Balancing donor and recipient risk factors in liver transplantation: the value of D-MELD with particular reference to HCV recipients

Donor-recipient match is a matter of debate in liver transplantation. D-MELD (donor age × recipient biochemical model for end-stage liver disease [MELD]) and other factors were analyzed on a national Italian database recording 5946 liver transplants. Primary endpoint was to determine factors predictive of 3-year patient survival. D-MELD cutoff predictive of 5-year patient survival <50% (5yrsPS<50%) was investigated. A prognosis calculator was implemented (http://www.D-MELD.com). Differences among D-MELD deciles allowed their regrouping into three D-MELD classes (A < 338, B 338-1628, C >1628). At 3 years, the odds ratio (OR) for death was 2.03 (95% confidence interval [CI], 1.44-2.85) in D-MELD class C versus B. The OR was 0.40 (95% CI, 0.24-0.66) in class A versus class B. Other predictors were hepatitis C virus (HCV; OR = 1.42; 95% CI, 1.11-1.81), hepatitis B virus (HBV; OR = 0.69; 95% CI, 0.51-0.93), retransplant (OR = 1.82; 95% CI, 1.16-2.87) and low-volume center (OR = 1.48; 95% CI, 1.11-1.99). Cox regressions up to 90 months confirmed results. The hazard ratio was 1.97 (95% CI, 1.59-2.43) for D-MELD class C versus class B and 0.42 (95% CI, 0.29-0.60) for D-MELD class A versus class B. Recipient age, HCV, HBV and retransplant were also significant. The 5yrsPS<50% cutoff was identified only in HCV patients (D-MELD ≥ 1750). The innovative approach offered by D-MELD and covariates is helpful in predicting outcome after liver transplantation, especially in HCV recipients.

Fecal calprotectin concentration in children affected by SIBO

BACKGROUND AND OBJECTIVES

Calprotectin is a protein especially expressed in neutrophil cytosol. In the last few years, Fecal calprotectin (FC) turned out to be a direct marker of gastrointestinal inflammation. Because of the simplicity of the method, it has been studied in several gastroenterologic diseases but no data are available about its concentration in children with small intestinal bacterial overgrowth (SIBO), a complex and not well known condition defined by an excessive germs proliferation, especially anaerobic, in the small bowel, and characterized by dyspeptic and malabsorption symptoms. The aim of this study was to evaluate FC values in children with SIBO, comparing to healthy subjects, in order to clarify if an inflammatory process coexists with SIBO.

MATERIALS AND METHODS

We enrolled fifty-eight children affected by SIBO, as diagnosed by Lactulose Breath Test (LBT). They were assessed for FC values on stool samples. We compared them with a control population of 60 healthy children.

RESULTS

In SIBO patients, a median value of 36.0 mg/kg and a mean value +/- SD of 43.0 +/- 31.6 mg/kg were calculated, while in healthy controls the median value was 29.5 mg/kg and the mean value +/- SD was 35.7 +/- 20.7 mg/kg, showing no statistically significant differences between the two groups (p = 0.07).

CONCLUSIONS

FC values are negative in children affected by SIBO, not differing from those obtained in healthy children, suggesting that no subclinical intestinal inflammation involving neutrophils occurs in patients with higher proliferation of bacteria in the small bowel. The presence of high FC levels in children affected by SIBO might not be caused by bacterial overgrowth itself and, in this case, another cause should be investigated.

Balancing donor and recipient risk factors in liver transplantation: the value of D-MELD with particular reference to HCV recipients

Donor-recipient match is a matter of debate in liver transplantation. D-MELD (donor age × recipient biochemical model for end-stage liver disease [MELD]) and other factors were analyzed on a national Italian database recording 5946 liver transplants. Primary endpoint was to determine factors predictive of 3-year patient survival. D-MELD cutoff predictive of 5-year patient survival <50% (5yrsPS<50%) was investigated. A prognosis calculator was implemented (http://www.D-MELD.com). Differences among D-MELD deciles allowed their regrouping into three D-MELD classes (A < 338, B 338-1628, C >1628). At 3 years, the odds ratio (OR) for death was 2.03 (95% confidence interval [CI], 1.44-2.85) in D-MELD class C versus B. The OR was 0.40 (95% CI, 0.24-0.66) in class A versus class B. Other predictors were hepatitis C virus (HCV; OR = 1.42; 95% CI, 1.11-1.81), hepatitis B virus (HBV; OR = 0.69; 95% CI, 0.51-0.93), retransplant (OR = 1.82; 95% CI, 1.16-2.87) and low-volume center (OR = 1.48; 95% CI, 1.11-1.99). Cox regressions up to 90 months confirmed results. The hazard ratio was 1.97 (95% CI, 1.59-2.43) for D-MELD class C versus class B and 0.42 (95% CI, 0.29-0.60) for D-MELD class A versus class B. Recipient age, HCV, HBV and retransplant were also significant. The 5yrsPS<50% cutoff was identified only in HCV patients (D-MELD ≥ 1750). The innovative approach offered by D-MELD and covariates is helpful in predicting outcome after liver transplantation, especially in HCV recipients.

Lactose intolerance in systemic nickel allergy syndrome

Some patients affected by nickel-contact allergy present digestive symptoms in addition to systemic cutaneous manifestations, falling under the condition known as systemic nickel allergy syndrome (SNAS). A nickel-related pro-inflammatory status has been documented at intestinal mucosal level. The aim of the present study is to evaluate the prevalence of lactose intolerance in patients affected by SNAS compared to a healthy population. Consecutive patients affected by SNAS referring to our departments were enrolled. The control population consisted of healthy subjects without gastrointestinal symptoms. All subjects enrolled underwent lactose breath test under standard conditions. One hundred and seventy-eight SNAS patients and 60 healthy controls were enrolled. Positivity of lactose breath test occurred in 74.7% of the SNAS group compared to 6.6% of the control group. Lactose intolerance is highly prevalent in our series of patients affected by SNAS. Based on our preliminary results, we can hypothesize that in SNAS patients, the nickel-induced pro-inflammatory status could temporarily impair the brush border enzymatic functions, resulting in hypolactasia. Further trials evaluating the effect of a nickel-low diet regimen on lactase activity, histological features and immunological pattern are needed.

Probiotics and small bowel mucosa: Molecular aspects of their interactions

Probiotics are described as "friendly bacteria" that could improve the intestine defense by interacting with the resident microflora. There is a large body of evidence suggesting that consumption of functional food containing probiotics exerts positive effects on human health. Several clinical trials have highlighted the efficiency of probiotics in the prevention and treatment of different gastrointestinal disorders including the prevention of antibiotic associated diarrhea, the remission in patients with inflammatory bowel disease, beneficial effects against Helicobacter pylori infection, positive effects in patients affected by allergies and atopic diseases. The clinical benefits of probiotics use are mainly attributed to their antimicrobial substances production and their positive interactions with the enterocytes to reinforce the intestinal epithelial barrier. Moreover, there is evidence suggesting that probiotics stimulate both specific and non-specific host immune responses. Recently, have been published some experiments performed with the DNA microarray technology which provided a global gene screening of the complex bacteria-host interplay. Nevertheless, the molecular mechanisms by which probiotics enhance the intestinal host defense are still not completely elucidated. Here, we review the experiments and clinical studies to date on the complex mechanisms regulating the communication between probiotics and their hosts.

Anticoagulants in cirrhotic patients: controversies and certainties in PVT management

Portal vein thrombosis (PVT) is a relatively common event in patients with advanced-stage liver cirrhosis, even in patients with a compensated disease. Because of the protean clinical manifestation of PVT, ranging from massive variceal bleeding and mesenteric infarction to the complete absence of any symptom, it is mandatory to provide an early diagnosis and a prompt management. However, even if various treatments have been tested in clinical studies, most of them can be suitable only for a limited number of patients and anticoagulants are recognized as the gold standard, even if the debate about their use in PVT management in cirrhotic patients is still opened. In particular, "old" and "new" generations of anticoagulants have always been used carefully and, sometimes, with skepticism or diffidence in cirrhotic patients. In this review, we report the rationale of anticoagulants use in PVT cirrhotic patients management, analyzing the most accepted controversies and certainties, with a particular attention to their possible role as preemptive therapy.

Ewing's sarcoma of the mobile spine

OBJECTIVES

To evaluate the role of enbloc resection on the oncological outcome of patients with Ewing's sarcoma of the mobile spine treated with systemic multiagent chemotherapy combined with radiation therapy. While the role of chemotherapy and radiation therapy is well known and accepted in the treatment of Ewing sarcoma, there is no consensus on the role of enbloc resection in those tumors occurring in the mobile spine and, therefore, it can be difficult to conclude the decision making process, particularly if to achieve a tumor-free margin resection functionally relevant structures should be sacrificed. The study design of this work was the retrospective analysis of a series of 27 cases of Ewing sarcoma of the mobile spine homogeneously treated.

METHODS

Twenty-seven patients with primary ES of the mobile spine were treated from 1979 to 2008 by the same multidisciplinary team. All the patients presented with pain. Motor deficits were present in 6 patients. All the patients were submitted to multiagent protocols of chemotherapy (always) and radiotherapy (alternative to surgery or associated to). Surgery was performed in 17 cases both for functional purpose (7 cases: intralesional piecemeal excision) both for curative purpose (10 cases: enbloc resection, resulting characterized by marginal/wide or intralesional margins). Patients were observed for a minimum of 2 years or until death. The mean follow-up time was 65 months (median 28 months; ranging 2 to 218 months). Neurological function, local recurrence, distant relapse, and treatment-related complications were evaluated.

RESULTS

Three periods were considered according to the evolution of therapeutic strategies. Four patients were treated in the period 1979 to 1982. All were submitted to chemotherapy (REA-2) and radiation therapy (RT). Two of them were submitted to intralesional excision. All these patients died 2 to 29 months later without significant difference in the two groups. In the period 1983 to 1990 all patients were treated with chemotherapy (REN-1/2) and RT. Two were submitted to intralesional excision and had a worse evolution as died of the disease at 2 and 11 months follow up, while the patients who did not received surgery evolved more favourably: 1 died of the disease 57 months after the end of the treatment, 3 are continuously disease free at 130, 190, 290 months. The sixteen patients treated in the period 1991 to 2008 received chemotherapy (REN-3 and ISG-SSG) and RT, combined with intralesional excision in 3, with enbloc with intralesional margins in 4, enbloc with tumor-free margins (wide or marginal) in 6. Only one patient submitted to tumor-free margin enbloc resection had local recurrence and died 29 months after the treatment (biopsy was performed by open approach), the other surviving continuously disease free at 17 to 193 months follow-up (av. 76 months). All the patients submitted to intralesional excision and to enbloc resection resulting in margin violation had the same prognosis, as died of the disease 10 to 63 months after the treatment. Only one of the 3 patients who had no surgery died of the disease 8 months after the treatment, the other surviving 9 and 49 months follow-up. Among the seven patients who had neurological symptoms at the occurrence, just those with no metastasis and who underwent enbloc resection are alive.

CONCLUSIONS

The current study seems to demonstrate that tumor-free margin enbloc resection provides better local control and longer survival, while the results after intralesional margin resection or piecemeal excision combined with chemotherapy and RT is less effective than chemotherapy and RT alone.

Effect of beta-glucan, inositol and digestive enzymes in GI symptoms of patients with IBS

BACKGROUND

Irritable bowel syndrome (IBS) is a very common functional gastrointestinal (GI). Diagnosis of IBS is based on the fulfilment of the Rome III criteria. Common GI symptoms are lower abdominal pain, bloating and disturbed defecation, such as urgent diarrhoea and/or episodes of chronic constipation. Many agents have been employed in the management of IBS, although only few have been demonstrated to show a relevant efficacy.

AIM

To evaluate the effectiveness of the administration of a mixture of beta-glucan, inositol and digestive enzymes (Biointo) in improving GI symptoms in patients affected by IBS.

PATIENTS AND METHODS

50 IBS patients (20 males, 30 females; mean age 51 +/- 19) were treated with Biointo (group A) while another group consisting of 40 IBS patients (15 males, 25 females; mean age 50 +/- 18) did not receive any therapy (group B).

RESULTS

Biointol administration improved significantly bloating, flatulence and abdominal pain, with a slight increasing of urgency for bowel movements. On the contrary, Biointol did not show any significant effect on the other IBS symptoms.

CONCLUSIONS

Currently, only few agents used in the management of IBS have been proven to be effective. Biointol administration has shown to improve some IBS symptoms, such as bloating, flatulence and abdominal pain, all connected to the presence of gas inside the intestinal lumen.

Management of hepatitis C virus infection recurrence after liver transplantation: an overview

Hepatitis C virus (HCV) infection is the major indication for liver transplantation worldwide. Its recurrence is virtually universal. Once reinfection is established, progression to cirrhosis occurs in 25%-30% of recipients within 5 years. Several studies have attempted to identify the ideal antiviral treatment for liver transplant recipients. At present, the management of recurrent HCV infection in liver transplant recipients is based on widely accepted indications, which represent a reliable guide to identify the "ideal" candidate for therapy, when therapy should be started, and what is to be expected in terms of side effects and response to treatment.

Adipose tissue-derived mesenchymal stem cells and hepatic differentiation: old concepts and future perspectives

Mesenchymal stem cells (MSCs) are multipotent cells, able to differentiate into elements of the mesodermal lineage. Bone marrow and adipose tissue represent the main sources for MSC isolation. In the last decade, several studies have reported the plasticity of MSCs toward a hepatocyte-like phenotype. The use of MSCs to generate hepatocyte-like cells holds great promises to overcome the scarcity of available organs for transplantation. However, little is known about the molecular pathways involved in lineage cross-differentiation and several issues remain to be answered before MSC application in clinical settings. Aim of this review is to critically analyze the possible sources of MSCs suitable for liver repopulation and the molecular mechanisms underlying MSC hepatic differentiation.

Effect of rimonabant on oesophageal motor function in man

BACKGROUND

Cannabinoid type 1 (CB1) receptors are implicated in the control of transient lower oesophageal sphincter relaxations (TLESRs) in animals. In man, it is unclear whether CB1 receptors are involved in the control of oesophageal function.

AIM

To study the effects of the CB1 receptor antagonist rimonabant on fasting and postprandial LES function in healthy subjects.

METHODS

Twelve healthy volunteers underwent two oesophageal manometry studies with administration of wet swallows and a meal after 3 days' premedication with placebo or rimonabant 20 mg.

RESULTS

Rimonabant did not significantly alter preprandial LES pressure (21.1±4.0 vs. 17.3±3.0 mmHg, N.S.), but postprandial LES pressures were significantly enhanced (9.9±1.9 vs.17.1±2.7 mmHg in the first and 10.0±1.4 vs. 19.3±3.6 mmHg in the second postprandial hour, both P<0.05). Swallow-induced relaxations and amplitude of peristaltic contractions were not altered, but rimonabant significantly increased the duration of peristaltic contractions at all time points (e.g. 5.0±0.3 vs. 8.0±0.3s preprandially and 5.0±0.2 vs. 8.2±0.3s at 60 min postprandially, both P<0.01). The number of postprandial TLESRs (3.1±0.5 vs. 1.2±0.5, P<0.05) and acid reflux episodes (1.4±0.2 vs. 0.3±0.1, P<0.05) were significantly lower after rimonabant.

CONCLUSION

The CB1 receptor antagonist rimonabant enhances postprandial LES pressure and decreases TLESRs in healthy subjects.

Sirolimus in liver transplant recipients: a large single-center experience

Sirolimus (SRL) is a newer immunosuppressant whose possible benefits and side effects in comparison to calcineurin inhibitors (CNIs) still have to be addressed in the liver transplantation setting. We report the results of the use of SRL in 86 liver transplant recipients, 38 of whom received SRL as the main immunosuppressant in a CNI-sparing regimen. Indications for the use of SRL were: impaired renal function (n = 32), CNI neurotoxicity (n = 16), hepatocellular carcinoma (HCC) at high risk of recurrence (n = 21), recurrence of HCC (n = 6), de novo malignancies (n = 4), cholangiocarcinoma (n = 1), and the need to reinforce immunosuppression (n = 6). Among patients on SRL-based treatment, four episodes of acute rejection were observed, three of which occurred during the first postoperative month. Renal function significantly improved when sirolimus was introduced within the third postoperative month, while no change was observed when it was introduced later. Neurological symptoms resolved completely in 14/16 patients. The 3-year recurrence-free survival of patients with HCC on SRL was 84%. Sixty-two patients developed side effects that required drug withdrawal in seven cases. There was a reduced prevalence of hypertension and new-onset diabetes among patients under SRL. In conclusion, SRL was an effective immunosuppressant even when used in a CNI-sparing regimen. It was beneficial for patients with recently developed renal dysfunction or neurological disorders.

Spinal Infection Multidisciplinary Management Project (SIMP): From Diagnosis to Treatment Guideline

Spine infections require a multidisciplinary approach to be treated and solved. A guide line to drive physicians in the deep complexity of such a disease is extremely helpful. SIMP suggests a flow-chart built up on clear concepts such as right and well managed antibiotic therapy, sound stability of the spine, correct and smart use of the standard and functional imaging techniques, such as f18 FDG PET/CT. In 16 months a total of 41 patients have been treated for spondylodiscitis, discitis and vertebral osteomyelitis by our team of physicians and 25 patients have been enrolled in a prospective study whose target is the assessment of the SIMP flow-chart and of every single aspect that characterize it.

The effects of itopride on oesophageal motility and lower oesophageal sphincter function in man

BACKGROUND

Itopride is a new prokinetic agent that combines antidopaminergic and cholinesterase inhibitory actions. Previous studies suggested that itopride improves heartburn in functional dyspepsia, and decreases oesophageal acid exposure in gastro-oesophageal reflux disease. It remains unclear whether this effect is due to effects of itopride on the lower oesophageal sphincter (LES).

AIMS

To study the effects of itopride on fasting and postprandial LES function in healthy subjects.

METHODS

Twelve healthy volunteers (five men; 32.6 ± 2.0 years) underwent three oesophageal sleeve manometry studies after 3 days premedication with itopride 50 mg, itopride 100 mg or placebo t.d.s. Drug was administered after 30 min and a standardized meal was administered after 90 min, with measurements continuing to 120 min postprandially. Throughout the study, 10 wet swallows were administered at 30-min intervals, and gastrointestinal symptoms were scored on 100 mm visual analogue scales at 15-min intervals.

RESULTS

Lower oesophageal sphincter resting pressures, swallow-induced relaxations and the amplitude or duration of peristaltic contractions were not altered by both doses of itopride, at all time points. Itopride pre-treatment inhibited the meal-induced rise of transient LES relaxations (TLESRs).

CONCLUSIONS

Itopride inhibits TLESRs without significantly affecting oesophageal peristaltic function or LES pressure. These observations support further studies with itopride in gastro-oesophageal reflux disease.

Clinical trial: the effects of a probiotic mixture on non-steroidal anti-inflammatory drug enteropathy - a randomized, double-blind, cross-over, placebo-controlled study

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) can cause serious gastrointestinal side effects. Faecal calprotectin assay represents a simple and practical method for diagnosis of NSAID enteropathy. Intestinal micro-organisms are necessary for the development of NSAID-induced small bowel lesions and hence it has been suggested that probiotics could protect against NSAID enteropathy.

AIM

To evaluate the effect of a probiotic mixture in comparison with placebo on faecal calprotectin concentrations (FCCs) in healthy volunteers receiving indomethacin.

METHODS

In a double-blind, cross-over trial, 20 healthy volunteers ingested a daily dose of probiotic mixture (VSL#3) or placebo for 21 days. From day 16 to day 19, all subjects were also administered 50 mg/day of indomethacin. FCCs were measured the day before starting probiotic/placebo ingestion (T0), and every day from day 15 to day 21.

RESULTS

During dosing with probiotic, median FCCs were significantly increased only at day 17 with respect to T0 values, whereas during dosing with placebo, they were significantly increased at every day from day 17 to day 21 with respect to T0 values.

CONCLUSIONS

Treatment with VSL#3 before and during indomethacin therapy significantly reduces FCCs in healthy subjects with respect to placebo, suggesting that this approach could be useful in decreasing indomethacin-induced intestinal inflammation.

Post-translational modulation of CD133 expression during sodium butyrate-induced differentiation of HT29 human colon cancer cells: implications for its detection

The CD133 molecule has been proposed as a surface marker of cancer stem cells in several human malignancies, including colon cancers. The function and the mechanisms regulating CD133 expression remain unknown. The HT29 human colon cancer cells undergo differentiation following treatment with various agents and represent a useful in vitro model of colon differentiation. This study evaluated the behavior of CD133 during sodium butyrate-induced differentiation of HT29 cells. Treatment with sodium butyrate induced a progressive decrease of CD133 expression, as assessed by flow cytometry using the AC133 monoclonal antibody. Indeed, expression of CD133, which was about 47% in untreated control cells, gradually decreased down to about 3% after 72 h in a time- and dose-dependent manner. No relationship was observed between CD133 protein evaluated by flow cytometry and mRNA expression level, and no changes were detected in the methylation status of the CD133 gene promoter during HT29 differentiation. Moreover, the expression of the CD133 protein, evaluated by Western blot analysis using a specific anti-CD133 antibody directed against the C-terminal intracytoplasmic region of human CD133 protein, did not correlate with flow cytometry results. Different results were also obtained using the two antibodies to analyze the expression of the CD133 molecule in human colon cancers. These findings demonstrate that membrane expression of the CD133 stem cell marker might undergo a complex regulation during differentiation of colon cells and suggest that HT29 cells are a useful in vitro model to study the mechanisms involved in this regulation which likely occurs at a post-transcriptional level.

Helicobacter pylori infection and diabetes

The bacterium Helicobacter pylori (H. pylori), prime causal agent of gastroduodenal diseases, has been involved in various aspects of several extragastric manifestations. Although currently available data do not provide proof of its role in most of them, a potential relationship cannot be ruled out. In the present review, the consistency of a role of H. pylori infection in the pathogenesis of diabetes mellitus (DM) as well as in the gastric abnormalities of diabetics is analyzed and critically discussed. Several controversies emerge from the epidemiological data. The clinical consequence of H. pylori infection in terms of metabolic control seems to be low. Regarding interventional studies, the bacterial eradication rate is significantly lower in DM patients than in controls. The difference in the eradication rate observed between adults and children affected by diabetes could be due to the fact that the latter have no history of repeated infectious diseases and antibiotic treatments, with minor antibiotic-resistant H. pylori strain selection. Finally, a higher H. pylori re-infection rate in DM patients than in general population has been shown.

Management of bone metastases

Bone metastases are only apparently similar lesions, considering the large varieties of istotypes and the spread of the primary tumour. Although these metastases develop early and are not terminal events, they have to be considered as severe complications. When possible, surgical treatment can improve the history of the patient in terms of life expectancy and quality of life. The approach to these lesions should be multidisciplinary in collaboration with oncologists and radiotherapists. In fact the average of survival of these patients has increased in recent years. The evolution of anesthesiological techniques permits surgical treatments that once were considered prohibitive. The application of new adjuvant therapies increases the effectiveness for surgical treatment. Controversy exists over the most appropriate treatment for patients with bone metastatic disease. The purpose was to determine the best sequential process to arrive at the most appropriate treatment considering the individual general conditions and the parameters of the metastases. As the number of treatment options for metastatic bone disease has grown, it has become clear that effective implementation of these treatments can only be achieved by a multidisciplinary approach.

The effect of oral supplementation with Lactobacillus reuteri or tilactase in lactose intolerant patients: randomized trial

BACKGROUND

Lactase enzyme supplements and probiotics with high beta-galactosidase activity may be valid treatment options for the lactose intolerance. Aim of this study was to assess whether supplementation with tilactase or Lactobacillus reuteri when compared to placebo affects hydrogen breath excretion and gastrointestinal symptoms in lactose intolerant patients during lactose breath test (H,-LBT).

METHODS

Sixty lactose intolerant patients participated in the study and were randomized to three 20 patients-treatment groups: tilactase group (tilactase 15 minutes before control H2-LBT); placebo group (placebo 15 minutes before control H2-LBT); Lactobacillus reuteri group (LR) (LR b.i.d. during 10 days before control H2-LBT). The outcomes were LBT normalization rate, and influences of treatments on both mean maximum hydrogen concentration and clinical score.

RESULTS

LBT normalization rate was significantly higher in tilactase and LR groups with respect to placebo. Tilactase was significantly more effective than LR in achieving LBT normalization (p <0.01). Both significant reduction of mean peak H2 excretion and improvement of the mean clinical score were observed in tilactase and LR groups after treatment with respect to placebo (p <0.0001). Tilactase was significantly more effective than LR in reducing both mean peak hydrogen excretion and mean clinical score.

CONCLUSIONS

In lactose intolerants, tilactase strongly improves both LBT results and gastrointestinal symptoms after lactose ingestion with respect to placebo. Lactobacillus reuteri also is effective but lesser than tilactase. This probiotic may represent an interesting treatment option for lactose intolerance since its use is simple and its effect may last in the time after stopping administration.

Reflux symptoms in wind instrument players

BACKGROUND

An occupation-related susceptibility of orchestral wind instrument players to gastro-oesophageal reflux was hypothesized.

AIM

To compare reflux symptoms reported by wind instrument players with those reported by players of other instruments.

METHODS

A questionnaire was distributed to 1083 musicians (414 wind instrument players and 669 players of other instruments) from 21 Italian orchestras to obtain information on reflux symptoms in the year preceding the survey together with selected individual characteristics and lifestyle habits. Crude and adjusted prevalence rate ratios (PRR) were computed by a model including gender, age, body mass index, smoking status, alcohol consumption and other confounding factors.

RESULTS

Wind instrument players reported a higher prevalence of heartburn in the previous year than the other instrument players (adjusted PRR 1.23, CI 95% 1.04-1.46). Wind instrument players also reported higher, although not fully significant, prevalence of regurgitation (adjusted PRR 1.22, CI 95% 0.97-1.54). Flute and double-reed instrument players seem to carry a higher risk of reflux symptoms.

CONCLUSIONS

Wind instrument players reported a prevalence of typical reflux symptoms higher than other instrument players.

Small bowel bacterial overgrowth and type 1 diabetes

BACKGROUND

Gastrointestinal motility disorders are often present in diabetic patients (pts). Such motility dysfunctions have been attributed to autonomic neuropathy. Impaired intestinal motility is often associated with small-bowel bacterial overgrowth (SIBO) but only few studies evaluated the relationship between autonomic neuropathy and SIBO in diabetic pts.

AIM

To compare the prevalence of SIBO between type 1 diabetic (T1D) pts with and without autonomic neuropathy.

PATIENTS AND METHODS

25 pts (13 males, 12 females; mean age 44.2+/-7) affected by type 1 diabetes with normal cardiovascular autonomic test (group A) and 25 type 1 diabetic pts with abnormal cardiovascular autonomic test (group B) were submitted to hydrogen lactulose breath test.

RESULTS

2 out of 25 (8%) showed SIBO among group A, while 11 out of 25 (44%) showed SIBO among group B (p<0.01). Interestingly, among group B, the daily insulin requirements was significantly higher in SIBO-positive pts compared to SIBO-negative: 0.66+/-0.3 vs. 0.59+/-0.1 UI/kg (p<0.05).

CONCLUSIONS

Pts with autonomic neuropathy have a significantly higher prevalence of SIBO, that is also associated with a higher daily insulin requirements.

Prevalence of small intestinal bacterial overgrowth in children with irritable bowel syndrome: a case-control study

OBJECTIVE

To assess the prevalence of small intestinal bacterial overgrowth (SIBO) in children affected by irritable bowel syndrome (IBS).

STUDY DESIGN

Consecutive children affected by IBS according to Rome II criteria (n = 43) were enrolled at the Gemelli Hospital, Catholic University of Rome. The control population (n = 56) consisted of healthy subjects without IBS symptoms, similar to patients for age, sex, and social background. All subjects underwent lactulose/methane breath test (LBT) to assess small intestinal bacterial overgrowth.

RESULTS

The prevalence of abnormal LBT result was significantly higher in patients with IBS (65%, 28/43) with respect to control subjects (7%, 4/56; OR 3.9, 95% CI 7.3-80.1, P < .00001). Patients with abnormal LBT showed a trend toward a worse visual analog scale score with respect to children with IBS without SIBO, but a significant statistical difference was observed only for bloating.

CONCLUSIONS

Results from this study suggest a significant epidemiologic association between SIBO and IBS in childhood. Placebo-controlled interventional studies with antibiotics used to treat bacterial overgrowth are warranted to clarify the real impact of the disease on IBS symptoms.

Molecular adsorbent recirculating system (Mars) in patients with primary nonfunction and other causes of graft dysfunction after liver transplantation in the era of extended criteria donor organs

Liver dysfunction is an important cause of morbidity and mortality after orthotopic liver transplantation (OLT). The Molecular Adsorbent Recirculating System (MARS) is an albumin-based dialysis system designed to enhance the excretory function of a failing liver. MARS has been successfully used in patients affected by advanced liver disease and presenting with severe cholestasis. The aim of this study was to evaluate the safety and clinical efficacy of MARS in patients with liver dysfunction after OLT. Seven patients (primary nonfunction, 2 patients; graft dysfunction, 5 patients) fulfilled the inclusion criteria of serum bilirubin level >15 mg/dL and least 1 of the following clinical signs: hepatic encephalopathy (HE) > or = grade II, hepatorenal syndrome (HRS), and intractable pruritus. Graft and patient survival rates at 6 months were 42.8% and 57.1%, respectively. All patients tolerated MARS treatment, with no adverse event. In all patients, a decrease in serum bilirubin (P < .05), bile acids (P < .05), serum creatinine, and ammonia levels was observed after treatment with MARS. A considerable improvement of HE, as well as renal and synthetic liver functions, was observed in 4 of 5 patients with graft dysfunction, but not among those with primary nonfunction. The patients with intractable pruritus showed significant improvement of this symptom after MARS therapy. Thus, MARS is a safe, therapeutic option for the treatment of liver dysfunction after OLT. Further studies are necessary to confirm whether this treatment is able to improve both graft and patient survival.

Methodology and indications of H2-breath testing in gastrointestinal diseases: the Rome Consensus Conference

BACKGROUND

Breath tests represent a valid and non-invasive diagnostic tool in many gastroenterological conditions. The rationale of hydrogen-breath tests is based on the concept that part of the gas produced by colonic bacterial fermentation diffuses into the blood and is excreted by breath, where it can be quantified easily. There are many differences in the methodology, and the tests are increasingly popular.

AIM

The Rome Consensus Conference was convened to offer recommendations for clinical practice about the indications and methods of H2-breath testing in gastrointestinal diseases.

METHODS

Experts were selected on the basis of a proven knowledge/expertise in H2-breath testing and divided into Working Groups (methodology; sugar malabsorption; small intestine bacterial overgrowth; oro-coecal transit time and other gas-related syndromes). They performed a systematic review of the literature, and then formulated statements on the basis of the scientific evidence, which were debated and voted by a multidisciplinary Jury. Recommendations were then modified on the basis of the decisions of the Jury by the members of the Expert Group.

RESULTS AND CONCLUSIONS

The final statements, graded according to the level of evidence and strength of recommendation, are presented in this document; they identify the indications for the use of H2-breath testing in the clinical practice and methods to be used for performing the tests.

Antibiotic therapy in small intestinal bacterial overgrowth: rifaximin versus metronidazole

BACKGROUND AND OBJECTIVES

Few controlled trials on antibiotic therapy for small intestinal bacterial overgrowth are available at present. Aim of the study was to assess efficacy, safety and tolerability of rifaximin with respect to metronidazole for the treatment of small intestinal bacterial overgrowth.

MATERIAL AND METHODS

We enrolled 142 consecutive patients with diagnosis of small intestinal bacterial overgrowth. Diagnosis of small intestinal bacterial overgrowth based on the clinical history and the positivity of glucose breath test. Patients were randomised to two 7-day treatment groups: rifaximin 1200 mg/day and metronidazole 750 mg/day. Glucose breath test was reassessed 1 month after. Compliance and side-effect incidence were also evaluated.

RESULTS

One drop-out was observed in rifaximin group. Five drops-out occurred in metronidazole group. The glucose breath test normalization rate was significantly higher in the rifaximin with respect to the metronidazole group (63.4% versus 43.7%; p < 0.05; OR 1.50, 95% CI 1.14-4.38). The overall prevalence of adverse events was significantly lower in rifaximin with respect to metronidazole group.

DISCUSSION

Rifaximin showed an higher SIBO decontamination rate than metronidazole at the tested doses, both with a significant gain in terms of tolerability. Either the present study or recent evidencies suggest that rifaximin represents a good choice for the management of patients affected by SIBO.

New therapeutic approach in inflammatory bowel disease

In the last decade, biologic agents, in particular infliximab and adalimum-ab, have deeply changed the therapeutic armamentarium of inflammatory bowel disease (IBD). However, these drugs have a number of contraindications and side-effects that physicians should know so to avoid and eventually manage them. Another important issue is the early introduction of immunomodulators and biologics in the therapeutic algorithm of IBD, the so called "top-down" approach compared to the traditional "step-up" approach. In this review, the indications to the use of anti-TNF-alpha molecules in IBD are briefly reported and the potential benefits and disadvantages of a more aggressive approach are discussed.

Mesenchymal stromal cells multipotency and plasticity: induction toward the hepatic lineage

BACKGROUND

Human mesenchymal stromal cells (MSCs) can be isolated from a variety of adult and perinatal tissues and exert multipotency and self renewal properties which make them suitable for cell-based therapy. Their potential plasticity extended to non-mesodermal-derived tissues has been indicated, although it is still a debated issue. In this study we have isolated MSCs from both adult and fetal tissues. Their growth, immunophenotype and multi-lineage differentiation potentials have been analyzed, focusing, in particular, on the hepatic differentiation.

METHODS

Cells were isolated from bone marrow (BMSC), adipose tissue (ATSC) and second trimester amniotic fluid (AFSC), upon a written informed consent obtained from donor patients. Cells were expanded and growth kinetics was assessed by means of proliferation assay. Their immunophenotype was analyzed using cytometry and multi-lineage differentiation potential was evaluated by means of in vitro differentiation assays. Finally, the expression of tissue-specific markers was also assessed by mean of semi-quantitative PCR.

RESULTS

Bipolar spindle-shaped cells were successfully isolated from all these tissues. Interestingly, ATSCs and AFSCs showed a higher proliferation potential than BMSCs. Mesodermal differentiation capacity was verified in all MSC populations, even if AFSCs were not able to undergo adipogenesis in our culture conditions. Furthermore, we showed that MSC cultured in appropriate conditions were able to induce hepatic-associated genes, such as ALB and TDO2.

CONCLUSION

Taken together the data here reported suggest that MSCs from both adult and fetal tissues are capable of tissue-specific commitment along mesodermal and non-mesodermal lineages. In particular we have demonstrated that a specific hepatogenic commitment can be efficiently induced, proposing these cells as suitable tool for cell-based applications aimed at liver regeneration.

Isolation and characterization of CD133+ cell population within human primary and metastatic colon cancer

BACKGROUND

"Cancer stem cells" (CSC) have been identified as a minority of cancer cells responsible for tumor initiation, maintenance and spreading. Although a universal marker for CSC has not yet been identified, CD133 has been proposed as the hallmark of CSC in colon cancer. The aim of our study was to assess the presence of a CD133+ cell fraction in samples of colon cancer and liver metastasis from colon cancer and evaluate their potential as tumor-initiating cells.

METHODS

Tissue samples from 17 colon cancers and 8 liver metastasis were fragmented and digested using collagenase. Cell suspensions were characterized by flow cytometry using anti-CD133, CD45 and CD31 antibodies. CD133+ cells were also isolated by magnetic cell sorting and their tumor-initiating potential was assessed versus the remaining CD133- fraction by soft-agar assay.

RESULTS

Our results confirmed the existence of a subset of CD133+ tumor cells within human colon cancers. Interestingly, CD133+ cells were detectable in liver metastasis at a higher percentage when compared to primary tumors. Soft-agar assay showed that CD133+ cell fraction was able to induce larger and more numerous colonies than CD133-cells.

CONCLUSION

Our findings data that the CD133+ colon cancer cells might play an important role in both primary tumors as well as in metastatic lesions thus warranting further studies on the role(s) of this subset of cells in the metastatic process.

Celiac Disease in the 21st Century: Issues of Under-and Over-Diagnosis

Until the 1960s celiac disease (CD) or sprue was considered a pediatric disease that was rarely diagnosed in adulthood. Thanks to greater awareness of the disease and the availability of improved diagnostic tools (above all, sophisticated endoscopic techniques and the development of reliable serological markers), the prevalence of CD in Western countries has been increasing steadily, and it is now recognized as a common disorder, even in adults. However, many cases of this disease still go undiagnosed, especially among the elderly and in patients with atypical clinical presentations (which are by no means uncommon). On the other hand, the frequency of unfounded diagnoses of CD is also on the rise. This reflects a tendency toward exclusively symptomatic diagnosis as well as the growing use of invalidated tests for CD (e.g., the cytotoxic test, the sublingual or subcutaneous provocation/neutralization test, etc.). As a result, public healthcare spending is being increased in several countries (Italy included) by the growing number of prescriptions for gluten-free diets. This editorial discusses the problems of under- and over-diagnosis of CD and provides an algorithm for management of suspected cases designed to minimize both problems with particular importance to morphologic aspects of small bowel (also in electron microscopy), in basal conditions or in gluten-free diets.

Low-dose lactose in drugs neither increases breath hydrogen excretion nor causes gastrointestinal symptoms

BACKGROUND

Despite the reported tolerance to a low dose of lactose, many lactose malabsorbers follow a rigorous lactose-free diet also avoiding lactose-containing drugs. Up to now, only a few case reports have described the onset of gastrointestinal symptoms in lactose malabsorbers following the ingestion of these drugs. It has been suggested that capsules/tablets contain no more than 400 mg of lactose.

AIM

To evaluate breath H(2) excretion and intolerance symptoms after ingestion of a capsule containing 400 mg of lactose or placebo through a randomized, cross-over, double-blind, controlled study.

METHODS

Seventy-seven lactose maldigesters with intolerance underwent two H2 breath tests with both 400 mg of lactose and 400 mg of placebo. Gastrointestinal symptoms occurring in the 8 h following the ingestion of different substrates were evaluated by a visual-analogue scale.

RESULTS

Ingestion of 400 mg of lactose did not cause a significant difference in breath H2 excretion or in the severity of gastrointestinal symptoms compared to placebo.

CONCLUSION

In patients with lactase deficiency, drugs containing 400 mg of lactose or less can be used safely.

Donor risk index and organ patient index as predictors of graft survival after liver transplantation

In liver transplantation the identification of risk factors and the risk quantification for each single case represent a field of great interest. There are donor-related and recipient-related risk factors. Donor risk index (DRI) was retrospectively calculated in 223 liver transplant cases. We did not include patients with preoperative diagnosis of hepatocarcinoma and retransplants. The cases were stratified into two classes according to the DRI (low risk, DRI<1.7, and high risk, DRI >or= 1.7). A new index, namely the organ patient index (OPI) was calculated adding the Model for End-stage Liver Disease (MELD) score to the DRI. Patients were stratified into two classes according to the OPI (low risk, OPI <or= 2.85, and high risk, OPI>2.85). The cases with low DRI (n=144) showed better survival than the cases with high DRI (n=82; P< .02). The cases with low OPI (n=173) showed better survival than cases with high OPI (n=50; P< .01). The OPI predicted outcomes better than DRI, increasing the gap in the long-term graft survival between the low- and the high-risk class. The inclusion of the MELD in the new index allowed better prediction of graft survival.

Treatment of chronic hepatitis C virus infection with pegylated interferon and ribavirin in cirrhotic patients awaiting liver transplantation

Successful treatment of chronic hepatitis C virus (HCV) infection can prevent reinfection after orthotopic liver transplantation (OLT). Pegylated interferon (PEG-IFN) may ameliorate virological response (VR), making the risk-to-benefit ratio of therapy favorable in waiting list patients. From January 2001 to April 2006, we treated 15 HCV cirrhotics with PEG-IFN alpha-2b (1.5 microg/kg/week) and ribavirin (RIBA; >or=10.6 mg/kg/d). Their mean age was 51.5 years. There were 9 men. In 6 cases the genotype was 1b. With Child-Pugh scores >or=9 (range 9-12) and Model for End-Stage Liver Disease (MELD) scores >or=14 (range, 14-22). Adverse events occurred in all subjects: thrombocytopenia (<40,000/microL) in 8; neutropenia (<700/microL) in 10; anemia (Hb <8.5 g/dL) in 1; grade III hepatic encephalopathy in 2; pelvic infection in 1; variceal hemorrhage in 1; and hepatocellular carcinoma (HCC) recurrence in 1. Adverse events caused treatment withdrawal in 6 (40.0%) and RIBA and/or PEG-IFN dose reduction in 10 (66.6%). Early VR (EVR) was obtained in 9 subjects (60.0%), end-of-treatment (EOT) VR in 7 (46.6%), and sustained VR (SVR) in 3 (20.0%). Three subjects--2 nonresponder and 1 breakthrough--were transplanted at 25, 23, and 16 months after the EOT, respectively. Three subjects died at 6, 8, and 15 months after the EOT due to HCC, spontaneous bacterial peritonitis, and liver failure. Nine patients are awaiting OLT. The risk-to-benefit ratio is against PEG-INF and RIBA treatment of severely decompensated cirrhotics infected with genotype 1 awaiting OLT, but therapy is probably beneficial in genotype 2 subjects, due to an expected SVR rate of more than 40%. However, one must carefully consider the high risk for severe adverse events.

New insights into the pathophysiology of IBS: intestinal microflora, gas production and gut motility

Irritable bowel syndrome (IBS) is a complex disorder clinically characterized by abdominal pain and altered bowel habit. Its pathogenetic mechanisms are still incompletely known; genes, psychosocial factors, changes in gastrointestinal motility and visceral hypersensitivity are traditionally thought to play a crucial role in symptom generation. Recent studies have identified new additional factors that can interact with the established mechanisms. Dysregulation of brain-gut axis, gastrointestinal infection, low-grade infiltration and activation of mast cells in the intestinal mucosa with consequent release of bioactive substances, and altered serotonin metabolism are the emerging factors of IBS pathogenesis. Finally, modification of small bowel and colonic microflora and altered gas balance may be of relevance in at least some subgroups of IBS patients. New therapies can be developed only on the basis of a better understanding of the heterogeneous picture of the pathophysiology of IBS.

Elastography assessment in patients with chronic HCV infection

INTRODUCTION

Liver fibrosis (LB) assessment plays an important role in hepatology. A common characteristic of all chronic liver diseases is the occurrence and progression of fibrosis towards cirrhosis. Besides its plain interest for prognosis purposes, determining the fibrosis reveals the natural history of the disease and the risk factors associated with its progression to guide the antifibrotic action of different treatments.

DISCUSSION

Today, in clinical practice there are three available methods for the evaluation of LB. Biopsy, which is still considered as the 'gold standard' method. Serological markers and their mathematical combination are suggested in the last years in alternative to LB. More recently, transient elastography (TE) was proposed. TE is a simple and noninvasive method for measuring liver stiffness. This technique is based on the progression speed of an elastic shear wave within the liver.

CONCLUSIONS

Currently, there are just a few studies capable of evaluating the TE effectiveness in chronic liver diseases, mainly in patients infected with hepatitis C virus (HCV). Its application must also be studied in the monitoring of patients suffering from chronic HCV infection and subjected to a treatment that can modify their degree of liver fibrosis. The results of TE must be interpreted according to the clinical background of the specialist.

Spinal metastasis: a retrospective study validating the treatment algorithm

A retrospective clinical study was conducted to validating the treatment algorithm in patients with spinal metastasis. The study participants were 43 patients with spinal metastasis from carcinoma. Since most interventions are palliative we had to seek for clear definitions to describe the results, aiming to increase the quality of life. To this purpose, we would introduce the concept of "target achievement". We presume that the target is achieved when all the following findings are present: a survival rate which is not inferior to the average, improvement or the maintenance of the neurological condition and achievement of local control. The results of this study demonstrate that performing the treatment suggested by the algorithm, the majority of the patients have a good residual quality of life. Worse results are obtained when a more aggressive treatment is selected.

Probiotics: which and when?

There is a natural feeling between our intestinal flora and the gut. These microorganisms, living in the various tracts of human intestine, may affect the host homeostasis. Some of these bacteria can perhaps be a source of infection and sepsis when the bowel barrier is physically or functionally breached. The term 'probiotic' dates from the beginning of the last century and in the last years a market for probiotics worldwide, estimated to be worth billions of pounds, has developed. Although there is persuasive advertising for probiotics and there have been methodological advances in the study of the intestinal microbiota, much remains unproven, e.g. how probiotics work, which strains are effective, what can be expected to be achieved, and what dosage is required for effectiveness. This review of the literature is an evidence-based guide through the developing microbial universe affecting our life.

Increased blood pressure variability in menopause

Blood pressure variability represents an independent risk factor for cardiovascular diseases. To detect possible blood pressure variability changes from fertile to menopausal status, we enrolled consecutively 219 women: 104 fertile women (46.6 +/- 3.4 years) and 115 menopausal women (53.9 +/- 3.98 years). We evaluated for each patient the body mass index (BMI), 24 h, daytime, night-time systolic and diastolic mean blood pressure values and blood pressure variability data by means of an Ambulatory Blood Pressure Monitoring device. We found a significant higher mean age, body mass index, systolic and diastolic 24 h, day and night-time blood pressure variability in menopausal women when compared to fertile women. Age and BMI were significantly correlated to most blood pressure variability data with the Spearman Rank test. The multivariate logistic regression with dichotomic variables showed that the menopausal status is independently correlated to 24 h systolic (p < 0.0005) and diastolic (p < 0.05) variability, systolic (p < 0.05) and diastolic (p < 0.05) daytime pressure variability and systolic night-time pressure variability (p < 0.05). Furthermore, we found independent correlations between age 24 h systolic (p < 0.05) and night-time diastolic blood pressure variability (p < 0.05), while the BMI was indepententely correlated to BMI 24h diastolic (p < 0.01), daytime systolic (p < 0.01) and diastolic (p < 0.05) blood pressure variability. These data show a significant increase of blood pressure variability in menopausal women when compared to fertile women, even after exclusion of confounding factors, such as aging and BMI. Menopausal status, aging and BMI increase may all, independently, contribute to the enhanced blood pressure variability we found in menopausal women.

[The surgical treatment of renal cell carcinoma metastases to the vertebrae: intra-operative anesthesia related problems]

AIMS

Analysis of the intra-operative anesthesia related problems were compared during intra-lesional or extra-lesional surgeries for patients with metastatic renal cell carcinoma to the spine.

MATERIALS AND METHODS

We retrospectively collected and analyzed the hemodynamic data on 30 patients who had undergone surgical intervention. Twenty patients had an intra-lesional excision of the metastatic lesion in the vertebra, whereas for the rest, an en-bloc wide or marginal margin resection was carried out.

RESULTS

The surgical time for the en-bloc resections was much longer, and thus also the exposure to the anesthesia, but lesser variability within the data on blood pressure and pulse as compared with intra-lesional curettage. There was also more blood loss with the intra-lesional surgeries.

CONCLUSIONS

En-bloc resections of the vertebral tumors not only give better oncological local control, but also have less compromising effects on the patient, especially with respect to the intra-operative hemodynamics. In selected cases, en-bloc resections present a good option of treatment in vertebral metastases, and especially in highly vascular tumors such as the renal cell carcinoma metastases.

Safety and efficacy profile of G-CSF therapy in patients with acute on chronic liver failure

BACKGROUND/AIM

We aimed to evaluate safety and efficacy of granulocyte-colony stimulating factor treatment in patients with acute on chronic liver failure and the effect of granulocyte-colony stimulating factor on the expression level of CXCR4, vascular endothelial growth factor receptor and very late activation antigen 4.

METHODS

Twenty-four patients with acute on chronic liver failure were randomised to receive standard therapy, standard therapy+granulocyte-colony stimulating factor (5 microg/kg/day for 6 days) and standard therapy+granulocyte-colony stimulating factor (15 microg/kg/day s.c. for 6 days). Data on CD34+cell mobilisation were compared to age-matched peripheral blood haematopoietic stem cell donors treated with granulocyte-colony stimulating factor. On day third of treatment, the expression level of CXCR4, vascular endothelial growth factor receptor and very late activation antigen 4 was analysed in mobilised CD34+ cells.

RESULTS

CD34 cell count increased after the second day of granulocyte-colony stimulating factor injection in both treatment groups compared to the linear increase observed in control. After the fifth day the increase was significantly higher in healthy donors versus patients with acute on chronic liver failure. A decrease in the expression of CXCR4, very late activation antigen 4 and vascular endothelial growth factor receptor compared to premobilisation values was observed. No major side effects were observed.

CONCLUSIONS

Granulocyte-colony stimulating factor treatment is able to induce CD34 mobilisation in patients with acute on chronic liver failure. The expression pattern of CXCR4, very late activation antigen 4 and vascular endothelial growth factor receptor suggests that these molecules are involved in the granulocyte-colony stimulating factor-induced stem cell mobilisation.

Stem cells, cancer, liver, and liver cancer stem cells: finding a way out of the labyrinth

Subsequent to an initiating event, tumor promotion requires sustained cell proliferation to allow for progressive accumulation of pro-oncogenic mutations. The unique characteristics of stem cells would seem to implicate these cells as particularly suitable targets for carcinogens. Several lines of evidence suggest that tumors harbor a small population of cancer stem cells (CSC) which both give rise to the bulk of the tumor and are tumorigenic in experimental models. Mounting evidence suggests that these cells are responsible for re-growth of a tumor following unsuccessful treatment and for the establishment of metastases. The concept of CSC has been demonstrated in several human cancers including leukemia, breast, prostate, lung, and brain tumors. Taken together, the properties of CSC suggest that they are appropriate targets for cancer therapies. Such treatments would require a deep understanding of the CSC origin, molecular profile, and interaction with the local microenvironment. This report will summarize what is currently known regarding CSC, with particular emphasis on hepatic cancers, the cellular origin of liver tumors, and the role of liver stem cells and their niche in hepatocarcinogenesis.

Gender affects 13C-ketoisocaproic acid breath test

BACKGROUND AND AIMS

13C-Ketoisocaproic Acid Breath Test (13C-Kica-BT) has been proposed to assess mitochondrial function. Aim of this study is to evaluate whether gender affects mithocondrial oxidation by means of 13C-Kica-BT in healthy subjects in basal conditions and after an acute oxidative stress induced by ethanol.

METHODOLOGY

50 healthy volunteers were given 1 mg/kg of 13C-Kica together with 20 mg/kg of L-leucine dissolved in 200 ml of orange juice. Breath samples were taken at baseline, every 5 minutes for 45 minutes and then every 15 minutes until 2 hours. Forty-eight hours later the test was repeated 30 min after ethanol ingestion (0.5 g/kg body weight). 13CO2 enrichment in breath was analyzed by isotope ratio/mass spectrometry. Statistical analysis was performed using the student's t test.

RESULTS

At baseline conditions, the percentage of Ketoisocaproic acid in 2 hours was significantly higher in females than in males. Ethanol significantly reduces the oxidation of Ketoisocaproic acid. Conversely, no differences were observed between groups after the ethanol oral load.

CONCLUSIONS

Decarboxylation of 13C-Kica was significantly higher in females than in males. Ethanol decreases Kica decarboxylation in particular in women. Further studies remain needed to establish whether sexual hormones could interfere with the metabolism of Kica.