Self-expanding metal stents for endoscopic treatment of esophageal achalasia unresponsive to conventional treatments. Long-term results in eight patients

BACKGROUND AND STUDY AIMS

The successful use of self-expanding metal stents has been demonstrated in the management of malignant esophagocardial strictures. This report assesses the role stents may play in the treatment of esophageal achalasia in selected patients.

PATIENTS AND METHODS

Between September 1996 and December 1997, eight patients (two men, six women; average age 67.6 years) underwent insertion of a self-expanding metal stent for management of achalasia. Previous myotomy and/or balloon dilation or injection of botulinum toxin had failed in all patients. Four nitinol coil stents and five covered Ultraflex stents, 10 cm long, were inserted, being passed through the gastroesophageal junction under mild sedation.

RESULTS

Stent placement was successful and uncomplicated in all patients. Early complications were seen in five patients: chest pain (1), gastroesophageal reflux (1), proximal migration (1), and distal migration (2). One patient underwent surgery for stent impaction in the colon. During the follow-up period of 35.5 months, on average (range 29 - 44 months), four patients experienced complications: chest pain (2), reflux esophagitis (1) and stent migration (1).

CONCLUSION

General use of self-expanding metal stents for esophageal achalasia cannot be recommended.

Inducible IL-2 production by dendritic cells revealed by global gene expression analysis

Dendritic cells (DCs) are strong activators of primary T cell responses. Their priming ability is acquired upon encounter with maturation stimuli. To identify the genes that are differentially expressed upon maturation induced by exposure to Gram-negative bacteria, a kinetic study of DC gene expression was done with microarrays representing 11,000 genes and ESTs (expressed sequence tags). Approximately 3000 differentially expressed transcripts were identified. We found that functional interleukin 2 (IL-2) mRNA, which gave rise to IL-2 production, was transiently up-regulated at early time-points after bacterial encounter. In contrast, macrophages did not produce IL-2 upon bacterial stimulation. Thus, IL-2 is an additional key cytokine that confers unique T cell stimulatory capacity to DCs.

Semiclassical simulations of azomethane photochemistry in the gas phase and in solution

We present semiclassical simulations of the dynamical events which follow the n --> pi excitation of an azomethane molecule: decay to the ground state, isomerization, and dissociation. Ab initio potential energy surfaces and couplings, slightly modified according to available experimental data, are employed in conjunction with a trajectory-surface-hopping method. For an isolated molecule, we show that dissociation takes place in the ground state, because the radiationless decay is very fast. The dissociation is mainly sequential: the methyldiazenyl radical first produced fragmentates very rapidly to N(2) + CH(3)*. The results of previous experiments by Lee's and Zewail's groups, from which partially conflicting conclusions had been drawn, are reproduced and interpreted. Molecular dynamics, coupled to the surface-hopping algorithm, allows us to simulate the photochemistry in acqueous solution. Here the fragmentation is suppressed because of vibrational energy loss to the solvent: only the isomerization takes place.

Hepatic uptake of organic anions affects the plasma bilirubin level in subjects with Gilbert's syndrome mutations in UGT1A1

Although in Gilbert's syndrome (GS), bilirubin glucuronidation is impaired due to an extra TA in the TATA box of the promoter of the gene for bilirubin UDP-glucuronosyltransferase 1 (UGT1A1), many GS homozygotes lack unconjugated hyperbilirubinemia. Accordingly, an additional defect in bilirubin transport might be required for phenotypic expression. Plasma bilirubin and the early fractional hepatic uptake rate (BSP K(1)) of a low dose of tetrabromosulfophthalein (0.59 micromol/kg) were determined in (1) 15 unrelated patients with unconjugated hyperbilirubinemia plus 12 random controls; (2) 4 unrelated GS probands and 15 of their first-degree relatives; (3) 7 unrelated patients with hemolysis due to beta-Thalassemia minor. Subjects were classified by DNA sequencing of the promoter region of both UGT1A1 alleles. In group 1, GS homozygotes showed a highly significant negative linear correlation between plasma bilirubin levels and BSP K(1). BSP K(1) values overlapped considerably between GS and normal subjects, whereas, in group 2, they were clustered within, and sharply segregated among, families. Patients with hemolysis, despite elevated plasma bilirubin levels, had mean BSP K(1) values similar to the normal subjects. Within each GS subgroup with defined UGT1A1 mutations, the plasma bilirubin level is in part determined by the organic anion uptake rate, assessed by early plasma disappearance of low-dose BSP. The lower BSP uptake in GS is not secondary to the hyperbilirubinemia, but probably caused by (an) independent, genetically determined defect(s) in hepatic transport mechanism(s), shared by BSP and bilirubin, that are likely necessary for phenotypic expression of GS.

Natural history of hepatitis C virus carriers with persistently normal aminotransferase levels

BACKGROUND & AIMS

Some patients with serum hepatitis C virus (HCV) have persistently normal aminotransferase (ALT) levels and are affected by cirrhosis. This study prospectively evaluated progression of the disease in a group of anti-HCV-positive patients with persistently normal ALT levels.

METHODS

Thirty-seven subjects were studied. Each subject underwent liver biopsy at baseline and after 5 years of follow-up. At baseline, serum samples were tested for genotypes and HCV RNA load. ALT levels and serum HCV RNA were tested every other month and every 6 months, respectively. Patients with increased ALT were discharged from the study and treated with IFN. Five years after the end of IFN therapy, a liver biopsy was performed.

RESULTS

Liver biopsy at baseline showed chronic hepatitis in 34 patients and normal histology in 3 patients, 2 of whom were negative for HCV RNA and 1 positive. HCV genotypes were distributed as follows: 2a, 56%; 1b, 41%; and 1a, 3%. At the end of 7-year follow-up, 73% of the patients still had normal ALT values. Liver histology after 5 years was comparable to that observed at entry to study.

CONCLUSIONS

Most patients with persistently normal ALT serum levels have very mild chronic hepatitis. However, healthy anti-HCV-positive subjects exist. In patients with HCV-related chronic hepatitis associated with persistently normal ALT levels, the grade of disease activity does not increase over years and progression to cirrhosis is slow or absent.

Cochlear dysfunction in type 2 diabetes: a complication independent of neuropathy and acute hyperglycemia

The effects of type 2 diabetes on evoked otoacoustic emissions (e-OAEs) elicited by clicks in subjects with normal hearing and the involvement of the central (CNS) and peripheral nervous system and acute hyperglycemia were investigated. In study 1, 110 type 2 diabetic patients and 106 control subjects matched for age and gender were investigated by e-OAEs. Central and peripheral neuropathy were evaluated respectively by auditory brainstem responses (ABRs) and according to San Antonio Consensus Conference criteria. In study 2, 10 healthy and 10 type 2 diabetic men matched for age, all with normal e-OAEs, underwent a 5-hour hyperglycemic clamp study. e-OAE tests were performed before and during the hyperglycemic clamp. In study 1, e-OAEs were impaired in 51.8% (57 of 110) of the diabetic subjects, in comparison to 4.7% (five of 106) of the control group (P < .0001). Diabetics with impaired e-OAEs (e-OAEs-), in comparison to those with normal e-OAEs (e-OAEs+), were older (51.0+/-5.8 v 45.1+/-6.0 years, P < .001), had diabetes longer (11.5+/-4.4 v 7.0+/-3.9 years, P < .001), achieved poorer metabolic control as judged by hemoglobin A1c ([HbA1c] 6.9%+/-0.4% v 6.5%+/-0.3%, P < .001), and had more peripheral neuropathy (46% v 23%, P < .02). No difference was observed between e-OAEs- and e-OAEs+ subjects for retinopathy or nephropathy. Nevertheless, when the duration of diabetes was corrected by multiple regression analysis, the correlation between sensorineural damage and peripheral neuropathy lost significance (P = .12). Diabetic groups (e-OAEs+ and e-OAEs-) showed greater latency in waves I, III, and V and greater interwave latency for waves I to V than the control group, but there was no significant difference in ABRs between e-OAEs+ and e-OAEs- subjects. In study 2, there were no significant changes in e-OAE intensities compared with basal values during the entire hyperglycemic clamp in either type 2 diabetic or control subjects. No difference was observed between the two groups at each time of the clamp. Thus, type 2 diabetic subjects show a higher rate of compromised e-OAEs than healthy individuals. The e-OAE dysfunction does not associate with either an injury to the auditory nervous pathway or diabetic microvasculopathy. The apparent interference of peripheral neuropathy in e-OAEs loses significance when corrected for the duration of diabetes.

Serological and clinical markers of autoimmune disease in HCV-infected subjects with different disease conditions

OBJECTIVE

To investigate whether the serological markers of autoimmunity and the clinical features of autoimmune disease which occur in hepatitis C virus (HCV)-infected subjects are correlated to each other and/or to the clinical pattern of the disease.

METHODS

Seventeen symptom-free, anti-HCV antibody positive subjects, 17 patients with chronic hepatitis C, 21 patients with mixed cryoglobulinemia (MC), and as controls 17 anti-HCV negative patients with dyspepsia were enrolled in a prospective study. A patient history, clinical examination, self-administered questionnaire and laboratory investigations (hepatic enzyme levels, serum HCV-RNA and anti-HCV antibody testing, and serum autoantibody profile) were performed to detect liver and/or autoimmune disease.

RESULTS

Serological markers of autoimmunity and clinical findings of autoimmune disease were found to be more frequent in the HCV-infected patients considered as a whole than in controls. However, rheumatoid factor and clinical findings of autoimmune disease were more frequent in MC patients, while anti-smooth muscle antibodies not linked to symptoms or signs of autoimmune disease were detected in all groups of HCV-infected individuals, including healthy carriers and subjects who had recovered from a previous HCV infection.

CONCLUSION

Anti-smooth muscle antibodies, a serological marker of autoimmunity, are detectable in HCV-infected subjects whatever their clinical status. Clinical findings of autoimmune disease prevalently occur in patients with mixed cryoglobulinemia.

Psychosocial correlates of psychopathology in a national sample of the morbidly obese

BACKGROUND

Although several studies have documented the existence of psychopathology in the morbidly obese, there is disagreement as to its extent and nature. The disagreement has been difficult to resolve because earlier studies have tended to use small, regional samples, and diverse, unstandardized approaches to measuring psychopathology.

METHODS

To add clarity, the present study utilized an unusually large, national sample, all subjects of which were administered a standardized, comprehensive test of psychopathology (the MMPI-2), an intensive interview concerning psychosocial history, and a medical examination. Subjects' scores on the MMPI-2 were compared to available norms. The psychosocial interview yielded information about families of both origin and reference. Information about comorbidities, medications, and body mass index (BMI) were available from the medical examinations. Multiple regression analyses were performed to determine the variables that best predicted psychopathology and BMI.

RESULTS

The percentage of subjects whose MMPI-2 scores exceeded and approached psychopathological levels was in excess of normative expectations. The 1,3,2 pattern of scale scores on this test expresses depressive disorder, with anxiety and somatization features. Regression analyses showed that abuse of the subject and of substances in the family of origin positively predicted, while education and number of children negatively predicted both psychopathology and BMI.

CONCLUSIONS

Dysfunctionality in the family of origin may lead to obesity through such regressive coping styles as stress eating, but this can be offset by personal development and nurturance responsibilities.

Mapping of the mouse Tdgf1 gene and Tdgf pseudogenes

Teratocarcinoma-derived growth factor-1 (Tdgf1), a member of the "EGF family" of growth factors, is expressed during mouse gastrulation in the forming mesoderm and later in the truncus arteriosus of the developing heart. In humans, TDGF1 is highly expressed in germ cell tumors and in colon and mammary carcinomas. In mouse, one gene (Tdgf1) and two pseudogenes (Tdgf1-ps1 and Tdgf1-ps2) have been isolated and characterized. Tdgf1 corresponds to the gene expressed in F9 teratocarcinoma cells. Tdgf1-ps1 and Tdgf1-ps2 are two intronless sequences with all the characteristics of retroposons. In the present paper, we assign the chromosomal location for Tdgf1, Tdgf1-ps1, and Tdgf1-ps2 sequences to Chromosomes (Chrs) 9, 16, and 17, respectively. Two previously described mouse mutants, scant hair (sch) and fur deficient (fd), map near the Tdgf1 gene. Analysis of their DNA coding region provided no evidence that Tdgf1 could be the responsible gene for these phenotypes. Finally, analysis of the DNA from several Mus musculus strains and from Mus spretus mice revealed a highly variable restriction pattern and the absence of the Tdgf1-ps1 genomic sequence from the Mus spretus genome.

[Aneurysms of the splanchnic arteries]

Although visceral aneurysms usually have an asymptomatic course, ruptures associated with high mortality do occur. When an asymptomatic lesion is found, the physician must decide whether it should be treated surgically and which surgical technique should be used. Because this type of aneurysm is relatively rare, the answer to these questions have not been determined previously. The outcome in 16 patients treated by surgical or embolization procedures was evaluated. A group of 16 patients with visceral aneurysms were observed in our institution between 1987 and 1993. Localization of aneurysms was on the splenic artery in 8 cases, renal artery in 4 cases, hepatic artery in 3 patients and superior mesenteric artery in one patient. Hypertension was related to renal aneurysms and angina abdominis to the patient with superior mesenteric artery aneurysm. Of the 16 patients, 8 (6 splenic and 2 hepatic aneurysms) were asymptomatic, 3 (2 splenic and 1 hepatic) were treated as an emergency because they presented with shock. In the splenic group (8 cases), 2 patients underwent embolization procedures with Gianturco's coils, and 6 surgical procedures; in the hepatic group 1 embolization and 1 surgical procedure were performed; and finally in the renal and mesenteric group surgical reconstruction was performed during aortic prosthetic surgery. Because of well documented natural history of progressive enlargement and eventual rupture, the aneurysms of visceral arteries should be corrected surgically when the diagnosis is confirmed by vascular imaging (ultrasounds, CT, RM, angiography). Ruptures are treated with emergency operations, when possible. In high-risk patients, non operative management by selective embolization (in case of splenic and hepatic aneurysms) may be suitable alternative.

Thrombocytopenia as a sensitive marker of immunologic activity in a patient with autoimmune chronic active hepatitis

The case of autoimmune chronic active hepatitis in a 57-year-old female is reported. Onset was signalled by an abrupt and dramatic thrombocytopenia, which was also the only laboratory parameter able to monitor treatment and progression of the disease. It is concluded that thrombocytopenia together with the presence of antiplatelet-antibodies might be useful markers to monitor the treatment and evolution of the disease.

Activation of fetal promoters of insulinlike growth factors II gene in hepatitis C virus-related chronic hepatitis, cirrhosis, and hepatocellular carcinoma

Increased prevalence of hepatitis C virus (HCV) infection has been found in patients with hepatocellular carcinoma (HCC). The expression of insulinlike growth factor II (IGF-II) has been linked to hepatocarcinogenesis in the experimental animal and in humans. Since reactivation of fetal IGF-II transcripts has been observed in human HCC, we have analyzed the levels of adult P1 and fetal P3 and P4 IGF-II promoter-derived transcripts in the liver of patients with HCV-related chronic active hepatitis (CAH), cirrhosis, and HCC by means of a semiquantitative reverse-transcription polymerase chain reaction (RT-PCR) assay. Transcripts derived from adult P1 promoter were increasingly expressed from normals to patients with CAH and cirrhosis, but were undetectable in the tumorous area of 5 of 7 HCC patients and present at low levels in the nontumorous area of all HCC patients. Transcripts derived from fetal P3 promoter were not detectable in normal subjects, while they were expressed abundantly in most CAH and all cirrhotic patients. Transcripts from fetal P4 promoter were detected at high levels in 3 of 9 CAH patients and in the majority of cirrhotic patients. Increased expression of fetal promoter-derived transcripts was also found in the liver of HCC patients, although levels were lower than in cirrhosis. Also, the activity of fetal P3 and P4 promoters was higher in the nontumorous than in the tumorous area of the liver of HCC patients. The expression of IGF-II transcripts was correlated with the rate of cell mitotic activity by measuring the expression of the proliferating cell nuclear antigen (PCNA) gene. PCNA messenger RNA (mRNA) levels progressively increased from normals to CAH and to cirrhotic patients, and persisted at a high level in the tumorous and in the nontumorous area of HCC subjects, thus showing that the increase of IGF-II transcripts in CAH and cirrhosis is accompanied by an activation of cell mitosis in these samples. These data suggest that the activation of IGF-II gene expression from adult and fetal promoters may play a role in premalignant proliferation observed in HCV-related chronic liver disease.

Non-ulcer dyspepsia and Helicobacter pylori in type 2 diabetic patients: association with autonomic neuropathy

Diabetic patients often suffer from symptoms arising from the gastrointestinal tract. Several factors are considered responsible for these alterations, including abnormalities of gastric motility. Recently Helicobacter pylori (HP) has been identified in a relevant aliquot of subjects with or without gastrointestinal abnormalities, but only scarce and controversial data are available on the prevalence of HP and the association between HP and chronic gastritis or peptic ulcer in diabetic patients. In addition, the possible association between alterations of gastric motility induced by autonomic neuropathy (AN) and the presence of HP has never been evaluated in diabetic subjects. In this study we document the presence of HP in the gastric biopsies of 73% out of a series of 29 patients affected by type 2 diabetes and non-ulcer dyspepsia (3 with oesophagitis, 10 with gastritis, 7 with bulbar duodenitis, and 9 with a normal endoscopy), with a significantly higher prevalence (P < 0.01) in subjects with AN (74%) than in subjects without AN (26%). Two other tests have been compared with the histological evidence of HP (used as golden standard), i.e. the urease test (CP-test) and the assay of anti-HP G-immunoglobulins, both of which were positive in a significantly (P < 0.01) higher percentage of neuropathic patients in comparison with non-neuropathic patients. The sensitivity and the specificity of the CP-test were 96% and 100%, respectively. Similarly, both the sensitivity and the specificity of the assay of IgG HP-Ab were 100%. Since patients affected by non-ulcer dyspepsia and NIDDM complicated by autonomic neuropathy are under a higher risk to be carriers of HP than non-neuropathic or non-diabetic patients. The assay of serum IgG HP-Ab could be used as a screening method, thus avoiding the more expensive and time-consuming endoscopy.