast cell density, hepatic stellate cell activation and TGF-beta1 transcripts in the aging Sprague-Dawley rat during early acute liver injury

Mast cells (MCs) have been indicated as a source of various inflammatory cytokines, chemokines and growth factors. This study evaluates liver tissue MC density as a quantitative marker of acute liver inflammation in 2- and 19-month old rats treated with carbon tetrachloride (CCl4) toassess the relationships between MC density, hepatocellular damage, mRNA encoding TGF-beta1, hepatic stellate cell (HSC) activation and collagen levels. Consecutive histological sections from each age group were stained with toluidine blue to identify granulated MCs, Direct Red 80 to recognize collagen matrix, and by immunohistochemistry to identify activated hepatic stellate cells (HSCs), which were subsequently counted by means of a computer-aided image analysis. Histology showed hepatocellular necrosis with inflammatory cell infiltration and collagen matrix deposition. Two and 24 hours after intoxication, MC density had considerably increased in the younger rats, but less in those aged 19 months. Although the untreated older rats had a larger area occupied by activated HSCs than the untreated younger rats, the increase in the number of HSCs was greater in the younger rats both two and 24 hours after intoxication. The greater MC density in younger rats suggests that older rats have a reduced immune response or recruit fewer MCs. The activated HSCs and TGF-beta1 transcripts did not increase significantly during the study period, thus indicating that these are later events in chemically induced hepatic toxicity. In conclusion. MC density may be an index of acute liver inflammation after CCl4 intoxication.

Major vascular injuries in laparoscopic surgery

BACKGROUND

Major vascular injuries (MVI) still occur in laparoscopic surgery.

METHODS

We report our institution's experience of two MVI (aortic lesions) in a series of 3545 laparoscopies (July 1991-December 2000). We compared this experience with other series reporting MVI from Medline, Embase, Current Contents, and Best Evidence.

RESULTS

There were no deaths, but we had 23 postoperative and eight intraoperative bleedings, including two hepatic vessel lesions during dissection and six vascular lesions (four minor vessels and two aortic) related to trocar insertion. Prevention and treatment options are also discussed.

CONCLUSIONS

The incidence of MVI reported in the literature is 0.05%, but the true incidence is difficult to estimate because results are not always comparable and there is a possibility of underreporting. The mortality rates (8-17%) are high. No technique or instrumentation is completely safe; therefore, a high level of alertness must be maintained at all times and precautions must be adopted to avoid major complications.

State of the art in thoracospic surgery: a personal experience of 2000 videothoracoscopic procedures and an overview of the literature

BACKGROUND

Herein we compare our personal experience with a series of > 2000 videothoracoscopic procedures with those reported in the literature to identify the procedures now accepted as the gold standard, those still regarded as investigational, and those considered unacceptable.

METHODS

Between June 1991 and December 2000, we performed 2068 videothoracoscopic procedures, including lung cancer staging (n = 910), wedge resections (n = 261), lobectomies (n = 221), pneumonectomies (n = 6), the diagnosis and treatment of pleural diseases (n = 200), the treatment of pneumothorax (n = 170), giant bullae (n = 57), lung volume reduction surgery (LVRS) for emphysema (n = 41), the diagnosis and treatment of mediastinal diseases (n = 133), the treatment of esophageal diseases (n = 39), and 30 other miscellaneous procedures.

RESULTS

A review of the literature indicates that videothoracoscopy is usually considered the preferred approach for the treatment of spontaneous pneumothorax, the diagnosis of indeterminate pleural effusions, the treatment of malignant pleural effusions, sympathectomy, and the diagnosis and treatment of benign esophageal or mediastinal diseases. The videoendoscopic approach to LVRS for emphysema is still under evaluation. Videothoracoscopic wedge resections for the diagnosis of indeterminate nodules and the treatment of primary lung cancer, metastases, and other malignancies are still controversial due to oncologic concerns. Videoendoscopic major pulmonary resections are usually considered investigational or even unacceptable due to oncologic concerns, technical difficulties, and the risk of complications.

CONCLUSIONS

Although we generally agree with the foregoing recommendations, we consider videoendoscopy the best approach for LVRS and particularly useful for the staging of lung cancer, where we always perform it as the first step of the operation. We widely perform videoendoscopic major pulmonary resections, but we believe that these procedures should only be used in strictly selected cases and at specialized centers.

Thoracoscopy and transplantation: a new attractive tool

BACKGROUND

Transplanted patients on immunosuppressive treatment have an increased risk of infections or neoplasms. Transplantation candidates with infection or a suspected malignancy are excluded from transplantation. In patients already transplanted, thoracoscopy can resolve complications or treat the pulmonary pathology without compromising the precarious existing reactive equilibrium. These patients require an approach that is as least traumatic as possible.

METHODS

From September 1991 to December 2000, of 2068 videothoracoscopic procedures carried out at our hospital, 2 were in patients who had undergone transplantation and 3 in candidates for kidney, liver, and bone marrow transplantation. Starting from our personal experience in videothoracoscopy as a diagnostic and therapeutic approach, the possibilities of the method in the field of transplantation are reported by a review of the literature carried out by consulting the reference systems of the most important data banks.

CONCLUSIONS

In our experience, videothoracoscopy had a major impact on the management of candidates for transplant, because it allowed us to rule out or treat conditions that would have determined exclusion from a transplant program. In transplanted patients, videothoracoscopy allows a correct diagnosis and treatment with minimal trauma.

Is hemochromatosis a risk factor for Alzheimer's disease?

Excess iron accumulation in the brain is a consistent observation in Alzheimer's Disease. Iron affects amyloid precursor protein (AbetaPP) processing and promotes deposition of Abeta. Iron is also among the most potent biological toxins because of its ability to react with oxygen to form reactive oxygen species. Consequently, elucidation of the mechanisms associated with maintaining brain iron homeostasis is fundamentally important to understanding the underlying pathogenesis in AD. The iron overload disorder, Hemochromatosis, is the most common genetic disorder (1:200) so a significant percentage of AD patients can be expected to carry this mutation. Heterozygotes for this mutation also have an increased, but sub-clinical iron burden. Given the high percentage of the population who are at significant risk for iron overload, we propose that the hemochromatosis mutation be considered as a confounding factor when evaluating the contribution of genetic associations with AD and treatment strategies and efficacy. Two recent papers and new evidence presented here that the protein associated with hemochromatosis is expressed on blood vessels, choroid plexus and the ependymal cells in the brain are offered as support for this proposal.

The hemochromatosis gene affects the age of onset of sporadic Alzheimer's disease

In the present study we analysed the genotype of HFE, the gene involved in hemochromatosis, in 107 patients with sporadic late-onset AD and in 99 age-matched non-demented controls. We observed that patients carrying the mutant HFE-H63D allele had a mean age at onset of 71.7 +/- 6.0 years versus 76.6 +/- 5.8 years of those who were homozygous for the wild-type allele (p = 0.001). The frequency of the HFE-H63D mutation was highest (0.22) in the patients aged <70 years at the time of disease onset, whereas it was 0.12 in those with disease onset at an age of 70-80 years, and 0.04 in those aged more than 80 years. The APOE genotype did not significantly modify the effect of HFE on age at onset. We conclude that mild disturbances of iron homeostasis associated with a common genetic determinant may interact with other pathogenic mechanisms involved in AD. HFE mutations may anticipate AD clinical presentation in susceptible individuals.

Complications of tracheal sleeve pneumonectomy: personal experience and overview of the literature

OBJECTIVES

Tracheal sleeve pneumonectomy, although technically demanding, is considered the choice for tracheobronchial angle cancers. Complications in our 49 tracheal sleeve pneumonectomies are reviewed. Results, complications, and technical aspects are critically discussed. Although series in the literature differ in selection of patients and surgical techniques and extend over long periods, we attempt to compare our experience with results from the literature.

METHODS

From 1983 to September 1999, 60 patients eligible for tracheal sleeve pneumonectomy after conventional staging underwent operation. A Sybilla Fome-Cuf ventilation tube (Bivona, Inc, Gary, Ind) was used starting in 1987 to facilitate anastomosis. Since 1993, all patients have undergone video-assisted thoracoscopy immediately before the operation.

RESULTS

There were 11 (18.3%) exploratory thoracotomies, 48 right tracheal sleeve pneumonectomies, and 1 left tracheal sleeve pneumonectomy. Among the tracheal sleeve pneumonectomies, we recorded 4 (8.2%) perioperative deaths (myocardial infarction, n = 1; heart failure, n = 1; pulmonary edema, n = 1; gastric ulcer hemorrhage, n = 1; and anastomotic fistula in a patient who received high-dose radiation before the operation, n = 1). We observed 5 (10.2%) complications (lung edema, n = 1; transitory recurrent nerve palsy, n = 2; empyema without fistula cured conservatively, n = 1; and pneumonia, n = 1). Anastomotic stenosis did not occur. Twenty-six (53%) patients are alive 14 to 87 months postoperatively, 12 (24.5%) of these more than 5 years postoperatively. Five (10.2%) died of mediastinal recurrence at 6 and 54 months. Two others (4.1%) died in road accidents.

CONCLUSIONS

Tracheal sleeve pneumonectomy is a demanding operation with a high risk of complications. Analysis of literature and personal experience shows that complications can be greatly reduced through accurate selection of patients, precise technique, and optimal postoperative care. Long-term survival equals that obtained after standard pneumonectomy.

Age-dependent expression of fibrosis-related genes and collagen deposition in rat kidney cortex

Because progressive fibrosis is a histological hallmark of the aging kidney, we sought to characterize the course of some fibrosis-related genes [pro-alpha2(I)collagen (COL-I), pro-alpha1(III)collagen (COL-III), and transforming growth factors beta1 and beta3 (TGF-beta1 and TGF-beta3)] of interstitial collagen accumulation [COL-I and COL-III proteins, hydroxyproline (PRO-OH), histology] and its degradation (matrix metalloproteinase MMP-1 and -2) during maturation and early aging in rats. During the lifespan considered we observed no changes in the mRNA, except that COL-I mRNA tended to be up-regulated from 2 to 19 months of age. However, progressive fibrosis was histologically detectable, with COL-I accumulation (p < .05 and p < .01 in 12-month- and 19-month-old rats vs the youngest), and confirmed by the PRO-OH tissue levels (p = .0001); COL-III seemed to be less involved. The MMP-1 protein level decreased significantly in the cortex of 12-month- and 19-month-old rats (p < .05), whereas MMP-2 protein level and activity remained essentially unchanged. These results show that, during aging of the kidney, (i) renal cortex fibrosis is explained by COL-I accumulation as a consequence of an altered balance between its synthesis and degradation, and (ii) the expression of the pleiotropic factor TGF-beta in the renal cortex is not modified.

Atherogenic lipid profile in elderly patients with ischaemic cerebrovascular disease

The significance of the link between plasma cholesterol concentrations and risk of cerebrovascular disease (CVD) in the elderly is still debated. In a case-control study we found that elderly patients with ischaemic CVD have an atherogenic lipid profile, despite having low or normal total cholesterol concentrations.

[Biology and needs of the aged]

The elderly age group is growing rapidly as a proportion of the total population of Italy. By the year 2020 the population aged 65 and over is expected to increase from 17% to 23%. The biological process of aging leads to a loss of functional reserves, and so elderly people are frail and affected by multiple diseases. However, health in the elderly is synonymous with self-sufficiency, which may be preserved even in the presence of a disabling disease. According to the new WHO International Classification of Functioning and Disability (ICIDH-2) the important elements in defining health status include personal activity and social participation, as well as body functions. As people age in different ways, the response to the needs of the elderly must be flexible and multidimensional. One of the priority objectives of modern medicine is to push disability to the end of life as much as possible.

Videothoracoscopic approach to primary mediastinal pathology

STUDY OBJECTIVES

Personal results and validity of videothoracoscopic (VTS) approach to primary mediastinal diseases are analyzed.

DESIGN

Retrospective review of personal experience.

SETTING

Department of Surgery, San Giuseppe Hospital, University of Milano, Italy.

PATIENTS

From September 1991 to January 1999, of a personal series of 1,653 VTS procedures, 118 regarded primary mediastinal diseases. In 47 cases, diagnostic videothoracoscopy was performed to obtain large biopsy specimens or to carry out accurate staging; in 71 cases, full resection was anticipated.

INTERVENTIONS

The patient, intubated with a double-lumen Carlen's tube and in the lateral decubitus position, underwent videothoracoscopy. Two ports and a small anterior utility thoracotomy were completed. Thorough exploration of the mediastinum and, if possible, complete resection of the lesion were accomplished.

MEASUREMENTS AND RESULTS

Videothoracoscopy yielded adequate diagnosis or staging in all patients operated on for diagnostic purposes. Of 71 patients operated on with resective intent, 66 had complete thoracoscopic resection (22 stage-I thymomas, 4 thymic cysts, 21 myasthenia gravis associated with thymic hyperplasia, 19 miscellaneous tumors). Conversion was required in five cases, mostly for invasion of mediastinal structures. Complications included the following: one patient developed intraoperative bleeding controlled endoscopically, two patients experienced postoperative bleeding requiring re-thoracoscopy, and one patient had postoperative pneumonia requiring assisted ventilation. One recurrence of malignant thymoma occurred 4 years postoperatively.

CONCLUSIONS

Videothoracoscopy can attain a leading role in obtaining large samples in lymphatic mediastinal diseases. Dysembriomas, schwannomas, simple cysts, and similar lesions can benefit from VTS removal. Total thymectomy for myasthenia gravis associated with thymic hyperplasia can be performed thoracoscopically. Further data and more extensive experience are needed.

Left ventricular response to beta-adrenergic stimulation in aging rats

The incidence of heart failure in the population increases steeply among older people. Overactivation of the sympathetic nervous system is associated to and responsible for worsening of heart failure. This study describes the influence of aging on short-term left ventricular (LV) adaptation to b-adrenergic stimulation in Wistar rats. In controls at 18 mo, interstitial fibrosis was increased with respect to 3-mo-old rats, whereas myocytes dimension and the messenger RNA (mRNA) abundance of atrial natriuretic peptide (ANP), a2(I) procollagen, transforming growth factor (TGF-b1, TGF-b3), and secreted protein, acidic and rich in cysteine (SPARC) were not different. To determine how aging affects LV adaptation to adrenergic stimulation, two groups of animals received isoproterenol (ISO, 1 mg/kg/d) for 3 days. There was no significant difference between young and older rats with respect to increase in LV weight, myocytes dimension, and mRNA abundance of all the genes considered, except a1(III) procollagen. These findings indicate that despite limited compensatory hypertrophy and higher fibrosis, LV from aged nonsenescent rats preserves the capacity to adapt to b-adrenergic stimulation through the upregulation of several genes encoding extracellular matrix-related proteins.

False radiographic appearance of a right bronchial stump following extended right pneumonectomy

The authors describe three cases in which postoperative frontal chest radiographs following extended right pneumonectomy showed a right hilar lucency producing the false appearance of a residual main bronchus that is shown by additional studies to represent a dilated esophagus.

Hepatitis C infection in an Italian population not selected for risk factors

AIMS/BACKGROUND

This study estimated the prevalence of HCV infection and relationship with viremia in a general population. The inhabitants of Albavilla town were personally invited to participate.

METHODS

Out of 3997 inhabitants falling within the age range 18-85 years, 2403 (participation rate 60.1%) were examined for transaminases, HCVAb, HCVRNA, genotype and immunoblot assay. The following information was collected: sex, age, blood transfusions, surgery, use of glass syringes, drug addiction, alcohol consumption, tattoos and body mass index.

RESULTS

115 (4.8%) were HCVAb+, the prevalence being 1.2% under 40 years. Transfusion in the past was the only risk factor for HCV infection. Among the HCVAb+ subjects, 71 (61.7%) were HCVRNA+. 40.8% of the HCVAb+/HCVRNA+ group had normal ALT, compared with 68% of those with HCVAb+/HCVRNA-. The HCV genotypes in the 71 HCVRNA+ subjects were: 2a/2c in 58 (81.7%), 40% of them with normal ALT;1b in 11 (15.5%), none with normal ALT; genotype 3 in two (2.8%).

CONCLUSION

The prevalence of HCVAb in this general population was 4.8%. About 3% were HCVRNA positive and of these genotype 2a/ 2c was present in 81.6%.