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Nutraceuticals are compounds that serve as nutrition with an easy accessibility and favourable safety profile. Recent studies showed their potential activity on osteoarthritis (OA) inflammation and cartilage metabolism. We investigated the effect of methylsulfonylmethane (MSM) and mobilee in human OA chondrocyte cultures exposed to interleukin (IL)-1β. OA cartilage was obtained from femoral heads of five patients undergoing total replacement surgery. Chondrocytes were incubated with mobilee (200 and 500 μM) and MSM (2000 and 6000 μM) in presence of IL-1β (10 ng/mL) and nuclear factor (NF)-κB inhibitor (BAY 11-7082, 1 μM), for 24 and 48 h. Viability and apoptosis were performed by MMT and flow cytometry. The metalloproteinase (MMP)-1,-3,-13 and type II collagen (Col2a1) were analyzed by qRT-PCR and ELISA, and NF-κB activation by immunofluorescence. IL-1β stimulus determined a significant regulation of survival, apoptotic ratio, as well as of gene expression and serum levels of MMP-1,-3,-13 and Col2a1 in OA chondrocytes compared to baseline. Mobilee and MSM incubation significantly reversed the effect of IL-1β. IL-1β significantly induced NF-κB p50 nuclear translocation, which was significantly counteracted by the pre-treatment of OA chodrocytes with the tested compounds. BAY11-7082 significantly modulated MMPs and Col2a1 expression respectively to basal state. Co-treatment of IL-1β with mobilee, MSM and BAY11-7082 didn't cause changes of MMPs or Col2a1 beyond that caused by each single treatment. We demonstrated that MSM and mobilee have a beneficial effect on OA chondrocytes metabolism, probably due to the modulation of NF-κB pathway, providing a powerful rationale for the use of these substances in OA treatment.

Technological instruments may help control paediatric obesity.We tested whether a personalized programme based on the energy expenditure obtained from a wristband (WB) and the energy intake obtained from a smartphone application (APP) is superior to a standard approach at promoting weight loss.We performed a randomized controlled trial in obese children aged 10-17 years. The experimental (EXP) and control (CTR) groups were given a low-energy diet and a prescription for physical activity. The EXP group was equipped with a WB and an APP and given personalized feedback every 7 days. The main outcome was weight loss at 3 months.The mean (standard deviation) z-score of body mass index at the enrollment was 2.20 (0.47) in the EXP (n = 16 out of 23) and 2.09 (0.34) in the CTR group (n = 14 out of 20) of children who completed the trial. The mean (95%CI) difference in weight loss at 3 months was 0.07 kg (95%CI: 2.81 to 2.96) for EXP vs. the CTR.A personalized lifestyle programme based on a WB and an APP was not superior to a standard lifestyle programme at promoting weight loss in obese children.

Precancerous duodenal lesions in patients with familial adenomatous polyposis can be detected with duodenoscopy and treatment may prevent the development of cancer. We proposed to determine the frequency, natural history, cumulative risk, and risk factors of the precancerous duodenal lesions in a series of patients diagnosed in northern Italy. METHODS: A prospective, endoscopic, follow-up protocol was performed in 50 patients examined by gastroduodenoscopy at two years of interval or less. The presence and severity of precancerous lesions of the duodenal mucosa were evaluated by Spigelman score. Twenty-five patients (50 percent) had proctocolectomy and ileoanal anastomosis, 15 (30 percent) had colectomy and ileorectal anastomosis, and 5 (10 percent) had proctocolectomy and definitive ileostomy from 0 to 3 years before the admission to the surveillance program. All patients showed more than a thousand adenomas in the colorectal mucosa. No patients with attenuated polyposis were found. RESULTS: At the first endoscopy, duodenal adenomas could be detected in 19 of 50 patients (38 percent), whereas at the end of the follow-up, 43 (86 percent) had duodenal lesions. The final mean Spigelman score increased during the follow-up period (P < 0.001 respect to baseline values). No duodenal cancer could be detected. Eleven patients had or developed severe precancerous duodenal lesions (Stage IV) treated with endoscopic or surgical resection. The istribution of patients with Stage IV according to the surgery of the colon was: 2 of 25 treated with ileoanal anastomosis and 8 of 15 with ileorectal anastomosis (P = 0.0024, Fisher_s exact test). CONCLUSIONS: Patients with familial adenomatous polyposis are at risk of significant neoplasia. The natural history of precancerous lesions might be related to surgical treatment of colorectal neoplasms.

While there is increasing evidence that non-alcoholic fatty liver disease (NAFLD) may be the most common liver disease in Western countries, its prevalence and risk factors have not undergone a formal evaluation in a representative sample of the general population. We therefore performed a cross-sectional study in the town of Campogalliano (Modena, Italy), within the context of the Dionysos Project. Subjects with suspected liver disease (SLD), defined on the basis of elevated serum ALT and GGT activity, HBsAg or HCV-RNA positivity, were matched with randomly selected subjects of the same age and sex without SLD. A total of 311 subjects with and 287 without SLD underwent a detailed clinical, laboratory and anthropometrical evaluation. Fatty liver was diagnosed by ultrasonography and alcohol intake was assessed using a seven-day diary. Multinomial logistic regression was used to detect risk factors for normal liver vs. NAFLD and for alcoholic fatty liver (AFLD) vs. NAFLD. The prevalence of NAFLD was similar in subjects with and without SLD (25 vs. 20%, p = 0.203). At multivariable analysis, normal liver was more likely than NAFLD in older subjects and less likely in the presence of obesity, hyperglycemia, hyperinsulinemia, hypertriglyceridemia and systolic hypertension; AFLD was more likely than NAFLD in older subjects, males and in the presence of elevated GGT and hypertriglyceridemia and less likely in the presence of obesity and hyperglycemia. We conclude that NAFLD is highly prevalent in the general population, is not associated with SLD, but is associated with many features of the metabolic syndrome.

We present a surgic solution that we adopted in a case of diffuse neoplasia from the upper urinary tract to the bladder and the prostatic urethra.Case67 year-old male, has been submitted to bladder mapping with results of diffuse CIS and sequential immunotherapy with BCG. The three month control had pathological findings of CIS in the bladder and in the prostatic urethra. The staging has shown neoplasia in both kidneys. We had performed a cystoprostatectomy with a bilateral ureterectomy and cleaning of the intrarenal tissue. We had performed a bilateral pyelocutaneous ileal conduit in accord with Holland.ResultsThe kidney parameters at 6 months were normal and the patient was well. The control, in general anesthesia with a pediatric gastroscope, in the pelvis and calyx with x-ray facility, didn't show a recidive in the kidney. Otherwise in annual control a little neoplasia in the right kidney was found. In the successive control at 18 and at 24 months we had found no signs of neoplasia.ConclusionsDespite this extreme case, in which the neoplasia is in all of the urinary tract, it is possible to preserve the kidneys, to have a good oncological result and to preserve the renal function with a good quality of life, to avoid or to delay the bilateral nefrectomy.

Background & Aims: Little data are available on the type and prevalence of mucosal changes involved in the development of ileal adenomas in patients with familial adenomatous polyposis who have undergone colectomy. However, colonic metaplasia of the ileal epithelium is thought to be an important step in the development of such adenomas. Methods: Retrograde endoscopy and biopsy of the distal ileum were performed in 17 affected patients who underwent total colectomy or proctocolectomy 3–184.1 months (mean, 80.3 ± 13.9 months) before the study. Results: Macroscopic ileal polyps were identified in 14 (82.4%) patients. All polyps were sessile and 1–5 mm in size. Histological analysis showed adenomas in 9 (52.9%) patients and lymphoid hyperplasia or inflammation in the others. In 1 patient, an area of colonic-type metaplasia of the ileal mucosa was found close to an adenoma. However, in 5 (29.4%) patients, random biopsy specimens of the normal-appearing mucosa showed foci of abnormal crypts in the absence of metaplasia, with histological appearence similar to the findings described in dysplastic aberrant crypt foci of the colon. Such lesions, previously observed only in colorectal mucosa and referred to as microadenomas or oligocryptal adenomas, are considered putative preneoplastic abnormalities. Conclusions: Although the hypothesized sequence normal ileal mucosa leading to colonic-type metaplasia leading to adenoma cannot be excluded, our findings support the sequence normal ileal mucosa leading to microadenoma leading to gross adenoma and possibly cancer as the main histogenetic pathway, as already suggested for the large bowel.

Purpose of the study : Besides its known effects on bone metabolism, vitamin D may regulate immune function. We performed a randomized controlled trial (RCT) to test whether cholecalciferol supplementation can improve vitamin D status and modulate immune responses in HIV-infected children and youth. Methods: Caucasian vertically HIV-infected patients (aged 8 to 26 years) with vitamin D deficiency and normal parathormone (PTH) levels were randomized into an experimental (n = 25) and control (n = 25) group to receive 100,000 IU of oral cholecalciferol every 3 months for a total of 4 doses, or placebo. A pre-randomization period (-3 months) was also taken into account to better model within-individual variability. Mixed linear regression models were used to evaluate the between-group changes in the outcomes of interest. The analysis was intention to treat. Summary of results: 47 subjects completed the RCT. Cholecalciferol supplementation produced an early decrease in PTH levels (3 months) and a later concomitant increase in 25(OH)D and 1,25(OH)2D levels (6 months), both persisting up to 12 months. The supplementation had no effect on CD4+ T-cell numbers or percentage while was associated with a decreased loge Th1, an increased loge Th2 (*p < 0.05), an increased loge Treg (**p < 0.01), and and a decreased loge Th17:Treg(*p < 0.05). Conclusions : In our cohort, supplementation with oral cholecalciferol was effective in increasing serum 25(OH)D and 1-25(OH) 2 D while decreasing serum PTH levels, had no effect on CD4+ T-cell count, but was associated with T-cell phenotype changes mainly favoring Tregulatory subset. (Published: 11 November 2012) Citation: Abstracts of the Eleventh International Congress on Drug Therapy in HIV Infection Vigano A et al. Journal of the International AIDS Society 2012, 15 (Suppl 4):18231 http://www.jiasociety.org/index.php/jias/article/view/18231 | http://dx.doi.org/10.7448/IAS.15.6.18231

AIM: To determine the efficacy of our therapeutic strategy for Helicobacter pylori (H. pylori) eradication and to identify predictive factors for successful eradication. METHODS: From April 2006 to June 2010, we retrospectively assessed 2428 consecutive patients (1025 men, 1403 women; mean age 55 years, age range 18-92 years) with gastric histology positive for H. pylori infection referred to our unit for 13-C urea breath test (UBT), after first-line therapy with proton pump inhibitor (PPI) b.i.d. + amoxicillin 1 g b.i.d. + clarithromycin 500 mg b.i.d. for 7 d. Patients who were still positive to UBT were recommended a second-line therapy (PPI b.i.d. + amoxicillin 1 g b.i.d. + tinidazole 500 mg b.i.d. for 14 d). Third choice treatment was empirical with PPI b.i.d. + amoxicillin 1 g b.i.d. + levofloxacin 250 mg b.i.d. for 14 d. RESULTS: Out of 614 patients, still H. pylori-positive after first-line therapy, only 326 and 19 patients respectively rechecked their H. pylori status by UBT after the suggested second and third-line regimens. “Per protocol” eradication rates for first, second and third-line therapy were 74.7% (95% CI: 72.7%-76.4%), 85.3% (95% CI: 81.1%-89.1%) and 89.5% (95% CI: 74.9%-103%) respectively. The overall percentage of patients with H. pylori eradicated after two treatments was 97.8% (95% CI: 97.1%-98.4%), vs 99.9% (95% CI: 99.8%-100%) after three treatments. The study found that eradication therapy was most effective in patients with ulcer disease (P < 0.05, P = 0.028), especially in those with duodenal ulcer. Smoking habits did not significantly affect the eradication rate. CONCLUSION: First-line therapy with amoxicillin and clarithromycin produces an H. pylori eradication rate comparable or superior to other studies and second-line treatment can still be triple therapy with amoxicillin and tinidazole.

Although an association between insulin resistance (IR) and body adiposity has been reported in obese children, this relationship has not been studied as thoroughly as in adults.We evaluated the association between oral glucose tolerance testing (OGTT) and percent body fat (PBF) in a sample of 1512 obese children followed at a Pediatric Obesity Clinic.Six hundred and twenty-eight male and 884 female obese children aged 6 to 18 yr were consecutively enrolled into the study. OGTT was performed with administration of 1.75 g of glucose per kg of body weight (up to 75 g). PBF was estimated through bioelectrical impedance analysis (BIA) using a population- specific formula recently published by our group. Multivariable median regression was used to evaluate the association between 4 outcomes [glucose area under the curve (AUC), insulin AUC, insulin sensitivity index (ISI), and insulinogenic index (IGI)] and gender, age or pubertal status and PBF.Median PBF was 52% (range 26 to 70%). After correction for age and gender, a 10% increase of PBF was associated with a decrease of -0.50 [95% confidence interval (CI): -0.65 to -0.35] units of ISI and an increase of 0.15 units of IGI (95%CI 0.07 to 0.24).In obese children, PBF is inversely associated with IR and directly associated to β-cell response as detected by OGTT.

Biochemical predictors of infants' growth changes are not available.We tested whether retinol-binding protein (RBP), docosahexaenoic acid and insulin (I) measured within 72 h from birth are associated with growth changes in infants born to mothers with gestational diabetes mellitus (GDM).Fifty-six children, 32 born to diabetic mothers treated with insulin (GDM-I) and 24 born to diabetic mothers treated with diet (GDM-D), were evaluated at 0, 1, 3, 6 and 12 months of life.At multivariable regression performed using generalized estimating equations, early RBP levels and maternal body mass index were associated to average weight changes and early RBP and insulin levels to average length changes, respectively. There was no difference between GDM-I and GDM-D infants.This exploratory study suggests that early RBP levels may be a predictor of growth changes.

Summary Background & aims Endoscopic submucosal dissection (ESD) was developed for en bloc resection of superficial neoplasm of the digestive tract. We evaluated feasibility and safety of ESD, as a salvage therapy of large refractory rectal polyps, in a tertiary care setting. Methods We prospectively enrolled in the present study and treated by ESD 11 consecutive patients with rectal polyps (median diameter 3.5 cm; range 2–5 cm), who had previously undergone several attempts of endoscopic resection and not suitable for further standard endoscopic treatment. The ESD was carried out with a standard needle knife. Follow up examinations were scheduled at 3, 6, 12 and 24 months. Results We achieved apparently complete resection of polyps in 10/11 patients. In one patient ESD was interrupted and the pathology of the resected fragment showed deep submucosal infiltration; this patient underwent surgery. Deep and lateral margins were shown to be free of neoplasm (radical resection) in six out of 11 patients. However all the 10 patients with apparently complete resection were free of recurrence after a mean follow up of 19.2 months (12–24). A T1 adenocarcinoma was radically resected by ESD, with no recurrence. We recorded 2 cases of subcutaneous emphysema, both treated conservatively. Conclusions Radical resection is difficult to be achieved by ESD in patients with rectal scar-embedded polyps. Nevertheless ESD may be proposed as a definitive treatment of selected patients with refractory polyps, avoiding surgery in the majority of them.

«Esculape» est un systeme de gestion de donnees etabli a l’usage d’unites d’endoscopie digestive travaillant avec un systeme informatique en reseau ou avec un ordinateur personnel de type MS-DOS. Ce systeme permet les activites suivantes: compiler le rapport du diagnostic, des investigations et procedes operatoires des voies digestives superieures — inferieures — bilio-pancreatiques, y compris la laparoscopie, de stocker les donnees d’endoscopie et les donnees cliniques et de les recuperer, de produire automatiquement le rapport, de saisir et de stocker les images en cours d’examen endoscopique et de les traiter simultanement, de fournir l’analyse statistiques des donnees enregistrees, enfin d’enregistrer et de decoder les observations histologiques relatives aux patients. L’elaboration du rapport est simplifiee grâce a l’utilisation de fenetres (windows), de menus a options et de la methode automatique «POP-UP». La terminologie se refere a la 3e edition du systeme OMED et les donnees histologiques sont enregistrees selon les codes SNOMED. Des que toutes les donnees ont ete introduites, un rapport est produit en langage codifie. La production du rapport s’effectue a une vitesse moyenne d’une minute. Actuellement, 170 centres italiens utilisent le programme et 42 % d’entre-eux l’emploient de facon quotidienne pour toutes leurs activites endoscopiques. Le programme est relie au gestionnaire de fichier et d’images ES IMAGE, qui utilise un disque dur de type WORM pour l’archivage des resultats d’examens d’endoscopie digitale ou de radiologie.

Colonic adenomas represent the natural precursor lesions of most colorectal cancers. The treatment of choice is endoscopic polypectomy. However, after endoscopic removal, polyps recur in a large fraction of cases. Thus, we evaluated the effect of antioxidant vitamins or lactulose on the recurrence rate of adenomatous polyps. After polypectomy, 255 individuals were randomized into three groups. Group 1 was given vitamin A (30,000 IU/day), vitamin C (1 g/day), and vitamin E (70 mg/day); Group 2 was given lactulose (20 g/day); Group 3 received no treatment. Forty-six subjects had to be excluded because the histologic diagnosis was not consistent with adenoma. The remaining 209 individuals were included in the analysis according to the "intention to treat" criterion, though 34 did not adhere to the scheduled treatment or were lost during the follow-up. Subjects were followed at regular intervals for an average of 18 months. Polyps recurring before one year from index colonoscopy were considered missed by the endoscopist. In the 209 evaluable subjects, the percentages of recurrence of adenomas were 5.7 percent, 14.7 percent, and 35.9 percent in the vitamins, lactulose, and untreated groups, respectively. The fraction of subjects remaining free of adenomas, estimated by Kaplan-Meier survival curves, was significantly different among the three groups (log-rank chi-squared = 17.138; P < 0.001). Using Cox's regression analysis, treatment was the only variable that significantly contributed to the model (regression coefficient = 0.905; P < 0.001). In conclusion, either antioxidant vitamins or, to a lesser extent, lactulose lower the recurrence rate of adenomas of the large bowel and can be proposed as chemopreventive agents, at least in high-risk individuals.

Generalized gastrointestinal juvenile polyposis is a rare form of diffuse polyposis in which cancer infrequently develops. A clinical case is described in which gastric polyps showed a variety of histological features, including both in situ and invasive adenocarcinoma. Many mixed lesions were observed, confirming a morphological sequence already documented in colorectal tumorigenesis but still undefined in gastric tumors. The patient seems strongly predisposed to gastric cancer, presumably on a genetic basis, because he developed a malignancy in a hyperplastic juvenile polyp, usually not considered a precancerous lesion. There is no doubt that cases like this may be important for accurate genetic evaluation and biological characterization.

Polyposis of the gallbladder is rare during childhood. This condition can be associated with three other conditions: metachromatic leukodystrophy, Peutz-Jeghers' syndrome, and pancreaticobiliary maljunction. We report the case of a child with hemobilia in metachromatic leukodystrophy, which rendered cholecystectomy necessary. Macroscopically, the gallbladder measured 4.6 cm in length and showed an opaque serous surface and focal brown petechiae. Moreover, a yellow polypoid lesion of 2 cm in diameter and a diffuse thickening of the fundus wall were observed. Many reports describe the importance of the association of gallbladder papillomatosis with metachromatic leukodystrophy, but only three cases presented with massive intestinal bleeding, such as our young patient had. It is thus imperative that this life-threatening condition should be well known.

Bleeding is the main complication of oral anticoagulant therapy, and one in five bleeding events occur in patients who are not excessively anticoagulated (1). The most common site of clinically important bleeding is the gastrointestinal tract, especially from peptic ulcers (2). There is unequivocal evidence that Helicobacter pylori is the most important risk factor for peptic ulcer disease, as well as for chronic gastritis (3) and gastric cancer (4). Therefore, we performed a prospective study in anticoagulated patients who had mild or no symptoms of dyspepsia to investigate the prevalence of H. pylori infection, the frequency of H. pylori–associated disease as identified by endoscopy, and the safety of eradication therapy.

Direct evaluation of the compliance with nutritional therapy is possible only in clinical trials while indirect methods such as self-reporting and interviews are used in clinical practice. Dietary history is the best method to evaluate nutritional habits in clinical practice; the same holds true for the compliance with low-protein diets in patients with chronic kidney disease. Other indexes to assess dietary compliance should be simple and easy to use in the clinical practice. Some of such functional and biological markers are blood urea nitrogen and serum phosphate levels (indirect markers of dietary intake), weight and body mass index (indirect markers of energy intake), and daily urinary excretion of nitrogen and sodium (indirect markers of protein and salt intake). The compliance with a low-protein diet in patients with chronic kidney disease is strongly influenced by psychosocial factors (e.g., satisfaction and comprehension), and thus by the supporting role of the physician and the dietitian, but also by the level of renal function and food characteristics. It must be pointed out that even a protein intake reduction of 0.2 g/kg/day improves blood urea nitrogen, phosphate levels, and acidosis.

Endoscopic sphincterotomy (ES) is particulary difficult in patients with previous Billroth II gastrectomy, when a reverse approach to enter and cut the papilla must be used. A further method using a diathermic needle type cutter has been proposed by us in Billroth II patients in 1984. Now we have developed a modified technique, positioning a naso biliary tube in the common bile duct before starting ES. So the sphincterotomy can be performed by a diathermic needle using the catheter as a guide. In this way the risk of perforation of the posterior duodenal wall and of pancreatitis are avoided because the cutting direction and the depth of the section are well controlled maintaining the diathermic needle upward respect to the position of the catheter. Over the last 10 years 2082 ERCP and 1557 ES have been carried out in our Endoscopic Unit. Of these 98 ES have been performed in Billroth II patients. Technical implications and results are described.

To assess the reliability of bioelectric impedance analysis (BIA) for predicting total body water (TBW) and extracellular water (ECW) in children affected by juvenile rheumatoid arthritis (JRA).Thirty-nine children affected by JRA and 23 healthy children of similar age (11.0 +/- 3.6, range 3.0-19.0 y) were recruited for the study.TBW and ECW were measured by deuterium oxide and bromide dilution, respectively. Bioelectric impedance (Z) was measured at frequencies of 5, 50 and 100 kHz. The prediction of TBW and ECW from BIA was based on the impedance index (ZI = height2/Z, cm2/omega).TBW standardized per kg of body weight and ECW standardized per litre of TBW were significantly higher in JRA as compared to control patients (59.7 +/- 2.4 vs 57.7 +/- 2.7% and 44.5 +/- 4.6 vs 38.1 +/- 7.9%, with P0.005 and P0.0001, respectively). Moreover, intracellular water standardized per litre of TBW was significantly lower in JRA than in control subjects (55.5 +/- 4.6 vs 62.5 +/- 8.1, with P0.0001). In both controls and patients, the use of ZI at 5kHz offered the more accurate prediction of ECW. However, the use of ZI at 100 kHz did not offer a better prediction of TBW as compared to its value of 50 kHz. Control-generated formulae for predicting water compartments from BIA [TBW = 0.716 x ZI at 100 kHz-1.504, r = 0.934, s.e.e. = 2.2 l;:ECW = 0.430 x ZI5-3.652, r = 0.869(7) s.e.e. = 1.7 l] underestimated TBW and ECW in JRA patients. However, population-specific formulae [TBW (1) = 0.766 x ZI at 100 kHz-0.053, r = 0.939, s.e.e. = 2.8 l; ECW (l) = 0.399 x ZI at 5 kHz-0.283, r = 0.886, s.e.e. = 1.7 l] allowed an accurate prediction of TBW and ECW in JRA patients, taking into account their altered body water distribution.Altered water distribution impedes the use of formulae developed on healthy children to predict TBW and ECW from BIA and JRA patients. It is hypothesized that chronic inflammation and subclinical malnutrition may be responsible for the altered body water distribution of JRA patients. Traditional body composition models may require adjustments for use in JRA children due to their altered body hydration and water distribution.

Background and goals Extracorporeal shockwave lithotripsy (ESWL) is an established treatment of irretrievable biliary and pancreatic stones, but the cost of the shockwave generators limits its widespread use. We revised data about the effectiveness of our treatment for refractory stones using a transportable shockwave generator. Study We retrospectively evaluated the short and medium-term outcomes of patients who underwent ESWL using a transportable electromagnetic shockwave generator between 1998 and 2003 at our unit, for the treatment of irretrievable bile duct or pancreatic duct stones. All patients received intravenous conscious sedation and antibiotic prophylaxis. Results Complete stone clearance was achieved in 70/82 patients (85.4%), in 66 of the patients (94.2%) with 1 session of ESWL. Despite the insertion of a stent in the bile duct, 2 patients had moderate cholangitis, while they waited for the next ESWL session. We did not record any moderate-severe complication of ESWL, but 2 patients underwent surgery owing to perforation/bleeding during endoscopic removal of residual fragments. A symptomatic recurrence of stones was recorded in 10/69 (14.5%) patients, who had been previously cleared and whose follow-up data (median follow-up 29 mo; range 7 to 66) were available. Conclusions We obtained satisfactory stone clearance by using a transportable shockwave generator. Most patients required 1 session. Our experience confirmed the safety of the treatment, even though patients may experience cholangitis while awaiting definitive treatment. The use of a transportable ESWL generator may be a valuable option in centers, while ensuring a sufficient proficiency in biliary endoscopy.

Although a lot of novel information and data on the epidemiology of hepatitis C virus (HCV) infection are available worldwide, the majority of these information are often fragmentary and sometimes contradictory. This review tries to highlight all the data available on the prevalence (i.e. the number of cases present in a known population), the risk factors, the natural history and the incidence (i.e. the number of new cases that occur every year) of HCV infection in the world, and particularly in Italy.

We have previously shown that a short-term weight (Wt) reduction programme consisting of energy restriction, physical activity and psychological counselling, produces physiological changes of body water distribution (BWD) in obese subjects as detected by bioelectrical impedance analysis. The present study was aimed at testing the contribution of diet and physical activity to the observed changes in BWD. A number of 96 obese inpatients were consecutively enrolled in the study at our Obesity Clinic. During a 3-wk period, they underwent a body Wt reduction programme comprising the same dietary strategy and psychological counselling. The programme differed as far as physical activity is concerned, with 52 subjects randomized to a baseline exercise programme (BEP), 22 to a cardiovascular exercise programme (CEP) and 22 to a cardiovascular and strength programme (CSP). Absolute and percent Wt reduction was significantly higher in CSP than BEP subjects (p0.05) and the same hold for the changes in impedance (Z) at frequencies of 5, 50 and 100 kHz (p0.05). The change in the Z5/Z100 ratio did not show however any between-group difference (p = NS). The average values of Z changes were 1.5 to 2 times higher in CEP and 5.0 to 5.5 times higher in CSP than BEP subjects. We conclude that the type of exercise performed does influence the absolute changes of total body water and extracellular water but not BWD in severely obese subjects undergoing Wt loss.

A giant abdominal stromal cell tumour was diagnosed at endosonography performed for a relatively small gastric submucosal lesion. Although the case is rare, it draws attention to the need for systematic investigations with endoscopic ultrasonography in any submucosal lesion.

The large majority of ingested foreign bodies (FBs) pass through the gastrointestinal tract spontaneously without complications. Thus, treatment has traditionally included an initial period of observation. 1 The overall rate of perforation from foreign objects is estimated at less than 1%. 2, 3 However, when considering sharp objects as a separate group, the rate of perforation increases to 15% to 35%, 4, 5 so that early extraction is usually advocated. After the advent of fiberoptic endoscopy, a wide variety of ingested FBs have been successfully removed from the gut. Nevertheless, a number of severe complications can occur during extraction, especially of sharp objects. 1, 6, 7 Several techniques for safe endoscopic retrieval have been proposed, 7-2° most of which can, however, be used only for the extraction of FBs of fixed size and form. We previously described our preliminary experience in adults and children with a new, commercially available protector device specially designed for the endoscopic removal of sharp FBs of the upper gastrointestinal tract. 21, 22 We report herein our 5-year experience with this device in removing a wide variety of large, sharp-pointed g astroesophageal objects.

World Health Organization has suggested that American standards may be adopted for use in countries where no local reference data are available. Since no locally accepted growth standard is available in Italy, this study investigated if American growth curves for weight, height and triceps skinfold (TSF) provide reliable values for Italian children. Weight, height and TSF were measured in 1273 Italian children (boys: 656, girls: 617) ranging in age from 6 to 12 years and their percentiles were compared with that provided by NCHS for American children. Despite some minor differences, it is shown that American standards can be used safely in Italian children aged from 6 to 12 years.

Ectopic sebaceous glands in the esophagus are a very rare anomaly which have, until now, been described in only 14 living individuals. We describe here the macroscopic, pathological, and clinical features of three new endoscopically diagnosed cases of this benign condition. One of the three patients showed a very high number of lesions (more than 100) distributed throughout the esophagus. A review of the existing literature is presented and the possible pathogenetic mechanisms involved are discussed.

Previous studies have failed to differentiate adenomatous from nonadenomatous diminutive polyps according to their gross macroscopic features at endoscopy. We prospectively evaluated the prevalence, distribution, and predictive value of a recently described morphologic feature-the "disappearing phenomenon"-in diminutive polyps of the distal 20 cm of the large bowel by studying 218 polyps in 90 consecutive patients. Disappearance was graded as complete, incomplete, or absent. Overall, complete disappearance was noted in 93 (43.1%) polyps, with a significantly higher prevalence in the middle and lower rectum (p.05) and among smaller, paler, and smooth-surface polyps (p.001). Incomplete disappearance was detected in both nonadenomas (23.1%) and adenomas (15.8%), but, more importantly, complete disappearance occurred in none of the 19 observed adenomas compared with 93 of 199 nonadenomas. Multiple logistic regression analysis revealed that disappearance was the strongest predictor (p.001) of nonadenomatous histology among considered morphologic criteria. When complete disappearance was used to predict histologic type of diminutive polyps, its sensitivity was 100% and its specificity was 46.7%. In conclusion, the disappearing phenomenon represents a reliable visual marker for identifying nonadenomatous rectal and rectosigmoidal diminutive polyps at endoscopy. Diminutive polyps that disappear completely upon insufflation are invariably nonadenomatous and should not require endoscopic biopsy or removal.

Colonic adenomas represent the natural precursor lesions of most colorectal cancers. The treatment of choice is endoscopic polypectomy. However, after endoscopic removal, polyps recur in a large fraction of cases. Thus, we evaluated the effect of antioxidant vitamins or lactulose on the recurrence rate of adenomatous polyps. After polypectomy, 255 individuals were randomized into three groups. Group 1 was given vitamin A (30,000 IU/day), vitamin C (1 g/day), and vitamin E (70 mg/day); Group 2 was given lactulose (20 g/day); Group 3 received no treatment. Forty-six subjects had to be excluded because the histologic diagnosis was not consistent with adenoma. The remaining 209 individuals were included in the analysis according to the "intention to treat" criterion, though 34 did not adhere to the scheduled treatment or were lost during the follow-up. Subjects were followed at regular intervals for an average of 18 months. Polyps recurring before one year from index colonoscopy were considered missed by the endoscopist. In the 209 evaluable subjects, the percentages of recurrence of adenomas were 5.7 percent, 14.7 percent, and 35.9 percent in the vitamins, lactulose, and untreated groups, respectively. The fraction of subjects remaining free of adenomas, estimated by Kaplan-Meier survival curves, was significantly different among the three groups (log-rank chi-squared = 17.138; P0.001). Using Cox's regression analysis, treatment was the only variable that significantly contributed to the model (regression coefficient = 0.905; P0.001). In conclusion, either antioxidant vitamins or, to a lesser extent, lactulose lower the recurrence rate of adenomas of the large bowel and can be proposed as chemopreventive agents, at least in high-risk individuals.

Endoscopic removal of sharp and pointed foreign bodies in the upper gastrointestinal tract still poses technical difficulties. Overtubes may be uncomfortable to the patients and only objects fitting within a lumen of about 11-15 mm can be removed. We present here our preliminary experience with a commercially available new endoscopic end protector hood having the unique characteristic of maintaining its bell portion inverted during the progression of the scope through the gut and flipping back to its original shape during withdrawal through the lower esophageal sphincter. This prevents exposure of the esophageal and pharyngeal wall to injuries from the edges of the foreign body. We used this device to remove nine large sharp or pointed gastroesophageal foreign bodies in six consecutive patients in whom conventional techniques were considered unsafe or not technically feasible owing to the size and shape of the objects. In all cases, removal was successful and easily performed without bowel damage. We believe that this device enhances the safe removal of a wide variety of potentially dangerous gastroesophageal foreign bodies.

Many changes and advances have been achieved in the last years, so that emergency endoscopy has now a definite role also in the diagnosis and treatment of diseases in childhood. In order to determinate main indications to endoscopic examination, and which are the most useful diagnostic and therapeutic measures that should be performed, we examined the records of 202 patients (aged 1 day-14 years) undergone emergency endoscopy from June 1979 to January 1990. Patients were referred to endoscopy because of foreign bodies or caustic ingestion, hematemesis, and in one patient a suspected intussusception. We didn't record any complication. Our study shows that emergency endoscopy has a definite role also in pediatric age and gives a diagnostic and therapeutic gain in the management of many diseases.

Endoscopy plays an important role in the treatment of complications of biliary stones [3]. An indication for endoscopic sphincterotomy (ES) may also occur in early complications after biliary surgery [23]. The indications for ES in our endoscopy unit over the past 10 years are presented in Table 1; those for patients with choledocholithiasis are listed in Table 2. Indications for emergency endoscopic sphincterotomy are urgent medical conditions that require a prompt, life-saving treatment. Indications for EES in our series are presented in Table 3.