Congenital metatarsus varus: early diagnosis and conservative treatment in 112 patients

PURPOSE

To describe a conservative treatment algorithm to manage Congenital Metatarsus Varus.

BACKGROUNDS

Congenital Metatarsus Varus is a congenital disorder with an estimated incidence of 1/1000 newborns. Despite the deformity being mostly an aesthetic problem, residual and incorrect forms may be responsible for abnormal in-toe gait and shoe-wearing issues. No consensus has still been gathered regarding its correct treatment algorithm.

METHODS

Between May 2019 and September 2020, 2156 newborn patients underwent an orthopedic examination at birth. Patients affected by Congenital Metatarsus Varus were classified according to Bleck's classification as flexible, semi-flexible or non-flexible deformity. A conservative treatment algorithm was followed, based on the application of manipulations, Bebax-type braces or plaster cast. All patient were followed until the clinical resolution of the deformity. Complications were also recorded.

RESULTS

One-hundred twenty-four patients were diagnosed Congenital Metatarsus Varus, with an overall prevalence of 5/1000. One-hundred twenty-two patients presented with a flexible or semi-flexible foot deformity and were firstly treated with manipulations: 52 patients reported good results, while 70 required additional treatment with Bebax-type braces for achieving correction. Two patients presented a non-flexible deformity at birth: one required plaster cast due to a non-flexible deformity, and one patient was firstly managed with Bebax-type braces due to a severe semi-flexible deformity. Only two patients presented superficial skin ulcerations, healed within a week. Two patients were lost during the follow-up.

CONCLUSION

An early diagnosis allowed by an orthopedic examination in all newborns may be a valid instrument to avoid Congenital Metatarsus Varus misdiagnosis. Early treatment with manipulation and orthosis resulted in good clinical outcome, with only few complications.

Effects of transcranial magnetic stimulation on cocaine addiction: A systematic review of randomized controlled trials

OBJECTIVE

While pharmacological strategies appear to be ineffective in treating long-term addiction, repetitive transcranial magnetic stimulation (rTMS) is emerging as a promising new tool for the attenuation of craving among multiple substance dependent populations.

METHOD

A systematic review of randomized controlled trials (RCTs) was conducted on the efficacy and tolerability of rTMS in treating cocaine use disorder (CUD). Relevant papers published in English through November 30th 2022 were identified, searching the electronic databases MEDLINE, Embase, PsycINFO and the Cochrane Library.

RESULTS

Eight studies matched inclusion criteria. The best findings were reported by the RCTs conducted at high-frequency (≥5 Hz) multiple sessions of rTMS delivered over the left dorsolateral prefrontal cortex (DLPFC): a significant decrease in self-reported cue-induced cocaine craving and lower cocaine craving scores and a considerable amelioration in the tendency to act rashly under extreme negative emotions (impulsivity) were found in the active group compared to controls.

CONCLUSION

Although still scant and heterogeneous, the strongest evidence so far on the use of rTMS on individuals with CUD support the high frequency stimulation over the left DLPFC as a well tolerated treatment of cocaine craving and impulsivity.

Phospho-DIGE Identified Phosphoproteins Involved in Pathways Related to Tumour Growth in Endometrial Cancer

Endometrial cancer (EC) is the most common gynecologic malignancy of the endometrium. This study focuses on EC and normal endometrium phosphoproteome to identify differentially phosphorylated proteins involved in tumorigenic signalling pathways which induce cancer growth. We obtained tissue samples from 8 types I EC at tumour stage 1 and 8 normal endometria. We analyzed the phosphoproteome by two-dimensional differential gel electrophoresis (2D-DIGE), combined with immobilized metal affinity chromatography (IMAC) and mass spectrometry for protein and phosphopeptide identification. Quantities of 34 phosphoproteins enriched by the IMAC approach were significantly different in the EC compared to the endometrium. Validation using Western blotting analysis on 13 patients with type I EC at tumour stage 1 and 13 endometria samples confirmed the altered abundance of HBB, CKB, LDHB, and HSPB1. Three EC samples were used for in-depth identification of phosphoproteins by LC-MS/MS analysis. Bioinformatic analysis revealed several tumorigenic signalling pathways. Our study highlights the involvement of the phosphoproteome in EC tumour growth. Further studies are needed to understand the role of phosphorylation in EC. Our data shed light on mechanisms that still need to be ascertained but could open the path to a new class of drugs that could hinder EC growth.

Somatic and Germline Variants Affect Prognosis and Susceptibility in Prostate Cancer

BACKGROUND/AIM

Prostate cancer (PCa) is one of the most common tumors in men accounting for the 7.3% of all cancer-associated diseases in 2020. In advanced stage, this pathology is a lethal disease and is the fifth cause of cancer death in men worldwide. The diagnosis of PCa is performed by prostate-specific antigen (PSA) detection combined with direct rectal examination (DRE). However, high PSA levels can be detected in non-malignant conditions leading to overtreatment of non-oncological patients. Moreover, PSA levels are not associated with disease progression; therefore, the research of novel biomarkers could improve diagnosis and prognosis of this tumor. In this regard, genetic polymorphisms may affect PCa outcome as well as to be associated with cancer familiarity. In fact, germline variations detected in different genes including BRCA1, BRCA2, ATM and HOXB13 seem to be associated with PCa susceptibility and progression.

MATERIALS AND METHODS

Somatic and germline polymorphisms were detected by next generation sequencing (NGS) in 48 PCa subjects and paired controls. Gene variants were matched with patient outcome and cancer familiarity to identify mutations linked to prognosis and tumor predisposition.

RESULTS

NGS sequencing has allowed to identify different genetic polymorphisms that could be linked to cancer outcome and predisposition. In particular, somatic and germline mutations found in ATM, FOXA1 and SPOP genes correlate with poor prognosis and/or high Gleason score. Moreover, germline variants lying mainly in ATM, but also in ZFHX3, SPOP, CHD1, CDK12 and APC seem to be associated with hereditary-predisposing cancer syndrome.

CONCLUSION

Variants correlating with poor prognosis and cancer susceptibility could be usable as possible tumor biomarkers in prostate cancer.

Proteomic tools to study phosphorylation of intrinsically disordered proteins

INTRODUCTION

Intrinsically disordered proteins (IDPs) represent a family of proteins that lacks secondary or tertiary structure. IDPs are hubs in interaction networks, participate in liquid-liquid phase separation processes, and drive the formation of proteinaceous membrane-less organelles. Their unfolded structure makes them particularly prone to post-translational modifications (PTMs) that play key functional modulatory roles.

AREAS COVERED

We discuss different analytical approaches to study phosphorylation of IDPs starting from methods for IDPs enrichment (strong acid extractions and heat-based pre-fractionation), strategies to enrich and map phosphopeptides/proteins, and mass spectrometry-based tools to study the phosphorylation-dependent conformational alterations of IDPs (limited proteolysis, HDX, chemical cross-linking, covalent labelling, and ion mobility).

EXPERT OPINION

There is a growing interest in IDPs and their PTMs since they are involved in several diseases. The intrinsic disorder could be exploited to facilitate purification and synthetic production of IDPs taking full advantage of those structural mass-spectrometry-based methods that can be used to investigate IDPs and their phospho-dependent conformational alterations. The diffusion and implementation of mass spectrometers with ion mobility devices and electron transfer dissociation capabilities could be key-elements for increasing information on IDP biology.

"Swab Team" in the SARS-CoV-2 outbreak containment among healthcare workers

INTRODUCTION

To analyze the virus spread among Sassari Hospital staff in the first Covid-19 wave and the impact of the Swab Team, a multidisciplinary task force entitled of nasopharyngeal swab collection and testing.

METHODOLOGY

Nasopharyngeal swabs from HCWs between March 6 and May 28 2020 are evaluated.

RESULTS

4919 SARS-CoV-2 tests were performed on 3521 operators. Nurses and doctors are the categories at highest risk. After the Swab Team institution, the average number of swabs raised from 47/day to 86/day (p = 0.007). Positive samples decreased from 18.6% to 1.7% (p < 0.0001).

CONCLUSIONS

The Swab Team is effective in increasing the cases tested and in reducing the reporting time. Procedure standardization reduces the risk for all the subjects involved (no transmission among swab team members, nor during the sample collection).

Herpes Zoster Following COVID-19 Vaccination in Long-Term Breast Cancer Survivors

Mortality from coronavirus disease 2019 (COVID-19) is higher among patients with cancer. Vaccination represents a cornerstone in overcoming the disease, and vaccine safety needs to be closely assessed. This article discusses two cases of herpes zoster (HZ) following the administration of the BNT162b2 mRNA vaccine in patients who are long-term survivors of breast disease. HZ developed 24 days and two days after the second dose of the vaccine in women aged 81 and 61, respectively. These two patients were breast cancer operated respectively nine and 16 years before; interestingly HZ developed in the same site of previous surgical resection. The patients did not show lymphocytopenia or other signs of immunosuppression and were treated with acyclovir, resulting in the complete resolution of HZ. To our knowledge, these two patients are the first described cases of HZ reactivation following COVID-19 vaccination in cancer survivors.

Spirituality, quality of life, psychological adjustment in terminal cancer patients in hospice

The purpose of this study was to show the different components of spirituality in the last few weeks of life for advanced cancer patients admitted to hospice and to evaluate quality of life (QoL), pain, anxiety, depression and psychological adjustment to cancer. One hundred and fifteen patients were interviewed with a series of rating scales: the Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being Scale, the Hospital Anxiety and Depression Scale, the Visual Analogue Scale for pain, the Brief Coping Orientation to Problem Experienced and the Functional Assessment of Cancer Therapy Scale - General Measure. Workers and single patients with higher education level showed a worse QoL. Moreover, anxiety and pain were negatively associated with QoL, while spirituality and 'Instrumental Support' coping style were positively associated with QoL. In the Italian sample, it was observed that when patients are close to death, faith is a more important component of spirituality than meaning/peace. This study confirms that QoL could be related to physical and psychological symptoms, and this reiterates the importance of faith in end-of-life care.

Anterior Combined Endopelvic (ACE) approach for the treatment of acetabular and pelvic ring fractures: A new proposal

PURPOSE

We present our experience of using the Anterior Combined Endopelvic (ACE) approach, which consists of a combination of a newly modified Stoppa approach with the lateral approach to the iliac crest. This approach is discussed in terms of fracture reduction and fixation, technical aspects, and the incidence of complications, and as an alternative to the ilioinguinal approach for the treatment of acetabular fractures.

METHODS

A consecutive group of 34 adult patients with acetabular fractures treated surgically with the ACE approach was compared with a group of 42 adult patients treated with the ilioinguinal approach between 2010 and 2013. Both approaches were performed by a single surgeon to fix the acetabular fractures with main anterior displacement and the anterior and lateral parts of the pelvis. All the patients were analysed with typical X-ray projections for acetabular fractures and CT-scan. Charts and radiographs were reviewed for fracture pattern. Operative time, blood loss, quality of reduction, functional outcomes and perioperative complications were compared between the two groups of patients.

RESULTS

The mean follow-up of patients was 26 months (range 6-49 months), with a median of 24.5 months. The types of acetabular fraction in the study were as follows: 32 anterior and posterior columns, 18 anterior columns, 10 anterior columns with posterior hemitransverse, 10 transverse associated with posterior walls, two transverse; two T-Type transverse and two anterior walls. Average blood loss was 1090 mL in the ACE group and 1200 mL in the ilioinguinal group. Anatomic or satisfactory reduction was achieved in 94% of the acetabular fractures. Two patients (one in each group) had mild symptoms of the lateral femoral cutaneous nerve and improved within 4-6 months; one patient in the ilioinguinal group developed ossification Brooks grade III.

CONCLUSION

The ACE approach for the treatment of acetabular fractures is highly recommended when the fracture involves the quadrilateral surface and anterior column. This approach provides a direct good-to-excellent visualisation and access to the entire fracture, which makes reduction and fixation easier. The clinical outcomes were slightly better with ACE compared with the ilioinguinal approach. Complication rate was similar in the two groups. The ACE technique is a viable alternative to the ilioinguinal approach when exposure of the anterior acetabulum is required.

HPV infection in HIV-positive females: the need for cervical cancer screening including HPV-DNA detection despite successful HAART

PURPOSE

To identify the presence of Human Papilloma Virus (HPV) infection and evaluate the role of Highly Active Antiretroviral Treatment (HAART) in patients with HIV-HPV co-infection. We also compared cytological screening results with HPV-DNA detection to implement screening programs and prevention of invasive cervical cancer (ICC) in HIV-infected females.

PATIENTS AND METHODS

We enrolled HIV-infected females presenting for routine clinical evaluation. HPV-DNA of high/intermediate and low-risk types was detected from cervical specimens by nucleic acid hybridization assay with signal-amplification. Patients were divided into two groups according to the presence of HPV co-infection (HPV+) or not (HPV-).

RESULTS

We enrolled 57 HIV-infected females. Median age was 40 (IQR 35-44) years, mean CD4 count was 547 ± 227 cells/mm(3), 45 (78.9%) had undetectable HIV-RNA and 52 (91.2%) received HAART. Globally, 19/57 (33.3%) patients were HPV-infected, 16/57 (28.1%) with high/intermediate and 3/57 (5.3%) with low-risk types. Five of the 19 (26.3%) HPV+ patients carried both types. Correlating high-risk genotype HPV-DNA detection with cytology, 17.5% of women with negative cytology, 36.4% with ASCUS (Atypical Squamous Cells of Uncertain Significance) and 83.4% of women with positive cytology (50% of LSIL: low-grade squamous intraepithelial lesion and 100% of HSIL: high grade SIL) were HPV positive. No statistical difference when comparing HPV+ and HPV-patients in age, CD4 cell count, in the proportion of previous intravenous-drug use, previous AIDS and of those receiving HAART with undetectable HIV-RNA was observed.

CONCLUSIONS

Cervical cancer screening including HPV-DNA detection should be implemented in HIV infected females across Europe, also when receiving successful HAART, to early identify the HIV patients at risk for ICC to be submitted to more frequent follow up and proper treatment.

Amenorrhea in eating disorders: poor stability of symptom after a one-year treatment

OBJECTIVE

To examine whether patients with Eating Disorders (ED) who restore menses differ from those who remain amenorrheic after treatment and to provide longitudinal data about this debated criterion of Anorexia Nervosa (AN).

METHODS

184 outpatients were recruited: 50 patients with AN Restrictive type, 75 amenorrheic Eating Disorder Not Otherwise Specified (EDNOS) patients, 24 patients who recovered from AN with persistent amenorrhea, and 35 amenorrheic patients without ED. All participants were clinically assessed by psychiatrists and gynaecologists at the beginning of treatment and at the one-year follow-up. They also completed several psychometric tests: Eating Disorder Inventory-2, Temperament and Character Inventory, and Beck Depression Inventory.

RESULTS

After treatment, a large portion of the sample resumed menses but very few recovered completely from the ED. No psychopathological variables could clearly predict the recovery of menses in the different groups. However, Body Mass Index and some biological variables were associated with restoration of menses in ED patients.

CONCLUSION

Resumption of menses was not associated with a less severe eating symptomatology at the beginning of treatment nor with unequivocal psychopathological changes after treatment. It is important that clinicians consider not only the presence or absence of regular menses but also that they improve both ED screening and assessment in amenorrheic patients. Amenorrhea does not seem to represent a specific predictor of severity of illness or to show prognostic value.

Outcome and length of stay in psychiatric hospitalization, the experience of the University Clinic of Turin

BACKGROUND

Given the current tendency to shorten psychiatric hospitalization and change its organization, an issue could be raised regarding its outcomes.

PURPOSE

To analyze features related to length of stay in a short-term inpatient treatment, to study outcomes and to evaluate the diagnosis-specific effects of hospitalization.

METHOD

A sample of 310 consecutive hospitalized patients, with psychotic disorder, depressive disorder and bipolar disorder (DSM IV-TR), was recruited at the University Psychiatric Clinic, Service for Cognitive Disorders, Department of Neuroscience, University of Turin. Severity of illness was rated using the brief psychiatry rating scale (BPRS). We evaluated relations between length of stay and clinical and socio-demographic features (linear regression) and possible differences confronting BPRS scores at admission and discharge in the different diagnostic subgroups (ANOVA for repeated measures).

RESULTS

All the sample of patients showed a significant improvement in symptomatology during hospitalization. Worse symptomatology in anxiety-depression domain of BPRS at admission in the whole sample was positively correlated with length of stay. A longer length of stay was also shown in patients with diagnosis of depressive disorder. Finally, a different pattern of improvement of BPRS (total score and domains) was shown between the different diagnostic groups.

CONCLUSION

Brief hospitalization in our service was shown to be highly effective. Different diagnostic groups had different response to hospitalization, showing faster improvement in characteristic symptomatology, but the anxiety-depression domain showed the highest percentage of change for all the diagnostic groups. We therefore suppose that hospitalization has two effects: a specific (due to tailored therapies) and a non-specific one (due to non-specific therapy and to a placebo-like effect).

Medical treatment and patient decisional power: the Italian state of the art

Therapy dissent and refusal are the situations most debated in the medical profession, that lead to various interpretations with regards to life and health, and even more in case of death risk. In the last decades, the medical treatment consent matter has become such an interesting and central issue that it has considerably modified the doctor-patient relationship. In particular, thanks to a fecund discussion on doctrine and case law, the informed consent became an autonomy act through which the patient exercises his/her personal health right. There are two international provisions that deserve to be mentioned for the matter: article no. 3 of the Charter of Fundamental Rights of the European Union, adopted in Nice on December 7, 2000, and the Oviedo Convention of April 4, 1997, which Italy passed under article no. 145, March 28, 2001. Both laws are symptomatic for the growing attention toward the person's self-determination, and for the impossibility to perform treatment in absence of personal, informed, recent and at any time revocable consent of the person concerned. Actually, these different and opposite ways of thinking correspond to a variable attitude of the case law that, in absence of a clear legislation regarding this matter, induces a deep insecurity in the physician's act on the one hand, and, does not allow the patient to totally avail him/herself of the self-determination principle on the other hand, particularly regarding the will and choices on health care.

Epidemiology of domestic injuries. A survey in an emergency department in North-East Italy

INTRODUCTION

Home injuries (HI) represent a social and public health problem worldwide. In Italy, there are 1,300,000-1,700,000 admissions to Emergency Department (ED) for HI and 130,000 hospitalizations every year, but the data are incomplete and fragmentary. A study of the phenomenon was carried out in Emergency Department (ED) of Civil Hospital of Verona to evaluate prevalence, characteristics and possible preventive actions.

METHODS

In 2007, 3120 admission for HI have been registered at the Eä of the Civil Hospital of Verona. The distribution was calculated in relation to sex, age, month, code of urgency, outcomes, type and location of trauma.

RESULTS

Children in pre-school age, men between 30 and 40 years and women over 60 years are the population groups most at risk, with a fairly homogeneous incidence distribution. Both sexes have similar distributions up to 41-50 years followed by an increase in females and a decrease in males at higher age. The traumas are generally slight (49.8% white code and 42.1% green code) and the hospitalizations represent 5.8% of all recorded HI. The most frequent injuries are wounds/abrasions (28.7%), contusions/crushing (27.7%) and fractures/distortions/ dislocations. The most affected body parts are hands and wrists (25.9%). Head trauma is significantly more frequent in children and elderly people, fracture in elderly people, and burn in adult women and male children. Every year about 30% of the admissions to emergency departments are caused by HI. Even though 92% of the times the events aren't serious, the sanitary cost is consistent due to the elevate number of admissions. It is therefore important to do prevention through sanitary education and adequate building legislation.

[Newborn resuscitation: from necessity of continous practice to professional liability]

The immediately postbirth extra uterine adaptation is the most important cause of death in the first two hours of life. In all risky cases, it is necessary to effect efficient and on time techniques of newborn resuscitation, because dubitation or delay may be very dangerous for the infant. In Italy courses of equipment in newborn resuscitation are regularly performed, but an excellent level of technique can be obtained only with continuous daily practice. Then, particularly in little hospitals where it is unusually necessary to act resuscitation on a newborn, courses of simulation for medical and nursering staff would be opportune to prevent neonatal handicap and to deal with the professional liability in the best way. The Italian current jurisprudence, in fact, has slowly confined the application of 2236 article of Civil code about professional liability in particularly difficult efforts. The Italian law asserts that a professional specialist is trained to be able resolve any type of problem among those of his specialistic competence, even if technically very difficult. It should be opportune to train health staff with practical exercises, in order to obtain complete technical skills in all neonatal centers.

Prevalence of alcohol and drugs in urine of patients involved in road accidents

OBJECTIVE

Road injuries are the leading injury-related cause of death among people aged 15-44. A clear dose-effect relationship has been demonstrated for drug and alcohol use and road traffic accidents. The objective of our study was to estimate the prevalence of drug and/or alcohol use in subjects admitted for road traffic accidents to an Emergency Department.

METHODS

In this study, conducted between January and April 2006, 100 patients of both sexes (age 18-65) examined after road traffic accidents were consecutively enrolled. A commercial rapid urine test was used to detect drugs by the Emergency Department staff The alcohol concentration was determined from a blood sample at the central laboratory.

RESULTS

Most of the patients were drivers under 35 years of age. 67/100 road traffic accidents occurred at the weekend (Friday-Sunday), nearly 60% between 24:00-09:00 hrs; on non-weekend days about 80% of road traffic accidents were recorded between 14:00-24:00 hrs (p < 0.0001). With the alcoholemia test and urine test for drugs detection 43/100 patients showed a single or multiple positivity. Alcohol and drug presence is relevant during the weekend (37/43 cases), in contrast with non weekend (6/43 cases) [OR 3.04 (95% CI 1.43; 6.46)]. Alcohol was the most frequently detected abuse substance (72%), followed by benzodiazepines (42%), tetrahydrocannabinol (21%) and cocaine (14%).

DISCUSSION

43% of patients examined were under the influence of psychotropic substances (alcohol, drugs or both). The greater part of road traffic accidents in positive test patients occurred during the week-end, in particular during the late night/early morning hours, probably after recreational time. The high incidence of alcohol and/or drug abuse may have caused physical and/or psychological problems, therefore the high number of road traffic accidents, especially if taken in combination.

CONCLUSION

The rapid urine test used cannot represent a diagnosis, and requires a confirmation test. It can be used for medical purposes as an easy and fast preliminary response which enables a faster diagnostic and therapeutic guideline, but it cannot be used for sanctions. Further studies are advisable with an increase of number of patients, in a wider temporal range, including control subjects, and using confirmation tests.

Cholangiocarcinoma in primary sclerosing cholangitis: risk factors and clinical presentation

BACKGROUND

Primary sclerosing cholangitis (PSC) confers a high risk of cholangiocarcinoma (CC) development. Since patients at risk of CC may be selected for early liver transplantation, it is a challenge to identify any predisposing factors. We compared the presentation and natural history of a large number of PSC patients with and without later CC development to identify features associated with risk of CC.

METHODS

Clinical and laboratory data from presentation and follow-up were collected from 394 PSC patients from five European countries. The cohort included 48 (12.2%) patients with CC.

RESULTS

CC was diagnosed within the first year after diagnosis of PSC in 24 (50%) cases and in 13 (27%) patients at intended liver transplantation. Jaundice, pruritus, abdominal pain and fatigue were significantly more frequent at diagnosis of PSC in the group that developed CC, but not after exclusion of cases diagnosed within the first year. Inflammatory bowel disease was diagnosed at least 1 year before PSC more often among patients with CC development than among those without (90% and 65%, respectively: P = 0.001). The duration of inflammatory bowel disease before diagnosis of PSC was significantly longer in patients who developed CC than in the remaining group (17.4 years and 9.0 years, respectively: P=0.009 in multivariate analysis).

CONCLUSIONS

A high proportion of CC cases is diagnosed within the first year after diagnosis of PSC. A long history of inflammatory bowel disease is a risk factor for CC development.

Alcohol abstinence does not offset the strong negative effect of lifetime alcohol consumption on the outcome of interferon therapy

Heavy alcohol consumption has been reported to negatively affect the outcome of interferon therapy. We studied the impact of lifetime alcohol consumption in patients with chronic hepatitis C treated with interferon after 6 months of alcohol withdrawal. Alcohol intake was measured when patients with chronic hepatitis C were referred to us for the first time, and from that moment complete abstinence was recommended. After 6 months of abstinence, 150 patients with persistent elevated serum alanine aminotransferase (ALT) have been treated with interferon (IFN)-alpha, 3 or 6 microU three times per week for 12 months. Univariate and multivariate analysis were performed to identify the predictors of treatment response. Carbohydrate-deficient transferrin was employed to assess alcoholic abstinence. The sustained response rate felt from 33% in nondrinkers to 20% of mild-drinkers and to only 9% in heavy drinkers. Drinker patients showed a relapse rate twice as high as that of nondrinkers. According to the multivariate analysis, the strongest independent predictors of nonresponse were genotype 1b infection, age of the patients and their lifetime alcohol intake. Carbohydrate-deficient transferrin detected at baseline, at 3 months of therapy and at the end of follow-up gave a positive result only in eight determinations (1.77%), confirming the compliance of patients to our recommendation of alcohol abstinence. Lifetime alcohol consumption has a strong negative effect on the outcome of interferon treatment, mainly in heavy drinkers. A 6-month period of abstinence may not be sufficient to offset this negative effect on treatment outcome.

Detection of anti-Saccharomyces cerevisiae antibodies in Crohn's disease: is it a reliable diagnostic and prognostic marker?

BACKGROUND

In the past few years, serologic markers have been proposed in inflammatory bowel disease. Anti-Saccharomyces cerevisiae antibodies showed high specificity for Crohn's disease. A prognostic role for serology has also been hypothesised.

AIMS

To evaluate anti-Saccharomyces cerevisiae antibody distribution in an unselected Italian inflammatory bowel disease population. To analyse whether anti-Saccharomyces cerevisiae antibody status (positive/negative) and/or anti-Saccharomyces cerevisiae antibody titres are associated with clinical variables and outcome measures in Crohn's disease patients.

PATIENTS AND METHODS

A series of 299 inflammatory bowel disease patients were evaluated; serum samples were taken and a short clinical history was recorded. anti-Saccharomyces cerevisiae antibodies IgG enzyme-linked immunosorbent assay Medilab (Milan, Italy) kit was used in order to determine anti-Saccharomyces cerevisiae antibody status.

RESULTS

Sensitivity, specificity and likelihood ratio for positive test in the differential diagnosis of inflammatory bowel disease was 59%, 89%, 8.1, respectively. Clinical variables significantly associated with anti-Saccharomyces cerevisiae antibody status in logistic regression were found to be ileal location (p=0.01) and earlier age at diagnosis (p<0.01). Among ileal Crohn's disease patients, there was a trend in concordance between anti-Saccharomyces cerevisiae antibody titres and higher number of surgical procedures which was not statistically significant applying more complex statistics.

CONCLUSIONS

In an Italian inflammatory bowel disease population, anti-Saccharomyces cerevisiae antibodies status showed characteristics similar to those previously reported. Anti-Saccharomyces cerevisiae antibody positivity is associated with ileal involvement and with earlier onset of Crohn's disease.

Omeprazole versus ranitidine in the medical treatment of acute upper gastrointestinal bleeding: assessment by early repeat endoscopy

The purpose of this study was to assess the effects of acid suppression in patients with upper gastrointestinal bleeding using early repeat endoscopy. Ninety-two patients with the diagnosis of acute upper gastrointestinal bleeding (endoscopically verified), entered a single-blind, randomised study comparing two treatment groups: omeprazole (40 mg orally daily) to ranitidine (50 mg intravenously four times daily). The lesions considered were gastric ulcers, duodenal ulcers and erosive gastritis. All patients were candidates for medical treatment. The parameters assessed included: 1) stabilisation of the lesion by repeat endoscopy at 7.0 +/- 3.0 days, 2) bleeding recurrence, 3) duration of stay in the intermediate medical care unit. For erosive gastritis only parameters 2 and 3 were considered. The study was limited to the hospitalisation period. Endoscopic stabilisation rate at 7.0 +/- 3.0 days for duodenal lesions was higher in the omeprazole group (71% vs 37%, p=0.03), but there was no significant difference for gastric lesions (50% vs 54%, NS). The overall bleeding recurrence rate (0% vs 17%, p=0.013) and the duration of stay (3.9 vs 6.4 days, p<0.01) were significantly lower in the omeprazole group. Our study suggests that omeprazole is more effective than ranitidine in the pharmacological treatment of acute upper gastrointestinal bleeding.

Clinical features of dysthymia and age: a clinical investigation

A few authors have described the clinical picture of dysthymia in groups of elderly patients and pointed out differences from literature reports of dysthymia in younger adults. The present study, an attempt to analyze age effects on clinical characteristics of dysthymia throughout a lifetime, was performed in a sample of 106 patients, all aged > or =18 years, who were diagnosed according to DSM-IV. The patients were evaluated using: (1) a semistructured interview to assess clinical features, family history and previous treatments; (2) the Hamilton Depression Rating Scale; (3) the Interview for Recent Life Events; and (4) the Structured Clinical Interview for DSM-IV Disorders. Statistical analysis with stepwise logistic regression revealed that age was positively related to concomitant medical illnesses and to the total score of recent life events, but negatively related to the presence of avoidant or dependent personality disorders. The data suggested different etiologic pathways in older and younger patients. Dysthymia appeared to be associated in younger adults with abnormalities of personality; in the elderly, with a history of health problems and life losses.

The HLA-DR3,DQ2 heterozygous genotype is associated with an accelerated progression of primary sclerosing cholangitis

BACKGROUND

An improvement of prognostic models in primary sclerosing cholangitis (PSC) is needed. In particular, inclusion of prognostic markers that are independent of the disease stage would be advantageous. We investigated whether HLA class II genes associated with PSC are also related to disease progression.

METHODS

The study included 265 PSC patients from five European countries with a median follow-up of 9.1 years. The end-points were death (n = 38) or liver transplantation (n = 52). Thirty patients developed cholangiocarcinoma during follow-up.

RESULTS

The DRB1*03,DQA1*0501, DQB1*02 (i.e. DR3,DQ2) heterozygous genotype was associated with an increased risk of death or liver transplantation (hazard ratio = 1.63; 95% confidence interval (CI) = 1.06-2.52). The presence of a DQ6 encoding haplotype (DQB1*0603 or DQB1*0602) in DR3,DQ2 negative individuals was associated with a reduced risk of death or liver transplantation (hazard ratio = 0.57; 95% CI = 0.36-0.88). There was a trend towards an increased risk of developing cholangiocarcinoma among DR4,DQ8 positive patients, but this did not reach significance (odds ratio = 2.27; 95% CI = 0.78-6.62).

CONCLUSION

The DR3,DQ2 heterozygous genotype is associated with a more rapid progression of PSC, whereas HLA-DQ6 is associated with a retarded disease progression. It is possible that the DR4,DQ8 haplotype is related to cholangiocarcinoma development.

Effect of macrovescicular steatosis and other donor and recipient characteristics on the outcome of liver transplantation

The influence of steatosis and of other donor and recipient characteristics in affecting liver performance post-orthotopic liver transplantation (OLT) was evaluated in 311 consecutive liver transplantations made in 278 patients. Donor variables considered were age, sex, blood group, cause of death, intensive care unit (ICU) days, need for vasopressors, hepatic enzymes and bilirubin, total and warm ischemia time, and macro- and microvescicular steatosis. Recipient variables considered were age, sex, blood group, biliary output, and post-OLT peak levels of hepatic enzymes. Patient and graft survival were the main outcome indicators. In the multivariate analysis, macrovescicular steatosis involving 25% or more of the hepatocytes was the only variable independently associated with shorter patient survival (p < 0.05). Five (62.5%) of the eight livers with macrovescicular steatosis involving 25% or more of the hepatocytes incurred in a delayed non-function (DNF) and one (12.5%) in a primary non-function (PRNF). The incidence of DNF and PRNF in the group with macrovescicular steatosis involving less than 25% of the liver cells was 1.6% (p < 0.001) and 2.3%, respectively. Microvescicular steatosis of any degree was not associated with a worse prognosis. Macrovescicular steatosis involving 25% or more of the hepatocytes identifies marginal livers, the use of which significantly increases the risk of graft non-function post-OLT.

Treatment with interferon-alpha2b of naive non-cirrhotic patients with chronic hepatitis C according to viraemia and genotype. Results of a randomized multicentre study. The North West Italian Hepatological Group

OBJECTIVE

To establish whether tailoring the dosage of interferon (IFN)-alpha2b in non-cirrhotic naive patients with chronic hepatitis C according to hepatitis C virus (HCV) genotype and viraemic level improves the rate of sustained response (normal alanine aminotransferase values and HCV-RNA negativity 6 months after the end of therapy).

PATIENTS

A total of 538 consecutively collected HCV-positive patients with non-cirrhotic chronic hepatitis who had not been previously treated.

METHODS

Quantitative viraemia and genotype were determined in each patient by a core laboratory. The patients were randomized to: Group 1, 86 patients with genotype non-1 and viraemia < 1,000,000 HCV genome equivalents/ml (GenEq/ml) treated with 3 Million Units (MU) IFN three times weekly (t.i.w.) for 1 year; Group 2, 42 patients with genotype 1 and viraemia < 1,000,000 GenEq/ ml treated with 3 MU IFN t.i.w. for 1 year; Group 3, 46 patients with genotype 1 and viraemia < 1,000,000 GenEq/ ml treated with 5 MU IFN t.i.w. for 1 year; Group 4, 85 patients with genotype non-1 and viraemia > 1,000,000 GenEq/ml treated with 3 MU IFN t.i.w. for 1 year; Group 5, 88 patients with genotype non-1 and viraemia > 1,000,000 GenEq/ml treated with 5 MU IFN t.i.w. for 1 year; Group 6, 94 patients with genotype 1 and viraemia > 1,000,000 GenEq/ml treated with 3 MU IFN t.i.w. for 1 year; Group 7, 97 patients with genotype 1 and viraemia > 1,000,000 GenEq/ml treated with 5 MU IFN daily for 2 months followed by 5 MU t.i.w. for a further 10 months.

RESULTS

According to an intention-to-treat analysis, a sustained virological response (negative HCV-RNA by polymerase chain reaction 6 months after the end of therapy) was observed in 42% of Group 1 patients, in 21% of Group 2 patients versus 24% of Group 3 patients [P = not significant (NS)], in 28% of Group 4 patients versus 35% of Group 5 patients (P = NS), and in 8.5% of Group 6 patients versus 12% of Group 7 patients (P = NS).

CONCLUSIONS

Even though a trend towards a therapeutic improvement is observed, the adoption of more aggressive IFN protocols, such as induction therapy, does not appear to significantly improve the rate of sustained response in patients with chronic hepatitis C associated with HCV genotype 1 and highly viraemic levels compared with standard therapy. Moreover, patients with only one unfavourable predictive factor (genotype 1 or high viraemia) do not gain major therapeutic benefits when treated with high doses of IFN.

[N2O-free sevoflurane anesthesia. Clinical evaluation]

BACKGROUND

The characteristics of sevoflurane make it able to be used without N2O avoiding its undesirable effects to this associates. The aim of the study is to evaluate the clinical characteristics of sevoflurane anesthesia "N2O free" in comparison to sevoflurane anesthesia with N2O.

METHODS

920 patient undergoing elective surgery in 12 centers were included in this study. All the patients were monitored with routine monitoring. The patients were randomized in two groups: group Air in which the anesthesia was maintained with sevoflurane in Air:O2; group N2O in which the anesthesia was maintained with sevoflurane in N2O:O2. Opioids were administered as necessary (changes of the heart rate and/or of the arterial pressure > 20% in comparison to the baseline values). For each patient we evaluated the consumption of opioids, the time from discontinuation of the sevoflurane and the extubation and full recovery, defined as presence of a complete cognitive function; the quality of awakening, the incidence of postoperative nausea and vomiting (PONV) and the quality of postoperative analgesia.

RESULTS

We didn't observe differences between the two groups. In conclusions, omitting N2O during sevoflurane anesthesia can be considered a safe technique, avoiding the acute and chronic side effects associated with the use of N2O, without modifying the intraop consumption of opioid, the recovery and the early postoperative incidence of nausea, vomiting and analgesia.

Genotype-phenotype relationship in inflammatory bowel disease

Crohn's disease (CD) and ulcerative colitis (UC) are chronic diseases of unknown etiology. Much effort has been made in the last years to clarify the pathogenesis of inflammatory bowel disease (IBD). Data are not conclusive at the moment, but the most important known risk factor for developing IBD is a positive familial history. Genetic analyses have shown a linkage between loci on several chromosomes and IBD (IBD1 gene on chromosome 16 for CD and on chromosome 12 for UC). The association of genotype to specific phenotypes of disease could be hypothesized by the concordance of clinical characteristics in familial IBD, by the association of specific HLA haplotypes to clinically different groups of patients, and by different responses to treatment related to different polymorphisms of other chromosome 6 genes. The clinical heterogeneity of IBD has led to classifications of patients with Crohn's disease based upon clinical features (e.g. Rome and Vienna classifications) that allow the identification of subgroups of patients with similar clinical behavior. The possible drawbacks of these classifications are the lack of validation of intra-interobserver concordance, the absence of prospective evaluations, and stratification into too many subgroups. Furthermore, in our experience, clinical presentation (surgical or medical) seems to have a good correlation with prognosis, is easy identifiable, and can be applied at the time of diagnosis. In UC, extension of disease and clinical behavior correlate with prognosis. For these reasons, studies correlating genotype to phenotype should be performed to improve our knowledge of the diseases and possibly to stratify patients into different subgroups for more personalized treatments, in clinical trials and for research purposes.

Hepatitis C virus genotypes in a non-cirrhotic Italian population with chronic hepatitis C: correlation with clinical, virological and histological parameters. Results of a prospective multicentre study

To identify correlations between the distribution of hepatitis C virus (HCV) genotypes and demographic, pathological and virological parameters of HCV-infected patients, we prospectively recruited 650 patients with biopsy-proven chronic hepatitis C without histological aspects of cirrhosis; none had been treated with antiviral therapy. Data regarding gender, age, mode of HCV transmission, alanine aminotransferase (ALT) and HCV RNA levels, immunoglobulin M (IgM) anticore values, liver histology and histological activity were obtained from each patient and correlated on multivariate analysis with infecting HCV genotype. Fifty-five per cent of the patients were infected with HCV genotype 1, 20% with HCV genotype 2, 18% with HCV genotype 3 and 7% with HCV genotype 4. Non-transfusional HCV transmission, low ALT levels, IgM anticore reactivity and a low histological grading score were independent variables associated with HCV genotype 1. Older age, female gender, post-transfusional transmission and a high histological grading score were related to HCV genotype 2, whilst younger age, history of current/previous drug abuse, high ALT values, low IgM anticore reactivity and high viraemic levels were associated with HCV genotype 3. History of illicit use of intravenous drugs and low HCV RNA levels were the only independent variables correlated with HCV genotype 4. Genotype 1 remains predominant in Italy but the prevalence of HCV genotypes is changing in relation to age and mode of transmission: Italian patients with HCV genotype 3 are younger and exhibit higher levels of ALT and HCV RNA than patients with other genotypes.

Changing pattern of chronic hepatitis D in Southern Europe

BACKGROUND & AIMS

The aim of this study was to assess changes in the clinical pattern of hepatitis D virus (HDV) infection in Italy, brought about by improved control of hepatitis B and D viruses, and to establish the natural history of chronic hepatitis D.

METHODS

Histological diagnosis and clinical features of 122 patients with HDV recruited from 1987 to 1996 in three Italian tertiary referral centers (Torino, northern Italy; San Giovanni Rotondo and Castellana Grotte, southern Italy) were compared with those of 162 patients collected in the same centers in the previous decade. Patients from both groups with at least 6 months of follow-up were included in a new subgroup to assess the natural history of the disease.

RESULTS

Among 162 patients referred from 1977 to 1986, 9 (6%) had mild hepatitis at histology vs. 9 (8%) of 122 patients referred in the second decade; 105 (65%) vs. 21 (17%) had severe hepatitis; 46 (28%) vs. 38 (31%) had histological asymptomatic cirrhosis; and 2 (1%) vs. 54 (44%) had clinically overt cirrhosis. For 159 patients (121 men and 38 women; mean age, 34 +/- 11), a follow-up of more than 6 months was documented, and they were included in the natural history subgroup. After 78 +/- 59 months of follow-up, 112 (70%) survived free of liver transplantation: 9 underwent transplantation, 32 died of liver failure, and 6 of acquired immunodeficiency syndrome. Estimated 5- and 10-year probability of survival free of orthotopic liver transplantation was 100% and 100% for patients with mild hepatitis, 90% and 90% for severe hepatitis, 81% and 58% for histological asymptomatic cirrhosis, and 49% and 40% for clinical cirrhosis (P < 0.01), respectively.

CONCLUSIONS

Occurrence of fresh and severe forms of hepatitis D has diminished greatly in Italy. Contemporary patients represent cohorts infected years ago who survived the immediate medical impact of hepatitis D. The disease has been asymptomatic and nonprogressive in a minority; in the majority, it rapidly advanced to cirrhosis but thereafter subsided with stable clinical conditions for more than a decade.

Quantitative electroencephalography and regional cerebral blood flow: discriminant analysis between Alzheimer's patients and healthy controls

Forty-two patients with probable Alzheimer's disease (AD) and 18 elderly healthy controls underwent quantitative EEG (qEEG) and regional cerebral blood flow (rCBF; 133Xe clearance) examinations. Correlations were sought between relative qEEG band powers and percent rCBF values in a posterior temporoparietal region of interest in either hemisphere. Moreover, stepwise discriminant analysis was applied to study the accuracy of the two techniques in differentiating AD from healthy ageing. rCBF and qEEG were correlated with one another, especially in the right hemisphere (p values ranging from <0.001 to <0.01). Significant correlations were found between Mini Mental State Examination (MMSE) and relative power of both the 2- to 6-Hz and the 6.5- to 12-Hz bands on either side (p < 0.001), and between MMSE and left rCBF (p < 0.005), while the correlation with right rCBF was poorer (p < 0.02). The statistical procedure identified the right values of both examinations for the discriminant analysis. Sensitivity of qEEG and rCBF employed together was 88% and specificity 89%, with a total accuracy of 88.3%. The unrecognized patients (n = 5) were affected by mild AD (4 scoring 3 at the Global Deterioration Scale and 1 scoring 4). qEEG alone showed an accuracy of 77% in the whole group and of 69% in mild AD, and rCBF alone an accuracy of 75% in the whole group and of 71% in mild AD. It is concluded that qEEG and rCBF examinations employed together are accurate tools to differentiate AD from normal ageing, although a lower degree of accuracy is achieved in mildly demented patients.

Non-variceal upper gastrointestinal bleeding and Forrest's classification: diagnostic agreement between endoscopists from the same area

BACKGROUND AND STUDY AIMS

The lack of uniformity in defining the stigmata of hemorrhage in patients with bleeding ulcers is suggested by the wide range among published studies in prevalence and rebleeding rates for the same stigmata. Moreover there is, in published trials of endoscopic hemostasis, little standardization of definitions of stigmata of hemorrhage. The aim of this study was to assess the interobserver agreement among endoscopists from the same area (Piedmont and Valley of Aosta).

PATIENTS AND METHODS

A workshop for 47 expert endoscopists was organized in order to evaluate their agreement in the diagnosis of stigmata of recent hemorrhage, according to Forrest's classification. During the meeting 25 videotapes from endoscopic examinations of patients with recent non-variceal bleeding were shown to the 47 endoscopists, who were asked to classify every lesion.

RESULTS

The overall and beyond chance interobserver agreement was calculated by means of the kappa statistic. The overall agreement among endoscopists was highly significant (p < 0.001, kappa=0.60), while the beyond chance agreement varied from excellent to good for lesions with active bleeding (kappa=0.76 and kappa=0.61 for FIA and FIB lesions respectively), whereas for lesions with stigmata of recent hemorrhage kappa varied from 0.44 to 0.49.

CONCLUSIONS

These data suggest the need for better knowledge of endoscopic criteria, in order to evaluate the results of endoscopic therapy and to assess new treatments.

Sequential versus concomitant administration of ribavirin and interferon alfa-n3 in patients with chronic hepatitis C not responding to interferon alone: results of a randomized, controlled trial

We conducted a three-arm, randomized trial in 96 patients with chronic hepatitis C who did not respond to interferon alfa to compare treatments. Group 1 (33 patients) received ribavirin alone (1,000 mg/daily for 6 months) followed by interferon alfa n-3 alone (3 MU thrice weekly for 6 months); group 2 (33 patients) received ribavirin plus interferon alfa n-3 for 6 months at the above doses; and group 3 (30 patients) received interferon alfa n-3 alone (3 MU thrice weekly for 6 months). At the end of treatment, 3 patients (10%) in group 1, 13 (41%) in group 2, and 5 (17%) in group 3 had normal alanine transaminase (ALT) levels (group 2 vs. groups 1 and 3, P = .008). After 6 months of follow-up, only 4 patients (12.5%) in group 2 still had normal ALT values (P = .03). At the end of therapy, hepatitis C virus (HCV) RNA was no longer detectable by polymerase chain reaction in 4 (13%), 9 (27%), and 2 (7%) patients, respectively, in groups 1, 2, and 3 (P = NS). Six months posttherapy, only 5 (15%) patients in group 2 were still HCV RNA negative (P = .02). At the time of follow-up liver biopsy, performed 6 months after the end of treatment, a significant improvement of the necroinflammatory scores was observed among group 2 patients (P = .01) but not in the other two groups. Side effects reflected the profile of each drug as monotherapy; mild hemolytic anemia was the most frequent side effect caused by ribavirin. In conclusion, concomitant administration of ribavirin and interferon alfa n-3 was significantly superior to the sequential schedule or interferon alfa n-3 monotherapy in inducing a sustained response in patients with chronic hepatitis C who had not responded to interferon alone. However, combination therapy at the dose and duration adopted in this study is capable of modifying the natural course of the disease in only a minority of these patients.

Platelet and white blood cell counts during therapy with different types of alpha interferon in patients with chronic viral hepatitis. Investigators of the Alpha Interferon Study Group of Piemonte, Italy

BACKGROUND

Platelet and white blood cell counts decrease in chronic viral hepatitis patients treated with alpha interferon.

AIM

To analyse whether delta negative variations in platelets and white blood cells are influenced by type, dose and duration of alpha interferon treatment, we studied 340 consecutive patients (mean treatment 8 months, range 4-18 months).

PATIENTS AND METHODS

A total of 204 (60%) patients were treated with recombinant alpha interferons (30% alpha-2a and 30% alpha-2b), 64 (19%) with N3.leukocytic and 72 (21%) N1.lymphoblastoid natural interferons. Median age and male/female ratios were comparable in the 3 groups (41, 41 and 43 years and 2.3, 2.6 and 2.5, respectively). The lowest platelets and white blood cells counts were observed between the 2nd and the 4th month of therapy in all patients. Age, sex, aetiology and duration of interferon therapy did nor influence the platelets and white blood cells reduction rates. The decrease was lower for patients treated with N3.leukocytic interferon than for the other interferons. A significant difference was observed between interferon doses when the groups treated with 3 or 9-10 MIU were compared. However, dose or cirrhosis-related bias are ruled out by similar proportions of cirrhosis and patients treated with 3 MIU in the 3 groups of patients treated with different types of interferon.

CONCLUSIONS

The type of interferon appears to represent a major cause of the different haemopoietic toxicity. The lowest toxicity of N3.leukocytic interferon may have clinical implications for the choice of interferon in patients with low baseline platelets and white blood cells counts. These findings prompt prospective studies on larger series of patients.

Effect of patient characteristics on hospital costs for cirrhosis: implications for the disease-related group (DRG) reimbursement system

The Prospective Payment System uses Diagnosis-Related Groups (DRG) as a reimbursement system. DRG 202 is a disease-related group including liver cirrhosis as a whole. Patients referring to the inpatient unit complain of variable severity and complications of cirrhosis, possibly implying different expenditure of resources. Aim of the investigation was to identify factors affecting cost variability in patients with cirrhosis. A total of 73 consecutive, DRG 202-assigned, cirrhotic patients classified according to demographic and clinical variables were evaluated for length and costs of hospitalization calculated on a full-cost basis. Mean length of hospitalization was 10.2 +/- 7 days. Mean cost of hospitalization was Lit. 4.348.000 +/- 2.718.000. Medical, nursing, diagnostic, drug and general charges accounted for 13%, 29%, 37%, 5% and 16% of the cost, respectively. Child-Pugh score significantly correlated with drug consumption (p < 0.005), length (p < 0.01) and costs (p < 0.001) of hospitalization, but not with cost per day. Age, sex, admission status, referral reason, associated diseases and liver transplant susceptibility did not correlate with duration and costs of hospitalization. Disease severity significantly modifies costs of hospital admission in cirrhotic patients mostly on account of longer hospital stay. Surrogate indexes of disease severity, derived from ISTAT/DRG records, cannot identify patients consuming larger resources. In liver cirrhosis, the DRG system could be improved by introducing parameters, such as Child-Pugh score, directly taking into account disease severity.

Hepatotoxicity of intravenous cyclosporin A in patients with acute ulcerative colitis on total parenteral nutrition

A group of 24 patients underwent a 7-14-day course of continuously infused Cyclosporin A (2 mg.kg-1.day-1) to treat a severe attack of ulcerative colitis. In 19 of them, including eight treated with total parenteral nutrition, we retrospectively analyzed the serum aminotransferase (AST/ALT) levels at the beginning and at the end of Cyclosporin infusion. The baseline levels of AST/ALT in the group were 19.9 +/- 3.2 and 31.4 +/- 6.4; on stopping Cyclosporin infusion, they were 43 +/- 15.8 and 119 +/- 56, respectively. Six patients showed an ALT change above 1.5 times the upper limit of reference. They included five of the eight patients treated with total parenteral nutrition (62.5%). In one of six, ALT rose to 1000 U/l and was accompanied by full-blown febrile cholangitis (proven by liver biopsy). This episode was preceded by excessive accumulation of Cyclosporin in blood. The development of liver toxicity was independent of the length of Cyclosporin treatment, nor did it impair drug efficacy. Thus, in these patients total parenteral nutrition and Cyclosporin were synergistic, causing twice the frequency of liver damage (62.5%) reported for ulcerative colitis patients on total parenteral nutrition alone (37%). Total parenteral nutrition should not be used to support patients needing Cyclosporin for autoimmune disease. However, too high a dose of Cyclosporin may cause liver disease per se.

Recurrent Sweet's syndrome in reactivated Crohn's disease

A 50-year-old woman developed an acute febrile dermatosis on two occasions concurrently with recurrent Crohn's disease of the colon. Based on the presence of painful erythematous plaques on both hands and forearms, on the leukocytosis with excess bands in peripheral blood, on the histology showing dermal infiltration by mature granulocytes, and on the prompt response to steroids, the diagnosis was made of Sweet's syndrome associated with Crohn's disease. Sweet's syndrome is thought to be a hypersensitivity reaction that leads to parainflammatory (e.g., infections, autoimmune disorders, vaccinations) and paraneoplastic (myeloproliferative disorders, solid malignancy) associations, with a frequency of 10-30%. The association of Sweet's syndrome with Crohn's disease is very rare, but the gastroenterologist should readily differentiate it; it is important to be aware that such patients may have a nonspecific elevated activity index owing to the underlying dermatosis.

Monitoring the natural course and response to therapy of chronic hepatitis B with an automated semi-quantitative assay for IgM anti-HBc

The clinical significance of a semi-quantitative microparticle enzyme immunoassay (IMx Core-M, Abbott) was evaluated for detection of IgM-class antibodies against the hepatitis B core antigen (IgM anti-HBc) in 136 hepatitis B surface antigen (HBsAg) positive individuals (96 chronic HBV carriers, 20 patients with chronic HBV-HDV infections and 20 patients with acute hepatitis B) and 50 HBV-negative controls. Baseline and follow-up sera (4-11 samples) were analysed from 79 carriers with chronic hepatitis B, 44 of whom were treated with interferon. IMx indexes above 3,000 were found in 95% of the acute hepatitis B patients and above 0.300 in 91.5% of patients with ongoing chronic hepatitis B. IMx indexes between 0.200 and 0.300 were observed in (a) patients with recent HBeAg to anti-HBe seronconversion (6-12 months) and normal serum ALT levels, (b) patients immuno-tolerant to HBV infection and without liver disease despite high levels of viremia, and (c) patients with anti-HBe-positive chronic hepatitis B during 7-13-month intervals of asymptomatic carriage between episodes of disease reactivation. IMx indexes below 0.200 were detected in all HBV-negative individuals and healthy HBV carriers, in 14 (70%) of 20 chronic hepatitis D patients and in all but 1 of 22 interferon-treated patients with histological remission of liver disease, 5-12 months after clearance of viremia and normalization of serum ALT levels. In contrast, IMx indexes remained above 0.200 in all patients with hepatitis B reactivation.(ABSTRACT TRUNCATED AT 250 WORDS)

Histologic changes in liver biopsy specimens produced by recombinant interferon alpha-2b therapy for chronic non-A,non-B viral hepatitis. A randomized controlled trial

The effects of interferon therapy on liver histologic findings were assessed in a randomized controlled trial consisting of 80 patients with chronic non-A,non-B hepatitis. Twenty-eight patients received 1 million units of recombinant interferon alpha-2b; 25 patients received 3 million units, subcutaneously, three times a week for 24 weeks; and 21 patients were observed as untreated controls; all of them underwent liver biopsy within 6 months from the beginning of the study and on the last day of therapy. Six patients were withdrawn from the study because of inadequate liver biopsy specimens. Alanine aminotransferase levels were determined before, during, and after therapy. For each biopsy, a semiquantitative score of histologic features, the histologic activity index, and the overall histologic assessment were performed. Ninety-five percent of patients tested positive for hepatitis C virus antibody. Portal inflammation, piecemeal and spotty necrosis, and bile duct proliferation were significantly decreased in patients with normalized alanine aminotransferase. The effectiveness of therapy was dose dependent: piecemeal and spotty necrosis and the histologic activity index showed a significant decrease only in 3-million-unit-treated patients. Hepatocellular degeneration and fibrosis did not change significantly after treatment.

Chondroitin sulfate proteoglycan surrounds a subset of human and rat CNS neurons

Chondroitin sulfate proteoglycan (CS-PG) bearing glycosaminoglycan (GAG) chains containing unsulfate (COS) and 6-sulfate (C6S) disaccharides was immunolocalized in rat and human CNS by using monoclonal antibodies (MAb) specific for the two disaccharides. The immunostaining with both MAb was restricted to the periphery of a neuronal subset in rat and human CNS. Double immunofluorescence showed codistribution of the antigens around the same neuronal population. The staining with anti-COS MAb was stronger than with anti-C6S MAb, suggesting that the proteoglycan (PG) contains mainly COS disaccharides. In different rat cortical areas, 40-60/mm2 positive interneurons were found, the visual cortex showing the highest value. In human cortex, positivity was also observed around the soma of some pyramidal cells. In the rat, positive neurons were also localized in deep cerebellar nuclei, reticular nucleus of the thalamus, and other structures of the midbrain and hindbrain. CA3 region of hippocampus and the external layer of pyriform cortex were characterized by positivity of the neuropil. Immunoelectronmicroscopy showed the antigens in the extracellular space around the neuronal soma, the synaptic elements and the cell processes of the neuropil. The neuronal surface of the soma and of the proximal dendrites were positive, but the pre- and postsynaptic membranes and clefts were negative.

Chondroitin 4-sulfate proteoglycan forms an extracellular network in human and rat central nervous system

Chondroitin 4-sulfate proteoglycan (C4S-PG) was localized both in rat and human central nervous system (CNS) by monoclonal and polyclonal antisera recognizing the 4-sulfate disaccharide (C4S). In the rat the whole CNS was studied in serial coronal sections. A positive extracellular meshwork was observed both in white and grey matters. In the white matter (WM) C4S-PG formed a network around myelinated axons, sparing myelin sheaths and axoplasms. The neuropil of the grey matter (GM) showed a positive meshwork constituted by delicate intermingling filaments. The cytoplasms of neuronal, glial and endothelial cells were negative. Stronger straining than in the neuropil was observed around the soma and the proximal part of the cell processes of some neurons located in the cortex, in the deep cerebellar nuclei and in some other CNS nuclei. A similar pattern was also observed in human CNS, the only difference being a smaller amount of cortical neurons surrounded by a rim of C4S-PG. This study shows that a PG bearing C4S disaccharide is located extracellularly in the rodent and human CNS and that C4S disaccharides can be present in different types of CNS proteoglycans (PGs).

A controlled trial of human lymphoblastoid interferon in chronic hepatitis B in Italy

Sixty-four heterosexual Italian carriers of HBsAg with chronic HBeAg and hepatitis B virus DNA-positive hepatitis were assigned randomly either to receive human lymphoblastoid interferon (injections of 5 million units per m2 three times per week for 6 months) or to serve as untreated controls. After 18 months of follow-up evaluation, 26 of the 33 treated patients (79%) had cleared hepatitis B virus DNA, 23 (70%) had lost HBeAg and 20 (61%) had seroconverted to anti-HBe. Fifteen of the 31 controls (48%) had cleared hepatitis B virus DNA (p = 0.01), 12 (39%) had lost HBeAg and nine (29%) had seroconverted to anti-HBe (p = 0.002). Eight treated patients but only one control had lost HBsAg and seroconverted to anti-HBs (24% vs. 3%, p = 0.01). Treated patients cleared hepatitis B virus markers after a mean interval of 4 months, compared with 8 months in the controls. All responders to interferon cleared intrahepatic HBcAg, and 50% showed histological improvement. The baseline hepatitis B virus DNA levels and the original histology were not predictive of a response to therapy; women appeared to respond better than men. Lymphoblastoid interferon provides an effective therapy in the heterosexual Italian patient with chronic hepatitis B.