Helicobacter pylori in patients with gastric and nongastric cancer

OBJECTIVES

To compare the seroprevalence of Helicobacter pylori in gastric and nongastric carcinoma patients and to investigate the relationship between H. pylori, gastric cancer site, and histological type.

METHODS

In a 24-month period, 307 gastric cancer patients (male/female: 185/122; age range 19-94 yr, mean 69 yr) were investigated by serology (IgG to H. pylori), histology, and urease test for H. pylori. One hundred and seventy-seven gastric cancers were in the antrum, 98 were in the corpus, and 32 were in the fundus; 227 were intestinal and 80 were diffuse type. In the same study period, we assessed the H. pylori seroprevalence in 162 patients with nongastric carcinoma (lung n = 41, breast n = 42, genitourinary n = 41, GI tract n = 22, others n = 16) (male/female: 84/78; age range 31-81 yr, mean 56 yr).

RESULTS

The overall seroprevalence of H. pylori in gastric cancer and in nongastric cancer was 82 and 56%, respectively (p < 0.001). In asymptomatic blood donors (age range 55-65 yr) and in dyspeptic patients older than 60 yr, a seroprevalence of 55 and 58% was found, respectively, which is significantly lower (p > 0.001) than the gastric cancer patients but similar to the nongastric cancer population. No difference was found in the H. pylori status according to the gastric cancer site (83, 82, and 81% in the antrum, corpus, and fundus, respectively). Two hundred and twenty-seven gastric cancers [185 (81%) H. pylori-positive] were found to be of an intestinal type and 80 [66 (82%) H. pylori-positive] of a diffuse type (not significant). No age-related difference (below and above 60 yr) in H. pylori prevalence was observed within each cancer population, and, in both age groups, the seroprevalence of infection was higher in gastric cancer patients (86 and 81%) than in nongastric cancer patients (56 and 56%) (below and above 60 yr, respectively).

CONCLUSION

H. pylori seroprevalence is significantly higher in gastric cancer compared with nongastric cancer patients. No differences were observed in H. pylori seroprevalence according to gastric cancer site or histological type. The higher H. pylori seroprevalence in gastric cancer patients is not age related.

Helicobacter pylori status, endoscopic findings, and serology in HIV-1-positive patients

We have carried out a large prospective study of the frequency of H. pylori infection and HIV-1 status in a community of ex-drug abusers including subjects with (N = 210) and without (N = 259) upper gastrointestinal symptoms, endoscopy and serology. Control groups were patients with upper gastrointestinal symptoms not at high risk of HIV-1 infection (N = 219) and asymptomatic blood donors (n = 322). H. pylori was present in 52% of symptomatic community residents having endoscopy and 55% of the control patients with symptoms but not at high risk of HIV-1 infection. H. pylori was less common in HIV-1-positive patients (40%) than those who were negative (66%; P < 0.001). In patients with AIDS (33%), the frequency of H. pylori infection was reduced compared to HIV-1-positive patients without AIDS (53%; P = 0.05). All the residents with AIDS had upper gastrointestinal symptoms. In community residents, peptic ulcer was always associated with H. pylori infection. By H. pylori serology, there was no difference in the frequency of infection in asymptomatic residents (56%) whether HIV-1 positive (55%) or HIV-1 negative (58%) compared with those residents with symptoms. Overall, H. pylori was less common in HIV-1-positive residents (49%) than those who were HIV-1 negative (61%; p < 0.05). This difference was due mainly to the low frequency of infection in residents with AIDS (33%). H. pylori infection is common in HIV-1 positive patients, and only slightly reduced when compared with at-risk HIV-1-negative subjects. Peptic ulcer is associated with H. pylori in HIV-1 infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatitis B virus, hepatitis C virus and human immunodeficiency virus infection in health care workers: a multiple regression analysis of risk factors

A seroprevalence survey of hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV), was conducted using serum samples obtained from 5813 health care workers (HCWs) in five public hospitals in the Latium region of Italy, during the 1985 vaccination campaign against HBV. The seroprevalences of HBV, HCV and HIV were 23.3% [95% confidence interval (CI) = 22.3-24.4%], 2% (95% CI = 1.6-2.4%) and 0.07% (95% CI = 0.001-0.13%), respectively. In a logistic regression model, sex, increasing age, all job categories vs. physicians, dental treatment in the previous six months, and needlestick injury during the previous year were significantly associated with HBV. Conversely, no occupational and community risk factors, but only history of blood transfusion were significantly associated with HCV. Nevertheless, the documented risk of HCV as well as of HIV transmission through percutaneous and mucocutaneous exposure to blood and body fluids should lead to continued efforts to minimize risks of infection by enhancing the compliance of HCWs with vaccination against HBV and adherence to infection control measures, and by introducing safer devices and techniques.

Proton MR spectroscopy in quantitative in vivo determination of fat content in human liver steatosis

To demonstrate that the lipid volume fraction in liver steatosis can be accurately estimated with in vivo hydrogen-1 magnetic resonance (MR) spectroscopy, the authors developed a calibration procedure based on in vitro MR spectroscopy of lipid extracts from steatotic liver specimens. The lipid volume fractions determined with the calibration procedure were compared with the results of histomorphometry and with calibrated computed tomographic (CT) data. The volume fraction of fat determined with MR spectroscopy was in good agreement with the CT results, whereas histomorphometry underestimated the amount of hepatic fat. The results indicate that determination of the fat volume fraction in steatotic liver can be achieved noninvasively with MR spectroscopy.

Ovarian influence on adrenal androgen secretion in polycystic ovary syndrome

OBJECTIVE

To determine whether the ovary influences adrenal androgen secretion in polycystic ovary syndrome (PCOS).

DESIGN

The adrenal androgen secretion was evaluated before and during ovarian suppression with a long-acting GnRH agonist.

SETTING

Department of Obstetrics and Gynecology, Pisa, Italy.

PARTICIPANTS

Women with PCOS and high (10 subjects) and normal (12 subjects) DHEAS levels and 6 normal women.

INTERVENTIONS

After 1 mg dexamethasone, an ACTH-(1-24) stimulation test was performed in the early follicular phase of the menstrual cycle. The test was repeated after two injections of a long-acting GnRH analogue (GnRH-a).

MAIN OUTCOME MEASURES

Basal plasma levels of gonadotropins, E2, T, androstenedione (A), 17 alpha-hydroxyprogesterone (17-OHP), DHEAS, and cortisol (F) were evaluated before the evening administration of dexamethasone. Serum A, T, 17-OHP, DHEAS, and F were measured 9 hours after dexamethasone and in samples collected 60 and 120 minutes after ACTH IV injection.

RESULTS

In the high DHEAS group the maximum increases in T, A, 17-OHP, and DHEAS in response to ACTH were significantly higher than in normal DHEAS PCOS women and in normal women. The GnRH-a modified the A and T responses to ACTH in the high DHEAS group.

CONCLUSIONS

Ovarian steroids, or other extra-ovarian factors, seem to be responsible for the increased A and T responses to the corticotropin stimulation demonstrated in some PCOS women.

Video-assisted thoracoscopy in the management of recurrent spontaneous pneumothorax

OBJECTIVE

To present our experience of video-assisted thoracoscopy in the treatment of recurrent spontaneous pneumothorax, and to compare the results with those of a historical control group treated by lateral thoracotomy.

DESIGN

Prospective evaluation with historical controls.

SETTING

Teaching hospital, Italy.

SUBJECTS

41 Patients with recurrent spontaneous pneumothorax, 20 of whom were treated by video-assisted thoracoscopy and 21 of whom underwent lateral thoracotomy (historical control group).

MAIN OUTCOME MEASURES

Duration of chest drainage, length of hospital stay, amount of narcotic analgesia required, postoperative complications, and recurrence during follow up.

RESULTS

The mean (range) duration of chest drainage in the group who underwent video-assisted thoracoscopy was 5 days (4-7) compared with 7 days (4-13) in the control group; the corresponding figures for length of hospital stay were 6 days (4-8) compared with 10 days (5-16). 3 Patients (15%) in the thoracoscopy group required parenteral narcotic analgesia compared with 14 (66%) in the control group, and 2 (10%) developed minor complications compared with 5 (24%). The mean length of follow up was 9 months (range 1-18) compared with 26 months (19-34), and no patient in either group developed a recurrence.

CONCLUSION

Our early results of treating recurrent spontaneous pneumothorax with video-assisted thoracoscopy have been encouraging, and we have adopted it in preference to lateral thoracotomy.

Preoperative chemotherapy and immunochemotherapy for locally advanced stage IIIA and IIIB non small cell lung cancer. Preliminary results

From January 1991 to November 1993, 110 patients with histologically confirmed stage IIIA and IIIB non-small cell lung cancer (NSCLC), were seen at our Institution. Our study was designed to evaluate whether redirection to surgery of otherwise unresectable patients may be obtained by preoperative therapy. Forty-nine patients were considered eligible for neoadjuvant treatment. Thirty-two (Group I) were treated with two or three cycles of cisplatin, vinblastine and mitomycin C and 17 (Group II) received two cycles of cisplatin, VP16, alpha 1 timosine and interferon. The overall response rate was 81.2% for Group I and 88.7% for Group II. Downstaging was predictive of resectability (P < 0.05). Forty-one patients (83.6%) underwent thoracotomy with 37 (75.5%) radical resections. Conservative techniques (bronchovascular reconstruction) (22 cases) were preferred over pneumonectomy (2 cases). The resectability rate was 84% for Group I and 87% for Group II (P = NS). Treatment-related complications were minor, with no deaths. Postoperative complications occurred in two cases in each group (7.4% and 14.3%). There was no histologic evidence of tumor in three patients. Two-year survival was 75% for Group I and 55% for Group II (P = NS). To date 35 patients who had complete resection are alive, and free of disease. We conclude that preoperative chemotherapy produces high response and resectability rates in both stage IIIA and IIIB unresectable NSCLC; radical resection using a conservative technique is possible in patients who are otherwise unresectable; no local recurrence occurred after radical resection; no significant differences were demonstrated between the two protocols.

Pancytopenia associated with thymoma resolving after thymectomy and immunosuppressive therapy. Case report

In a 43-year-old woman, pancytopenia accompanying thymoma persisted after thymectomy, requiring weekly blood transfusions, and did not respond to prednisone 50 mg/day. Cyclosporine 10 mg/kg/day plus prednisone 20 mg/day for a month gradually corrected the blood parameters. Thirty months later the patient is well and haematologically stable.

Enhanced pressor responsiveness to norepinephrine in type II diabetes. Effect of ACE inhibition

OBJECTIVE

To evaluate the effect of angiotensin-converting enzyme (ACE) inhibition on the pressor responsiveness to norepinephrine in type II diabetes.

RESEARCH DESIGN AND METHODS

Eight normotensive subjects, eight mild-to-moderate hypertensive type II diabetic patients, and eight nondiabetic patients with essential hypertension were studied before and after 4 weeks of being administered enalapril. The pressor response to norepinephrine was assessed by infusing the hormone in an antecubital vein at incremental doses of 30 ng.kg-1.min-1 for periods of 5 min until reaching an increase of 20 +/- 2 mmHg in mean arterial pressure (MAP) measured by an automatic device at 1-min intervals. An effective dosage of norepinephrine that increased MAP by 20 mmHg (EDNE 20) was thereafter calculated. Before and during the last minute of norepinephrine infusion at maximum dosage, a venous blood sample was drawn to determine plasma renin activity (PRA), aldosterone, and norepinephrine levels.

RESULTS

In the three groups of patients, blood pressure and aldosterone were reduced while PRA was raised following ACE inhibition. Basal and maximum postinfusion levels of norepinephrine were not modified by enalapril. The EDNE 20 was basally lower in diabetic patients and remained unchanged after ACE inhibition, contrary to that observed in nondiabetic patients with essential hypertension.

CONCLUSIONS

Both normotensive and hypertensive type II diabetic patients have an increased pressor responsiveness to norepinephrine that is not modified by therapeutic doses of enalapril, contrary to what is observed in nondiabetic patients with essential hypertension.

Effects of finasteride, a 5 alpha-reductase inhibitor, on circulating androgens and gonadotropin secretion in hirsute women

An oral 5-mg dose of finasteride, a 5 alpha-reductase inhibitor, was administered for 3 months to 10 hirsute women to determine the effect on gonadotropin secretion, on basal and stimulated androgen secretion, and on hair growth. Hair growth was assessed by the Ferriman-Gallwey score. All of the above determinations were evaluated before and after 1 and/or 3 months of finasteride treatment. Basal and GnRH-stimulated gonadotropin secretions were not affected. Indeed, finasteride did not modify the pulsatility of LH secretion. No change was seen in estradiol, PRL, free testosterone, androstenedione, dehydroepiandrosterone sulfate, and sex hormone-binding globulin concentrations. Serum concentrations of cortisol (F) were significantly reduced after 1 month of finasteride treatment. The F levels returned to pretreatment levels after 3 months. Plasma levels of dihydrotestosterone and 3 alpha-androstanediol glucuronide significantly decreased during finasteride treatment. A significant increase in testosterone concentrations was observed after 3 months. Finasteride did not modify the responses of testosterone, androstenedione, and dehydroepiandrosterone sulfate to ACTH-(1-24) injection. Conversely, finasteride blunted the F response to corticotropin stimulation. Three months of finasteride treatment significantly decreased the Ferriman-Gallwey score. In conclusion, finasteride significantly decreased dihydrotestosterone and hair growth in hirsute women without negatively affecting gonadotropin secretion.

Haemostasis profile in smoking and nonsmoking women taking low-dose oral contraceptives

The effects of oral contraceptives on coagulation in 258 nonsmoking and in 190 smoking women were determined. In smokers and in nonsmokers taking oral contraceptives, fibrinogen and fibrinopeptide A concentrations were higher than in oral contraceptive nonusers. In nonsmokers, oral contraceptives increased antithrombin III activity. The effects on coagulation of oral contraceptives with a different ethinylestradiol content (from 35 mcg to 20 mcg) were then evaluated in 333 of these women. The biggest changes in coagulation were observed in smokers taking the preparation with the highest estrogen content. Reduction of the ethinylestradiol dose caused a decrease of the changes in coagulation induced by oral contraceptives both in smokers and nonsmokers. These results might suggest that during oral contraception the coagulation system is affected mainly in smokers and that the decrease of the estrogen dose might lower the effects of the association of smoking and oral contraception on coagulation.

Protection and revascularization of bronchial anastomoses by the intercostal pedicle flap

We used an improved method for preparation of the intercostal pedicle flap for encircling bronchial anastomoses, and we studied its vascular supply after the operation. The flap was used in 56 patients undergoing various types of sleeve resection and in three patients undergoing single lung transplantation. The technique is simple, fast, and causes neither extra surgical trauma nor complications. It allows satisfactory isolation and sealing of the bronchial anastomosis. Even if complete anastomotic dehiscence occurs (one case), the flap preserves the continuity of the airway, thus avoiding bronchopleural fistulas or other complications. The postoperative arteriographic study of the intercostal artery supplying the flap (performed in 14 patients) demonstrated the full patency of the vessel in all cases. It also showed that a fine vascular network develops around the anastomosis early in the postoperative period.

Comparative merits of thoracoscopy, mediastinoscopy, and mediastinotomy for mediastinal biopsy

Between April 1992 and April 1993, we performed fifty-four mediastinal biopsies in 51 patients with a mediastinal mass. Nine of these had lung cancer with mediastinal lymphadenopathy, and the remaining 42 had various primary mediastinal lesions. We have performed twenty video-assisted thoracic surgical procedure, twenty-six mediastinoscopies, and eight anterior mediastinotomies. In 3 patients the diagnosis was not obtained by mediastinoscopy, and video-assisted thoracoscopy was performed. We conclude that mediastinoscopy is indicated for the majority of lesions involving the peritracheal space. Restaging of lymphoma and highly infiltrative lesions are better managed by video-assisted thoracic surgery. Anterior mediastinotomy is indicated when feasible under local anesthesia for tumors infiltrating the anterior chest wall. In all other cases video-assisted thoracic surgery is preferable because it allows removal of large tissue biopsy specimens and even resection with wide surgical exposure and low operative trauma.

Reconstruction of the pulmonary artery in patients with lung cancer

Between March 1990 and December 1992, we performed 17 resections and reconstructions of the pulmonary artery (PA) in patients with lung cancer. Three patients with intrapericardial infiltration of the PA underwent left pneumonectomy and PA angioplasty through a median sternotomy during cardiopulmonary bypass. The first patient survived in excellent general health for 25 months and then died of brain metastases; the second died of bronchopneumonia on postoperative day 24; and the third died of generalized tumor spread after 3 months. Fourteen patients had extrapericardial infiltration of the PA. They underwent sleeve upper lobectomy and PA reconstruction instead of pneumonectomy. In 6 patients we performed a sleeve resection of the PA, and in 8, the vessel was reconstructed using a patch of autologous pericardium. Two minor postoperative complications occurred. Three patients died after 14, 15, and 20 months; the remaining 11 are alive and well 5 to 31 months after operation. We conclude that PA reconstruction associated with sleeve lobectomy is an advantageous alternative to pneumonectomy in select patients with lung cancer. Intraoperative indications, surgical technique, and perioperative management are crucial to achieve good results. Reconstruction of the main PA during cardiopulmonary bypass in association with left pneumonectomy can be performed successfully. The long-term results need further evaluation.

Efficacy of cyclosporine to reduce steroids in patients with idiopathic pulmonary fibrosis before lung transplantation

Lung transplantation today is considered an effective option for patients with severe idiopathic pulmonary fibrosis. The standard medical treatment for this disease consists of high-dose steroids alone or combined with other immunosuppressive drugs. Unfortunately, pretransplantation administration of steroids may jeopardize the healing of the airway anastomosis and cause other complications; therefore it is considered a relative contraindication to lung transplantation. For this reason we try to reduce the dose of prednisone to 15 to 20 mg/day or less before the transplantation, but this creates many difficulties and is sometimes impossible in severely ill patients. Therefore we used cyclosporine (4 to 7 mg/kg/day) in 10 patients who were receiving high-dose prednisone (> or = 50 mg/day) therapy, but who were otherwise suitable candidates for lung transplantation. In seven cases prednisone could be tapered to 20 mg/day or less, allowing acceptance in our program. These patients had a CRP score of 60 or more before entering our trial and remained stable at this level after conversion to cyclosporine. The 6-minute walk test showed a mild improvement in five cases (71.5%). Three patients underwent single lung transplantation; two patients are on our waiting list after 3.5 and 4 months of treatment with cyclosporine and prednisone (10 mg/day), and two patients died while awaiting a suitable organ 6 and 7.5 months after starting cyclosporine therapy. Combined administration of cyclosporine and prednisone may extend the waiting time while receiving low-dose steroids and allow more patients with idiopathic pulmonary fibrosis to qualify for lung transplantation while reducing the risk of steroid-induced complications.

Clinical and endocrine effects of flutamide in hyperandrogenic women

OBJECTIVE

To investigate the clinical and endocrine effects of the antiandrogen flutamide in hirsute women.

DESIGN

Hirsutism was assessed before and after 3 months of treatment with flutamide 500 mg/d. Endocrine evaluations were performed before and during the 2nd month of treatment with flutamide 500 mg or 750 mg/d.

SETTING

Department of Obstetrics and Gynecology, Pisa, Italy.

PARTICIPANTS

Eighteen hirsute women were studied: nine women were hyperandrogenic, and the other 9 had an idiopathic hirsutism.

INTERVENTIONS

Women were randomly treated with flutamide 500 mg/d (9 patients) or 750 mg/d (9 patients) for 3 and 2 months, respectively. Six received placebo 1 month before flutamide treatment.

MAIN OUTCOME MEASURES

Hirsutism was assessed by measuring hair diameter. Follicle-stimulating hormone and LH responses to GnRH were evaluated. Basal plasma levels of T, androstenedione (A), 17-hydroxyprogesterone (17-OHP), DHEAS, cortisol (F), and sex hormone-binding globulin (SHBG) were evaluated. The same hormones were determined after a single dose of flutamide (250 or 500 mg) or placebo throughout a 12-hour period and in samples collected 60 and 120 minutes after ACTH intravenous injection.

RESULTS

Hair diameter was reduced by 30%. Both dosages of flutamide did not change basal and stimulated gonadotropin, T, A, 17-OHP, F, and SHBG levels. Both dosages reduced stimulated DHEAS levels.

CONCLUSIONS

Flutamide may have a beneficial effect on hirsutism. This effectiveness is mainly due to its peripheral antiandrogen action. However, an effect on the adrenal gland seems to be present.

Thoracoscopic resection of mediastinal cystic schwannoma

Mediastinal cystic schwannoma is of very rare occurrence. Our patient came with chest pain of 6 months duration. Abnormal shadow on chest x-ray was found. A sharp dissection space was evident by computed tomography (CT-scan) and magnetic resonance imaging (MRI) between the tumor, the left pulmonary artery, and the descending aorta. The patient underwent surgical removal using thoracoscopic surgery. Postoperative discomfort was markedly reduced and hospitalization short. We can conclude that interventional thoracoscopy is a safe, well-tolerated procedure, with excellent therapeutic potentials.

Bronchovascular sleeve resection. Technique, perioperative management, prevention, and treatment of complications

Between May 1989 and May 1992, we performed bronchial sleeve resections or complex reconstructions of the pulmonary artery in 55 patients. Forty-four patients had bronchogenic carcinoma, and 11 had benign lesions. One patient died (mortality 1.8%) and three (5%) had minor complications (dehiscence or granuloma), which were treated by laser recanalization and recovered within 1 year. Ten patients underwent sleeve resection of the pulmonary artery or reconstruction of the vessel with a pericardial patch with no complications. In patients with lung cancer, 2-year survival was 72%, whereas all patients with benign lesions were alive and well at 8 months to 3 years after the operation. We consider accurate surgical technique, bronchial protection with a pedicled intercostal flap, and the use of steroids in the postoperative period as the key factors for success. If anastomotic complications occur, these can be treated conservatively by laser recanalization and bronchial stenting.

[Benign esophageal-respiratory fistulae. The surgical treatment and results of 10 cases]

Benign esophago-respiratory fistula is a relatively rare condition of great surgical interest because of its potential total curability. The ratio of benign to malignant fistula is around 1:5. Sometimes the diagnosis is difficult because of the non specific nature of presenting symptoms. This report concern 10 cases of benign esophagorespiratory fistulas observed during a period of twenty years. There were 6 esophago-tracheal fistulas and 4 esophagobronchial fistulas. In 4 cases the fistulas were congenital, in 1 the fistula was due to perforation of esophageal diverticulum and in 3 patient the fistula developed after prolonged intubation. All patient underwent surgical treatment consisted of division of the fistula and suture of both esophageal and respiratory defect. In 4 cases we performed pulmonary parenchyma resection because of irreversible inflammatory lesions. There were no perioperative death. One young patients with tubercular fistula developed a dehiscence of esophageal suture successfully treated with pleural drainage and several application of fibrin glue. All patient were considered to have very good results.

Fatty infiltration of the liver. Quantification by 1H localized magnetic resonance spectroscopy and comparison with computed tomography

RATIONALE AND OBJECTIVES

The authors evaluated the degree of fatty infiltration of the liver in subjects with diffuse liver steatosis using image-guided 1H localized MR spectroscopy and correlated the magnetic resonance (MR)-determined fat fraction with the computed tomography (CT) liver/spleen density ratio and histologic evaluation.

METHODS

MR measurements were performed at 1.5 T by applying a double-spin-echo localization sequence. Twenty-six patients underwent MR and CT examinations and ultrasound (US)-guided biopsy. Additionally, three healthy volunteers underwent MR examination. Steatosis severity was estimated using 1) the ratio between fat and total MR signal areas; 2) the ratio between liver and spleen CT number; and 3) histologic score.

RESULTS

The linear correlation between MR fat/fat-plus-water signal ratio and CT liver/spleen density values ratio is statistically significant. Both techniques correlate well with histologic score. No significant correlation exists between water or fat T2 values and the severity of steatosis.

CONCLUSIONS

1H MR spectroscopy allows a noninvasive estimate of the hepatic fat content.