A case of pegylated interferon alpha-related diabetic ketoacidosis: can this complication be avoided?

We report the case of a 42-year-old woman with chronic hepatitis C (genotype 1), who in June 2004 started therapy with pegylated interferon alpha (PEG-IFNalpha) plus ribavirin. Two months later, she discontinued treatment because of polydipsia, polyuria and vomiting leading to a marked dehydration. Biochemical data showed type 1 diabetes mellitus with ketoacidosis, and insulin therapy was started. The patient, who before starting PEG-IFN alpha plus ribavirin therapy tested negative for glutamic acid decarboxylase antibodies (GADAb) and islet cell (ICAb) antibodies, became strongly positive for both autoimmune markers. This case confirms that patients with chronic hepatitis C who do not have baseline markers of pancreatic autoimmunity may develop severe ketoacidosis during treatment with PEG-IFNalpha, as well as with standard IFNalpha. In order to avoid this complication, as no guidelines are available and the pancreatic autoimmunity markers are not routinely analysed, we suggest frequent monitoring (e.g., every one to two weeks) of glycaemic values: e.g., every one to two weeks during the first 3 months (when this complication occurs most frequently) and monthly thereafter so as to identify diabetes at an early stage and before the onset of the appearance of severe ketoacidosis, which is life-threatening.

Hand-assisted laparoscopic management of liver tumors

BACKGROUND

Laparoscopy has clearly advanced the treatment of many diseases related to the liver and biliary tree. The addition of hand assistance can further facilitate minimally invasive liver surgery by providing tactile feedback, atraumatic and versatile retraction, finger-fracture parenchyma dissection, and more precise placement of probes and staplers.

METHODS

Over a 7-year period, 28 patients with liver tumors underwent 31 hand-assisted laparoscopic operations at a tertiary care center. The candidates for hand-assisted laparoscopic resection were patients with lesions involving two hepatic segments or fewer located at the inferior edge of the liver (segments 5 and 6), or confined to the left lateral segment (segments 2 and 3). Ablation was reserved for patients with poor functional status or limited hepatic reserve, and hand-assistance was added for laparoscopic ablation of centrally located tumors (segments 7, 8, and 4a).

RESULTS

The selection criteria were met by 52 patients, 6 of whom had benign lesions. The remaining 46 patients had malignant disease, and 15 of these patients (33%) were found to have extrahepatic disease: 11 at initial laparoscopy and 4 at hand-assisted abdominal exploration. Manual exploration also detected additional intrahepatic treatable lesions in two cases. A total of 19 patients (68%) had metastatic disease, and 3 (11%) had primary liver cancer. The most extensive resections were five left lateral segmentectomies. All margins were negative. The mean operative time was 2.75 h, and the mean blood loss was 230 ml. Two diaphragmatic injuries occurred during ablation of segment 8 lesions. Three cases were converted to open surgery because of adhesions. The mean hospital stay was 3.7 days. A group of 15 patients who had metastatic colorectal cancer treated with resection and/or ablation had a mean follow-up period of 24 months (range, 2-61 months) and a mean survival time of 36 months.

CONCLUSIONS

For selected patients, the hand-assisted technique can be applied safely and effectively to laparoscopic liver surgery and may identify the presence of previously undetectable intrahepatic or extrahepatic disease.

Probiotics for non-alcoholic fatty liver disease and/or steatohepatitis

BACKGROUND

Non-alcoholic fatty liver disease comprises a spectrum of diseases ranging from simple steatosis to non-alcoholic steatohepatitis, fibrosis, and cirrhosis. Probiotics have been proposed as a treatment option because of their modulating effect on the gut flora that could influence the gut-liver axis.

OBJECTIVES

To evaluate the beneficial and harmful effects of probiotics for non-alcoholic fatty liver disease and/or steatohepatitis.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (July 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2, 2006), MEDLINE (1966 to May 2006), and EMBASE (1980 to May 2006). No language restrictions were applied.

SELECTION CRITERIA

Randomised clinical trials evaluating probiotic treatment in any dose, duration, and route of administration versus no intervention, placebo, or other interventions in patients with non-alcoholic fatty liver disease. The diagnosis was made by history of minimal or no alcohol intake, imaging techniques showing hepatic steatosis and/or histological evidence of hepatic damage, and by exclusion of other causes of hepatic steatosis.

DATA COLLECTION AND ANALYSIS

We had planned to extract data in duplicate and analyse results by intention-to-treat.

MAIN RESULTS

No randomised clinical trials were identified. Preliminary data from two pilot non-randomised studies suggest that probiotics may be well tolerated, may improve conventional liver function tests, and may decrease markers of lipid peroxidation.

AUTHORS' CONCLUSIONS

The lack of randomised clinical trials makes it impossible to support or refute probiotics for patients with non-alcoholic fatty liver disease and non-alcoholic steatohepatitis.

Severe reactivation of hepatitis B virus infection in a patient with hairy cell leukemia: Should lamivudine prophylaxis be recommended to HBsAg-negative, anti-HBc-positive patients?

The reverse seroconversion to hepatitis B virus infection has been sporadically described in onco-haematological patients receiving cytotoxic therapy or allogeneic bone marrow transplantation and can be associated with the development of acute icteric hepatitis. We present a male HBsAg-negative, anti-HBc-positive patient with Hairy Cell Leukemia who developed acute B hepatitis more than 1 year after the last course of 2-CdA and 6 months after splenectomy, while the patient was receiving therapy with alphaIFNr. The acute B hepatitis promptly responded to lamivudine therapy followed by viral clearance.

Antioxidant supplements for non-alcoholic fatty liver disease and/or steatohepatitis

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is characterised by fatty deposition in the hepatocytes of patients with minimal or no alcohol intake and without other known cause. NAFLD includes a wide spectrum of histologic abnormalities ranging from hepatic steatosis to non-alcoholic steatohepatitis (NASH), or even cirrhosis. Antioxidant supplements, therefore, could potentially protect cellular structures against oxidative stress and the resulting lipid peroxidation.

OBJECTIVES

To systematically evaluate the beneficial and harmful effects of antioxidant supplements versus no intervention, placebo, or other interventions for patients with NAFLD or NASH.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (June 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2, 2006), MEDLINE (1966 to June 2006), EMBASE (1980 to June 2006), and the Chinese Biomedical Database (1978 to June 2006). No language restrictions were applied.

SELECTION CRITERIA

Randomised clinical trials evaluating any antioxidant supplements versus no intervention, placebo, or other interventions in patients with NAFLD or NASH. Our inclusion criteria for NAFLD or NASH were based on history of minimal or no alcohol intake, imaging techniques showing hepatic steatosis, and/or histological evidence of hepatic damage (including simple steatosis, fatty infiltration plus nonspecific inflammation, steatohepatitis, fibrosis, and cirrhosis), and by exclusion of other causes of hepatic steatosis.

DATA COLLECTION AND ANALYSIS

We extracted data from the identified trials and contacted authors. We used a random-effects model and fixed-effect model with the significant level set at P = 0.05. We evaluated the methodological quality of the randomised trials by looking at how the generation of allocation sequence, allocation concealment, blinding, and follow-up were performed. We made our analyses following the intention-to-treat method by imputing missing data.

MAIN RESULTS

We identified six trials: two were regarded of high methodological quality and four of low methodological quality. None of the trials reported any deaths. Treatment with antioxidant supplements showed a significant, though not clinically relevant, amelioration of aspartate aminotransferase levels, but not of alanine aminotransferase levels, as compared to placebo or other interventions. Gamma-glutamyl-transpeptidase was decreased, albeit not significantly, in the treatment arm. Radiological and histological data were too limited to draw any definite conclusions on the effectiveness of these agents. Adverse events were non-specific and of no major clinical relevance.

AUTHORS' CONCLUSIONS

There is insufficient data to either support or refute the use of antioxidant supplements for patients with NAFLD. It may be advisable to carry out large prospective randomised clinical trials on this topic.

Bile acids for non-alcoholic fatty liver disease and/or steatohepatitis

BACKGROUND

Non-alcoholic fatty liver disease is a condition characterised by fatty deposition in the hepatocytes of patients in patients with minimal or no alcohol intake. Some patients develop non-alcoholic steatohepatitis. Bile acids may potentially protect cellular structures and may be of benefit in patients with non-alcoholic fatty liver or steatohepatitis.

OBJECTIVES

To systematically evaluate the beneficial and harmful effects of bile acids versus no intervention, placebo, or other interventions for patients with non-alcoholic fatty liver or steatohepatitis.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (July 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2, 2005), MEDLINE (1966 to July 2005), EMBASE (1980 to July 2005), and The Chinese Biomedical Database (1978 to July 2005). No language restrictions were applied.

SELECTION CRITERIA

Randomised clinical trials evaluating any bile acids versus no intervention, placebo, or other interventions in patients with NAFLD.

DATA COLLECTION AND ANALYSIS

We extracted data from the identified trials as well as contacted authors. We evaluated the methodological quality of the randomised trials by assessing the generation of allocation sequence, allocation concealment, blinding, and follow-up. We made our analyses following the intention-to-treat method by imputing missing data.

MAIN RESULTS

We identified four randomised clinical trials randomising 279 patients. Only one of the trials was considered a low-bias risk trial. One of the trials reported a non-liver-related death in the bile acid group. No significant differences were found regarding mortality or improvement in liver function tests observed after treatment with ursodeoxycholic acid. Data on the radiological and histological responses were too scant to draw any definite conclusions. Adverse events were non-specific and considered of no major clinical relevance.

AUTHORS' CONCLUSIONS

Presently, there are insufficient data to support or refute the use of ursodeoxycholic acid for patients with non-alcoholic fatty liver or steatohepatitis. It may be advisable to carry out large randomised clinical trials on this topic.

Development of mantle cell lymphoma in a patient with adrenocortical carcinoma and an 18-year survival after complete removal of the primary cancer and resection of local recurrences

The case of a patient with a non-functional and poorly-differentiated adrenocortical carcinoma, who had an unexpected long-term survival after a right adrenalectomy and subsequent removal of 2 local recurrences, is reported. However, fifteen years after the complete resection of the primary neoplasm, the patient first developed an autoimmune thrombocytopenic purpura and later a mantle cell lymphoma located in the mediastinal lymph nodes. This case confirms the possible growth of a second tumour in patients with adrenocortical carcinomas, especially if presenting a long survival after resection of the primary malignancy, and emphasises the need for the close follow-up of these patients.

Vibrational Spectrum of Katoite Ca3Al2[(OH)4]3: A Periodic ab Initio Study

The vibrational spectrum of the Si-free katoite hydrogarnet (116 atoms in the unit cell) has been calculated at the periodic ab initio quantum mechanical level with the CRYSTAL program, by using a Gaussian type basis set and the hybrid B3LYP Hamiltonian. The harmonic frequencies at the Gamma point have been obtained by diagonalizing the mass-weighted Hessian matrix, that is evaluated by numerical differentiation of the analytical first derivatives of the energy with respect to the atomic Cartesian coordinates. The parameters controlling the numerical differentiation, as well as the numerical integration of the exchange-correlation functional for the self-consistent field (SCF) calculation, are shown to affect the obtained frequencies by less than 3 cm-1. Before diagonalization, the dynamical matrix is transformed to a block diagonal form according to the irreducible representations of the point group, so that the 345 vibrational modes are automatically classified by symmetry. Various tools are adopted (graphical representation, isotopic substitution, "freezing" part of the unit cell) that permit a complete classification of normal modes and, in particular, an analysis of the modes in terms of simple models (octahedra modes, Ca modes, H stretching, bending, rotations). The harmonic OH stretching band (48 modes) is quite narrow (20 cm-1), indicating that the interaction among OH groups is very weak. As the OH stretching modes are known to be totally separable from the other modes and strongly anharmonic, the one-dimensional Schroedinger equation for the anharmonic oscillator is solved numerically for the two extreme situations, corresponding to the vibration of one decoupled OH and of all 48 OH groups moving in phase. The anharmonic frequencies are 3682 and 3673 cm-1, respectively, in good agreement with IR experiments (a single band at 3661 cm-1 with a width at half band height of 33 cm-1) and confirming that the interaction between OH groups is extremely weak.

Analysis of the SAGES outcomes initiative cholecystectomy registry

BACKGROUND

In 1999, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) introduced the SAGES Outcomes Initiative as a method for its members to use for tracking their own outcomes. This report provides a descriptive analysis of the cholecystectomy database.

METHODS

The SAGES Outcome Initiative database was accessed for all gallbladder cases from September 1999 to February 2005. The data from the preoperative, intraoperative, and postoperative entries were summarized. These data are purely descriptive, and no statistical analysis was performed.

RESULTS

The gallbladder registry contained 3,285 cases, with 2,005 follow-up cases. Most patients were employed women with some comorbidities who had elective surgery under general anesthesia. Most of the operating surgeons were attending surgeons and surgical assistants. Most of the patients had biliary colic, and symptoms were improved for more than 95% of the patients. More than 90% of the cases were managed laparoscopically, with a conversion rate of 3%. Biliary imaging was used in the vast majority of cases, with most shown to be normal. Intraoperative gallbladder perforation was common, with bile duct injury occurring in 0.25% of cases. The most frequently cited postoperative event was wound infection, with most complications classified as class 1. More than 95% of the patients were able to return to work.

CONCLUSIONS

The SAGES Outcomes Initiative database demonstrates that most participating SAGES members perform laparoscopic cholecystectomies themselves using intraoperative cholangiograms. Adverse outcomes are few, with most patients able to return to normal activity. Importantly, there were relatively few missing data points, implying that when surgeons enter data, the information is relatively complete.

Congenital anomalies of the spleen mimicking hematological disorders and solid tumors: a single-center experience of 2650 consecutive diagnostic laparoscopies

Congenital anomalies of the spleen range from splenic lobulation, to accessory spleen to polysplenia. Though most of these anatomical variants have no clinical significance, an accessory spleen may simulate a tumor in the adrenal gland, pancreas, stomach or intestine. Alternatively, a missed accessory spleen may be the site of the relapse of a hematological disorder. We, therefore, assessed retrospectively: (i) the frequency of congenital anomalies of the spleen observed during 2650 consecutive laparoscopies and (ii) looked for possible misdiagnoses of the accessory spleen as hematological disorders or solid tumors located in the left upper quadrant of the abdomen. Congenital anomalies of the spleen were detected in 55 cases, accounting for 2.07%. Accessory spleens were observed in 44 patients (1.6%) and spleen lobulation in 11 (0.47%). An accessory spleen was the most common of the splenic anomalies. Among the 44 patients in whom an accessory spleen was discovered laparoscopically, the recognition of this anomaly prevented a relapse of a hematological disease in one case and avoided a useless exploratory laparotomy in the second, where the radiologist had interpreted this malformation as a space-occupying lesion. In the third case, the accessory spleen was initially misdiagnosed as a solid tumor of the pancreas, but was eventually recognized as a congenital anomaly by a second laparoscopy.

Vibration Frequencies of Ca3Fe2Si3O12 Andradite: An ab Initio Study with the CRYSTAL Code

The vibrational spectrum of Ca3Fe2Si3O12 andradite is calculated at the Gamma point by using the periodic ab initio CRYSTAL program that adopts an all-electron Gaussian-type basis set and the B3LYP Hamiltonian. The full set of frequencies (17 IR active, 25 Raman active, and 55 inactive modes) is calculated. The effect of the basis set on the calculated frequencies is discussed. The modes are characterized by direct inspection of the eigenvectors and isotopic substitution. The present calculations permit us to clarify some of the assignment problems raised by experiments. The mean absolute differences of the various modes with respect to the available experimental IR and Raman data are as small as 9 and 5 cm(-1), respectively.

The Trypanosoma cruzi Proteome

To complement the sequencing of the three kinetoplastid genomes reported in this issue, we have undertaken a whole-organism, proteomic analysis of the four life-cycle stages of Trypanosoma cruzi. Peptides mapping to 2784 proteins in 1168 protein groups from the annotated T. cruzi genome were identified across the four life-cycle stages. Protein products were identified from >1000 genes annotated as "hypothetical" in the sequenced genome, including members of a newly defined gene family annotated as mucin-associated surface proteins. The four parasite stages appear to use distinct energy sources, including histidine for stages present in the insect vectors and fatty acids by intracellular amastigotes.

Bile leakage and resultant bile peritonitis during or after diagnostic laparoscopy: an unpredictable event

Bile peritonitis secondary to bile leakage is a rare complication of laparoscopy-guided liver biopsy. We report two cases of bile peritonitis occurring, respectively, during and 6 days after liver biopsy in patients with an initial diagnosis of intrahepatic cholestasis associated with chronic pancreatitis. In both cases, bile leakage was first managed by compression with a palpating probe and, at onset or worsening of symptoms, by suture during laparotomy. However, while the first patient progressed uneventfully during the postoperative period, the second died 13 days after laparotomy. In the latter patient, bile leakage was associated with bleeding from the biopsy site with consequently diminished peritoneal irritation and delayed onset of symptoms. In this patient, pancreatic carcinoma, of which evidence was found at autopsy, may also have contributed to the fatal outcome. In conclusion, bile leakage and secondary peritonitis may also occur in the absence of dilation of the biliary tree and may be fatal, especially if not recognized and treated early.

The katoite hydrogarnet Si-free Ca3Al2([OH]4)3: A periodic Hartree–Fock and B3-LYP study

The structure of the Si-free katoite hydrogarnet (116 atoms in the unit cell) has been investigated at the periodic ab initio quantum mechanical level with the CRYSTAL program, by using a Gaussian type basis set and both the HF and the hybrid B3-LYP Hamiltonians. The structure has been fully optimized at various pressures in the 0-46 GPa range; the modifications of the structure, and in particular of the (OH)4 group, as a function of pressure are analyzed. At the B3-LYP level and P greater than 15 GPa, a O-H...O interaction of increasing strength appears, with important modifications in the local geometry of the tetrahedral site. The calculated omega01(O-H) fundamental vibrational frequency at zero pressure is in excellent agreement with experiment (3674 and 3663 cm(-1), respectively); the omega01(O-H) stretching frequency remains essentially constant in the 0-15 GPa interval, whereas it dramatically decreases at higher pressures with a corresponding anharmonicity increase, as a consequence of the formation of a strong hydrogen bond. The hydration energy of grossular and the formation energy of Si-free katoite have also been computed, and the B3-LYP results are in quite good agreement with experiment.