Event-related potentials in posttraumatic headache

OBJECTIVES

To assess impairment of cognitive functions occurring in patients with posttraumatic headache as a consequence of a minor cranial trauma in the absence of organic damage involving the central nervous system.

BACKGROUND

The term posttraumatic syndrome defines a stereotypic set of symptoms following traumatic brain injury that are subjective and varied. A deficit of cognitive function and impairment of the rapid processes of learning, attention, and short-term memory have frequently been identified. Moreover, headache is the most frequent symptom reported by the patients. Due to the nature of the symptoms, a great limitation in defining the posttraumatic syndrome is represented by the lack of methods and diagnostic tools that allow quantification of the subjective disturbances and evidence of the signs indicative of central nervous system involvement in this pathological condition.

METHODS

Twenty-five subjects (16 women, 9 men; mean age, 28 +/- 9 years) were examined between 3 and 6 months after the traumatic event. The P300 event-related potential was recorded by an odd-ball paradigm with an acoustic modality. The patients underwent electroencephalography and brain stem auditory evoked potentials; magnetic resonance imaging was performed to exclude the presence of cerebral lesions.

RESULTS

The mean latency of P300 was increased in both central electrodes (Cz and Pz) in patients with posttraumatic syndrome compared with controls (P<.001); assuming the value of mean +/- 2 SD was the cutoff point between normal and abnormal results, the P300 latency results were altered in 13 patients (52%). In the patient group, a significant correlation was demonstrated between Zung Depression Scale score and P3 and N2 wave latencies (r = 0.54, P <.004; r = 0.56, P<.003) and between Zung Anxiety Scale scores and P3 wave latencies (r = 0.46, P<.02).

CONCLUSIONS

These data suggest the usefulness of the P300 event-related potential in evaluating cognitive disturbances in patients affected by posttraumatic syndrome. Alteration of cognitive potential in such patients, even in the absence of lesions detectable by neuroimaging, indicate the functional impairment of specific cerebral areas that can occur after a traumatic event.

Food habits in a southern Italian town (Nicotera) in 1960 and 1996: still a reference Italian Mediterranean diet?

BACKGROUND

A follow-up analysis of cohorts surveyed in the "Seven Countries Study" has provided increasing evidence of an association between diet and morbidity or mortality from coronary heart disease (CHD) and cancer. The effects of the "Mediterranean diet" on mortality is still evident in Italy, where food patterns differ significantly in different geographical areas.

OBJECTIVE

To examine differences in food habits in Nicotera, one of the Italian rural areas of the Seven Countries Study, between 1960 and 1996.

METHODS

In 1996, 80 subjects, 37 females and 43 males, aged 40-59 years, were examined in Nicotera assessing food intake by means of a semiquantitative questionnaire of food frequency, validated for the Italian population. In 1960, food intake of a sample of Nicotera subjects was assessed by weighed record method for three seasons.

RESULTS

Food choices differed markedly between 1960 and 1996. Consumption of animal foods increased, as did that of cakes, pies and cookies and sweet beverages in both male and female groups; an increase of alcoholic beverages was observed only in females.

CONCLUSIONS

In 1960, Nicotera inhabitants were following a diet defined as a "reference Italian Mediterranean diet", but by 1996 the Nicotera diet approached that of an average Italian diet, whose characteristics fall short of a true Mediterranean diet. This change in dietary habits may be responsible for an increased risk of CHD and cancer in the general population in the absence of other factors.

High levels of soluble tumor necrosis factor superfamily receptors in patients with hepatitis C virus infection and lymphoproliferative disorders

BACKGROUND

Chronic hepatitis C virus (HCV) infection is associated with a variety of extrahepatic disorders that may relate to direct or indirect effects of virus infection. Increased levels of soluble forms of tumor necrosis factor (TNF) receptors I and II, found in lymphoproliferative and infectious diseases, can interfere with TNF induced apoptotic cell death. The aim of the present study was to evaluate soluble TNF family receptors levels in lymphoproliferative disorders associated with HCV infection.

METHODS

One hundred and forty-nine subjects were studied, including 120 anti-HCV positive patients (60 without lymphoproliferative manifestations, 47 with type II cryoglobulinemia and 13 with low-grade B-cell non-Hodgkin's lymphoma (B-NHL)) and 29 anti-HCV negative subjects (19 with low-grade B-NHLs and ten normal controls).

RESULTS

Soluble forms of TNF receptor I, TNF receptor II and Fas were significantly higher in HCV positive patients compared with normal controls. The highest levels were found in patients affected by type II cryoglobulinemia or HCV positive lymphoplasmacytoid lymphomas (LP-NHLs), while HCV positive patients without type II cryoglobulinemia or with other B-NHLs had lower values (P < 0.01).

CONCLUSIONS

Among HCV infected individuals, very high levels of soluble TNF receptors are significantly associated with type II cryoglobulinemia and LP-NHLs, suggesting that they may be involved in these proliferative disorders.

Human leucocyte interferon-alpha in the treatment of chronic hepatitis C

AIM

To assess the efficacy of different schedules of human leucocyte interferon alpha in chronic hepatitis C.

PATIENTS AND METHODS

A total of 213 naive patients with chronic hepatitis C were treated with 4 different schedules of human leucocyte interferon alpha. Sustained response was defined as persistently normal alanine amino transferase values with negative serum hepatitis C virus-RNA up to 12 months after therapy withdrawal.

RESULTS

Rates of sustained response were 16% with 3 MU tiw for 6 months, 33% with 6 MU tiw for 5 months after a priming dose of 9 MU tiw for a month, 32% with 3 MU tiw for 12 months and 20% with 3 MU daily for 6 months. The major factors affecting the response rate were age and the hepatitis C virus genotype, as a sustained response was significantly higher in patients under 45 years and infected by hepatitis C virus types other than hepatitis C virus-1. Treatment was well tolerated and side-effects and drop-out events were similar to those described with other types of alpha-interferons.

CONCLUSIONS

Human leucocyte interferon alpha appears to be equivalent to recombinant interferon-alpha in the treatment of chronic hepatitis C.

Prospective randomized trial of steroid withdrawal in liver transplant patients: preliminary report

Although steroid withdrawal has been successfully performed in heart and kidney transplant recipients, no controlled studies of SW have been carried out in liver transplant patients. To evaluate this possibility a prospective controlled study was carried out in 46 liver transplant recipients operated on after may 1991. They all received a sequential quadruple immunosuppression consisting of 3 mg/kg antithymocyte globulins (RATG) for the first 5 postoperative days, cyclosporin A (starting from day 3-5 and maintaining parenteral whole-blood trough levels at 200-300 ng/ml during the first month and at 150-250 thereafter), azathioprine (1 mg/kg per day for the first month) and steroids. Prednisone was started at a dose of 200 mg per day 1 and then tapered to 20 mg/day over the first posteroperative week; this dose was maintained until day 90 when the patients were randomly allocated either to long-term steroid therapy (0.1 mg/kg per day) or to steroid withdrawal. Minimum follow-up after randomization was 6 months (6-27 months). Liver biochemistry was checked at regular intervals throughout the follow-up period. Liver biopsies were performed whenever clinically indicated and also in the first 19 patients during readmission for annual review. The incidence ot acute and chronic rejection 90 days from liver transplantation was 2.5% in patients maintained on long-term therapy. No patient in the steroid-withdrawal group had experienced either an acute or a chronic rejection episode so far. Steroid-related complications did not differ significantly between the two groups. The most recent interim analysis showed that steroid withdrawal is a safe undertaking in liver transplant recipients and may be successfully accomplished in almost all patients.

Evidence for an association between the aetiology of cirrhosis and pattern of hepatocellular carcinoma development

BACKGROUND

Patients with liver cirrhosis are at significant risk of hepatocellular carcinoma (HCC) that may develop as well defined nodular lesions or as more aggressive infiltrating tumours.

AIM

To compare prospectively risk factors associated with nodular or infiltrating HCC in cirrhotic patients.

PATIENTS AND METHODS

We studied 370 patients with cirrhosis, followed prospectively by periodic ultrasound (US) of the liver, for a mean period of 74.6 (SD 32.4) months to define the incidence and patterns of HCC development. Patients who developed HCC were compared according to tumour pattern using univariate and multivariate analysis.

RESULTS

Sixty one (16.5%) patients developed HCC: HCC was classified as nodular in 49 (80.3%) and infiltrating in 12 (19.7%) according to US and computerised tomography (CT) imaging. The five and 10 year cumulative probabilities were 8.1% (95% confidence interval (CI) 5. 2%-11%) and 25.2% (15.0-35.4%) for nodular HCC and 2.1% (0.5-3.7%) and 6.9% (2.1-11.7%) for infiltrating HCC. Patients with infiltrating HCC were younger than those with nodular HCC (59.5 v 66. 2 years, 95% CI 55.2-63.8 and 64.1-68.3 years; p=0.014). Using multivariate analysis, development of nodular HCC was associated with older age (p=0.0002; relative risk (RR) 3.1; 95% CI 1.6-5.2), longer duration (p=0.09; RR 2.6; 95% CI 1.8-3.4), and more advanced stage (p=0.002; RR 2.5; 95% CI 1.3-4.5) of cirrhosis but not with the aetiology of liver disease. In contrast, development of infiltrating HCC appeared to be unrelated to age or disease duration or stage, while it was associated with hepatitis B virus infection (p=0.07; RR 3.96; 95% CI 1.1-5.2) and with hepatitis B/hepatitis C virus coinfection (p=0.0007; RR 16.9; 95% CI 3.8-36.7).

CONCLUSIONS

In liver cirrhosis, we identified two patterns of HCC developing with distinct risk factors. Nodular HCC was related to the cirrhotic process per se independent of aetiological factors and may depend on the proliferative activity within regenerative nodules, while the infiltrating form of HCC was linked to hepatitis B virus infection and may reflect more direct virus induced carcinogenesis.

Nitric oxide metabolites, prostaglandins and trigeminal vasoactive peptides in internal jugular vein blood during spontaneous migraine attacks

Despite evidence emerging from the experimental model of nitroglycerin-induced headache, the endogenous increase in nitric oxide (NO) production during migraine attacks is only speculative. It has been hypothesized that there is a close relationship between activation of the L-arginine/NO pathway and production of certain vasoactive and algogenic prostaglandins during spontaneous migraine attacks, but this suggestion also needs to be confirmed. In the present study the levels of nitrites, the stable metabolites of NO, were determined with high performance liquid chromatography (HPLC) in the internal jugular venous blood of five patients affected by migraine without aura examined ictally. These samples were taken within 30 min, 1, 2, and 4 h from the onset of the attack and at the end of the ictal period. At the same time, the plasma levels of calcitonin gene-related peptide (CGRP), neurokinin A (NKA), prostaglandin E2 (PGE2) and 6 keto PGF1alpha, the stable product of PGI2, were assessed with radioimmunoassay (RIA) kits in the same samples. The levels of the intracellular messengers, cGMP and cAMP, were also measured with the RIA method. Nitrite, cGMP, CGRP and NKA levels reached their highest values at the first hour, then they tended to decrease progressively and returned, after the end of attacks, to values similar or below those detected at the time of catheter insertion (ANOVA, statistical significance: P<0.001; P<<0.002; P<0.002; P<0.003, respectively). PGE2 and 6 keto PGF1alpha, as well as cAMP levels also significantly increased at the first hour but reached a peak at the 2nd hour and remained in the same range until the 4th and 6th hours. Then their values tended to decrease after the end of attacks, becoming lower than those measured immediately after catheter positioning for internal jugular venous blood drawing (ANOVA: P<0.002, P<0.004, P<0.001, respectively). Our results support early activation of the L-arginine/NO pathway which accompanies the release of vasoactive peptides from trigeminal endings and a late rise in the synthesis of prostanoids with algogenic and vasoactive properties which may intervene in maintaining the headache phase.

Two PKR inhibitor HCV proteins correlate with early but not sustained response to interferon

BACKGROUND & AIMS

The NS5A and the E2 proteins of hepatitis C virus (HCV)-1b can bind and inhibit in vitro the interferon (IFN)-induced cellular kinase PKR. The role of such interaction in modulating the antiviral effect of IFN is still controversial. We have analyzed the E2 and the NS5A sequences in HCV-1b-infected patients treated with IFN to assess whether and how different combinations of wild-type and mutant proteins correlated with early and long-term virological response.

METHODS

In 30 patients, sequences of pretreatment and on-treatment E2-PePHD and NS5A-PKR binding domain (including the putative ISDR) were analyzed in parallel by sequencing cDNA-polymerase chain reaction products and up to 25 independent clones.

RESULTS

The E2-PePHD sequence was highly conserved with a homogeneous quasispecies and was identical in 29 of 30 cases with no association with the pattern of response and no evidence of evolution during therapy. Patients with a mutated NS5A-ISDR had a higher rate of early virological response (67%) than cases with wild-type ISDR (17%). This association was lost in long-term responders (33% vs. 17%).

CONCLUSIONS

Although the highly conserved E2-PePHD motif might contribute to reduce IFN responsiveness, variations within this region do not seem to play a role in modulating IFN sensitivity. The NS5A-ISDR sequence influenced the early, but not the sustained response, to IFN, suggesting that other factors may be more important for the long-term outcome of therapy.

"Skirt" technique for coronary artery bifurcation stenting

Stent implantation in the treatment of coronary artery bifurcation lesions frequently impairs blood flow and gives the coronary tree a new, metallic configuration. The new technique we describe uses a single short stent in a "skirt" shape which produces no "jailing" effects and can be used in the treatment of true coronary Y-shaped bifurcation lesions.

[Periampullar tumors: role of intraoperative color-Doppler ultrasonography in the evaluation of vascular invasion. Methods available to the surgeon and personal experience]

BACKGROUND

Tumors of the head of the pancreas and of the periampullary region, similar nosologic entity, represent the fourth most common cause of cancer death. These tumors are characterized bt high mortality rate associated with a low percentage of surgical resectability. Vascularly involvement is, in our experience, one of the criteria of exclusion for curative surgical resection. For this reason regional pancreasectomy don't show, in several case records, comforting datas about survival.

METHODS

From 1995 to 1998 we introduced in the operative practice the color--doppler ultrasonography to diagnose vasculary involvement. We evaluated twenty patients that previously were candidated for surgical therapy consisting in a duodenal-pancreasectomy. All the patients were staged by preoperative abdominal ultrasound, E.R.C.P., CT, and angio M.R.I.. In no one of these patients were founded signs of vascularly involvement. We recognized by intraoperative color-doppler ultrasound three microscopic invasions of spleno-mesenteric-portal vasculary axis.

RESULTS

U.S. I.O. C.D. in our case reports has underlined a sensibility and specificity of 100%. It has discovered, also, a false positive for neoplastic thrombosis, and a case of false negative.

CONCLUSIONS

Intraoperative ultrasound shows a high sensibility about the intraoperative staging for the bibliopancreatic tumors. The study about the possible vascularly involvement is helped by the application of the colour in terms of an high sensibility and diagnostic care.

[Short- and long-term monitoring with high-resolution ultrasonography of postoperative thyroid residue. Personal experience with 200 thyroidectomies]

BACKGROUND

After having abandoned conservative operations of the thyroid (partial resection, enucleal resection) today total thyroidectomy and sub-total thyroidectomy and near total thyroidectomy are the operations of choice. Cause the frequent post-operative scintigraphic signs, on the 3rd month, of thyroidal residue of significative size, founded in our patients operated for sub-total thyroidectomy, we begun to study the echografical monitoring of the thyroidal recess.

METHODS

From January 1995 to December 1997 we operated 200 patients for Thyroidectomy. The kinds of operations were: total thyroidectomy for 96 patients (48%), sub-total thyroidectomy for 64 patients (32%), and near total thyroidectomy for 40 patients (20%). We controlled all the patients by ecografical monitoring of the thyroidal recess to detect and to determinate the possible thyroidal residue, that it will be monitorized on the 7th day, on the 1st month, on the 6th month and on the 12th month. We measured the thyroidal residual dimensions and volume. We recorded all the examinations by VCR or film and after we elaborated the results by exponential graphics. The patients that showed the thyroidal residues underwent to a scintigraphy.

RESULTS

The thyroidal residuals were measured within the 7Th post-operative day. In the following controls we have noted a thyroidal residue hypertrophy. Multinodular goither was the disease with the highest degree of growth (until the 200% of the first measure of the residue). After an initial phase of growth almost all the patients showed a trend to the stabilization, with the exception only of the patient that suffered from multinodular goither. The scintigraphic examination was not realiable, in our experience, about the mathematic measurement of the thyroidal tissue, showing always an overvaluation of the residue. The best specificity was showed by US-HR.

CONCLUSIONS

The patient that undergoes to total thyroidectomy needs an adequate suppressive and substitutive therapy. We identify the presence of several stimulating factors the growth of the residual thyroidal tissue that could arise to promote the hyperplasia and the hypertrophy of the parenchyma (EGF, TSG, TSI, PG). There are factors that are unidentified and are not subject to the suppression caused by substitutive therapy.

The pattern of response to interferon alpha (alpha-IFN) predicts sustained response to a 6-month alpha-IFN and ribavirin retreatment for chronic hepatitis C. TVVH Study Group

BACKGROUND/AIMS

In chronic hepatitis C, interferon-alpha (alpha-IFN) and ribavirin combination therapy improves sustained response compared to alpha-IFN monotherapy, both in naive patients and in previous alpha-IFN relapsers, but the efficacy of such therapy remains limited in non-responder cases. The aim of this study was to assess whether the pattern of response to alpha-IFN alone may predict sustained response to combination therapy during retreatment.

METHODS

Fifty previous alpha-IFN relapsers and 50 previous alpha-IFN non-responders were retreated with a high alpha-IFN dose (6 MU/thrice weekly for 2 months; induction phase) and then randomised to continue with alpha-IFN alone (3 MU/thrice weekly) or to receive combination therapy (3 MU/thrice weekly of alpha-IFN and 1000-1200 mg/daily of ribavirin) for an additional 6 months according to the biochemical response to alpha-IFN shown after the induction phase. All patients were also evaluated for virological and histological response.

RESULTS

Eleven of 25 (44%) relapsers treated with combination therapy and 4/25 (16%) treated with alpha-IFN alone achieved a sustained response. The corresponding figures among non-responders were 1/25 (4%) and 0/25, respectively. Among 26 patients with a complete ALT and HCV-RNA response after 2 months of alpha-IFN, sustained response was seen in 11/14 (79%) treated with combination therapy and in 4/12 (33%) treated with alpha-IFN alone (p=0.05). On the other hand, of 74 cases still HCV-RNA positive after 2 months of alpha-IFN alone, biochemical and virological end of therapy response was better with combination therapy (11/36; 30.5%) compared to alpha-IFN alone (4/38; 10.5%), but only one patient developed a sustained response (1/36; 3%).

CONCLUSIONS

The retreatment with a 6-month combination therapy was associated with a high rate of sustained response only in patients showing a complete biochemical and virological response to alpha-IFN alone. Longer retreatment with combination therapy may be needed to achieve a sustained response in patients without a prompt virological response to alpha-IFN.

Different pathways of degradation of SP-A and saturated phosphatidylcholine by alveolar macrophages

Alveolar macrophages degrade surfactant protein (SP) A and saturated phosphatidycholine [dipalmitoylphosphatidylcholine (DPPC)]. To clarify this process, using rabbit alveolar macrophages, we analyzed the effect of drugs known to affect phagocytosis, pinocytosis, clathrin-mediated uptake, caveolae, the cytoskeleton, lysosomal pH, protein kinase C, and phosphatidylinositol 3-kinase (PI3K) on the degradation of SP-A and DPPC. We found the following: 1) SP-A binds to the plasma membrane, is rapidly internalized, and then moves toward degradative compartments. Uptake could be clathrin mediated, whereas phagocytosis, pinocytosis, or the use of caveolae are less likely. An intact cytoskeleton and an acidic milieu are necessary for the degradation of SP-A. 2) Stimulation of protein kinase C increases the degradation of SP-A. 3) PI3K influences the degradation of SP-A by regulating both the speed of internalization and subsequent intracellular steps, but its inhibition does not prevent SP-A from reaching the lysosomal compartment. 4) The degradation of DPPC is unaffected by most of the treatments able to influence the degradation of SP-A. Thus it appears that DPPC is degraded by alveolar macrophages through mechanisms very different from those utilized for the degradation of SP-A.

Epidemiology of hepatitis C virus infection in seven European Union countries: a critical analysis of the literature. HENCORE Group. (Hepatitis C European Network for Co-operative Research

Hepatitis C is now recognized as the most common infection causing chronic liver disease in the European population. Our aim was to assess the prevalence of the antibody to hepatitis C virus (HCV), and the incidence of HCV seroconversion in the general population and the main risk groups, namely intravenous drug users, haemodialysis and transfused patients, in seven countries of the European Union, by carrying out a critical analysis of the literature. Data sources used were the Medline database and a manual search using the key words: hepatitis C, prevalence, incidence, transmission, risk factors and epidemiology. Articles published between January 1990 and March 1997 were reviewed. Articles were reviewed according to a critical analysis method regarding title, type of article, study design, period and population, tests, results and their consistency with data. The tests performed were mainly second- or third-generation serological tests. The average prevalence rate in blood donors was 1%, with a north-south gradient ranging from 0.04% to 2%. Prevalence varied from 20% to 30% in haemodialysis patients. The incidence in transfused patients was less than 1% after 1991. The prevalence in intravenous drug users was about 80%. Multicentre studies conducted in larger samples are needed to obtain more accurate and reliable results, in particular. However, the epidemiological studies available allowed us to assess the magnitude of HCV infection in Europe.

Cloning and characterization of the lactate-specific inducible gene KlCYB2, encoding the cytochrome b(2) of Kluyveromyces lactis

In yeast the utilization of lactate requires two enzymes, the D and L-lactate ferricytochrome c oxidoreductase (D and L-LCR), which stereospecifically oxidize D- and L-lactate to pyruvate. These enzymes are nuclearly encoded and localized in mitochondria. In the yeast Kluyveromyces lactis, a mutant devoid of D- and L-LCR activities and unable to grow on racemic lactate was isolated. Transformation of the mutant with a K. lactis genomic library allowed the isolation of the KlCYB2 gene, restoring the growth on lactate and the L-LCR activity. The KlCYB2 gene and its flanking regions were sequenced (Accession No. AJ243324; EMBL/GenBank databases). The deduced amino acid sequence is highly homologous to the corresponding Saccharomyces cerevisiae and Hansenula anomala protein sequences previously characterized. The homology is missed in the N-terminal region, corresponding to the presequence cleaved during import into mitochondria. Analysis of KlCYB2 gene expression indicated that, in contrast to S. cerevisiae, the major regulatory feature is induction by lactate.

[Palliative treatment of neoplasms of the bilio-pancreatic area. Surgical diversion treatment versus endoscopic-percutaneous approach]

Bilio-pancreatic (BPD) tumours are pathologies with an overall resectability rate of 20-25%, with a high percentage of patients directed towards palliative treatment (70-90%). One hundred and twenty-eight patients underwent palliative treatment for BPD tumours. The M:F ratio was 1:1.5 and the mean age 61 years. The tumours were topographically divided into: 84 (63%) localised in the pancreatic head region; 34 (25%) biliary duct tumours and 6 arising in the ampulla of Vater. 42 patients (30%) underwent palliative surgical treatment (group 1) and 86 (70%) received non-surgical treatment (endoscopic percutaneous) (group 2). We also performed 6 gastrointestinal by-passes (GEA). The early morbidity rate was 36% in the first group and 12.8% in the second. The incidence of late morbidity in the first group was nil, with a mean survival of 10 months. Mortality was nil in both groups. Surgical by-pass is advisable in the presence of patients with a longer life expectancy and in good clinical condition but presents a high rate of early morbidity and a low percentage of late complications. The authors conclude that validity of the methods is similar. They believe that, in selected cases, surgical treatment remains the therapy of choice for BPD tumours.

Current awareness on yeast

In order to keep subscribers up-to-date with the latest developments in their field, this current awareness service is provided by John Wiley & Sons and contains newly-published material on yeasts. Each bibliography is divided into 10 sections. 1 Books, Reviews & Symposia; 2 General; 3 Biochemistry; 4 Biotechnology; 5 Cell Biology; 6 Gene Expression; 7 Genetics; 8 Physiology; 9 Medical Mycology; 10 Recombinant DNA Technology. Within each section, articles are listed in alphabetical order with respect to author. If, in the preceding period, no publications are located relevant to any one of these headings, that section will be omitted. (4 weeks journals - search completed 16th Feb 2000)

Incorrect echocardiographic diagnosis in patients with mechanical prosthetic valve dysfunction: correlation with surgical findings

PURPOSE

To identify the rate of occurrence and type of incorrect echocardiographic diagnoses in patients with mechanical valve prostheses.

PATIENTS AND METHODS

We studied 170 consecutive patients (73 women and 97 men) with a total of 208 prostheses who underwent surgery for mitral (n = 136) or aortic (n = 72) valve dysfunction between January 1991 and December 1997. Preoperative echocardiographic data were compared with surgical findings. Any major discrepancy between the echocardiographic reports and surgery was judged to be unconfirmed when the preoperative echocardiographic diagnosis was not confirmed at surgery, but the prosthesis was found to be dysfunctioning; and was judged to be erroneous when the preoperative echocardiographic diagnosis was not confirmed, and surgical inspection failed to reveal any other prosthetic abnormality.

RESULTS

There were 25 (12%) diagnostic errors. Of the 136 mitral prostheses, there were 9 unconfirmed diagnoses of paravalvular regurgitation (6 had a fibrous tissue overgrowth, 1 had a thrombus with fibrous tissue overgrowth, 1 had endocarditis vegetations, and 1 had a ball variance) and 5 erroneous diagnoses. Eleven diagnostic errors were made in the 72 aortic prostheses: there were 9 unconfirmed diagnoses (paravalvular regurgitation was diagnosed as transvalvular in 7, and transvalvular regurgitation as paravalvular in 2 cases), and 2 erroneous diagnoses.

CONCLUSIONS

Although echocardiography has gained great credibility among clinicians, special care should be taken when assessing patients in whom prosthetic valve dysfunction is suspected.

Liver cell apoptosis in chronic hepatitis C correlates with histological but not biochemical activity or serum HCV-RNA levels

In hepatitis C virus (HCV) infection, mechanisms responsible for liver cell damage are still poorly understood and both necrosis and apoptosis may be operative. By using terminal deoxynucleotydil transferase-mediated d-UTP-biotin nick-end labeling (TUNEL) we have evaluated and quantified apoptosis in liver biopsy specimens from 61 patients with chronic hepatitis C. All patients had detectable apoptotic cells in the liver. Presence of increased apoptotic activity was confirmed in selected cases by electron microscopy and by DNA gel electrophoresis. The amount of liver cell apoptosis expressed as apoptotic index, ranged between 0.01% to 0.54% and showed a positive correlation with histological activity grading (P <.0005) and with the amount of infiltrating CD8-positive cells (P =. 01). Apoptosis did not correlate with transaminase levels or with HCV load and genotype. These results support the concept that immune-mediated apoptosis may play a role in the pathogenesis of chronic hepatitis C and indicate that this type of reaction may occur in the absence of significant alanine transaminase (ALT) elevation, thus explaining the lack of correlation between biochemical activity and liver histological damage.

Comparison between three quantitative assays in patients with chronic hepatitis C and their relevance in the prediction of response to therapy

To compare three quantitative assays measuring viral load in patients with chronic hepatitis C and to determine their value in predicting response to interferon (IFN) therapy, we analysed serum from 896 patients from eight European Centres using QUANTIPLEXtrade mark bDNA, MONITOR AMPLICORtrade mark and SUPERQUANTtrade mark assays. Analyses were performed on the same sample. Viral genotype was assessed using INNO-LiPA HCV II kits. Intercentre variations were observed that were related to the handling of specimens not processed and stored within 6 h of blood sampling. Among sera with optimal handling, a stronger correlation was observed between bDNA and SUPERQUANT (0.806) than between bDNA and MONITOR (0.677) and between MONITOR and SUPERQUANT (0.632). These discrepancies were greatest with genotype 2 (bDNA/SUPERQUANT= 0.772; bDNA/MONITOR=0. 456; SUPERQUANT/MONITOR= 0.299). This correlation was influenced by viraemia level and was better at lower viral loads. The proportion of sera with undetectable viral load was 15% with bDNA, 9.7% with MONITOR and 7.7% with SUPERQUANT. For the three measurements, the best cut-offs of sustained response to IFN treatment were located at their detection threshold. Among patients with viral load below the detection level, a sustained response was observed in 35% tested with bDNA, 38% with MONITOR and 80% with SUPERQUANT. Hence a stronger correlation was observed between bDNA and SUPERQUANT than between either of these assays and MONITOR. SUPERQUANT was the most sensitive assay and this greater sensitivity was associated with a better predictive value of treatment response.

Coinfection by hepatitis B virus and hepatitis C virus

Coinfection by hepatotropic viruses can occur due to the fact that hepatitis B virus (HBV) and hepatitis C virus (HCV) share similar routes of transmission. Different clinical features of liver disease can be observed in infected patients, ranging from fulminant, acute and chronic hepatitis to hepatocellular carcinoma (HCC). The relative role of the infecting viruses in determining the final clinical picture is not yet well defined. Several reports indicate that clinical and pathological severity of liver disease among coinfected patients is increased and in patients with HCC, co-occurrence of both viruses is a common event. The potential mechanism of tumour development still remains speculative, although direct and indirect roles for both HBV and HCV have been proposed. At the molecular level, reciprocal interference of virus replication has been repeatedly described and the extent of interference is influenced by the infecting HCV genotype, genotype 1 of HCV having more efficient inhibitory activity on HBV than genotype 2. Sequence similarities between an arginine-rich nucleocapsid motif of both viruses could support these clinical observations. Concerning response rates to interferon therapy, no satisfactory results have been achieved to date, although identification of effective therapeutic schemes, based on virological status of both viruses are warranted.

Comparison of three probiotics in the treatment of acute diarrhea in mentally retarded children

BACKGROUND

This article aims to compare the use of VIS-01 (Yovis) with two other probiotics (lactic acid bacteria), such as Lactogèrmine and Codex in the treatment of acute diarrhea in children with mental retardation. A recent paper highlights the superiority of the first drug, claiming new perspectives in probiotic therapy.

METHODS

The authors perform a prospective study on 33 mentally retarded children (mean age 10.3 years), divided in three groups, each treated with a different probiotic (VIS-01, Lactogèrmine and Codex) at the beginning of an acute diarrhea. These children were admitted at the Pediatric Unit of the Oasi Maria SS. Institute in Troina. The dosage was suited to the technical record of the drug. During the clinical course the following items have been recorded: number of evacuations; time of alvine normalization; presence, quality, and length of fever; other associated features or side effects.

RESULTS

The time of alvine normalization did not show statistically significant differences between the three groups.

CONCLUSIONS

In conclusion, the use of Yovis does not modify in a statistically significant way with respect to the remaining drugs the clinical course of acute diarrhea in the mentally retarded children of the present study.

Effect of increasing dose of interferon on the evolution of hepatitis C virus 1b quasispecies

The effects of interferon therapy on hepatitis C virus (HCV) genome are still controversial in terms of biological and clinical significance. Changes in the quasispecies of the hypervariable (HVR) and non-structural 5A (NS5A) regions of HCV 1b were evaluated in nine patients treated with increasing doses of interferon and five untreated controls. HCV quasispecies were analyzed in HVR and NS5A by single-strand conformation polymorphism assay. The HVR quasispecies varied over time both in treated and untreated patients. However, at least one persistent strain was present in all patients. With low doses of interferon, variations in HVR complexity were found in seven of nine patients and in four patients new variants became detectable. A reduction in the heterogeneity of the HVR quasispecies was observed after increase of the interferon dose. In contrast, NS5A profiles remained unmodified in all but three cases in which direct sequencing showed no changes in amino acid sequences of the predominant strain. The results suggest that interferon sensitivity of some HCV strains may be dose dependent. The homogeneity of NS5A pattern populations during treatment suggests that interferon exerts much less pressure on this region.

Natural history of hepatitis C

Ten years after the discovery of the hepatitis C virus (HCV) and its association with NANB hepatitis as a major cause of chronic liver disease worldwide, our knowledge of the natural history of hepatitis C is still limited. The asymptomatic course of the disease in most patients, its slow and silent progression and heterogeneous outcome and the widespread use of interferon therapy during the past decade explain why many questions are still unsolved. The changing epidemiological pattern of HCV and the significant contribution of several cofactors to the severity of liver disease also complicate the development of a general model describing the natural history of hepatitis C. Available data indicate that HCV infection may resolve without any clinical signs of liver disease in individuals exposed to low dose inoculum and that these cases may develop T cell immunity even in the absence of anti-HCV seroconversion. Rates of complete biochemical and virological resolution of acute hepatitis C range between 10 and 50%, and are probably affected by the route of infection, size and type of inoculum and acute phase clinical features. Chronic HCV infection may develop with or without ALT abnormalities and with or without chronic inflammation and increasing fibrosis in the liver. Studies conducted in patients who acquired hepatitis C by blood transfusion 15-25 years ago indicate that 20-30% of them have now progressed to cirrhosis, including 5-10% with end stage liver disease and 4-8% who died of liver-related causes. Similar studies conducted in patients infected by other routes have shown a more benign course of hepatitis C, with little evidence of cirrhosis and no liver-related mortality during the first two decades. Outcomes after longer follow-up need to be assessed. In patients presenting with chronic hepatitis C, fibrosis progression is extremely variable over time and can be partially predicted by the age at infection, disease duration, liver histologic activity and stage of fibrosis and by the ALT profile. However, it is often difficult to predict clinical outcomes in individual cases. In patients who have developed cirrhosis, the 5-year risk of decompensation is between 15 and 20% and that of hepatocellular carcinoma around 10%. Several variables have been shown to influence the natural course of shown C, the most significant being age at infection, alcohol consumption and coinfection with HBV and HIV Studies are being performed to assess the role of host genetics. Viral factors, such as the HCV type and load, seem to have inconsistent or marginal effects.

An accessory open reading frame (orf-x) of jaagsiekte sheep retrovirus is conserved between different virus isolates

Jaagsiekte sheep retrovirus (JSRV) is the etiological agent of a contagious lung tumour of sheep known as sheep pulmonary adenomatosis (syn: ovine pulmonary carcinoma, jaagsiekte). JSRV exhibits a simple genetic organization, characteristic of the type D and type B retroviruses, with the canonical retroviral sequences gag, pro, pol and env encoding the structural proteins of the virion. An additional open reading frame (orf-x), of approximately 500 bp overlapping pol, is present in the only two complete sequences of JSRV published to date. Since very little information is available on the biology of JSRV it is important to establish if orf-x is conserved between different virus isolates. In this study we analysed the orf-x region of JSRV isolates collected from the United Kingdom, Italy, Spain and South Africa. In addition we also analysed the presence of orf-x in JSRV-related endogenous sequences (enJSRVs) present in the sheep genome. Orf-x was highly conserved in all the exogenous isolates (n=10) and in most of the endogenous sequences (n=8). Thus orf-x may be an accessory gene of JSRV and haves a biological function which might be advantageous to JSRV. Phenetic analysis conducted on the complete orf-x nucleotide sequences seems to highlight the presence of three distinct groups statistically well supported by bootstrapping: i) exogenous JSRV sequence from the UK; ii) exogenous JSRV sequences from Southern Europe and iii) the exogenous South African strain plus all the endogenous sequences analyzed and collected from Australia, Italy, UK and South Africa.

Incidence and clinical characteristics of posttransplant lymphoproliferative disorders: report from a single center

In the period 1973-1998, among 2139 allograft recipients treated with standard immunosuppression, posttransplant lymphoproliferative disorders (PTLD) developed in 19 patients (0.9%): one plasmacytic hyperplasia, two polymorphic PTLD, one myeloma, and 15 lymphomas. PTLD developed 1 year after transplantation (tx) in 14 patients. Five patients were diagnosed at autopsy, 2 were lost to follow up, 3 died before therapy could be instituted, and 1 patient has just started chemotherapy. Of the 8 evaluable patients, 2 received acyclovir and are alive in complete remission (CR) and 6 received chemotherapy +/- surgery. Of these 6, 4 died of lymphoma and/or infection, 1 died of unrelated causes in CR, and 1 is alive in CR. PTLD is a severe complication of tx, usually running an aggressive course which may preclude prompt diagnosis and treatment. Nevertheless, therapy is feasible and must be tailored on the histologic subtype. Seventy-four percent of patients were diagnosed with late-onset PTLD stressing the need for long-term follow up.

[Sensitivity and specificity of transrectal ultrasonography in the preoperative staging and postoperative follow-up in rectal neoplasms. Experience with 100 clinical cases]

Preoperative staging plays an important role in the surgical treatment of rectal cancer. The most sensitive imaging techniques currently available are CT, MRI and transanal ultrasound (TAUS). The aim of the study was to evaluate the sensitivity and specificity of TAUS in the preoperative staging and postoperative follow-up of rectal cancer.

METHODS

From January 1992 to May 1999, TAUS was used to study 100 patients with rectal cancer.

RESULTS

Patients were staged according to the Astler-Coller classification: 1) A: 8 patients; 2) B1: 16 patients; 3) B2: 22 patients; C1: 30 patients; C2: 24 patients. The sensitivity and specificity of TAUS in the preoperative staging of these tumors were 96% for the T parameter, and 100% for the N parameter. The N but not the T parameter results are in line with the values reported in the international literature.

CONCLUSION

Transanal ultrasound, in our personal experience, has proved to be a very accurate imaging technique in the preoperative staging and postoperative follow-up of rectal cancer.

Regulation of the Saccharomyces cerevisiae DLD1 gene encoding the mitochondrial protein D-lactate ferricytochrome c oxidoreductase by HAP1 and HAP2/3/4/5

Expression of the nuclear gene encoding the mitochondrial enzyme D-lactate ferricytochrome c oxidoreductase (D-LCR) was investigated in Saccharomyces cerevisiae. This gene (DLD1) was found to be subject to several regulatory controls at the transcriptional level: synthesis of DLD1 mRNA is repressed by glucose, is derepressed in ethanol or lactate and is heme dependent. We therefore examined the role of the heme-dependent transcriptional activator Hap1p and the carbon source-dependent Hap2/3/4/5 complex. We found that the Hap2/3/4/5 complex and Hap1p have additive effects on the activation of DLD1 transcription: the Hap2/3/4/5 complex is necessary for DLD1 derepression following a shift from fermentable to non-fermentable carbon sources, while the Hap1p effect was independent of the carbon sources tested. An upstream region required for expression and regulation of the DLD1 gene was identified. Within this region the binding sites for both the Hap2/3/4/5 complex and Hap1p were defined by gel retardation experiments and site-directed mutagenesis. Comparison between sequences recognized by Hap1p in different promoters showed that the Hap1p binding site in the DLD1 promoter diverges from the consensus Hap1p binding site.

The limitations of echocardiography in the overall diagnosis of the morphological lesions associated with infective endocarditis: comparison of echocardiographic and surgical findings

Echocardiography is commonly accepted as the method of choice for the non-invasive diagnosis of vegetations and other lesions associated with infective endocarditis. To assess the accuracy of echocardiography in the overall diagnosis of the morphological cardiac lesions we retrospectively analyzed and compared the preoperative echocardiographic data with the surgical findings of 120 consecutive cases operated for infective endocarditis. Transthoracic echocardiography (TTE) was used in 60 cases (51 with native and 9 with prosthetic valves), both TTE and transesophageal echocardiography (TEE) in 50 (26 with native and 24 with prosthetic valves) and only TEE in 10 patients who underwent emergency surgery. The echocardiographic diagnosis was correct in all the cases, but incomplete in 26 (16 with native and 10 with prosthetic valves). Most of the incomplete diagnoses occurred regarding vegetations, perforations of the valvular leaflets and perivalvular abscesses. There were no differences between aortic or mitral valves (14/66 vs 11/60; p = ns), native or prosthetic (16/79 vs 10/37; p = ns), TTE or TEE (13/60 vs 13/60; p = ns); however, TEE was performed in more complex cases and in severely ill patients. In six of the incomplete diagnoses, echocardiography preceded surgery by one week or more, and in six the mistakes were not confirmed by the reviewer. In conclusion, our study suggests that an echocardiographic diagnosis of endocarditis may be correct but sometimes incomplete. In patients without prosthetic valves who have a technically-adequate transthoracic echocardiogram, transesophageal echocardiography is not indispensable but should be chosen from time to time. However, the patients with endocarditis and no contraindication to the transesophageal procedure should undergo both transesophageal and transthoracic echocardiography before surgery in order to obtain as much and the most definite information possible. An echocardiographic study should be repeated just before any surgical procedures in patients with active endocarditis. Finally, it needs to be emphasized that the training and clinical judgement of the operator performing the study are important elements determining the results of echocardiographic study.

The role of hepatitis C and B virus infections as risk factors for severe liver complications following allogeneic BMT: a prospective study by the Infectious Disease Working Party of the European Blood and Marrow Transplantation Group

BACKGROUND

Severe liver disease, including fulminant hepatic failure and venoocclusive disease can occur after bone marrow transplantation (BMT). The aim of our study was to assess risk factors for veno occlusive disease and severe liver disease occurring within 6 months from BMT.

METHODS

A total of 193 consecutive patients from 15 BMT Centers were prospectively enrolled between January and June 1995. Data on donors and recipients before and after transplant were collected and included age, gender, alanine aminotransferase (ALT), hepatitis B (HBV), and hepatitis C virus (HCV) markers, hematological disease, status and type of BMT, conditioning regimen and graft versus host disease prophylaxis. Statistical analysis included univariate descriptive and multivariate analysis based on logistic regression on major end-points.

RESULTS

Forty-three of 193 patients died during the study period, and liver disease was the main cause of death (13 of 43, 30%). Incidence of severe veno occlusive disease was 8%, fulminant hepatic failure 0.5% and 12% of cases had ALT >500 U/L (normal < or =42 U/L). A de novo HBV or HCV infection occurred in 3.2 and 7% of patients respectively. Predictive risk factors for life-threatening liver disease were: unrelated donors (relative risk=5.8, confidence interval=1.7-19.8) and abnormal BMT donor ALT (relative risk=6.3, confidence interval=1. 5- 25.5).

CONCLUSIONS

This study indicates that ongoing or previous infection with HBV or HCV in donor or recipient is not an absolute contraindication for BMT. However, abnormal ALT levels in BMT donors were a significant predictor of potentially lethal liver complications. The occurrence of de novo HBV or HCV infection did not correlate with severity of liver disease observed in the first 6 months posttransplant. These findings should be carefully evaluated before disregarding HBV or HCV positive siblings with normal transaminase levels in favor of unrelated donors.

[Minimally invasive percutaneous ultrasonography-guided treatment of postoperative splenic abscess. Personal experience with 5 clinical cases]

INTRODUCTION

Splenic abscesses are very rare pathologies encountered in daily clinical practice. The treatment, after failure of other medical treatments, has basically been surgical, in spite of large diffusion of percutaneous echo and CT techniques. The initial hesitation in applying this sort of method was caused by an unfounded fear of difficult management of haemorrhagic complications.

METHODS

In our Clinic we treated 6 postoperative abscesses, observed in 5 patients. One of these (16%) was double and 3 concomitant with other intraperitoneal abscessual septic collections, which received priority in percutaneous treatment. In four cases (67%), Van-Sonnemberg drainage catheters were placed which caliber varied from 12 to 14 F. In the remaining two cases, we evacuated the abscess using an echo-guided needle puncture. In two cases we applied fibrinic glue; in one case as a haemostatic agent and in the other, to protect the wide abscessual cavity.

RESULTS

We recorded the resolution of the symptomatology and instrumental findings in all patients. One patient died two weeks later due to unrelated causes. We recorded one minor complication which involved an intra-abscessual haemorrhage, which was then treated by fibrinic glue (Tissucol).

CONCLUSION

Echo-guided percutaneous treatment, at present, is the treatment of choice for both multiple or single splenic abscesses. This treatment is not used for the miliaric form because we believe that in this case, the most appropriate choice is intensive medical treatment, which if fails, may require splenectomy.

Long-term clinical outcome after beta-interferon therapy in cirrhotic patients with chronic hepatitis C. TVVH Study Group

BACKGROUND/AIMS

Few data are available concerning the short and long-term effects of beta-IFN in patients with chronic hepatitis C.

METHODOLOGY

We randomized 61 consecutive patients with HCV-related cirrhosis to receive: a) natural beta-IFN with a 6 MU/tiw for 6 months followed by 3 MU/tiw for 6 months schedule or b) no treatment. Biochemical and virological response was defined by normalization of ALT and negativization of serum HCV-RNA. Patients were followed-up for 5 years.

RESULTS

A biochemical end-of-therapy response (ETR) was observed in 5/38 patients (13%) who received beta-IFN compared to 2/23 (9%) of untreated cases, but a virological ETR appeared only in 4/38 (11%) treated cases. At long-term follow-up, 6 cases (16%) who received beta-IFN and 4 untreated (17%) developed a persistent normalization of alanine aminotransferase (ALT) but only 2 (5%) and 1 (4%), respectively, were also HCV-RNA negative. The cumulative probability of liver decompensation (variceal bleeding ascites or hepatic encephalopathy) at 60 months was 24% in treated and 35% in untreated cases. Hepatocellular carcinoma developed in 2 treated and in 1 untreated patients.

CONCLUSIONS

beta-IFN therapy was not associated with a significant improvement either in biochemical or virological response in cirrhotic patients with chronic hepatitis C. No significant reduction of cirrhosis related clinical events was linked to treatment.

Nitric oxide pathway, Ca2+, and serotonin content in platelets from patients suffering from chronic daily headache

An alteration in serotonin concentration has been found in patients with chronic headache caused by abuse of analgesic substances as well as an up-regulation of 5HT2 platelet receptors, which has been correlated with chronicization of the headache. In a previous study we demonstrated an increase in L-arginine/nitric oxide (NO) pathway activity in platelets from patients affected by migraine with or without aura, particularly during attacks. In the present research we assessed the variations in platelet L-arginine/NO pathway and cyclic guanosine monophosphate (cGMP) levels in 32 patients affected by chronic daily headache (CDH) (8 M, 24 F, age range 34-50 years) both during and between attacks. In these same patients, the platelet aggregation to different collagen concentrations (0.3, 1, 3 micrograms/ml) was determined as well as the intracellular platelet calcium concentration using fluorescence polarization spectrometry. These parameters were compared with those of an age- and sex-matched control group (n = 25; n = 10, n = 15, age range 35-51 years). A reduction found in platelet aggregation response to each collagen concentration used (p < 0.001) was coupled with an increased NO and cGMP production (NO: p < 0.0001; cGMP: p < 0.001). This was accompanied by a significant increase in intracytosolic Ca2+ (p < 0.0001) concentration and a reduced platelet serotonin content compared to those in control individuals (p < 0.0002). Changes in the above platelet parameters were accentuated more in patients with analgesic abuse than in CDH patients with no drug abuse. These findings suggest the occurrence of an activation of cGMP-Ca2+ mediated events in CDH patients with analgesic abuse. This physiologic compensatory mechanism, which intervenes in overcoming the increase in cytosolic Ca2+ levels, is not as efficient at limiting serotonin depletion by platelet dense bodies. A similar depletion in the central serotoninergic pathway can be assumed in the same patients.

Intracellular Mg++ concentration and electromyographical ischemic test in juvenile headache

One-hundred-and-twenty-eight young headache outpatients underwent an electromyographical (EMG) ischemic test and determination of Mg++ levels in red and mononuclear blood cells. In migraine patients, with and without aura (MwA and MwoA), Mg++ concentration in the erythrocytes and in mononuclear cells was significantly reduced compared to tension-type headache (TTH) patients and healthy controls (p < 0.0001). The EMG ischemic test was positive in 71% of migraineurs, but only in 9.5% of TTH patients. Low intra-erythrocyte and mononuclear cell levels were evident in 84.3% and 81.2% of migraine patients, respectively; those whose ischemic tests were positive had intra-erythrocyte and mononuclear cell levels of Mg++ below the norm, respectively. However, reduced levels of Mg++ in erythrocytes were found in only two patients with TTH, and in mononuclear cells in one patient with TTH. These data provide further confirmation of the role of Mg++ in determining the status of neuromuscular hyperexcitability in about two-thirds of migraine patients, including childhood and adolescence. They also support the validity of carrying out EMG ischemic testing for distinguishing this condition, which can be corrected with adequate oral Mg++ supplementation and with a possible positive impact on headache.

Chronic hepatitis C: interferon retreatment of relapsers. A meta-analysis of individual patient data. European Concerted Action on Viral Hepatitis (EUROHEP)

Relapse after interferon (IFN) therapy for chronic hepatitis C virus (HCV) infection occurs in 50% of patients after the initial response. The benefit of retreatment with IFN alone has not been assessed in large controlled studies. To assess the effectiveness and the tolerability of IFN retreatment and to identify the optimal second course regimen, we performed a meta-analysis of individual patient's data on a set of 549 patients (mean age 43.8 years; 12.2 SD, men: 65%) who had an end-of-treatment biochemical response to a first IFN course and then relapsed. Retreatment was started within 24 months after the end of the first course. Biochemical end-of-treatment responses (ETR) and sustained responses (SR) were observed in 405 of 549 (73.8%; 95% confidence interval [CI] 70.1-77.5) and in 124 of 549 (22.6%; CI 19.1-26.1) patients, respectively. One hundred seventy-five of 404 patients (43.3%; CI 38.6-48.2) developed an end-of-treatment, biochemical, and virological response when retreated. A biochemical and virological SR to retreatment occurred in 73 of 494 (14.8%; CI 11.7-18) patients. Thirty-two patients (5. 8%; CI 3.5-7.8) stopped retreatment for adverse effects. Biochemical and virological SR was predicted independently by logistic regression analysis using a negative HCV RNA at the end of the first cycle of IFN (P =.01) and by retreatment with a high IFN dose (P =. 03). Age, cirrhosis, genotype, and gamma-glutamyl transferase levels before retreatment were not significant by multivariate analysis. The excellent tolerability of IFN monotherapy retreatment makes it an option for patients who transiently cleared HCV-RNA during their first IFN course. Patients should be retreated with a high IFN dose regardless of the strength of the dose received during the previous course of treatment.

Evidence for sequence selection within the non-structural 5A gene of hepatitis C virus type 1b during unsuccessful treatment with interferon-alpha

Resistance of the hepatitis C virus (HCV) to interferon-alpha (IFN-alpha) therapy in patients with hepatitis C may be genetically controlled by an IFN sensitivity-determining region (ISDR) within the non-structural 5A (NS5A) gene. To assess whether HCV 1b strains carrying a 'resistant' type of ISDR are selected during unsuccessful IFN therapy, we analysed the evolution of the NS5A quasispecies, as detected by the clonal frequency analysis technique, and of the ISDR sequence by nucleotide sequence determination, in 11 patients showing no virological response during two consecutive cycles of IFN-alpha therapy. IFN-resistant patients had a homogeneous ISDR quasispecies with sequences identical to those described as 'resistant-' or 'intermediate-' type ISDR. After retreatment with IFN, further selection towards a homogeneous viral population was observed and 10 out of 11 patients had only one variant of HCV with no or just one single amino acid mutation within the ISDR sequence. Treatment and retreatment with IFN was associated in our non-responder patients with evolution of the ISDR quasispecies towards a rather homogeneous viral population carrying a conserved or minimally mutated ISDR motif, supporting the idea that this motif may be relevant for IFN resistance in HCV 1b-infected individuals.

Effect of retreatment with interferon alone or interferon plus ribavirin on hepatitis C virus quasispecies diversification in nonresponder patients with chronic hepatitis C

Alpha interferon (IFN-alpha) treatment is effective on a long-term basis in only 15 to 25% of patients with chronic hepatitis C. The results of recent trials indicate that response rates can be significantly increased when IFN-alpha is given in combination with ribavirin. However, a large number of patients do not respond even to combination therapy. Nonresponsiveness to IFN is characterized by evolution of the hepatitis C virus (HCV) quasispecies. Little is known about the changes occurring within the HCV genomes when nonresponder patients are retreated with IFN or with IFN plus ribavirin. In the present study we have examined the genetic divergence of HCV quasispecies during unsuccessful retreatment with IFN or IFN plus ribavirin. Fifteen nonresponder patients with HCV-1 (4 patients with HCV-1a and 11 patients with HCV-1b) infection were studied while being retreated for 2 months (phase 1) with IFN-alpha (6 MU given three times a week), followed by IFN plus ribavirin or IFN alone for an additional 6 months (phase 2). HCV quasispecies diversification in the E2 hypervariable region-1 (HVR1) and in the putative NS5A IFN sensitivity determining region (ISDR) were analyzed for phase 1 and phase 2 by using the heteroduplex tracking assay and clonal frequency analysis techniques. A major finding of this study was the relatively rapid evolution of the HCV quasispecies observed in both treatment groups during the early phase 1 compared to the late phase 2 of treatment. The rate of quasispecies diversification in HVR1 was significantly higher during phase 1 versus phase 2 both in patients who received IFN plus ribavirin (P = 0.017) and in patients who received IFN alone (P = 0. 05). A trend toward higher rates of quasispecies evolution in the ISDR was also observed during phase 1 in both groups, although the results did not reach statistical significance. However, the NS5A quasispecies appeared to be rather homogeneous and stable in most nonresponder patients, suggesting the presence of a single well-fit major variant, resistant to antiviral treatment, in agreement with published data which have identified an IFN sensitivity determinant region within the NS5A. During the entire 8 months of retreatment, there was no difference in the rate of fixation of mutation between patients who received combination therapy and patients who were treated with IFN alone, suggesting that ribavirin had no major effects on the evolution of the HCV quasispecies after the initial 2 months of IFN therapy.

Sulphation deficit in "low-functioning" autistic children: a pilot study

BACKGROUND

Parents of autistic children and autism support groups often report that autistic episodes are exacerbated when the children eat certain foodstuffs such as dairy products, chocolates, wheat, corn sugar, apples, and bananas. The hypothesis that autistic behavior might be related to metabolic dysfunctions has led us to investigate in a group of "low functioning" autistic children and in an age-matched control group each made up of 20 subjects, the sulphation capacity available.

METHODS

Utilizing the biochemical characteristics of paracetamol we evaluated by high performance liquid chromatography, the urine paracetamol-sulfate/paracetamol-glucuronide (PS/PG) ratio in all subjects following administration of this drug.

RESULTS

The PS/PG ratio in the group of autistic subjects gave a significantly lower results than the control group with p < .00002.

CONCLUSIONS

The inability to effectively metabolize certain compounds particularly phenolic amines, toxic for the CNS, could exacerbate the wide spectrum of autistic behavior.

Clinical and hormonal response to general anaesthesia in patients affected by different degrees of mental retardation

BACKGROUND

Poor or no clinical signs of psychological distress are usually observed in patients affected by severe or profound mental retardation (MR). The aim of this study was to use clinical and hormonal parameters in order to compare the amount of stress in patients affected by different degrees of MR undergoing general anaesthesia for dental care.

METHODS

Nine patients affected by mild or moderate MR (group A: intellective quotient > 35) and 12 affected by severe or profound MR (group B: intellective quotient < 36), undergoing general anaesthesia for dental care, were studied. The reaction to venipuncture before anaesthesia induction and the recovery from anaesthesia were assessed by clinical scores. Cardiac rate and arterial pressure were recorded before and after venipuncture and after removing the endotracheal tube. Cortisol and prolactin, two hormones affected by stress, were determined in plasma the day prior to surgery (1), after anaesthesia induction (2), and after removing the endotracheal tube (3).

RESULTS

During venipuncture, group B was significantly less reactive than group A (p < 0.05) and showed no arterial pressure increase while group A presented a significant increase of systolic pressure; conversely, the groups shared the same hormonal pattern at time 2 (cortisol did not change, prolactin increased significantly). Postoperatively A and B groups did not differ regarding cardiac rate and arterial pressure, while a wider range of postoperative scores was observed in group A in which a further prolactin increase was registered at time 3.

CONCLUSIONS

Clinical evaluation can underestimate the stress to which patients affected by severe or profound MR are subjected during anaesthesia induction.

Comparison of thrice weekly vs daily human leucocyte interferon-alpha therapy for chronic hepatitis C. TVVH Study Group

Standard treatment for chronic hepatitis C currently consists of 3-6 million units (MU) of interferon-alpha (IFN-alpha) given thrice weekly (t.i.w.) for 12 months, obtaining rates of sustained response (SR) that usually do not exceed 15-25%. Some recent reports have suggested that daily administration of IFN-alpha may be more efficacious. More than 7 years ago, when standard therapy for hepatitis C was usually given for 6 months, we conducted a randomized clinical trial comparing daily vs t.i.w. treatment. In this study, 149 patients with chronic hepatitis C were randomized to received 3 MU of IFN-alpha either t.i.w. for 6 months or daily for 3 months followed by t.i.w. for 3 months. All patients were treated with human leucocyte IFN-alpha and were followed-up for up to 72 months after inclusion. Overall, patients treated daily or t.i.w. had similar rates of virological response after 3 months of induction [24/49 (50%) vs 40/100 (40%)], at the end of therapy [15/49 (31%) vs 36/100 (36%)] and at the end of follow-up [6/49 (12%) vs 9/100 (9%)]. However, when patients infected with HCV types other than HCV-1 were studied, there was a trend favouring the daily schedule that was associated with a higher [5/20 (25%) vs 5/48 (10%)] rate of long-term SR. All patients with a virological response - hepatitis C virus (HCV) RNA negative in serum as determined using the polymerase chain reaction - at 6 months after therapy remained in biochemical and virological remission at long-term follow-up, while seven of eight subjects who had normal alanine aminotransferase (ALT) levels but were serum positive for HCV RNA at 6 months, relapsed later, indicating that serum HCV RNA is better than ALT at predicting long-term cure after IFN-alpha therapy in chronic hepatitis C.

[Echo-guided percutaneous drainage of abscesses and abdominal fluid collections]

Abdominal abscesses are pathologies characterized by an high decree of mortality and morbidity. The pathology was once dealt with surgery evacuation the percentage of success reaches 60% while mortality runned around 24%. Today this technic has been substituted by the echo-guided treatment. The minimal invasive approach reduced dramatically the cases of complications (4-6%) and mortality (4%); it is highly suggested in the majority of the cases of visceral or endoperitoneal abscesses. Our study case counts 57 echo-guided drainages due to multiply surgery pathologies. The number of successful ends runs on 93%, this perfect agrees with the data given by literature that states a decree of success around 90%. We did no test an higher or lower decree of complications nor mortality. According to our opinion the echo-guided drainage is a primary technic in abdominal septic collections. Surgery drainage has to be aside for patients with general good health or for collections accompanied with divertcular disease of the large intestine, crohn disease, rectocolitis ulcerosis and periappendix abscess.

Absolute quantification of brain metabolites by proton magnetic resonance spectroscopy in normal-appearing white matter of multiple sclerosis patients

The aim of this research was to obtain an absolute quantification of the N-acetyl-aspartate, choline, creatine and phosphocreatine levels in normal-appearing white matter by means of 1H magnetic resonance spectroscopy in a group of multiple sclerosis patients (27 with the relapsing-remitting form and 13 with the secondary progressive form). These values were compared with those of a group of 12 age-matched healthy control subjects. A significant decrease in the N-acetyl-aspartate concentration was found in normal-appearing white matter of frontal and parietal brain areas in multiple sclerosis patients compared with the same areas in control subjects. This reduction was more evident in progressive patients. The decrease in the N-acetyl-aspartate concentration in normal-appearing white matter significantly correlated with the Expanded Disability Status and the lesional load. No significant change was found in the concentration of creatine or choline. This finding concurs with previous evidence of heterogeneity in the multiple sclerosis pathological process which is not confined to the lesions and involves not only myelin, but also axons, even in white matter which appears normal on MRI.

[Preoperative diagnosis using color Doppler flowmetry in focal and diffuse thyroid pathology]

Color-doppler was first used in the study and classification of specific pathologies in 1992. One hundred and eighteen patients with focal and diffuse thyroid pathologies underwent color-doppler, flowmetry analysis and peak systolic velocity measurement (CD-FM-PSV). The PSV results allowed us to identify two subclasses a and b in class three and four (a: = < or = 30 cm/sec., b: = > 30 cm/sec.). Class 3a and 3b lesions are the most likely to represent neoplastic nodules. Based on our results, we assigned 58 patients to type 2 (follicular hyperplasia), 20 patients to type 3a (follicular adenoma and carcinomas), 16 patients to type 3b (carcinomas and Plummer's adenoma), 15 patients to type 4a (autoimmune thyroiditis and hypothyroidism) and 12 patients to type 4b (Graves' disease). Preliminary results were compared with FNAB, intra-operative and post-operative histological data. The specificity of CD-FM-PSV in diagnosis is 86%. We have concluded that CD-FM-PSV is an effective imaging technique for pre-operative diagnosis of thyroid pathologies and along with FNAB, a adequate predictive tool for thyroid nodules.