Asthma incidence can be influenced by climate change in Italy: findings from the GEIRD study-a climatological and epidemiological assessment

An association between climatic conditions and asthma incidence has been widely assumed. However, it is unclear whether climatic variations have a fingerprint on asthma dynamics over long time intervals. The aim of this study is to detect a possible correlation of the Summer North Atlantic Oscillation (S-NAO) index and the self-calibrated palmer drought severity index (scPDSI) with asthma incidence over the period from 1957 to 2006 in Italy. To this aim, an analysis of non-stationary and non-linear signals was performed on the time series of the Italian databases on respiratory health (ISAYA and GEIRD) including 36,255 individuals overall, S-NAO, and scPDSI indices to search for characteristic periodicities. The ISAYA (Italian Study on Asthma in Young Adults) and GEIRD (Gene Environment Interactions in Respiratory Diseases) studies collected information on respiratory health in general population samples, born between 1925 and 1989 and aged 20-84 years at the time of the interview, from 13 Italian centres. We found that annual asthma total incidence shared the same periodicity throughout the 1957-2006 time interval. Asthma incidence turned out to be correlated with the dynamics of the scPDSI, modulated by the S-NAO, sharing the same averaged 6 year-periodicity. Since climate patterns appear to influence asthma incidence, future studies aimed at elucidating the complex relationships between climate and asthma incidence are warranted.

A novel oncogenic BTK isoform is overexpressed in colon cancers and required for RAS-mediated transformation

Bruton's tyrosine kinase (BTK) is essential for B-cell proliferation/differentiation and it is generally believed that its expression and function are limited to bone marrow-derived cells. Here, we report the identification and characterization of p65BTK, a novel isoform abundantly expressed in colon carcinoma cell lines and tumour tissue samples. p65BTK protein is expressed, through heterogeneous nuclear ribonucleoprotein K (hnRNPK)-dependent and internal ribosome entry site-driven translation, from a transcript containing an alternative first exon in the 5'-untranslated region, and is post-transcriptionally regulated, via hnRNPK, by the mitogen-activated protein kinase (MAPK) pathway. p65BTK is endowed with strong transforming activity that depends on active signal-regulated protein kinases-1/2 (ERK1/2) and its inhibition abolishes RAS transforming activity. Accordingly, p65BTK overexpression in colon cancer tissues correlates with ERK1/2 activation. Moreover, p65BTK inhibition affects growth and survival of colon cancer cells. Our data reveal that BTK, via p65BTK expression, is a novel and powerful oncogene acting downstream of the RAS/MAPK pathway and suggest that its targeting may be a promising therapeutic approach.

Fistula in ano: anatomoclinical aspects, surgical therapy and results in 844 patients

BACKGROUND

Several new therapies, including advancement flaps and fibrin glue, have been proposed for fistula in ano, with conflicting results. Most colorectal surgeons continue to use classic methods, e.g. fistulotomy, fistulectomy, a combined method, loose or cutting seton, and rubber loop. The aim of the present study is to report the outcome of our patients, operated on by such methods.

METHODS

We retrospectively reviewed the clinical records of 844 patients treated for anal fistula over a 30-year period, and assessed fistula morphology, surgical procedure and healing period. For patients treated 2 or more years prior to this study, we evaluated rates of persistent fistula and relapse, as well as prevalence of incontinence and patient satisfaction.

RESULTS

The majority of patients had trans-sphincteric fistulae (58.3%). We observed 274 secondary extensions (32.5%); these were common in all fistula types except for intrasphincteric fistulae. Most patients were treated by fistulotomy alone (594 patients, 70.4%) or by the combined fistulectomy-fistulotomy method (237 patients, 28.1%), with or without loose seton. All patients with trans-, supra- and extrasphincteric fistulae were re-examined in the operations theatre. Follow-up data were available for 652 (87%) of 751 patients at least two years after surgery. The anal fistula persisted in 3.2% and recurred in 2.1% of cases. A second procedure lowered the initial rate of unsuccessful operations from 5.3% to 2.5%. Continence disorders were reported in 6.9% of patients: 4.0% complained of incontinence to gas, 2.6% to liquid and 0.3% to solid feces.

CONCLUSIONS

Fistulotomy and fistulectomy with loose seton supported by preoperative anal manometry and postoperative evaluation under anaesthesia are followed by good clinical and functional results.

Submucosal reconstructive hemorrhoidectomy (Parks' operation): a 20-year experience

BACKGROUND

Submucosal reconstructive hemorrhoidectomy has never been a popular operation due to its difficulty and duration, the amount of blood loss, and the risk of incontinence. The main indication for hemorrhoidectomy according to Parks is fourth-degree hemorrhoids with prolapse of the dentate line outside the anus and with simultaneous presence of external hemorrhoids. We report our experience in the treatment of hemorrhoids using submucosal reconstructive hemorrhoidectomy according to Parks.

METHODS

A total of 640 patients (381 men and 259 women) of median age 42 years (range, 18-81) were treated between 1983 and 2002; 80% of patients had fourth-degree, 19% third-degree and 1% second- degree hemorrhoids. All patients underwent rectosigmoidoscopic examination before surgery; patients over 35 years of age or with a suspected inflammatory or neoplastic disease underwent colonoscopy or barium enema. All patients underwent anorectal manometry before operation, to measure anal resting pressure, maximal squeeze and sphincter length, with the purpose of determining if an internal sphincterotomy was also necessary (in case of high anal resting tone). One-third of the patients also had an internal sphincterotomy to correct anal hypertonia.

RESULTS

Postoperative bleeding occurred in 19 patients (2.9%), 0.9% requiring a reintervention. Severe pain was reported by 9 patients (1.4%); fecal impaction occurred in 3 cases (0.5%) and suture disruption in 2 patients (0.3%). In 74 patients (11.6%), bladder catheterization was needed due to urinary retention. Of 550 patients who had a minimum follow-up of 3 years and were sent a postal questionnaire, 374 patients responded, with a median 7.3-year follow- up; 176 patients (32%) were lost to follow-up. Eleven patients (2.9% of 374 cases) reported pain during defecation, 6 (1.6%) developed skin tags or recurrence, 3 (0.8%) reported gas incontinence, 2 (0.5%) developed anal fistula and 1 (0.3%) had anal stricture.

CONCLUSIONS

Submucosal reconstructive hemorrhoidectomy according to Parks still represents a good choice for the treatment of high-degree hemorrhoids with prolapse of the dentate line outside the anus and external circumferential hemorrhoids.

Calibrated lateral internal sphincterotomy for chronic anal fissure

Lateral internal sphincterotomy is an effective procedure for the treatment of anal fissure, but may affected anal continence. We describe a procedure aimed at tailoring the division of the sphincter according to the degree of the hypertonia and to the sphincter length in order to offer an effective and safe treatment for chronic anal fissure.

METHODS

The internal sphincter was divided on the basis of anal manometry results. The average of maximum values of resting pressure determined by the stationary motility protocol was considered the reference parameter to measure hypertonia. Mild hypertone was considered to be 50-60 mmHg, moderate hypertone 60-80 mmHg, and severe hypertone >80 mmHg. In case of mild hypertone, 20% of the internal sphincter was divided; in case of moderate hypertone; 40% and 60% for severe hypertone. Calibrated lateral internal sphincterotomy is the division of the internal sphincter based on these parameters. Over 5 years, 388 patients underwent this procedure (197 men, 191 women) with a median age of 43 years (range, 18-80).

RESULTS

Postoperative complications consisted of abscess in 4 patients (1.0%), hemorrhage in 2 patients (0.5%), and pain in 6 patients (1.5%). Follow-up data are available for 261 patients (67.3%). Two months after surgery, 9 patients (3.4%) complained of persistent or recurring pain with or without fissure and 1 (0.4%) complained of gas incontinence. At postoperative manometry, 12 patients (4.6%) revealed persistence of anal resting pressure over 40 mmHg, 9 patients (3.4%) were still symptomatic and 97.6% were cured at a median follow-up of 8 months. An anal resting pressure lower than 30 mmHg was found in 10 patients (3.8%), only one of whom was incontinent.

CONCLUSIONS

Calibrated sphincterotomy may represent an effective and safe procedure for the treatment of chronic anal fissure.

[Fournier's gangrene in a patient with Hodgkin's disease: a clinical case]

The authors report a case of Fournier's gangrene in a 54-year-old patient subjected 6 days earlier to chemotherapy for mediastinal Hodgkin's disease. The patient had fever and reported the onset of worsening pain and heat sensations in the inguinal, perineal and scrotal areas. Objectively, there was local oedema followed by the onset of crepitation. The patient had a very low white blood cell count (900/cu.mm). The Patient underwent emergency surgery with multiple, communicating incisions in the inguinal, perineal and scrotal areas, with the removal of necrotic tissue and daily washing with physiological solution and 12% H2O2. He also received antibiotic treatment with metronidazole and gentamicin and 5 cycles of high-pressure oxygen therapy, with disappearance of pain and fever and good local tissue repair.

Growth hormone (GH) rebound rise following somatostatin infusion withdrawal: studies in dogs with the use of GH-releasing hormone and a GH-releasing peptide

OBJECTIVE

Evidence has been presented that in both animals and humans the rebound secretion of growth hormone (GH) following withdrawal of an infusion of somatostatin (SS) is due to the functional activation of the hypothalamic GH-releasing hormone (GHRH) neurons of the recipient organism. Based on this premise, this study has sought to assess the existence of functional interactions between endogenous GHRH released by a SS infusion withdrawal (SSIW) and growth hormone-releasing peptides (GHRPs), a class of compounds allegedly acting via GHRH.

METHODS

Five young dogs (3 to 4 years old, 2 male and 3 female) were administered, on different occasions, three consecutive intravenous boli of physiological saline (0.1 ml/kg), or GHRH (2 microg/kg), or EP92632 (125 microg/kg), a GHRP compound, or GHRH plus EP92632 at the end of three cycles of 1-h SS infusions (8 microg/(kg x h)) or during a 6-h infusion of saline.

RESULTS

Under saline infusion (SALI), plasma GH levels were unaltered, whereas each SSIW cycle was followed by similar GH secretory episodes. Administration of the first GHRH bolus under SALI induced a rise in plasma GH concentrations slightly higher than that induced by the first cycle of SSIW, but the GH response to the second and third GHRH boli was similar to that after SSIW. Following SSIW, the response to the first bolus of GHRH was higher than that during SALI, but the second and third cycles of SSIW induced GH responses similar to those evoked by the GHRH bolus. During SALI, administration of the first bolus of EP92632 induced a rise in plasma GH which was higher than that induced by the first GHRH bolus, the second bolus elicited a GH peak of lesser amplitude and there was a partial restoration of the GH response to the third peptide bolus. SSIW strikingly enhanced the GH release to the first EP92632 bolus, a pattern also present, although to a lesser extent, with the second and third cycles of SSIW. Under SALI, combined administration of GHRH and EP92632 had a synergistic effect on GH release, but a progressive reduction was present in the GH response to the second and third GHRH plus EP92632 boli. SSIW increased only weakly the GH response to the first co-administration of the peptides over that present after administration of EP92632 alone, and did not induce a GH response higher than that present during SALI when the second bolus of the peptides was administered; after the third SSIW a GH rise higher than that present during SALI was elicited by the combined administration of the peptides.

CONCLUSIONS

(i) the uniformity of the GH rebound responses to multiple cycles of SSIW may indicate that the latter activate a physiological mechanism which mimics that normally controlling GH pulse generation; (ii) EP92632 elicits, under our experimental conditions, a plasma GH rise higher than that induced by GHRH; (iii) SSIW enhances the GH response to EP92639 alone, to an extent reminiscent of that following combined administration of GHRH and EP92632. This pattern reinforces the view that SSIW elicits release of endogenous GHRH, and infers that the GHRP challenge after SSIW may be exploited in humans to distinguish between healthy and GH-deficient adults.

[Appendiceal mucocele associated with colonic neoplasm. Report of 2 cases and review of the literature]

Appendiceal mucocele is a rare entity frequently associated with colorectal cancer. We report two cases of mucocele associated with colorectal tumours. The first case (male, 64 yrs) is an appendiceal mucinous cystadenoma found incidentally during surgery for colon cancer. There is no evidence of disease after a 4-year follow-up. The second case (male, 66 yrs) is a mucocele associated with mucosal hyperplasia that was found during surgery for acute appendicitis with a periappendicular abscess. Endoscopic follow-up showed a rectal adenocarcinoma that was initially treated with local excision with T.E.M.. Examination of the pathology specimen documented vascular invasion and the patient underwent curative colorectal resection. The preoperative radiological and endoscopic diagnostic procedures and the current therapeutic approaches described in the literature are reviewed. The relevance of the association between appendiceal mucocele and colorectal cancer is emphasized. Thorough investigation of the colorectal tract is recommended after diagnosing an appendiceal mucocele.

[Endometriosis of umbilical cicatrix: a clinical case]

The Authors report a case of umbilical endometriosis in a 46-year-old patient. The woman came in for observation describing acute pain in the vicinity of the umbilical scar. The pain was occasional at first and then became steady and increased at the time of menstruation. Medical examination revealed a left paraumbilical nodule, measuring 1 cm in diameter. The patient underwent surgical treatment: the nodule was excised and the subsequent histological examination was diagnostic for umbilical endometriosis. The surgical excision was effective: at follow-up 3 months later, there was no recurrence and the patient was in good general condition.

[Bilateral pheochromocytoma associated with duodeno-jejunal GIST in patient with von Recklinghausen disease: report of a clinical case]

The authors present the case of a 60-year-old male patient suffering from von Recklinghausen's disease (neurofibromatosis type I, NF1) with bilateral pheochromocytoma and occasional intraoperative reports of duodenojejunal GIST (GastroIntestinal Stromal Tumour). Through a review of the literature the authors analyze the frequency and the features of bilateral pheochromocytoma and its rare histological variant, the so-called composite pheochromocytoma, characterized by the combination of pheochromocytoma and ganglioneuroma or ganglioneuro-blastoma. Bilaterality of pheochromocytoma is more frequent in patients with familiarity for pheochromocytoma without NF1. Composite pheochromocytoma accounts for about 3% of total pheochromocytomas. In addition, the authors summarize the present knowledge about gastrointestinal stromal tumours and investigate the possible association between them and NF1 or pheochromocytoma, concluding that any such association is purely casual, while confirming the well known, genetically determined association between NF1 and pheochromocytoma.

Cellular mechanisms for diminished scarring with aging

The study of an age-dependent spectrum of scar formation is driven by the desire to understand and recapitulate scarless healing. Although focus in the past has been directed toward scarring in the fetus, less exuberant scarring is a common clinical observation in the elderly. Cell turnover is a major contributor to the development of scar tissue and is governed by the proliferative and apoptotic cellular fractions within a healing wound. We hypothesize that the balance between cell proliferation and apoptosis during late stages of excisional wound healing is, at least in part, responsible for age-related variations in scarring potential. Full-thickness 7-mm ulcers (four per ear), exposing bare cartilage, were made on the inner surface of the ear on 12 young and 12 aged New Zealand White rabbits. Analyses were performed at days 15, 21, and 28 postwounding. A previously described Scar Elevation Index was derived from histomorphometric analysis, along with the quantification of epithelial ingrowth and total cellularity. Apoptotic cellular fractions were derived from TdT-mediated dUTP nick end-labeling assay-stained histologic sections; proliferative fractions were derived from proliferating cell nuclear antigen-labeled serial sections. Young rabbits demonstrated significantly greater scar elevation/area. Apoptosis was strongly associated with progress of epithelialization in both groups. Significantly higher proliferative indices were seen in the young and were sustained through day 28, by which time levels had substantially declined in the aged. No differences in apoptotic indices were demonstrated between groups at any time point. The clinical observation of less exuberant scarring with aging is supported by this animal model. Apoptosis follows the progression of epithelialization but does not appear to independently influence scar morphology. A diminished proliferative response during later stages of healing is an important contributing mechanism for the decrease in scar formation seen in the elderly.