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Unlabelled: Abdominal blunt trauma is the main cause of death in people younger than 40 years old. The liver injury still represents a challenging problem. Isolated hepatic injury is rare and it occurs more frequentely in polytraumatizated patients and causes massive haemoperitoneum. The Authors report a case of a 83 years-old woman admitted to Emergency Department for syncope due to an active bleeding arising from a rupture of a right hepatic lobe unsuspected tumor. The computer tomography (CT) scans showed a clear pattern of liver laceration of the VI segment with contrast enhancement spreading in the surrounding tissues, and detected a multifocal hepatocarcinoma located in the VI, VII and VIII segments. Patient's haemodinamically unstable conditions suggested an urgent laparotomy. An accurate perihepatic packing with sterile-drape were successfully employed to control liver hemorrage. Temporary abdominal closure, followed by hepatic arteriography and the right hepatic artery embolization, completed the damage control. Re-exploration laparotomy after 72 hours confirmed the definitive haemostasis and the pack removal was performed without complications., Conclusions: CT plays a leading role in the diagnosis of liver damage. The patient's haemodynamic status is the principal criterion determining conservative or operative therapy in blunt liver injury. The early perihepatic packing followed by artheriographic embolization to stop liver hemorrhage showed efficacy and safety for the patient. The packing performed with sterile-drape is able to avoid removal complications and 72 hours timing for the pack removal is effective to avoid re-bleeding.

Hepatocellular carcinoma (HCC) is the most common malignancy of the liver and the third most common cause of cancer mortality worldwide. The major risk of developing HCC is associated with HBV and HCV hepatitis. Liver transplant (LT) is the gold standard for "small" HCC (HCCs) in Child-Pugh class A cirrhotic patients. However its use has been restricted by the severe shortage of donors, so that hepatic resection (HR) is often performed in these patients. In the last two decades image-guided interventional catheterization and ablative regional treatment procedures have revolutionized the therapy of unresectable primary and secondary liver tumors. The Authors present a case of a 61-years old man with Child-Pugh class A HCCs. The age and the previous history of bladder carcinoma made the patient not suitable for LT. The patient refused HR so that transarterial chemoembolization combined to thermo-ablation therapy and oral intake of tamoxifen were proposed. Patient's tolerance to the treatments has been good. During 11-year follow-up there was earlier intrahepatic progression of the tumor followed by reduction in size and number of the lesions. In spite of the scarce prognosis, chemoembolization and immunotherapy allowed to achieve a satisfactory local control of disease in our patient and guaranteed a good quality of life at long-term follow-up.

Uterine carcinosarcoma is a highly aggressive neoplasm with tendency to early recurrence and/or metastasis. The neoplasia has both epithelial and stromal malignant components. Clinically, it is characterized by a postmenopausal metrorrhagia, associated sometimes with abdominal pain. The Authors describe a case of carcinosarcoma in a 82-year old woman with a vaginal bleeding since 10 months and an ingravescent hypochromic anemia. The RMN of the abdomen and pelvis showed a mass occupying the whole uterine lumen, without signs of pelvic diffusion. A bilateral hystero-oophorectomy was performed; the patient's critical conditions and a high anaesthesiological risk advised us not to perform a bilateral pelvic lymphadenectomy with aortic sampling. Six months after operation, a clinical follow-up with a total-body CT didn't show any sign of local recurrence and/or distant metastasis. From the analysis of this case report and from the data of the literature some important considerations can be done: a) gynecologic check up in post-menopausal women with associated risk factors (obesity and hypertension) can allow an early diagnosis also in asymptomatic patients; b) sovrapubic and transvaginal US, abdomino-pelvic CT and MRI are essential for a correct clinical staging; c) surgical excision followed by the histological examination of the specimen is mandatory to establish a correct diagnosis.

Purpose: This study was designed to assess the long-term results of stapled hemorrhoidopexy in 291 patients with Grade III and Grade IV hemorrhoids after a minimum follow-up of five years., Methods: Records of patients submitted to stapled hemorrhoidopexy for Grade III and Grade IV hemorrhoids between January 1999 and December 2002 were retrospectively analyzed. Long-term outcome was evaluated with a standardized questionnaire and an office visit, including anorectal examination and rigid proctoscopy., Results: A total of 291 patients with Grade III (57.4 percent) and Grade IV (42.6 percent) hemorrhoids were evaluated. Intraoperative (20.3 percent) and postoperative (4.8 percent) bleeding was the most frequent complication. The questionnaire was submitted to all patients at a median follow-up of 73 (range 60-93) months. There were no symptoms related to hemorrhoids in 65.3 percent of patients, moderate symptoms in 25.4 percent of patients, and severe symptoms in 9.3 percent of patients. Fifty-three (18.2 percent) patients had recurrence. Reoperation was necessary in 21 (7.2 percent) patients (4 in Grade III hemorrhoids and 17 in Grade IV hemorrhoids; P < 0.001), with no recurrent symptoms and/or prolapse. Patient satisfaction for operation was 89.7 percent., Conclusions: Stapled hemorrhoidopexy is a safe and effective treatment for Grade III and Grade IV hemorrhoids. Recurrence requiring reoperation was higher in Grade IV hemorrhoids than in Grade III hemorrhoids.

Familial polyposis coli is a heterogeneous disease with a broad spectrum of clinical manifestations including not only multiple polyposis of the small bowel, but also multiple primary tumours, such as carcinoma of the ampulla of Vater, subcutaneous tumours, bone tumours, central nervous system tumous and gynaecological malignancies. This report is of two brothers with familial polyposis, each showing peculiar distinctive features. In one case, polyposis was diagnosed during emergency surgery for ileo-colic intussusception. The patient later developed a tumour of the uterine cervix. Polyposis coli was identified late in the second patient who showed an evolution towards colonic adenocarcinoma with multiple hepatic metastases. The possible association of familial polyposis and extracolonic malignancies has already been emphasized in the literature. In this report we wish to stress the advisability of periodic gynaecological check-ups in affected patients.

Background and Study Aims: This study was undertaken to compare the efficacy, side effects and patient acceptance of standard 4-liters polyethylene glycol (PEG) and 2 doses of sodium phosphate (NaP) solution for precolonoscopy colon cleansing., Patients and Methods: A total of 182 patients were randomized to receive either standard 4-L PEG (88 patients) or 80 mL of NaP (94 patients) in a split regimen of two 40 mL doses separated by 24 h, prior to colonoscopic evaluation. The primary endpoint was the segmental assessment of colonic wall visualization. Secondary outcomes included percent of assumed preparation, and the patient tolerance and acceptability., Results: A significantly higher completion rate was found in the NaP group compared to the PEG group (84.3% vs 62.9%; difference, 21.40%; 95% confidence interval [CI], 8.29% to 34.51%; p = 0.001). PEG solution caused more nausea than NaP solution (p = 0.024). Patient acceptance for bowel preparation with NaP was greater (p = 0.019). Adequate colon wall visualization was achieved in similar proportion of patients in both groups with exception of the descending colon, where NaP regimen was superior (72.0% vs 52.9%; difference, 19.10%; 95% CI, 5.20% to 33.00% ; p = 0.012)., Conclusions: Two doses of NaP solution, taken 24 h and 12 h before colonoscopy, tend to guarantee superior results in colonic cleansing with respect to standard 4-liters PEG solution. Taking the second dose of NaP 24 h after the first dose reduces side effects and allows achieving a more satisfactory compliance of the patient.

Carcinosarcoma is a rare tumor of the uterus with a poor prognosis. We present a case of uterine carcinosarcoma in an 82-year-old woman who suffered from pervaginal bleeding for ten months duration with progressive anemia. Abdominopelvic nuclear magnetic resonance (NMR) imaging showed the presence of an intrauterine mass, infiltrating the myometrium and reaching the cervix. The patient was submitted to total abdominal hysterectomy with bilateral salpingo-oophorectomy. The carcinosarcoma, arising from the lumen of the uterus, infiltrated the inner one-third of the myometrial layer (pT1b, pNx, pMx; FIGO Stage 1B). A CT of the total body performed six months after surgery showed no signs of recurrent and/or metastatic tumor. The clinicopathological features, treatment options and prognosis of this aggressive neoplasm are reviewed.

The Authors report a rare case of a 57 years old man affected by a left radial nerve schwannoma that occurred as an asymptomatic lesion of the axilla. At clinical examination the lump was undistinguishable from the most common axillary lymphadenopathy. A lymphoadenopathy was erroneously diagnosed with ultrasonography (US). This mistake was due to the low specificity of the instrumental methodology and to the rarity of an asymptomatic schwannoma of the infraclavicular brachial plexus. The neoplasia was excised without using the microscope. In the early post-operative follow up, a "falling" attitude of the wrist, the hand and the fingers appeared, peculiar for a lesion of the radial nerve. Furthermore a hypoaesthesia of the skin of first finger and of the first interosseus space was associated. The sensitive and motor electromyography showed a radial nerve suffering. The "stupor" of the nerve trunk was treated with steroid therapy for 7 days and the patient underwent to some series of neuro-rehabilitative physical therapy for 12 weeks. The postoperative total body CT, showed that the lesion was unique: therefore it was possible to exclude the diagnosis of neurofibromatosis. After 28 months electromyography and axillary US were performed showing the complete resolution of the motor and sensitive deficit and the absence of local recurrence.

We present a case of sigmoid colon injury after blunt abdominal trauma. The patient was submitted to sigmoid resection with primary end-to-end colo-colic anastomosis. He died 22 days after operation with septic shock and acute respiratory failure. Post-mortem examination showed left lung generalized pneumonia with no signs of intra-abdominal pathology; colo-colic anastomosis was intact. We reviewed the literature about the management of this rare trauma.

The aim of this study was to evaluate the role of the pulmonary vessel endothelium in the metabolism of fibrinogen (FBG), by measuring the FBG, D-dimer, and fibrin(ogen) degradation product levels in the blood from pulmonary and radial arteries from 99 patients undergoing aortocoronary bypass. For comparison, protein C, protein S, and factor VII, were also measured. The results showed, with respect to the pulmonary arterial blood levels, significantly lower FBG levels (3.72 +/- 0.83 vs 3.66 +/- 0.81 g/L; P < .001) and higher fibrin(ogen) degradation product levels (7.36 +/- 1.53 vs 8.15 +/- 1.59 mg/L; P < .000 01) in the radial arterial blood. No difference was found for d -dimer, protein C, protein S, and factor VII. The study demonstrated that the pulmonary capillary endothelium contributes to the FBG catabolism for about a 0.02 fractional rate and support the view of an endothelial FBG catabolic pathway as the main catabolic pathway, owing to the fact that the pulmonary endothelial surface is about a 0.1 fraction of the peripheral vessel endothelial surface.

Background: The finding that expression of metalloproteinases (MMPs) is induced in atherosclerotic plaques prone to rupture suggests the possibility that patients with atherosclerotic diseases would show enhanced blood levels of MMPs and that MMPs might represent a potential inflammatory risk factor for atherosclerosis. Therefore, the present study was aimed at verifying whether MMPs may represent sensitive markers of inflammation in patients with coronary artery disease., Methods: MMP-2, MMP-9, interleukin (IL)-6, C-reactive protein (CRP), and fibrinogen levels were measured in blood samples obtained from 66 cases with previous acute myocardial infarction and 66 control subjects similar for age, sex, and major atherosclerotic risk factors but without history or evidence of atherothrombotic diseases., Results: Biohumoral markers of inflammation and MMP-9 levels were significantly elevated in cases compared with controls (median values 40.6 versus 9.8 ng/mL; p < .0001), whereas MMP-2 levels did not differ between the two groups (median values 839 versus 873 ng/mL; p = .53). A direct correlation was found among MMP-9, CRP, IL-6, and fibrinogen levels. Conditional logistic regression analysis showed that MMP-9 is related to myocardial infarction (p = .006) even after adjusting for cardiovascular medications and CRP., Conclusion: These findings suggest that measurement of serum MMP-9 levels may represent a novel marker of inflammation in patients with known coronary artery disease and might provide an index of plaque activity in this clinical setting.

Using isolated bovine brain microvessels as an in vitro model of the blood-brain barrier (BBB) we have evaluated the role of free radical generating solutions on some amino acid transport systems operating on the endothelial cell membrane. Fe(2+)/ascorbate, phenylhydrazine and CuSO(4) did not affect any of the transport system tested, while exposure of bovine brain microvessels to tert-butylhydroperoxide (t-BHP) caused a reduced capacity to take up small neutral amino acids via the Na(+)-dependent A-system. The presence of glucose during t-BHP treatment did not prevent this inhibition, which was partially counteracted when the isolated microvessels were incubated with 5mM inosine before the oxidative stress. Incubation of the isolated capillaries with 5mM dithiothreitol, after exposure to t-BHP, resulted in a 50% recovery of the alpha-methylaminoisobutyrate (MeAIB) uptake by the A-system. Treatment with t-BHP, which had no effect on the L-system of neutral amino acid transport, caused a significant decrease of the intracellular levels of ATP, of glutathione (GSH), and of gamma-glutamyltranspeptidase (GGT) activity, while no significant modification of hexokinase (HK) or of alkaline phosphatase (ALKP) activities were observed. Oxidative damage of the BBB appears therefore to impair essentially the metabolic pathways which ensure the energy requirement for the endothelial cells, thus inhibiting the energy-dependent amino acid transport system "A".

In isolated brain microvessels, used as an in vitro model of the blood-brain barrier, the rate of hypoxanthine uptake was modulated by the presence of inorganic phosphate. A single high-capacity, low-affinity transport system was apparently active in a phosphate-free medium (Vmax = 840 pmol/mg protein/min, Km = 750/uM); in the presence of 10 mM phosphate, there was also a low-capacity, high-affinity system (Vmax = 47 pmol/mg protein/min, Km = 27/uM). The phosphate-dependent component was inactive in the absence of glucose or of Na+ ions, or upon addition of phloretine (but was scarcely affected by 2,4-dinitrophenol). This activity was apparently coupled to the intracellular phosphoribosyltransferase-catalyzed conversion of purines into the corresponding nucleotides: when inorganic phosphate was present in the suspending medium, labeled hypoxanthine was transported with higher efficiency and was readily converted to inosine monophosphate and to other related nucleotides. In the absence of phosphate ions, hypoxanthine was instead metabolized to xanthine and uric acid.

The functionality of isolated brain microvessels - used as anin vitro model of the blood-brain barrier - can be influenced by interaction with cationic proteins. The various polylysines (Mr ranging from 0.9 to 180 kDa) tested affected the activity of both the Na(+)-dependent ("A") and the Na(+)-independent ("L") systems for neutral amino acid transport. Exposure to the 180 kDa polylysine caused a conspicuous inhibition of both transport systems, associated to an increased passive permeability. There was a constant, Mr-dependent, inhibition of the the L-system-mediated uptake of hydrophobic neutral amino acids. The activity of the A-system was enhanced, upon exposure to polymers larger than 22 kDa reaching its peak at 68 kDa and and declining at higher Mr values. The effect which was Na(+)-ions dependent and abolished by phloretine, could be essentially ascribed to an increased affinity of the MeAIB for its carrier (Km value decreasing from 265 to 169µM in presence of 68 kDa polylysine).

The polar long-chain amino acids glutamine and methionine can be transported across the endothelial cells of brain microvessels either by an L-system which operates by a facilitated diffusion, exchanging mechanism, or by a concentrating, energy-dependent A-system. The presence of glutamine and/or of methionine can induce a synergism between the two transport systems which results, by a transstimulation mechanism, in a net increased uptake of neutral hydrophobic aminoacids. The methionine analog S-methylthiocysteine, which is the mixed disulfide resulting from the combination of methanethiol with cysteine, behaves similarly to methionine in stimulating the uptake of neutral hydrophobic amino acids. The same transstimulating effect can even be obtained in collagenase-treated, A-system-deprived microvessels by inducing the direct formation of S-methylthiocysteine within the cytoplasmic compartment of the endothelial cells.

Abnormalities in lipid metabolism have been widely described in cancer-bearing patients and animals. In particular, the presence of the tumor seems to profoundly affect triglyceride (TG) utilization by interfering with lipoprotein lipase (LPL) activity. Exogenous TG plasma clearance was evaluated in 10 nonmalnourished patients with cancers of various origin and 10 normolipidemic volunteers by means of a three-stage intravenous lipid clearance test. This technique allows precise determination of both the fractional removal rate (K2) and the maximal clearing capacity (K1) for exogenous lipids. Mean K2 values (min-1) were found to be significantly reduced in cancer patients compared with control subjects (0.07 +/- 0.006 vs 0.13 +/- 0.013 SEM, p less than 0.005). K1 values (mumol/L/min) were also found to be significantly lower in cancer patients than in the control group (109.43 +/- 6.3 vs 143 +/- 6.3 SEM, p less than 0.01). The data obtained indicate that the capacity to eliminate exogenous lipids from the bloodstream is reduced in cancer-bearing patients. This may be the consequence of a tumor-related impairment of LPL system activity.

Eighteen untreated cancer patients and ten sex- and age-matched healthy volunteers were studied. In all patients eating behavior was investigated by means of a specific questionnaire from which the presence of anorexia and anorexia-related symptoms was assessed. To investigate the role of tryptophan in cancer anorexia, fasting plasma and CSF levels of tryptophan and other neutral amino acids were assayed in patients and controls. Cancer patients showed abnormally high plasma free tryptophan levels. In case of patients with cancer anorexia a significant rise of the ratio in plasma between free and tryptophan/large neutral amino acids, competing with tryptophan for its brain entry, was observed. This increase was correlated to a consistent rise of CSF tryptophan levels suggesting a specific role of the serotoninergic system in the pathogenesis of cancer anorexia.

The neurological disorders seen in patients with chronic renal failure and liver cirrhosis are analogous. Previous in vivo studies have shown that the impaired blood-brain amino acid transport seen in rats with chronic renal failure is similar to that of rats with portocaval anastomosis. To elucidate whether a comparable underlying pathogenic mechanism plays a role in both pathological conditions, blood and brain amino acid levels together with amino acid transport by isolated brain microvessels have been studied in rats with chronic renal failure and in sham-operated rats. Brain microvessels isolated from rats with experimental chronic renal failure showed that the uptake of labeled large neutral amino acid, i.e., leucine or phenylalanine, but not of lysine or alpha-methylaminoisobutyric acid, was significantly increased with respect to sham-operated rats; conversely, the uptake of glutamic acid in rats with chronic renal failure was significantly lower compared with values in controls. Kinetic analysis indicated that this was mainly due to increased exchange transport activity (Vmax) of the L-system, rather than to changes in the affinity (Km) of the carrier system for the relative substrate. These data, together with the significant rise of brain glutamine levels and an increased brain-to-plasma ratio of the sum of large neutral amino acids, are analogous to what was previously observed in rats with portocaval anastomosis.(ABSTRACT TRUNCATED AT 250 WORDS)

A correlation between anorexia and brain levels of serotonin and tryptophan (TRP) has been reported in tumor-bearing animals. In the present investigation 45 patients with various types of cancer and 13 control subjects were studied. Prior to the study the patients had received no antineoplastic therapy and were unaware of the malignancy of their disease. Feeding behavior was investigated by means of a questionnaire in which the presence of anorexia (A), aversion to meat (MA), taste (TA) or smell (SA) alterations, nausea and/or vomiting (NV) and early satiety (ES) was assessed. Plasma levels of free TRP, the other neutral amino acids (NAA), albumin and non-esterified fatty acids (NEFA) were assayed. Plasma-free TRP was significantly increased in anorectic cancer patients. The free TRP/competing NAA ratio, which might better predict brain TRP levels, was significantly higher in patients with A, MA, TA, SA, NV and ES than in controls or in non-anorectic (NA) cancer patients. These findings seem to confirm that free TRP may play an important role in human cancer anorexia.

Nineteen obese female subjects with body mass index ranging between 30 and 40 were included in a double-blind crossover study aimed at evaluating the effects of oral 5-hydroxytryptophan administration on feeding behavior, mood state and weight loss. Either 5-hydroxytryptophan (8 mg/kg/day) or placebo was administered for five weeks during which patients were not prescribed any dietary restrictions. Feeding behavior was investigated by means of a questionnaire designed to establish the onset of anorexia and related symptoms. Food intake was evaluated using a three-day diet diary. BDI, SI, STAI-T, and STAI-S were used to assess mood state. The administration of 5-hydroxytryptophan resulted in no changes in mood state but promoted typical anorexia-related symptoms, decreased food intake and weight loss during the period of observation.