Efficacy of ACE-inhibitor therapy on renal disease in glycogen storage disease type 1: a multicentre retrospective study

BACKGROUND

The efficacy of ACE-inhibitors in decreasing microalbuminuria and proteinuria has been reported in a few patients with glycogen storage disease type 1 (GSD1); however, no case-control study has ever been published.

AIM

The aim of the current study was to evaluate the efficacy of ACE-inhibitors in reducing glomerular hyperfiltration, microalbuminuria and proteinuria, and in delaying the progression of renal damage.

PATIENTS AND METHODS

Ninety-five patients (median age at the time of the study: 14.5 years) were enrolled from nine Italian referral centres for metabolic diseases. A retrospective study of a 10-year follow-up was conducted in order to compare the evolution of these parameters in treated patients with those who were not treated with ACE-inhibitors.

RESULTS

A significant and progressive decrease of glomerular filtration rate was observed in treated patients vs. those who were not treated with ACE-inhibitors (P < 0.05). No difference was observed for microalbuminuria and proteinuria between the two groups of patients. Moreover, the ACE-inhibitors significantly delayed the progression from glomerular hyperfiltration to microalbuminuria, but not that from microalbuminuria to proteinuria.

CONCLUSIONS

The results of the present study underline the importance of a strict follow-up of renal function in GSD1 patients. The detection of glomerular hyperfiltration suggests precocious initiation of ACE-inhibitor treatment to delay the progression of renal damage. A randomized prospective study is needed to establish for certain the real effectiveness of this treatment in GSD1 patients.

Initial clinical experience using a diode red laser (670 nm) in the treatment of retinal disease

AIM

To investigate the clinical use of a 670-nm diode red laser in the treatment of a number of retinal conditions.

METHODS

In all, 17 eyes of 17 patients were treated for conditions such as proliferative diabetic retinopathy, retinal neovascularization in central retinal vein occlusion, rhegmatogenous retinal lesions and retinal breaks, and prophylactic peripheral retinopexy prior to silicone oil removal after three port pars plana vitrectomy.

RESULTS

Regression of neovascularization was observed in all the eyes treated for vascular proliferation at the 3-month follow-up visit. Adhesive pigmented scars were observed in the remaining eyes 1 month after treatment. No major complications were recorded.

CONCLUSIONS

In this pilot study, the 670-nm diode laser appears to be a promising modality for laser photocoagulation of the retina.

Proliferation, differentiation and apoptosis in connexin43-null osteoblasts

Osteoblasts are highly coupled by gap junctions formed primarily by connexin43 (Cx43). We have shown that interference with Cx43 expression or function disrupts transcriptional regulation of osteoblast genes, and that deletion of Cx43 in the mouse causes skeletal malformations, delayed mineralization, and osteoblast dysfunction. Here, we studied the mechanisms by which genetic deficiency of Cx43 alters osteoblast development. While cell proliferation rates were similar in osteoblastic cells derived from calvaria of Cx43-null and wild type mice, camptothecin-induced apoptosis was 3-fold higher in mutant compared to wild type osteoblasts. When grown in mineralizing medium, Cx43-null cells were able to produce mineralized matrix but it took one week longer to reach the same mineralization levels as in normal cells. Likewise, expression of alkaline phosphatase activity per cell--a marker of osteoblast differentiation--was maximal only 2 weeks later in Cx43-null relative to wild-type cells. These observations suggest that Cx43 is important for a normal and timely development of the osteoblastic phenotype. Delayed differentiation and increase programmed cell death may explain the skeletal phenotype of Cx43-null mice.

Deep tissue biopsy vs. superficial swab culture monitoring in the microbiological assessment of limb-threatening diabetic foot infection

AIMS

The results of ulcer swabbing vs. deep tissue biopsy have been compared prospectively in 29 diabetic patients with limb-threatening foot infection, to investigate the effectiveness and reliability of each method, and to evaluate whether any of the two could be more suitable for the microbiological follow-up of severe lesions.

METHODS

Microbiological samples were collected by using both methods at fixed intervals after therapy commencement (i.e. at day 0, 7, 14, and 30). Statistical comparison was performed between the results of each sampling procedure after the end of follow-up.

RESULTS

At enrolment, the mean number of isolates per patient was 2.34 by swabbing and 2.07 by tissue biopsy sampling; the rate of isolation for anaerobes with the two methods was 35% and 25%, respectively; no statistical differences could be observed between the two procedures in terms of either species or frequency of isolation. Anaerobic species were never detected after the first 2 weeks of appropriate treatment, and those ulcers which were still active at day 30 yielded almost exclusively Gram-positive bacteria. At the end of follow-up, deep tissue cultures appeared to exhibit a higher diagnostic sensitivity with respect to swabs.

CONCLUSIONS

Swabbing and deep tissue cultures appear to be equally reliable for the initial monitoring of antimicrobial treatment in severe diabetic foot infection. However, our experience seems to suggest that deep tissue might be more sensitive than swabbing for monitoring those isolates that have been selected for antibiotic resistance, i.e. those from ulcers that are still active after 30 days of treatment.

Connexin43 deficiency causes delayed ossification, craniofacial abnormalities, and osteoblast dysfunction

Connexin(Cx)43 is the major gap junction protein present in osteoblasts. We have shown that overexpression of Cx45 in osteoblasts expressing endogenous Cx43 leads to decreased cell-cell communication (Koval, M., S.T. Geist, E.M. Westphale, A.E. Kemendy, R. Civitelli, E.C. Beyer, and T.H. Steinberg. 1995. J. Cell Biol. 130:987-995) and transcriptional downregulation of several osteoblastic differentiation markers (Lecanda, F., D.A. Towler, K. Ziambaras, S.-L. Cheng, M. Koval, T.H. Steinberg, and R. Civitelli. 1998. Mol. Biol. Cell 9:2249-2258). Here, using the Cx43-null mouse model, we determined whether genetic deficiency of Cx43 affects skeletal development in vivo. Both intramembranous and endochondral ossification of the cranial vault were delayed in the mutant embryos, and cranial bones originating from migratory neural crest cells were also hypoplastic, leaving an open foramen at birth. Cx43-deficient animals also exhibited retarded ossification of the clavicles, ribs, vertebrae, and limbs, demonstrating that skeletal abnormalities are not restricted to a neural crest defect. However, the axial and appendicular skeleton of Cx43-null animals were essentially normal at birth. Cell to cell diffusion of calcein was poor among Cx43-deficient osteoblasts, whose differentiated phenotypic profile and mineralization potential were greatly impaired, compared with wild-type cells. Therefore, in addition to the reported neural crest cell defect, lack of Cx43 also causes a generalized osteoblast dysfunction, leading to delayed mineralization and skull abnormalities. Cell to cell signaling, mediated by Cx43 gap junctions, was critical for normal osteogenesis, craniofacial development, and osteoblastic function.

Incidence of secondary Helicobacter pylori resistance to antibiotics in treatment failures after 1-week proton pump inhibitor-based triple therapies: a prospective study

BACKGROUND

Antibiotic-resistant Helicobacter pylori strains are becoming increasingly prevalent, although it is not clear to what extent the new resistant organisms will spread.

AIM

To evaluate the incidence of secondary Helicobacter pylori resistance to metronidazole, clarithromycin and/or amoxycillin after one-week proton pump inhibitor based triple therapy failure in patients who were, before therapy infected with Helicobacter pylori strains susceptible to these antibiotics.

PATIENTS AND METHODS

Enrolled in the study were 97 consecutive Helicobacter pylori-positive subjects infected by Helicobacter pylori strains susceptible to metronidazole, clarithromycin and amoxycillin. Activity of tested antibiotics was determined by means of the E-test. Patients were treated for seven days with a proton pump inhibitor, omeprazole 20 mg twice daily or pantoprazole 40 mg once daily, plus clarithromycin 250 mg twice daily and metronidazole 250 mg four times daily; or with a proton pump inhibitor plus amoxycillin 1 g twice daily and clarithromycin 500 mg twice daily. Two months after completion of therapy, endoscopy and gastric biopsies for histology, rapid urease test and culture were repeated.

RESULTS

Four patients were dropped from the study Overall Helicobacter pylori cure rates expressed as both intention-to-treat and per-protocol analyses, were, respectively 80% (40/50) and 81.6% (40/49) with proton pump inhibitor, clarithromycin and metronidazole and 76.6% (36/47) and 81.8% (36/44) with proton pump inhibitor amoxycillin and clarithromycin. No significant differences were observed between the two treatments. Subjects in whom treatment failed were significantly younger and had less active ulcer than cured patients. Of treatment failures, 70.6% (12 out of 17 subjects) de veloped a secondary resistance to metronidazole (35.33% and/or clarithromycin (64.7%). Secondary antibiotic resistance occurred in 77. 8% of treatment failures treated with proton pump inhibitor, clarithromycin and metronidazole and in 62.5% of those treated with proton pump inhibitor, amoxycillin and clarithromycin. Considering all patients treated, the overall incidence of secondary metronidazole and/or clarithromycin resistance after therapy was reported in 12.9% of subjects (12 out of 93 treated patients).

CONCLUSIONS

Secondary Helicobacter pylori resistances to metronidazole and/or clarithromycin occurred in large percentages in patients with treatment failure after the one-week proton pump inhibitor-based triple therapies, proton pump inhibitor, clarithromycin and metronidazole and proton pump inhibitor, amoxycillin and clarithromycin. It is likely that new antibiotics or treatment strategies will be needed in the near future to successfully treat Helicobacter pylori infection.

Transforming growth factor-beta1 gene polymorphism, bone turnover, and bone mass in Italian postmenopausal women

Transforming growth factor beta1 (TGF-beta1) is abundant in bone and is an important regulator of the osteoclastic-osteoblastic interaction (coupling). The sequence variation, 713-8delC in the TGF-beta1 gene has previously been found to be associated with very low bone mass in osteoporotic women and with increased bone turnover in both osteoporotic and normal women. The possible association of this polymorphism with bone mass and bone turnover has now been investigated in 256 postmenopausal Italian women. A significant association of TGF-beta1 with bone mass was detected in the populations. Subjects carrying the sequence variation 713-8delC (Tt) genotype showed a significantly lower bone mineral density (BMD) at the hip than those without sequence variation in the genotype (TT). Individuals carrying the tt genotype have a more severe osteoporosis (P=0.0001 vs. TT and Tt genotypes). The frequency of the fragility fractures was significantly lower in individuals with TT genotype than in those with the Tt and tt genotypes (X2=21.9; P=0.006). Furthermore a significant association was found between 713-8delC and bone turnover. The results suggest a strong evidence for an association among the 713-8delC allele of the TGF-beta1 gene and the femoral BMD, the prevalence of osteoporotic fractures, and finally a high bone turnover in a sample of Italian postmenopausal women.

Noninvasive diagnosis of Helicobacter pylori infection in older subjects: comparison of the 13C-urea breath test with serology

BACKGROUND

The potential influence of cognitive status, physical activities, comorbidity and cotreatments on the feasibility and diagnostic accuracy of two noninvasive diagnostic tests for Helicobacter pylori (Hp) infection, i.e., the 13C-urea breath test (13C-UBT) and serology (immunoglobulin G [IgG] anti-Hp antibodies), in older subjects is not known.

METHOD

The study involved 100 consecutive symptomatic elderly subjects (mean age, 78.3 years; range, 65-96 years), who had undergone an upper gastrointestinal endoscopy. Patients were considered Hp positive if at least two of the three invasive methods, i.e. histology, culture, and/or the rapid urease test were positive for Hp infection. Patients were considered Hp negative if all three invasive methods were negative. The 13C-UBT was performed according to the European standard method and the assaying of IgG anti-Hp antibodies by enzyme-linked immunosorbent assay. Cognitive status and functional activities were determined by the Mini-Mental State Examination (MMSE), the activities of daily living (ADLs) and instrumental ADLs (IADLs).

RESULTS

According to invasive methods, 49 patients were Hp positive and 47 were Hp negative (4 subjects were excluded from the study). Hp-positive patients demonstrated a significantly higher prevalence of peptic ulcers (p =.02) and activity of chronic gastritis (p<.0001) than Hp-negative subjects. The 13C-UBT demonstrated a sensitivity of 100%, a specificity of 95.7%, and a diagnostic accuracy of 97.9%. Serology had significantly lower sensitivity (74.4%), specificity (59%), and diagnostic accuracy (67%, p<.001) than the 13C-UBT. The feasibility and the diagnostic accuracy of the 13C-UBT were not altered by the cognitive status (MMSE) and functional activities (ADL, IADL) of the patients, their drug consumption, or the prevalence of concomitant diseases.

CONCLUSIONS

In older subjects, the 13C-UBT had a significantly higher diagnostic accuracy than serology without influence of cognitive function, disability, comorbidity and cotreatments. This method may be considered an excellent, clinically useful, noninvasive test for the diagnosis of Hp infection in older subjects.

Urinary galactosyl-hydroxylysine in postmenopausal osteoporotic women: A potential marker of bone fragility

Alterations of the collagen matrix, e.g., increased hydroxylation and glycosylation of lysyl residues in collagen I, were found in human osteoporotic bone, and it was suggested that they could alter the mechanical properties of skeleton. To test this hypothesis, we evaluated the content of galactosyl-hydroxylysine (GHYL) in bone collagen, as assessed by its urinary excretion, and related it to the occurrence of fracture. Two hundred and fifteen unselected postmenopausal women with osteoporosis were divided in two subgroups (comparable for age, age of menopause, bone mineral density, and biochemical parameters of bone turnover) on the basis of the history of fragility fracture; 115 patients had suffered no fracture and 100 patients had suffered one or more fractures 3 or more years before. Four urinary markers of bone turnover (hydroxyproline, cross-linked N-telopeptide, free deoxypyridoline, and GHYL) were evaluated in all patients. There was no difference between the two groups with regard to all the parameters studied except for GHYL, which was significantly higher in the group with a history of fracture (1.35 +/- 0.82 mmol/mol of creatinine [Cr] versus 1.03 +/- <0.48 mmol/mol Cr, p < 0.001); this marker did not correlate with other markers of bone remodeling in the fracture group, indicating a possible defect in bone collagen. In conclusion, provided that increased levels of urinary GHYL do reflect overglycosylation of hydroxylysine in bone collagen, the GHYL may be considered a marker of bone collagen quality. Our results, showing higher urinary GHYL in osteoporosis patients with fracture, seem to confirm this suggestion.

[Echo-guided compression in the treatment of femoral pseudoaneurysms secondary to cardiological interventional procedures]

PURPOSE

To analyze perspectively a set of 13 patients affected by femoral artery pseudoaneurysm treated with Us-guided compression.

MATERIAL AND METHODS

From January to December 1997 we observed 13 patients (7 females and 6 males; mean age: 67.4 years old) affected by femoral artery pseudoaneurysm which were treated with Us-guided compression. The compression was repeated for 15 minutes up to complete closure of the pseudoaneurysm. Every patient was followed up 24 hours after the procedure, before the discharge and every 3 months.

RESULTS

In 6 cases the cardiologic procedure had diagnostic purposes while in 7 cases had interventional purposes. The pseudoaneurysm was located in the common femoral artery in 10 cases, in the superficial femoral artery in 2 cases and in the profunda femoris in the last case. The fistula between the aneurysmatic chamber and the arterial lumen had a mean length of 1 centimeter (range: 0.5-2.5 cm) and the mean diameter of the pseudoaneurysm was 3 centimeters (range: 1.5-6 cm). The mean length of the compression was 34 minutes (range: 10-120 min). The technical success rate was 92.3% with one case of failure in the unique localization in the profunda femoris. The procedure was well tolerated from the patients, with minimal discomfort. After the treatment the mean hospital stay was 2 days and to date we have had no recurrences after a mean follow-up of 18 months.

CONCLUSIONS

In accordance with the data of the literature, Us-guided compression is the treatment of choice of femoral pseudoaneurysms after cardiac catheterization. The procedure is well tolerated in almost all the patients and it deters the need of surgery with reduction of complications, costs and hospital stay.

The effect of antibiotic resistance on the outcome of three 1-week triple therapies against Helicobacter pylori

BACKGROUND

Resistance of Helicobacter pylori to antibiotics may be a major reason for treatment failure.

AIM

To evaluate the effect of primary H. pylori resistance to antibiotics on the cure rates of three anti-H. pylori 1-week triple therapies.

METHODS

One hundred and sixteen consecutive patients diagnosed H. pylori-positive by gastric histology, rapid urease test and culture were enrolled. Activity of tested antibiotics was determined by means of the E-test. Patients were treated for 7 days with: (i) pantoprazole 40 mg o.d. plus amoxycillin 1 g b.d. and metronidazole 250 mg q.d.s. (PAM); (ii) pantoprazole 40 mg o.d. plus clarithromycin 250 mg b.d. and metronidazole 250 mg q.d.s. (PCM); or (iii) pantoprazole 40 mg o.d. plus amoxycillin 1 g b.d. and clarithromycin 250 mg b.d. (PAC). Two months after completion of therapy, endoscopy and gastric biopsies were repeated.

RESULTS

Primary resistance rates to metronidazole, clarithromycin and amoxycillin were 17.2, 6.9 and 0%, respectively. Overall H. pylori cure rates expressed as intention-to-treat and per protocol analyses were, respectively, 79% and 86% with PAM, 82% and 89% with PCM, and 85% and 85% with PAC. Significantly lower cure rates were observed in metronidazole-resistant patients treated with PAM (56% vs. 96%, P = 0.01) or PCM (50% vs. 97%, P = 0.01). A trend towards lower H. pylori cure rates was observed in clarithromycin-resistant patients treated with PCM (67% vs. 91%, P = 0.74) or PAC (50% vs. 87%, P = 0.68).

CONCLUSION

Primary resistance to metronidazole influences the H. pylori cure rate of anti-H. pylori proton pump inhibitor-based triple therapies which include this antibiotic. A similar trend exists for primary clarithromycin resistance.

Cytotoxin-associated gene A-positive Helicobacter pylori infection in the elderly. Association with gastric atrophy and intestinal metaplasia

To evaluate if the infection with strains of cytotoxin-associated gene A (CagA)-positive Helicobacter pylori is associated with either peptic ulcer and gastric atrophy or intestinal metaplasia in the elderly, we studied 71 H. pylori-positive patients older than 62 years old (34 men, 37 women; mean age, 77.5 years; range, 62-89 years) affected with gastric ulcer (GU) (n = 10), duodenal ulcer (DU) n = 22), or chronic gastritis (CG) (n = 39). H. pylori infection was documented by means of gastric histology, rapid urease test, and polymerase chain reaction (PCR) assay performed on gastric biopsies using two sets of primers: one for the ureC gene specific for H. pylori, and the second specific for the CagA gene. H. pylori-CagA positivity was significantly more common in patients with GU (9 of 10, 90%) than with DU (11 of 22, 50%; p < 0.05) or CG (17 of 39, 43.5%; p = 0.01). Gastric atrophy and intestinal metaplasia were significantly more common in CagA-positive patients than in CagA-negative patients (gastric atrophy: 40.54% vs 11.76, p = 0.007; intestinal metaplasia: 40.54% vs 14.70%, p = 0.01). No difference in prevalence of gastric atrophy and intestinal metaplasia was found in patients divided according to pathology (GU, DU, or CG). Logistic regression demonstrated that gastric atrophy and intestinal metaplasia were independent factors significantly associated with CagA-positivity (gastric atrophy: odds ratio = 4.53, 95% confidence interval 1.25-16.4; intestinal metaplasia: odds ratio = 3.44, 95% confidence interval 1.01-11.7). Our findings help to confirm the hypothesis that an infection with CagA-positive H. pylori strains may be catalytic in inducing gastric changes which can evolve into malignancies.

[Criteria for utilization and indications for use of permanent and short- and medium term temporary endocaval filters. Personal experience and review of the literature]

Screening and prophylaxis of the population at risk is the most correct approach to thromboembolic disease. Caval filters play a major role in the prevention of pulmonary embolism, but their use remains widely controversial, even if they are an alternative or additional method to medical therapy and not antithetical to it. July, 1990, to September, 1995, seventy-seven permanent vena cava filters (59 LGM, 13 Filcard and 5 titanium-Greenfield), 22 short-duration temporary vena cava filters (11 LGT, 6 Filcard, 3 Filcard-Emanuelli and 2 Lysofilter) and 10 mid-duration temporary vena cava filters (Tempofilter) were inserted in 109 patients (55 men and 54 women) aged 17-88 years. An inferior vena cavogram was always made before filter insertion to "map" the inferior vena cava and its tributaries (renal veins) and to assess caval size. This is a mandatory step to exclude or confirm the presence of endocaval thrombi. Sixty-eight filters were inserted percutaneously via a right internal transjugular approach, 40 via a common transfemoral approach (34 right and 6 left) using the same route as inferior cavography and digital pneumoangiography. One temporary filter was inserted via a right transhumeral approach. Sixty-three patients (57.8%) (44 with a permanent filter, 14 with a temporary filter and 5 with a Tempofilter) had medical diseases, 7 patients (6.4%) (4 with a permanent filter, one with a temporary filter and 2 with a Tempofilter) had surgical conditions; 10 patients (9.2%) (7 with a permanent filter and 3 with a Tempofilter) were surgical-orthopedic patients. Twenty-seven patients (24.8%) (22 with a permanent and 5 with a temporary filter) had cancer. Two patients (1.8%) with a temporary filter were breast feeding. All the patients had deep venous thrombosis of the lower limbs, including the inferior vena cava and the right renal vein in two patients. A proximal floating thrombus and a pulmonary thromboembolism was diagnosed in 41 (37.6%) and 34 (31.2%) cases, respectively. The temporary filters remained in situ 1-4 days and the Tempofilters 3-5 weeks. A pelvic hematoma developed (because of heparin?) after the insertion of a temporary filter and a Tempofilter branch detached and migrated into a lower branch of the left pulmonary artery were reported as immediate and short-term consequences. There were no early or late consequences for the patients. An axillary hemorrhage was observed in the site of previous surgery, during fibrinolysis with a Lysofilter, as well as the incomplete opening of a titanium-Greenfield filter and of two permanent LGM filters, partly trapped within endocaval thrombi. No further consequences to the patients due to permanent filters were observed, nor any case of symptomatic pulmonary thromboembolism, in patients with permanent or temporary filters. With reference to the relative literature and to their own experience, the Authors propose a detailed and rational synthesis of the diagnostic-instrumental approach protocol to thromboembolic disease.

Acute cholecystitis: ultrasonographic staging and percutaneous cholecystostomy

Experience in the treatment of acute cholecystitis with percutaneous cholecystostomy in 29 high-risk and elderly patients is reported. The treatment group included 14 men and 15 women, 21 of whom were over 70 years of age. The suspected clinical diagnosis of acute cholecystitis was confirmed in all cases by ultrasonography (accuracy: 95.6%). The percutaneous cholecystostomy was successful in 27 of 29 cases and these patients had a sudden improvement in their clinical condition; failure of the procedure was due in one patient to dislodgement of the catheter and in another patient to the guide-wire slipping out of the gallbladder. Six patients complained of pain radiating to the right shoulder which disappeared within 30-60 minutes after the procedure. Twenty-three of the 27 patients subsequently underwent elective cholecystectomy. In 22 patients the ultrasonographic findings were compared with the histology; thus enabling us to establish an ultrasonographic staging of acute cholecystitis related to the seriousness of the disease. Percutaneous cholecystostomy is the treatment of choice in high-risk patients, in the elderly, as well as in young patients with impending perforation.

[The treatment of acute cholecystitis by percutaneous cholecystostomy]

The authors report on their personal experience with percutaneous cholecystostomy (PC) in 36 cases of acute cholecystitis (AC). PC was successful in 34 cases, improving the clinical condition of the patients within the first hour following treatment and normalizing the laboratory data within 24-48 hours. Twenty-seven patients with calculous AC underwent cholecystectomy within 4-15 days. In 6 cases (3 calculous and 3 acalculous ACs) PC was the only treatment performed; in one case (calculous AC) PC was combined with lithotomy, the stone fragments being extracted via the cholecystostomy. According to literature reports, to date PC has been performed mainly--as an alternative to surgical cholecystostomy--on the patients unsuitable for cholecystectomy due to their age or to severe impairment of their conditions. In our experience, the procedure can be performed on a wider range of patients as a final (notably in acalculous AC) or temporary step (notably in calculous AC where it may allow cholecystectomy to be delayed and thus performed under better clinical conditions, with decreased morbidity and mortality risks).

[Hepatic abscess]

The Authors review the medical records of 9 patients with liver abscess over a 15-year period from 1975 to 1989. They report on 5 pyogenic abscess, 3 amebic abscess and one case of tuberculosis of the liver. The most common initial diagnosis was fever of unknown origin, abdominal pain and hepatomegaly. The treatment consisted of 6 percutaneous transhepatic drainage, 2 open surgical drainage, and one explorative laparotomy (tbc infection). The Authors had no mortality and recommend the percutaneous transhepatic drainage as first-choice treatment.

[The echo-guided percutaneous therapy of dysontogenetic liver cysts]

Congenital hepatic cysts are a frequent disease, symptomatic in 16-18% of the cases. The Authors report their personal experience about 4 cases and they make a review about 56 cases treated with ultrasonically-guided therapy. In 20 cases the therapy was simple aspiration, in 39 was alcohol sclerotherapy and in 1 was external percutaneous drainage. All the 20 cysts treated with simple aspiration recurred after 0.5-24 months. All the 39 patients treated with alcohol sclerotherapy presented a complete remission of symptoms and are disease-free after 1-48 months. The patient treated with percutaneous drainage, is disease-free after 10 months from the procedure. The alcohol sclerotherapy is the treatment of choice for the congenital hepatic cysts. The simple aspiration is an effective procedure only from a diagnostic point of view but not therapeutic. The external percutaneous drainage is the treatment of choice in case of infected cysts. Surgery is indicated only in the cysts with acute presentation, with biliary content and in case of failure of alcohol sclerotherapy.

[The role of echo-guided percutaneous cholecystectomy in acute cholecystitis]

Personal experience in the treatment of acute cholecystitis with percutaneous cholecystostomy in high risk patients and in elderly patients is reported. Between January 1989 and November 1990, 28 patients affected by acute cholecystitis were treated with percutaneous cholecystostomy at Emergency Surgery Department, Verona University Hospital. The patients treated included 13 men and 15 women; 8 of them were under 70 years old, 5 between 70th and 75th and the remaining patients over 75 years old. The suspected clinical diagnosis of acute cholecystitis was confirmed in all cases by ultrasonography (accuracy 95.4%). The percutaneous cholecystostomy was successful in 26 over 28 cases. In all these cases patients had a sudden improvement of their clinical conditions. In one case we failed because the guide-wire slipped out of the gallbladder and we couldn't perform a second attempt for the patient's refuse; in an other case there was the dislodgment of the catheter after less than 12 hours from the cholecystostomy and the patient was operated on. Twenty-two of 26 patients whose conditions were improved by percutaneous cholecystostomy, subsequently underwent elective cholecystectomy. In 2 cases of acalculous cholecystitis the patients did not undergo the operation; in 2 cases because of the elderly age of the patients and their bad cardiorespiratory conditions we preferred not to perform the operation. We had not major complications; 6 patients complained pain irradiating to right shoulder which disappeared within 30-60 minutes from the end of the procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

[The conservative treatment of hepatic abscesses with echo-guided transcutaneous drainage]

Liver abscesses are a rare disease with 80-100% mortality in untreated cases. The advent of ultrasound in the clinical practice has improved the prognosis. Surgery for this disease has a percentage of complications of 15-52% and a mortality of 12-33%. In a review of the literature about 200 liver abscesses treated with ultrasound-guided percutaneous drainage the complications were 7.5% and the mortality was 3%. The authors report their personal experience about 21 hepatic abscesses in 13 patients. Nineteen abscesses were treated with ultrasound-guided percutaneous drainage and two with antibiotics. Six patients had pyogenic liver abscesses, two amebic and in five patients the cultures were sterile. In 9 cases the location was in the right lobe of the liver, in 3 was in the left lobe. One patient had multiple abscesses. The size of the abscesses ranged from 0.5 to 13 cm. We drained with Seldinger technique or direct procedure with Trocar's needle under ultrasound guidance without serious complications and without mortality. In 6 cases the patients had pain during the procedure and in 3 cases medical therapy was necessary. In one case we had a pleuritis for the puncture of costophrenic space. All the patients treated had a complete resolution of the abscesses. The ultrasound-guided percutaneous drainage is the treatment of choice for liver abscesses. But other reports with more patients are necessary to clarify the indications and the ultrasound criteria of recovery.

[The therapy of symptomatic and/or complicated dysontogenetic liver cysts]

Congenital hepatic cysts are a frequent disease, symptomatic in the 16-18% of the cases. The authors report a review of the literature of the last 20 years about 135 treated surgically patients with symptomatic and/or complicated hepatic cysts. They analyse the different models of treatment both surgical and conservative, referring in special way about the alcoholization of the cysts. The authors finally report their personal experience about eight cases.