Elderly patients with multimorbidity in the home setting: umbrella review on therapeutic non-adherence causes

OBJECTIVE

The elderly population is the most at risk regarding adherence, especially in the coexistence of multiple diseases. This study aims to detect factors contributing to therapeutic non-adherence in elderly patients in home settings.

MATERIALS AND METHODS

A review protocol was developed to conduct the umbrella review using the methodological framework of the Richardson et al study. The search strategy was developed in December 2022 to conduct a systematic search and to perform an Umbrella Review of systematic reviews, meta-analyses and integrative reviews published from 2012 to 2022 in English.

RESULTS

A total of 26,038 articles were identified and screened. 18 relevant articles were included in the study.

CONCLUSIONS

Therapeutic adherence in elderly patients with comorbidities in polypharmacotherapy at home is a significant problem in public health and health care. Several factors of non-adherence have been identified in the studies reviewed, confirming that the problem is multifactorial. Reducing the number of medications prescribed would appear optimal, although often not possible, as this has been seen to have an immediate positive impact. A multidisciplinary approach makes it possible not to fragment care, ensuring positive feedback on therapeutic adherence.

P302 ENDOTHELIALITIS AS A POSSIBLE CAUSE OF MYOCARDIAL INJURY DURING COVID–19 INFECTION

A 53–year–old woman was admitted for chest pain for over two weeks, fever, dry cough, fatigue and myalgia. Chest pain increased in supine position and inspiration. Nasopharyngeal swab was positive for SARS–CoV–2 RT–PCR assay. Admission ECG displayed mild ST–segment elevation (0,5 mm) in inferolateral leads and echocardiogram showed normal left ventricular volume, mildly decreased left ventricular EF (52%) and no regional wall motion abnormalities. Blood tests exhibited elevated values of high–sensitivity troponin I (818 pg/mL), proBNP (19.190 pg/mL), CRP (42 mg/dL), D–Dimer test (1090 ng/mL) and WBC (13000/uL, N 89%, L 7%). IL–6 resulted slightly increased (18 ng/mL). ECG after 24 hours showed T wave inversion in inferolateral leads. Coronary CT angiography revealed normal epicardial arteries. A new echocardiogram, after five days, showed infero–basal hypokinesia, improved global EF (57%) and minimal pericardial effusion. Aspirin and fondaparinoux were started. Myopericarditis was suspected and high dose steroids were administered. After a few days, symptoms improved and ECG, echocardiographic abnormalities and troponin levels were normalized. At 6 weeks follow–up the patient was asymptomatic, ECG and echocardiogram were both normal. Instead cardiac MRI showed signs of endothelial injury: presence of interstitial oedema in the inferoapical and anteroseptal wall (STIR–T2–weighted), without late gadolinium enhancement. We measured blood levels of endothelial dysfunction markers: soluble ICAM–1, VCAM–1 and von Willebrand factor (vWF). They all resulted elevated as compared to a laboratory pool of normal serum (535 ng/ml, 265 ng/ml, and 1659 ng/ml, respectively). Our case was suggestive of myopericarditis related to Sars–Cov–2, but echocardiogram and MRI did not show signs of myocarditis permanent damage. However MRI showed interstitial oedema and hyperemia, typical signs of endothelial injury. Moreover we found high levels of soluble endothelial adhesion molecules, vWF, ICAM–1 and VCAM–1, likely expression of the microcirculatory endothelial dysfunction due to myocardial endothelialitis.

In conclusion, our case report suggests that, in COVID–19, acute myocardial injury associated with clinical and investigational signs of myocarditis can be due to myocardial endothelialitis rather than true myocarditis and that an early management with anti–inflammatory drugs (steroids) can be particularly beneficial in patients with unexplained elevated cardiac troponin.

Project for interventional Oncology LArge-database in liveR Hepatocellular carcinoma - Preliminary CT-based radiomic analysis (POLAR Liver 1.1)

OBJECTIVE

The objective of this study is to find a contrast-enhanced CT-radiomic signature to predict clinical incomplete response in patients affected by hepatocellular carcinoma who underwent locoregional treatments.

PATIENTS AND METHODS

190 patients affected by hepatocellular carcinoma treated using focal therapies (radiofrequency or microwave ablation) from September 2018 to October 2020 were retrospectively enrolled. Treatment response was evaluated on a per-target-nodule basis on the 6-months follow-up contrast-enhanced CT or MR imaging using the mRECIST criteria. Radiomics analysis was performed using an in-house developed open-source R library. Wilcoxon-Mann-Whitney test was applied for univariate analysis; features with a p-value lower than 0.05 were selected. Pearson correlation was applied to discard highly correlated features (cut-off=0.9). The remaining features were included in a logistic regression model and receiver operating characteristic curves; sensitivity, specificity, positive and negative predictive value were also computed. The model was validated performing 2000 bootstrap resampling.

RESULTS

56 treated lesions from 42 patients were selected. Treatment responses were: complete response for 26 lesions (46.4%), 18 partial responses (32.1%), 10 stable diseases (17.9%), 2 progression diseases (3.6%). Area-Under-Curve value was 0.667 (95% CI: 0.527-0.806); accuracy, sensitivity, specificity, positive and negative predictive values were respectively 0.66, 0.85, 0.50, 0.59 and 0.79.

CONCLUSIONS

This contrast-enhanced CT-based model can be helpful to early identify poor responder's hepatocellular carcinoma patients and personalize treatments.

The diagnostic performance of PIVKA-II in metabolic and viral hepatocellular carcinoma: a pilot study

OBJECTIVE

Hepatocellular carcinoma (HCC) is a primary liver tumor derived from metabolic or viral chronic hepatitis, with few treatment options in advanced cases. New biomarkers that allow improving diagnosis and staging are widely desired. Here, we aim to evaluate the performance of Protein Induced by Vitamin K Absence or Antagonist-II (PIVKA-II) in combination with α-fetoprotein (AFP), in the diagnosis of HCC in patients with metabolic or viral hepatitis.

PATIENTS AND METHODS

We enrolled 60 HCC patients (20 metabolic and 40 viral) and 20 healthy subjects (HS) as negative controls. PIVKA-II, AFP, Matrix metalloproteinase-9 (MMP-9) and Fibroblast growth factor (FGF) serum levels were assessed by immunoassays.

RESULTS

AFP and PIVKA-II levels were obviously higher in patients than in HS. AFP displayed a better diagnostic performance than PIVKA-II for viral HCC while PIVKA-II was better for metabolic HCC. The combination of the two biomarkers did not improve the discriminating ability.

CONCLUSIONS

PIVKA-II may be considered an independent predictor of macrovascular invasion from HCC cells and it can be used to better stratify HCC patients and should be evaluated in prospective studies for early detection of advanced HCC in metabolic subjects.

Mediterranean diet and the prevention of non-alcoholic fatty liver disease: results from a case-control study

OBJECTIVE

Few studies report that Mediterranean dietary (MD) pattern has a beneficial role in the progression of non-alcoholic fatty liver disease (NAFLD). Evidence on its potential effect on the onset of disease are, however, scanty. With our study, we evaluated whether MD affects the risk of NAFLD with a large case-control study performed in Italy.

PATIENTS AND METHODS

Three hundred and seventy-one cases of NAFLD and 444 controls were questioned on the demographic data and their dietary habits before diagnosis. Additionally, information about lifestyles and other related diseases, such as hypertension and diabetes mellitus were collected. The MD adherence was assessed using a pre-defined Mediterranean Diet Score (MDS). Odds ratios (OR) and 95% confidence intervals (CI) were obtained using a multiple logistic regression model.

RESULTS

A high adherence to the MD is significantly associated with decreased risk of NAFLD (OR: 0.83 95% CI: 0.71-0.98). When the different MD components were examined separately, higher legumes consumption (OR: 0.62 95% CI: 0.38-0.99) and high fish consumption (OR 0.38 95% CI: 0.17-0.85) were reported to be protective against NAFLD.

CONCLUSIONS

Our study shows that a high adherence to the MD decreases the risk of NAFLD.

Erythrocyte viscoelastic recovery after liver transplantation in a cirrhotic patient affected by spur cell anaemia

In physiological conditions, red blood cells (RBCs) are capable of dramatic deformations when passing through the microvasculature. This extreme deformability is closely related to the RBC biconcave shape, to the fluidic nature of the haemoglobin and the cell membrane structure, primarily consisting of a phospholipid bilayer with an underlying two-dimensional spectrin network. In many pathological and inflammatory conditions, the shape and the extreme deformability of erythrocytes appear to be significantly altered. These findings have stimulated intense research towards the search and validation of novel erythrocyte-based mechanical biomarkers, useful for disease diagnosis and therapy monitoring. In this study, we investigated with Atomic Force Microscopy (AFM) the mechanical properties of erythrocytes obtained from a 68 years old cirrhotic man diagnosed with spur cell anaemia and cold agglutinated disease, before and after liver transplantation. Mechanical changes are compared with ultrastructural alterations as studied by scanning electron microscopy and discussed according to confocal fluorescence microscopy results, showing possible alterations induced by the cirrhotic environment at the level of the RBCs cytoskeletal organisation and lipidic composition. Taken together, the results here presented show that liver transplantation not only contributes to restoring the proper RBC morphology, but it also induces recovery of the physiological viscous behaviour of cells, further stressing the relevance of viscous and dissipative forces in determining the RBC biomechanical response.

The impact of Multidisciplinary Tumor Boards on breast cancer care: results of a systematic review

A Multidisciplinary Tumor Board (MTB) is a group of professionals from different clinical areas that meets to examine oncological patients to face multiple aspects of the pathology. MTBs represent an effective way for clinical decision making and management of complex diseases like cancer that needs an integrated approach. They have the potential to implement patient's care optimizing both evaluation and treatment. The aim of this study was to evaluate the clinical and organizational impact and benefits of MTBs on breast cancer cases.

The databases investigated to carry out the research were Pubmed and Web of Science. Only Italian and English articles focused on breast cancer patients evaluated through MTB approach were included. No time restriction was adopted. Articles about other types of cancer were not included; systematic reviews and non-peer reviewed papers such as editorial and commentaries were excluded from the study.

The research found 5163 publications; duplicated records were omitted. 5086 articles were excluded through the analysis of title and abstract; after full text reading 52 studies were excluded. Only 25 publications fulfilled the inclusion and exclusion criteria. Two articles considered the impact of MTB on overall survival; 1 publication studied the effect of diagnostic changes; 7 articles examined the impact of MTBs on cancer treatment; 2 studies analysed the effects on clinical performance. Other publications examined secondary outcomes and indicators.

MTB has been described to have a positive impact on breast cancer. It improves overall survival (substantial results for over 65), diagnostic accuracy (up to 65%) and treatment scheme making it more adherent to guidelines (28%-93,1%). Furthermore, MTB makes patient's management more functional and avoids inappropriate interventions.

Further studies are needed to deepen on some topics such as the economic aspects and the importance of the participation of general practitioners to MTBs.

Key messages

MTB could improve patient’s care and clinical management of cancer. It is necessary to study if greater accuracy in patient’s management could have economic impact as it avoids inappropriate procedures.

Acute HEV hepatitis: clinical and laboratory diagnosis

OBJECTIVE

Hepatitis E Virus (HEV) is probably the most common cause of acute hepatitis worldwide. It has been regarded for a long time as a disease limited to developing countries. Recently, the refinement of diagnostic techniques, on the one hand, and migratory flows, on the other hand, have also led to the identification of an increased number of HEV infections in industrialized countries. Four HEV genotypes have been identified across the world, with different epidemiological burdens and a wide range of clinical presentations. Here, we report a case series of acute HEV hepatitis observed in the last three years in our hospital.

PATIENTS AND METHODS

We performed a search for HEV IgM and IgG in all subjects admitted for acute hepatitis without evidence of other possible infectious, toxic or metabolic causes of liver damage. In subjects with HEV IgM positivity, the search for HEV-RNA was performed.

RESULTS

We diagnosed eight acute HEV infections: 2 epidemic and 6 sporadic forms. HEV-RNA was detected in serum in 2 cases.

CONCLUSIONS

HEV infection appears to be a cause of acute hepatitis that we must keep in mind even in developed countries.

Role of Immunoscintigraphy in Clinical Assessment of Gastrointestinal Tumors

From June 1986 until April 1989 31 patients with gastrointestinal tumors were studied at follow-up for recurrences by Immunoscintigraphy (IS) using F(ab)2 fragments of monoclonal antibodies anti CEA and anti CA 19-9. IS was employed to confirm the presence of metastases already found (group A) and to verify metastases suspected following physical and Instrumental examinations and/or increases in CEA and/or CA 19-9 (group B). Thirty-four IS findings have been evaluated to date: 19 in group A, with 18 true positive and 1 false negative results; 15 in group B. In these patients there were 12 cases of pathologic high fixation: 6 were confirmed using standard examinations after a median follow-up of 1 month (range 1-12); 6 cases had no metastatic evolution at the suspected site after a follow-up of 5-28 months. In 3 cases IS was negative, these patients are disease free at 13, 14 and 24 months. In group B, 5 of 8 abdominal intense fixations were early diagnoses of local or peritoneal recurrences. The overall accuracy was 79.4% and it was not affected by circulating CEA levels; sensitivity was 96%. IS can be considered useful as a primary diagnostic examination in the follow-up of patients with suspected abdominal metastases.

Post-liver transplant intrahepatic cholestasis: etiology, clinical presentation, therapy

Post-liver transplant intrahepatic cholestasis is consequent to the impairment of bile flow or formation. It may develop in the early (within 6 months) or in the late (more than 6 months) post-liver transplant period and different causes may be recognized according to the time elapsed from a liver transplant. The raise at various degrees of serum bilirubin, alkaline phosphatase, and gamma-glutamyl transpeptidase, with or without increased transaminases levels, are common hematochemical findings. Liver histology is helpful for diagnostic assessment, and sometimes crucial to differentiate among possible causes of cholestasis. Although timely treatment of underling conditions as well as supportive care may resolve post-liver transplant intrahepatic cholestasis, the risk of graft loss and retransplantation are remarkable. For this reason, post-liver transplant intrahepatic cholestasis should be managed in collaboration with the LT center, and treatment should be devolved to expert hepatologists.

Fatty liver and drugs: the two sides of the same coin

Drug-induced liver injury (DILI) is a common and underestimated cause of liver disease. Several drugs and other xenobiotics can be the cause of different clinicopathologic patterns of liver disease. Steatosis and steatohepatitis are rare but well-documented types of DILI. Over the past decades commonly used drugs like amiodarone, tamoxifen, irinotecan, methotrexate, valproic acid and glucocorticoids have been recognized to be associated with steatosis. Even though the pathophysiological pathways are still only partially understood, inhibition of mitochondrial beta-oxidation, reduced very low-density lipoprotein secretion, insulin resistance induction and increased de novo synthesis or increased liver uptake of fatty acids are considered the main pathogenic mechanisms through which drugs can lead to hepatic steatosis. On the other hand, fatty liver itself is a very common clinical condition, and there is a growing awareness of the potential risk factors for DILI due to the underlying metabolic condition itself.

Drug-induced liver injury 2017: the diagnosis is not easy but always to keep in mind

A drug-induced liver injury (DILI) is defined as a liver injury caused by exposure to a drug or a non-infectious toxic agent with a variable degree of organ dysfunction. A better understanding of DILI epidemiology has been obtained in recent years with the institution of international registries in the United States and Europe. Despite the advances in the understanding and characterization of the phenomenon, DILI remains an exclusion diagnosis so, probability scores and the analysis of literature reports are useful tools in dealing with a suspected DILI. Idiosyncratic DILI can be considered a relatively rare event but it is one of the leading causes of acute liver failure. Thus, proper management is essential to avoid serious consequences. Here, we present an updated review of diagnostic and classification criteria of DILI. Prognostic tools, and principles of management and therapy have also been briefly discussed.

Liver transplantation for drug-induced acute liver failure

OBJECTIVES

To summarize the different clinical features of drug-induced acute liver failure, the diagnostic work-up, conservative management and the prognostic scores currently used to list patients for liver transplantation.

EVIDENCE AND INFORMATION SOURCES

The current review is based on an analysis of the current literature and the caseload experience of the Authors on this topic.

STATE OF THE ART

Drug-induced liver injury is the leading cause of acute liver failure in the adult population in Western countries, with a transplant-free survival rate of less than 50%. Main subtypes include paracetamol and idiosyncratic drug-induced injury, which differ in epidemiology, clinical course, prognosis and conservative management. In cases of a high likelihood of death, urgent hepatic transplantation is indicated, but the decision whether and when to put a patient with drug-induced acute liver failure on the list for urgent liver transplant is extremely difficult and requires constant interdisciplinary exchange and continuous updating of the clinical picture.

CONCLUSIONS

Intensive management should be done in a clinical tertiary referral center which has a specialized team of hepatologists and a liver transplant center.

Impairment of Recent Thymic Emigrants in HCV Infection

Hepatitis C Virus (HCV) often has a more favorable course in younger patients. Considering the involution of the thymic function with age, we investigated the output of recent thymic emigrants (RTE) in HCV patients. To evaluate RTE, we used a competitive quantitative PCR in order to determine the percentages of cells with cj-T cell receptor excision circles (TREC). This study was performed in 14 HCV patients at diagnosis and before any anti-HCV treatment. The results obtained in this group were compared to those obtained in a group of age-matched controls. We found that in the 14 HCV patients naive for anti-HCV treatment the mean percentage of cj-TREC was 3%. We could not detect a correlation between the percentages of cj-TREC and age or patients' viremia. In contrast, in the 26 age-matched controls mean percentage of cj-TREC was 5.6% (P=0.01). Our study describes a novel immune defect in HCV patients. Additional studies are needed to get further insight in the possible role of TREC defect in the pathogenesis and prognosis of the disease.

An update on clinical applications of hepatospecific contrast media in magnetic resonance imaging of liver parenchyma

Hepatobiliary-specific contrast agents are now widely used in magnetic resonance imaging (MRI) of liver parenchyma. As extracellular fluid agents, they provide informations regarding lesion vascularity and their use in the hepatobiliary or delayed phase (DPI), and give additional data regarding hepatocyte presence and function. The aim of this article is to review the recent literature about MRI using hepatobiliary-specific contrast agents and to discuss benefits and limits of their clinical applications. Since November 2008, hepatobiliary contrast agents were routinely employed in our Institution for the characterization of equivocal liver lesions detected by other imaging modalities, and for the evaluation of hepatic nodules in liver cirrhosis. The informations provided are particularly relevant for the detection of metastases, for the differentiation between focal nodular hyperplasia (FNH) and hepatocellular adenoma (HCA), and for the detection and differentiation between dysplastic nodules (DNs) and hepatocellular carcinoma (HCC) in the cirrhotic liver. The role in the cirrhosis grading and the quantification of liver function is still controversial. Finally, their biliary excretion allows evaluation of anatomy and function of the biliary tree. According to our and reported data, hepatobiliary contrast agents are able to improve liver lesions detection and characterization; their introduction in clinical practice has improved MRI diagnostic efficacy/accuracy, allowing to decrease the number of invasive diagnostic procedures.

Towards 100 channel dense wavelength division multiplexing with 100GHz spacing on silicon

A 1 by 4 wavelength division multiplexer with 0.5nm bandwidth and no free spectral range limitation is demonstrated on silicon. The device utilizes wide bandwidth filters cascaded with ring resonators in order to select specific ring resonator modes and route each resonant mode to a separate port. This technology will enable dense wavelength division multiplexing covering the C - and L - bands with up to 100 10GB/s channels separated by 100GHz to be implemented for optical interconnects applications. A 1 by 4 wavelength division multiplexer with 3dB channel bandwidths as small as 0.5nm and 1dB insertion loss are demonstrated with 16dB inter-channel crosstalk suppression. A second wavelength division multiplexer scheme with four channels, each spaced 0.5nm apart without any free spectral range limitations is also demonstrated using wide bandwidth filters centered at the same wavelength to select resonances from four different ring resonators with slightly different widths.

Silicon nanophotonic devices for chip-scale optical communication applications [Invited]

This paper reviews recent work in the area of silicon photonic devices and circuits for monolithic and heterogeneous integration of circuits and systems on a chip. In this context, it presents fabrication results for producing low-loss silicon waveguides without etching. Resonators and add-drop distributed filters utilizing sidewall modulation fabricated in a single lithography and etching step are demonstrated. It also presents an optical pulse compressor that monolithically integrates self-phase modulation and anomalous dispersion compensation devices on a silicon chip. As an example of heterogeneous integration, we demonstrate vertical emitting metallo-dielectric nanolasers integrated onto a silicon platform. Future research directions toward large-scale photonic circuits and systems on a chip also are discussed.

Single-step multimodal locoregional treatment for unresectable hepatocellular carcinoma: balloon-occluded percutaneous radiofrequency thermal ablation (BO-RFA) plus transcatheter arterial chemoembolization (TACE)

PURPOSE

This study was undertaken to evaluate the feasibility, safety and efficacy of a new combined single-step therapy in patients with unresectable multinodular unilobar hepatocellular carcinoma (HCC), with at least one lesion >3 cm, with balloon-occluded radiofrequency ablation (BO-RFA) plus transcatheter arterial chemoembolization (TACE) of the main lesion and TACE of the other lesions. The second purpose of our study was to compare the initial effects in terms of tumour necrosis of this new combined therapy with those obtained in a matched population treated with TACE alone in a singlestep treatment in our centre in the previous year.

METHODS AND MATERIALS

This pilot study was approved by the institutional review board, and informed consent was obtained from all patients. Ten consecutive patients with multinodular (two to six nodules) unilobar unresectable HCC and with a main target lesion >3 cm (range, 3.5-6 cm) not suitable for curative therapy were enrolled in our single-centre multidisciplinary pilot study. The schedule consisted of percutaneous RFA (single 3-cm monopolar needle insertion) of the target lesion during occlusion of the hepatic artery supplying the tumour, followed by selective TACE, plus lobar TACE for other lesions (450-mg carboplatin and lipiodol plus temporary embolisation with SPONGOSTAN). Adverse events and intra- and periprocedural complications were clinically assessed. Early local efficacy was evaluated on 1-month follow-up multiphasic computed tomography (CT) on the basis of the Modified Response Evaluation Criteria in Solid Tumors (m-RECIST). A separate evaluation of target lesions in terms of enhancement, necrotic diameter and presence and distribution of lipiodol uptake was also performed.

RESULTS

No major complications occurred. Overall technical success, defined as complete devascularisation of all nodules during the arterial phase, was achieved in seven of 10 patients, with three cases of partial response (persistence of small hypervascular nodules). When considering only target lesions, technical success was obtained in all patients, with a nonenhancing area corresponding in shape to the previously identified HCC (necrotic diameter, 3.5-5 cm) and with circumferential peripheral lipiodol uptake (safety margin) of at least 0.5 cm (0.5-1.3cm).

CONCLUSIONS

TACE and BO-RFA, plus TACE in a singlestep approach seems to be a safe and effective combined therapy for treating advanced, unresectable HCC lesions, allowing a high rate of complete local response to be achieved in large lesions also.

Potential use of liver function breath tests in the clinical practice

BACKGROUND

Assessment of hepatic functional reserve in acute and chronic liver disease is a discriminating factor for prognostic and therapeutic reasons. For this reason dynamic liver function tests have been developed.

AIM

To review the breath method with stable carbon isotopes in hepatological setting.

MATERIALS AND METHODS

We conducted a literature review to analyze the experimental evidence about the diagnostic potential of breath tests of liver function.

RESULTS

Liver breath tests are able to discriminate between healthy subjects and patients with liver cirrhosis. The use for the assessment of liver fibrosis seems to be still burdened with less capability to discriminate between intermediate stages.

CONCLUSIONS

Liver breath test are a promising tool for the evaluation of hepatic functional reserve but the use of such methods in clinical practice is limited to specialized or research centers. Most extensive studies are necessary to facilitate the spread of these methods in clinical practice.

Severe Giant Cell Arteritis Associated with Essential Thrombocythaemia

Giant-cell arteritis (GCA) is a chronic vasculitis of the elderly usually involving the ophthalmic arteries, which can result in visual loss. High platelet counts may have some pathogenic significance in the obstruction of the ophthalmic circulation and a few cases of associated essential thrombocythaemia and GCA have been described. Here we report a case of severe temporal arteritis associated with essential thrombocythaemia.

Transarterial chemoembolization (TACE) for unresectable HCC: a new life begins?

BACKGROUND AND OBJECTIVES

To provide an overview on the loco-regional therapy performed by transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC), either as sole, either as neoadjuvant to surgery or bridge therapy to orthotopic liver transplantation (OLT).

EVIDENCE AND INFORMATION SOURCES

The current review is based on an analysis of the current literature and the caseload experience of the Authors on this topic.

STATE OF THE ART

Chemoembolization combines de-arterialization of the tumor and selective delivery of chemotherapeutic agents into tumor's feeding vessels during angiography. Tumor ischemia raises the drug concentration compared to infusion alone and extends the retention of the chemotherapeutic drug. As locoregional therapy, TACE allows a complete local tumor control of 25-35% and permits an increase of survival in patients with intermediate HCC according to Barcelona-Clinic Liver Cancer (BCLC) classification. Excellent results were also achieved by combined therapies, such as with percutaneous ethanol injection or radiofrequency ablation, as neoadjuvant therapy prior to liver resection and in some circumstances as a bridging tool before liver transplantation.

PERSPECTIVES

Drug eluting beads are microspheres that can be loaded with doxorubicin and induce toxic and ischemic necrosis with the same device; that allows an increase of drug selectively exposed to tumor cells and simultaneously a reduction of systemic toxicity. Tumor embolization induces a neoangiogenic reaction with a significant growth of adiacent satellites, so the association with sorafenib has a strong rationale for a combined therapy and is currently under investigation.

CONCLUSIONS

Today TACE is the standard of care for treatment of intermediate hepatocellular carcinoma. To get the best performance it should be tailored according to the individual patient's condition.

[The treatment of hepatocellular carcinoma: an update]

Hepatocellular carcinoma (HCC) is the third most frequent cause of death from cancer with an increasing incidence in the world. Hepatic cirrhosis is the main risk factor for the development of this tumor, present in more than 80% of cases. The prognosis of this tumor is still poor and appears to be strictly related to liver residual function and tumor extension. A regular surveillance program was defined to increase early detection of tumor in cirrhotic patients when curative treatment could be applied. Liver transplantation and liver resection offer a high rate of positive response when applied in a early stage of the disease; locoregional therapies are effective, palliative options for patients with unresectable HCC: transarterial chemoembolisation being the only with a proven positive impact on survival. Several prognostic systems are proposed in the last years to stratify patients in different risk groups and to identify those who could achieve the best survival benefit from different therapeutic strategies: the Okuda system, the Cancer of the Liver Italian Program and the Barcelona Clínic Liver Cancer are the most widely used, but there is no consensus to which is the best in predicting outcome most accurately.

Gastrointestinal amyloidosis: a case of chronic diarrhoea

Amyloidosis is a rare disease caused by extracellular deposits of insoluble fibrillar proteins in various organs and tissues. There are different forms of amyloidosis distinguished by the type of protein fibrils, by the sites of deposition and by associated conditions. Gastrointestinal involvement is common both in primary and secondary amyloidosis, while isolated gastrointestinal amyloidosis is rare. We describe a case of AL amyloidosis with a gastrointestinal involvement and restrictive cardiomiopathy. A 64 year old woman came to our attention with a history of chronic diarrhoea and weight loss, associated with dysphagia, dry mouth, xerophtalmia, chronic gastritis and depression. Clinical diagnosis has been difficult because of aspecificity of symptoms that mimed other more common diseases, like gastro-paresis, epigastric discomfort, gastric or duodenal ulcers, perforation, malabsorption, intestinal pseudo-obstruction. There is an important risk of misunderstanding and diagnostic delay. Indeed in this patient a diagnosis of irritable colon syndrome was erroneously established two years before admission in our hospital. Therefore gastrointestinal amyloidosis should be considered among differential diagnoses of chronic diarrhoea and weight loss when other more common diseases have been excluded.

Evaluation of microbial contamination of air in two haematology departments equipped with ventilation systems with different filtration devices

BACKGROUND

Nosocomial infections (NI) are above all due to health-care workers practices, but also the contamination of the environment could lead to their rise in health-care facilities. Introduction. In the last years, the incidence of NI has increased due to a substantial rise in the number of immuno-compromised patients. These patients are often gathered in hospital areas declared at "high risk" of infection such as Hematology and Bone Marrow Transplant ward. In this study, we evaluated microbial contamination of the air in two divisions with high risk patients, focusing on the validity of the air system with correlation to the presence or not of the HEPA absolute filters.

METHODS

An environmental surveillance study has been carried out in two Divisions of Haematology, in two different Hospitals. Investigations have been performed by sampling air and by analyzing bacterial and fungal growth on microbiology plates after an incubation period.

RESULTS

Unit A, without HEPA filters in the ventilation systems, showed a gradual increase in the bacterial load 20 and 60 days after cleaning of the ventilation system. Mycetes and Aspergilli were not present in basal conditions, at 20 or 60 days after decontamination. Unit B, equipped with HEPA filters placed at the inlet vents, showed extremely low values of the bacterial load either in basal conditions or upon inspection 60 days after cleaning. No mycetes were present.

DISCUSSION

From the results obtained, it was evident that following the cleaning operation, the quality of the air is excellent in both types of equipment, since no mycetes were present and the bacterial load was < 20 CFU/mc in all the sites tested. However, although in subsequent controls mycetes were absent in both types of equipment, a great difference in the suspended bacterial load was found: Unit B was close to sterility whereas in Unit A a progressive increase was observed.

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.

Mild hepatitis at recommended doses of acetaminophen in patients with evidence of constitutionally enhanced cytochrome P450 system activity

Acetaminophen (paracetamol) is used throughout the world for pain relief and antipyresis in both children and adults. In many countries, it can be purchased without a medical prescription and it is also a common component of a number of over-the-counter remedies for colds, influenza and the like. Fasting, malnutrition and use of alcohol and/or other drugs are thought to play causal roles in hepatotoxicity associated with recommended doses of acetaminophen although liver injury provoked by therapeutic doses has also been observed in the absence of these factors. We describe two patients who experienced subclinical hepatotoxic reactions after taking acetaminophen at therapeutic doses. The results of an antipyrine metabolism test suggest the presence of constitutional hyperactivity of the cytochrome P450-dependent mixed function oxidative system in both patients. We hypothesize that the latter contributed to the hepatotoxicity and that it may play a role in idiosyncratic reactions to this drug.

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.

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.

Alcoholic and nonalcoholic forms of fatty liver disease

Fatty liver (or steatosis) is an increasingly common finding in histolgical evaluation of liver biopsies. It is frequently associated with obesity, diabetes, metabolic syndromes, and/or alcohol abuse. When the steatosis is accompanied by inflammation and fibrosis, the risk of progression to severe liver disease is high. The aim of this paper is to review the clinical features, pathophysiology, natural history, and options for the treatment of nonalcoholic and alcoholic forms of fatty liver disease.

[Polycystic ovary syndrome and obesity: non pharmacological approaches]

In patients affected of polycystic ovary syndrome (PCOS), obesity has an high percent of incidence and represents an important factor increasing its clinic evolution, both in metabolic than in reproductive terms. For these patients non pharmacologic treatments aimed at the reduction of body weight, such as diets and physical exercise, represent the first line therapeutic approach. The aim of this review is to analyze the changes in life style and to highlight their efficacy in reducing the negative effects of PCOS on metabolism and reproductivity. Specifically different types of diet have been compared, in health or PCOS women, such as low glycemic index diets, moderate carbohydrate, high protein and low fat diets, very low carbohydrate and high fat diets and, finally, moderate carbohydrate and high monounsaturated fat diets. In the global view of the approach to the disease, different regimens of physical activity and the usefulness of a behavior therapy were also evaluated. Results obtained in health women suggest that diets higher in proteins and lower in carbohydrates are to be preferred to the conventional diet lower in fats and higher in carbohydrates. Anyway other studies are necessary to justify a similar assertion in women with PCOS. At the same way, the optimum regimen of physical exercise for PCOS women is still to be demonstrated.

Sjogren's syndrome in a celiac patient: searching for environmental triggers

In the last few years many studies have shown the potential role of different triggers in the pathogenesis of several autoimmune diseases. In particular, in Sjogren's syndrome the presence of a genetic background is considered determining, but environmental factors have recently been described as triggers or precipitators. In this report, we describe the case of a young woman affected by celiac disease in which an Ascaris lumbricoides infestation and estrogen therapy could have played a role in the development of Sjogren's syndrome.

Anticholinergic syndrome due to 'Devil's herb': when risks come from the ancient time

We describe a case of Mandragora autumnalis poisoning which occurred in a 72-year-old female patient who had eaten the venenous M. Autumnalis, picked near her home, mistaking it for the edible Borago Officinalis. M. Autumnalis is a solanaceous plant, common in the Sicilian countryside, which contains a variable concentration of solanum alkaloids, causing gastrointestinal irritation, and tropane alkaloids, with anticholinergic properties. Unluckily, M. Autumnalis is often mistaken for the edible B. Officinalis, likewise widespread in Sicilian countryside. The diagnosis of Mandragora poisoning was made on the basis of clinical symptoms and signs of anticholinergic syndrome associated with a history of vegetable meal of uncontrolled origin, moreover analysing the vegetable obtained from gastric lavage. Decontamination and symptomatic treatment were useful in our patient to control acute poisoning.

Nonalcoholic fatty liver disease: defining a common problem

Non Alcoholic Fatty Liver Disease (NAFLD), with prevalence of 10-51% in general population involving all ages, is the major cause of elevation of ALT and a common finding by ultrasound screening and may range from simple steatosis, to Non Alcoholic Steatohepatitis (NASH) and its clinical consequences as cirrhosis and hepatocellular carcinoma. In this review will be analyse factors influencing the onset of the disease. NAFLD, primarly associated with insulin resistance, is in fact considered the hepatic manifestation of the metabolic syndrome: a cluster of disorder that includes obesity, diabetes mellitus, dyslipidaemia, arteriosclerosis and hypertension. The increased incidence and prevalence of obesity and diabetes may explain growing interest in NAFLD. Racial, ethnic, enviromental and behaviour models are also reviewed.

The natural history and risk factors for progression of non-alcoholic fatty liver disease and steatohepatitis

Nonalcoholic fatty liver disease (NAFLD) is a condition of increasing incidence in western Countries seldom associated to other diseases of high prevalence in general population (i.e. diabetes and obesity). NAFLD ranges from simple fatty liver to steatohepatitis (NASH), which may lead to cryptogenic cirrhosis and in some cases hepatocellular carcinoma (HCC). Natural history of NAFLD in humans is poorly understood and progression of liver disease seems to be due to interaction between hosting (i.e. genetic, gut flora, insulin resistance) and environmental factors (social and eating behaviours) that should be responsible of increased oxidative stress within hepatocytes. Even if we need non-invasive markers able to describe the progression of liver disease, only meaning of liver biopsy is useful to characterize the stigmata of worsening such as inflammation and fibrosis.

Hepatic steatosis and vascular disease

Nonalcoholic fatty liver disease (NAFLD) refers to a wide picture of liver damage, ranging from steatosis to steatohepatitis, fibrosis and cirrhosis. The epidemiological studies demonstrated an association of NAFLD with obesity, type 2 diabetes and hyperlipidemia. Under this light the metabolic syndrome (MS), including NAFLD, obesity, central fat distribution, diabetes, dyslipidemia, hypertension and atherosclerotic cardiovascular disease (CVD) can be considered the link to explain the presence of vascular diseases in patients with NAFLD. In NHANES III, the authors demonstrated that the presence of MS was associated with increased risk of myocardial infarction, stroke or both. In a prospective study on 1209 Finnish middle-aged men without CVD or diabetes at baseline, Lakka showed that MS per se is associated with an increased risk of CVD and all-cause mortality. Finally the Atherosclerosis Risk in Communities (ARIC) confirmed that subjects with MS were 2 times more likely to have prevalent coronary heart disease. From a pathophysiological point of view, growing evidences implicate the oxidative stress as the unifying mechanism for many CVD risk factors. Under this light there is emerging evidence suggesting that there is a significant increase in vascular oxidative stress in patients with MS, with the presence of endothelial dysfunction in the early stage of the syndrome. Indeed, the inflammation process evidentiated in these patients is initiated at the endothelial level, stressing the key role of this active and dynamic tissue in the pathophysiological pathways. Under this light the endothelium can be considered as the last effector of a multi-syndrome and the main target of all the future studies focused on the underlying mechamisms of this complex network. Because of the potential serious public health impact, the comprehension of these patophysiological pathways will be crucial to design new preventive measures and therapeutic strategies.

Fatty liver and drugs

Drug-induced liver diseases (DILD) are clinico-pathologic patterns of liver injury caused by drugs or other foreign compounds. Steatohepatitis is a rare form of DILD, and drugs account for fewer than 2% of non-alcoholic steatohepatitis (NASH). Drugs known to be capable of inducing steatosis and steatohepatitis can be divided into three broad groups: those that cause steatosis and steatohepatitis independently (e.g., amiodarone, perhexiline maleate); drugs which can precipitate latent NASH (e.g., tamoxifen); drugs whic duce sporadic events of steatosis/steatohepatitis (e.g., carbamazepine). Clinical DILD syndromes include acute viral hepatitis-like injury, acute liver failure, cholestatic hepatitis,liver disease with signs of hypersensitivity, autoimmune hepatitis-like injury, acute venous-Outflow obstruction, chronic cholestasis, ciirrhosis, steatosis and steatohepatitis. The clinical picture is by no means dependent on the mechanism of injury (direct hepatotoxicity, idiosyncratic reactions, hypersensitivity reactions). Reliable diagnosis of drug-induced liver disease requires demonstration of close correlation between the patient history and clinical, laboratory, and histological data.

Nutritional aspects in patients with non-alcoholic steatohepatitis (NASH)

BACKGROUND AND OBJECTIVES

Metabolic alterations are a common feature in patients affected by non-alcoholic steato-hepatitis (NASH). A strong correlation exists between overweight, in particular visceral fat accumulation, and prevalence of NASH, especially in men. Thus, diet-induced weight loss represents a fundamental tool in disease management of these patients. The aim of the present study was to evaluate body composition and nutrient utilisation in patients with NASH, comparing them with patients affected by chronic hepatitis related to hepatitis C virus (HCV) infection and with healthy subjects.

MATERIALS AND METHODS

Twenty male outpatients with NASH (age: 41 +/- 11 yr; BMI: 26.2 +/- 2.1 kg/m2) and 14 HCV male patients (age 44.6 +/- 13 yr; BMI: 24.8 +/- 2.8 kg/m2) were enrolled in the study. A group of 20 healthy male subjects (age: 39 +/- 10 yr; BMI: 23.3 +/- 1.1 kg/m2) were studied as controls. Body composition was assessed by anthropometry and dual-energy X-ray absorptiometry; resting metabolic rate and nutrient oxidation by indirect calorimetry. A 7-day food diary was collected. The main biochemical parameters were measured using standardised laboratory techniques.

RESULTS

Body weight was higher in NASH patients with respect to HCV patients and control subjects (respectively 75.2 +/- 8.9 vs 68.5 +/- 9.4 and vs 67.0 +/- 8.0 kg; P < 0.01) and this was essentially due to fat mass increase. Fat-free mass reduction was found in HCV patients with respect to both NASH and control subjects. Patients with NASH had a significantly higher waist circumference (P < 0.01) and a lower resting metabolic rate (RMR) with respect to HCV and control subjects. Energy intake was significantly higher in NASH patients (P < 0.01) compared to the other two groups.

CONCLUSIONS

NASH patients showed an increase in body weight, fat mass and visceral fat accumulation with respect to HCV and control subjects. The reduction in RMR, coupled with increase energy intake may explain the body composition alterations found in these patients.