Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with ascites: a meta-analysis

The incidence of spontaneous bacterial peritonitis (SBP) in hospitalized patients with cirrhosis ranges from 7 to 25% [1, 2], with an in-hospital mortality rate ranging from 20 to 50% [1, 3–5]. Prospective studies have shown that the 1-year mortality rate in these patients ranges from 65 to 93% [5]. Recurrence of SBP is common (69% at 1 year) [5]. The most accepted pathogenic mechanism for SBP is the passage of intestinal bacteria into the general circulation and then into the ascitic fluid [6].

Review article: Overview of medical treatments in unresectable hepatocellular carcinoma--an impossible meta-analysis?

BACKGROUND

Controversies surrounding medical treatment in patients with unresectable hepatocellular carcinoma continue to persist.

AIM

To perform a meta-analysis of therapeutic modalities which had been evaluated in two or more randomized trials.

METHODS

Fifty-two randomized trials were studied; only 30 were included. This overview identified seven therapeutic modalities which had been evaluated in two or more trials: adriamycin, 5-fluorouracil, interferon, percutaneous ethanol injection, transarterial chemotherapy, the combination of lipiodol with transarterial chemotherapy, and tamoxifen.

RESULTS

Comparisons of survival between control groups showed substantial heterogeneity. There was no survival benefit at 1 year with adriamycin (mean difference 4%), 5-fluorouracil (mean difference -3%), percutaneous ethanol injection (mean difference 6%) or transarterial chemotherapy (mean difference -2%). For interferon, the survival benefit was significant with the Der Simonian & Laird method (mean difference 9%, 95% CI = 1-18%, P = 0.04) but not with the Peto et al. method (2.4 mean odds ratio, 95% CI = 0.9-6.8). The meta-analysis of tamoxifen showed a borderline survival benefit (mean difference 25%, 95% CI = 0-49%, P = 0.05). However, in sensitivity analyses, the survival benefit of tamoxifen was no longer significant.

CONCLUSIONS

No treatment has clearly proven efficacy in survival. 5-Fluorouracil, adriamycin and transarterial chemotherapy were not associated with survival benefit at 1 year. The number of randomized controlled trials was insufficient to enable a conclusion to be reached for interferon and percutaneous ethanol injection. Controversy persists concerning tamoxifen efficacy. Interferon and tamoxifen require new randomized controlled trials on a larger population of patients.

[Biology of papillomavirus II infections. Their role in the carcinogenesis of the cervix]

The association of human papillomaviruses (HPV), i.e., papillomavirus type 16, with cervical dysplasias and carcinomas is now well established. Additional agents such as sexual behaviour, immunity deficiency, sociodemographic factors, microbiological agents..., are however implicated in the multistage progression from viral infection to cancer. And inactivation of tumor suppressor gene products (p53, p105Rb), oncogene activation (c-myc, c-ras), aneuploidy, karyotypic abnormalities are key events in the tumor progression. Numerous aspects of the biology of human papillomavirus, i.e. natural history, epidemiology, nature and mechanisms of the immune response are under active investigation. Screening strategies of HPV infections (cytology, HPV DNA detection and HPV antibody detection) demonstrated their efficacy in many countries, while prophylaxy and treatment of these infections by vaccines are still under development.

Tissue distribution and metabolism of radioiodinated DTPA0, D-Tyr1 and Tyr3 derivatives of octreotide in rats

Lesions containing somatostatin receptors (SSR) in rats and in man can be visualized in vivo using radiolabeled octreotide (OCT) analogs. SSR scintigraphy was initially performed with [123I-Tyr3]OCT and later with [111In-DTRA0]OCT. With the latter the residence time of radioactivity (111In) in SSR-positive targets is prolonged, most probably due to the DTPA group. Therefore, we hypothesized that its presence might also affect the metabolism of radioiodinated DTPA-OCT analogs. [D-Tyr1]OCT, [DTPA0, D-Tyr1]OCT, [Tyr3]OCT and [DTPA0,Tyr3]OCT were synthesized, and all 4 showed high and specific binding to the SSR in vitro, with IC50 values in the nanomolar range. The rate of internalization of the 4 radioiodinated OCT analogs by mouse AtT20 pituitary tumors cells was in accordance with the IC50 values. The metabolism and tissue distribution of the 4 radioiodinated analogs were investigated in rats at 4, 24 and 48 hours pi, and the tissue vs blood ratios were calculated. High uptake of all OCT analogs was found in the somatostatin receptor-positive tissues at 4 hours, but only remained high at 24 and 48 hours with [125I-D-Tyr1]OCT and [DTPA0,125I-D-Tyr1]OCT. Kidney uptake of [125I-D-Tyr1]OCT and [DTPA0,125I-D-Tyr1]OCT was also high. Blood clearance and disappearance from muscle was rapid for all 4 analogs. Urinary excretion of [125I-D-Tyr1]OCT, [DTPA0,125I-D-Tyr1]OCT,[125I-Tyr3]OCT and [DTPA0, 125I-Tyr3]OCT amounted to 63%, 67%, 31% and 80% of injected dose respectively. [DTPA0,125I-D-Tyr1]OCT showed highest tissue to blood ratio and residence time in SSR-positive tissues, such as adrenals (ratio: 31, 79, and 66 at 4, 24 and 48 hours respectively) and pancreas (ratio: 14, 48 and 44 at 4, 24 and 48 hours respectively).

CONCLUSION

The position of the Tyr residues and the addition of the DTPA group greatly influence the biodistribution of radioiodinated [Tyr]OCT analogs.

Randomized comparative multicenter study of hydroxyethyl starch versus albumin as a plasma expander in cirrhotic patients with tense ascites treated with paracentesis

OBJECTIVE

Large-volume paracentesis associated with plasma volume expansion with albumin is an effective, safe, but costly therapy for ascites in patients with cirrhosis. The aim of this study was to compare the use of a synthetic plasma expander, hydroxyethyl starch (HES), with that of albumin.

DESIGN

Sixty cirrhotic patients with ascites were studied. Patients were randomly assigned to be infused with either albumin (8 g/l of ascites removed, n = 33) or HES (200 ml/l of ascites removed, n = 27). None of the patients was treated with diuretics or had renal impairment or hyponatremia at entry. Clinical and laboratory data were obtained before and 1, 3 and 15 days after treatment.

RESULTS

There were no significant differences in clinical and laboratory parameters between the two groups at entry into the study. None of the patients developed renal impairment during the trial. One patient (HES group) presented with hyponatremia. Plasma atrial natriuretic factor and aldosterone levels did not differ between the two groups at baseline or at 1 and 3 days after paracentesis. The volume of ascites removed did not differ between the albumin (7.9 +/- 4.4 l) and HES (6.9 +/- 5.3 l) groups. However, there was a significant difference in weight loss between the albumin and HES groups (7.9 +/- 5.2 kg vs 4.7 +/- 3.4 kg; p = 0.01). Clinical and laboratory parameters indicated that HES was well tolerated except for hypoalbuminemia.

CONCLUSION

HES is well tolerated in patients with cirrhosis. There is no difference between HES and albumin in the prevention of complications related to large-volume paracentesis. The lesser degree of weight loss observed with HES needs further study.

[Biology of papillomavirus infections. I. General characteristics]

Papillomaviruses are pathogens which induce cutaneous and mucosal lesions in man and in many animal species. The characterization of these viruses was rather low, because viral infection cannot be fully reproduced in cell culture. The development of molecular biology techniques in the 1970s permitted to establish the remarkable plurality of the viruses, the tissue specificity and pecular pathogenicity linked to the type. Studies of the genome organization, the gene expression regulation and the protein characterization gave many informations leading to understand the mechanisms of viral-related carcinogenesis, especially the role of HPV16, the major risk factor for the development of squamous cervical carcinoma.

Are aluminium potroom workers at increased risk of neurological disorders?

OBJECTIVE

To determine whether long term potroom workers in an aluminium smelter are at increased risk of neurological disorders.

METHODS

Cross sectional study of 63 current and former aluminium potroom workers first employed before 1970 and with at least 10 years of service. A group of 37 cast house and carbon plant workers with similar durations of employment and starting dates in the same smelter were used as controls. The prevalence of neurological symptoms was ascertained by questionnaire. Objective tests of tremor in both upper and lower limbs, postural stability, reaction time, and vocabulary were conducted. All subjects were examined by a neurologist.

RESULTS

No significant differences in age, race, or education were found between the two groups. Although the potroom group had higher prevalences for all but one of the neurological symptoms, only three odds ratios (ORs) were significantly increased; for incoordination (OR 10.6), difficulty buttoning (OR 6.2), and depression (OR 6.2). Tests of arm or hand and leg tremor in both the visible and non-visible frequencies did not show any significant differences between the two groups. Testing of postural stability showed no definitive pattern of neurologically meaningful differences between the groups. There were no significant differences between the two groups in reaction time, vocabulary score, or clinical neurological assessment.

CONCLUSIONS

The objective measures of neurological function provided little support for the finding of increased neurological symptom prevalences in the potroom workers, although increased symptoms may be an indicator of early, subtle neurological changes. The results provide no firm basis for concluding that neurological effects among long term potroom workers are related to the working environment, in particular aluminium exposure, in potrooms. These findings should be treated with caution due to the low participation of former workers and the possibility of information bias in the potroom group.

Myocardial and vascular adrenergic alterations in a rat model of endotoxin shock: reversal by an anti-tumor necrosis factor-alpha monoclonal antibody

OBJECTIVES

a) To investigate responsiveness to exogenous catecholamines in rat endotoxin shock by studying both myocardial and vascular functional parameters, and to determine the relationship of these parameters with other relevant biological parameters of the adrenergic pathway, such as myocardial beta-adrenergic receptors and cyclic adenosine monophosphate (cAMP); b) to investigate the role of tumor necrosis factor (TNF)-alpha via prophylactic anti-TNF-alpha monoclonal antibody administration.

DESIGN

Experimental, comparative hospital.

SETTING

Laboratory in a university hospital.

SUBJECTS

Male Sprague-Dawley rats, weighing 280 to 340 g.

INTERVENTIONS

Intravenous injection of Escherichia coli endotoxin (5 mg/100 g) in the first group; injection of the same dose of endotoxin preceded by 2 mg/100 g of anti-TNF-alpha monoclonal antibody in the second group; injection of saline in the third (control) group.

MEASUREMENTS AND MAIN RESULTS

TNF-alpha concentration was measured before and during the first 3 hrs in all three groups. Myocardial and vascular functional parameters were obtained, respectively, from Langendorff perfused hearts and isolated aortic rings. Adrenergic biochemical parameters (catecholamines, density and affinity of beta-receptors, and isoproterenol-stimulated myocardial cAMP) were determined 3 hrs after injections in the three groups. After endotoxin injection, serum TNF-alpha concentrations peaked at 60 mins (2496 +/- 412 pg/mL) and returned slowly to control values at 3 hrs; serum TNF-alpha concentrations remained under the limit of detection in the other two groups. When compared with the control group, plasma concentrations of epinephrine and norepinephrine were significantly (p < .05) increased. Baseline values for differential left ventricular pressure and coronary flow were significantly (p < .001, p < .01, respectively) reduced in the endotoxin group; heart rate remained unchanged. In the endotoxin and control groups, isoproterenol induced a similar increase in differential left ventricular pressure and in heart rate. Anti-TNF-alpha antibody increased cardiac response by partially preventing the decrease by endotoxin in differential left intraventricular pressure. Maximal specific binding of 125iodocyanopindolol and myocardial cAMP accumulation were significantly (p < .01) reduced in the endotoxin group in comparison with the control group. Anti-TNF-alpha antibody prevented the endotoxin-induced decrease in cAMP synthesis (p < .05) but did not modify the density of receptors. Affinity of receptors was similar in the three groups. In aortic rings, endotoxin administration significantly (p < .01) shifted the dose-response curve to norepinephrine to the right, both in the presence and absence of endothelium. NG-monomethyl-L-arginine significantly increased the contractions to attain the control level: p < .001 in the presence of endothelium; p < .05 in the absence of endothelium. Anti-TNF-alpha antibody did not prevent endotoxin-induced vascular hyporeactivity to norepinephrine in either endothelium-intact or -denuded rings, but partially attenuated the decrease in maximal response.

CONCLUSIONS

In ex vivo experiments, 3 hrs after endotoxin injection, vascular responsiveness was sharply decreased. This impaired response was improved in vitro by the inhibition of nitric oxide. The heart response to isoproterenol, nevertheless, was maintained, even though there was an obvious decrease in receptor density and an impaired myocardial accumulation of cAMP. Anti-TNF-alpha antibody partially prevented the alteration of both myocardial pressure response to isoproterenol and biochemical parameters, and was not efficacious in preventing vascular hyporeactivity to vasoconstrictor agents.

Propranolol and sclerotherapy in the prevention of gastrointestinal rebleeding in patients with cirrhosis: a meta-analysis

BACKGROUND/AIMS

A meta-analysis of nine selected randomized trials was performed to compare the effects of propranolol and sclerotherapy in the prevention of rebleeding and on survival in patients with cirrhosis.

METHODS

Five end points were assessed: rebleeding, esophageal rebleeding, death, death due to bleeding, and adverse events. Analyses were performed according to the intention-to-treat method. For each end point, heterogeneity and treatment efficacy were assessed by the Der Simonian and Peto methods. When a significant difference was observed, sensitivity analyses were performed by successive stratification according to treatment duration, type of publication, severity of cirrhosis, and methodological quality.

RESULTS

The mean percentage of patients free of rebleeding, the mean survival rate and the mean percentage of patients free of death from bleeding were not significantly different between patients treated with propranolol and those treated by sclerotherapy. The mean percentage of patients free of variceal rebleeding was 39% in propranolol group and 55% in sclerotherapy group (mean difference: 17%, 95% confidence interval: 9-25%, p < 0.001). The mean percentage of patients free of adverse events was significantly higher in the propranolol group than in the sclerotherapy group (mean difference: 22%, 95% confidence interval: 6-38%, p < 0.007).

CONCLUSION

In patients with cirrhosis and esophageal varices, endoscopic sclerotherapy is more effective than propranolol in preventing variceal rebleeding, but the incidence of adverse events is significantly higher with sclerotherapy. There was no difference in survival between the treatments. Propranolol should be considered as a first choice treatment for preventing rebleeding.

[Recurrent lower digestive hemorrhage in young adults: a surgical indication]

The cause of low digestive bleeding remains unknown despite numerous investigations in less than 15% of cases. The case of a 22-year-old young female who presented 3 episodes of low digestive bleeding during a 25 months period, without any cause identified despite numerous investigations, is presented. Laparoscopy performed to establish a diagnosis showed a large Meckel's diverticulum which was removed. In adults, Meckel's diverticulum causes uncommonly symptoms and are revealed by an episode of digestive bleeding in less than 10% of cases. After several episodes of low digestive bleeding, a surgical procedure can be proposed, by coelioscopy better than laparotomy, to look for Meckel's diverticulum. This observation shows that this attitude, recommended in children, can be proposed also in young adults.

Beta-adrenergic antagonists in the prevention of gastrointestinal rebleeding in patients with cirrhosis: a meta-analysis

A meta-analysis of 12 selected randomized trials was performed to assess the efficacy of beta-blockers in the prevention of rebleeding and the effect on long-term survival in patients with cirrhosis. Five end points were assessed: rebleeding, variceal rebleeding, death, death from bleeding, and adverse events. Analyses were performed according to the intention-to-treat method. For each end point, heterogeneity and treatment efficacy were assessed by the Der Simonian and Peto methods. When a significant difference was observed, sensitivity analyses were performed by successive stratifications according to treatment duration, cause of initial bleeding, use of placebo, type of beta-blocker, type of publication, certainty of randomization, severity of cirrhosis, interval between index bleed and randomization, and methodological quality. Beta-blockers significantly increased the mean percentage of patients free of rebleeding (21% mean improvement rate, CI 95%: 10%-32%, P < .001, relative risk 1.42), the mean percentage of patients free of variceal rebleeding (20% mean improvement rate, CI 95%: 11%-28%, P < .001), the mean survival rate (5.4% mean improvement rate, CI 95%: 0%-11%, P = .05, relative risk 1.27), the mean percentage of patients free of bleeding death (7.4%, CI 95%: 2%-13%, P < .01, relative risk 1.50). Five patients would need to be treated with beta-blockers to prevent one rebleeding episode, 14 treated to prevent one death, and 13 treated to prevent one death from bleeding. There was no significant heterogeneity among studies by both methods of analysis. In patients with esophageal varices, beta-blockers significantly increase the mean percentage of patients free of rebleeding and the mean survival rate at 2 years.

Beta-adrenergic antagonists in the prevention of gastrointestinal rebleeding in patients with cirrhosis: a meta-analysis

A meta-analysis of 12 selected randomized trials was performed to assess the efficacy of beta-blockers in the prevention of rebleeding and the effect on long-term survival in patients with cirrhosis. Five end points were assessed: rebleeding, variceal rebleeding, death, death from bleeding, and adverse events. Analyses were performed according to the intention-to-treat method. For each end point, heterogeneity and treatment efficacy were assessed by the Der Simonian and Peto methods. When a significant difference was observed, sensitivity analyses were performed by successive stratifications according to treatment duration, cause of initial bleeding, use of placebo, type of beta-blocker, type of publication, certainty of randomization, severity of cirrhosis, interval between index bleed and randomization, and methodological quality. Beta-blockers significantly increased the mean percentage of patients free of rebleeding (21% mean improvement rate, CI 95%: 10%-32%, P < .001, relative risk 1.42), the mean percentage of patients free of variceal rebleeding (20% mean improvement rate, CI 95%: 11%-28%, P < .001), the mean survival rate (5.4% mean improvement rate, CI 95%: 0%-11%, P = .05, relative risk 1.27), the mean percentage of patients free of bleeding death (7.4%, CI 95%: 2%-13%, P < .01, relative risk 1.50). Five patients would need to be treated with beta-blockers to prevent one rebleeding episode, 14 treated to prevent one death, and 13 treated to prevent one death from bleeding. There was no significant heterogeneity among studies by both methods of analysis. In patients with esophageal varices, beta-blockers significantly increase the mean percentage of patients free of rebleeding and the mean survival rate at 2 years.

Familial Creutzfeldt-Jakob disease with a five-repeat octapeptide insert mutation

We report a familial form of Creutzfeldt-Jakob disease, associated with a unique insert mutation of the PRNP gene in an American family of Ukrainian origin. Ten family members exhibited early age at onset and long-duration illnesses characterized primarily by personality changes, cognitive impairment, and spasticity. The proband, presenting at age 42 years, exhibited a fairly stable, nonprogressive course over 7 years, followed by precipitous decline and death in the eighth year. Other affected family members exhibited marked clinical heterogeneity. Each tested affected member had an insert mutation consisting of five extra octapeptide repeats between codons 51 and 91 of the PRNP gene on chromosome 20. Examination of two autopsy cases showed classic spongiform change, neuronal loss and astrocytosis in one case, and minimal pathologic abnormality in the other case. This report documents a new insert mutation of the PRNP gene, and confirms the early age of onset, characteristically prolonged clinical course, and clinical and pathologic heterogeneity seen in such mutations.

Cyclosporin A-mediated cholestasis in patients with chronic hepatitis after heart transplantation

Viral chronic hepatitis often occurs in heart transplant recipients receiving cyclosporin. This essential immunosuppressive drug may induce cholestasis. We investigated the effect of treatment with cyclosporin on serum conjugated bile acids in patients with chronic hepatitis developing after heart transplantation. Fifty-nine patients were studied: 17 with chronic hepatitis, 15 heart transplant patients with normal alanine aminotransferase activity, and 27 heart transplant patients with chronic hepatitis, the last two groups receiving cyclosporin. Hepatic biochemical tests and total bile acid concentration were determined on fasting blood samples. The individual glyco- and tauroconjugated bile acids were quantified by high-performance liquid chromatography and direct spectrometry. In patients taking cyclosporin the bilirubin concentration and the alkaline phosphatase activity were increased only when hepatitis was present, in association with a slight increase in cholic acid level (5.13 microM vs. 0.68 microM; P < 0.01). Conjugated lithocholate concentration was dramatically higher when hepatitis and immunosuppression with cyclosporin were associated (1.17 microM vs. 0.03 and 0.04 microM; P < 0.01). Chenodeoxycholate was the main circulating bile acid only in the heart transplant patients treated with cyclosporin but without hepatitis. These results suggest that the mechanisms which explain the cyclosporin-associated modifications of the bile acid pool are different according to the presence or absence of hepatitis. The occurrence of hepatitis in patients on cyclosporin led to an increase in serum lithocholate and primary bile acid concentrations. Further studies are required to assess the effect of ursodeoxycholic acid for this cholestasis.

Prognostic significance of bacterial infection in bleeding cirrhotic patients: a prospective study

BACKGROUND/AIMS

In cirrhotic patients, bacterial infection is frequently associated with gastrointestinal bleeding and seems to increase mortality. The aims of this study were to determine the incidence of bacterial infections in bleeding cirrhotic patients and the influence of infections on the risk of rebleeding and death.

METHODS

Cirrhotic patients admitted for gastrointestinal bleeding who had not received antimicrobial chemotherapy in the previous 7 days were included. Blood, urine, and ascitic fluid cultures were systematically performed 1, 2, 4, and 7 days after admission.

RESULTS

Sixty-four patients were enrolled. Forty-two bacterial infections were documented in 23 patients (36%) within 7 days of admission. In patients with bacterial infection, mean Child-Pugh score and mean number of blood units transfused were significantly higher, early rebleeding was more frequent (43.5% vs. 9.8%; P < 0.01), and 4-week mortality was higher (47.8% vs. 14.6%; P < 0.01). Multivariate analysis only identified bacterial infections as predictive of early rebleeding (P < 0.02) and a high Child-Pugh score as predictive of death (P < 0.001).

CONCLUSIONS

In bleeding cirrhotic patients, bacterial infections only increase the risk of early rebleeding, and mortality is related to the severity of cirrhosis.

Fluconazole penetration in cerebral parenchyma in humans at steady state

We studied fluconazole penetration in the brain in five patients who had a deep cerebral tumor whose removal required the excision of healthy brain tissue. Plasma and brain samples were simultaneously obtained after oral ingestion of 400 mg of fluconazole daily for 4 days (90% of steady state). Fluconazole penetration in healthy cerebral parenchyma was determined. Plasma and brain samples were assayed by high-pressure liquid chromatography. Concentrations in plasma and brain tissue were 13.5 +/- 5.5 micrograms/ml and 17.6 +/- 6.6 micrograms/g, respectively. The average ratio of concentrations in the brain and plasma (four patients) was 1.33 (range, 0.70 to 2.39). Despite the lack of data concerning the penetration of fluconazole in brain abscesses, these results should permit the use of a daily dose of 400 mg of fluconazole in prospective clinical studies that evaluate the effectiveness of this drug in the treatment of brain abscesses due to susceptible species of fungi.

Job task and psychosocial risk factors for work-related musculoskeletal disorders among newspaper employees

OBJECTIVES

A cross-sectional study was conducted to assess the association of upper extremity musculoskeletal disorders and work-related factors among employees using video display terminals at a large metropolitan newspaper.

METHODS

The study included 1050 randomly selected workers from four departments. The workers were asked to complete questionnaires on symptoms, job tasks, and psychosocial and work organization conditions. Musculoskeletal disorders of the upper extremities were defined by frequency, duration, and intensity of symptoms not attributable to acute injury. Data were analyzed with the use of logistic regression.

RESULTS

A total of 973 workers completed the survey. The one-year period prevalence rate for any musculoskeletal disorder of the upper extremities was 41%. Neck symptoms (26%) were the most frequently reported, followed by hand or wrist (22%), shoulder (17%), and elbow (10%) symptoms. Greater time working at the video display station was associated with increased hand or wrist symptoms in a dose-response relationship. In addition, variables corresponding to increased work-load demands (eg, increased time working under deadline and increased job pressure) were associated with increased neck, shoulder, and hand or wrist disorders. Women were more likely to report symptoms in several areas, but this finding may reflect the concentration of women in jobs involving more risk factors.

CONCLUSIONS

The results suggest a high prevalence of musculoskeletal disorders of the upper extremities among newspaper employees, and they provide additional evidence that increased work load, time pressure, and greater hours of computer use are related to the occurrence of work-related musculoskeletal disorders among these workers, particularly for disorders in the hand or wrist area.

Transport of thyroxine into cultured hepatocytes: effects of mild non-thyroidal illness and calorie restriction in obese subjects

OBJECTIVE

Inhibitors of cellular T4 transport leading to diminished plasma T3 production have been identified as 3-carboxy-4-methyl-5-propyl-2-furanpropanoic acid (CMPF) and indoxyl sulphate in uraemia and bilirubin and non-esterified fatty acids (NEFA) in critically ill patients with hyperbilirubinaemia. We question whether other factors are responsible for the altered thyroid hormone parameters observed in mild illness and during calorie restriction.

PATIENTS

We studied (i) 18 non-uraemic patients with non-thyroidal illness (NTI) (T4 > or = 60, T3 < or = 1.1 and rT3 > or = 0.45 nmol/l) with serum molar ratios of bilirubin:albumin < or = 0.17 and NEFA:albumin < or = 2.6. These molar ratios have been shown to be the minimum ratios which inhibited T4 transport into rat hepatocytes; (ii) four obese euthyroid subjects on 600 kcal/day for 10-14 days. This diet is known to inhibit the unidirectional T4 transport into human liver in vivo.

MEASUREMENTS

We measured iodide production from 125I-T4 by incubating rat hepatocytes with 10% human serum. The deiodination of T4 was used as an index of cellular transport of T4 in vivo.

RESULTS

The mean iodide production from 125I-T4 by rat hepatocytes in the presence of 10% serum from NTI patients (98 +/- 17%, mean +/- SD) was not significantly different from the normals (100 +/- 9%). Calorie restriction in euthyroid obese subjects resulted in a small but significant reduction (-12%) of iodide production. Calorie restriction increased the total serum NEFA by 91%.

CONCLUSIONS

Our study demonstrates that CMPF, indoxyl sulphate, bilirubin and NEFA are not responsible for the inhibition of T4 tissue uptake in patients with mild illness. In addition, studies with calorie restricted obese subjects indicate that high concentration of NEFA during calorie restriction inhibits T4 tissue uptake. This inhibition may partly explain the lower plasma T3 during calorie restriction.

Grand mal seizures as a complication of treatment with pefloxacin in patients with cirrhosis. A report of three cases

In this paper, three cases of grand mal seizures are reported as a complication of pefloxacin at usual doses (400 mg twice a day) in patients with cirrhosis. Grand mal seizures occurred from 12 h to 8 days after the onset of pefloxacin treatment. In 1 case, seizures recurred after inadvertent rechallenge with the drug. Elevated pefloxacin serum levels were demonstrated in 2 cases. Brain computed tomography in all 3 cases and cerebrospinal fluid examination showed normal results. No etiology other than pefloxacin overdose was found. After pefloxacin withdrawal, no recurrence of seizures were observed. Therefore, when pefloxacin treatment is indicated for cirrhotic patients, a reduced dosage and/or careful monitoring of pefloxacin serum levels should be recommended.

Inhibition of thyroxine transport into cultured rat hepatocytes by serum of nonuremic critically ill patients: effects of bilirubin and nonesterified fatty acids

We investigated bilirubin and oleic acid as causes of low plasma T3 in nonuremic critically ill patients with gross changes in serum thyroid hormone levels (T4, < or = 60; T3, < or = 1.1; rT3, > or = 0.45 nmol/L) and elevated bilirubin concentrations (> or = 33 mumol/L). Iodide production from [125I]T4 was inhibited by 42% when rat hepatocytes in primary cultures were incubated with 10% serum from these patients. The mean serum concentration of albumin was reduced by 41%, while the concentrations of bilirubin and nonesterified fatty acids (NEFA) were increased by 2022% and 115%, respectively, in the patients. The molar ratios of bilirubin/albumin and NEFA/albumin in the patients were 0.42 and 3.18, respectively. Addition of oleic acid (50-400 mumol/L) and bilirubin (3-130 mumol/L) to 10% normal human serum (albumin, 70 mumol/L; NEFA, 54 mumol/L; bilirubin, 1.1 mumol/L) progressively inhibited the production of iodide by rat hepatocytes. The decreased iodide production was presumed to be caused by inhibition of T4 transport into hepatocytes. The deiodination of rT3 by rat liver microsomes was unaltered by free bilirubin and free oleic acid concentrations up to 0.1 mumol/L. These free concentrations are at least 1 order of magnitude higher than that attained in nonthyroidal illness. The inhibition of iodide production by the sera of critically ill patients (n = 12) was significantly correlated with the molar ratios of bilirubin/albumin (r = 0.72; P < 0.01) and NEFA/albumin (r = 0.58; P < 0.05). Extensive dialysis or treatment of the sera with charcoal did not completely remove the inhibitory activity on iodide production. Serum concentrations of indoxyl sulfate, 3-carboxy-4-methyl-5-propyl-2-furan propanoic acid, and hippuric acid in the critically ill patients (other known T4 transport inhibitors into hepatocytes) were similar to those in the normal subjects. This study together with the well known effects of carbohydrate on T3 neogenesis suggest that elevated bilirubin and NEFA and the low albumin level in non-uremic critical illness may be at least partly responsible for the T4 transport inhibition in T3-producing tissues (e.g. the liver) and, thus, the low plasma T3 levels in these critically ill patients. The question of whether inhibitors of T4 transport into the hepatocytes are also present in other patients with nonthyroidal illness who show only mild changes in thyroid hormone levels and have low concentrations of bilirubin and NEFA remains to be determined.

Spontaneous dialytic ultrafiltration with intraperitoneal reinfusion of the concentrate versus large paracentesis in cirrhotic patients with intractable ascites: a randomized study

Dialytic ultrafiltration of ascites through a hemofilter associated with peritoneal reinfusion (DUF) of the concentrate has been proposed for the treatment of refractory ascites. In five cirrhotic patients, 18 ascites evacuation procedures were randomized either to DUF (n = 8) or to large paracenteses (LP) (n = 10). The effects of these two methods on hemodynamic and renal function were assessed. After DUF, the protein concentration in ascites increased transiently from 28 +/- 7 g/l to 64.8 +/- 8 g/l (p less than 0.04); urinary output increased from day 1 to day 4 (1000 +/- 100) VS 1430 +/- 140 ml/24h; p less than 0.02). After LP, ascitic protein concentration and urinary output were unchanged. No side effects were observed with the two methods. The mean amount of albumin infused was 20 +/- 15 g after DUF and 15 +/- 5 after LP (ns).