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A standing posture including various ankle positions might effectively facilitate pelvic floor muscle activity (PFMa) in incontinent women, and an ankle dorsiflexion (DS) at 15 degrees was identified as the best position able to increase PFMa. Nevertheless, this ankle inclination is very uncomfortable. We carried out this study aiming at identifying smaller ankle inclinations able to significantly affect PFMa in incontinent women reducing patient discomfort.Twenty women, not yet entered menopause and with mild-moderate uncomnplicated stress urinary incontinence, were enrolled. An electromyographic (EMG) biofeedback instrument using surface electrodes was employed to measure changes in PFMa while each patient assumed the following different ankle inclinations in upright position: horizontal standing (HS); DS at degrees (5DS), 10 degrees (10DS) and 15 degrees (15DS); and ankle plantar flexion (PS) at 5 degrees (5PS), 10 degrees (10PS) and 15 degrees (15PS).No EMG differences were found between HS and PS. PFM tension in DS, at whatever angle, was significantly greater than in both HS (P0.020) and PS (P0.040). No differences were found between IODS and 15DS in terms of resting PFMa. Concerning maximal PFMa, it was higher in 10DS than in 15DS (P = 0.010), and in 5PS than in both 5DS (P = 0.006) and 15DS (P = 0.010); no EMG differences were found between 5PS and 10DS.These preliminary results showed that 10DS in upright standing had comparable effects on resting PFMa than 15DS with same effectiveness and less patient's discomfort, facilitating a better maximal contraction. Moreover a slight PS might effectively facilitate maximal PFMa.

To evaluate the prevalence of psoriatic arthritis (PsA) in Italian patients with psoriasis and to compare the Moll and Wright criteria, the European Spondylarthropathy Study Group (ESSG) criteria, and Amor criteria when applied to this patient population.We examined 205 unselected patients with psoriasis. The diagnosis of PsA was based upon the clinical experience of a rheumatologist. After, we tested these classification criteria. HLA class I and II antigens were also analyzed.Thirty-six percent (75) of psoriatic patients were considered by a clinical expert to have PsA. Moll and Wright criteria identified 46 patients (22%) with PsA; 49 patients (24%) were identified by ESSG criteria and Amor criteria; 12 patients identified by Amor criteria but not by ESSG criteria presented enthesitis or dactylitis; 10 patients identified by ESSG but not by Amor criteria had peripheral synovitis. In patients with peripheral arthritis and psoriasis, the evaluation of NSAID response was critical to fulfilling Amor criteria. However, it was not easy to retrospectively evaluate NSAID response using these criteria. The sensitivity was low for each of the 3 classification criteria (from 61 to 65%), whereas the specificity was high (from 99 to 100%).Our study confirms a high prevalence of PsA among an unselected population of Italian patients with psoriasis. Our data reveal the inadequacy of the existing criteria for PsA, including the ESSG criteria and Amor criteria for the classification of spondyloarthropathy.

Objective. To examine consecutive patients with Whipple’s disease (WD) for the full clinical spectrum of spondyloarthritis. Methods. Nine consecutive patients, 8 men, 1 woman, with WD were clinically evaluated and examined for clinical and radiological manifestations of spondyloarthritis by 2 rheumatologists with special interest in spondyloarthritis. The mean age of the patients at the time of study and at the time of their initial diagnosis of WD by duodenal biopsy was 62.4 years (range 42–71) and 54.4 years (range 40–62), respectively. Each patient had an anteroposterior radiographic view of the pelvis and also had HLA typing for class I and II alleles. Pelvis radiographs were read blindly for evidence of sacroiliitis. Results. All but one patient had rheumatologic manifestations related to WD. The mean interval between the onset of these symptoms and the diagnosis of WD was 6.1 years (range 1–15). One had recurrent polyarthritis, 1 recurrent oligoarthritis, 3 recurrent monoarthritis, 2 recurrent synovitis with pitting edema of the dorsum of hands and/or feet, and 1 isolated De Quervain’s tenosynovitis. Of the 5 patients with arthritis, 3 also had episodes of swelling with pitting edema over the dorsum of hands and/or feet together with flexor digit tenosynovitis, 2 also had olecranon bursitis, and 1 tibial tenosynovitis. No patient had clinical or radiological manifestations of spondyloarthritis. None had the HLAB27. Conclusion. In Italian Caucasian patients with WD there was no association with spondyloarthritis and HLA-B27.

We performed retrospective analysis of 141 Northern Italian patients with rheumatoid arthritis (RA). This series represents all the patients seen as in and/or outpatients at the rheumatologic unit of Reggio Emilia Hospital during a 2 year period (1987-88). We observed a low frequency of nodules (16%) and vasculitis (2.1%). Thus, RA seems to be milder in our population compared to Caucasian patients with RA originating from North America or England. We observed a weak association with DR4 (RR = 2.4) in the total group of patients with RA. A low frequency of DR4 was observed in patients and controls (29 vs 14.5%, p = 0.001). When compared with controls the frequency of DR4 was significantly higher in seropositive (p = 0.001), but not in seronegative patients. We found that DR4 was significantly associated with nodules (RR = 6.4), with extraarticular features (EAF) (RR = 4) and with erosions (RR = 3) compared with controls. The subgroups with nodules and EAF had a DR4 frequency (respectively, of 52 and 40%) which was significantly higher than that observed in remaining patients (respectively, 25 and 24%). No significant difference was observed in the DR4 frequency between the patients with erosions and those without (34 vs 18%). Thus, DR4 in our population seems to be predominantly associated with a subgroup of patients characterized by seropositivity and EAF.

Pigmented or "black" cortical adenoma is a rare variant of the compact or eosinophilic cell type of adrenal gland cortical adenoma. Usually it is non functioning so representing an incidental finding at autopsy, but rare cases producing Cushing's syndrome or hyperaldosteronism have been reported. The simultaneous occurrence of a cortical adenoma and pheochromocytoma in the ipsilateral adrenal gland is an extremely rare event, which has been so far described only seven times with the cortical adenoma always being of the usual yellow or clear cell type. So far no case of "black adenoma" associated with a proliferative condition of the ipsilateral adrenal medulla has ben described.A case of functioning pigmented ("black") cortical adenoma in a male patient affected by Cushing's syndrome associated with asymptomatic medullary nodular hyperplasia in the ipsilateral adrenal gland is described. The results of light microscopy, histochemistry, immunohistochemistry, and electron microscopy studies are presented. It is worthy of note the finding of two types of pigment granules (lipofuscin type, neuromelanin type) observed at elecatron microscopy.The authors underline the difficulty of classifying adrenal medullary nodules and the arbitrarity usually adopted in separating nodular adrenal medullary hyperplasia from early neoplasia (pheochromocytoma). Thus nodular medullary hyperplasia in this case could also be interpreted as an early neoplastic condition. The case herein presented is the first report of a combined cortico-medullary proliferative process in which a "black" adenoma is involved.

The aim of our study was to determine whether the enhancement pattern of pancreatic adenocarcinoma at contrast-enhanced ultrasonography (CEUS) is related to patient prognosis after resection. CEUS of 42 resected adenocarcinomas were retrospectively reviewed. Tumors were divided into two groups: group A=poorly vascularized (presence of avascular areas) or group B=well vascularized (absence of avascular areas). All lesions were resected and underwent pathological examination assessing tumor differentiation as: undifferentiated (poorly differentiated) or differentiated (moderately and well differentiated). Mean vascular density (MVD) was also evaluated. CEUS enhancement and pathology were correlated (Spearman's test). Survival was analyzed with the Kaplan-Meier method. Multivariate analysis was performed with the Cox regression model. There were 30 differentiated and 12 undifferentiated adenocarcinomas at pathology. At CEUS, 10 lesions were poorly vascularized, whereas 32 lesions were well vascularized. Positive correlation was observed between CEUS groups and tumoral differentiation (rs=0.51; p=0.001) and between CEUS and MVD (rs=0.74; p0.0001). Median survival in patients with group A vascularization at CEUS was significantly lower than in group B (p=0.015). Cox proportional hazard model revealed the presence of poorly vascularized tumor at CEUS (p=0.0001) as a predictor of higher mortality. In conclusion, CEUS enables accurate depiction of the vascularization of adenocarcinoma, with positive correlation to histology grade and MVD.

Antibodies to liver/kidney microsome type 1 occur in Italian patients with hepatitis C, but rarely develop in North American patients. Our goals were to compare the frequencies of the HLA markers associated with autoimmune expression in Italian and North American patients with chronic hepatitis C and to determine genetic bases for regional differences in antibody production. HLA B8, DR3, DR4, DR7, DR11, DR13, DQ2, and the B8-DR3-DQ2 haplotype were determined by microlymphocytotoxicity and polymerase chain reaction in 105 Italian patients (50 with microsomal antibodies), 100 North American patients (none with microsomal antibodies), and Italian and North American healthy control subjects. Italian patients with microsomal antibodies differed from North American patients without these antibodies by having a higher frequency of HLA DR7 (54% vs. 27%, P=0.002). HLA DR7 occurred more frequently in seropositive Italian patients than in seronegative counterparts (54% vs. 11% P < 0.0001), Italian healthy control subjects (54% vs. 29%, P=0.0009), and North American healthy control subjects (54% vs. 19%, P < 0.0001). The frequency of HLA DR7 was similar in North American patients and controls (27% vs. 19%, P=0.2), but it was lower than in Italian controls (19% vs. 29%, P=0.059). Seropositive Italian patients had a lower frequency of HLA DR11 than seronegative Italian patients and Italian controls (18% vs. 34%, P=0.07, and 18% vs. 35%, P=0.02, respectively). In contrast to seropositive Italian patients, North American patients had HLA DR4 (30% vs. 12%, P=0.02), HLA DR13 (29% vs. 10%, P=0.01), and the B8-DR3-DQ2 haplotype (23% vs. 6%, P=0.01) more often. Similarly, HLA DR4 and the B8-DR3-DQ2 phenotype were more frequent in North American patients than in Italian controls (30% vs. 16%, P=0.005, and 23% vs. 7%, P=0.00002, respectively). HLA DR7 is associated with the development of microsomal antibodies in Italian patients with chronic hepatitis C. The lower frequency of HLA DR7 in North America could contribute to the rarity of these antibodies in this region. HLA DR11 may be protective against the development of microsomal antibodies in Italian patients, whereas HLA DR4, HLA DR13, and the B8-DR3-DQ2 haplotype may be protective in North American patients.

Although studies on the use of the somatostatin analogues in the elective pancreatic surgery are mostly prospective, double blind and randomised, the results are contradictory and not univocally interpretable. Through the examination of all randomised perspective works published on this subject, a critical interpretation is attempted which may give relevant suggestions for further studies. A new clinical, randomised, double blind and multicentric prospective trial should take into proper consideration even the changes which have occurred in the care of the patients. Over the years a significant decrease of postoperative hospital stay and a deeper awareness of the medical expenses have been observed. Moreover, since the drug has a potential advantage on specific pancreatic complications, only these must be considered among the end points of the study and the population studied will be limited exclusively to patients who underwent resection of the pancreatic head or of the periampullar region because of neoplastic disease. Finally, the selection of the centres that enrol the patients must be considered, since the expertise of each operator or of the team, affects, as an independent variable, both morbidity and mortality.

The aim of the present study is to assess whether or not there has been improvement in the therapeutic strategy for body-tail pancreatic carcinoma over the past decade.A total of 215 patients suffering from cytologically and histologically documented ductal carcinoma in the pancreatic body-tail, observed from 1990 to 1999, were analysed. Changes in tumour stage at diagnosis, in the percentage of patients treated surgically, in resectability rates and in the use of anticancer therapies over the years were sought. Survival curves were evaluated in relation to the treatments adopted.Over the 10-year period, no significant differences were observed with respect to the stage at diagnosis, resectability or type of surgery adopted. There was a significant increase in the percentage of unoperated patients (p < 0.0001) and, as expected, in the percentages of patients submitted to chemo- and/or radiotherapy (p < 0.0001). With the sole exception of tumour stage in the case of patients undergoing radiotherapy, a comparison between groups revealed no element of patient selection bias other than time. The survival of patients undergoing chemotherapy is significantly better, also at multivariate analysis, than that of patients not undergoing such therapy (13 vs. 5.8 months; p < 0.0001).There has been no change over the years in the direction of earlier diagnosis and the prognosis remains distinctly poor. More extensive use of anticancer therapies, however, has led to a significant increase in median survival. Radical resection, when possible, assures the longest survival.

Only limited prospective data are available regarding the long-term outcome of local resection of the pancreatic head in combination with longitudinal pancreaticojejunostomy in patients with chronic pancreatitis. From 1997 to 2001, 40 patients affected by chronic pancreatitis were subjected to the Frey’s procedure. Preoperative selection criteria included confirmed diagnosis of chronic pancreatitis, dilation of Wirsung’s duct to a diameter greater than 6 mm, and the absence of obstructive chronic pancreatitis secondary to fibrotic stenosis at the pancreatic body or tail. Preoperative pain was present in 38 cases (95%), and follow-up was performed in all patients at least once Yearly up to 2003 (median 60 months, inter percentile range 20.1-79.6). Postoperative morbidity occurred in three cases (7.5%). The percentage of pain-free patients was 94.7%, 93.7%, 87.5%, and 90% at 1, 2, 3, and 4/5 Years after surgical operation, respectively. After surgery, three patients developed diabetes. Both the body mass index and quality of life showed statistically significant improvements at all follow-up intervals. Whenever surgery is indicated, the short-term and long-term outcomes confirm that Frey’s procedure is an appropriate means of management for patients with chronic pancreatitis in the absence of doubts of neoplasia and/or distal ductal obstruction.

Background Pancreatic metastases from renal cell carcinoma are rare but highly resectable. The aim of this study was to review a series of patients with this condition. Methods The study involved 22 consecutive patients with histologically proven pancreatic metastases from renal cell cancer. Results Seventeen of the 22 patients had surgery. No patient died but eight of the 17 patients had a postoperative complication. Median follow-up was 33 (range 1–96) months. The 24- and 60-month survival probabilities were 0·84 and 0·53 respectively. Five patients who did not undergo surgery had 24- and 60-month survival probabilities of 0·53 and 0·26 respectively. The difference between the two groups was significant (P = 0·040). Conclusion Despite the slow development of these secondaries and their well encapsulated morphology, the high rate of recurrence after limited resection suggests that radical resection should be recommended.

SummaryCeliac disease (CD), a malabsorption disorder of the small intestine, results from ingestion of gluten. The HLA risk factors involved in CD are well known but do not explain the entire genetic susceptibility. To determine the localization of other genetic risk factors, a systematic screening of the genome has been undertaken. The typing information of 281 markers on 110 affected sib pairs and their parents was used to test linkage. Systematic linkage analysis was first performed on 39 pairs in which both sibs had a symptomatic form of CD. Replication of the regions of interest was then carried out on 71 pairs in which one sib had a symptomatic form and the other a silent form of CD. In addition to the HLA loci, our study suggests that a risk factor in 5qter is involved in both forms of CD (symptomatic and silent). Furthermore, a factor on 11qter possibly differentiates the two forms. In contrast, none of the regions recently published was confirmed by the present screening.