Is alcohol a risk factor for liver cirrhosis in HBsAg and anti-HCV negative subjects? Collaborative Groups for the Study of Liver Diseases in Italy

BACKGROUND/AIMS

In order to evaluate the association between alcohol intake and the risk of liver cirrhosis in the absence of B and C hepatitis viruses, we analyzed data from three hospital-based case-control studies performed in various Italian areas.

METHODS

From the case and control series we excluded HBsAg and/or anti-HCV positive patients. Cases were 221 cirrhotic patients admitted for the first time to hospital for liver decompensation. Controls were 614 patients admitted to the same hospitals during the same period as the cases for acute diseases unrelated to alcohol. Alcohol consumption was expressed as lifetime daily alcohol intake (LDAI).

RESULTS

We found a dose-effect relationship between LDAI and the risk of liver cirrhosis (LC). Considering the extreme LDAI categories (LDAI = 0 g: lifetime teetotallers and LDAI > or = 100 g), the LC odds ratio (OR) increased from 1.0 (reference category) to 44.7 (95% confidence interval: 95% CI: 20.0-99.9). An increased risk of LC associated with the female gender independent of alcohol consumption was also observed (OR = 2.9; 95% CI: 1.8-4.6).

CONCLUSIONS

Alcohol intake acts as a risk factor for symptomatic liver cirrhosis also in the absence of HBV and/or HCV infection. Besides alcohol and viruses, some unknown gender-related factors might be involved in the occurrence of the disease.

Alcoholic liver cirrhosis after the advent of hepatitis C virus: some reflections on its epidemiology and on the concept of attributable risk. Collaborative GESIA and AISF Groups. Gruppo Epidemiologico della Società Italiana di Alcologia and Associazione Italiana per lo Studio del Fegato

The recent availability of hepatitis C virus (HCV) infection markers has led to the hypothesis that the prevalence of alcoholic liver cirrhosis (ALC) may be far lower than has hitherto been believed. On the other hand difficulties in obtaining a reliable patient history of alcohol consumption and of making a differential diagnosis on the basis of histology suggest that the aetiology role of alcohol may be underestimated. Furthermore, epidemiological data strongly suggest that an individual susceptibility of alcoholic liver damage exists. The interaction between alcohol consumption and acquired factors, in particular hepatitis B and C viruses and nutrition, can be studied using an epidemiological approach. The concept of attributable risk, which depends on the strength of the aetiological factors and on their diffusion in the target population, is helpful in this context. Preliminary estimates suggest that alcohol is at least as important as HCV infection in causing liver cirrhosis in Italy. A nationwide study (SIDE-CIR Project) is currently being conducted in order to clarify this issue.

Trends of liver cirrhosis mortality in Europe, 1970-1989: age-period-cohort analysis and changing alcohol consumption

BACKGROUND

Since the mid 1970s, a striking reduction in alcohol-related problems has been observed in many Western countries. Liver cirrhosis mortality is considered to be a major indicator of alcohol-related problems in the general population. The aim of the present study is to describe liver cirrhosis mortality trends in European countries between 1970 and 1989.

METHODS

This is a descriptive study on liver cirrhosis mortality in 25 European countries, and in four grouped European regions. A Poisson log-linear age-period-cohort model is used to clarify whether the recent trend in mortality represents a short-term fluctuation or an emerging long-term trend. In addition, a descriptive comparison between trends in per capital alcohol consumption and liver cirrhosis mortality is conducted.

RESULTS

In the whole European population and in that of Western and Southern Europe increasing period effects were observed until the second half of the 1970s followed by a decline in the next periods. In Eastern Europe the decline in period effects started in the first half of the 1980s, whereas in Northern Europe an increasing period effect was observed until the second half of the 1970s, followed by a stabilization. Similar trends were observed for per capita alcohol consumption. The age effect analysis showed a continuously rising effect in Eastern Europe, whereas an attenuation of the effect at around age 65 years was observed in Western Europe. Intermediate patterns were observed in Southern and Northern Europe. The birth cohort effect suggested that in the Western and Southern populations mortality could continue to decrease over the next decade, while in Eastern and Northern mortality is still rising and this will probably continue for the next decade.

CONCLUSIONS

The age-period-cohort analysis allows targeting of health care and prevention programmes based on future trends. Aetiological and prognostic factors act differently in Europe. A better understanding of the trends would require more detailed information on alcoholism treatment rates, alcohol habits, viral hepatitic infections and other factors involved in the aetiopathogenesis of the disease.

Prognostic factors for long-term survival in cirrhotic patients after the first episode of liver decompensation

BACKGROUND/AIMS

Prognostic studies on cirrhosis are needed, since several attempts to obtain better survival predictors than the empirically derived Child-Pugh's score have failed.

METHODS

Four hundred and ninety-four consecutive in-patients with cirrhosis at the first episode of decompensation (ascites, jaundice, encephalopathy) and/or of digestive haemorrhage from ruptured oesophageal varices were followed from admission (1983-1989) to 1993, studying the relationship between 26 prognostic variables and survival. Three prognostic models were constructed using Cox's regression model and the Receiver Operating Characteristic (ROC) analysis was used to compare their predictive ability.

RESULTS

During follow-up 351 patients died (median cumulative survival 1.82 years). Child-Pugh's score (explicative variable of the first Cox's model), albumin and encephalopathy among the 5 Child-Pugh variables (second model), and oesophageal varices haemorrhage and 3 biochemical indexes among the 7 significant variables on univariate analysis (third model) correlated with survival. The area under the ROC curve of the first model did not significantly differ from that for the other 2 models.

CONCLUSIONS

The Child-Pugh's score is still the best and simplest index for assessing the prognosis of liver cirrhosis.

Incidence of inflammatory bowel disease in Italy: a nationwide population-based study. Gruppo Italiano per lo Studio del Colon e del Retto (GISC)

BACKGROUND

The epidemiology of inflammatory bowel disease (IBD) in Southern Europe is still unclear. Sporadic reports suggest a lower incidence of IBD in Italy than in other Western Countries and the USA.

METHODS

A nationwide population-based study was carried out to estimate IBD incidence rates in eight Italian cities. All new cases of IBD diagnosed over 4 years in the target populations were collected from multiple information sources.

RESULTS

From 1989 to 1992, 509 ulcerative colitis (UC), 222 Crohn's disease (CD) and 10 undefined IBD cases were collected, giving age-adjusted incidence rates (per 100,000 per year) of 5.2 for UC and 2.3 for CD. Using the capture-recapture method, an estimated completeness of 0.81 was obtained for case archives, without appreciable and significant differences between areas. The rates computed after correcting underestimation were 6.8 for UC and 2.8 for CD. The sex ratio M/F was 1.7 for UC and 1.0 for CD. The highest age-specific incidence rates were between 30 and 39 years for UC and between 20 and 29 years for CD.

CONCLUSIONS

The incidence rate of CD in italy is homogeneous between the cities investigated and lower than those reported for other Mediterranean countries. In contrast, the UC incidence rate is within the range of those reported in European studies. A wide variability in the UC rates between the cities was also observed. These results could be related to different environmental factors or the genetic background of the populations, or both.

Estimating the incidence of coeliac disease with capture-recapture methods within four geographic areas in Italy

STUDY OBJECTIVE

To estimate the incidence rate of newly diagnosed cases of coeliac disease in Italy.

DESIGN

This was a descriptive study of coeliac disease incidence in the period 1990-91.

SETTING

During 1990-91 newly diagnosed cases of coeliac disease were signalled by several sources including diagnostic records of departments of paediatrics, general medicine and gastroenterology, national health service records for the supply of gluten free diets and the archives of the Italian Coeliac Society.

PATIENTS

Altogether 1475 cases were flagged throughout Italy, 478 of whom were selected, corresponding to 270 individual patients from a target population resident in four areas: Provices of Turin and Cuneo (Piedmont Region, northern Italy); Province of Brescia (Lombardia Region, northern Italy); Umbria Region (central Italy) and Sardinia Region (insular Italy). Only for these areas were patients flagged from several sources and the reference population was identifiable.

MAIN RESULTS

The overall crude incidence rates for all ages per 100,000 residents per year were 2.4, 2.7, 1.5, and 1.7 in the four areas, respectively. The childhood cumulative incidence rates (aged < or = 15 years) per 100,000 live births were 143, 141, 72, and 80 respectively. The mean ages at diagnosis were similar for both childhood and adult cases throughout the areas--these were around 4 and 34 years respectively. For each area, the incidence rate was constantly higher in the main city than elsewhere. Using the capture-recapture method, an estimated completeness of case archives of 0.84 was obtained, whereas this figure was only 0.47 for hospital sources.

CONCLUSIONS

This population based study on the incidence of coeliac disease shows that several information sources should be used to avoid underestimation. The incidence rate of coeliac disease in Italy was among the highest in Europe, and was widely variable showing highest figures in Piedmont and Lombardia and the lowest in Umbria and Sardinia. This trend was not due to different age at diagnosis, which suggests variable diagnostic awareness of the disease rather than different environmental patterns affecting the clinical presentation.

Prognostic factors for postoperative recurrence of Crohn's disease. Gruppo Italiano per lo Studio del Colon e del Retto (GISC)

Prognostic factors for postoperative recurrence of Crohn's disease (CD) have been widely investigated but not yet clearly identified.

PURPOSE

Aim of this study was, therefore, to analyze the association between demographic, clinical, laboratory, and surgical characteristics of patients and the cumulative probability of endoscopic postoperative recurrence.

METHODS

The study was performed in 110 patients who were enrolled in the Italian multicenter, randomized, controlled trial on the effectiveness of 5-aminosalicylic acid (5-ASA) in the prevention of postoperative recurrence in CD. Patients had undergone their first intestinal resection for CD of the terminal ileum with or without involvement of cecum ascending colon. Recurrence was defined on the basis of endoscopy. The following variables were evaluated as potential prognostic factors: gender, age, years since diagnosis, clinical course (perforative and non-perforative), Crohn's Disease Activity Index score, white blood count, erythrocyte sedimentation rate, C-reactive protein, and orosomucoids assessed before the operation. Timing of operation (elective or urgent), type of anastomosis (end-to-end, end-to-side, side-to-side), and prophylactic treatment were also evaluated. Colon ileoscopy was performed at 6, 12, 24, and 36 months after operation. The association between variables and the cumulative proportion of recurrence was analyzed both by univariate analysis (life table method, log-rank test) and multivariate regression analysis (Cox's model, stepwise procedure).

RESULTS

Results of this study indicate that, of the features considered before surgery, only leukocytosis (white blood count, >9,000 ml) was significantly associated with an increased risk of recurrence (P < 0.05) at univariate analysis. This finding was not confirmed by multivariate analysis. A trend toward a higher risk of recurrence for patients who have had a resection with end-to-end anastomosis compared with those who have had a resection and other types of anastomosis was also observed. This trend reached significantly in the group of patients submitted to treatment with 5-ASA. The multivariate analysis showed that 5-ASA-treated patients with end-to-end had a risk of recurrence more than threefold higher than those with other types of anastomosis (relative risk, 3.40; 95 percent confidence interval, 1.00-11.96; P < 0.03).

CONCLUSIONS

From a practical point of view, it has been estimated that the combination of intestinal resection plus side-to-side or end-to-side anastomosis with oral 5-ASA treatment reduces by 64 percent the postoperative recurrence rate in CD at three years follow-up.

Exploring the role of diet in modifying the effect of known disease determinants: application to risk factors of liver cirrhosis

The analysis of the combined effects of nutritional factors with other putative disease determinants in log-linear or logistic models is methodologically complicated by the strong multicollinearity between nutritional factors, resulting in poor precision in estimating the parameters. Furthermore, the generally used multiplicative structure is not always the most appropriate for describing the resulting joint effect of two or more factors on the disease risk. The authors addressed such problems in a case-control study assessing the interactions between alcohol intake, chronic hepatitis C virus (HCV) infection, and nutrient intake on the risk of liver cirrhosis. During the period from November 1989 to May 1990, 282 patients admitted to the medical departments of the hospitals of the Province of L'Aquila (central Italy) were enrolled: 115 cirrhotic patients aged 24-82 years (78 of whom were males) hospitalized because of liver decompensation, and 167 control patients aged 25-84 years (100 of whom were males) admitted to the same hospitals for acute diseases unrelated to alcohol intake, infection with hepatotropic viruses, and nutrition. No dose-effect relation was found between the intake of any nutrient and the risk of cirrhosis using classical methods. The analysis of principal components showed, however, that a pattern of higher lipid but lower protein and carbohydrate intakes was significantly associated with the risk of cirrhosis. The Breslow and Storer parametric family of relative risk functions showed that a multiplicative structure was the most adequate to describe the joint effect of nutritional pattern with alcohol intake and/or chronic HCV infection, whereas an additive structure best described the joint effect of chronic HCV infection and alcohol intake. In conclusion, the analysis of principal components and the Breslow and Storer family are useful tools to explore the role of diet on disease risk when precise pathogenic knowledge is not available. As an original finding, the authors suggest that a higher lipid intake, combined with lower protein and carbohydrate intakes, modifies multiplicatively the risk of cirrhosis associated with alcohol intake and/or chronic HCV infection.

Improved tissue culture method for the study of prostatic carcinoma: a significant diagnostic tool

A new in vitro method for early detection of prostatic cancer is described. The results of tissue culture of prostatic epithelial cells harvested during digital rectal examination were compared with patient-matched biopsy findings in a double-blind study. An arbitrary combination of five culture parameters (displayed in vitro by cultured prostatic cells and related to neoplastic and differentiation features of the sample [growth capacity, proportion of epithelium and morphologic atypia of overlapping cells, multinucleated cells and vacuolized cells]), was created after two weeks of culture; this combination, referred to as the Global Tissue Culture Score (GTCS), ranged from 0 (negative result or benign behavior) to 15 (highly abnormal neoplastic behavior). The GTCS was significantly higher in biopsy-proven prostatic carcinoma than in other prostatic diseases. The combination of GTCS and patient age was highly sensitive and specific for a diagnosis of prostatic carcinoma, according to the biopsy results. Our findings indicate that the early diagnosis of prostatic carcinoma can be obtained by a tissue culture method which allows in vitro growth of epithelial cells harvested through digital rectal prostatic massage. This method is easy to perform, is non-invasive, is able to discriminate between biologically aggressive and non-aggressive neoplasms, and may be useful for mass screening of prostatic carcinoma in conjunction with digital rectal exam. Early diagnosis of prostatic carcinoma may maximize the potential curative value of radical prostatectomy or other forms of therapy for this highly prevalent cancer.

The measure of life-time alcohol consumption in patients with cirrhosis: reproducibility and clinical relevance

Our aims were to design a reproducible method of measuring life-time alcohol consumption in patients with cirrhosis, and to assess the risk of liver decompensation associated with alcohol intake using a case-control design and a multivariate analysis. We studied 439 patients ("cases") with decompensated cirrhosis, and 233 with compensated cirrhosis ("controls"). Mean life-time daily amount and duration of alcohol intake were measured by a standardized questionnaire, whose reproducibility, assessed by interviewing 75 relatives, was 70% for daily alcohol intake and 84% for duration of intake. Better reproducibility was found by re-interviewing patients at discharge from hospital. Daily alcohol intake was significantly higher in males, younger patients and patients with liver decompensation. After stratification according to the average life-time daily alcohol intake, we found a significant increase in the risk of liver decompensation from 125 g ethanol intake per day onwards. No association was found between duration of alcohol intake and risk of liver decompensation. We conclude that alcohol intake can be reliably and reproducibly measured: in patients with cirrhosis, increased alcohol intake is associated with increased risk of liver decompensation, with a significant dose-effect above a daily intake of 125 g ethanol.

Bone mass and metabolism in patients with celiac disease

BACKGROUND & AIMS

Several aspects of the pathogenesis of osteopenia in celiac disease are still unclear. Therefore, bone mass and metabolism were evaluated in adults with celiac disease in a cross-sectional study.

METHODS

Bone mineral density (BMD), assessed by total body dual-photon absorptiometry, and serum indices of bone metabolism and remodeling were evaluated in 17 patients with untreated celiac disease, 14 with celiac disease on a gluten-free diet, and 24 healthy volunteers.

RESULTS

BMD, expressed as a z score, was significantly lower in patients with untreated celiac disease than in patients with treated celiac disease and volunteers and lower in patients with treated celiac disease than in volunteers. Similar changes were observed in serum calcium level, whereas intact parathyroid hormone level was significantly higher in untreated than in treated patients with celiac disease and volunteers, and no difference was found between the latter two groups. 25-Vitamin D level was significantly lower and 1,25-vitamin D level significantly higher in untreated celiac disease than in treated celiac disease and volunteers. Indices of bone remodeling were significantly higher in untreated than in treated patients and volunteers and significantly and positively correlated with iPTH in untreated patients with celiac disease.

CONCLUSIONS

BMD is almost invariably low in patients with untreated celiac disease. Results in treated patients suggest that gluten-free diet improves but does not normalize BMD. Untreated celiac disease is characterized by high levels of 1,25-vitamin D and by increased bone turnover, caused by the increase in intact parathyroid hormone level.

Short-chain fatty acid topical treatment in distal ulcerative colitis

BACKGROUND

Some evidence indicates that short-chain fatty acid (SCFA) enemas are effective in the treatment of distal ulcerative colitis.

METHODS

In a randomized, double-blind, placebo-controlled study, we tested the efficacy of a 6-week course of topical SCFA (100 mL, twice daily enemas of sodium acetate 80 mmol/L, sodium propionate 30 mmol/L and sodium butyrate 40 mmol/L) in 40 patients with mild to moderate distal colitis. Clinical, endoscopic and histological data were collected at the beginning and end of the study.

RESULTS

Fourteen patients on SCFA improved (overall score 11.3 +/- 2.0 vs. 7.4 +/- 3.5) as compared to five in the placebo group (overall score 10.0 +/- 1.9 vs. 8.9 +/- 2.5). In the SCFA-treated group all parameters significantly improved except the number of bowel motions, whereas no significant changes were recorded in the control group. A statistically significant difference between the two treatment regimens, however, was observed only for intestinal bleeding (P < 0.05), urgency (P < 0.02) and the patient self-evaluation score (P < 0.05). This was probably due to the random inclusion of more patients with moderate disease into the SCFA-treated group, thus causing pretrial differences between the two groups.

CONCLUSION

The present study confirms that irrigation with SCFA enemas is effective in distal colitis, and may represent an alternative therapeutic tool in the treatment of the disease.

The effect of drinking coffee and smoking cigarettes on the risk of cirrhosis associated with alcohol consumption. A case-control study. Provincial Group for the Study of Chronic Liver Disease

In order to assess the interaction between alcohol intake, tobacco smoking and coffee consumption in determining the risk of liver cirrhosis we carried out a hospital-based case-control study involving 115 patients at their first diagnosis of cirrhosis and 167 control patients consecutively enrolled in the General Hospitals of the Province of L'Aquila (Central Italy). The mean life-time daily alcohol intake (as g ethanol consumed daily) was measured by direct patient interviews, whose reproducibility was > 0.80 and similar for cases and controls, as checked by interviewing the relatives of a sample of 50 cases and 73 controls. During the same patient's interview we also measured the mean consumption of coffee (daily number of cups of filtered coffee) and tobacco (life-time daily number of cigarettes smoked). A dose-effect relationship on the risk of cirrhosis was present both for alcohol intake--for which the risk was significantly increased above 100 g of daily intake--and for cigarette consumption. The latter did not however improve the goodness-of-fit of a logistic regression model including alcohol intake as covariate. By contrast, coffee consumption had a protective effect on the risk of cirrhosis and significantly improved the goodness-of-fit of such a model. Abstaining from coffee consumption determined both a significantly increased risk of cirrhosis, even for daily alcohol intake below 100 g, and a multiplicative effect with alcohol intake on this risk. In patients drinking > or = 101 g ethanol daily the relative risk increased from 5.5 (95% confidence interval: 1.4-22.0) for coffee consumers to 10.8 (95% confidence interval: 1.3-58.1) for coffee abstainers.(ABSTRACT TRUNCATED AT 250 WORDS)

Family compliance to a treatment programme for alcoholics: a prospective study of prognostic factors

A total of 198 alcoholic subjects was recruited into a treatment programme according to Hudolin's method. The programme included three steps: (1) presentation of the programme to the alcoholic family (four meetings); (2) a therapeutic community that met weekly over 4 months; and (3) attendance at an on-Treatment Alcoholic Club located close to the family's home residence (weekly self-conducted meetings). Data on the families' compliance to the treatment programme were obtained in January 1993 and the prognostic significance of 11 variables collected during the first step was determined by the proportional hazards regression model. The cumulative proportion of family compliance after 40 months was 36.4%, with similar drop-out rates at each of the three steps of the programme. The prognostic factor which was the major determinant of family compliance to treatment was the active presence of the whole family in the first step, while a good job performance was independently associated with family compliance, being a significant prognostic factor in the second step of the programme. Alcohol abstinence was obtained in 35.9% of the whole study group. This programme provided results for alcohol abstinence which are comparable with methods that require more expensive resources.

Mortality study on a cohort of Italian licensed pesticide users

This study describes the mortality experience in a cohort of 23,401 farmers, residing in southern Piedmont, Italy, and licensed to use pesticides. From 1970 to 1986 the cohort included 340,794 person-years and 2683 deaths were observed. A strong attenuation of the death risk was found due to the healthy worker effect (seen as an active role in the application for the license by the members of the cohort) and due to the limited comparability of the cohort with respect to the reference population. The standardized mortality ratios (SMRs) were remarkably < 100 for all causes (SMR = 59; 95% confidence interval = 57-61) and for all tumors (SMR = 60; 95% CI 55-64), but they increased with the increasing duration of the follow-up. A risk increase was observed with respect to melanomas and eye tumors in the entire cohort and lymphoma and tumors of the connective tissue in the subcohort of subjects living in villages with mainly arable land.

A strong negative association between alcohol consumption and the risk of hepatocellular carcinoma in cirrhotic patients. A case-control study

We carried out a hospital-based, case-control study to assess the association of both the Hepatitis B Virus (HBV) infection and the lifetime daily alcohol intake with the risk of developing hepatocellular carcinoma (HCC) in patients with liver cirrhosis (LC). Cases were 62 consecutive inpatients of a Gastroenterology Division in whom a first diagnosis of HCC superimposed on LC was made. Two control groups were used: 310 patients without liver disease, matched 1:5 with cases and randomly selected from inpatients of the same hospital, and 97 consecutive asymptomatic inpatients in whom the first diagnosis of LC was made. Alcohol intake was quantified in all subjects by a standardized questionnaire. HBV infection was associated with HCC development in cirrhotics (odds ratio = 6.8; 95% confidence interval = 1.4-32.3), whereas we observed a trend towards a decreased HCC risk at increased alcohol intake values (odds ratio from 1 for lifetime abstainers to 0.2 for drinkers of 175 g/day or more). Our results suggest that alcohol intake is not a direct determinant of HCC, but its role is mediated by LC. Cirrhotics with high alcohol intake do not usually survive long enough to develop HCC.

Serological screening of coeliac disease: choosing the optimal procedure according to various prevalence values

The aim of this study was to select the best approach for screening coeliac disease patients among populations with different grades of disease prevalence. The diagnostic performance was assessed of class A and G antigliadin antibodies and class A antiendomysium antibodies in 93 consecutive outpatients with suspected malabsorption, 44 of whom (47%) had coeliac disease according to duodenal histological tests. Class G antigliadin antibodies provided the worst diagnostic values, whereas a high diagnostic validity was found for the other two tests. The positive predictive value corrected for the disease prevalence expected in coeliac disease relatives (5%) and the general population (0.2%) fell to 30% and < 2% respectively for class A antigliadin antibodies, whereas it remained 100% for antiendomysium antibodies in both situations, providing an optimal value for their use as a screening test and as a valid alternative to duodenal biopsy when this is not feasible. The high cost of anti-endomysium antibodies and the invasive nature of duodenal biopsy prevent them being used widely as screening procedures. A cost effective two step approach was simulated measuring class A antigliadin antibodies in all subjects of the target population (first step), and performing a confirmation test (antiendomysium antibodies or duodenal biopsy) only in subjects positive for antigliadin antibodies. The results show that such a procedure should be recommended only for subjects with an expected low disease prevalence--that is, 5% for coeliac disease relatives and 0.2% for the general population--as the positive predictive value was always 100% with an acceptable false negative rate (6% and 11% respectively), irrespective of which of the two confirmation tests was used. This approach avoids the use of the confirmation test in 63% and 89% of subjects respectively for the two levels of prevalence, resulting in a considerable reduction of the cost. Patients seen for suspected malabsorption with an expected high prevalence of coeliac disease should not have such a serological screening procedure. In conclusion, antigliadin antibodies are useful to screen for asymptomatic coeliac disease in non-hospital communities if antiendomysium anti-bodies are used as a confirmation test: the latter is reasonable valid alternative to duodenal biopsy.

Amount and duration of alcohol intake in patients with chronic liver disease: an Italian multicentre study. AISF Group for the Study of Alcohol and Liver Disease

We report the results of an Italian multicenter study aimed at measuring retrospectively the lifetime amount and duration of alcohol consumption in non-selected consecutive patients with chronic liver disease. We used a standardized, reproducible questionnaire for measuring the lifetime daily alcohol intake (globally and separately for wine, beer and spirits), total alcohol intake and duration of alcohol consumption in 1,258 patients recruited from 17 medical centers. Wine intake contributed to the total alcohol intake in a proportion ranging from 44% to 85% throughout the centers. Spirits and beer intake contributed in smaller proportions (15% to 56%; and 3% to 27%, respectively). Males showed higher alcohol intake: those from northern-central Italy showed significantly higher intake than their southern-insular counterparts; of these, younger patients also showed a higher alcohol intake, due to a higher beer and spirit intake. Older patients showed higher intakes in southern-insular Italy, whereas the opposite was found in northern-central Italy. In this area, a longer duration of alcohol consumption was found, reflecting an earlier start in the use of alcohol. In conclusion, we believe that measuring alcohol intake on a wide series of patients in a multicenter study is feasible. This should stimulate gastroenterologists to approach the relationship between alcohol and liver disease using standardized and epidemiologically correct methods, and form the basis for well-designed case-control studies on a large scale, aimed at clarifying the risk of both hepatic and extrahepatic diseases associated with alcohol intake.

Oral mesalazine (5-aminosalicylic acid; Asacol) for the prevention of post-operative recurrence of Crohn's disease. Gruppo Italiano per lo Studio del Colon e del Retto (GISC)

METHODS

A multicentre randomized controlled trial was conducted to evaluate the efficacy of oral mesalazine (5-aminosalicylic acid) for the prevention of post-operative recurrence in 110 patients operated on for Crohn's disease by first intestinal resection. Patients were randomly allocated to receive 2.4 g/day of mesalazine, or no treatment at all. The protocol included colonoscopy with ileoscopy at 6 months and yearly thereafter. Recurrence was defined on the basis of endoscopic criteria and classified as mild or severe.

RESULTS

The demographic and pre-trial characteristics were very similar in the two groups of patients. The cumulative proportion of recurrence at 6, 12 and 24 months was significantly lower in the mesalazine group than in untreated group (P = 0.002). At 24 months the cumulative proportions of endoscopic recurrence were 0.52 +/- 0.12 (+/- S.E.M.) and 0.85 (+/- 0.07), respectively. At the same time the cumulative proportions of symptomatic recurrence were 0.18 +/- 0.09 and 0.41 +/- 0.09 (P = 0.006). The cumulative proportions of the severe recurrence was also significantly lower in the mesalazine group (0.17 +/- 0.09 vs. 0.38 +/- 0.09; P = 0.021).

CONCLUSIONS

The preliminary results of this study show that administration of oral mesalazine soon after surgery is effective in preventing post-operative endoscopic recurrence in Crohn's disease over a 2-year period. It is estimated that this treatment prevents 39% of all recurrences and 55% of the severe recurrences.

Alcohol-related problems within the family and global functioning of the children: a population-based study

We carried out a population-based prevalence study to assess the association between the presence of alcohol-related problems within the family and the risk of disorders in the children's global functioning level. We enrolled 394 children attending nursery, primary and secondary schools and their parents living in two municipalities in Central Italy. Alcohol-related problems within the family were reported by registered records obtained from general practitioners and teachers, who were considered as preference raters. The children's level of functioning was assessed by teachers, who attributed to each school child a score according to the Children Global Assessment Scale (CGAS). The number of reports of alcohol-related problems within the family and the CGAS scores were considered, respectively, as independent and dependent variables in a multiple logistic regression model for ordinal outcome variables. The children's sex and age, and the age of their parents, the duration of the parents' education and family size were considered as covariates. We found a strong association between a poor level of functioning in the children in the social environment and alcohol-related problems within the family. The prevalence odds ratio (and 95% confidence interval) decreased from 0.5 (range 0.2-1.3) for children whose families were reported by one rater to 0.4 (range 0.2-0.8) for children whose families were reported by two raters, the non-reported families being the reference category, suggesting that the level of functioning of the child decreased as reports of alcohol-related problems in the family increased.

[Reduction modality of a dietary questionnaire]

The data relative to the average daily intake of 7 nutrients and total energy obtained through the answers to a dietary questionnaire, consisting of 152 items and administered to 200 patients (admitted for acute pathologies) has been analysed. The aim has been to elaborate a questionnaire consisting of a more limited number of items but maintaining a great part of the informative contents from the original questionnaire. For this aim, a multiple regression model with a selection procedure for independent variables, of the stepwise type, has been used, where the dependent variable is the daily average intake of the nutrient and the independent variables are the consumption of each food included in the complete questionnaire (QC). By combining the results of the model with the 7 nutrients and total energy, 3 reduced questionnaires have been produced (QR): the first two are based on the sole criteria of the inter-individual variance of the intake of the nutrient, explained by the consumption of the foods included in the QR, the third by adding the foods that offer an adequate contribution in order to explain the supply of the nutrient under examination. The application potentials of the 3 QRs have been analysed both by evaluating the inter-class correlation coefficient, deduced by an concordance/discordance matrix relative to the quintilis values of the nutrient deduced by the QC and by each QR, and by simulating their use in a case-control study; for this aim, the attenuation of the odds ratio trend and the increase of the sample dimension has been calculated following the use of a QR instead of a complete one.(ABSTRACT TRUNCATED AT 250 WORDS)

Amount and duration of alcohol intake as risk factors of symptomatic liver cirrhosis: a case-control study

We carried out a hospital based case-control study involving 320 patients with symptomatic liver cirrhosis (LC) and 320 pair-matched control individuals, in order to estimate the dose-response relationship between both the daily amount and the duration of alcohol intake and the risk of LC. Lifetime alcohol consumption was measured by a standardized and reproducible questionnaire, and expressed as lifetime daily alcohol intake (LDAI) and duration of alcohol consumption (DAC). The odds ratio (OR) for LC was estimated by the conditional logistic regression. It increased from 1.0 for lifetime abstainers to 4.2 for LDAI of 225 g or more. Comparing durations of alcohol consumption of < or = 10 and > or = 30 years in the model, the ORs consistently decreased for all the LDAI categories: from 4.1 to 0.6 in the 25-50 g category; from 15.1 to 0.9 in the 75-100 g category; from 67.2 to 1.5 in the 125 g or more category. Our results suggest that the dose-dependent relationship between alcohol and LC may be mediated by the degree of individual susceptibility to the detrimental effect of alcohol to the liver.