Post-hepatitis primary disease does not influence 6-year survival after liver transplantation beyond 1 year

Orthotopic liver transplantation (OLT) is used as a definitive treatment for end-stage liver disease and prolonged posttransplant survival has already been reported. The incidence of late mortality and graft morbidity is, however, not well defined and the role of primary viral disease in the long-term follow-up results is not clear. Data of posttransplant follow-up in 213 patients, 156 adults and 57 children, who survived at least 1 year were reviewed in order to define causes of graft dysfunction, graft loss and death. In 98 patients, 103 persistent graft dysfunctions were found. Thirty-four grafts were later lost [28 deaths and 6 successful retransplantations (re-OLT)]. The results were reviewed grouping patients according to their age and viral hepatitis status at the time of the transplantation. HBV-positive patients (51) showed 4 re-OLT (1 HBV), 3 liver-related deaths (2 HBV), 24 graft dysfunctions (8 HBV, 5 HCV), and 85.2% 6-year survival (based on 100% survival at 1 year). HCV-positive adults (28) showed 1 re-OLT, 3 HCV-related deaths, 24 graft dysfunctions (19 HCV), and 68.8% 6-year survival. HBV-HCV-positive patients (14) showed no graft loss and death, 10 graft dysfunctions (7 HCV, 1 HBV, 2 HBV-HCV), and 81.8% 6-year survival. HBV-HCV-negative adults (63) showed 3 non-hepatitis-related re-OLT, 5 liver-related deaths (2 HCV), 24 graft dysfunctions (6 HCV, 2 HBV), and 83.1% 6-year survival. HBV-HCV-negative children (49) showed no re-OLT, 1 HCV-related death, 14 graft dysfunctions (3 HCV), and 92.6% 6-year survival. HCV-positive children (8) showed 1 HCV-related re-OLT, 2 HCV-related deaths, 4 graft dysfunctions (3 HCV), and 81.3% 6-year survival. The main cause of graft dysfunction was hepatitis (45 HCV and 13 HBV), followed by technical complications (21), rejection (16), recurrent alcoholism (3), HIV infection (1), and unknown causes (4). In this long-term post-transplant follow-up series, viral hepatitis led to graft dysfunction in 58/103 (56.3%) cases, late graft failure was viral hepatitis-related in 11/ 20 (55%) cases, and, as a total, HCV infection was present in 45/58 (77.5%) cases of viral hepatitis-related graft damage. Looking at the timing of hepatitis-related graft failure, in 70% of cases death occurred after the 5th post-transplant year. In our experience, the occurrence of hepatitis, particularly HCV induced, was common and led to abnormal graft function, but the 6-year post-transplant survival (based on 100% survival at 1 year) in patients surviving for at least 1 year did not differ on the basis of the pretransplant viral hepatitis status. This finding may be consistent with the slow progression of the viral damage and longer follow-up results remain to be established. Nevertheless, data from the present study suggest that in long-term liver transplant survivors, the risk of deteriorating liver damage and eventual failure after 5 years remains only in those patients experiencing a viral hepatitis infection.

Rescue FK506 early conversion for refractory rejection after pediatric liver transplantation: experience in 20 children

Tacrolimus (FK506) is an effective and relatively safe novel immunosuppressant able to revert refractory rejection after pediatric liver transplantation (LTx). Between April 1993 and October 1996, 20 pediatric patients were converted to tacrolimus for biopsy-proven, steroid-resistant liver rejection. The mean follow-up was 18 months. The median time from LTx to switch was 20 days. Tacrolimus was administered per os at a mean dosage of 0.23 mg/kg per day to maintain median blood levels of 10.8 ng/ml at 1 week and 9.2 ng/ml at 1 year from the switch. Of the 20 patients, 15 are alive and they all recovered from rejection without the need of OKT3 after conversion. The major causes of death were: one multiorgan failure, two infections (cytomegalovirus Aspergillus), one bowel perforation, and one posttransplant lymphoproliferative disease. One patient experienced late side effects and was reconverted to cyclosporine when she was already rescued from hepatic allograft rejection. The results confirm that an earlier conversion to tacrolimus should be recommended after pediatric liver transplantation in order to revert hepatic allograft rejection with the best safety profile.

A process for the recovery of strontium from the urine of patients injected with 89Sr

89Sr is a beta emitter used for palliation of pain in patients with metastatic bone cancer. After each intravenous administration, up to 80% of the isotope is eliminated in the urine. A simple chemical process is described, which permits the recovery and purification of the 89Sr from the urine.

Flunarizine in migraine prophylaxis: predictive factors for a positive response

The efficacy of flunarizine in migraine prophylaxis is confirmed in both open and controlled trials. However, it is unknown what factors may influence a good response to prophylaxis with flunarizine. The aim of this study was to determine the possible predictive factors for therapeutic responsiveness to 3 months' treatment with flunarizine. One-hundred headache patients treated with flunarizine were evaluated. We considered "responders" those patients who recorded a reduction in migraine frequency of 75% after treatment. Statistical analysis revealed four factors which might influence therapeutic responsiveness in our patients. Positive factors were a family history (p<0.01) and high intensity of pain (p<0.01); negative factors were frequent attacks (p<0.01) and a history of analgesic abuse (p<0.001). Patients with no previous history of analgesic abuse, low frequency of attacks at baseline, higher levels of migraine pain, and positive family history constitute the prototype of flunarizine long-term treatment responders.

An antibody raised against a conserved sequence of the prion protein recognizes pathological isoforms in human and animal prion diseases, including Creutzfeldt-Jakob disease and bovine spongiform encephalopathy

Antibodies to the prion protein (PrP) have been critical to the neuropathological and biochemical characterization of PrP-related degenerative diseases in humans and animals. Although PrP is highly conserved evolutionarily, there is some sequence divergence among species; as a consequence, anti-PrP antibodies have a wide spectrum of reactivity (from strong immunopositivity to lack of reactivity) when challenged with PrP from diverse species. We have produced an antibody (anti-PrP95-108) raised against a synthetic peptide corresponding to residues 95 to 108 of human PrP and have characterized it by epitope mapping, Western immunoblot analysis, and immunohistochemistry. The antibody recognizes not only human PrP isoforms but also pathological PrP from all species tested (ie, cattle, sheep, hamsters, and mice). This is probably due to the fact that the epitope recognized by this antibody includes residues 100 to 108 of human PrP, a sequence that is also present in PrP of several other species. Thus, this reagent is valuable not only for the study of human prion diseases but also for analysis of the possible relationship between human and animal disorders.

[New computerized tomography sign of intestinal infarction: isolated pneumoretroperitoneum or associated with pneumoperitoneum or late findings of intestinal infarction]

INTRODUCTION

We retrospectively reviewed the CT findings of the acute abdomen patients examined in the last two years to investigate the frequency of a new CT sign of intestinal infarction, the pneumoretroperitoneum, and its association with other CT findings highly suggestive of this condition.

MATERIAL AND METHODS

The CT findings of 60 patients with diagnostic confirmation of intestinal infarction were retrospectively reviewed. CT was performed without (no. = 55) and with (no. = 5) oral administration of contrast material and without (no. = 3) and with (no. = 57) the i.v. injection of nonionic contrast agents in repeated 50 mL boluses. To assess the specificity of this sign, we selected a control group of 400 patients submitted to CT for acute abdomen, but not blunt trauma; 19 of these patients had pneumoretroperitoneum.

RESULTS

Pneumoperitoneum was found in five patients with intestinal infarction; it was an isolated sign in two cases and it was associated with few small perihepatic air bubbles in one case. Finally, it was associated with highly suggestive findings of late intestinal infarction in the other two cases. All cases of pneumoretroperitoneum in the control group had been correctly referred to other diseases by previous plain film and/or CT findings and surgery and/or endoscopy confirmed this diagnosis.

DISCUSSION AND CONCLUSIONS

Pneumoretroperitoneum has been described as a complication of different benign or severe disorders; prompt recognition of its origin is essential since surgical and/or septic conditions may be involved. However, if the patient's history is negative for abdominal trauma, gastroduodenal ulcer or sepsis, pneumoretroperitoneum is generally cured with conservative treatment. Intestinal infarction or severe ischemia, a usually surgical conditions, should be considered among the different causes of pneumoretroperitoneum alone or associated with pneumoperitoneum or with highly suggestive late findings of infarction such as portal venous gas or pneumatosis intestinalis. This sign had a non-negligible incidence in intestinal infarction in our review (8.5%), but it should be known of and sought with specific window setting to enhance gas depiction on CT images to avoid false negatives.

Fasciola hepatica-induced immune suppression of spleen mononuclear cell proliferation: role of nitric oxide

The aim of the present study was to evaluate the proliferative response of spleen mononuclear cells (Spm) to mitogens in rats infected with Fasciola hepatica and its correlation with Spm and peritoneal cell (PC) nitric oxide (NO) production on Days 1, 3, 7, 14, 30, and 60 postinfection. In addition, histological changes in the liver were also studied. The proliferative response to Con A of F. hepatica-infected Spm was significantly decreased on Day 7 postinfection (P < 0.01). However, a pronounced increase of the proliferative response was detected from Day 3 until Day 60 when Spm were stimulated with LPS. In order to determine whether NO levels were modified during F. hepatica infections, we quantified nitrite in Spm and PC supernatants in cultures. Our results indicate a profound decrease of nitrite production by LPS-stimulated PC on the first and second weeks postinfection, and an increase in the levels of this mediator on LPS-stimulated Spm at the same postinfection time. The F. hepatica excretory-secretory antigen (ESA) was in part involved in the decrease of nitrite production by LPS-stimulated PC. A mechanism to avoid an immune response during the first stages of liver penetration could explain the transient suppression observed in Spm proliferative responses. On the other hand, the decrease in NO production by rat-infected PC could also be one of the strategies of the parasite to avoid the potential killing effect of NO during peritoneal migration.

A Pixel-Array Detector for Time-Resolved X-ray Diffraction

An integrating pixel-array detector for recording time-resolved X-ray diffraction measurements on microsecond timescales has been designed and tested as a 4 x 4 pixel prototype. Operational characteristics and radiation tolerance are discussed. A 100 x 92 array with 151.2 micro m square pixels is currently under construction.

Effects of recombinant granulocyte colony-stimulating factor (G-CSF) in patients treated with ProMACE-CytaBOM for HIV-related non-Hodgkin's lymphoma (NHL)

BACKGROUND AND OBJECTIVE

The use of hematopoietic growth factors in association with chemotherapy in human immunodeficiency virus (HIV)-related non-Hodgkin's lymphoma (NHL) has been recommended, but few studies have evaluated its cost-effectiveness.

DESIGN AND METHODS

The effects of recombinant granulocyte colony-stimulating factor (G-CSF) were analyzed in 33 consecutive patients with HIV-related NHL treated at a single institution with the same chemotherapy program, ProMACE-CytaBOM, with G-CSF, in 21 cases diagnosed after December 31, 1991, or without G-CSF, in 12 cases diagnosed earlier. Pearson's chi-square analysis and the two-sided Student's t-test were used for statistical comparisons. The method of Kaplan-Meyer and the log-rank-test were used for survival analyses.

RESULTS

G-CSF support significantly reduced the frequency of day-1 drug dose reductions (p < 0.001) and of chemotherapy delays (p < 0.001), and improved the actual delivered doses of adriamycin, cyclophosphamide and etoposide (p < 0.02). In patients with a CD4+ count < 0.01 x 10(9)/L, chemotherapy could be given at full doses in 90% of cycles with G-CSF compared to only 20% without it. G-CSF affected neither the frequency and duration of fever and hospitalization nor the complete remission and survival rates after stratification according to the CD4+ count.

INTERPRETATION AND CONCLUSIONS

G-CSF support significantly improved dose-intensity in patients with HIV-related NHL treated with aggressive chemotherapy, particularly in the subgroup with a CD4+ count < 0.1 x 10(9)/L, but it did not improve their clinical outcome.

Differential expression of a truncated form of the urokinase-type plasminogen-activator receptor in normal and tumor thyroid cells

We studied the urokinase-type plasminogen activator (uPA) receptor (uPA-R) in normal and neoplastic human thyroid cells. It has recently been shown that cleaved forms of uPA-R display an extremely strong chemotactic activity. Normal human thyroid TAD-2 cells express the intact form of the uPA-R and a truncated form lacking the uPA-binding domain on their surface, in a similar manner to tumor thyroid cell lines. However, in tumor thyroid cell lines, the amount of the truncated form is variable: high in papillary carcinoma cells, very low in follicular carcinoma cells, and not detectable in anaplastic carcinoma cells. Similar studies on primary cell cultures confirm the presence of the truncated form of uPA-R in normal and in papillary carcinoma cells and its partial or total loss in follicular carcinoma cells. The presence of truncated uPA-R correlates to uPA secretion, except in papillary carcinoma cells, which express the truncated form of uPA-R but do not release uPA. uPA-R is also able to act as an adhesion receptor by binding vitronectin (VTN) and interacting with integrins. We observe that removal of uPA-R from the surface of normal thyroid and anaplastic carcinoma cells by phosphatidylinositol-specific phospholipase C or treatment with anti-uPA-R antibodies decreases the adhesion of both cell types to VTN and, less efficiently, to fibronectin or collagen. On the other hand, uPA treatment strongly increases the adhesion of anaplastic carcinoma cells specifically to VTN.

[Epidemiology and chronorhythmicity of recurrences of attempted suicide]

The authors examine cases of attempted suicide admitted to Hospital of Foggia from 1 January 1990 to 31 December 1996. They describe characteristics of repeaters. A total of 611 episodes of attempted suicide regarding 552 different subjects were observed during the study period. Women attempted suicide more than men. No significant difference was observed for age and repeaters between men and women; while women outnumbered men in cases of single episode. Attempted suicide showed a circadian rhythm for both in first-event cases and repeaters; against, circaseptan and circannual periodicity were not present in both groups. Women had a greatest risk of an other repetition after a free period from events, in fact the time between the first and the latest episode was greater for women than for men. Commonly, the repeaters attempted at suicide again making use of the same method used for the first episode.

Soluble intercellular adhesion molecule-1 serum profile in physiologic and preeclamptic pregnancy

PROBLEM

The aim of this study was to determine serum levels of soluble intercellular adhesion molecule (sICAM)-1, an adhesion receptor that mediates interactions with the immune system, in physiologic and preeclamptic pregnancies. Moreover, we evaluated whether the release of sICAM-1 during pregnancy correlated to plasma fibronectin concentrations.

METHOD OF STUDY

Serum was collected from 18 nonpregnant, control women, from 58 normal pregnant women during the first (n = 13), second (n = 15), and third (n = 30) trimesters, and from 25 preeclamptic patients at 27-39 weeks' gestation. All samples were assayed for sICAM-1 by a specific enzyme-linked immunoassay and for fibronectin by a nephelometric system. Serum sICAM-1 levels in preeclamptic patients were compared to those obtained from gestational-matched normal pregnant women.

RESULTS

Levels of sICAM-1 were significantly elevated (P < 0.001) in each of the three trimesters of normal pregnancy (I trimester: 390.4 +/- 25.7 ng/ml; II trimester: 386.3 +/- 15.4 ng/ml; and III trimester: 367.3 +/- 15.8 ng/ml) when compared to those of healthy nonpregnant women (263.3 +/- 11.6 ng/ml). No significant difference in sICAM-1 concentrations was observed among the three trimesters. Preeclampsia was associated to a significant decrease (P < 0.01) of sICAM-1 levels (309.8 +/- 11.6 ng/ml) relative to those observed in gestational-matched pregnant women (367.3 +/- 15.8 ng/ml). Fibronectin and sICAM-1 levels did not correlate.

CONCLUSION

The increased levels of sICAM-1 found in physiologic pregnancies and its reduction in preeclampsia may account for some of the immunologic alterations demonstrated to be associated with pregnancy.

Vestibular function and cochlear implant

The authors illustrate their personal experience relating to 32 patients, aged between 12 and 74 years, undergoing cochlear implant, in whom vestibular reflexes were evaluated before and after surgery. This series did not include cases of areflexia, but only 1 case of reduced vestibular reflexia consequently to surgery. In this case, owing to the probable intervention of central compensation processes, labyrinthine hyporeflexia never became clinically significant. These personal results enable the authors to affirm that preoperative vestibular reflexes do not offer elements able to influence the choice of the ear in which to perform the cochlear implant. In the series of patients reported by the authors, a cochleostomy by removal of the floor of the round window niche, following the suggestions of O'Leary et al., always headed the electrode implant. This contrivance may reduce or eliminate the negative effects on vestibular receptors indirectly caused by the consequent and inevitable alteration of perilymph pressure produced by the implant.

Isospora thibetana N. sp. (Apicomplexa, Eimeriidae), a parasite of the Tibetan siskin (Serinus thibetanus = Carduelis thibetanus) (Passeriformes, Fringillidae)

Tibetan siskins are birds native to the Himalayan region often imported into Italy for commercial purposes. Fecal examination of 45 imported subjects with clinical signs of diarrhoea revealed the presence of a large number of coccidian oocysts. After sporulation, accomplished by mixing feces with 2.5% (w/v) aqueous K2Cr2O7 at room temperature (22 degrees C +/- 1 degree C), exogenous stages of an Isospora species were revealed. The oocysts of this Isospora are spherical, have a bilayered colorless wall, and average 23.24 microm x 23.05 microm; oocyst residuum and micropyle are absent, while an oval polar granule is rarely present. The elliptical sporocysts average 18.44 microm x 10.97 microm and the Stieda body protrudes slightly from the end of the sporocyst. A spherical sporocyst residuum, is present though it sometimes consists of scattered granules. The spindle-shaped sporozoites average 11.53 microm x 2.86 microm, and have two refractile bodies. The taxonomic position of the tibetan siskin is controversial. Some authors include this species in the genus Serinus, while others include it in the genus Carduelis. The coccidian species isolated from these tibetan siskins was, for this reason, compared with the Isospora species previously described both in the genus Carduelis and in the genus Serinus. As a result of this comparison a new species, Isospora thibetana, was named. In the intestine of dead subjects, oocysts were found only in the ileum where the mucosa was greatly thickened and presented a heavy leucocytic infiltration consisting mainly of lympho-monocytic cells. A similar infiltration was observed in liver and lungs as well.

Fatal familial insomnia: genetic, neuropathologic, and biochemical study of a patient from a new Italian kindred

Fatal familial insomnia (FFI) is an inherited prion disease linked to a mutation at codon 178 of the PRNP gene that results in aspartic acid to asparagine substitution, in coupling phase with methionine at position 129. The disease is characterized clinically by insomnia with disturbances of the autonomic, endocrine, and motor systems and neuropathologically by selective degeneration of the thalamus. Phenotypic variability is well known and has been linked to homozygosity or heterozygosity at PRNP codon 129. We report the clinical, neuropathologic, and biochemical findings and genomic analysis of a patient with FFI from a new Italian kindred. Although homozygous for methionine at codon 129, this patient showed some clinical and pathologic features most commonly found in heterozygotes.

[Intra-arterial antiblastic treatment of breast carcinoma]

PURPOSE

To report our personal experience with the locoregional treatment of breast cancer.

MATERIAL AND METHODS

Eighteen patients aged 33-67 years (mean: 54 years) were treated with 31 sessions of intra-arterial antiblastic infusion, 5 of them for neoadjuvant purposes (Group 1), 5 for palliation in unresectable tumors (Group 2) and 8 for cutaneous recurrences after mastectomy (Group 3).

RESULTS

2/5 CR and 3/5 PR were obtained in Group 1; 2/5 lesions were made resectable and 3/5 RP obtained in stage III or unresectable lesions (Group 2). Finally, 3/8 CR, 3/8 PR, 1/8 SD and 1/8 PD were observed in Group 3. An objective response according to WHO criteria was demonstrated in 15/18 cases (88%). We had no post-treatment hematologic complications, but one patient presented focal subcutaneous sclerosis and one cutaneous necrosis.

CONCLUSIONS

The morphological efficacy of intraarterial antiblastic infusion in our series was similar to that of other series. No definitive conclusions can be drawn yet about clinical results and long-term survival. This poorly invasive and low risk procedure, which should be combined with other treatments, permits to reduce the extent of surgery and to treat skin recurrences.