End-of-life and palliative care provision to adults with congenital heart disease: mortality follow-back study using administrative data

Background

Although many adults with congenital heart disease (CHD) still die prematurely, end-of-life care for these patients receives limited attention. There are indications that current care provision at the end of life is burdensome, expensive, and not in line with patients' needs and preferences. We sought to analyse end-of-life care in adult CHD patients to determine whether health services need to be optimized.

Purpose

This study aimed to describe patterns of healthcare consumption of adults with CHD who died in the last year of life.

Methods

This retrospective mortality follow-back study used data of the BELgian COngenital heart disease Database combining Administrative and Clinical data (BELCODAC), including individually linked healthcare claims, death certificates and clinical data from adults with CHD in Flanders (Belgium). For this study, adults with CHD who died between 2007 and 2016 from any cause except sudden death, accident or violence, were selected for inclusion. Accidental, violent, and sudden deaths were identified based on causes of death and healthcare use in the last 3 months of life. Healthcare consumption was based on nomenclature codes derived from healthcare claims data.

Results

A total of 327 eligible patients (median age: 58 y; 54% women; 43% mild CHD; 45% moderate CHD; 11% complex CHD; 49% cardiovascular cause of death) were identified. During the last year of life, healthcare use increased substantially (Fig. 1). During the last month of life, 54% of patients were hospitalised, 55% visited the emergency department, and 15% were admitted to an intensive care unit at least once (Fig. 2). A total of 8% and 5% of patients underwent heart surgery or catherization in the last month of life, respectively. Furthermore, 70% of patients had at least one encounter with a general practitioner and 11% with a CHD specialist in the last month of life. Specialist palliative care was provided to 13% of patients in the last month of life.

When looking at the subgroup of patients with CHD that died due to a cardiovascular cause, proportions of patients that were hospitalised or had visits at the emergency department or intensive care unit in the last month of life were similar (Fig. 2). However, these patients underwent more heart surgeries (11%) and catherizations (8%), had more encounters with CHD specialists (15%), and received remarkably less specialized palliative care (4%) in the last month of life.

Conclusion

Resource utilization increased substantially during the last year of life, resulting in high acute healthcare consumption in the last month of life. It is remarkable that only a minority of patients received palliative care, especially when looking at patients who died due to a cardiovascular cause. Our findings motivate the need to assess if and how end-of-life is planned for adults with CHD. Future studies using qualitative analyses and survey methodology are needed to optimize the management of end-of-life care.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Research Foundation Flanders, European Society of Cardiology, Koning Boudewijnstichting, National Foundation on Research in Pediatric Cardiology, Swedish Research Council for Health, Working Life and Welfare-FORTE

Healthcare use at the end of life of patients with congenital heart disease: does heart failure matter?

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Research Foundation Flanders (to PM, EG, and LVB)

European Society of Cardiology (Nursing Training Grant to LVB)

Background

Heart failure (HF) is a common cause of morbidity and mortality in patients with congenital heart disease (CHD). Although limited in scope, previous studies suggest that patients with heart failure follow a specific end-of-life trajectory with episodes of serious complications, which may impact the patterns of care as death approaches.

Aims

The study aims to identify differences in characteristics and patterns of care in the last year of life in deceased CHD patients with and without HF.

Methods

This retrospective study used data of deceased adult patients included in the BELgian COngenital heart disease Database combining Administrative and Clinical data (BELCODAC). To describe patterns of care in the last year of life, we captured information about hospitalisations, emergency department visits, and visits to the general practitioner using nomenclature codes. Heart failure was identified as having HF as cause of death and/or at least one prescription of a loop diuretic in the last year of life. Sensitivity analyses with a stricter definition for HF (HF as cause of death or ≥ 1 prescription of a loop diuretic combined with a prescription of digoxin, dopamine, dobutamine, other non-glycoside stimulants, metoprolol, bisoprolol, carvedilol, aldosterone antagonists, ACE inhibitors or ARBs) were performed as well.

Results

During the period 2007–2016, 390 adults with CHD died, of which 170 patients with HF (44%). Patients with HF were older, died more often due to a cardiovascular cause of death, and had more complex heart lesions, compared to patients without HF (Table 1). While the number of emergency department visits and hospitalisations in the last year was similar, patients with HF had almost twice as much monthly visits at the general practitioner in their last year of life (Table 1). As shown in Figure 1, the mean number of hospitalisations and emergency department visits increased in a similar fashion throughout the last year of life, but the pattern of general practitioner visits was substantially different for patients with and without HF. The sensitivity analyses, in which a stricter definition for HF was used, yield very similar results. In these analyses, the difference in mean monthly hospitalisations was also significant between the two groups.

Conclusions

This study shows clinically important differences in characteristics and patterns of care of deceased patients with CHD with and without heart failure. Patients with HFhave different needs and should receive a tailored approach at the end of life. Future research is needed to understand these differences and investigate these patients' end-of-life care needs in more detail.

Funding acknowledgments: This work was supported by Research Foundation Flanders; European Society of Cardiology; the King Baudouin Foundation; the National Foundation on Research in Pediatric Cardiology; and the Swedish Research Council for Health, Working Life and Welfare-FORTE.

Pan-tropical Sentinel-2 cloud-free annual composite datasets

Sentinel-2 MSI is one of the core missions of the Copernicus Earth Observation programme of the European Union. This mission shows great potential to map the regional high-resolution spatio-temporal dynamics of land use and land cover. In tropical regions, despite the high revisiting time of 5 days including both Sentinel-2A and 2B satellites, the frequent presence of clouds, cloud-shadows, haze and other atmospheric contaminants are precluding the visibility of the Earth surface up to several months. In this paper we present four annual pan-tropical cloud-free composites computed and exported from Google Earth Engine (GEE) by making use of available Sentinel-2 L1C collection for the period spanning from 2015 to 2020. We furthermore propose empirical approaches to reduce the BRDF effect over tropical forest areas by showing pros and cons of image-based versus swath-based methodologies. Additionally, we provide a dedicated web-platform offering a fast and intuitive way to browse and explore the proposed annual composites as well as layers of potential annual changes as a ready-to-use means to visually identify and verify degradation and deforestation activities as well as other land cover changes.

Hypertensive disorders of pregnancy in women with structural heart disease: data from the ESC EORP Registry of Pregnancy and Cardiac disease (ROPAC)

Background

Hypertensive disorders of pregnancy (HDP) are estimated to occur in 10% of pregnancies in the general population and preeclampsia specifically in 3–5%. HDP are suggested to be more common in and less well tolerated by women with heart disease. However, the current data are conflicting and this knowledge gap impacts clinical practice guidelines.

Purpose

To harness the well characterized data of the Registry of Pregnancy and Cardiac disease (ROPAC) to examine the frequency of HDP in women with structural heart disease and its impact on maternal and perinatal outcomes.

Methods

The ROPAC registry (n=5739) is a worldwide prospective registry on pregnancies in women with heart disease, including congenital heart disease (CHD, n=3295), valvular heart disease (VHD, n=1648), cardiomyopathy (CMP, n=438), aortopathy (AOP, n=217), ischemic heart disease (IHD, n=95), and pulmonary arterial hypertension (PAH, n=45). We defined HDP as either chronic hypertension, gestational hypertension, and/or preeclampsia (including HELLP syndrome and eclampsia) and assessed the frequency of HDP in each heart disease category. Predictors of preeclampsia were identified using multivariable logistic regression. The proportion of women with adverse maternal, pregnancy, and fetal/neonatal outcomes were described among women with preeclampsia or HDP, and compared between women with and women without HDP using chi-square tests.

Results

In total, the frequency of HDP and preeclampsia was 9.3% and 2.6% in CHD, 7.5% and 2.2% in VHD, 18.7% and 7.1% in CMP, 15.7% and 2.8% AOP, 35.8% and 6.3% in IHD, and 22.2% and 11.1% in PAH. Independent predictors of preeclampsia were chronic hypertension (OR 3.06, 95% CI 2–4.69), nulliparity (2.39, 1.68–3.38), HDP in a previous pregnancy (2.29, 1.11–4.7), gestational diabetes in the current pregnancy (2.13, 1.13–4.03), pulmonary hypertension (1.71, 1.08–2.7) and age (1.04, 1.01–1.07). In women with preeclampsia and heart disease, maternal mortality was 3.5% and heart failure was 29.1%. Maternal mortality (1.4% vs 0.6%, p=0.042), heart failure (18.5% vs 10.6%), Caesarean section (61.2% vs 48.4%), preterm births (27.4% vs 16.9%), low Apgar score (9.8% vs 6.6%), small for gestational age (14.6% vs 9.7%) and neonatal mortality (1.7% vs 0.4%) were higher in women with than women without HDP (all p<0.001 except maternal mortality).

Conclusions

The frequency of HDP is increased (>10%) in CMP, AOP, IHD and PAH, but not in CHD and VHD. The high frequency of HDP is partly due to chronic hypertension, but the incidence of preeclampsia is also increased (>5%) in CMP, IHD and PAH. Among women with cardiac disease, HDP were associated with adverse maternal and perinatal outcomes. The high maternal mortality rate of 3.5% in women with heart disease and preeclampsia warrants close clinical monitoring and a better understanding of the optimal management strategies in the complex population group.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Funding from “Zabawas Foundation” and “De Hoop Foundation” in addition to the support from EORP is greatly acknowledged. Since the start of EORP, the following companies have supported the programme: Abbott Vascular Int. (2011–2021), Amgen Cardiovascular (2009–2018), AstraZeneca (2014–2021), Bayer AG (2009–2018), Boehringer Ingelheim (2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and Pfizer Alliance (2011–2019), Daiichi Sankyo Europe GmbH (2011–2020), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2014–2017), Edwards (2016–2019), Gedeon Richter Plc. (2014–2016), Menarini Int. Op. (2009–2012), MSD-Merck & Co. (2011–2014), Novartis Pharma AG (2014–2020), ResMed (2014–2016), Sanofi (2009–2011), Servier (2009–2021), Vifor (2019–2022). HDP in women with heart diseaseIncidence of HDP per diagnosis group

Provision of palliative care to adults with congenital heart disease at the end of life

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by Research Foundation Flanders [grant numbers G097516N to PM, 12E9816N to EG and 1154719N to LVB]; the King Baudouin Foundation (Fund Joseph Oscar Waldmann-Berteau & Fund Walckiers Van Dessel); the National Foundation on Research in Pediatric Cardiology; and the Swedish Research Council for Health, Working Life and Welfare -FORTE (grant number STYA-2018/0004).

OnBehalf

BELCODAC consortium

Background

Although recent position papers have discussed and advocated for the integration of palliative care in the treatment course of adults with congenital heart defects (CHD), empirical studies reporting to what extent palliative care is currently provided, are still lacking.

Purpose

(1) To explore the current provision of palliative care to adults with CHD in the last 6 months of their life; and (2) to describe the profile of patients who received palliative care.

Methods

In this retrospective study, data of deceased adult patients included in the BELgian COngenital heart disease Database combining Administrative and Clinical data (BELCODAC) were analysed. Palliative care provision (i.e., admission to palliative care ward, or palliative care at home) was identified using nomenclature codes. The level of anatomical complexity was based on the Bethesda classification. Descriptive analyses were performed.

Results

During the period 2006-2016, 480 adults with CHD died (mean age: 54.4y; 45% simple CHD, 43% moderate CHD, 12% complex CHD). We identified that 75 patients (16%) had at least one nomenclature code linked to palliative care in the last 6 months of their life. More specifically, 16 patients were admitted to an inpatient palliative care service and 67 patients received palliative care at home. Of the patients who received palliative care at home, 40 patients were cared for by a multidisciplinary team specialized in palliative care provision and 59 patients received care from nurses and/or general practitioners while being recognized as a palliative patient. A total of 8 patients received palliative care both at the inpatient palliative care service and at home.

Of the 75 patients receiving palliative care, 44 (59%) had a neoplasm as the primary cause of death and a cardiac cause of death was reported for 10 patients (13%) (see Figure 1). The mean age of patients receiving palliative care was 57.9 years. Most patients receiving palliative care had a simple CHD (n = 40; 53%), 29 patients (39%) had a moderate lesion, and 6 patients (8%) had a complex lesion. That means that, respectively, 19%, 14%, and 11% of all deceased patients with a simple, moderate, and complex heart lesion received palliative care.

Conclusions

This is the first exploratory study on palliative care in adults with CHD. About one in six patients who died received palliative care. Of those who received palliative care, the cause of death was in most cases of a non-cardiac nature. Further research is needed to investigate the care trajectories and care needs of adults with CHD in the last months of life.

Figure 1. Causes of death of adults with CHD who received palliative care in the last 6 months of life (n = 75).

Trajectories of care in congenital heart disease - the long arm of disease in the womb

Our understanding of the development of congenital heart disease (CHD) across the lifespan has evolved. These include the evidence for the change in demographics of CHD, the observations that lifelong complications of CHD result in CHD as a lifespan disease, and the concept of long windows of exposure to risk that start in foetal life and magnify the expression of risk in adulthood. These observations set the stage for trajectories as an emerging construct to target health-service interventions. The lifelong cardiovascular and systemic complications of CHD make the long-term care of these patients challenging for cardiologists and internists alike. A life-course approach is thus required to facilitate our understanding of the natural history and to orient our clinical efforts. Three specific examples are illustrated: neurocognition; cancer resulting from exposure to low-dose ionizing radiation; and cardiovascular disease acquired in ageing adults. As patients grow, they do not just want to live longer, they want to live well. With the need to move beyond the mortality outcome, a shift in paradigm is needed. A life-course health development framework is developed for CHD. Trajectories are used as a complex construct to illustrate the patient's healthcare journey. There is a need to define disease trajectories, wellness trajectories and ageing trajectories in this population. Disease trajectories for repaired tetralogy of Fallot, transposition of the great arteries and the Fontan operation are hypothetically constructed. For clinicians, the life-course horizon helps to frame the patient's history and plan for the future. For researchers, life-course epidemiology offers a framework that will help increase the relevance of clinical enquiry and improve study design and analyses. A health-service policy framework is proposed for a growing number of conditions that start in the before birth and extend as long as contemporary survival now permits. Ultimately, the goal is the precision delivery of health services that enables lifelong health management, organization of developmental health services, and integration of vertical and horizontal health-service delivery.

Characterizing the Subcortical Structures in Youth with Congenital Heart Disease

BACKGROUND AND PURPOSE

Congenital heart disease is a leading cause of neurocognitive impairment. Many subcortical structures are known to play a crucial role in higher-order cognitive processing. However, comprehensive anatomic characterization of these structures is currently lacking in the congenital heart disease population. Therefore, this study aimed to compare the morphometry and volume of the globus pallidus, striatum, and thalamus between youth born with congenital heart disease and healthy peers.

MATERIALS AND METHODS

We recruited youth between 16 and 24 years of age born with congenital heart disease who underwent cardiopulmonary bypass surgery before 2 years of age (n = 48) and healthy controls of the same age (n = 48). All participants underwent a brain MR imaging to acquire high-resolution 3D T1-weighted images.

RESULTS

Smaller surface area and inward bilateral displacement across the lateral surfaces of the globus pallidus were concentrated anteriorly in the congenital heart disease group compared with controls (q < 0.15). On the lateral surfaces of bilateral thalami, we found regions of both larger and smaller surface areas, as well as inward and outward displacement in the congenital heart disease group compared with controls (q < 0.15). We did not find any morphometric differences between groups for the striatum. For the volumetric analyses, only the right globus pallidus showed a significant volume reduction (q < 0.05) in the congenital heart disease group compared with controls.

CONCLUSIONS

This study reports morphometric alterations in youth with congenital heart disease in the absence of volume reductions, suggesting that volume alone is not sufficient to detect and explain subtle neuroanatomic differences in this clinical population.

Metastasis in the chest wall and in the right ventricle from hepatocellular carcinoma. Description of a clinical case

The ante mortem diagnosis of right ventricular metastasis from hepatocellular carcinoma (HCC) is quite rare. Also the metastatic invasion of the chest wall following a liver biopsy is seldom reported. We describe a 67 year old patient that, 30 months after a liver biopsy showing HCC, developed an isolated metastasis of the chest in the site of the biopsy which was treated by radiotherapy. The same patient, after 8 months, complained of dyspnea on effort and ECG showed signs of ischemia: echocardiogram, CT scan and MRI revealed the presence of a metastatic mass in the right ventricular cavity. Post mortem examination confirmed the diagnosis.

Monitoring the trend of overweight children in Cremona (anni 1990-1998)

AIM

To evaluate the trend of infantile obesity in the school-aged population of Cremona over time.

METHODS

The weight and height of all children aged 6, 9 and 11 attending schools within the health district of Cremona were measured for 9 consecutive years (January 1990-March 1998), giving a total of 17,730 measurements. Pupils whose bodyweight was 20% above the mean weight for stature and sex given by NCHS canthimetric classes were defined as obese. In addition, three degrees of obesity were defined: slight obesity (20-29% excess bodyweight), moderate obesity (30-50%) and severe obesity (over 50%).

RESULTS

This study showed the trend of the increasing prevalence of infantile obesity in the zone in question: it rose from an overall level of 6.1% to 13.6% in 1998. The increase regarded all age groups; levels were three times higher in older children, but obesity had more than doubled in 6-year-olds. With regard to the three classes of obesity, there was a particularly striking increase in moderate obesity, whereas the cases of severe obesity remained constant.

CONCLUSIONS

These data underline the need for more incisive educational and preventive work in the field of infantile obesity to be carried out as soon as possible.

Antioxidant drugs combined with alpha-interferon in chronic hepatitis C not responsive to alpha-interferon alone: a randomized, multicentre study

OBJECTIVE

After non-response to the initial course of therapy, retreatment with alpha-interferon is not effective. The aim of this study was to ascertain whether the administration of N-acetyl cysteine and vitamin E could increase the response rate to retreatment with alpha-interferon.

DESIGN

Prospective, multicentre clinical trial.

SETTING

Twelve hospitals in Lombardy, Italy.

PARTICIPANTS

120 consecutive patients affected by biopsy-proven chronic hepatitis C who had been non-responders to a previous course of alpha-interferon, administered at the dosage of 3-6 million units (MU) three times a week (tiw) for 6 months.

INTERVENTIONS

The patients were randomly assigned to one of two groups of treatment: group A, natural interferon-alphaN3, 6 or 9 MU tiw, when the body weight was < 60 kg or > or = 60 kg, respectively; group B, the same dosage of natural interferon-alphaN3 in association with oral administration of N-acetyl cysteine 1200 mg/day and vitamin E 600 mg/day. The period of treatment was 6 months in both groups.

RESULTS

Neither end-therapy biochemical response nor sustained biochemical response rates were improved by the combination treatment, and in no case was clearance of the virus from serum observed.

CONCLUSIONS

In this randomized study carried out on 120 patients with chronic hepatitis C not responsive to alpha-interferon, oral supplementation with N-acetyl cysteine and vitamin E did not improve the poor efficacy of retreatment with alpha-interferon alone.

[Therapy of chronic hepatitis C with alpha-interferon in 182 patients. Evaluation of results, response predictive factors and side effects]

BACKGROUND

The aim of this study was to assess the results, predictors of response and side effects of therapy with alpha-interferon (IFN) in chronic C virus (HCV) infection.

METHODS

A group of 182 patients (150 chronic hepatitis and 32 cirrhosis) was treated with alpha-interferon--recombinant IFN in 120 cases (66%), and lymphoblastoid IFN in 62 cases (34%)--at a dosage of 3 MU three times weekly for 12 months. All our patients were prospectively followed for at least 6 months, and 133 patients for more than 2 years.

RESULTS

A short-term positive response was achieved in 65% of our patients, a sustained response in 34%, and a long-term response in 35%, the responses being similar both for hepatitis and cirrhosis. Liver histology, after 2 years, improved in 73% of long-term responders, whereas it improved only in 34% of relapsers. The predictors of response were: age, duration of disease, baseline levels of gamma-glutamyltranspeptidase (GGT) and serum ferritin. Both types of IFN proved to have the same efficacy. Side effects were observed in 52% of our patients, which were correlated with age and female sex.

CONCLUSIONS

Interferon therapy yields good results, if administered for 12 months, in young patients with disease of short duration and low baseline levels of GGT and serum ferritin, even in the presence of cirrhosis, if at early-stage. Patients with normal alanine aminotransferase (ALT) levels after 3 years may be considered fully recovered. The dosage employed was well tolerated.

[Spontaneous bacterial peritonitis (SBP): prevalence and characteristics in a population of 314 cirrhotic patients evaluated at hospital admission]

BACKGROUND

The aim of this study was to evaluate the incidence and the characteristics of the infections of ascitic fluid in cirrhotic patients at the moment of hospital admission.

METHODS

A total of 314 patients consecutively submitted to ascitic fluid tap within 3 days of hospital admission were studied. Each patient was classified according to Child-Plugh classes. Neoplastic ascites were excluded. The ascitic fluid was analyzed for PMN count, protein and albumin content, cultural and cytological examinations. The patients with ascitic fluid PMN > 250/ml were immediately treated with antibiotics.

RESULTS

Out of 314 patients 11% had SBP (94% in class C patients according to Child-Plugh classification), 17% CNNA and 3% MNNB. 15% of SBP patients were asymptomatic. Total protein content in ascitic fluid was significantly lower in SBP and MNNB compared to CNNA and sterile ascites. 56% of the isolated bacteria was Gram-negative, and the most frequently found were Streptococcus, Escherichia coli and Staphylococcus. 80% of the patients with ascites infection underwent third generation cephalosporin treatment. SBP mortality (29%) was significantly higher than CNNA (9%), MNNB (10%) and sterile ascites (11%), also taking into account the subgroup without ascites infection and class C group (14%).

CONCLUSIONS

In view of the high incidence (even in the absence of invasive procedures), of the possibility of symptom free patients and of the high mortality of SBP, it is advisable to carry out routine tap in all cirrhotics with ascites at hospital admission.

[Anomalies of the trunk. An analysis of their prevalence in young athletes]

BACKGROUND

To evaluate the influence of some sports (swimming, tennis, soccer, artistic gym, classical dance, basket, volley) on the development of the musculoskeletal system in prepuberal children.

METHODS

From January 1994 to December 1997, 3,765 students of the 4th and 6th class of primary schools in the area of the health district of Cremona, underwent orthopaedic screening. The prevalence of kyphosis, hyperlordosis and back asymmetry in children playing and not playing sports were compared. Statistical analysis was performed using X2-test.

RESULTS

The incidence of hyperlordosis was significantly lower in boys playing soccer while the incidence of back asymmetry was higher in girls playing basketball. Tennis was found not to be a suitable sport for either male or female prepuberal children. Swimming was the best sport for females whereas males who swan registered a higher incidence of hyperphosis compared to the control group. In females the incidence of hyperlordosis did not correlate with any of the sports considered whereas the incidence in boys playing soccer and swimming showed a decrease. Hyperkyphosis in females can be reduced by swimming and volleyball, in males by playing basketball.

CONCLUSIONS

The results obtained suggest the importance of an orthopaedic evaluation of children who want to take up sports.

[Intrahepatic cholestasis: clinical and nosological classification. Critical survey of personal experience]

We reviewed 20 patients (16 females and 4 males) with intrahepatic cholestasis and recognised the following miscellaneous disorders: 12 primary biliary cirrhosis (PBC), 3 primary sclerosing cholangitis (PSC), 1 immune cholangiopathy (IC), 3 liver sarcoidosis and 1 cholestasis with Horton's arteritis. The aim of the study was to identify potentially differetiating clinical and biochemical findings in intrahepatic cholestasis. Sixty females were affected with changes reflecting a cholestatic pattern including an elevated alkaline phosphatasis and gammaglutamyltransferase level. Pruritus was found in 50 percent of PBC patients; fever addressed often, in liver sarcoidosis and Horton's arteritis. A striking increase of unesterified cholesterol was a common feature of PBC. An elevated polyclonal serum IgM in PBC such as in PSC. A circulating IgM antimitochondrial antibody and antinuclear antibodies were found in 90 percent of PBC patients; isolated antinuclear antibodies were detected in immune colangiopathy patients (IC). Liver biopsy was necessary to establish the diagnosis of intrahepatic cholestasis. Overlapping histopathologic features made diagnosis hard in cholestatic disorders, all but in liver sarcoidosis. Treatment with UDCA or TUDCA+/-colchicin, reduced cholestatic enzymes in 85 percent of PBC cohort, while it was unsuccessful in PSC-group. Steroid treatment was successful in sarcoidosis, Horton's arteritis and immune colangiopathy. Cy A did not improve clinical and biochemical features in PBC.

[Comparison between torasemide and furosemide in the treatment of ascites in cirrhotic patients]

Twenty patients with cirrhosis and ascites were randomly divided in two groups to receive 20 mg/die of the new-loop-diuretic torasemide (T), and 50 mg/die of furosemide (F). All patients also received 200 mg/die of potassium canrenoate. Natriuretic and diuretic effects and consequent loss of weight were significantly better in the torasemide-group (T-group). Otherwise, loss of potassium and sodium/potassium ratio in urine were not significantly higher for T-group. Ammonium lowered with T and remained unchanged with F, but the difference was not statistically significant. No change was observed in blood-pressure, pulse-frequency, electrolyte plasmatic levels, azotemia, creatininemia and serum albumin. A significant increase of diuresis was obtained from the fourth day of treatment onwards by replacing F with T in the F-group. The T-group maintained T for eight days just to evaluate its efficacy and tolerability in the middle term: diuresis kept efficient and no side-effects occurred. This trial showed that T was a good and handy drug for cirrhosis with ascites whether as an alternative to F, or as a sequential treatment.

[The neuroleptic malignant syndrome (NMS). A report of a clinical case with a protracted and recurrent course. A review of the literature]

Neuroleptic malignant syndrome (NMS), characterized by catatonic behavior, generalized muscular rigidity, hyperthermia and autonomic dysfunction, can suddenly arise in patients treated with neuroleptic agents and carries a high mortality rate even today. A case of NMS due to i.m. therapy with haloperidol decanoate is reported in this paper, characterized by sustained course and a severe relapse due to a different therapy with another neuroleptic agent. The patient however, after a prolonged remission from the relapse, was able to resume long term therapy with neuroleptic drugs. The importance of monitoring blood levels of CPK during the follow-up and the effectiveness of therapy with bromocriptine and dantrolene in confirmed. Although the patient presented a good clinical response, she developed permanent cerebral and muscular damage. A wide review of the literature on NMS is reported to throw light on this syndrome, whose recognition and prompt diagnosis are necessary to reduce mortality.

[Prevalence of infections of the ascitic fluid in 81 consecutive cirrhotic patients]

During a period of 30 months the ascites of 81 patients with liver cirrhosis (65 males and 16 females; 25 in Child B class and 56 in Child C class) consecutively admitted to an Internal Medicine Department have been examined. The number of polymorphonuclear leukocytes (PMNs) and the protein content of ascites were evaluated, and cultures for aerobic and anaerobic bacteria were performed. In 46 patients ascites were sterile (SA); bacteriascites (BA) was observed in 3 patients; neutrocytic ascites (NA) in 18 patients; spontaneous bacterial peritonitis (SBP) in the remaining 14 patients. The number of PMNs and total protein content turned out to be significantly higher and lower respectively in SBP compared to the other groups (p < 0.02). In 10 out of the 17 patients with BA and SBP bacteria of enteric origin were isolated. Total mortality was 23.5% (4 cases).

Clinical evaluation of CAP System and RAST in the measurement of specific IgE

We investigated the diagnostic value of a new in vitro test, Pharmacia CAP System (Pharmacia Diagnostics AB, Uppsala, Sweden), for the quantitative measurement of allergen-specific IgE antibodies by comparison with RAST in 2 groups of patients, 71 atopic and 48 non-atopic. In the last 20 years RAST has supplied a good diagnostic tool, but this test presents some problems, the main one being sensitivity. The new test has a solid phase able to bind even very small amounts of specific IgE and an anti-IgE tracer with very low cross-reactivity with other immunoglobulins, thus presenting more favourable conditions. From the analysis of our results, Pharmacia CAP System gave higher sensitivity (94% compared to 88% of RAST) with no loss of specificity (96% for both tests). The reliability of these results is ensured by the proper selection of patients who were all suffering from pollinosis and were clinically diagnosed as certainly hypersensitive to a single pollen. A positive trend was found between severity of asthma and levels of specific IgE for timothy. Pharmacia CAP System appears to identify a larger number of atopic patients than RAST.

[Vasopressin-sensitive diabetes insipidus. Case histories]

Twelve patients, aged 16-66 years, affected by cranial diabetes insipidus either idiopathic or secondary (head injuries, histiocytosis X, metastatic tumors, pituitary or hypothalamic surgery) were studied. Diagnosis was made on the basis of both dehydration test and sensitivity to exogenous vasopressin. The relationship between plasma and urine osmolality at the end of the dehydration test was evaluated (and its usefulness for diagnostic purpose confirmed). According to this test two different conditions, namely partial and complete, of cranial diabetes insipidus were defined. All the patients underwent the following diagnostic procedures: skull x-ray, evaluation of visual fields, encephalic CT-scan. Idiopathic central diabetes insipidus incidence was found to be 33.3% of all cases, with a sharp prevalence for male sex; the median age of onset was 12.5 years. In our experience the frequency of idiopathic condition was similar to that reported in most recent literature confirming a decreasing incidence, most likely due to the use of more sophisticated diagnostic procedures.

A case of Langerhans histiocytosis with HIV-like immunodeficiency

A case of histiocytosis X (Langerhans type) associated with bullous pulmonary emphysema and acquired immune deficiency, regarding CD4 positive cells, is described. Previous history was remarkable for skin lesions which first appeared in 1981 and progressively worsened, diabetes insipidus diagnosed in 1986, and bullous pulmonary emphysema detected in 1988. Biopsy results of skin lesions were consistent with histiocytosis X. Thyroid gland involvement was found by means of cytological examination. The search for HIV infection (also performed by means of immunoblotting and PCR) was negative. To our knowledge the immunodeficiency detected in histiocytosis X affects the T suppressor lymphocyte subset, so we thought this peculiar case was worth describing.

[Pharmacokinetics of defibrotide in uremic patients undergoing hemodialysis]

Defibrotide pharmacokinetics were studied in 6 voluntary healthy subjects and in 10 uremic patients undergoing dialysis during which (instead of heparin) defibrotide was administered to prevent fibrino-formation in the circuit. Blood concentrations of the drug were assessed (expressed with reference to the residual glycidic deoxyribose) during a standard dialysis using defibrotide, 3.5, 15, 30, 45, 60 and 90 minutes after the defibrotide bolus (200 mg) had been injected into the arterial channel. The half-lives of the alpha and beta plasmatic phases were found to be equal at 3.79 and 41.4 min in dialysed subjects and at 1.13 and 16.54 in healthy volunteers. These results indicate that in uremic patients undergoing dialysis at intervals using defibrotide, a longer time is required to eliminate the drug from the circulation. This variation does not however appear to be significant in terms of the therapeutic use of the drug during dialysis.

Bilateral abductor paralysis of the vocal cords in the course of neurological diseases: report of 5 cases

We report 5 cases of bilateral abductor paralysis of the vocal cords (Gerhardt syndrome) with attacks of nocturnal asphyxia in patients with Parkinson disease, Shy-Drager syndrome, amyotrophic lateral sclerosis and tumor of the posterior cranial fossa.

[Nosographic and diagnostic classification of congenital thrombocytopathies. Clinical interpretative notes]

Substantial progress has been made in recent years in the understanding of platelets and their functions. This has permitted a more reasonable classification of congenital platelet diseases, primarily thanks to the standardization of haemostasis and platelet function tests. A comparison is made between the pictures best defined in 17 cases studied at the S. Matteo Polyclinic in recent years. This brought out certain contradictions and suggested that further study in greater depth is required.

Effect of gamma-aminobutyric acid on growth hormone and prolactin secretion in man: influence of pimozide and domperidone

To investigate the possibility that GH release induced by gamma-aminobutyric acid (GABA) in man is mediated by a dopaminergic mechanism(s), we evaluated the effect of two antidopaminergic compounds, pimozide and domperidone, on the plasma GH response to acute GABA administration (5 g, orally). Only the former compound can freely cross the blood-brain barrier. In 9 normal volunteers, GABA caused a significant increase of plasma GH levels (P < 0.0001 vs. GH levels in a group of 14 controls). In these subjects, pimozide (6 mg/day, orally, for 4 days) significantly blunted the GH elevation induced by GABA (P < 0.01). Unlike pimozide, in 8 additional subjects, domperidone (4 mg injected iv immediately before GABA administration) did not influence the GABA-induced GH response. GABA did not alter either baseline or pimozide-stimulated plasma PRL levels. Likewise, it did not significantly modify the brisk PRL rise after domperidone injection. These findings are consistent with the hypothesis that GABA-stimulated GH secretion is mediated via dopamine release at a suprapituitary level. With regard to PRL secretion, no GABA-dopamine interactions are readily apparent.

[Portal cavernoma. Observation of a case and clinico-nosographic considerations (author's transl)]

The clinical case of a sixty-two year old woman suffering for about six years from rare episodes of cramplike pains in the right hypochondriac region, radiated to the homolateral scapula, is described. After diagnosis of biliary calculosis, the patient was admitted to hospital and her gallbladder removed. During the operation a number of venous ectasias of the portal system were evidenced at the hepatic hilus, and their biopsy led to a diagnosis of portal cavernoma. The possible part played by the cavernoma in producing the patient's clinical picture is discussed, with reference also to other cases of cavernoma of varying location. This is followed by a review of the literature, in which stress is placed on the different aetiopathogenetic interpretations of angiomas and in particular of portal cavernomas. The possible evolution of angiomas and present treatment trends are also mentioned.

[The utility of angiography in the diagnosis and localisation of hepatic angiomas (author's transl)]

In the study of benign hepatic tumours, angiography of the coeliac tripod is a fundamental step in the diagnostic course, allowing them to be characterised in detail; within the framework of evaluation of the said expansive forms, particular attention has been directed to differential diagnosis in relation to those malignant lesions that can simulate a benign process.

Effect of acute and repeated administration of gamma aminobutyric acid (GABA) on growth hormone and prolactin secretion in man

A single oral dose of 5 g gamma aminobutyric acid (GABA) was given to 19 subjects and serial venous blood samples were obtained before and 3 h after drug administration. A placebo was administered to 18 subjects who served as controls. GABA caused a significant elevation of plasma growth hormone levels (P less than 0.001), but did not consistently alter plasma prolactin concentration since only 5 out of 15 subjects showed an increase of the hormone. Eight additional subjects were submitted to an insulin tolerance test before and after per os administration of 18 g GABA daily for 4 days. Protracted GABA treatment significantly blunted the response of growth hormone and enhanced that of prolactin to insulin hypoglycaemia (P less than 0.01). These results indicate that pharmacological doses of GABA affect growth hormone and prolactin secretion in man. The precise nature of GABA's effects as well as its mechanism of action remains to be clarified.