[Surface antigen (HBsAg) and core antibody (anti-HBc) in chronic uremia during periodic hemodialysis treatment of hepatitis B patients. Correlation with viral replication markers (HBeAg and DNA polymerase activity)]

Sera of thirty-five hepatitis B surface antigen (HBsAg) positive hemodialysis patients and fifty-three asymptomatic HBsAg chronic carrier were studied to assess the relationship between markers of virus activity (hepatitis B e antigen and core-associated DNA polymerase activity) and titers of HBsAg and of antibody to hepatitis B core antigen (anti-HBc). All sera were tested by solid-phase radioimmunoassay methods. HBeAg was detected in 20 (51%) hemodialysis patients and in 14 (26%) asymptomatic carriers, whereas DNA P activity was present in sera of 21 (60%) and 17 (32%) respectively. The highest titers of HBsAg and anti-HBc expressed as P/N ratio between positive and negative controls, were detected in the majority of hemodialysis patients, whereas asymptomatic carriers showed low titers of these markers. These data suggest that in HBsAg positive hemodialysis patients a more active viral replication occurs and further underline the difference between these patients and other categories of HBsAg carriers in terms of infectivity.

[Serologic diagnosis of acute hepatitis A. Refinement and evaluation of 3 methods of determining specific anti-HAV IgM]

A solid phase radioimmunoassay (RIA) procedure was developed and three methods for detection of IgM specific antibody to hepatitis A virus (anti-HAV IgM) were compared: triple antibody method, 2-MercaptoEthanol (2-ME) for IgM cleavage and Staphylococcal A Protein (StAP) for IgG absorption. Specificity and sensitivity of the tests were checked for evaluating acute and convalescent sera from 40 patients with serologically (seroconversion) diagnosed hepatitis A and 64 sera from patients with various acute viral diseases or with high titre of rheumatoid factor (RF). Specimens to be assayed for anti-HAV IgM were pretreated with 2-ME or StAP and tested by RIa using 125I labelled anti-HAV IgG. Triple antibody method showed to be more sensitive than other two methods giving false positive result in only one serum containing high levels of monoclonal RF. No significant difference in sensitivity and specificity was found between 2-ME and StAP procedure, but these methods were able to detect anti-HAV IgM for only two weeks after the onset of the disease, whereas triple antibody method gave positive results for at last seven weeks.

[Non-A, non-B post-transfusion hepatitis. Serological survey of 85 patients with acute hepatitis following blood transfusion]

In a serological survey of 85 adult patients hospitalized for an episode of transfusion-associated hepatitis, 45 were reactive for hepatitis B surface antigen and therefore diagnosed as having hepatitis B. Forty HBsAg non reactive patients were examined for development of antibody to hepatitis A and B antigens, cytomegalovirus and Epstein-Barr virus. Three patients showed serologic evidence of hepatitis B and one for hepatitis A. None of the remaining 36 subjects developed serologic evidence of acute infection with the viruses tested during the study period, so that they were classified as having so-called NANB hepatitis. As reported in other studies, analysis of the incubation period showed that two subgroups of NANB hepatitis may be identified with short and long incubation period, so that it appears likely that at least two agents are implicated in NANB hepatitis. Our data confirm that also in our area a large proportion of transfusion-associated hepatitis is related to NANB agent(s) requiring additional measures for its prevention.

Discontinuing therapy in childhood acute lymphocytic leukemia. A multicentric survey in Italy

The results of discontinuing therapy in children with acute lymphocytic leukemia observed at four associated institutions are presented. Of the 247 patients who achieved complete remission, 122 (49.3%) reached the point of discontinuing therapy after 2-4 years of continuous remission. The median period off therapy was 13 months with a range of 1-69 months. Of the 122 children removed from therapy, 27 (22.1%) relapsed, mainly in the bone marrow; relapses occurred 1-32 months after cessation of therapy (median ten months) with only two relapses occurring later than two years. By actuarial analysis, 57% of the patients are projected in continuous remission after five years from cessation of therapy. Neither selected features at diagnosis nor single modalities of treatment were found to predict whether relapse would occur after discontinuing therapy. Long-term remission and possibly cure can be expected in over one-third of newly diagnosed children with ALL after 2-4 years of antileukemic treatment.

[Radiotherapy of anal carcinomas. Case reviews]

Radiotherapy is commonly assigned an important role in the treatment of anal neoplasia. Interstitial treatment with 192Ir and high-energy transcutaneous therapy will lead to survival and cure percentages comparable with those obtainable surgically, if correctly employed in accordance with precise indications, in stage T1 and T2 tumours. External high-energy management, with or without surgery, may also be effective in stage T3 cases. The seriousness and frequency of radionecrosis have hitherto helped to create a lack of trust in radiation management. Modern irradiation techniques, however, have reduced these complications to low percentages, and their resolution by destructive surgery is rarely required.

HBeAg/anti-HBe system and cell-mediated immunity in patients with HBsAg-positive chronic active hepatitis

Determinations of HBeAg, anti-HBe and cell-mediated immune response were carried out in 29 patients with HBsAg-positive chronic active hepatitis. Out of 29 patients with chronic active hepatitis B, 18 were found to be HBeAg positive, 7 anti-HBe positive, and 4 without detectable HBeAg/anti-HBe by radioimmunoassay. The presence of HBeAg in serum (n = 18) was associated with impaired lymphocyte response in 15 patients (83.3%, p less than 0.05). Out of these 15 patients 6 developed cirrhosis within a period of 6 months to 2 years. By contrast, this occurred in only 1 out of 8 HBeAg-negative patients (6 were anti-HBe positive) with normal lymphocyte function. Although HBeAg and depressed cellular immune response in chronic active hepatitis is not necessarily associated with a bad clinical and histological outcome of the disease, these data suggest that, in a number of cases, host cell-mediated immune response seems to be correlated with the presence of HBeAg and the outcome of chronic active hepatitis and, in this respect, HBeAg could assume the significance of a prognostic marker in hepatitis B virus infection.

Radioimmunoassay in the detection of the hepatitis B e antigen/antibody system in asymptomatic carriers of hepatitis B surface antigen. Correlation with serum Dane particle associated DNA polymerase activity

A radioimmunoassay for hepatitis e antigen (HBeAg) and antibody to e (anti-HBe) was developed and sera of 71 asymptomatic chronic carriers of hepatitis B surface antigen (HBsAg), in 44 of whom liver biopsy was obtained, were tested. In addition, testing for Dane particle associated DNA polymerase activity was performed in all sera. HBeAg was detected in 14 subjects (19.7%) and anti-HBe in 46 (64.8%). The highest proportion of HBeAg positivity (40%) was found among carriers with histological evidence of chronic hepatitis, whereas anti-HBe was present in 80% of carriers with normal liver histology, in 58% of carriers with non-specific reactive hepatitis and in 60% of carriers with chronic liver lesions. DNA polymerase activity was present in 92.8% of sera positive for HBeAg, in 13% of sera positive for anti-HBe, and in 9% of sera negative for both markers. Our results demonstrate that not all HBsAg carriers reactive to HBeAg show evidence of chronic hepatitis nor, conversely, that anti-HBe is invariably associated with the healthy carrier state of HBsAg. Finally, circulating Dane particles, as revealed by the presence of serum specific DNA polymerase activity, may also be present in anti-HBe positive sera other than those of some HBsAg carriers lacking both HBeAg and anti-HBe.

[Distribution of anti-HAV in a population sample from Puglia]

To investigate the prevalence and distribution of antibody to hepatitis A virus (anti-HAV), we tested by solid phase radioimmunoassay method 461 sera of selected people of Bari, according to age. In addiction, sera from cord blood of 11 newborns and their mothers at delivery were also investigated for anti-HAV. Taken together 64.4 per cent of subjects tested were found to be anti-HAV positive. The rate of antibody detection was strongly correlated with age. The prevalence were 4.5 per cent from 6 months to 3 years but gradually increased throughout childhood (from 35.6 to 80 per cent). Anti-HAV was detected in all cord blood samples from newborns whose mothers carried anti-HAV. These data suggest that circulation of hepatitis A virus in our area is very high, so that serological evidence of infection become evident in the majority of individuals during infancy.

[Antinuclear antibody (anti-HBc) and liver pathology in acute and chronic virus B hepatitis]

HBsAg and anti-HBc, the antibody to core antigen of hepatitis B virion, were titrated by solid phase radioimmunoassay in 40 sera of HBsAg carriers with acute and chronic hepatitis and in 20 healthy subjects carrying anti-HBc alone or associated with anti-HBs. No correlation was found between HBsAg and anti-HBc titers in the single category of patients. In contrast, geometric mean titer of anti-HBc (ranging from 2(14) to 2(15)) of patients with chronic active hepatitis was significantly higher ( p = < 0.01) than that of patients with acute or chronic persistent hepatitis and healthy HBsAg carriers (ranging from 2(9) to 2(14)). Anti-HBc titer of 20 subjects without detectable HBsAg was less than 2(7). These data suggest that in subjects with persistent B virus infection, anti-HBc response is correlated with synthesis of viral genome rather than of surface antigens, so that a much higher titer of anti-HBc was detected only in patients with a more active liver disease.

[Serodiagnosis of acute hepatitis A]

Hepatitis A antibody (anti-HAV) was detected by specific radioimmunoassay (RIA) method in sera from 10 patients with acute icteric hepatitis. Anti-HAV was detectable in many subjects very early before the onset of jaundice, but the diagnosis of type A hepatitis in all patients was confirmed by the demonstration of seroconversion during convalescence. Since the initial antibody detected by RIA is predominantly IgM, while IgG specific anti-HAV appears later reaching peak levels within 1 to 2 months, we treated serum specimens of these patients with 2-mercaptoethanol (2ME) in order to differentiate acute-from convalescent-phase hepatitis A sera. Inactivation of IgM fraction with 2ME produced a significant reduction of anti-HAV titer only in acute-phase sera, so that this procedure may be used for early diagnosis of acute type A hepatitis.

[Prognostic value of alpha-foetoprotein in fulminant hepatitis (author's transl)]

Serum concentrations of alpha-foetoprotein (AFP) were measured sequentially by radioimmunoassay in 32 patients with fulminant hepatitis and coma, 22 of whom died. Levels were significantly elevated in 100% of patients who survived and in 7 out of 22 patients (38.5%) who died (P = less than 0.005). In the survivors the rise of AFP levels was found early after the development of coma and subsequently in all serum samples obtained during acute phase of illness. In 2 of 7 fatal cases who had raised AFP levels and the more protracted illness, AFP levels fall after 6 days. The high levels of serum AFP observed in severe forms of hepatitis may represent active hepatocyte regeneration after extensive hepatic necrosis. Although the correlation between survival and serum concentration of AFP is not absolute, our finding indicate that the rise in serum of this protein in patients with massive hepatic necrosis may be considered a favorable prognostic sign.

Persistence of e antigen as prognostic marker in acute hepatitis B

Serial determinations of HBeAg and anti-HBe were made in sera of 155 selected patients with acute hepatitis B who were followed up for one to four years. In the early phase of hepatitis, HBeAg was present in 43 cases (27.7%) and anti-HBe in 12 cases (7.7%). Evaluation of the outcome of hepatitis showed that development of chronic hepatitis occurred in 11 out of 43 HBeAg positive patients, in 10 out of 100 HBeAg negative patients (P = less than 0.05) and in 2 out of 12 patients carrying anti-HBe. Nine out of 11 HBeAg positive chronic subjects showed persistent HBe antigenemia over two months, while the remaining 32 patients, who recovered completely, lost HBeAg within two to three weeks from the onset of the disease. These data suggest that the prognostic value of HBeAg in acute hepatitis patients may be taken into account when HBeAg persists in the serum and that anti-HBe does not invariably protect from the development of chronic hepatitis.

[Factors of contagiousness in the epidemiology of hepatitis type B (author's transl)]

Since morbidity of viral hepatitis B is increasing, the causes of diffusion of this infection have been studied. There are several routes of transmission and undoubtedly apparent non-parenteral routes have a great importance. In a study performed on 32 families of HBsAg carriers, familial aggregation of infection has been acquired through close personal contact. Transmission of infection from mother to infant may occur transplacentally for vertical transmission, or, after the birth, for horizontal transmission, so that a high percentage of children is infected. Percutaneous transmission of hepatitis B in families affected by scabies is evident. The presence of infectivity markers is of major importance for transmission of virus: these are HBeAg and specific DNA-polymerase activity of serum. Well, when the carrier exhibits the markers, the contacts are involved in the infection in a high percentage. From this point of view the carriers with chronic liver disease are more dangerous than the asymptomatic ones. The problem of carrier exists: nevertheless it is possible to carry out a better prophylaxis, if we take into account the presence of the infectivity markers.

[Role of chronic HBsAg carriers in intrafamilial diffusion of hepatitis B virus infection]

To assess the hepatitis B virus infection risk to household contacts exposed to HBsAg-positive chronic carriers, 169 family members of 20 healthy carriers of HBsAg and of 12 with chronic hepatitis were followed up prospectively for two to five years. All family members are investigated for the presence of serum HBsAg/antiHBs system and for the presence of liver disease. Our results indicate that the family contacts of HBsAg carriers with evidence of chronic liver disease are at greater risk of exposure to HBV than the contacts of healthy carriers and that acquisition of HBsAg is more common among males than among females. Evidence of exposure to HBsAg is very frequent in young age with a striking rise between 10 and 20 years. On the contrary acquisition of anti-HBsAg is more common after 40 years of age. These data suggest that persistent circulation of HBV in a family of chronic HBsAg carrier increases the risk of infection in household contacts and that HBV is eliminated in a more infective form from the carriers with chronic liver disease.

Clustering of HBsAg in a family

A study was performed on a family of 7 followed up over a 4-year period in which an outbreak of B-antigen-positive hepatitis occurred. Of the 5 male members who acquired HBsAg, 1 became a chronic asymptomatic carrier and 4 had episodes of acute icteric hepatitis during a 15-month period with development of histologically documented chronic hepatitis with persistent HBs antigenaemia in all. Of the 2 female members, 1 had an attack of acute HBsAg-positive hepatitis but recovered normally and cleared HBsAg from her serum, while the other was found to have anti-HBs with no evidence of liver disease. Serological and immunological studies carried out in all members of this family suggested that a sex-linked defect of T cell function itself could explain the differing host immune response to HBV infection in genetically related subjects.

[Epidemiologic study of chronic hepatitis in relation to heptatis B virus infections (author's transl)]

In order to evaluate the role of hepatitis B virus (HBV) in the etiology of chronic liver diseases, paired sera of 143 patients with biopsy-documented chronic hepatitis were tested for HBsAg and anti-HBs by radioimmunoassay method. HBsAg was detected in 67.3% of patients with a preceding verified eipsode of acute hepatitis, and in 26.7% of patients with a cryptogenic form of chronic hepatitis. HBsAg was not found in any of patients with alcoholic chronic hepatitis and in only two of 18 patients with other forms of chronic liver disease. No significant difference in the incidence of anti-HBs was observed in all groups of patients. According to previous studies our results confirm the higher prevalence of HBV infection in etiology of chronic persistent and aggressive hepatitis and indicate that this prevalence may be observed especially in Middle and South Italy. The presence of HBsAg in the serum of 37.2% of our patients with cirrhosis compared with 9% of reported cases in North Italy suggest that HBV plays an important role in the etiology of cirrhosis of the liver in our area.

[Behavior and clinical significance of the eAg/ anti-e system in carriers of HBsAg]

An investigation has been carried out in 315 patients with acute and chronic HBsAg positive and negative hepatitis in order to study the relationship between a new recently identified antigen/antibody system designed eAg/anti-e and HBV pathology. eAg was detected in sera of 37,8% patients with acute hepatitis who recovered normally and of 65% patients with acute protracted hepatitis and circulating HBSAg. eAg was not found in the serum of any of 52 cases of acute HBsAg negative hepatitis. Prevalence of eAg positivity was also demonstrated especially in patients with more severe forms of chronic hepatitis. Anti-e was not found in any of 20 patients with acute protracted hepatitis, but in 40% of subjects with acute hepatitis who recovered, in 54,5% of asymptomatic HBsAg carriers and in 30% of patients with chronic persistent hepatitis. Our results confirm the specific association between eAg/anti-e system and hepatitis B infection and indicate that eAg determinant is associated with continuing activity and chronicity of hepatitic process. In contrast, anti-e is correlated with normal recovery of acute hepatitis, but it may be indicative also of asymptomatic carriage of HBsAg and of non-progressive liver disease.

Mortality from Esophageal Cancer in Piedmont, Italy

Piedmont is located at the borderline between Italy (where mortality from esophageal cancer is relatively low) and France and Switzerland (where it is relatively high). Therefore, it seemed of interest to investigate the mortality from this cancer in Piedmont. Age-adjusted yearly mortality rates for 1965–1969 were 4.3 and 0.8 per 100,000 for males and females, respectively. Rates were very similar in the town of Torino, in the 23 suburbs of the first belt, in the nonmetropolitan areas of the province of Torino, and in the other 5 provinces of Piedmont. In both sexes, the rates did not differ from those observed in Italy during 1966–1967, whereas rates for males were lower than the national rates for France and Switzerland (14.0 and 8.5/100,000/year, respectively). Rates for males were also lower than in the adjacent French departments of Savoie, Haute-Savoie, and Isère (where in 1967–1968 they ranged between 9 and 16). Mortality rates from esophageal cancer in the town of Torino were constant from 1951–1971. During the same period, mortality from laryngeal cancer in men doubled. This suggests that although some etiological agents (alcohol consumption and tobacco smoking) are common to esophageal and laryngeal cancer, the interplay between these 2 factors as well as that with other carcinogens is different for the 2 types of cancer.

Prevention of Meningeal CNS Involvement as a Factor Influencing the Duration of Complete Remission and Survival in Childhood Acute Lymphoblastic Leukemia

The influence on the duration of CR and survival of 2 modalities (MTX + hydrocortisone IT, with and without TCT) for the prevention of meningeal CNS involvement was assessed in 24 children with acute lymphoblastic leukemia. Of the 9 subjects who received MTX and hydrocortisone only, 42 % were still in CR 33 months after its attainment, as opposed to 75 % of the 15 who also received TCT. Survival at 33 months after diagnosis was 89 % and 82 % in the 2 groups. The results are compared with those obtained in an earlier series of 14 children who received no prophylactic treatment. Here CR at 45 months was 25 % and survival 46 %. Eight subjects died, as opposed to 3 (1 in CR) in the present series.

[Wilms' tumor. Our clinical experience]

The survival of children with Wilms' tumour is evaluated in 11 males and 12 females treated between 1967 and 1975 in the light of the clinical stage, age at diagnosis, and sex. The subjects were aged from 4 months to 6 years. Six were in stage I, 4 in stage II, 4 in stage III, 7 in stage IV, and 2 in stage V. Survival in stage I was 100% at 36 months and gradually decreased with the stage. Patients aged less than 2 years presented a survival of 50% two years after diagnosis, compared to 24% in those over 2 years old. Sex appears to be irrelevant to prognosis.

Trimethoprim-sulphamethoxazole in the treatment of cholera. Comparison with tetracycline and chloramphenicol

67 of the bacteriologically proved adult acute cholera patients have been examined in order to evaluate the efficacy of TM-SMX in comparison with tetracycline and chloramphenicol in the eradication of Vibrio cholerae from stools. Our results demonstrated that all three drugs sterilized the stools of all patients within 3 days with the exception of one case of TM-SMX's group, which had negative culture stools after 4 days. On the basis of our experience it can be emphasized that TM-SMX can support chloramphenicol and tetracycline in the antibacterial treatment of cholera with the advantage that the drug is efficacious with daily administrations.

A bioptic study of gastrointestinal mucosa in cholera patients during an epidemic in southern Italy

A histological biopsy study of gastric and jejunal mucosa of eight acute cholera patients during an epidemic in Southern Italy was carried out. The study demonstrated in all patients an intact epithelial lining of gastric and jejunal mucosa, a moderate degenerative process of enterocytes, presence of inflammatory lesions manifested by edema, vascular congestion, mononuclear cell infiltrate of lamina propria, and discharge of goblet-cells mucus. These changes reverted to normal in a few days. The authors emphasize that, contrary to cholera patients of Asiatic areas in whom an underlying chronic spruelike enteropathy is very common, the histological picture observed in Western patients may be considered more specific since Vibrio cholerae acts upon a normal intestinal mucosa.

[Treatment of cholera in the adult. Studies during recent epidemics in Apulia]

A rapid and adequate intravenous infusions of saline and alkali in correcting hypovolemic shock, alectrolyte abnormalities, acidosis and renal failure, is the choice treatment in the majority of acute cholera patients. On the basis of the knowledge of chemical composition of the gastrointestinal fluids loss and the definition of exact mechanism of metabolic features observed in acute cholera patients, it has been possible, in the last ten years, to develop and utilize in a large numbers of patients, a more exact and adequate treatment consisting of replacement of water and electrolytes depletion with saline and alkali of the same ionic composition of fluids lost through the gastrointestinal tract. The isotonic saline and isotonic sodium lactare regimen in a 2:1 ratio has been employed in the treatment of our adult acute cholera patients. Hypotensive patients received a rapid fluids infusion of 2-4 liters within the first 4-6 hours immediately after admission. Later on the quantity of intravenous fluids replacement was regulated on the basis of blood electrolytes pattern, blood pressure, diuresis and patient's hydratation. With this regimen of treatment we observed electrolytes and acid-basic abnormalities in only 25% of our patients. The peritoneal dialysis was applied in three of these patients with irreversible renal failure. Antibiotic therapy, that assume a secondary role in the treatment of cholera patients, was carried out in each case: in 19 cases were given 1 gram every 12 hours i.m. of chloramphenicol succinate; 14 cases received mg 500 of tetracycline orally every six hours; 34 cases received two tablets of trimethoprim-sulphamethoxazole every 12 hours (mg 240 of TM and g 1,6 of SMZ total dose). Except one case of TM-SMZ group who had stool culture positive for Vibrio on 4th day of therapy, in each other patients the stool cultures were sterilized in a period of 24-72 hours of antibiotic treatment.

[Renal complications of Asiatic cholera]

Seventy cases of cholera were admitted to Hospital during 1973 cholera epidemic; 49 showed the symptoms of renal failure, 19 of whom with anuria. Acute renal failure is caused from hypertonic or isotonic dehydration, metabolic acidosis and potassium depletion. Clinically the pattern of a tubulo-interstitial nephritis can be found; a short oliguric or anuric phase followed by a poliuric phase lasting about 10 days. The glomerular function usually cames back to normal in 20 days time. As for the therapy, 16 of the above mentioned 19 anuric patients received a conservative treatment only; 3 patients with preexisting chronic nephropathy required peritoneal dialysis. Only one patient died and one patient with lupic nephropathy was put on chronic haemodialysis treatment. Concluding: 17 patients out of 19 completely recovered their renal function.

Gastric abnormalities in cholera: epidemiological and clinical considerations

The anatomofunctional status of the stomach was studied in cholera patients during the outbreak in Bari, Italy, in 1973. Of a total of 70 patients examined, 24 were found to have undergone gastric resection for ulcer in the past. Stomach secretions induced by fasting and histamine stimulation were studied in 30 patients, the majority of whom showed achlorhydria and other disturbances of gastric secretion. These abnormalities not only predisposed the patients to cholera infection but shortened the incubation period. The clinical course and severity of the disease were also related to the degree of gastric damage, the most serious cases occurring in gastrectomized patients.