Gastric pathology in patients with common variable immunodeficiency

BACKGROUND/AIMS

Common variable immunodeficiency (CVID) is an immunological disorder characterised by defective antibody production. Patients with CVID have a high risk of gastric cancer. It has been suggested that gastric cancer results from an interaction between environmental factors and a genetic predisposition. The role of Helicobacter pylori as an environmental factor in gastric carcinogenesis is of current interest. Moreover, p53 gene mutations have been reported in gastric cancer. This study focuses on the gastric pathology of patients with CVID and correlation with H pylori infection.

METHODS

Thirty four consecutive dyspeptic patients with CVID (mean age 49.6 years, range 14-72; 17 men) were included in the study. An upper gastrointestinal endoscopy was performed and biopsy specimens were taken from the antrum, incisura angularis, and gastric body. Biopsies were used for histological assessment, to identify the presence of H pylori, and to evaluate p53 overexpression.

RESULTS

H pylori infection was detected in 14/34 (41%) patients. Chronic active gastritis involving both antrum and body was observed more frequently in H pylori positive (79%) than H pylori negative (20%) patients (p = 0.001). Similarly, a histological feature of multifocal atrophic gastritis was found more frequently in infected (50%) than uninfected patients (10%) (p = 0.012). In addition, one case of gastric adenocarcinoma and another of notable dysplasia were observed in the H pylori positive group. Overexpression of p53 was found in six (18%) patients, including one with normal gastric mucosa.

CONCLUSIONS

It can be hypothesised that both H pylori and p53 alterations play a role in the gastric carcinogenesis of patients with CVID.

Onset of hepatocellular carcinoma in a non-cirrhotic patient affected with haemochromatosis

The increased incidence of hepatocellular carcinoma in patients affected with haemochromatosis has previously been attributed to cirrhosis. However, some cases of hepatocellular carcinoma without cirrhosis have recently been reported in patients with haemochromatosis, leading to reconsideration of the role of iron in the tumorigenesis of hepatocellular carcinoma. We describe a 79 year old male patient affected with haemochromatosis and with a multinodular hepatocellular carcinoma, but without any evidence of cirrhosis. The absence of any other cancer risk factor (alcohol abuse, liver viral infections, heredity) has lead us to reconsider the possible role of iron as a direct carcinogen in the onset of hepatocellular carcinoma in patients with haemochromatosis.

[The long-term results of low-calorie diet therapy in the obese]

PURPOSE

To evaluate long-term results of hypocaloric dietetic treatment in patients with essential obesity.

PATIENTS AND METHODS

The study was carried out in 1,479 woman and 320 men. Body weight was evaluated at 3 months and at 1, 2 and 3 years.

RESULTS

The best results in short term reduction of weight excess were found in obesity due to sedentariness or arisen after operation or emotional stress. It has been also observed that the percentage of subjects loosing weight decreased after the first year of treatment, while the percentage of subjects gaining body weight.

CONCLUSIONS

Long term hypocaloric dietetic treatment in subjects with low or moderate essential obesity should primarily be aimed preventing further gain in body weight.

[Latent thyroid diseases in obesity]

We have investigated 2672 obese subjects (2324 females and 348 males); of these, the following two groups were considered: obese subjects with or without thyroid disease. Subjects were stratified according to age, sex, and BMI. The prevalence of thyroid disease was correlated to age, sex and BMI increased body weight. Our data showed that 22% of patients affected by essential obesity and not resident in area of iodine deficiency is affected by thyroid diseases which are not diagnosed (18%). In the obese subjects, presence of goiter is more frequent than in the normal weight subjects and affects mainly adult males. Chronic thyroiditis is typical of females (9:1 female:male ratio) with no difference between normo and overweight subjects. Prevalence of single nodule in the obese is similar to the normal weight subjects, it is more frequent in adults and in subjects with medium size obesity. However, occurrence of carcinoma (8%) in single nodules appears higher in the overweight (5-6%) as compared to the normal weight subjects.

[Thyroid tumors in obesity]

BACKGROUND

The presence of nodules in the thyroid gland is the most frequent cause of endocrinopathy. The prevalence of thyroid nodules in the United States is estimated to be between 3-10%, whereas the prevalence of thyroid nodules in European adult population is estimated to be between 4-10%. At our Clinic of Obesity, the presence of nodules in the thyroid gland of obese patients is often found, incidentally, for this reason, we decide to investigate the prevalence of this pathology in obese patients and to quatify the number of times in which the presence of nodules had not been previously diagnosed.

METHODS

3248 obese patients were examined during in the last six years (1991-1996); of these patients 747 were affected by obesity and thyropathy; of these 747 we took into consideration only those with a cold single nodule and correlated the presence of the nodule with BMI, sex and age.

RESULTS AND CONCLUSIONS

The prevalence of a cold single nodule in the obese patients was 31%, of which 83% has not been previously diagnosed. Of cold nodules 8% was represented by carcinoma. The carcinoma appeared more often in females than in males (3:1). The incidence of cold nodules was more frequent in adults and in mild-medium obesity.

Analysis of p53 expression in precancerous and malignant gastric mucosa

P53 overexpression, detected by immunohistochemical analysis, has been reported in about 50% of gastric cancers whereas scarce data are available on the p53 oncoprotein in precancerous gastric lesions. This study focused on the p53 expression in gastric cancerous and precancerous lesions. One hundred gastric specimens obtained during endoscopy were analyzed: 14 cases of normal gastric mucosa, 53 of chronic gastritis with intestinal metaplasia and/or dysplasia and 33 gastric tumors. An immunoperoxidase technique and monoclonal anti-p53 antibodies were employed. Eleven out of 31 gastric carcinomas overexpressed p53. No correlation was observed between p53-positivity and histological type and grade of tumors. All precancerous lesions were p53-negative. Our results suggest that p53 overexpression is a relatively late event in gastric carcinogenesis.

Vitamin E and nicotinamide have similar effects in maintaining residual beta cell function in recent onset insulin-dependent diabetes (the IMDIAB IV study)

OBJECTIVE

Protection of residual beta cell function at the time of diagnosis of insulin-dependent diabetes mellitus (IDDM) by intensive insulin therapy and the addition of nicotinamide (NA) has been established. The objective of this study was to evaluate the effect of a free oxygen radical scavenger such as vitamin E (Vit E) on residual beta cell function and parameters of metabolic control in patients with recent onset IDDM undergoing intensive insulin therapy.

DESIGN

The effect of Vit E was compared with that of NA (control group) in a randomized multicentre trial.

METHODS

Eighty-four IDDM patients between 5 and 35 years of age (mean age 15.8 +/- 8.4 (s.d.) years) entered a one year prospective study. One group of patients (n = 42) was treated with Vit E (15 mg/kg body weight/day) for one year; the other group (n = 42) received NA for one year (25 mg/kg body weight/day). All patients were under intensive insulin therapy with three to four injections a day. Basal and stimulated (1 mg i.v. glucagon) C-peptide secretion, glycosylated haemoglobin and insulin dose were evaluated at diagnosis and at three-monthly intervals up to one year.

RESULTS

Preservation and slight increase of C-peptide levels at one year compared with diagnosis were obtained in the two treated patient groups. No statistically significant differences were observed in basal or stimulated C-peptide levels between the two groups of patients for up to one year after diagnosis. Glycosylated haemoglobin and insulin dose were also similar between the two groups; however patients receiving Vit E under the age of 15 years required significantly more insulin than NA-treated patients one year after diagnosis (P < 0.04).

CONCLUSIONS

Our data indicate that Vit E and NA possess similar effects in protecting residual beta cell function in patients with recent onset IDDM. Since their putative mechanism of protection on beta cell cytotoxicity is different, combination of these two vitamins may be envisaged for future trials of intervention at IDDM onset.

Surgical revascularization for acute coronary insufficiency: analysis of risk factors for hospital mortality

BACKGROUND

A retrospective study of 444 patients undergoing urgent and emergent coronary artery bypass grafting for acute coronary insufficiency was performed to identify the risk factors for hospital death specifically associated with the clinical severity of the acute coronary insufficiency syndrome.

METHODS

The patients were divided into three groups-urgent, emergent A, and emergent B-on the basis of the evolution of the clinical pattern of the acute coronary insufficiency syndrome on full medical treatment. The three categories were defined as follows: urgent (257 patients), surgical revascularization could be delayed for 24 to 36 hours after surgical consultation because of adequate control of ischemia; emergent A (127 patients), prompt myocardial revascularization was required because medical treatment achieved only transient regression of an unrelenting ischemic pattern; and emergent B (60 patients), prompt myocardial revascularization was required because the acute coronary insufficiency was entirely refractory to medical treatment.

RESULTS

Mortality rates were 7.4% for the urgent group, 13.4% for the emergent A group, and 31.7% for the emergent B group. Multivariate analysis identified the following as risk factors for hospital mortality: ejection fraction (p = 0.023) and aortic cross-clamp time (p = 0.10) for the urgent group; aortic cross-clamp time (p = 0.017), ejection fraction (p = 0.03), and nonuse of blood cardioplegia (p = 0.04) for the emergent A group; and cardiogenic shock (p = 0.00), preoperative ischemic interval (p = 0.00), aortic cross-clamp time (p = 0.018), and nonuse of blood cardioplegia (p = 0.012) for the emergent B group.

CONCLUSIONS

A more exact definition of patient risk can be achieved when predictive outcome models are constructed using the risk factors specifically related to each level of clinical severity of the ischemic syndrome.

[Incidentaloma of the adrenal gland. A clinical case]

The case of a 58 years-old woman with incidental adrenal tumor without endocrinological features of Cushing's syndrome, dexamethasone nonsuppressible uptake of 131I-19 iodocholesterol on right adrenal gland, and no uptake of the left, is described. Right adrenalectomy was performed with the diagnosis of adrenal tumor. The histopathological study revealed that the mass was an adrenal adenoma composed of mixtures of clear and compact cells. Postoperative course was uneventful without replacement therapy with cortisol. This case report suggest that in patients with incidental adrenal tumor, the adrenocortical scintigraphy is very useful for the identification for autonomously functioning adrenal mass.

[Comparison of results of short- and long-term therapy of obesity]

A study concerning long term results of dietetic treatment of obesity has been conducted on 1479 obese women, aged 16 to 76 years, who attended the ambulatory during the period 1992-1995. Best results in short term reduction of weight excess were found in obesity due to sedentariness or arisen after operations or emotional stress. Also, it has been noticed that percentage of subjects who went on to loose weight decreased after first year of treatment instead, percentage of subjects who grew fat increased. So, authors believe that long term therapy main object in obese people isn't loss of weight but to avoid further weight increases.

[Prevalence of obesity in school age: preliminary study on students from 2 Roman schools]

The present study, aimed at the prevention of infantile obesity was carried out in two schools of Roma and regarded also the alimentary education. 295 students 101 males and 194 females was considered; the result pointed out that 114 (38.6%) were found obese, 57 (19.3%) overweight and 124 (42.0%) normal weight. The alimentary behaviour was the same of other students: usually three meals and often snacks use during the day, a lot of the student use to eat watching the television and the physical activity is done not so much. The results of these paper are related to the literature data.

[Interferons in the therapy of solid tumors]

Belonging to the vast family of cytokines, interferons (IFN) have recently been widely investigated concerning their possible clinical applications, both in virology and oncology. In this field results have been quite mixed but definitely encouraging. The best achievements have been obtained in hematology, and particularly in the treatment of hairy cell leukemia and chronic myelogenous leukemia, but new perspectives have also opened in the therapy of solid tumors, especially in the local treatment of superficial bladder cancer and ovarian cancer, AIDS-related Kaposi's sarcoma and malignant melanoma. IFN have in certain cases showed an efficacy comparable to that of classic treatments but with lower toxicity, and in some tumors they have even improved the results obtained so far, especially in combined therapy. We have here gathered the most recent results concerning the use of IFN in the therapy of solid tumors in order to highlight the new therapeutic opportunities available to clinical oncology.

[Surgical revascularization in acute coronary insufficiency: an analysis of the risk factors for hospital mortality in urgencies and emergencies]

OBJECTIVES

A retrospective analysis of 444 patients (Pts) with acute coronary insufficiency (A.C.I.) submitted to coronary artery bypass grafting between January '85 and December '92 was performed in order to identify incremental risk factors associated with perioperative mortality and to evaluate whether prediction of mortality can be accomplished utilizing risk models specifically linked to the severity of myocardial ischemia.

METHODS

Based on clinical and ECGraphic standpoints three different groups were identified: urgent group, comprehensive of 257 Pts. in whom, because of full medically controlled ischemia, myocardial revascularization could be delayed until to 24-48 hours. Emergency-A group, comprehensive of 127 Pts with recurrent ischemia despite medical therapy, but with no signs of coronary insufficiency at the time of institution of cardiopulmonary bypass (CPB). Emergency-B group, comprehensive of 60 Pts operated on after a mean preoperative ischemic interval of 3.9 +/- 2.4 hours who presented unrelenting signs of ischemia, either persisting since the inception of the clinical picture or lasting for over 30 minutes at the time of institution of CPB; among those, 27 Pts were in cardiogenic shock.

RESULTS

Mortality rate in the three groups was respectively: 7.4%, 13.4%, 31.7%. Multivariate analysis identified the following risk factors of in-hospital mortality: urgent group: aortic cross-clamping time (A.C.C.T.) (p = 0.10) and ejection fraction (E.F.) (p = 0.023). Emergency-A group: A.C.C.T. (p = 0.017), E.F. (p = 0.023) and non-use of blood cardioplegia (B.C.) (p = 0.04). Emergency-B group: cardiogenic shock (p = 0.00), preoperative ischemic interval > 6 hours (p = 0.00), A.C.C.T. (p = 0.018) and non-use of B.C. (p = 0.012).

CONCLUSIONS

A useful stratification of Pts with A.C.I. in three different groups, each with its own risk model, can be obtained by means of clinical-ECGraphic criteria alone. Different prognostic weights can be attributed to the variables A.C.C.T., E.F. and non-use of B.C. depending on clinical status. A significant reduction of mortality rate in Pts with cardiogenic shock can be achieved by the utilization of individually-tailored surgical management.

Early postprandial energy expenditure and macronutrient use after a mixed meal in cirrhotic patients

The effect of meal ingestion (9 kcal/kg of body weight, 53% carbohydrate, 30% fat, 17% protein, as a liquid formula) on energy expenditure and oxidation rate of carbohydrate, fat, and protein was assessed by indirect calorimetry and urinary nitrogen excretion before and for 3 hours after eating in stable cirrhotic patients and control subjects of comparable age. Postprandial modifications of substrate and hormone levels were also studied. Compared with basal values, the mean +/- SD resting energy expenditure during the first 3 hours after meal ingestion increased similarly in cirrhotic patients (+0.32 +/- 0.12 kcal/min) and control subjects (+0.31 +/- 0.08 kcal/min). Dietary induced thermogenesis was equivalent to 10% of the energy contained in the meal in both groups. Before eating, the carbohydrate oxidation rate was lower and fat oxidation higher in cirrhotic patients than in the control subjects. After eating, glucose oxidation increased whereas fat and protein oxidation rates were reduced in both groups. As a consequence the amount of fat oxidized in the postprandial period remained higher in cirrhotic patients than in the control subjects. After meal ingestion, serum glucose levels increased whereas plasma free fatty acid and glycerol levels decreased in both groups. The substrates, however, remained significantly higher in cirrhotic patients than in control subjects, despite the higher postprandial insulin increment in the patients group, thus suggesting the presence of insulin resistance. Because the postprandial glucose oxidation rate was normal, the low insulin-mediated glucose uptake observed in cirrhotic patients seems to reflect a defect in the nonoxidative disposal of the glucose ingested.(ABSTRACT TRUNCATED AT 250 WORDS)

Resistance to insulin suppression of plasma free fatty acids in liver cirrhosis

Insulin action on carbohydrate metabolism is known to be reduced in liver cirrhosis. However, little is known about the effect of insulin on free fatty acid (FFA) metabolism in these patients. To investigate this aspect we performed a two-step insulin euglycemic clamp in 11 cirrhotic patients and 6 controls. Insulin was infused at 0.25 mU/Kg min from 0 to 100 min and at 1 mU/Kg from 100 to 200 min. The FFA lowering capacity of insulin was studied during the first step; the glucose metabolizing capacity (M) was evaluated during the second step. In the cirrhotic patients, the M value was lower than in controls (3.91 +/- 0.48 vs 7.75 +/- 1.09 mg/kg/min, respectively). During the low insulin infusion, FFA and glycerol plasma levels were decreased in both groups. However, the ability of insulin to suppress plasma FFA and glycerol was lower in cirrhotics than in controls. In fact, at 100 min, FFA were 50% of basal values in cirrhotics and 20% in controls (p less than 0.01), while glycerol plasma levels decreased to 70% of basal values in patients and to 56% in controls. The slope of the linear regression obtained between Ln-FFA concentrations vs time was significantly less in cirrhotic patients than in controls (p less than 0.001). In addition, a positive correlation was found between the M value (r = 0.70; p less than 0.01) and the slope of the Ln-FFA in each patient. These findings suggest that in cirrhotic patients the effects of insulin on both FFA and glucose metabolism are reduced.

Basal energy production rate and substrate use in stable cirrhotic patients

The basal energy production rate was measured using indirect calorimetry in 25 stable cirrhotic patients and 10 controls of comparable age. The endogenous substrate oxidation was also calculated by measuring urinary nitrogen excretion. The energy production rate was similar in cirrhotic patients and controls. The origins of liver disease and the degree of liver damage did not seem to influence the energy production rate. On the other hand, in cirrhotic patients, as in controls, a significant correlation was present between the energy production rate and parameters of body size, such as body weight and fat-free mass. As a consequence, cirrhotic patients with poor nutritional status, with a reduced fat-free mass, showed a lower energy production rate. The measured energy production rate was compared with the resting energy expenditure estimated by formulas commonly used in healthy individuals. The good agreement found between the measured energy production rate and calculated energy expenditure suggests that these formulas may be applied to stable cirrhotic patients in clinical practice. In cirrhotic patients, the oxidation of endogenous fat is the main contributor to basal energy production rate. The fat oxidation rate does not appear to be influenced by the hormonal pattern found in the cirrhotic patients. However, a significant correlation was present between fat oxidation and plasma free fatty acid levels. This confirms that the prevalent fat use in cirrhotic patients is supported by the greater availability of fat-derived substrates.

Malabsorption and nutritional abnormalities in patients with liver cirrhosis

Cirrhotic patients often present muscle and adipose tissue depletion as well as reduced visceral protein concentration. Impaired absorption of nutrients may contribute to this altered nutritional status. To verify this hypothesis fecal fat excretion, intestinal mucosal function evaluated by means of the combined sugar oral load test, and intestinal clearance of alpha-1-Antirypsin were studied in 25 cirrhotic patients with clinical and biochemical signs of liver insufficiency and with portal hypertension. About 50% of the patients showed clinical evidence of malnutrition. Three of the 12 well-nourished, and 8 of the 13 malnourished patients presented significant steatorrhoea. Cirrhotics showed no impairment in mediated malabsorption and in passive permeability, as plasma D-xylose/3-O-methyl-glucose concentration and urinary lactulose/L-rhamnose excretion ratios were within the normal range. An increased value of alpha-1-Antitrypsin clearance was found only in two patients. These findings indicate that fat malabsorption is frequent in cirrhotic patients, particularly when malnourished, and does not depend on the presence of mucosal intestinal damage.

Circadian rhythmicity of plasma amino acid variations in healthy subjects

The circadian periodicity of plasma amino acids (AA) was explored using Cosinor analysis. Six healthy subjects eating a standard diet (30 Kcal and 1 g of protein/Kg of body weight) were studied. Plasma samples for AA determination were taken at 07:00, 11:00, 15:00, 17:00, 21:00 and 24:00. The majority of AA showed an increment in the evening samples. This 24-h variability led to a circadian rhythmicity for all AA, except for taurine, threonine, glutamate, alanine, cystine, and total tryptophan. On average, the fluctuation was approximately 15% of the mesor and the acrophase timing was between 17:00 and 22:00.

Optimal nutritional indexes in chronic liver disease

A population of 70 patients with liver cirrhosis, most of whom were nonalcoholic, was studied. Distribution of ideal body weight and body mass index was below the median of controls, but very few patients were below the cut-off points for normalcy. Distribution of triceps skinfold and arm muscle circumference was also below the median and, in most patients, was also below the cut-off points. Serum visceral protein concentrations and anthropometric parameters each were reciprocally correlated with one another, but no correlation was observed between visceral proteins and anthropometric parameters. Serum visceral proteins appeared to correlate better with the degree of liver damage than with the degree of malnutrition. Therefore, anthropometric parameters seem preferable to serum visceral proteins for the assessment of nutritional status in patients with liver cirrhosis.