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Learning on the Web. Case 6: aortic valve replacement in the elderly. A 90 year old man was found at home by his daughter, slumped at the bottom of his stairs. He recalled quite severe tight central chest pain associated with breathlessness and sweating while going up stairs which was not relieved by taking a spray of sublingual glyceryl trinitrate (GTN). He sensed that he was "about to die" before collapsing with loss of consciousness. He was sent to the accident and emergency department (emergency room) of his local hospital by ambulance. The patient had a five year history of angina pectoris that limited him to one flight of stairs within the house and light housework only. Over the two weeks preceding his admission to hospital he had experienced increasing frequency of these symptoms and used his GTN spray more often than usual. He had not smoked for over 50 years and there were no other risk factors for cardiovascular disease. There was no other notable past medical history and he was otherwise fit, living completely independently. The significance of these signs and symptoms, the diagnosis, and the short and long term treatment of these problems are discussed in an interactive case presentation.

Learning on the Web. Case 7: recurrent pleural effusions, resistant atrial arrhythmias, and abnormal liver function tests: general medicine or cardiology? A 65 year old man presented with recurrent pleural effusions. Repeated pleural fluid examination and pleural biopsy were unremarkable. Pericardial calcification was noted on admission and attributed to an uncomplicated episode of pericarditis 30 years previously. His symptoms and signs were not thought not to be associated with the heart. While awaiting an open pleural biopsy the patient was admitted with a further pleural effusion, jaundice, resistant atrial arrhythmias, and dyspnoea. Hepatic investigations including autoantibody screen and transjugular liver biopsy were normal. The significance of these signs and symptoms, the diagnosis, and the management of these problems are discussed in an interactive case presentation.

Urotensin-II and cardiovascular diseases. Urotensin-II (U-II) is a vasoactive factor with pleiotropic effects. U-II exerts its activity by binding to a G-protein-coupled receptor termed UT. U-II and its receptor are highly expressed in the cardiovascular system. Increased U-II plasma levels have been reported in patients with cardiovascular disease of varying etiologies. We and others have shown that U-II and UT expression is elevated in both clinical and experimental heart failure and atherosclerosis. U-II induces cardiac fibrosis by increasing fibroblast collagen synthesis. In addition, U-II induces cardiomyocyte hypertrophy and increased vascular smooth muscle cell proliferation. We have shown that U-II antagonism using a selective U-II blocker, SB-611812 reduces neointimal thickening and increases lumen diameter in a rat restenosis model of carotid artery angioplasty. These findings suggest an important role for U-II in cardiovascular dysfunction and remodeling.

[Infiltrative pulmonary tuberculosis: course and efficiency of treatment]. The purpose of the investigation was to study the course of and the efficiency of treatment for new-onset infiltrative pulmonary tuberculosis. Two hundred and two patients with this condition were examined. Among the 202 patients, 15 (7.4%), 49 (24.3%), and 46 (22.8%) patients had lobular, rounded, and cloud-like infiltrates, respectively. 31 (15.3%) patients had periscissuritis and 61 (30.2%) had lobitis. The extent of infiltrative pulmonary tuberculosis within 1 segment was encountered in 19.3% and more frequently in the presence of rounded and lobular infiltrates; the specific process in 2 segments was detected in 24.3% of cases and more frequently when rounded and cloud-like infiltrates were observed. In periscissuritis and lobitis, the process occupied 1 lobe in 87.1 and 44.3% of cases, respectively, and 2 lobes or more in 34 (55.7%) patients. Infiltrates were located in the upper lobe in 167 (82.7%) patients, in Segment IV in 21 (10.4%), Segment IX in 6 (3%), Segment X in 5 (2.5%). The signs of lung tissue decay were detected in 140 (69.3%) persons. Decay cavities of less than 2 cm, 2-4 cm, and more than 4 cm in diameter were found in 56 (40%), 62 (44.3%), and 22 (15.7%) patients, respectively. Mycobacterium tuberculosis (MTB) was detected in 13.3, 46.9, 54.4, 70.9, and 83.6% of the patients who had lobular, rounded, and cloud-like infiltrates, periscissuritis, and lobitis, respectively. The drug-sensitive MBT population was seen in 58.4% of the patients; the drug-resistant MBT population was detected in 18.1% of the patients: in 14.3% with a lobular infiltrate, in 10% with a rounded infiltrate, in 28.6% with a cloud-like one, in 21.4% with perscissuritis, and in 15.7% with lobitis. Multi-drug MBT resistance was ascertained in 3.5% of the patients. Bacterial isolation ceased in 100% of the patients with a lobular infiltrate after 1-month therapy, in 47.8 and 52.2% of those with a rounded infiltrate after 1- and 2-month therapy, respectively, in two thirds and one third of the patients with a cloud-like infiltrate after 1- and 2-month therapy, respectively, in 45.4 and 31.8% of those with periscissuritis after 1- and 2-month therapy, respectively, and in 45.1 and 11.8% of cases of lobitis after 1- and 4-month therapy, respectively.

[X-ray features of disseminated pulmonary tuberculosis at late stages of HIV infection]. The paper analyzes the results of a study of X-ray features of disseminated pulmonary tuberculosis in HIV infection on the basis of a retrospective analysis of the case histories of 65 HIV-infected patients with disseminated pulmonary tuberculosis and 60 patients with disseminated tuberculosis without HIV infection, who have been followed up in the Krasnodar Territory. X-ray changes characteristic for patients with disseminated tuberculosis in HIV infection and their difference from those with disseminated tuberculosis without HIV infection have been ascertained, which assists in timely establishing the diagnosis of tuberculosis in HIV infection.

[Thirty years' experience in following up patients with nonspecific respiratory diseases]. The paper sums up the work of the Diagnosis Department of the Central Research Institute of Tuberculosis, Russian Academy of Medical Sciences in the past 30 years. It also presents the results of examinations, treatment, and follow-ups of 5000 patients with sarcoidosis, exogenous allergic alveolitis, pulmonary tuberculosis of questionable activity, pneumonia, benign and malignant tumors, respiratory malformations, systemic vasculitis, pulmonary eosinophilia, lymphogranulomatosis, and rare lung diseases.

[On the morphological diagnosis of drug-resistant pulmonary tuberculosis]. The intraoperative samples taken from 15 patients with acutely progressive drug-resistant fibrocavernous pulmonary tuberculosis were studied. There were typical signs of granulomatosis inflammation, a predominance of an exudative tissue reaction, and an extensive vascular bed lesion. Two types of perifocal cellular infiltrates were identified. Mononuclear infiltrates with epithelioid cellular transformation along the periphery were defined as specified. Nonspecific infiltrates were composed of foam macrophages-lipophages and they reflected lipid metabolic disturbances. In addition, the severity of the process was determined by an extensive specific bronchial lesion of all generations. A morphological study of the samples could reveal the tissue and cellular features of respiratory organs in drug-resistant tuberculosis and identify the diagnostically significant signs of specific and nonspecific inflammation.

Genetic and pharmacological basis for therapeutic inhibition of beta- and gamma-secretases in mouse models of Alzheimer's memory deficits. Alzheimer's disease (AD) is a dementing neurodegenerative disorder for which effective disease-modifying therapeutic treatments have not yet been developed. Genetic and molecular biological studies provide accumulating evidence supporting the hypothesis that the production of amyloid-beta (Abeta) peptides, especially neurotoxic Abeta42, is central to the pathophysiology of AD--the 'amyloid cascade' hypothesis. Abeta is proteolytically generated from a type I integral membrane amyloid precursor protein by the sequential action of two enzymes, called beta- and gamma-secretase, in reference to their cleavage sites at the N- and C-terminals, respectively. Given the strong association between Abeta and AD, the strategies to inhibit the production of Abeta, the first step of the amyloid cascade, should prove beneficial as truly disease-modifying therapeutic approaches for the treatment of AD. Recent advances in genetic strategies including knockouts, transgenics and virus-delivered small interfering RNAs and the development of potent and specific small-molecule inhibitors have opened a new window to test the impacts of beta- and gamma-secretase inhibition in vivo. Since cognitive deficits are at the heart of AD, one of the most important challenges is to determine the therapeutic potential of secretase-inhibiting approaches for AD-related memory deficits, linking perspectives through the prism of molecular/pathological events and those through behavioral and neurophysiological manifestations. I review recent progress in this field, with special focus on the functional consequences of beta- and gamma-secretase inhibition and altered amyloid neuropathology in mouse models of AD memory deficits.

[Non-traumatic pathology of the shoulder: medical treatment]. Recently published meta-analyses emphasized weak methodology of clinical research evaluating medical treatment of non-traumatic shoulder pathology. Experts recommend medical treatment as the first step in the management of rotator cuff tendinopathies, the focus of this review. This step precedes surgical treatment of rotator cuff tear with the objective of recovering passive motion of the shoulder. It can be the unique therapeutic phase of rotator cuff tear or simple tendinopathy when clinical results match functional needs of the patient. Therefore, the physician prior treatment has to establish a lesion diagnostic, which is necessary to propose an appropriate strategy. Medical treatment includes NSAID, local injections of corticosteroids and physiotherapy with the double objective of a painless shoulder and normal range of motion. In case rotator cuff calcifying tendinitis, medical treatment is specific with first NSAID and local injections of cortico-sterods, second needle aspiration and third arthroscopic removal, which remains the gold-standard procedure when other treatments failed.

[Non traumatic pathology of the shoulder: when to perform surgery?]. Non traumatic pathology of the shoulder was broken down in four entities: (1) articular stiffness are best treated with rehabilitation and an arthroscopic arthrolysis is rarely recommended; (2) rotator cuff pathology is represented by calcifying and non calcifying tendinitis, partial and full thickness rotator cuff tears; surgical treatment is performed nowadays under arthroscopy; after 50 years old, surgery is indicated after failure of conservative treatment; (3) glenohumeral osteoarthritis and arthritis are best treated with prosthesis; the results are now comparable to hip arthroplasty; (4) chronic acromio-clavicular pathology is usually treated conservatively.

The role of SEMS in malignant and benign colon obstruction. SEMS are highly valuable in the management of pati-ents with malignant colon obstruction with high technical and clinical success. Currently, their role is in colon deco-mpression as a bridge before surgery and in the palliative management of inoperative patients. SEMS appear to be more effective and less costly than emergency surgery. SEMS should be avoided in benign strictures. More data is needed in reference to the role of plastic expandable stents in the management of patients with benign colon strictures.

Cytoreductive approach to peritoneal carcinomatosis originated from colorectal cancer: Turkish experience. Peritoneal carcinomatosis (PC) in contrast to lymph nodes and liver metastases was assumed as a terminal condition with no curative treatment options having a 5 to 9 months median survival rate until recently. Today, in properly selected patients, curative surgical treatment of PC is possible like resection of lymph nodes and liver metastases. Between 1996 and 2005, 29 patients who underwent cytoreductive surgery combined with intraperitoneal chemotherapy for PC originated from colorectal cancer (CRC) were analysed prospectively at the Department of Surgery in Dokuz Eylul University Hospital. Mean age was 54 year (range, 23-75 years). There was no peroperative mortality in 29 patients. The morbidity rate was 41% (12/29) and 6 (20%) patients required reoperation(s) for major complications. Mean and median survival time was 34 and 21 months, respectively. The overall 1-year, 3-year, and 5-year survival rates were 72%, 13%, and 7%, respectively. Mean survival time was 56 months in patients with peritoneal cancer index (PCI) < 10, and 22 months in patients with PCI > 10 (P = 0.075). The mean survival time was 62 months in patients with complete cytoreduction (CC)-0 score, 21 months in patients with CC-1 score, and 7 months in patients with CC-2 and 3 scores. Patients who had CC-0 score had better survival than patients having CC-1 and CC-2 scores (P = 0.003 and P = 0.000, respectively). Patients who had CC-0 and 1 scores had better survival than patients with CC-2 score (P = 0.000). The overall 1-year, 3-year, and 5-year survival rates for patients with CC-0 score were 87%, 37%, and 25%, respectively. There was a positive correlation between the PCI and CC score (P = 0.001, correlation coefficient = 0.585 with correlation is significant at level 0.01). Cytoreductive approach combined with intraperitoneal chemotherapy and systemic chemotherapy prolongs survival in selected patients with PC of CRC with acceptable morbidity and mortality. Prognosis is better in patients with limited disease and in whom complete cytoreduction is achieved. In patients with PC of CRC, the key issue is to select the patients in whom complete cytoreduction is feasible. Better patient assessment with new diagnostic tools such as (PET)-CT or PET-magnetic resonance imaging will be used to detect more precisely the patients with low tumor burden in the new feature.

Radiofrequency surgery--novel techniques in the treatment of ano-rectal disease. BACKGROUND Radiofrequency surgery is a method of utilizing high frequency (3.8 to 4MHz) radio wave energy to incise, excise, or coagulate tissues. Radiofrequency (RF) is a relatively new modality that is being used for ano-rectal surgeries with increasing frequency. As the RF energy is applied, frictional heating of tissues results, with cell death occurring at temperatures between 60 and 100 degrees C. OBJECTIVE This paper discusses author's clinical experience with radiofrequency for various ano-rectal pathologies namely hemorrhoids, anal fistula, anal polyps, sinuses and anal papillae. A Ellman dual frequency radiofrequency generator was used to carry out the procedures. This study is intended to be somewhat of a "how we do it" manual, explaining the principles of radiofrequency. CONCLUSION Radiofrequency proctological procedures are simple to perform with many advantages over the more traditional techniques. The procedures take less operative time, the postoperative recovery is accelerated and the incidences of complications are negligible.

The role of cytology in the diagnosis of benign and malignant anal lesions. Squamous cell carcinoma is a rather infrequent neoplasm of the gastrointestinal tract. Nevertheless its frequency is increasing lately especially in high risk groups of the population infected from HIV or HPV viruses. Squamous cell carcinoma is a slowly and locally growing neoplasm which metastasizes in advanced stages. Its diagnosis must be accomplished by the least traumatic examinations possible. In our study we reviewed our five years experience that included 116 cases. In 89 of them cytological material from ulcerated positions of the anal region was examined. In the rest 27 cytological material was obtained by fine needle aspiration of subcutaneous or submucosal anal lesions. All 116 case reports were retrospectively evaluated. Cytological evaluation revealed 29 cases of normal anal epithelium, 13 granulomas, 12 cases of HPV infection, 28 anal squamous intraepithelial lesions (ASIL), 17 post radiation injuri-es of the anal mucosa and 17 carcinomas. The neoplasms were further subclassified in 12 well differentiated squamous cell carcinomas, 4 cloacogenic carcinomas and 1 leiomyosarcoma. Histological examination followed the initial cytological diagnosis in 75 cases. The correlation between cytological and histological reports did not reveal any false negative or any false positive result. The agreement between histological and cytological evaluation was absolute. Cytological examination is proved to be an easily accessible and totally reliable, low cost diagnostic method, not requiring any kind of anesthesia. It is well accepted by the patients and of paramount clinical utility for the initial diagnostic assessment, the long-term follow up after treatment of anal cancer patients. It is also valuable for the differential diagnosis among benign, premalignant and malignant anal lesions.

The T/G mutation in exon 8 of hMSH2 gene in the sporadic colon cancer patients. The DNA mismatch repair (MMR) system guards against genomic instability, therefore the mutations in the human MMR genes cause the majority of the hereditary nonpolyposis colorectal cancer (HNPCC) and a small percentage of the sporadic colon cancer. hMSH2 is one of MMR genes involved in the correction of mispairing during replication and its mutations are associated with both--microsatellite instability and the hereditary and sporadic colon tumourgenesis. The aim of this study was to analyse the T/G mutation (codon 458) in exon 8 of hMSH2 gene in the sporadic colon cancer cells. We also examined the relationship between the T/G mutation of hMSH2 gene, and the selected prognostic factors such as Dukes' stage, histological grade and lymph node metastasis. We analysed samples of tumour from 75 patients with sporadic colorectal cancers. The mutation in the hMSH2 gene ware determined by the RFLP-PCR. We found T/G mutation in exon 8 of hMSH2 gene in 5 patients (6,7%). There was no statistically significant difference between this mutation and selected clinical parameters. The results of our studies revealed that mutations of hMSH2 gene may lead to development of colorectal cancer. No dependence between the mutation of hMSH2 gene and clinical parameters, suggests that the mutation of hMSH2 gene may have a critical significance for the first steps of carcinogenesis in colon epithelial.

Management of T1 carcinoma of the lower third rectum. The earliest invasive carcinoma of colon and rectum is an invasion into the submucosa. For the TNM classification, these lesions are T1 Nx Mx. They present as an adenoma with invasive carcinoma, or a frank carcinoma. Local excision for T1 carcinoma of the rectum can be curative if the lesion is accessible for an adequate excision and if the lesion has not spread to the lymph nodes or distant metastasis. The key to success in local excision is selecting the lesions that have low risk of metastasis.

Holistic approach to chronic constipation. By "holistic approach" (greek "olos" = "all") we mean a clinical approach which is not only confined to the diseased segment of the body, say the inert large bowel or the spastic pelvic floor in case of constipation, but takes under consideration the whole "mind and body complex", which is a unique indivisible entity. According to a prospective study carried out in our Unit and under press in Colorectal Disease, 66% of the patients with obstructed defecation suffer either from anxiety or depression, thus showing the major role played by an altered psyche in the etiology of their constipation.

Recto-vaginal/urethral fistula: repair with gracilis muscle transposition. UNLABELLED This study was designed to assess the efficacy of gracilis muscle transposition in repairing recto-vaginal and rectourethral fistula. All patients had fecal diversion as a preliminary or concurrent step to fistula repair. Success was defined as healed fistula after stoma closure. RESULTS Six females and four males underwent gracilis muscle transposition from 1999 to 2006. Gracilis muscle transposition is a viable option for repairing fistulas between the urethra, vagina and the rectum, especially after failed perineal or trans-anal repair. It is associated with low morbidity and good success rate. Underlying Crohn's disease and previous radiation are associated with poor prognosis.

Colon polyposis syndromes. Indications to surgery. Familial polyposis syndromes create a group of hereditary syndromes of gastrointestinal tumours. We shall focus on those, touching mostly large bowels and need radical surgery.

Treatment results of colorectal cancer--10-years series of UMC Ljubljana (1991 - 2000). UNLABELLED In Slovenia the incidence of colorectal cancer is growing rapidly. In 1998 1022 new cases were registered. Our study compares results of two groups of patients with colorectal cancer. Patients and methods. In the period from 1.1.1991 to 31.12.2000 1478 patients with a colorectal carcinoma underwent potentially curative resection. We divided them in two groups, one operated in the first 5-years and second in later 5-years period. 5-years survival was estimated with Kaplan-Meier statistical analysis. Patients who died within 30 days after the operation were censored. Differences in survival curves between both groups were assessed by the log rank test. RESULTS We resected 1478 /1599 (92,4%) patients. There was 913 (61,7%) patients resected with colon cancer and 528 (35,8%) with rectal cancer and 37 (2,5%) with sinhronius tumors. R0 resection was performed in 1174 (79,4%) patients, R1 in 29 (2,0%), and R2 in 273 (18,5%) patients. Postoperative mortality rate in resected patients was 5,48% (81/1478), in the group with paliative operations was 17,35% (21/121). Overall five-years survival rate was 54,9% (56,18% for colon cancer and 52,4% for rectal cancer Five-years survival rate for the patients with radical resection (R0) was 66,54% for colon cancer and 59,47% for rectal cancer. CONCLUSION 5-years survival for R0-resected patients with colon cancer was in the last period from 1996 to 2000 statistically significantly better compared with the period from 1991 to 1995 (76% vs 60%) in stage I (p = 0,04048) and in stage III (p = 0,01842). 5-years survival for R0-resected patients with rectal cancer was significantly better in the same period (63% vs 55%) (p = 0,03627) in stage III (p = 0,01663).

Straight and colonic J-pouch reconstruction after low anterior resection. PURPOSE A complication after restorative rectal surgery with a straight anastomosis is low-anterior resection syndrome with a postoperatively deteriorated anorectal function. The colonic J-reservoir is sometimes used with the purpose of reducing these symptoms. An alternative method is to use a simple side-to-end anastomosis or a coloplasty. MATERIAL AND METHODS Three-hundred fiftyseven patients with rectal cancer undergoing total mesorectal excision (TME). Three-hundred (84.0%) received a low anterior resection with primary anastomosis and colo-rectal n = 194 (64.6%) or colo-anal anastomosis n = 106 (35.3%). A colonic pouch using the descending colon was created in 24 patients and in 75 patients respectively. Surgical results and complications were recorded. Patients were followed with a functional evaluation at 6 and 12 months postoperatively. RESULTS Patient characteristics in both groups were very similar regarding gender, age, tumor level, and Dukes' stages. A large proportion of the patients received short-term preoperative radiotherapy (72%). There was no significant difference in surgical outcome between the 2 techniques with respect to anastomotic height, perioperative blood loss, postoperative complications, reoperations, hospital stay or pelvic sepsis rates except the anastomotic stricture rate in the colonic J-Pouch group after coloanal anastomosis (p < 0.02). CONCLUSIONS These data show that either a colonic J-pouch or a straight anastomosis performed on the descending colon in low-anterior resection with TME are methods that can be used with similar expected surgical and functional results.

Endorectal ultrasound (ERUS) in pelvic disorders. Endorectal ultrasound (ERUS) imaging is a complex process using electronic devices to control ultrasound waves and produce images of anatomic structures. It is a simple, cheep and well-tolerated procedure that provides excellent images of rectal and anal canal wall and pelvic floor muscles together with surrounding organs and tissues. The direct imaging of anal canal and pelvic floor muscles with surrounding tissues allows one to identify sphincter defects, anorectal abscesses and fistulas as well as great variety of benign and malignant pathology of the pelvis. Basically, techniques for ERUS are very similar, but there are some slight modifications regarding equipment, indications, and localization of pathologic process. We describe the technique, indications, results and pitfalls of ERUS with the Bruel and Kjaer type 1850 endosonic probe with 7 and 10 MHz transducers in benign pelvic disorders.

[Laparoscopic surgery of colon cancer. State of art and literature review]. Over the past decade advances in laparoscopic surgery have revolutionized the surgical approach to many diseases. Although the first case series on laparoscopic segmental colectomy in patient with sigmoid cancer was described in 1991, this technique has not been readily accepted. Despite reduced morbidity and improved convalescence after laparoscopic surgery for benign disorders, surgeons have been sceptical about similar advantages of laparoscopic colectomy for cancer. The safety of the procedure has been questioned because of early reports of port-site metastases and there has been uncertainty about whether minimally invasive surgery for colonic malignancies would achieve adequate oncologic resection. Open surgical resection of the primary tumor, until just recently, has been widely considered the most effective treatment of colon cancer. The adherence to the principles of complete abdominal exploration, high ligation of mesenteric vessels, lymphnodal clearance and adequate bowel resection margins is essential. Several randomized trials were initiated in the early 1990s to compare the short- and long-term outcomes of patients undergoing minimally invasive and conventional open surgery for colon cancer. Today the results of this large multiinstitutional randomized trials have been reported. This review examines recent data from randomized, controlled trials and meta-analysis, that report the short- and long-term outcomes after laparoscopic colectomy for cancer.

[The BIB intragastric balloon]. INTRODUCTION Since 1998, we adopted in our clinical practice for obesity treatment the new intragastric balloon (BioEnterics Intragastric Balloon, BIB), it has the characteristics of an "ideal gastric balloon" (Workshop Tarpon Springs, 1987). MATERIALS AND METHODS Since March 1998 we have placed by endoscopic approach 518 BIB in 480 patients affected by first, second and severe morbid obesity; 124 male and 356 female, mean age 41.6 years (18-72), mean weight Kg 116.9 (67-229), mean BMI 42 Kg/m2 (27.34-81.14). All our patients underwent to diet of 1000 Kcal/day and treatment with antisecretory drugs. RESULTS The mean weight lost was Kg 14.69 and the mean reduction in BMI was 5.11 Kg/m2. Weight loss was greater in male severe obese (BMI > 40). Weight was accompanied by an improvement of the disease associated with obesity, in particular diabetes, hypertension and sleep apnoea. DISCUSSION AND CONCLUSION The best indication for BIB were: morbidly obese patients (BMI > 40) and super-obese patients (BMI > 50) in preparation for bariatric operation; obese patients with BMI 35-40 with co-morbilities in preparation for bariatric surgery; obese patients with BMI < 30 only in a multidisciplinary approach patients with BMI 30-35 with a chronic disease otherwise unresolved.

[Acute acalculous cholecystitis: pathophysiology and treatment]. The absence of reliable correlation between clinical features and pathological evolution and the molteplicity of risk factors, often related to various pathophysiological pathways, make of acute acalculous cholecystitis a clinical entity well distinct from other affecting gallbladder. In spite of the slight incidence, its occurrence among serious multiple trauma patients may reach 90%. The arguability of diagnostic criteria and the missed or delayed recognition, then affecting timing of surgery are important in determining morbidity and mortality of this condition. The Authors reviewed 16 patients operated for acute acalcolous cholecystitis. US, although sometimes underestimate the severity of affection and cause false negatives, had been the first choice investigation because of its rapidity, facility of execution and repeatability. TC adds subsequent information when US images were doubtful and reveleated pericholecystic involvement more carefully. Hepatobiliary scintigraphy has high diagnostic accuracy but needs of too long execution time. Reasons of early cholecystectomy lay on clinical and experimental evidences that focal or diffuse ischemic damage of gallbladder's wall may affect natural history of the illness and infectious overwhelming is a late event. Surgical intervention has been performed in 16 patients, must within 24 hours. Morbility has been very low, mortality scored 18.7%.

Blunt trauma to the extrahepatic biliary tract. A multicenter study. BACKGROUND/AIMS Blunt trauma to the extrahepatic biliary tract is a rare and challenging injury The purpose of this paper is to review our experience of these injuries, with special reference to their clinical presentation. PATIENTS AND METHODS In a retrospective multicenter study of the records of a trauma-admitting in three hospitals, seven patients with blunt extrahepatic biliary tract trauma were identified, one with combined gallbladder and common bile duct injuries and six with a ruptured gallbladder. RESULTS Except for the patient with the common bile duct injury developing peritoneal signs during observation and being operated 24 hours post-admission, all other patients underwent early laparotomy for shock, peritonitis or positive diagnostic peritoneal lavage (DPL) caused by associated injuries. The common bile duct injury was treated with suture repair over a T tube and the gallbladder injuries with cholecystectomy, except for two cases in which a cholecystostomy was performed. CONCLUSIONS In patients with blunt trauma, especially to the right upper quadrant, a high index of suspicion and liberal use of diagnostic studies to exclude an isolated extrahepatic biliary tract injury is recommended.

[Endo-arthroscopically assisted surgery of selected orthopaedic conditions: technique and results]. The minimally invasive and arthroscopically assisted surgery is a new therapeutic resource in the surgical treatment of degenerative and prosthetic orthopaedic pathology; in the field of neoplastic one it is just dawning. In this work the AA. report the technique and results of the arthroscopically assisted percutaneous arthrodesis of the ankle and of the arthroscopically assisted percutaneous curettage of epiphyseal chondroblastoma (E.C.) and osteoid osteoma (O.O.) of skeleton. From 1992 to 2002 they treated 12 selected cases: 4 affected by E.C., 3 located at proximal tibia and 1 at proximal humerus, in patients aged from 13 to 16 years and evaluated at a follow-up ranging from 7 to 3 years, with a 75% of good results; 4 affected by osteoid osteoma of proximal femur (2) and tibia (2), in patients aged from 13 to 18 years, evaluated at a follow-up ranging from 12 to 3 years with very good results (75%); 4 cases of ankle'painful stiffness, with 1 case of severe weightbearing instability, in patients aged from 17 to 75 years, evaluated at final bone fusion, radiographically observed at a average of 3.2-month follow-up from operation. All cases were treated by MIS criteria under accurate radiographic and CT-3D pre-operative planning, endoscopic (trans-osseous tunnels) and/or arthroscopic (ankle arthrodesis) continuous assistance under fluoroscopy. Two cases received cortico-cancellous bone autografts. All neoplastic cases had histologic confirmation by excision biopsy. They report 2 cases of failure, 1 in the E.C. series (25%) and 1 among the O.O. (25%), respectively at 6 and 12 months from the operation. In conclusion the authors report good results in 75% of cases together with very good aestheticism, well accepted by patients, and with articular function not minimally altered by the technique.

[Mucinous cystoadenocarcinoma of the appendix. A case report]. CASE REPORT The Authors report a case of a 66-years-old male patient with mucinous cystoadenocarcinoma of the appendix. Preoperative diagnosis was appendiceal mucocele. At laparatomy was revealed the presence of a large mass of the appendix involving the caecum. No mucinous ascites was present and no mucinous implants on the peritoneum surface. Operation consisted in appendectomy and resection of the caecum bottom. Hystology revealed diagnosis of mucinous cystoadenocarcinoma of the appendix. After two weeks patient underwent right hemicolectomy, he is alive without disease at 36 months follow up. Mucinous cystic neoplasms of the appendix is an uncommon disease that is rarely suspected before surgery. CONCLUSIONS The Authors stress the importance of an appropriate surgical treatment. Right hemicolectomy appears to be the appropriate treatment with aggressive debulking when mucinous cystoadenocarcinoma is associated with pseudomyxoma peritonei. The role of chemotherapy in the treatment of patients with appendiceal cancers remains controversial. No controlled data on the efficacy of adjuvant chemotherapy are available. All patients with any form of appendiceal tumor appear to have an increased incidence of synchronous and metachronous neoplasms, especially in the gastrointestinal tract, and should be investigated and followed up appropriately.

Multiple meningiomas induced by cranial irradiation. The role of radiation in the induction of central nervous system tumours has repeatedly been documented. Meningiomas induced by low doses of cranial irradiation have been described in many series of cases, but meningiomas induced by high doses of irradiation have still been reported in a limited number of cases. We report the case of a 25-year-old man who presented multiple meningiomas and who had received therapeutic dose of irradiation for a 4th ventricle ependymoma when he was 8 years old.

Abdominal aortic aneurysm and concomitant malignancy: what treatment? UNLABELLED The association of neoplasm and abdominal aortic aneurysm (AAA), although rare, may represents a therapeutic dilemma. MATERIALS AND METHODS Between January 1990 and December 2004 in our departement 127 patients were submitted because of an AAA, in 8 cases there was an association with a neoplasm, in the greater part being a colon cancer. In 3 cases we performed a one stage surgery, in 1 case the chose was for a two stage surgery, for 3 patients we opted for an endovascular treatment by an endograft, in 1 case a pancreatic cancer was diagnosed 3 months after the prosthetic replacement of an AAA and there were no surgical indications because of the patient was in an advanced neoplastic stage. RESULTS There weren't any prosthetic infection or more serious complications. The endovascular treatments were performed successfully without complications after few days being followed by cancer's resection. DISCUSSION In case of this association the prognosis is related to neoplasm's stage. Timing depednds on the pathology that has the higher risk of short-term complication. Since Nineties author's reports in Literature about one stage surgery are more frequent, while now endovascular methods open new chances. CONCLUSIONS One stage surgery is a safe option in case of association between AAA and cancer. We think that a good porpouse is the use of a vascular endograft in aneurysmal treatment followed, after few days, by cancer's resection.

[Transrectal ultrasonography by rotating feeler in the perianal fistulae/abscesses surgery. Anatomo-functional description]. INTRODUCTION Anal fistula represents a big topically subject above all as regards the complex correlated surgical implications. The transectal ultrasonography (TUS) is the first help for a careful, cheep, poorly invasive diagnosis. MATERIALS AND METHODS From September 2002 to December 2003 we submitted TUS 53 patient with clinical diagnosis of perianal fistula abscesses and 27 patients, already subordinates to surgical intervention for perianal fistulae/abscesses, which only presented perianal pain without clear signs of perianal pathology (48 males and 15 females). RESULTS TUS diagnosis and surgical confirmation of abscess and/or anal fistulae in all the patients; in the 27 patients, in whom at clinician exam was not clear an abscess, it was diagnosed in 21 patients (6 positive-false). DISCUSSION The obtained data show the validity of this methodical diagnostics and its importance for a correct surgical management. The 7.2% of discovered positive-false (surgical response: scary tissue), they are to charge to the objective technical dfficulty with discriminating scary outcomes; in confirmation of that the datum that in all these cases the patients had already been submitted to previous ano-rectal surgery. CONCLUSIONS Surgery of the anal abscesses and fistulas, for effective being, must stay in balance between aggressiveness and safeguards surgery. Surgery, to be correct, cannot leave out of consideration TUS: a valid tool in the Pre-operatory diagnosis, but also in the Post-operatory phase to highlight possible recidivisms.

Laparoscopic treatment of a solitary fibrous tumor of the greater omentum presenting as spontaneous haemoperitoneum. A 24-year-old man was admitted at the emergency department with a lower quadrant abdominal pain and a slight hypoglycaemia. Abdominal ultrasonography showed the presence of a fluid peritoneal collection and a 3.2 x 2.5 cm hypoisoechogenic mass closed to the left iliac vessels with an echo-color-Doppler pattern similar to that of a hamartoma. CT examination confirmed the hypothesis of a vascular tumour. Although an abdominal angiography added no new information to establish a preoperative diagnosis, it showed a well vascularized mass. The patient underwent laparoscopy that revealed a bleeding mass of the great omentum. Laparoscopic stapled resection of the greater omentum was carried out. The solid lesion consisted of spindle-shaped cells, but no atypical cells were observed. The histological findings were diagnostic of a benign solitary fibrous tumor, an extremely rare neoplasm for a long time considered to be an exclusively thoracic lesion. This is the first case of a solitary fibrous tumor presenting as haemoperitoneum and the first time it was removed laparoscopically. The patient is disease-free at the 2-year follow-up.

Dealing with trichomoniasis. Trichomoniasis is a common but less well known sexually transmitted infection affecting men and women. In men it is often asymptomatic and goes undetected. In women it can produce a profuse, frothy, unpleasant-smelling vaginal discharge with pruritus and soreness which is sometimes confused with vulvo-vaginal candidiasis (thrush) and bacterial vaginosis. Women often mistakenly treat themselves for thrush with no result. Diagnosis is by laboratory culture and treatment is with metronidazole. Partner notification and treatment should be undertaken. Trichomoniasis often coexists with chlamydia and gonorrhoea. It can have consequences for reproduction, including low birth weight and preterm labour, and has been found to be a co-factor in the transmission of HIV. It is therefore mandatory to ensure prompt and appropriate treatment for all patients diagnosed with trichomoniasis.

Ovulatory failure, fertility preservation and reproductive strategies in the setting of gynecologic and non-gynecologic malignancies. The advances in assisted reproductive technology over time have paralleled the insights gained into the natural history of different gynecologic malignancies. Subgroups of young patients with early stage ovarian cancer, endometrial carcinoma and cervical carcinoma may be considered to be at relatively low risk of recurrence and may be treated conservatively with the aim to preserve fertility when this is of prime concern. Unilateral adnexectomy with preservation of the contralateral ovary and uterus may be appropriate for some patients with epithelial ovarian cancers, and certainly should be the procedure of choice for those young women with borderline tumors and early stage sex cord-stromal and malignant germ cell tumors. Administration of high-dose progestins may obviate the need for immediate hysterectomy in a young patient with a well-differentiated endometrial carcinoma desirous of childbearing. The performance of vaginal radical trachelectomy in conjunction with laparoscopic pelvic lymphadenectomies has emerged as a real breakthrough for a highly select group of young women with early invasive tumors of the cervix. In this review, we also discuss reproductive strategies for women who experience chemotherapy-induced ovulatory failure and also address the potential for ovarian cortex cryopreservation and transplantation, and uterine transplantation, all of which are looming on the horizon.

Telomerase activity and the subunit of telomerase in hydatidiform mole and their relationship with the development of postmolar tumor. OBJECTIVES To investigate the pattern of telomerase activity and the subunit of telomerase in normal placentae and GTD, and to determine the prognostic significance of telomerase activity and the subunit of telomerase in GTD. METHODS Telomerase activity human telomerase (hTERT) and human telomerase (hTR) expression were analyzed in the initial uterine evacuation specimen of 63 hydatidiform moles (HMs), 42 normal human placental tissues, 17 malignant gestational trophoblastic tumors, primary cultures of normal villi and JAR cell lines by use of the polymerase chain reaction-based telomeric repeat amplification protocol (TRAP) assay and reverse transcription-polymerase chain reaction (RT-PCR) methods. RESULTS Telomerase activity was 100% in primary cultures of normal villi and JAR cell lines and in less than 60-day early placental villi, while only 9.1% in greater than 60-day placental villi, 27% in HMs and 58% in malignant trophoblastic tumors. High levels of hTR could be found in all groups. hTR expression was detected in all cases of < 60-day placental villi, in 72.7% > 60-day placental villi, in 87.3% in HMs and 100% in malignant trophoblastic tumors. Telomerase activity and hTERT expression had significant differences among the groups. Telomerase activity was associated with serum hCG levels but not related to other clinical risk factors. CONCLUSIONS Telomerase activity may be correlated with the development of trophoblastic tumors, and hTERT may be a useful diagnostic marker for detecting the existence of malignant trophoblastic cells.

Influence of diabetes mellitus and nodal distribution in endometrial cancer and correlation to clinico-pathological prognostic factors. OBJECTIVE The aim of this study was to describe the relationships between the distribution of nodal disease, clinico-pathological patterns and recurrence and survival in surgically staged cases of endometrial cancer. METHODS Charts were abstracted from patients with endometrial carcinoma from 1985 to 1995. Data on clinicopathologic variables, adjuvant treatment, site of recurrence and survival were collected. The chi square test was used to test associations between variables. The Kaplan-Meier method was used for survival analysis and Cox's proportional hazards model for multiple regression analysis. RESULTS Sixty-nine out of 181 patients underwent lymph node dissection. Twenty-three had pelvic lymph node dissection, 23 underwent pelvic and paraaortic lymph node dissection and 20 patients had lymph node sampling. The median count of removed lymph nodes was 22.4. Fifty-four lymph node dissections showed negative lymph nodes and in 15 cases there was a minimum of one positive lymph node. Overall survival was in correlation to nodal involvement with a p value of 0.0017. Patients with lymph node involvement showed significantly more recurrence than patients with negative lymph nodes (p = 0.003). The depth of myometrial invasion correlated with lymph node metastasis (p = 0.01) and patients with additional diabetes mellitus showed significantly more nodal involvement (p = 0.02). CONCLUSION Endometrial cancer showed pelvic lymph node (PLN) and paraaortic lymph node (PALN) involvement. Under-diagnosis of the disease might result if there was only a PLN, but with or without PALN involvement there was no significant difference in overall survival or recurrence. There was an univariate correlation between lymph node involvement and diabetes.

Prognostic significance of fascin expression in endometrioid carcinoma. PURPOSE OF INVESTIGATION Actin bundling protein fascin has been previously associated with tumor progression in human cancers. We evaluated whether fascin also plays a role in endometrioid carcinomas. METHODS Cases of 28 proliferative and hyperplastic endometrium and 43 endometrioid carcinomas were examined by immunohistochemistry using antihuman fascin antibody. RESULTS Weak fascin expression in glandular epithelium was observed in 39% of non-neoplastic samples and various degrees of fascin expression were observed in 74% of neoplastic samples. The number of positively stained samples and intensity of epithelial staining were significantly higher in endometrioid carcinoma compared to the non-neoplastic group (p < 0.001). The number of positively stained samples and total fascin scores of stroma were significantly higher in proliferative and hyperplastic endometrium biopsies compared to the endometrioid carcinoma (p < 0.001). Higher grade endometrioid carcinoma cases had significantly increased total epithelial fascin scores (.042, p < 0.05). There was also a significant difference between tumor grade and patient survival (.040, p < 0.05). There was a significant correlation between microvessel count and disease-free survival (r = .412, p = .006). In the proliferative and hyperplastic endometrial biopsies microvessels stained homogeneously in all cases (28/28), but in the endometrioid carcinoma group eight out of 43 cases showed heterogeneous fascin staining of microvessels. The difference was significant (.019, p < 0.05). CONCLUSIONS Our study supported the dynamic role of actin bundling protein fascin in generating and maintaining endometrial neoplasms. It also showed that in the development of neoplasia, stromal fascin expression decreases but epithelial fascin expression up-regulates.

Preoperative diagnosis of 221 consecutive ovarian masses: scoring system and expert evaluation. OBJECTIVE The aim of our work was to assess the diagnostic accuracy of a scoring system versus subjective assessment of the risk of malignancy of pelvic masses achieved by gynecologist/sonologists in the preoperative triage of a busy gynecology department. METHODS One hundred and eighty-two consecutive patients who underwent surgical removal of ovarian neoplasms were examined. In 39 patients pelvic masses were bilateral. The total number of neoplasms analyzed in this series was 221. Lesions were examined and scored according to the sonographic characteristics. Gynecologist/sonologists also recorded a subjective evaluation of the adnexal masses defining them as "probably benign", and "suspicious/probably malignant". Preoperative ultrasound risk assessment was compared to the final pathologic report and diagnostic accuracy was calculated. CA125 was obtained in all patients and its independent and combined accuracy was calculated. RESULTS The sensitivity of the scoring system and subjective evaluation was 86% and 95% respectively, specificity was 79% and 91% with a positive predictive value of 41% and 53%. The frequency of positive diagnoses for CA125 was 44% due to the high prevalence of endometrosis in this series (48%). In premenopausal patients (75%) the specificity was 93% and 89% for scoring and subjective evaluation, respectively. The combined use of morphological scoring and CA125 achieved higher specificity and positive predictive values both for the whole series and in premenopausal patients. CONCLUSIONS These results confirmed that the experience of gynecological surgeons with ultrasound skills, outperforms the morphological indexing assessment of ovarian masses. Nonetheless an easy sonographic descriptive scoring system is not significantly lower in accuracy than the expertise achieved by gynecologists with sonographic skills.

Analysis of the relationship between cancer procoagulant activity and PCNA and Ki-67 expression in cases of common and cellular uterine leiomyomas. PURPOSE Histological subtypes of uterine leiomyomas may substantially differ in their cellular biology, including the intensity of synthesis of cancer markers and expression of cell proliferation markers. The present investigation aimed to determine the activity of cancer procoagulant (CP) in subtypes of leiomyomas, including cellular leiomyomas, and to verify whether these activities correlate with immunoexpression of cell proliferation markers: the proliferating cell nuclear antigen (PCNA) and Ki-67. MATERIALS AND METHODS Preoperative peripheral venous blood and postoperative tissue material were obtained from 24 women operated on in a tertiary referral academic department. The activity of CP in serum was measured with the use of a coagulative method according to Gordon and Benson, and in tissue homogenates with the use of a spectrophotometric method according to Colucci et al. The control serum values were obtained from 20 healthy women without any gynecological disease, and the control solid tissue values from histologically confirmed postoperative normal reproductive tissues obtained from six patients. PCNA and Ki-67 expression were determined immunohistochemically using monoclonal antibodies. RESULTS Both the tissue and serum activity for CP was considerably higher for common leiomyomas and cellular leiomyomas than for control tissues, but did not differ significantly between the leiomyoma subtypes. Intratumor CP activity significantly correlated with PCNA expression but not with Ki-67 expression. CONCLUSIONS Cellular leiomyomas do not differ substantially in the serum and intratumor CP activity from common leiomyomas. There is a relationship of intratumor CP activity with PCNA expression, a finding which requires further investigation.

CD24 expression is a poor prognostic marker in endometrial carcinoma. OBJECTIVE CD24 is a cell adhesion molecule that has been implicated in metastatic tumor progression of various solid tumors. Its expression is known to be related to the prognosis of several kinds of tumors. This study was designed to examine the prognostic significance of CD24 in endometrial cancer patients. METHODS Forty-four endometrial carcinoma tissues were immunostained for CD24 antibody (Ab2, clone 24 C02). Cytoplasmic and membranous immunoreactivity were scored semiquantitatively by Fisher's exact test. RESULTS CD24 expression was detected in 34 (77.3%) out of 44 cases. Membranous and cytoplasmic staining of CD24 was significantly associated with the International Federation of Gynecology and Obstetrics (FIGO) grade (p = 0.011 and p = 0.002, respectively) and nodal status (p = 0.002 and p = 0.000, respectively). CONCLUSION Our data suggests that CD24 expression in endometrial carcinoma as detected by immunohistochemistry might be a new marker for a more aggressive endometrial cancer biology. CD24 is commonly up-regulated in endometrial cancer and this corroborates the importance of CD24 in tumor progression among these cases.

Endometrial carcinoma and diabetes revisited. OBJECTIVE To investigate whether endometrial adenocarcinomas are intrinsically different in diabetic as compared to non-diabetic patients. METHODS A series of 208 patients with histologically confirmed endometrial adenocarcinomas were divided into groups of diabetic (n = 63) and non-diabetic (n = 145) patients. The two groups were compared in terms of tumor morphology, FIGO stage, clinical risk factors and 12-year survival. RESULTS A history of a second neoplasia was significantly more frequent in diabetic than in non-diabetic patients (p = 0.001), but other endometrial cancer associated characteristics, such as tumor morphology, FIGO stage, obesity, hypertension, nulliparity, estrogen use and menopausal status did not differ between the groups. More importantly, the two groups had a similar 12-year survival rate (p = 0.8742). CONCLUSIONS A second neoplasia occurred significantly more frequently in diabetic than in non-diabetic patients with endometrial carcinoma, but long-term survival and other clinical and histological features were the same in the two groups. These results indicate that endometrial adenocarcinoma is not intrinsically different in diabetic patients.

Malignant mixed Mllerian tumor with heterologous component arising in the fallopian tube--a case report. Primary malignant mixed Mllerian tumors (MMMTs) of the fallopian tube are rarities in gynecologic oncology with only 26 cases of MMMTs with a heterologous component reported thus far. We report a case of FIGO Stage II primary MMMT of the fallopian tube with a heterologous tumor portion in an 80-year-old woman presenting with abdominal discomfort at the time of primary diagnosis. After performance of total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy follow-up examination three months postoperatively did not show signs of disease recurrence. The patient finally presented six months after the initial diagnosis with extensive intraabdominal metastasis and died several days thereafter. The present report supports the aggressive nature of these neoplasms. The efficacy of chemotherapy and radiation remains to be defined in future studies.

Gorlin syndrome associated with basal cell carcinoma of the vulva: A case report. Gorlin syndrome, also known as nevoid basal cell carcinoma syndrome (NBCCS), is a hereditary condition transmitted as an autosomal dominant trait with high penetrance and variable expressivity. The syndrome is characterized by numerous manifestations: basal cell carcinomas (BCCs) and odontogenic keratocysts (OKCs) are the leading ones. In this article a typical Gorlin syndrome case associated with basal cell carcinoma of the vulva is described.

Fallopian tube carcinoma: incidental finding during surgery for acute pelvic inflammatory disease--case report. BACKGROUND Primary carcinoma of the fallopian tube is a rare condition. Preoperative diagnosis is difficult and in most cases it is an intraoperative finding or a histopathological diagnosis. CASE A 49-year-old woman presented with pelvic pain, fever (38 degrees C), elevated white blood cell count and a right adnexal mass. Pelvic inflammatory disease was suspected and broad spectrum antibiotics were established. Five days later, due to lack of clinical response, a total abdominal hysterectomy, bilateral salpingo-oophorectomy and appendectomy were performed. Histopathology showed a primary fallopian tube carcinoma. Postoperatively she received chemotherapy. Afterwards she underwent a staging laparotomy. Some months later, new chemotherapy regimens were instituted because of the presence of lymph node metastases. CONCLUSION Malignancy should be included in the differential diagnosis of pelvic inflammatory disease.

Management of a case of primary vaginal cancer with irreducible massive uterine prolapse--a case report. Primary cancer of the vagina constitutes 1-2% of all malignant genital tract tumors in women. As one of the most complicated therapeutic problems in gynecological oncology, this disease had been deemed to be untreatable until the end of 1930s. Presently, as a result of technological improvements in radiotherapy and radical surgery, more favorable prognoses are known to be achieved even in advanced cases. In the present case, a woman with vaginal cancer and Stage IV massive uterovaginal prolapsus, which could not be repositioned under general anesthesia, was repositioned by surgical intervention prior to radiotherapy to avoid any potential vesicovaginal fistula formation. The cervix was bilaterally suspended to the pectineal ligaments by polypropylene mesh.

Robotic-assisted laparoscopic radical hysterectomy (Piver type III) with pelvic node dissection--case report. OBJECTIVE The aim of this study was to describe the first robotic-assisted radical hysterectomy (Piver type III) and bilateral pelvic lymph node dissection for a patient with Stage Ib1 cervical carcinoma. CASE A 43-year-old woman G1, P1, previously operated on due to endometriosis with removal of the left ovary and fallopian tube, came under our care. In addition, hysteroscopic myomectomy had been done two years before. Otherwise the patient was healthy. Preoperative conization histology revealed 6 mm of stromal infiltration. The patient was offered the da Vinci robotic Wertheim operation for the first time which was well accepted and she was discharged uneventfully on the 4th day postoperatively. Four months later at a routine check-up we found asymptomatic bilateral lymphocysts but otherwise normal status. CONCLUSION It is fully possible to perform Piver type III laparoscopic radical hysterectomy using the da Vinci robotic system and it seems that radical dissection is much more precise than the conventional laparoscopic radical hysterectomy.

Incidental finding of a malignant peritoneal mesothelioma in an inguinal hernia sac: report of a case. We report the case of a 46-year-old female who underwent a routine operation of herniorraphy for a right inguinal hernia. Physical findings revealed a moveable tender mass in the right lower inguinal area. Pathological examination revealed a mass with multiple nodules scattered in the inguinal hernia sac. The histological features of these nodules were compatible with malignant peritoneal mesothelioma (MPM). The incidental finding of MPM in the inguinal hernia sac is very rare. The incidence of this neoplasm is 2-2.6 cases per million annually, and the prognosis is very poor.

Squamous cell carcinoma arising in a mature cystic teratoma of the ovary with synchronous invasive lobular breast cancer: case report. Malignant transformation of a mature ovarian cystic teratoma is the most serious complication of this relatively common neoplastic lesion. While any constituent tissue of the teratoma can undergo malignant transformation, squamous cell carcinoma represents approximately 80% of those malignancies. Furthermore, the synchronous occurrence of a second malignancy in that setting is extremely rare. Preoperative diagnosis of malignant transformation within a mature cystic teratoma is extremely difficult and poses a great challenge to current clinical surgical practice. The particularly aggressive behavior of this rare tumor, also poses significant surgical managing dilemmas. We present a case report of a premenopausal woman with an invasive squamous cell carcinoma arising in a mature cystic teratoma and a synchronous invasive lobular carcinoma of the breast.

[Our results in surgical treatment of laryngotracheal stenosis--ten years experience]. INTRODUCTION There are numerous techniques for the treatment of laryngotracheal stenosis. The aim of this paper was to present surgical techniques and results of treatment of laryngeal and laryngotracheal stenosis in a ten-year period by retrospective analysis. MATERIAL AND METHODS Medical records of 34 patients (17 male and 17 female) surgically treated for laryngeal or laryngotracheal stenosis between 1995 and 2004 were analyzed. 19 (55.9%) patients had previous surgical procedures, whereas fifteen patients (44.1%) were diagnosed and treated for the first time. RESULTS 5 patients had a glottic-subglottic stenosis, 11 patients had a subglottic stenosis, 16 patients had subglottic-tracheal stenosis and 2 patients had a glottic-subglottic-tracheal stenosis. 21 patients had normal vocal cord motion, 8 patients showed unilateral vocal cord fixation, and 5 had bilateral vocal cord fixation. Laryngotracheoplasty with anterior-posterior costal cartilage graft was performed in 24 patients, while single stage segmental laryngotracheal resection of the stenotic part was performed in 8 patients. One patient was operated in direct laryngomicroscopy and one with dilatation of the stenotic segment with T tube insertion. The most common complication was the development of granulation due to use of the Montgomery T-tube which was removed in direct laryngomicroscopy. Except for one patient, 33 (97%) patients were decannulated. There was no perioperative mortality. CONCLUSION Although laryngotracheoplasty with anterior-posterior costal cartilage graft placement cannot be used in all cases of laryngotracheal stenosis, it was the method of choice in previously operated patients with segmental resection of the stenotic segment. This method requires use of Montgomery T-tube or anesthesiological tube, which is very hard to keep clean. Better recovery, short hospitalization and excellent results were obtained with the cricotracheal segmental resection.

[The role of lamivudine in the treatment of HBe antigen negative liver cirrhosis]. INTRODUCTION Lamivudine is effective in suppressing hepatitis B virus replication and hepatic necroinflammatory activity. Patients with HBV-related chronic liver disease often present with hepatic decompensation and are not eligible for interferon therapy. The effectiveness of antiviral therapy in preventing disease progression in patients with hepatitis B cirrhosis is unknown. The aim of this study was to evaluate the effectiveness of lamivudine treatment in patients with cirrhosis due to chronic hepatitis B. MATERIAL AND METHODS The study included 24 patients with cirrhosis B. During one year, all of them were treated with Lamivudine (100 mg/day). All patients underwent routine laboratory tests and abdominal ultrasound. After that, they were followed-up from 1-15 months. RESULTS AND DISCUSSION Most patients presented with improved general condition. We also noticed a reduction in SBP, ALT level, bilirubin level, hepatic encephalopathy and ascites. Five patients died, due to HCC, and two due to variceal bleeding. There was no significant improvement in liver synthetic function. CONCLUSION Lamivudine is highly effective in reducing viral load in HBeAg-negative patients significantly improving the clinical and biochemical status of liver functions.

[The importance of social support to chronically ill adolescents]. INTRODUCTION Improvements in medicine have significantly prolonged life of chronically ill children and adolescents in the past several decades. There is a great variability in adaptation to illness among chronically ill persons--some of them seem to be very well adapted, with almost no problems. However, research results suggest that chronically ill children are more likely to have psychological problems than their healthy peers. MATERIAL AND METHODS Eightyfour subjects, all elementary school pupils, participated in the study. The first group included adolescents with chronical illness (malignant illness, insulin dependent diabetes mellitus, epilepsy, or asthma), and the second their healthy peers. Depression and social support were evaluated. The Birleson's Depression Scale and Perceived Social Support Scales (forms for friends and for family members) were used. RESULTS AND DISCUSSION The results show significant differences for two of the three variables: depression, and perceived social support from family, while there was no significant difference for perceived social support from friends. The results suggest that chronically ill adolescents are more depressed and that they perceive that the social support they receive from their families is lower when compared to their healthy peers. CONCLUSION The results of this study showed that chronically ill adolescents are more depressed than their healthy peers. This group of adolescents also perceives that they have less social support from their families than their healthy peers. When it comes to perceived social support from friends, these two groups do not differ.

[Clinical analysis of congenital abdominal wall defects--omphalocele and gastroschisis]. INTRODUCTION This is a retrospective analysis of therapeutic approaches and treatment outcomes of congenital abdominal wall defects (omphalocele and gastroschisis) in a five year period. The aim of this study was to identify factors which can affect the prognosis of future therapeutic procedures. MATERIAL AND METHODS We evaluated 13 children, 7 with omphalocele (2 female/5 male; mean birth weight of 2862 g; mean gestational age of 37 weeks), and 6 patients with gastroschisis (2 female/4 male; mean birth weight of 2640 g; mean gestational age of 36/2 weeks). All patients were treated at the Clinic of Pediatric Surgery from 1999 to 2003. RESULTS In this study, thirteen cases of congenital abdominal wall defects (omphalocele and gastroschisis) were retrospectively investigated. All patients underwent prenatal ultrasound. Omphalocele was prenatally detected in 42.8% of fetuses, and gastroschisis in 16.7%. Coexisting anomalies were present in 57.1% of patients with omphalocele and in 16.7% of newborns with gastroschisis. Three patients with omphalocele were treated operatively, and four only conservatively. The abdominal wall of patients with gastroschisis was primarily closed in three patients. Two patients required a staged abdominal wall closure. One patient with gastroschisis and intestinal atresia underwent primary closure after partial intestinal resection and enterostomy. Based on these responses, a management protocol (algorithm) was recommended. The most common postoperative complication, in 7 cases of omphalocele, was mechanical ileus (n = 1), whereas among patients with gastroschisis the commonest were mechanical ileus (n = 1) and intestinal perforation (n = 1). The mortality of patients with omphalocele was 52% and with gastroschisis 66.7%. CONCLUSION A strategy designed to optimize antenatal and neonatal factors is expected to increase the survival rate of patients with abdominal wall defects.

[Changes in plasma osmolality in food poisoning]. INTRODUCTION Changes in plasma osmolality may occur during acute intestinal infections due to dehydration (loss of water and/or electrolytes). Depending on whether the water and electrolyte deficit is primary, or a proportional loss of water and electrolytes, dehydration can be classified into three categories: hypertonic, hypotonic and isotonic. MATERIAL AND METHODS Thirty (30) patients with food poisoning were included in this research. All patients were hospitalized because of frequent vomiting, with resultant dehydration. A diagnosis of food poisoning was made based on the clinical picture, short incubation period and positive epidemiological history. Plasma osmolality was measured by a freezing point depression with an osmometer, while effective plasma osmolality was determined by using the following formula: EPO (eff. plasma osmolality) = 2 x serum sodium concentration + serum glucose level. Apart from plasma osmolality, other parameters were also measured in patients' sera: sodium, chloride, potassium, urea, glucose and hematocrit. In order to follow-up the changes in these parameters, they were also measured after treatment of the gastrointestinal disorder. Statistical analysis was performed using the equality of mean values for 2 basic groups. RESULTS The statistical results showed that the values of total and effective plasma osmolality (TPO and EPO) among patients with gastrointestinal disorders were not significantly higher than values after the alimentary infection. DISCUSSION Such results suggest that food poisoning is associated with disorders of water and electrolyte metabolism, that is isotonic type of dehydration.

[Endothelial dysfunction: mechanisms of development and therapeutic options]. INTRODUCTION Vascular endothelial cells play a key role in cardiovascular regulation by producing a number of potent vasoactive agents, including the vasodilator molecule nitric oxide (NO) and the vasoconstrictor peptide endothelin (ET). ENDOTHELIAL DYSFUNCTION Endothelial dysfunction is recognized as the initial step in the atherosclerotic process. Impairment of NO synthesis, or increased inactivation of NO by superoxide radicals, may account for the increased periferal vascular tone, as well as contribute to the clinical consequences of different pathophysiological conditions which include vascular hypertrophy, increased platelet and monocyte adhesion to the endothelium, atherosclerosis, myocardial infarction and stroke. To date, most interventions attempting to improve endothelial dysfunction have targeted one or more of the numerous risk factors that can cause endothelial damage: hypertension (ACE inhibitors and calcium antagonists), hypercholesterolemia (lipid-lowering agents), cigarette smoking (cessation), sedentary lifestyle (increased physical activity), menopause (estrogen replacement therapy), and diabetes mellitus (control of metabolic abnormalities). Several pharmacologic agents have been suggested to achieve vascular protection through mechanisms that go beyond their primary therapeutic actions (ACE-and HMG-CoA reductase inhibitors). Beneficial changes to the endothelium might result from promotion of vasorelaxation, inhibition of vasoconstriction, reduction in the production of free radicals, or other mechanisms that protect the endothelium from injury. CONCLUSION This study deals with the results of many experimental and clinical investigations. The possibility of using different classes of drugs was also established, including ACE inhibitors, Ca-antagonists, AT and endothelin receptor antagonists, direct activator of adenyl cyclase, statins, antioxidants, L-arginine, phosphodiesterase inhibitors, beta-blockers and organic nitrates.

[Arthrogryposis multiplex congenita--a rare congenital stiff joints syndrome]. INTRODUCTION Arthrogryposis multiplex congenita is not a disease but a term describing multiple congenital contractures. Etiological factors include neurological and primary myogenic diseases. This rare syndrome is present at birth and is characterized by reduced mobility of many joints. The contractures involve two or more joints with ankylosis. The accompanying musculature is hypoplastic, but multiple pterygia are also present. Arthrogryposis multiplex congenita is a heterogeneous group of disorders with the incidence rate of 6.2/100000 liveborn infants. The true incidence cannot be established, because many cases result in spontaneous miscarriages or stillbirth. More than 90% of cases are associated with birth defects. The cause of this syndrome is unknown. Many forms are not hereditary, though there are hereditary forms as well. CASE REPORT This paper presents a case with arthrogryposis multiplex congenita. The pregnancy was not controlled regularly. During the pregnancy, oligohydramnion was detected. Due to contractures, labor ended is cesarean section. The child was born in the 34th week of gestation. Flexion and extension joint contractures were observed. Active and passive mobility of the afflicted joints was reduced. There was a limited motor function in the shoulder, elbow and wrist joints with a slight internal rotation of the shoulder joint and lower arm joints during pronation. The hips were subluxated; the feet were in equinovarus position and the fingers in ulnar deviation with partial syndactyly of the 4th and 5th fingers on the left hand. The infant had abnormal dermatoglyphics. The neck was short, and the 2nd and 3rd cervical vertebrae were fused. There was also a slight left-sided thoracic scoliosis. Trismus was present due to the existing ankylosis of the temporomandibular joint. The karyotype was normal. The serum creatinine phosphokinase was slightly elevated The electromyographic picture indicate non-specific signs of myopathy. DISCUSSION AND CONCLUSION This is a case report of a "stiff joint syndrome". Due to the fact that data from the family history were unavailable, we could not establish the type of syndrome. However, heredity, growth and development at later age, as well as IQ, might significantly help in definite differentiation of this syndrome. In pregnancy, oligohydramnion should indicate more detailed ultrasonographic examination, as ankylosed joints can be detected in utero.

[Effects of reperfusion on late potentials of the QRS complex in acute myocardial infarction]. INTRODUCTION Cardiac rhythm disorders are common in patients after myocardial infarction. They play an important role in the course and in prognosis of this illness. Signal-averaged electrocardiogram (SAECG) is a non-invasive diagnostic method for the induction of sustained monomorphic ventricular tachycardia. Early opening of the infarct-related artery decreases occurrence of ventricular disorders in these patients. The aim of this study was to establish the connection between the late potentials of the QRS complex (SAECG) and unsuccessful reperfusion in patients with acute myocardial infarction (AMI). MATERIAL AND METHODS After myocardial infarction, presence of SAECG was examined in patients receiving reperfusion therapy in order to establish the treatment outcome. Late potentials in SAECG were determined by computer measurements in regard to criteria for its positivity. RESULTS The study group consisted of 33 patients. Out of 23 patients with successful reperfusion, only 6 (26.1%) had late potentials, in contrast to the group without reperfusion, 8 (80%) out of 10 patients had late potentials. CONCLUSION Based on our results, we can conclude that there is a significant association between the presence of late ORS-complex potentials (SAECG) and unsuccessful reperfusion. Also, we can conclude that presence of late potentials is an independent predictor of infarct-related artery patency in patients with AMI treated with thrombolytic therapy.

[Prevention of hyperamilasemia and pancreatitis after endoscopic retrograde cholangiopancreatography with rectal administration of indomethacin]. BACKGROUND Acute pancreatitis (AP) represents the main complication after endoscopic retrograde cholangiopancreatopgraphy (ERCP) and appears in 1% to 10% of the cases. The incidence increases in patients with opacification and instrumentation of pancreatic duct and it varies according to the indications of the procedure and the intervention performed. Risk factors for this complication include history of pancreatitis, difficult canulation, pancreatic acinar opacity, Oddi sphincter hypertension and sphincterotomy. OBJECTIVE Evaluate the efficacy of rectal indometacine to reduce the incidence of hyperamylasemia and AP post-ERCP. METHODS AND MATERIALS Control clinical trial simple blind perfomed between June and December of 2004. One hundred seventeen patients were included in the study. They were randomly assigned in two groups: 1) study group (n = 61, 52%), 100 mg of rectal indomethacin was administered 2 hours previous to the procedure and, 2) control group (n = 56, 47.8%) received placebo (glycerine suppository). Hyperamylasemia was diagnosed with levels > 151 U/L and AP with levels > 600 U/L and characteristically abdominal pain. RESULTS Gender distribution was of 79 (67.5%) women and 38 (32.5%) men. Mean age was of 54.2 +/- 18.8 years for the study group and 50.1 +/- 18.1 years for the control group. After ERCP, 12 patients (10.2%) of the study group and 19 (16.2%) of control group presented hyperamylasemia (p = 0.09). AP was present in 3 patients (2.5%) in the study group and 8 patients (6.8%) of the control group (p = NS). There was no mortality in our study. CONCLUSION The use of 100 mg of rectal indomethacine previous to ERCP decreases the risk of hyperamylasemia and AP. However, these differences did not reach statistical significance, probably because a greater sample of patients was needed.

[Expression of p53 and BCI-2 as prognostic markers and for anatomical location in gastrointestinal stromal tumors (GIST). Clinico-pathological and immunohistochemistry study of 19 cases]. OBJECTIVE To correlate the expression of p53 and BCl-2 with the clinical outcome and anatomic location of the gastrointestinal stromal tumours (GIST). BACKGROUND DATA The GIST are the most common nonepithelial neoplasm of the gastrointestinal tract. In spite of the existence of a wide range of predictive factors, their clinical outcome is unpredictable. There are several studies that correlate the expression of p53 and Bcl-2 with the clinical outcome and anatomic location of the GIST. METHODS We obtained 19 cases from the archives of the Department of Pathology of the ABC Medical Center, in Mexico City. GIST were classified into risk groups according to the Fletcher et al. classification. We performed an immunohistochemestry panel including CD117, CD34, actin, desmin, P-S100, p53 and BCl-2 and correlated their expression to the risk group and anatomical site of the tumors. RESULTS There was less expression of p53 in the gastric tumors (27%) than in small bowel tumors (100%). There was greater expression of p53 in the high-risk tumors than in the very low-risk ones, regardless of the anatomical site. Bcl-2 expression was more expressed in the small intestine tumors (100%) than in those located in the duodenum (50%) The high risk tumors showed slightly more expression of Bcl-2 than the low risk ones (89% vs. 100%), despite the anatomical location. CONCLUSIONS Both, p53 and Bcl-2 are important markers to establish the anatomical site of GIST and are also helpful to predict the clinical behavior of these tumors.

[Endocrine tumors of the pancreas: experience in the ABC Medical Center]. OBJECTIVES To analyze presentation, diagnosis and treatment of islet cell tumors at the ABC Medical Center. MATERIALS AND METHODS Medical records of the 7 patients with endocrine tumors diagnosed between 1995 and 2005 were reviewed and analyzed, with emphasis to clinical, biochemical and radiological characteristics, surgical treatment and outcome. RESULTS There were 3 insulinomas, 1 gastrinoma, 1 VIPoma, and 2 non-functioning tumors. All insulinomas presented the Whipple's triad. The tumor was localized before surgery in 2 cases. In all patients intraoperative ultrasound confirmed the tumor and enucleation was performed in all three. The patient with gastrinoma was diagnosed by endoscopy in the presence of metastatic disease, therefore no surgical treatment was performed. The patient with VIPoma, presented the typical secretory diarrhea. A tumor in the pancreatic head was found and it was resected by pancreaticoduodenectomy. Histology revealed a malignant lesion. Both non functioning tumors were found by imaging studies, one benign tumor was treated by central pancreatectomy and the other was malignant and underwent distal en-block pancreatectomy. Immunohistochemistry was positive for VIP in the benign lesion. Two of the 3 malignant tumors have died and one is alive with recurrent disease. CONCLUSIONS Distribution of islet cell tumors in our series followed the usual patterns. In all functioning lesions hormonal production was identified before surgery. Imaging studies localized the tumor in 7 of the 8 patients. Surgical resection cured all benign tumors.

Hematochezia due to a renal cell carcinoma metastasis to the rectum: A case report and review of the literature. While primary tumors of the GI tract are a frequent cause of gastrointestinal bleeding, metastatic lesions to the bowel uncommonly present with hematochezia, and rectal involvement is particularly rare. We describe the case of a 70-year-old man with an exceedingly late recurrence of renal cell carcinoma who presented with hematochezia due to a metastasis in the rectum. This is the first report to include both endoscopic and endoscopic ultrasound images of such a lesion. In the correct clinical setting, metastatic disease to the rectum should be included on the differential diagnosis of lower gastrointestinal bleeding.

[Presentation of gastric cancer as a soft tissue tumor]. Soft tissue metastasis of gastric cancer is extremely rare. We report an 82 year old male, who was being evaluated for benign prostate hyperplasia and incidentally a soft tissue mass in the right buttock was discovered. Differential diagnosis included neurofibroma vs. soft tissue sarcoma. Patient underwent surgical resection and pathologic analysis reported adenocarcinoma with ring cell differentiation. Postoperative work-up included a CT scan of abdomen and pelvis and upper gastrointestinal endoscopy. An ulcer in the gastric antrum was discovered and biopsied. Pathology reported the same tumor as the soft tissue mass. PET scan demonstrated extensive metastatic disease. We reviewed the literature looking for other cases of soft tissue metastasis of gastric cancer.

[Chromoendoscopy]. Accurate detection of premalignant lesions and early cancers in the gastrointestinal tract is essential for curative endoscopic or surgical therapy, because prognosis of the affected patients is closely related to the size and stage of the neoplastic lesion. Recently, it has emerged new endoscopic devices that allow even cellular images in vivo during an endoscopic procedure. These technologies will change and improve endoscopic diagnosis. The combination and integration of different technologies in a multifunctional endoscope will offer new optical features in GI endoscopy. Cytoendoscopy will characterize the surface architecture, confocal laser endomicroscopy will immediately clarify the nature of the lesions by in vivo histology of the mucosal layer, and optical coherence tomography will accurately grade the invasion depth. It will need some additional time before this scenario comes true. Endoscopy will become more complex due to the new visible details. Education and training will play an important future role in GI endoscopy. However, it is not possible to use these novel technologies without before learn to identify early GI cancers lesions. Meanwhile these technologies are perfectionated and we overcome the learning curve to identify early GI lesions, chromoendoscopy will continue to be a safe, easy and inexpensive method.

[Hereditary nonpolyposis colorectal cancer (Lynch syndrome). Clinical case]. Colorectal cancer is an important neoplasm in general population, about 90% of the cases are sporadical, but near of 5% are due to hereditary non polyposis colorectal cancer. Early detection is imperative due to genetic linkage and association to other neoplasms diagnosed an early age. This case report is about a young man diagnosed with colorectal cancer that presented multiple recurrences and had at least two affected generations. The most important aspects of diagnosis, management and genetic counseling are discussed.

[Limb salvage with osteoarticular allografts after resection of proximal tibia bone]. OBJECTIVE To evaluate the short-term efficacy of osteoarticular allografts in the limb salvage of the proximal tibia. METHODS From 1998 to 2003, 15 patients (7 males, 8 females; aged 14-56 yr. average 33) with bone tumor of the proximal tibia underwent osteoarticular allografts. among whom 7 had progressive giant cell tumor without any previous chemotherapy; 8 had malignant tumor with previous chemotherapy, including 6 patients with osteosarcoma, 1 with spindle cell sarcoma, and 1 with malignant fibrous histiocytoma. According to the Enneking system, the patients were classified into I B (7 patients), II A (2 patients), and II B (6 patients). All the patients underwent the marginal resection with an allograft (average length 12 cm, range 6-16 cm) implanted. RESULTS The follow-up for an average of 21 months (range, 3-58 months) revealed that among the 8 patients with malignant tumor of the proximal tibia undergoing chemotherapy, 5 had union of the bone, 3 had no union of the bone; among the 3 patients, 2 had a complication of infection and 1 had a local recurrence. All the 3 patients underwent amputation at the lower part of the femur. According to the Mankin score, 2 patients had a perfect result, 2 good, 1 fair, and 3 poor, with a 50% effectiveness rate. Among the 7 patients with progressive giant cell tumor at the upper part of the tibia, none had infection or local recurrence, but 2 had nonunion of the bone and 2 had joint instability, aided by the knee-aiding system. According to the Mankin score, 3 patients had a perfect result, 2 good, and 2 fair, with a 71% effectiveness rate. CONCLUSION The osteoarticular allograft of the proximal tibia has many advantages in spite of a relatively high rate of complications, and it is the limb salvage of choice for the progressive benign or malignant bone tumors of the proximal tibia.

[Endoprosthetic reconstruction after wide resection of sarcoma in lower extremities]. OBJECTIVE To assess the clinical outcome of the limb salvage surgery and complications occurring in the lower extremities after a wide resection of sarcoma. METHODS A total of 167 patients underwent a limb-sparing procedure by means of the implantation of a custom-made or modular tumor endoprosthesis from July 1997 to July 2004. Of the 167 patients, 100 were followed up, including 56 males and 44 females, with their ages ranging from 13 to 57 years at surgery. In 5 patients, a proximal femur prosthesis was implanted; in 57 patients, a distal femur prosthesis was implanted; and in 38 patients, a proximal tibia prosthesis was implanted. According to the Enneking staging, 3 patients were grouped in the stage of II A, 85 in I B, and 12 in III. Seventy-one patients used a domestic prosthesis, and 29 patients used a prosthesis made in Link Company, Germany. For the reconstruction, 17 patients used an autograft prosthesis composite, 21 patients used the allograft prosthesis composite, and the remaining 62 patients used an artificial prosthesis. All the patients received chemotherapy for 1-2 courses and 3-5 courses before operation and after operation, respectively. After operation, The Musculoskeletal Tumor Society(MSTS) score was used to evaluate the recovery of their corresponding functions. RESULTS According to the follow-up for 1-8 years, with a median of 3.5 years, and the assessment by the Kaplan-Meier estimate, the 3-year survival rate of the prostheses was 81.8%, and the 5-year survival rate was 65%. As for the complications, prosthesis breakage occurred in 6 patients, periprosthesis infection in 13 patients, aseptic loosening in 2 patients, non-union between the host bone and graft bone in 5 patients, allograft absorption in 2 patients, prosthesis sinking in 2 patient, and periprosthesis fracture in 1 patient. Local recurrence developed in 7 patients within 6 months to 2 years after operation. Of the 7 patients, 4 had a recurrence of the soft tissue tumor for which resection was performed; the other 3 patients underwent amputation of the diseased limb. The mean MSTS score was 23. 30 +/- 5.17, with an excellent limb function in 62 patients, good in 27 patients, fair in 7 patients, and poor in 4 patients. The overall excellent and good function was obtained in 89% of the patients. CONCLUSION We conclude that tumor prostheses can give a satisfactory functional outcome after the tumor around the knee is removed; however, the tumor prostheses still need to be further improved because of a high complication rate.

[Surgical management of limb salvage for osteogenic malignant tumors around knees]. OBJECTIVE To probe a satisfactory surgical management of the limb salvage for osteogenic malignant tumors around the knees. METHODS From January 1989 to December 2001, 42 patients (19 males and 18 females, aged 12-46) with osteogenic malignant tumors around the knees underwent surgical management of the limb salvage, including prosthesis replacement, allogenous bone grafting, and bone cement with adriamycin filled. Based on the pathological examination, osteosarcoma was found in 11 patients, synoviosarcoma in 4 patients, malignant fibrous histiocytoma in 3 patients, and giant cell tumor of the bone in 19 patients. All the patients underwent neoadjuvant chemotherapy for 1-2 courses before operation except the patients with giant cell tumor of the bone. The patients underwent prosthesis replacement, allogenous bone grafting, bone cement with adriamycin filled, and postoperative chemotherapy. By the Enneking evaluating system, the patients were assessed on their reconstructed limb functions after the reconstructive operation for the musculoskeletal malignant tumors. Of the patients, 37 were followed up after operation. RESULTS According to the follow-up for 3-11 years (mean, 5.6 years) in the 37 patients, 2 patients had recurrence and metastasis of the tumor, and died 3 and 4 years after operation, respectively. One patient underwent amputation of the limb for local recurrence of the tumor. One patient had amputation of the limb for the preoperative radiotherapy and the infection and necrosis of the operative wound after the limb-salvage surgery. Two patients had amputation of the limb for the rejection of the allogenous bone graft and the formation of the fistula. Thirty-one patients had good wound healing and good functions of the limb. The results were evaluated by the Enneking evaluating system as follows: excellent in 7 patients, good in 14, fair in 10, and poor in 6. CONCLUSION Making an early diagnosis, recognizing the operative indication, choosing the operative method, and performing the preoperative and postoperative chemotherapy and/or radiotherapy are the keys to achieving an ideal limb-salvage surgery for osteogenic malignant tumors around the knees.

[Vascularized fibular combined with iliac grafting to repair bone defect after tumor extensive resection for giant cell tumor of bone around knee]. OBJECTIVE To study the method and effect of the vascularized fibular combined with iliac grafting after the tumor extensive resection for giant cell tumor of the bone around the knee. METHODS Twenty-five patients with giant cell tumor of the bone around the knee were reviewed, who had been admitted to our hospital from October 1996 to November 2002, including 17 patients undergoing the fibular and iliac transplantation with the vessels anastomosed after the extensive excision of the bone tumor. By the surgically-staged manner of Enneking, all the patients were grouped in the stage of I A; by the Campanacci's radioactive image staging, 11 patients were grouped in stage I, 5 in stage II , and 1 in stage III; by the Jaffe's pathological staging, 9 patients were grouped in stage I, 7 in stage II, and 1 in stage III. Of the patients, 9 were treated by the vascularized fibular combined with iliac grafting in the proximal tibia after the tumor extensive resection, and 8 were treated by the distal femur reconstruction by the operation. The following items were also analyzed: postoperative infection, growth of the bone graft, rate of local recurrence, tumor metastasis, and bone death. The function of the knee joint was evaluated. RESULTS According the follow-up of the 17 patients for 26-87 months (mean, 54 months), all the bone graft healed well within 75-120 days (mean, 93 days) after operation. Two patients had a local recurrence and 3 had a mildly-narrowed joint. The flexion and extension function of the knee joint recovered, with a range of motion of the reconstructed distal femur of 80 degrees-105 degrees (mean, 96 degrees) while the proximal tibia had a range of motion of 90-120 degrees (mean, 110 degrees). The functional outcome was excellent in 11 patients, good in 3 patients, fair in 1 patient, and bad in 2 patients, with a total satisfactory rate of 82.4%. CONCLUSION The vascularized fibular combined with iliac grafting after the tumor extensive resection to treat giant cell tumor of the bone around the knee has advantages of complete resection of the tumor and well-restored or reconstructed structure and function of the knee joint.

[Segmental allograft reconstruction in skeletal defect after limb tumor resection]. OBJECTIVE To study the clinical feasibility of the prosthetic composites of the intercalary allograft and the segmental allograft in reconstruction of the skeletal defect after the limb tumor resection. METHODS Between August 1999 and December 2003, 28 patients with skeletal defects after the limb tumor resection were treated with the intercalary allograft or the segmental allograft megaprosthesis composite for reconstruction of skeletal defects. The bone involvements were observed in 16 patients with osteosarcoma, 4 patients with parosteal osteosarcoma, 5 patients with Ewing sarcoma, and 3 patients with soft tissue sarcoma. Preoperative biopsy was performed on all the patients, and the pathological result was confirmed after surgery. According to the Enneking system, 5 patients were grouped in I B and 23 patients in I B. The patients with osteosarcoma or Ewing sarcoma received the standard chemotherapy before and after operation. Eighteen and ten patients received the segmental allograft prosthetic composite replacement and the intercalary allograft with the interlocking intramedullary nail fixation, respectively. The functional outcome was evaluated by the MSTS score. RESULTS According to the follow-up for 5-48 months (average, 24 months), local recurrence was observed in 1 patient who underwent amputation eventually. Of the 28 patients, 3 developed nonunion of the allograft-host junction accompanied by severe resorption and 2 developed deep infection. No allograft fracture was seen in the patients. Most of the patients achieved a good functional result with an average MSTS score of 23. 4. CONCLUSION The prosthetic composite replacement of the intercalary allograft and the segmental allograft can be used in the skeletal defect reconstruction after the limb tumor resection. The stable contact in the allograft-host junction and the strong intramedullary internal fixation can help to reduce the complication rate of the allograft.

[Treatment of tumorous disease in proximal femur by customized hip arthroplasty]. OBJECTIVE To summarize and analyze the clinical experience and the clinical outcome of treating tumorous diseases in the proximal femur by the customized hip arthroplasty. METHODS Eleven patients (7 males and 4 females, aged 40-69 years) with a tumorous disease in the proximal femur received a removal of the proximal femur and the customized hip arthroplasty from February 1994 to November 2002. Of the 11 patients, 7 had giant cell tumor in the proximal femur, 2 had chondroblastoma, 1 had osteitis deformans, and 1 had fibrous dysplasia. Six patients received the artificial total hip replacement and 5 underwent the dipolar-cup artificial femoral head prosthesis replacement. RESULTS The follow-up for 1-5 years in 9 patients (2 patients lost the follow-up) revealed that after operation one patient with hemorrhage from the incision had been given a local compression for 5 days, and finally lost the function of the quadriceps muscle and had sensory deprivation in the anterior part of the thigh. Five years later, the patient had a quadriceps muscle power of the "0" degree, a decreased sensation, the "3" degree of the hamstring and the extension and flexion muscles of the lower limb, with lameness and crutch walking. The quadriceps muscle power test showed that 5 patients had the "3" degree of the muscle power and 2 of them had paroxysms of pain in the upper part of the thigh, especially after a long time of standing and walking, so both of them received the dipolar-cup artificial femoral head prosthesis replacement. Three patients had the "4" degree of the quadriceps muscle power, with an extension range of the hip joint of 10 degrees-27 degrees and an average flexion degree of 74 degrees. According to the Harris scale, 3 patients were assessed to be good (80-89), 5 moderate (70-79), but 1 bad (<70). No infection, recurrence or the loosening of the prosthesis was found in all the patients during the follow-up. CONCLUSION The customized hip arthroplasty has a good clinical outcome in treatment of a tumorous disease in the proximal femur. However, there is a high incidence of deficiency of the quadriceps muscle power after operation, which may be relevant to the removal of the upper attachment of the quadriceps muscle. If the attachment of the quadriceps muscle, especially the internal, external and posterior septum attachment, can be fixed in the body of the prosthesis during operation, the power of the quadriceps muscle can be enhanced and the patient can have a better therapeutic effect.

[Reconstruction of bone defects with autograft after resection of upper extremity bone]. OBJECTIVE To discuss the reconstructive method of the bone defect after resection of the upper extremity bone tumor and to assess the outcome of the autograft to reconstruct the bone defect after the bone tumor resection. METHODS From August 1998 to March 2004, 16 patients aged 7-45 years suffering from bone tumor of the upper extremity were treated with the wide resection of the bone tumor and the reconstruction of the bone defect by the autograft. The following diagnoses were confirmed by pathological examination: Ewing's sarcoma and osteosarcoma of the proximal humerus in 1 patient each; Ewing's sarcoma of the distal humerus in 2 patients; giant cell tumor in 8 patients, high-grade chondrosarcoma in 2, malignant fibrohistiocytoma in 1; and osteosarcoma in 1 of the distal radius. Substitution of the proximal humerus with the clavicle was performed in 2 patients, and the distal humerus with the fibula in other 2 patients. Of the 12 patients with tumor in the distal radius, 1 was reconstructed with autograft of the iliac bone and 11 with autograft with the fibula. The functional outcome was evaluated by the MSTS score. RESULTS The follow-up for 36 and 12 months respectively revealed that in the 2 patients undergoing the autograft with the clavicle in the proximal humerus, good shoulder functions of flexion and extension were obtained although the function of abduction was poor, with the MSTS scores of 23 and 22 respectively. In the 2 patients undergoing the autograft with the fibular in the distal humerus, good elbow function and bone union were observed according to the follow-up for 3 and 4 months respectively, with the MSTS scores of 24 and 19 respectively. Of the 12 patients undergoing the autograft in the distal radius, 11 had an excellent or good function with no complication, with the average MSTS score of 22.6 (ranging from 18 to 27), according to the follow-up for 6-75 months; only 1 had no bone union 10 months after operation and lost the follow-up afterwards. CONCLUSION Reconstruction of the bone defect with the autograft after the wide resection of the upper extremity bone tumor is an ideal and reliable method for some suitable patients, especially for some children.

[Clinical studies on treatment of patients with malignant spinal tumors by percutaneous vertebroplasty under guidance of digital subtraction angiography]. OBJECTIVE To investigate the clinical therapeutic effects on malignant spinal tumors treated by percutaneous vertebroplasty (PVP) under the guidance of the digital subtraction angiography (DSA). METHODS A retrospective analysis was performed in 196 patients (99 males and 97 females, aged 23-85 years, averaged 60.4 years) with malignant spinal tumors, who underwent the PVP treatment combined with standard chemotherapy and other comprehensive treatment from January 2002 to January 2005. The malignant spinal tumors had their origins as follows: lung cancer (66 cases), breast cancer (55 cases), liver cancer (19 cases), colon cancer (15 cases), stomach cancer (9 cases), prostate cancer (12 cases), multiple myeloma (16 cases), and malignant lymphoma of the spine (4 cases). The metastatic tumors involved the cervical vertebra (32 cases), thoracic vertebra (93 cases), lumbar vertebra (71 cases), and spinal column, including 1 vertebral segment (135 cases), 2 segments (50 cases), and more than 3 segments (11 cases). During the follow-up survey, changes in the visual analogue pain scale (VAS) and changes in the X-ray measurements of the average anterior height, midline height, and posterior height of the diseased vertebra were observed. RESULTS The follow-up for 6 months to 3 years revealed that the percutaneous vertebroplasty on 279 vertebral segments had a success with an operational success rate of 100%. Bone cement was injected into the lesions 1-9 ml per segment of the spine. The postoperative X-ray and CT evaluations revealed that spinal stabilization was obtained in all the patients. After operation, 193 (98.5%)patients had an obvious decrease or disappearance of the pain in the lower back, and only 3 (1.5%) patients had no obvious improvement in the pain. There was a significant statistical difference in the VAS scores between before operation and after operation (P < 0.05). There were also significant statistical differences in the average anterior height of the diseased vertebra between before operation and after operation (15.71 +/- 2.80 mm vs. 16.61 +/- 3.01 mm), in the midline height (13.65 +/- 2.93 mm vs. 14.52 +/- 2.72 mm), and in the posterior height (23.67 +/- 2.81 mm vs. 23.70 +/- 3.13 mm, P < 0.05). The patients with lung or liver cancer had a mean survival time of 9 months after PVP; the patients with breast cancer, stomach cancer, prostate cancer, lymphoma, or other metastatic tumors had a mean survival time of 18 months. The patients with multiple myeloma had a mean survival time of 27 months. The differences were statistically different (P < 0.01). CONCLUSION PVP under the guidance of the DSA is an easier operation with a small wound and few complications. It can effectively alleviate the patient's pain due to metastatic spinal tumor, stabilize the spine, improve the patient's quality of life, and reduce the incidence of paraplegia.

[Reoperation after limb salvage surgery with prosthesis for bone tumor]. OBJECTIVE To analyze the causes and the reoperation therapies after salvage limb surgery with prosthesis for bone tumors. METHODS The retrospective analysis was performed on 85 patients undergoing the limb salvage operation with prosthetic replacement for tumors from January 1994 to December 2004. Of the patients, 21 (13 males and 8 females, aged 18-58 years) underwent reoperations for various reasons. All the diagnoses were pathologically confirmed (10 patients with osteosarcoma, 4 with chondrosarcoma, 5 with giant cell tumor of the bone, 2 with osteofibrosarcoma). The distal femur was involved in 9 patients, proximal tibia in 8, proximal femur in 2, proximal humerus in 1, and acetabulum in 1. According to the Enneking surgical grading system, there were 5 patients in I B and 16 in II B. The time between the first operation and the reoperation was 2 weeks to 20 years. The common reasons for the reoperation were tumor recurrence in 8 patients, prosthetic loosening in 5, no healing of the incision in 4, joint dislocation in 3, and implant fracture in 1. The amputation and the prosthesis revision were respectively performed on 6 patients, extensive resection of the tumor on 3, the myo-skin flap translocation on 4, internal hemipelvectomy without reconstruction on 1, and open reduction on 1. RESULTS The follow-up in 18 patients for 1-5 years (average, 3 years and 4 months) revealed that 4 patients died of osteosarcoma with pulmonary metastasis. The other 14 patients had no tumor recurrence or loosening of the prosthesis, and the incisions healed well. The assessment on the joint function was performed on 13 of the 18 patients and the results were as follows: excellent in 2 patients, good in 5, fair in 4, and poor in 2, with a satisfaction rate of the reoperation with limb salvage of 84.6% and an excellent-good rate of 53.8%. CONCLUSION Tumor recurrence is the most common reason for the reoperation after the limb salvage with prosthesis for tumors, and loosening of the prosthesis is an important reason, too. By the rules of the bone tumor limb savage, the limb salvage operations can also be performed, which can achieve a satisfactory result of the limb function.

[A clinical study on implantation of autologous bone marrow mononuclear cells after bone marrow stimulation for treatment of lower limb ischemia]. OBJECTIVE To observe the clinical efficiency of the implantation of the autologous bone marrow mononuclear cells for treatment of lower limb ischemia after the bone marrow stimulation. METHODS From May to December 2005, 43 ischemic limbs in 35 patients (23 males, 12 females; aged 34-90 years,averaged 71.3 year) were treated. Of the 35 patients, 30 had diabetic lower limb ischemia with 38 lower ischemic limbs, 2 had atherosclerosis obliterans with 2 ischemic lower limbs, and 3 had thromboangiitis obliterans with 3 ischemic lower limbs. Five patients with 5 ischemic limbs were in stage I lower limb ischemia (intermittent claudication), 15 patients with ischemic 19 limbs were in stage II (rest pain), 9 patients with 12 ischemic limbs were in stage IIIa (ulceration), and 6 patients with 7 ischemic lower limbs in stage IIIb (gangrene); 88.4% of all the ischemic lower limbs (38/43)had a pain, 79.1% (34/ 43) had coldness, and 69.8% (30/43) had limb numbness. The bone marrow of each patient was stimulated by an injection of the recombinant human granulocyte-macrophage colony-stimulatory factor (GSF), 300 microg/d for 2-3 days. The bone marrow 130-200 ml was drawn from the iliac spine and the mononuclear cells were obtained. Each patient received implantation of the autologous bone marrow mononuclear cells by an intramuscular injection, an arterial intraluminal injection or a combined injection of the two routes. RESULTS The pain relief was found in 94.7% of the ischemic lower limbs, and pain improvement in 97.1% . Relieved numbness was found in 93.3%. The distance of the claudication was increased by all the ischemic limbs. An increase in the ankle/ brachial index (ABI) was found in 47.9%. The transcutaneous oxygen pressure (TcPO2) increased in 92.3%. The ulcer heal rate was 9.1% (1/11). Markedly-reduced ulcer wound was found in 27.3% (3/11). The amputation rate was 6.3% (3/48). Arterial angiography revealed that there was a new collateral vessel formation in 91.2%. Complications were as follows: fever and mild fatigue developed respectively in 1 patient after the bone marrow stimulation, but relieved by themselves. Acute but mild myocardial infarction was found in 1 patient with a slight precordial pain and elevation of myocardial enzymes 1 week after transplantation of the bone marrow mononuclear cells, but recovered after medical treatment. The follow-up averaged 5 months. According to the subjective criteria, the overall efficacy was 90%. ABI increased in 62.5% of the patients after operation and the value of TcPO2 was higher in 90% of the patients after this kind of therapy. Arterial angiography revealed a new collateral vessel formation in 90.5% of the 21 ischemic limbs. The foot ulcer healed in 7 and obviously improved in 3. Three of the foot ulcer patients were discharged 2-3 months after the amputation was performed on the diseased toes. CONCLUSION Implantation of the autologous bone marrow mononuclear cells after the bone marrow stimulation of treatment of the lower limb ischemia has advantages of less marrow aspiration, more mononuclear cell content, satisfactory short-term effect, and relatively high safety. It is a new method of treating the lower limb ischemia besides the autologous bone marrow and peripheral blood mononuclear cell implantation. The long-term effect of this method needs a further study.

[Experimental studies on effect of grafting injury to vein graft]. OBJECTIVE To study the mechanism of restenosis of the vein graft and the effect of the grafting injury to the vein graft. METHODS One side of the 36 healthy rabbits was randomly chosen as the V-A group, and on the side a 1.5-cm-long femoral vein was obtained, and an 0.5-cm-long segment of the obtained femoral vein was separated as the control group. The remaining 1-cm-long femoral vein was inverted and was autogenously implanted into the femoral artery on the same side of the rabbit. The other side of the rabbits was chosen as the V-V group, and on this side a 1-cm-long femoral vein was obtained ex vivo and then was sutured in situ. The vein grafts on both sides were harvested 4 weeks after operation. The specimens from the harvested vein grafts were stained with HE and the elastic fiber Victoria blue for an observation on the histological changes in the walls of the vein grafts, and the specimens were also stained by the immunohistochemistry of the proliferating cell nuclear antigen (PCNA) for an observation on the wall cell proliferation of the vein grafts. The changes in the ultrastructure of the proliferated wall cells of the vein grafts were observed under electron microscope. The two sides of the rabbits were compared. RESULTS The smooth muscle cells of the media developed hyperplasia, but the intima and the media remained unchanged in their thickness (3.50 +/- 0.41 microm, 12.23 +/- 1.59 microm) in the V-V group, with no difference when compared with the control group (3.40 +/- 0.37 microm, 12.14 +/- 1. 62 microm); however, when compared with the V-A group (25.60 micro 3.21 microm, 21.30 +/- 2.47 microm), there was a significant difference in the thickness (P < 0. 01). There were no cells positive for PCNA by the immunohistochemistry examination in the control group. The cells positive for PCNA were found in the intima and the media in both the V-V group and the V-A group; however, the percentage of the cells positive for PCNA in the intima and the media was significantly greater in the V-A group than in the V-V group (16.4% +/- 1.9% and 36.5% +/- 3.7% vs. 5.9% +/- 1.3% and 23.4% +/- 3.4%, P < 0.01). In the V-V group, the endothelial cell could be observed under transmission electron microscope, which was flat and had a process-like villus at its free end, and the endothelial cells were closely arranged and had hyperplasia of the smooth muscle cells in the media. But in the V-A group, the endothelial cells had an obvious hyperplasia with an irregular shape and a widened space between the cells, and in the intima a great amount of the smooth muscle cells could be observed, which had a broken basement membrane. The smooth muscle cells also had an obvious hyperplasia in the media. The shape and alignment of the endothelial cells in the control group were similar to those in the V-V group, but the hyperplasia of the smooth muscle cells was not observed in the media. CONCLUSION The grafting injury can cause hyperplasia of the vascular wall cells, and if the hemodynamics is changed simultaneously, more serious hyperplasia and cell migration can be observed from the media to the intima, resulting in restenosis of the blood vessels. So, if we can reduce the grafting injury and improve the microcirculation of the vein graft. we may find out the methods of preventing restenosis of the vein graft. The animal model of the V-V graft can help to understand the mechanism of restenosis of the vein graft.

[Application of skin soft tissue expansion to reconstruction of scalp soft tissue defect]. OBJECTIVE To explore an improved method of reconstructing the scalp soft tissue defect with the expanded skin soft tissue and treating and preventing the related complication. METHODS From October 2002 to June 2005, 32 patients (20 males and 12 females, aged 5-48 years) underwent reconstruction of the scalp soft tissue defects with the expanded scalp soft tissue in the two-stage operation. In the first stage, a tissue expander (cylindrical form, 50-250 ml) was implanted into the skin to achieve a skin soft tissue expansion. After a sufficient skin expansion (8 cm X 5 cm to 25 cm X 23 cm) was made by the routine water effusion for 6-16 weeks, a properly-designed skin flap was taken and transferred to reconstruct the scalp soft tissue defect in the second-stage of the operation. All the scalp defects were left after the resections of the scalp lesions, which ranged in size from 7 cm x 5 cm to 20 cm x 20 cm. RESULTS After operation, all the 32 patients had their scalp defects repaired and reconstructed well. The expanded skin flaps of all the 32 patients survived except 1 patient who had a necrosis of the distal epidermis of the flap, which healed after the dressings of the wound. The hair grew well and the scars were hidden with a satisfactory appearance. Four patients developed complications (necrosis of the distal flap in 1 patient, hematoma in 1, expander exposure in 1, and wound rupture in 1). CONCLUSION Reconstruction of the scalp soft tissue defect with the skin soft tissue expansion is an ideal method.

[Primary repair of tissue defects of achilles tendon and skin by free grafting of anterolateral femoral skin flap and iliotibial tract]. OBJECTIVE To observe the clinical outcome of primary repair of the tissue defects of the Achilles tendon and skin by thigh anterolateral free flap and free iliotibial tract. METHODS From January 2000 to January 2005, the thigh anterolateral free flap and the iliotibial tract were used to primarily repair the defects of the Achilles tendon and skin in 11 patients (7 males and 4 females, aged 6-45 years). The defects of the skin and Achilles tendon were found in 6 patients, and the defects of the Achilles tendon and skin accompanied by the fracture of the calcaneus were found in 5 patients. The defect of the Achilles skin was 6 cm X 5 cm-14 cm X 8 cm in area. The defect of the Achilles tendon was 5-11 cm in length. The skin flap was 11 cm X 6 cm-17 cm X 11 cm in area. The iliotibial tract was 7-13 cm in length and 3-5 cm in width. The medial and lateral borders were sutured to from double layers for Achilles tendon reconstruction. The wound on the donor site could be sutured directly in 5 patients, and the others could be repaired with skin grafting. RESULTS After operation, all the flaps survived and the wound healed by first intention. The follow-up of the 11 patients for 6 mouths-4 years (average, 30 months) revealed that according to Yin Qingshui's scale, the result was excellent in 6 patients, good in 4, and fair in 1. The excellent and good rate was 99%. The results showed a significant improvement in the "heel test" and the Thompson sign, and both were negative. No complications of ulceration on the heel and re-rupture of the Achilles tendon occurred. CONCLUSION The primary repair of the tissue defects of the Achilles tendon and skin by free grafting of the anterolateral femoral skin flap and the iliotibial tract is an effective surgical method.

[Have we defeated the principal zoonoses?]. Following an overview of some successful campaigns against zoonoses, this paper examines other zoonotic diseases that are likely to be brought under control in industrialized countries, such as brucellosis, tuberculosis and canine or wildlife rabies. The author goes on to explain the reasons for the failure to eradicate some other zoonoses in developing countries, and concludes by examining reasons for optimism or pessimism, taking into account new methods of prevention and control.

[Bacterial zoonoses: emerging concepts]. Bacterial zoonoses are evolving with changes in society, climate and lifestyles. A hierarchy of non food-borne zoonoses was recently proposed in France, and includes characteristics such as severity criteria and bioterrorism potential. The creation of specific networks and reference centers has provided the means to monitor the emergence (or re-emergence) of zoonoses such as brucellosis and Q fever. Molecular tools have facilitated the detection of bacteria that are transmitted by arthropod vectors (ticks, fleas, etc.) and that cause diseases such as Lyme borreliosis, bartonellosis and ehrlichiosis.

[Emerging viral diseases]. Emerging and re-emerging infectious diseases have again entered the public arena in recent years. This is due to factors such as evolving lifestyles, ecological and socio-political upheavals, and recent diagnostic advances. Numerous pathogens, including viruses like West Nile, Chikungunya and Japanese encephalitis on the one hand, and hemorrhagic fever viruses like Ebola and Maburg, are particular concerns. Recently, the Corona virus responsible for SARS, which caused an epidemic sufficiently worrisome to challenge crisis management concepts, was successfully isolated. It is in this context that so-called "bird flu'", may be on the verge of causing a human pandemic. Pox and Monkeypox are "virtually emerging" viruses that have potential for use in bioterrorism. The management and treatment of these emerging infectious diseases calls for new approaches, organizations and infrastructures.

[How to define the species barrier to pathogen transmission?]. A given microbial pathogen usually targets a restricted number of animal species. Some pathogens can be transmitted to humans from another animal species, either directly (rabies, brucellosis, etc.) or through a vector (Lyme's disease, West Nile fever, etc.). Few infectious agents with animal reservoirs infect humans, and even fewer are capable of human-human transmission. This is attributed to the "species barrier", a simplistic concept that in fact involves a series of conditions for successful inter-species transmission. These include access to an infectable surface, multiplication on that surface, colonisation, invasion, multiplication inside the new host, and resistance to innate and adaptive immune mechanisms. Each of these steps requires a specific ligand-receptor interaction. The full series of events must be "reprogrammed" for efficient implantation in a new host. These changes occur through mutations or genetic exchanges. Direct human-to-human transmission often requires additional adaptive modifications.

[Medical treatment of critical leg ischemia: current status and future perspectives of gene and cell therapy]. Critical limb ischemia (CLI) is associated with a high risk of amputation and death. For patients who cannot be surgically revascularized, medical options include prostanoids, spinal cord stimulation and lumbar sympathectomy, but none of these treatments has a demonstrated impact on the amputation rate at six months. Gene and cell therapy, aimed at stimulating angiogenesis, have mainly been tested in phase I and II clinical trials. These approaches appear to be feasible and safe in the short-term, but large randomized studies are necessary to demonstrate their clinical benefits and long-term safety.

[Metabolic syndrome: prevalence, risk factors and mortality in a French population of 62 000 subjects]. We evaluated the prevalence, risk factors and impact on all-cause mortality of the metabolic syndrome (MetS) and its components in a large French population. The study population consisted of subjects aged 40 years or more who volunteered for a free health check-up at the IPC Center (Investigations Prventives et Cliniques, Paris) between 1999 and 2002. There were 40 977 men (53.2 +/- 9.1 years) and 21 277 women (55.9 +/- 10.3 years). The cutoff date for mortality data was March 2004. The mean follow-up period was 3.57 +/- 1.12 years. During this period, 271 men and 87 women died. MetS was defined according to NCEP-ATP III criteria. Cox regression models were used to evaluate the risk of death [hazards ratio (95% CI)]. MetS was present at baseline in 11.8% of men and 7.6% of women. The prevalence of MetS increased from 9% in men aged 40 to 49 years to 12.5% in men aged 70 years. In women, the prevalence rose from 4.9% to 11.3%, respectively. From 1999 to 2002, the prevalence of MetS increased from 11.0% to 12.8% in men and from 7.2% to 8.8% in women. The following clinical and biological parameters were significantly associated with MetS in men and women, after adjustment for age: lower physical activity, lower vital capacity ratio, higher pulse pressure and heart rate, higher gamma-glutamyl transpeptidase, ASA and ALA transaminase and alkaline phosphatase levels, higher uricemia, leukocyte and globulin levels, dental and gingival inflammation, and higher stress and depression scores. After adjustment for age, the excess risk of all-cause mortality in subjects with MetS compared to subjects without MetS was 1.82 (1.35-2.43) in men and 1.80 (1.01-3.19) in women. After adjustment for age, gender, smoking, cholesterol, physical activity, socioeconomic status and prior cardiovascular disease, the risk of all-cause mortality was 1.69 (1.28-2.22) in the entire population. In order to evaluate the impact of each Mets component, and combinations of three MetS components, on all-cause mortality, a control group of subjects with no MetS components was used. After adjustment for age and gender, the risk of death associated with each MetS component was 2.36 (1.65-3.37) for high waist circumference, 2.08 (1.44-3.01) for elevated triglyceride levels, 1.71 (1.07-2.72) for low HDL-cholesterol levels, 1.75 (1.29-2.38) for elevated arterial pressure, and 2.93 (2.04-4.22) for elevated glucose levels. Waist circumference + elevated triglycerides + elevated glucose was the three-component combination with the strongest impact [HR = 4.95 (2.92-8.37)]. In this large French population, in which MetS was moderate, MetS was associated with other hemodynamic, hepatic, inflammatory and psychological risk factors, and with a 70% increase in all-cause mortality. The three-component combination most strongly associated with mortality was high waist circumference + elevated glucose + elevated triglycerides.

[Protecting the unborn child. Information needed long before pregnancy]. The unborn child is at risk from several maternal diseases and behaviors, such as smoking (tobacco and cannabis) and alcohol consumption. Other threats come from maternal infections (AIDS, hepatitis, rubella, toxoplasmosis, etc.), certain medicines, obesity, diabetes, etc. Many young women of child-bearing potential are unaware of these risks, and need to be informed well before they conceive. Healthcare professionals must be trained to provide this information, notably during preconceptional consultations. The first examination should take place during the first month of pregnancy (rather than before the third month at present), given the risks of early embryonic and fetal damage. This is not just a question of public health but also a social issue, as the lack of information is most flagrant among the poor. Everything must be done to ensure that all children have the best possible chance of growing up in good health.

Virological, serological and histopathological evaluation of fish strain susceptibility to experimental infection with salmonid alphavirus. Pancreas disease (PD) of farmed Atlantic salmon Salmo salar L., which is caused by an alphavirus known as salmon pancreas disease virus (SPDV), can have serious economic consequences. An epidemiological survey carried out in Ireland in 2003 indicated that within individual farms there were significant differences in the susceptibility of different strains of farmed Atlantic salmon to infection with SPDV, as measured by levels of clinical disease and mortality. The aim of this preliminary study was to investigate this field observation by comparing lesion development, viraemia and serological responses of 3 commercial strains of Atlantic salmon (A, B and C) experimentally infected with SPDV. Highly significant differences in the severity of lesions in the pancreas at Day 21 post-infection (pi) were detected (p < 0.01), with Group B being more severely affected. There were also significant differences in the prevalence and severity of lesions in heart and skeletal muscle at Day 21 and 35 pi respectively, with Group B results again significantly higher than those from both Groups A and C (p < 0.05). There was no overlap between viraemia and the presence of specific SPDV antibody. Some fish in all groups had no viraemia, lesions or evidence of seroconversion. There were no significant differences seen between the challenged groups in relation to the percentage of viraemic fish at each time point. Viral loads were not determined. Differences between the number of antibody-positive fish in each challenge group were found at Days 28 and 35 pi (p < 0.1). Highly significant differences (p < 0.01) in the geometric mean titres of seropositive fish were detected at Day 28. These results, obtained using a challenge model, confirm that there are strain differences in the susceptibility to experimental SPDV infection in commercial farmed Atlantic salmon.

Aquatic Francisella-like bacterium associated with mortality of intensively cultured hybrid striped bass Morone chrysops x M. saxatilis. The present study identifies an emerging disease associated with an aquatic Francisella-like bacterium that can cause mortality in hybrid striped bass Morone chrysops x M. saxatilis reared intensively in freshwater. Clinically affected fish were lethargic, had scattered haemorrhagic cutaneous lesions and diffuse gill pallor. The head kidney and spleen were markedly swollen and contained numerous interstitial granulomas; histological examination revealed small, pleomorphic Gram-negative coccobacilli within vacuolated cells. The bacterium could not be cultured from head kidney homogenates either with standard or enriched microbiological media or following inoculation of a Chinook salmon embryo (CHSE)-214 cell line. No amplification product was obtained from head kidney DNA by polymerase chain reaction (PCR) assay using Piscirickettsia salmonis-specific primers. PCR analysis of infected head kidney homogenate with primers designed for the eubacterial 16S rRNA produced a single amplicon. Phylogenetic analysis of this DNA sequence demonstrated that the sequence aligned most closely with members of the genus Francisella, identified from tilapia Oreochromis spp. in Taiwan and an aquatic Francisella species that was recently isolated from the three-line grunt Parapristipoma trilineatum in Japan. This Francisella-like disease was transmitted to naive hybrid striped bass fingerlings by intraperitoneal injection of tissue homogenates prepared from a natural outbreak. All fish developed gross and histological lesions identical to those from natural outbreaks. Intracellular Gram-negative bacteria were observed within the cytoplasm of cells (presumably macrophages) within the granulomas, but bacteria were not recovered. The 16S DNA sequence of the bacterium obtained from tissues of experimentally infected fish was identical to that obtained from the fish used as infected donor tissue.

Pathological and molecular studies on mycobacteriosis of milkfish Chanos chanos in Taiwan. investigated in milkfish Chanos chanos, which had a cumulative mortality of up to 66.7% over the course of 1 yr. Gross reddish- or greyish-white nodules appeared on the peritoneal surface, spleen, kidney, liver and gastrointestinal (GI) tract. Epithelioid granulomas with the formation of Langhan's type giant cells were the prominent histopathological changes. Despite large numbers of acid-fast bacilli in the granulomas, neither caseous necrosis nor dystrophic calcification were observed. Using degenerate primers that targeted the heat shock protein 65 kDa gene of Mycobacterium spp., a 441 bp product was amplified. When compared with published sequences, our products were identical to those of Mycobacterium abscessus Type II (GenBank accession number AY603554). This is the first report of M. abscessus infection in milkfish.

Viral interference between infectious hypodermal and hematopoietic necrosis virus and white spot syndrome virus in Litopenaeus vannamei. White spot syndrome virus (WSSV) is highly virulent and has caused significant production losses to the shrimp culture industry over the last decade. Infectious hypodermal and hematopoietic necrosis virus (IHHNV) also infects penaeid shrimp and, while being less important than WSSV, remains a major cause of significant production losses in Litopenaeus vannamei (also called Penaeus vannamei) and L. stylirostris (also called Penaeus stylirostris). These 2 viruses and their interactions were previously investigated in L. stylirostris. We report here laboratory challenge studies carried out to determine if viral interference between IHHNV and WSSV also occurs in L. vannamei, and it was found that experimental infection with IHHNV induced a significant delay in mortality following WSSV challenge. L. vannamei infected per os with IHHNV were challenged with WSSV at 0, 10, 20, 30, 40 and 50 d post-infection. Groups of nave shrimp infected with WSSV alone died in 3 d whereas shrimp pre-infected with IHHNV for 30, 40 or 50 d died in 5 d. Real-time PCR analysis showed that the delay correlated to the IHHNV load and that WSSV challenge induced a decrease in IHHNV load, indicating some form of competition between the 2 viruses.

No evidence for the presence of apolipoprotein epsilon4, interleukin-lalpha allele 2 and interleukin-1beta allele 2 cause an increase in programmed cell death following traumatic brain injury in humans. BACKGROUND Brain injury after trauma is an important cause of mortality and morbidity in society. There is evidence in both man and laboratory animals that in addition to necrosis, cell loss may occur as a result of programmed cell death (PCD). The cellular and molecular responses after head injury are partly influenced by genetic polymorphisms of apolipoprotein E and the pro-inflammatory cytokine IL-I. AIM The principal aim of this study was to determine whether the presence of the ApoE epsilon4, IL- 1 alpha2 or IL- 1beta2 allele types influenced the amounts of PCD after head injury compared with controls. METHODS Paraffin sections from the hippocampus of 38 patients (32 M : 6 F, aged 15 - 75, mean 38 years, survival 7- 576 hours; mean 36 hours) who died after a head injury were stained by Tunel histochemistry and quantified, and genotyping was undertaken by PCR "blind" to clinical detail. RESULTS There were more Tunel+ cells (neurons and glia) after head injury than in controls with statistically increased numbers in all sectors of the hippocampus including the dentate fascia. However, there was no correlation between ApoEepsilon4, IL- 1 alpha allele 2 and IL- 1beta allele 2 and the amount of Tunel positivity. CONCLUSION Given that both the ApoE and IL-1 influence outcome after various forms of acute brain injury, further work will be required to determine the mechanism underlying this relationship.

Increased serum levels of S100A12 in patients with MPO-ANCA-associated glomerulonephritis. BACKGROUND Increased serum levels of S100A12, a proinflammatory protein secreted by activated neutrophils, have recently been shown in patients with active inflammatory diseases, such as rheumatoid arthritis and Kawasaki disease. In this study, we investigated serum levels of S100A 12 in patients with small-vessel vasculitis, myeloperoxidase anti-neutrophil cytoplasmic antibodies- (MPO-ANCA) associated pauci-immune glomerulonephritis. METHODS Serum S100A12 concentrations were measured by a sandwich enzyme-linked immunosorbent assay (ELISA) in 46 patients with MPO-ANCA-associated glomerulonephritis and 29 healthy controls. We analyzed correlations between serum S100A12 levels and a clinical index of vasculitis activity, the Birmingham Vasculitis Activity Score (BVAS), various laboratory parameters, and pathological activity scores in the patients. We also analyzed changes of serum S100A12 levels in 10 patients after treatment. RESULTS ELISA showed about 4-fold higher levels of serum S100A12 in patients with MPO-ANCA-associated glomerulonephritis than healthy controls. Serum S100A12 levels correlated with the BVAS scores, the peripheral white blood cell count, levels of serum C-reactive protein and creatinine, and pathological activity scores in the patients, but did not correlate with serum MPO-ANCA titers. Serum S100A12 levels after treatment decreased in all the 10 patients examined. CONCLUSION We demonstrated that increased serum S100A12 levels correlate with clinical, laboratory and pathological parameters of disease activity in patients with MPO-ANCA-associated glomerulonephritis. Serum S100A12 level may be one of the useful markers of disease activity in MPO-ANCA-associated glomerulonephritis.

Nephrotoxicity of iso-osmolar versus low-osmolar contrast media is equal in low risk patients. BACKGROUND Contrast media-induced nephropathy (CIN) is an increasing cause of hospital-acquired acute kidney injury and leads to a significant increase in mortality. There is uncertainty whether the use of iso-osmolar contrast media as opposed to the use of low-osmolar contrast media would be associated with a lower incidence of CIN. Therefore, we compared the nephrotoxicity of isoosmotic contrast media iodixanol with the low-osmotic contrast media iopromid in patients receiving contrast media during coronary angiography. METHODS In this prospective double-blind study we examined 221 patients with normal renal function who received up to 1,000 ml of contrast media during coronary angiography, and compared the effect of iodixanol and iopromid on inducing contrast media nephropathy. Patients received 800 ml fluid orally before contrast media administration and 1,000 ml saline i.v. thereafter. Creatinine clearance, serum creatinine and urine-N-acetyl-beta-D-glucosaminidase (NAG) concentration was obtained 24 h before and 48 h after contrast media administration. Decrease of 20% of the creatinine clearance, increase of 25% of serum creatinine and increase of 20% of the urine concentration of NAG was defined as CIN. RESULTS Incidence of CIN assessed by decreased creatinine clearance was 22.2% in the iopromid group and 19.7% in the iodixanol group. CIN defined by increased serum creatinine was 6.9% in the iopromid group and 8.6% in the iodixanol group. The difference between these two groups was not significant. Subgroup analysis of the diabetic patients or the patients that received high dose of contrast media revealed no significant difference in the incidence of CIN between the two contrast media. CONCLUSION The iso-osmolar and the low-osmolar contrast media exhibited the same incidence of CIN in our study population. If fluid administration is sufficient, the selection of either iopromid or iodixanol has no impact on the risk of developing CIN in patients with normal renal function, even when they are diabetic or receive a high dose of more than 500 ml contrast media.

Benign metastasizing leiomyomatosis with massive brachial plexus involvement mimicking neurofibromatosis type 1. We report the case of a patient who presented with right arm and shoulder pain due to compression of the infraclavicular brachial plexus due to benign metastasizing leiomyomatosis (BML). She was initially and had been repeatedly misdiagnosed as having neurofibromatosis type 1 (NF 1). The diagnosis of BML was not obvious due to its rare nature, the patient's not detailing the specifics of her gynecologic history of having undergone resection of a large uterine leiomyoma and followed by disseminated pelvic leiomyomatous nodules, histologic misinterpretation of an extrauterine lesion of the spine and the brachial plexus as a neurofibroma and the radiologic diagnosis of lung nodules as being "non-specific" in nature. In addition and importantly, no clinical, radiographic or histologic features of NF 1 were present. Although a rare condition, BML should be considered in the differential diagnosis of NF and in patients having a history of uterine leiomyoma. The remarkable, selective involvement of the brachial plexus in this case is unexplained.

The utility of non-HDL in managing dyslipidemia of stage 5 chronic kidney disease. BACKGROUND The Kidney Disease Outcomes Quality Initiative (K/DOQI) treatment guidelines for managing dyslipidemia in patients with chronic kidney disease (CKD) designate CKD as a high-risk category for coronary heart disease and, in Stage 5 CKD patients, recommend maintaining low-density lipoprotein (LDL) < 100 mg/dl and, for patients with hypertriglyceridemia (> or = 200 mg/ dl), non-high-density lipoprotein (non-HDL) < 130 mg/dl, the latter to achieve very low-density lipoprotein (VLDL) < 30 mg/dl. More recently, the National Cholesterol Education Program has recommended an LDL target of < 70 mg/dl for high-risk patients. AIMS The purposes of this study were: to document the point prevalence of dyslipidemia in CKD patients at hemodialysis inception, prior to potential impact of dialysis treatments; to assess the hypothesis that non-HDL serves as a reliable surrogate marker for elevated VLDL; to examine the performance of K/DOQI guidelines in treating dyslipidemia; and to evaluate the utility of non-HDL as an alternative primary trigger/target of lipid-lowering therapy in Stage 5 CKD patients. METHODS Consistent with K/DOQI guidelines, lipid levels drawn immediately prior to hemodialysis sessions, thus possibly non-fasting, were analyzed in 21,893 incident dialysis patients by laboratory measurements of triglycerides, total cholesterol, and HDL and from calculated values of non-HDL, LDL, VLDL and intermediate-density lipoprotein. RESULTS Prevalence of dyslipidemia, by guideline definitions, was 82%, predominantly manifested by elevated triglycerides (52%) and VLDL (52%) and decreased HDL (51%), with less frequent elevations of LDL (40%) and total cholesterol (24%). Non-HDL > or = 130 mg/dl was neither a sensitive (61%) nor specific (75%) marker for elevated VLDL. There was a striking disparity between the high prevalence of dyslipidemia and the percentage of dyslipidemic patients qualified by K/DOQI guidelines for therapy. Non-HDL > or = 130 mg/dl was as effective in qualifying dyslipidemic patients for lipid-lowering therapy (54%) as the entire K/DOQI treatment algorithm (57%). Lowering the trigger of non-HDL to > or = 100 mg/dl would qualify 81% of dyslipidemic patients for treatment while offering the important advantage of being uninfluenced by the non-fasting state. CONCLUSIONS In Stage 5 CKD patients at hemodialysis inception, dyslipidemia is highly prevalent with predominance of the atherogenic triad (hypertriglyceridemia, elevated VLDL and reduced HDL). Non-HDL is a poor surrogate marker for VLDL. As a valid non-fasting lipid parameter, non-HDL alone at the level of > or = 130 mg/dl qualifies dyslipidemic Stage 5 CKD patients for therapy as effectively as the K/DOQI guidelines. Setting the non-HDL trigger/target cut-off at 100 mg/dl overcomes the insensitivity of non-HDL as a marker for atherogenic lipoproteins represented by the VLDL designation while ensuring more aggressive lipid-lowering therapy for Stage 5 CKD patients at high risk for cardiovascular events. Accordingly, non-HDL of 100 mg/dl is proposed as the all-encompassing primary trigger/target of lipid-lowering therapy in high-risk Stage 5 CKD patients, particularly those patients on dialysis in whom lipid samples obtained before dialysis cannot be guaranteed to be fasting.

Olfactory tau pathology in Alzheimer disease and mild cognitive impairment. OBJECTIVE To examine the occurrence of tau pathology in the olfactory system in aged subjects and its relation to the severity of Alzheimer disease (AD) pathology. MATERIAL AND METHODS 273 autopsy cases (167 female, 106 male, aged 61-102, mean 83.2+/-4.5 SD years) underwent a standard neuropathological assessment with immuno-histochemical study of tau and Abeta amyloid in the olfactory bulb and nerve, and diagnosis of AD using established consensus criteria including Braak staging of neuritic AD pathology. RESULTS All cases of definite AD (Braak stages 5 and 6, n = 96) showed large numbers of neuropil threads and neurofibrillary tangles, with amyloid deposits in 50%, and neuritic plaques only in two cases. Braak stage 4 (n = 73) was associated with tau pathology in the olfactory system in 90.4 and amyloid deposits in 9%, Braak stage 3 (n = 56) with mainly mild to moderate olfactory tau lesions in 44.6 and Abeta deposits in 9%. Braak stage 2 (n = 22) showed olfactory tau pathology in 36.4% without amyloid deposits, whereas Braak stages 0 and 1 (n = 25) were all negative. Olfactory tau pathology showed highly significant correlation with neuritic Braak staging in the brain, while both scores showed significant but low correlation with age. CONCLUSIONS These data confirm previous studies demonstrating considerable tau pathology in the olfactory system in all definite AD cases, in more than 2/3 of limbic AD and in more than 1/3 of elderly individuals with or without mild cognitive impairment associated with Braak stage 2. Clinical dementia correlated with both Braak and olfactory tau scores, indicating that both are associated with a high risk of cognitive decline.

Withdrawal from dialysis: a palliative care perspective. A retrospective chart review was conducted in this pilot study of 35 patients who withdrew from dialysis and were followed by a palliative care team. Data included etiology of end-stage renal disease, comorbid illnesses, mode of dialysis and duration, survival time after withdrawal, reason for withdrawal, mental competency, symptom management, and the nature of death. Mean survival time was 10 days. The most frequent symptoms following withdrawal were confusion, agitation, pain and dyspnea. 1/3 of the sample were cognitively impaired at the time of the withdrawal decision. 17% experienced suffering during the withdrawal period, 24% had unrelieved symptoms, 19% psychological distress, while just over 1/3 of patients died alone. With the provision of palliative care, symptom prevalence in the last 24 hours dropped from 53 to 20% for pain, 68 to 33% for agitation and 46 to 26% for dyspnea. Opioids and benzodiazepines were used in the treatment of over 90% of patients. Palliative medicine has the potential to improve the care of patients who discontinue dialysis.

Metformin and antihypertensive therapy with drugs blocking the renin angiotensin system, a cause of concern? BACKGROUND The burden of diabetes mellitus type 2 (DM2) is increasing worldwide. The combination of DM2 and hypertension (HT) is frequently encountered. Concurrent use of drugs blocking the renin angiotensin system (angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB)) and metformin have become frequent in this group of patients. That combination can become life-threatening under certain circumstances. METHOD We present 5 patients with DM2 and HT who developed severe metformin-associated lactic acidosis in a setting with acute renal failure, precipitated by dehydration and aggravated by the use of ACEI or ARB. RESULTS None of the patients had reduced renal function before the acute illness. They were admitted to the hospital in critical condition with severe metabolic acidosis (pH 6.60 6.94), high S-lactate (14 - 23 mmol/l) and S-creatinine 796 1,621 micromol/l. They were all hypothermic and 3 were hypoglycemic. All developed circulatory and respiratory collapse. They were treated with either intermittent bicarbonate hemodialysis (HD) or with continuous venovenous hemodiafiltration (CVVHDF) and bicarbonate buffering. All patients recovered without renal sequela. CONCLUSION We believe that the incidence of metformin-associated lactic acidosis in Norway may become more frequent due to increased use of metformin and drugs blocking the renin angiotensin system. The awareness of lactic acidosis as a complication to the use ofmetformin in predisposed individuals is important. General advice should be given to patients regarding reduction of dosage or withdrawal of the drugs during acute intercurrent illness with dehydration. Early diagnosis and treatment of metformin-associated lactic acidosis are crucial for the patient outcome. Hemodialysis can be life-saving and should be started without delay.

Cholesterol atheroembolic disease in kidney allografts--case report and review of the literature. Cholesterol atheroembolic renal disease is a rare cause of renal allograft dysfunction. Two recipients of cadaveric kidney transplantats from the same donor are discussed with presumed graft failure due to cholesterol emboli of donor origin. A review of the literature summarizes the reported cases in renal transplant recipients. While cholesterol embolization of presumed donor origin seems to have a poor renal outcome, cholesterol emboli originating in the recipient have a more favorable prognosis. As donors and recipients of increasing age or prominent atherosclerosis are accepted for transplantation, cholesterol atheroembolic renal disease may become more prevalent and should be considered in patients with renal allograft dysfunction.

Metabolic alkalosis in a hemodialysis patient--successful treatment with a proton pump inhibitor. Hemodialysis patients develop metabolic acidosis due to their impaired excretion of daily produced protons (H+). The following report will show a rare case of severe metabolic alkalosis (predialysis pH 7.52, base excess (BE) +17) in a hemodialysis woman caused by self-provoked upper gastrointestinal H+ losses based on an eating disorder. Treatment with a proton pump inhibitor resulted in the normalization of acid/base homeostasis (predialysis pH 7.40, BE +1.6).

Immunohistochemical analysis of p53 and p21(WAF1/Cip1) expression in primary intracranial germ cell tumors. Primary intracranial germ cell tumors (GCTs) comprise 3.1% of all brain tumors and 13.6% of those in patients younger than 15 years of age in Japan. They are classified into five basic histological types: germinoma, teratoma, choriocarcinoma, yolk sac tumor, and embryonal carcinoma; or into mixed tumor types when they consist of two or more components. Radiation therapy with or without chemotherapy has proven effective in the treatment of germinoma, whereas there is a poor prognosis for choriocarcinoma, yolk sac tumor, embryonal carcinoma, and mixed tumors having components of the group of malignant intracranial GCTs. The underlying mechanisms for such different responses to radio- and chemotherapies of intracranial GCTs remain unknown. In this study, the authors analyzed the expression of p53 and p21(WAF1/Cip1) proteins by immunohistochemical analysis in 35 intracranial GCTs. Expression of p53 protein was observed in 33 (94%) of 35 intracranial GCTs. Expression of p21(WAF1/Cip1) was detected in seven (20%) of 35 intracranial GCTs. None of the 15 germinomas was immunoreactive for p21(WAF1/Cip1) protein, whereas in a group of malignant intracranial GCTs, four (80%) of five cases showed immunoreactivity for p21(WAF1/Cip1) protein. Analysis of the data suggests that overexpression of p21(WAF1/Cip1) in intracranial GCTs may correlate with decreased sensitivity to radio- and chemotherapy and suggest a poor prognosis.

Expression of CD44 adhesion molecules in intracranial germinomas. Adhesion molecules play a role in tumor growth, invasiveness, and the metastatic process. The expression of CD44 adhesion molecules in 11 intracranial germinoma specimens was investigated using anti-CD44 monoclonal antibody and immunohistochemical methods. In six of 11 specimens studied, CD44 antibodies were bound to the membrane of tumor cells; in five of six specimens, CD44 antigen was also present in the cytoplasm of tumor cells. The only three patients who showed CD44-positive expression in tumor cells, lymphocytes, and extracellular matrix (ECM) exhibited either cerebrospinal fluid dissemination or multiple tumors at different locations. In all 11 specimens, no expression of CD44 in normal glial cells or capillary endothelium was detected. According to the authors' findings, the expression of CD44 in intracranial germinomas is similar to that of gonadal seminomas. Analysis of the results further suggests the possibility that the expression of CD44 in intracranial germinoma tumor cells, lymphocytes, and ECM may contribute to tumor cell migration, adhesion to cerebrospinal fluid dissemination, and/or multiple tumor locations.

Blood to cerebrospinal fluid human chorionic gonadotropin-beta ratios in intracranial germ cell tumors. Levels of human chorionic gonadotropin-beta (HCG-beta) are elevated in up to 43% of patients with intracranial germ cell tumors (GCTs) and are useful in the diagnosis of these tumors and the follow up of such patients. The ratio of blood HCG-beta to lumbar cerebrospinal fluid (CSF) HCG-beta in these patients at presentation has not been defined. Twenty-two patients with intracranial GCTs have been treated at St. Bartholomew's Hospital over the past 15 years. Two (17%) of 12 germinomas and seven (70%) of 10 nongerminomatous GCTs had elevated blood HCG-beta at presentation. Four cases of pineal region GCTs (one of 12 germinomas and three of 10 nongerminomatous GCTs) had paired, elevated, blood and lumbar CSF HCG-beta levels. The mean blood to CSF ratio was 1:10 (range 1.7-18.4), which is substantially lower than the ratio of 286:1 reported in systemic GCTs. The authors confirm the finding of a previous single report showing that ventricular CSF HCG-beta sampling via an accessible ventriculoperitoneal shunt reservoir may give a spuriously negative result, and they discuss the pathophysiology of the blood-brain barrier in the pineal region and the implications of the intrathecal administration of chemotherapy.