[Influence of nonsteroidal antiinflammatory drugs in gastrointestinal bleeding due to gastroduodenal ulcers or erosions in patients with liver cirrhosis]

INTRODUCTION

Peptic ulcer disease, with or without complications, is more common in patients with liver cirrhosis than in the general population. Factors associated with portal hypertension are involved in its pathogenesis. The prevalence of Helicobacter pylori infection in patients with liver cirrhosis and the general population is similar. The aim of the present study was to determine the influence of nonsteroidal antiinflammatory drugs (NSAIDs) in the etiology of bleeding peptic ulcer disease in patients with liver cirrhosis.

PATIENTS AND METHODS

We studied 35 patients with liver cirrhosis and gastrointestinal bleeding due to gastroduodenal ulcers or erosions (group A), 125 noncirrhotic patients with gastrointestinal bleeding due to gastroduodenal ulcers or erosions (group B), and 70 patients with liver cirrhosis who were admitted to hospital without gastrointestinal bleeding (group C). All patients were questioned about NSAID consumption, including aspirin, during the week prior to hospital admission.

RESULTS

NSAID consumption was reported by 15 patients (42.8%) in group A, 102 patients (58.2%) in group B, and 6 patients (8.5%) in group C. Statistically significant differences were obtained when the results for group A were compared with those for group C.

CONCLUSIONS

NSAID consumption in patients with liver cirrhosis without gastrointestinal bleeding was low (8.5%) and was much lower than that observed in patients with cirrhosis admitted to hospital for bleeding due to gastroduodenal ulcers or erosions (42.8%). As occurs in the general population, NSAIDs play a significant role in the pathogenesis of bleeding due to peptic ulcer disease in patients with liver cirrhosis and portal hypertension.

Determinación del genotipo del virus de la hepatitis B y detección de mutaciones de resistencia al tratamiento con lamivudina

OBJECTIVES

To determine hepatitis B virus (HBV) genotypes in southern Seville (Spain) and investigate the development of lamivudine-resistance mutations by using a hybridization technique with specific probes and by comparing the results with those of the direct sequencing technique. To evaluate the temporal relationship between variations in the level of HBV-DNA and detection of mutant variants. To analyze the influence of several genotypes on the pattern of mutations developed and on values of viral load and alanine aminotransferase (ALT) after their development.

PATIENTS AND METHOD

In 37 patients with chronic HBV infection, HBV genotype was determined using the LiPA technique. In 10 of these patients undergoing lamivudine treatment for a mean of 19.2 months, the development of lamivudine-resistant mutations was investigated. In these 10 patients, the LiPA technique was compared with direct sequencing. During lamivudine treatment, we determined HBV-DNA by polymerase chain reaction (PCR) and ALT every 3-6 months.

RESULTS

The most frequent genotypes were D (45.9%) and A (18.9%); 2 patients were genotype B while 18.9% had mixed genotypes. Sequencing showed identical results except in one mixed genotype. Mutations were found in 60% of the cases. The results of sequencing were in agreement, except in the detection of mixed populations composed of mutants and wild-type (WT). Patients with genotype A showed the pattern M204I+WT in the first 12 months and those with genotype D showed the pattern L180M+M204V with or without WT at 18 months. In 5/6 cases, an increase of > 1 log10 in HBV-DNA was observed 3-8 months before the mutation was detected by LiPA. In patients with genotype B, levels of HBV-DNA and ALT after the development of mutations was lower than basal levels and was also lower than those in patients with genotypes A and D.

CONCLUSIONS

The LiPA technique for determination of HBV genotype and detection of lamivudine-resistance mutations shows excellent correlation with the most complex sequencing technique. Genotype D predominates in southern Seville. During lamivudine treatment, an increase in the level of HBV-DNA detected by PCR predicts the development of mutations before these are demonstrated by LiPA.

[Wallenberg's syndrome secondary to dissection of the vertebral artery caused by chiropractic manipulation]

INTRODUCTION

Chiropractic manipulations of the cervical region are techniques that are used more and more frequently to treat a number of osteomuscular pathologies, but can give rise to important complications, such as the dissection of the cervical arteries. Dissection of the vertebral artery generally presents as alternating syndromes, of which Wallenberg s syndrome, either complete or incomplete, is the most frequent. In this paper we review the literature published to date on the pathogenesis, risk factors, clinical features, chronopathology, diagnosis, treatment and prognosis of this complication.

CASE REPORT

We describe the case of a young patient who suffered from incomplete Wallenberg s syndrome a few hours after a single session of cervical chiropractic manipulation, and we also show the resonance images that were used to support the diagnosis.

CONCLUSIONS

The appearance of a pain in the neck and neurological symptoms in a patient who has undergone chiropractic manipulation in the last few hours or days must lead us to consider a possible dissection of the cervical arteries. Dissection of the vertebral artery usually gives rise to alternating syndromes, the most frequent of which is lateral bulbomedullary infarction or Wallenberg s syndrome due to proximal occlusion of the posteroinferior cerebellar artery. Magnetic resonance angiography of the supra aortic trunks and cranial magnetic resonance scanning are valid techniques for demonstrating the dissection of the artery and the associated ischemic lesion.

[Anaplastic large cell lymphoma. Report of an unusual case]

An anaplastic large cell lymphoma which fulfills all the criteria required for its inclusion among the soft tissue forms is reported. We point out in this case, in addition to its low frequency in adults, the severe systemic involvement of the disorder with out generalization, the lack of expression of the ALK1 protein, frequently positive in the generalized forms and the absence of response to polichiomiotherapy. We think that this case emphasizes the heterogenicity if the disorder on the clinical pathologycal relation ship of this kind of lymphomas.

Synthesis of 2,3-disubstituted pyrrolidines and piperidines via one-pot oxidative decarboxylation-beta-iodination of amino acids

A new synthesis of 2,3-disubstituted pyrrolidines and piperidines is described. This mild procedure is based on the one-pot oxidative decarboxylation-beta-iodination of alpha-amino acid carbamates or amides. The iodine is introduced at the previously unfunctionalized 3-position. Different substituents can be introduced at C-2, e.g., hydroxy, alkoxy, allyl, alkyl, etc. A trans relationship between the C-2 and C-3 substituents is exclusively obtained. The influence of the solvent and the ring size of the starting amino acid are studied, as well as the nature of the protecting group on the nitrogen. The stereoselectivity of the reaction was also studied using chiral methyl (2S,4S)-4-acetyloxyproline-1-carboxylate (8). The products obtained can be manipulated to give bicyclic systems present in many natural products. By using the tandem decarboxylation-iodination-alkylation reaction, 2-substituted-3-iodopyrrolidines are formed, which are precursors of 2-substituted-2,5-dihydropyrrols.

Reductive fragmentation of carbohydrate anomeric alkoxy radicals. Synthesis of alditols with potential utility as chiral synthons

A series of anomeric nitrate esters and N-phthalimido glycosides of carbohydrates in furanose and pyranose forms have been synthesized in order to generate the corresponding alkoxy radicals and study the C1-C2 fragmentation reaction under reductive conditions. This reaction constitutes a two-step method for the transformation of carbohydrates into the corresponding alditols with one less carbon. Using this methodology, interesting four- and five-carbon building blocks for natural products synthesis possessing D-erythritol, D-threitol, D-xylitol, and D-arabinitol stereochemistry have been prepared. The synthesis of 1,2-O-isopropylidene-beta-L-threose (40) and 1-acetamido-2,4,5-tri-O-acetyl-D-arabinitol (50) have also been achieved from 1,2:5,6-di-O-isopropylidene-beta-D-glucofuranose and 2-acetamido-3,4,6-tri-O-acetyl-2-deoxy-D-glucopyranose, respectively.

Depression scores following migraine treatment in patients attending a specialized center for headache and neurology

OBJECTIVE

To determine the changes in clinical characteristics and depression levels among patients following treatment for migraine.

BACKGROUND

Epidemiologic studies have provided consistent evidence regarding an association between migraine and depression. In Puerto Rico, however, migraine has not yet been systematically investigated.

METHODS

A chart review of 144 Puerto Rican patients who presented with migraine, diagnosed according to the International Headache Society criteria, and depression over a 2-year period was performed. The level of depression, before and after migraine treatment, was evaluated using the Zung Self-rating Depression Scale.

RESULTS

The mean age of patients was 37.0 +/- 14.4 years; 77.1% were women. More than half (52.8%) reported severe headache and 56.9% reported a monthly frequency of five attacks or more. Nearly 9% were using antidepressant therapy and 8% were under psychiatric treatment. The mean Zung index score at baseline was 50.6 +/- 10.9. Following treatment with triptans, the intensity and frequency of migraine and the Zung index score decreased significantly (P<.00001). A trend for a greater reduction in Zung index scores among patients receiving triptan medications for more than a year was demonstrated (P =.07).

CONCLUSIONS

These results indicate that migraine treatment with triptans appears to be effective in decreasing the headache frequency and intensity, and depression levels, independent of antidepressant medication use or psychiatric treatment.

A novel role of neuregulin in skeletal muscle. Neuregulin stimulates glucose uptake, glucose transporter translocation, and transporter expression in muscle cells

Neuregulins regulate the expression of acetylcholine receptor genes and induce development of the neuromuscular junction in muscle. In studying whether neuregulins regulate glucose uptake in muscle, we analyzed the effect of a recombinant neuregulin, (r)heregulin-beta1-(177-244) (HRG), on L6E9 muscle cells, which express the neuregulin receptors ErbB2 and ErbB3. L6E9 responded acutely to HRG by a time- and concentration-dependent stimulation of 2-deoxyglucose uptake. HRG-induced stimulation of glucose transport was additive to the effect of insulin. The acute stimulation of the glucose transport induced by HRG was a consequence of the translocation of GLUT4, GLUT1, and GLUT3 glucose carriers to the cell surface. The effect of HRG on glucose transport was dependent on phosphatidylinositol 3-kinase activity. HRG also stimulated glucose transport in the incubated soleus muscle and was additive to the effect of insulin. Chronic exposure of L6E9 cells to HRG potentiated myogenic differentiation, and under these conditions, glucose transport was also stimulated. The activation of glucose transport after chronic HRG exposure was due to enhanced cell content of GLUT1 and GLUT3 and to increased abundance of these carriers at the plasma membrane. However, under these conditions, GLUT4 expression was markedly down-regulated. Muscle denervation is associated with GLUT1 induction and GLUT4 repression. In this connection, muscle denervation caused a marked increase in the content of ErbB2 and ErbB3 receptors, which occurred in the absence of alterations in neuregulin mRNA levels. This fact suggests that neuregulins regulate glucose transporter expression in denervated muscle. We conclude that neuregulins regulate glucose uptake in L6E9 muscle cells by mechanisms involving the recruitment of glucose transporters to the cell surface and modulation of their expression. Neuregulins may also participate in the adaptations in glucose transport that take place in the muscle fiber after denervation.

Posterior corneal curvature changes after myopic laser in situ keratomileusis

OBJECTIVE

To assess the posterior corneal power and asphericity changes after myopic laser in situ keratomileusis (LASIK) and to correlate these changes with the amount of correction and the residual stromal bed thickness.

DESIGN

Prospective nonrandomized (self-controlled) comparative study.

PARTICIPANTS

Fifty-seven eyes of 14 women and 15 men, mean age at the time of surgery 33 +/- 9 (range, 19-53) years with a spherical equivalent (SEQ) of -1.00 to -15.50 (mean, -5.07 +/- 2.81) diopters (DI).

INTERVENTION

All procedures were performed with the Keratom II Coherent-Schwind excimer laser and and the Moria Model One microkeratome (150-microm head). Subjective refractometry, Orbscan slit scanning corneal topography analysis and pachymetry were performed before and 3 months after LASIK for myopia (n=35, -1.00 to -15.50 D, mean -4.75 +/- -3.07 D) or myopic astigmatism (n=22, sphere 0.00 to -9.75 D, mean -4.75 +/- 2.36 D; cylinder -0.75 to -3.50 D, mean -1.68 +/- 0.86 D). Intended ablation depth ranged from 12 to 108 (mean, 48 +/- 22) microm. Topographic raw data were decomposed into a set of Zernike polynomials as published in detail previously, and parameters potentially indicative for detection of a "mild keratectasia" were derived.

MAIN OUTCOME MEASURES

Posterior central corneal power and asphericity before and after LASIK were compared, and changes of these variables were correlated with the SEQ change (deltaSEQ)and the residual corneal bed thickness RBT).

RESULTS

The mean RBT after LASIK was 280 +/- 42 microm. Overall, change of posterior power (-6.28 +/- 0.22 D/ -6.39 +/- 0.23 D, P=0.02) was statistically significant and change of asphericity (0.98 +/-0.07/1.14 +/- -.20, P<0.0001) was highly significant. In eyes with RBT < or =250 microm, the average change of posterior central power (-0.20 +/- 0.10 D vs. -0.08 +/- 0.18 D) was significantly greater than in eyes with RBT >250 microm (P=0.003). The change of posterior corneal power correlated significantly with deltaSEQ (P=0.004) and the RBT (P=0.002).

CONCLUSIONS

Increased negative keratometric diopters and oblate asphericity of the posterior corneal curvature suggest that mild "keratectesia" of the cornea may be common early after LASIK. Further stuudies with longer follow-up are required to clarify whether this biomechanical deformation is progressive and whether a residual bed thickness of >250 microm can completely prevent it.

Fragmentation of carbohydrate anomeric alkoxy radicals. synthesis of polyhydroxy piperidines and pyrrolidines related to carbohydrates

Imino sugars of the piperidine and pyrrolidine types can be specifically obtained when protected 5-amino-5-deoxyfuranopentoses, 5-amino-5-deoxyfuranohexoses, 6-amino-6-deoxyfuranohexoses, and 6-amino-6-deoxypyranohexoses undergo a tandem alkoxy radical beta-fragmentation-intramolecular cyclization reaction. The reaction is promoted by the system: iodosylbenzene-iodine under mild conditions. The tert-butoxycarbonyl, benzyloxycarbonyl, and diphenylphosphinoyl radicals have been studied as amino-protecting groups. Using this methodology, polyhydroxylated pyrrolidines of the D-erythrofuranoses 34 and 35, D-threofuranose 36, L-xylofuranose 42, and D-arabinofuranose 43 series and polyhydroxylated piperidines of the D-arabinopyranose type 37 and 38 were obtained.

Multicenter retrospective study of response to interferon in chronic hepatitis B

AIM

The only agent known to have a lasting beneficial effect in chronic hepatitis B is interferon alpha, which achieves long-term remission in 25-40% of the patients. The goals of treatment are to induce clearance of HBV DNA from serum, to return serum aminotransferases to normal, and to improve histological findings in the liver. The most important factors predictive of response to treatment are high serum aminotranferases levels, low serum HBV DNA concentrations, and active histologic changes on liver biopsy. The aim of this study was to assess the response to interferon alpha in patients with chronic hepatitis B and to analyze the factors predictive of response.

METHODS

We conducted a multicenter retrospective study to investigate the effect of interferon treatment in 132 patients with chronic hepatitis B in overall terms and based on HBeAg, and factors predictive of response.

RESULTS

A overall sustained response was noted in 59 of 132 interferon-treated patients (45%) and 61 patients were nonresponders (46%). 12 patients relapsed (9%). None of the patients had negative HBsAg. No difference was observed in the response rate between the two treatment groups (HBeAg-positive and HBeAg-negative patients). Overall, high initial levels of serum AST and ALT predicted a good response. Age and liver biopsy findings were factors predictive of response in HBeAg-positive and HBeAg-negative patients respectively. Sex, epidemiological factors, treatment and type of virus did not correlate with the response to interferon.

CONCLUSIONS

A sustained response to interferon alpha was observed in 45% of the patients with chronic hepatitis B. HBeAg seroconversion was found in up to 50% of HBeAg-positive patients. None of the patients had negative HBsAg. Overall, the response rate was higher in patients with high pretreatment serum aminotransferase levels. Age was the predictive factor in HBeAg-positive patients, and histological features were predictive in the HBeAg-negative group. However, further studies in a larger patient population are necessary to obtain well-substantiated conclusions.