Euthyroid sick syndrome as an early surrogate marker of poor outcome in mild SARS-CoV-2 disease

BACKGROUND

The new coronavirus 19 disease (COVID-19) represents the current worldwide emergency. According to past evidence, a simple biomarker, such as low free triiodothyronine (fT3) levels, within the framework of euthyroid sick syndrome (ESS), might help to identify patients with unfavourable outcomes.

OBJECTIVE

Evaluation of ESS significance in hospitalized mild COVID-19 patients.

DESIGN

Prospective study, from 1 April 2020 to 31 May 2021.

PARTICIPANTS

COVID-19 patients with mild disease at hospital admission.

MAIN MEASURES

At hospital admission, eligible patients underwent a complete thyroid function evaluation. Subjects with previous thyroid disease or with thyroid-interfering medications were excluded. Levels of fT3 were correlated to biochemical markers and to patient outcome, the latter considered as favourable in the event of infection recovery and unfavourable in the event of death or transfer to an intensive care unit (ICU).

KEY RESULTS

Of 600 screened patients, 506 were eligible for this study. Of those, 94 (19%) died during hospitalization and 80 (18%) required a transfer to ICU. The most frequent thyroid disorder was ESS (57%). Admission levels of fT3 were significantly lower within the unfavourable outcome subgroup (p < 0.001) and were negatively associated with several poor prognostic markers, including IL-6 (p < 0.001). In Kaplan-Meier and Cox regression analyses, fT3 was independently associated with poor outcome and death (p = 0.005 and p = 0.037, respectively). A critical fT3 threshold for levels < 2.7 pmol/l (sensitivity 69%, specificity 61%) was associated with a 3.5-fold increased risk of negative outcome (95%CI 2.34-5.34).

CONCLUSION

Low fT3 levels, in the framework of ESS, resulted as being a valid predictor of unfavourable outcomes in a very early stage population of COVID-19.

A case report: Use of FT-IR analysis to improve Colovesical fistula diagnosis

Colovesical fistula (CVF) is an abnormal connection between the colon and the urinary bladder. Faecaluria, reported in 40–70% of cases, is virtually pathognomonic for CVF. During the 5th day of recovery in an 84 years old subject, the passage of cloudy, malodorous urine with visible debris was observed. According to the pathognomonic character of faecaluria, the sample was signed to the laboratory for biochemical and microbiological investigation, able to define the type and origin of materials. Following clinical requirements, both biochemical pathways and instrumental procedures able to confirm or exclude the presence of faecal components in urine were considered. No biochemical compound or component addressing faecal compounds in urine results available between laboratory tests. The brown powder component of the pellet was identified as Keratin, with 90% overlapping with the reference spectrum of the compound. FT-IR analysis on urine pellet can be proposed as a simple, non-invasive, and fast method to improve the diagnostic course of CVF.

[Therapeutic infusion of heparin. Application of a nomogram correlated with weight]

We performed a retrospective study to determine whether the use of a nomogram in General Medicine Wards is superior to the empiric method for the adjustment of heparin dosage. In the period october 1998-september 1999 we treated 138 patients with continuous infusion of heparin using a weight-based nomogram. Then we compared these data (nomogram group) with data from period october 1997-september 1998, when we had treated 155 patients with heparin, using empiric method for dose adjustments (empiric group). The proportion of patients reaching the therapeutic aPTT 24 hours after the start of therapy was 90.5% in nomogram group compared with 56.1% in the empiric group (P < 0.001). The proportion of nontherapeutic and subtherapeutic aPTT was significantly reduced in the nomogram group (6.0% vs. 11.1%, P < 0.001; 13.7% vs. 19.3%, P < 0.001). Furthermore, in the nomogram group the proportion of consecutive nontherapeutic or overtherapeutic values were significantly reduced (0.1% vs. 2.2%, P < 0.001; 1.8% vs. 2.3%, P < 0.001). We conclude that a weight-based heparin nomogram adapted for own aPTT range is successfully used in General Medical Wards of a community hospital.

Aetiologic diagnosis of ischaemic stroke in the emergency department: relevance for triage and clinical management

Effective strategies for the aetiologic diagnosis in patients with ischaemic stroke can be implemented based on simple clinical criteria and instrumental tests which can be performed in a modern emergency room (ER) within 24 hours from admission. This may bear prognostic and therapeutic relevance for patients with acute stroke. Therefore, in this study we set out to establish the feasibility and accuracy of the aetiologic diagnosis of ischaemic stroke in an ER. A total of 136 consecutive patients (mean age 72+/-10 years, 60 females) with first ever ischaemic stroke admitted during 1996-1997 were evaluated with assessment of clinical features, CT scan, ECG, ultrasonography of the extracranial arteries, transthoracic echocardiography, and, in selected patients, transoesophageal echocardiography. Patients were classified into two major categories defined as stroke of determined origin and stroke of undetermined origin (a stroke with two or more possible causes or with a negative evaluation), according to the TOAST criteria. Ninety-six patients were considered affected by stroke of determined origin (70.5%), (22.7% with large artery atherosclerosis, 19.1% with cardioembolic stroke, 26.4% with lacunar stroke and 1.4% with other aetiology). The remaining 40 patients (29.4%) had stroke of undetermined origin: of these, 13 patients (9.5%) had a totally negative evaluation, 15 patients (12.5%) showed cardioembolism among the two or more possible causes of stroke and seven patients (5.1%) had atherothrombotic or lacunar aetiology. Additional work-up with transoesophageal echocardiography succeeded in demonstrating aortic embolism in five patients (3.6%; i.e. four patients with aortic plaques more than 4 mm in thickness and one patient with ulcerated plaques). In conclusion, the subtype classification system for ischaemic stroke allowed the aetiological diagnosis in 70.5% of patients while in the ER. Stroke of undetermined origin represented one-third of patients in a consecutive population with acute onset neurologic deficit of ischaemic origin. In approximately half of the patients with negative standard evaluation, cardiogenic or aortic arch embolic sources could be identified by transoesophageal echocardiography. Thus, the latter is indicated in patients with stroke of undetermined origin with negative first-line evaluation in order to identify embolic sources in the aortic arch.

Efficacy and safety of adenosine in diagnosis and treatment of regular tachycardia in the elderly

BACKGROUND

Adenosine is currently used in the treatment and differential diagnosis of regular tachycardia. However, the efficacy of its employment has not been studied in elderly people.

METHODS

We evaluated the safety, and the diagnostic and therapeutic utility of adenosine in elderly people aged over 70 years with regular sustained tachycardia, compared with a group of patients aged under 70 years affected by the same arrhythmia. Adenosine was given to 107 patients in increasing bolus doses up to 18 mg during regular broad and narrow complex tachycardia; 49 patients were aged 70 and over, and 58 patients were aged less than 70 years. In the former group, surface ECG showed 38 narrow complex tachycardias and 11 broad complex ones; in the second group there were 48 narrow complex tachycardias and 10 broad complex ones.

RESULTS

Adenosine was effective in 94% of the elderly patients and in 93% of the younger patients. In the group aged over 70 years, adenosine restored sinus rhythm in 37% of patients and revealed the mechanism of arrhythmia in 57%. Adenosine restored sinus rhythm in 50% of patients under 70 years and revealed atrial or sinus tachycardia in 43%. The incidence of symptomatic side effects and peri-conversion ventricular arrhythmias was similar in the two groups. There were ventricular pauses over 3 s long in four (8%) of the older patients (maximum pause 7 s) and in two patients (3%) of the group under 70 years (maximum pause 6 s). No adverse haemodynamic effects were observed.

CONCLUSION

These data demonstrate the safety and the value of adenosine in the diagnosis and treatment of regular tachycardia in elderly patients.

Disease history in 382 Italian patients with Crohn's disease

AIMS

This large-scale study was aimed at evaluating the long-term history of Crohn's disease in a cohort of consecutive patients referred to the Careggi Hospital in Florence from January 1973 to June 1996.

PATIENTS

A total of 382 patients (187 females, 195 males; mean age of 47 years) were included in our study. The median follow-up was more than 11 years and only 46 patients (12%) had a follow-up of less than 1 year. The main endpoints evaluated in these patients included mortality for any cause, disease-specific mortality, recurrences, and need for surgery. Furthermore, in a subgroup of 130 patients observed during the last 6 months of our study, a more detailed assessment of the disease was carried out in which the distribution of inflammatory, fibrostenosing and fistulizing forms was determined.

RESULTS

Our results showed that the disease-specific mortality rate was extremely low (around 3% at 10 years and 5% at 20 years), but the rate of recurrence was approximately 50% at 3 years and more than 60% at 6 years. Surgery was needed in more than 50% of the patients over the 10 years following diagnosis, and the risk of a second operation was of a further 30% within 4 years of the first operation.

CONCLUSIONS

These epidemiological data emerging from our study are interesting since a large patient population was evaluated and the duration of the follow-up is extremely long.

A population-based study of inflammatory bowel disease in Florence over 15 years (1978-92)

BACKGROUND

In the group of inflammatory bowel disease (IBD), ulcerative colitis (UC) and Crohn's disease (CD) are considered to be more frequent in Western countries and in areas with a high socioeconomic development but relatively infrequent in southern Europe. Sporadic reports have indicated a lower incidence and a milder course of the disease in Mediterranean countries. Although conclusive data on this point are still lacking, recent reports suggest an increase in both incidence and prevalence rates.

METHODS

The incidence of UC and CD during the period January 1978 to December 1992 and their prevalence on 31 December 1992 were estimated in the 15-year-old population of the metropolitan area of Florence. Clinical, demographic, and follow-up information was collected for all identified IBD patients.

RESULTS

A total of 796 residents (345 females and 454 males) were newly diagnosed as having IBD during the study period. Of these 593 had UC and 203 CD. The age-standardized incidence rates, calculated for each of five 3-year consecutive periods, rose from 3.8 (in 1978-80) to 9.6 per 100,000 person-years (in 1990-92) for UC and from 1.9 (in 1978-80) to 3.4 (in 1990-92) for CD. Both trends were statistically significant. The prevalence estimated on 31 December 1992 was 121.0 and 40.0 per 100,000 inhabitants for UC and CD, respectively.

CONCLUSIONS

Our results confirm that IBD incidence rates and prevalence in this area of central Italy are currently comparable with those reported in northern Europe. These data are necessary for planning adequate health care services for IBD patients.

Intermittent versus continuous 5-aminosalicylic acid treatment for maintaining remission in ulcerative colitis

We performed a 12-month clinical trial to compare the relative effectiveness of an intermittent 5-ASA regimen and a continuous 5-ASA regimen for the maintenance treatment of patients with ulcerative colitis in remission. Fifty patients with ulcerative colitis in remission for a minimum period of 1 month participated in the study. Twenty five patients received an intermittent treatment with 5-ASA tablets (2.4 g for the first week of each month) and 25 received a continuous treatment with tablets (1.6 g each day). Patients were assessed clinically every two months and endoscopically every 6 months. Our results show that the two treatments were equally effective. The relapse-free rates at 12 months were 71% in patients receiving the intermittent treatment and 66% in patients given the continuous treatment. This difference is not statically significant. Further studies are needed to assess whether the intermittent regimen can be an alternative to life-long treatment in patients who have maintained remission for a long period of time.

[Hyperparathyroidism due to parathyroid carcinoma located in the mediastinum]

Parathyroid gland carcinoma is a rare cause of primary hyperparathyroidism. The authors discuss the case of a 56-year-old man who presented with hypercalcemia and multiple bone lesions suggestive of tumor metastases. Laboratory and radiological investigations revealed primary hyperparathyroidism in a patient with evidence of osteitis fibrosa cystica, sustained by carcinoma of a mediastinal parathyroid gland. Early titration of parathyroid hormone (PTH) levels in all patients with hypercalcemia of unclear cause is important for early diagnosis of cases that are tumor-sustained and prevention of the most severe complications. The role of immunostaining with anti-PTH antibodies in demonstrating parathyroid gland tissue in ectopic and/or non-functioning primary tumors, as well as metastases, is also discussed.

Epidemiology of inflammatory bowel disease over a 10-year period in Florence (1978-1987)

The epidemiology of inflammatory bowel disease (IBD) in southern Europe is still not well-known. Sporadic reports have suggested a lower incidence and a milder course of the disease in Italy, but conclusive data are still lacking. To shed light on this issue, we conducted a retrospective study of IBD incidence (from January 1978 to December 1987) in the metropolitan area of Florence (650,000 inhabitants). We also estimated IBD prevalence at December 31, 1987. Our study included both in-patients and out-patients referred to the Gastroenterological and Surgical Departments of the area. The diagnosis was based on well-established clinical, endoscopical, radiological, histological and surgical criteria. Overall, nine-hundred IBD patients were identified, but only 359 (195 males, 164 females) met the eligibility criteria for inclusion in the incidence study (area of residence and period of diagnosis); of these, 263 had ulcerative colitis (UC), 96 had Crohn's disease (CD), and 6 had IBD. The average incidence rate of CD was 1.5/100,000 per year while its prevalence was 17.3/100,000. The average incidence rate of UC was 4.0/100,000 per year and the prevalence was 49.6/100,000. Both the incidence and the prevalence rates for UC and CD were higher in males than in females. This retrospective, hospital-based study shows that, in this area, the incidence rate of IBD has steadily increased over the period considered. Further studies specifically focused on risk factors are needed.

[Ultrasonography in the diagnosis of chronic inflammatory intestinal disease]

The accuracy of ultrasonography (US) in diagnosing active inflammatory bowel disease (IBD) is assessed on the basis of a randomized prospective study of 61 patients. Twenty-six of the patients were affected with Crohn's disease (CD) and 12 with ulcerative colitis, while the remaining 23 patients were control subjects with no specific chronic IBD. The US signs considered as significant for active CD and UC were: --visualization of a typical target image, that is a hyperechoic center corresponding to luminal bowel content, surrounded by a hypoechoic ring corresponding to loop walls; --at least 2 of the following: solid abdominal mass, distended loops, luminal narrowing, reduced peristalsis, stiff loops, and accumulation of fluid between the loops. US sensitivity and specificity for CD were 77% and 95.6%, respectively. As for UC, no significant results were obtained. In our experience, US is a reliable method for detecting alterations and, especially, complications typical of CD in its active phase. Considering the young age of the patients affected with CD and the number of exams they must undergo, US is considered as a useful tool in disease follow-up.

Intermittent therapy with high-dose 5-aminosalicylic acid enemas for maintaining remission in ulcerative proctosigmoiditis

Sixty patients who had presented recently with a relapse of mild to moderate ulcerative colitis with rectosigmoid involvement were randomly assigned to treatment with either 5-aminosalicylic acid enemas (N = 29) or oral sulfasalazine (N = 31). All patients were in remission, which was documented by clinical, histologic, and endoscopic criteria. Five-aminosalicylic acid treatment was administered on an intermittent schedule, consisting of 4 gm daily for the first seven days of each month; sulfasalazine was given as continuous therapy (2 gm daily as oral tablets). The study period was 2 years. Overall, 9 relapses occurred in the 5-aminosalicylic acid group and 12 occurred in the sulfasalazine group. The actuarial relapse rate at 12 months was 20 percent in the 5-aminosalicylic acid group and 24 percent in the sulfasalazine group; at 24 months, these rates were 37 and 43 percent, respectively. The actuarial relapse curves of the two groups were very similar. The relapse severity was also similar between the two groups. These results show that the authors proposed schedule of maintenance treatment with high-dose 5-aminosalicylic acid enemas is effective in subjects with rectosigmoiditis. This form of intermittent therapy may therefore be proposed for maintaining remission in patients who are refractory to oral and/or rectal treatment with sulfasalazine and steroids or who are intolerant or allergic to sulfasalazine. Treatment with 5-aminosalicylic acid enemas for seven days each month can also constitute an alternative for patients who favor the intermittent schedule over the classic continuous regimen of oral administrations.

[Incidence of exertion hypertension in normotensive individuals]

Exercise hypertension is the blood pressure response to dynamic exercise stress which is considered excessive as compared to what is normally observed in a healthy population. It is a useful indicator to assist in detecting those persons who may develop sustained hypertension. Research has been conducted on a large number of patients, carefully selected using as criteria: arterial pressure, presence of other diseases and age. The examination has been conducted by observing the stressor test on the cycloergometer and annotating the Pa with the traditional method. The data was then analyzed using statistical methods. We conclude that at the moment of maximum effort the patients can be divided into two groups based upon PaD values superior or inferior to 20% of base values or to 95 mmHg. Those who exceed these values (43% of all patients studied) are considered as effort hypertensive subjects. The work's originality derives from the statistically proven consideration that the evaluation of PaD at the 8th minute of the test with cardiac rate between 70 and 90% of the maximum theoretical cardiac rate is predictive of effort hypertension. Hence continuation of the test can be avoided with advantages in terms of time and reduction of the generic risks inherent in carrying out a maximal test. Follow up on the patients is in progress.

The Valsalva maneuver in vasodepressor syncope

In this work the authors propose the Valsalva maneuver as a diagnostic test in a group of patients shown, by anamnestic, physical, and instrumental criteria, to be affected by vasodepressor syncope. They studied the response of heart rate and baseline arterial pressure to the maneuver performed in passive orthostasis in 7 healthy volunteers and 24 patients. These patients showed a hypotensive response and a time of recovery to the initial values that was significantly longer than in the control group (p less than 0.01). The authors conclude that studying the response to the Valsalva maneuver can be useful in the diagnosis of vasodepressor syncope.

Cimetidine, 800 mg at night versus 400 mg twice daily, in the treatment of duodenal ulcer

A multicentre double-blind study was carried out on a total of 197 patients, to evaluate the safety and efficacy of an 800 mg nighttime dose of cimetidine in comparison with 400 mg twice daily in the treatment of duodenal ulcer. At 4 weeks 84% of the 187 patients eligible for analysis had healed ulcers with the once daily regimen and 68% with the twice daily regimen (p less than 0.05). An early decrease in both day and nighttime pain and in antacid consumption was observed during the first 2 weeks. Adverse effects were few and mild, confirming the safety profile of cimetidine.

Antihypertensive action of nifedipine: effects on arteries and veins

Nifedipine is a calcium-channel antagonist with effective antihypertensive activity and has been suggested for the treatment of high blood pressure as an alternative to vasodilators. The aim of this study was to define the acute effect of nifedipine and in particular the dose-effect relationship, effects on veins, influence on adrenergic reflexes, and effectiveness on hypertension according to severity and etiologic type. The effects of nifedipine on blood pressure, heart rate, forearm blood flow, peripheral vascular resistance, orthostatic and cold reflexes, and venous tone were examined in 45 patients with hypertension of different etiologies (essential, renovascular, and renal parenchymal) and different World Health Organization grades. The antihypertensive effect was dose dependent, but a dose of 20 mg has nearly maximal activity with acceptable side effects. The drug acts by lowering peripheral vascular resistance, and this lowering is directly related to baseline values; therefore, the antihypertensive effect increases with severity of the hypertension. Nifedipine had the same effect in all three etiologic groups of hypertension studied. The drug seems to increase venous tone, since it caused venoconstriction when locally injected in hand veins. Nifedipine did not alter adrenergic reflexes induced by both cold application and standing and was well tolerated. In conclusion, the calcium antagonist nifedipine for its characteristics of action, at least in acute administration, seems to be a useful alternative in the treatment of various forms of hypertension.

Comparison of cimetidine 800 mg once daily and 400 mg twice daily in acute duodenal ulceration

A double blind trial was conducted in seven centres to evaluate the safety and efficacy of cimetidine 800 mg given at night compared with 400 mg given at breakfast and at bedtime. Altogether 197 patients with active duodenal ulcer confirmed by endoscopy entered the study, of whom 187 were eligible for analysis. After four weeks' treatment the ulcer was healed in 76 of 91 patients (84%) receiving the once daily regimen and in 65 of the 96 patients (68%) receiving the twice daily regimen (p less than 0.05). Both dosage regimens were equally effective in reducing ulcer pain and consumption of antacids. Pain relief was considerable within the first two weeks, and most of the patients were free of symptoms by the end of treatment. No patients were withdrawn because of adverse events as these were few and mild, consistent with the proved safety profile of cimetidine. Cimetidine 800 mg given at night is as effective as 400 mg twice daily; the single dose regimen may improve patient compliance, thus facilitating treatment.

[Arrhythmogenic dysplasia of the right ventricle. Description of a case]

A 43 year old man was admitted to our Clinic because of recurrent episodes of palpitation. The electrocardiogram showed incomplete right bundle branch block, frequent ventricular extrasystoles with left bundle branch block morphology and negative T waves in the precordial leads. Two dimensional echocardiography showed marked right ventricular dilatation and right ventricular radionuclide angiography located the enlargment in the infundibulum. Arrhythmogenic right ventricular dysplasia was then suspected. Cardiac angiography excluded the other most common causes of right ventricular dilatation and confirmed the diagnosis. Arrhythmogenic right ventricular dysplasia should thus be regarded as a possible cause of ventricular arrhythmias of unknown etiology.

Efficacy of mexiletine in the medium-term treatment of ventricular arrhythmias. A randomized, double-blind, crossover trial against placebo in ambulatory patients

A double-blind, crossover study was designed to compare the safety and efficacy of mexiletine with that of placebo in reducing premature ventricular complexes (PVC) in ambulatory patients and to find out the dose which gives a good therapeutic response with a minimal incidence of side-effects. Twenty-six patients, who had on average 427.9 PVCs/hour, were admitted to the study. The doses given were designed to reduce the frequency of PVCs by 50% or more from the baseline value. Two out of the twenty-six patients stopped treatment because of major side-effects. In the remaining twenty-four patients the 3 weeks of treatment with mexiletine significantly reduced the rate of PVCs by comparison with placebo (-63.8% versus +7.5%). In the nineteen responders (per cent reduction of PVCs over 50%) the dose of mexiletine was 600 mg daily (200 mg every 8 hours). In the non-responders plasma levels of mexiletine proved to be in the therapeutic range, not in any way different from responders. The most frequent side-effects were digestive difficulties (fifteen patients taking mexiletine and six taking placebo). These results show that mexiletine is an effective anti-arrhythmic drug in the management of ventricular arrhythmias occurring in ambulatory patients. In the majority of patients mexiletine was found to be effective even at the lowest dose studied of 600 mg/day.

Reduced prostacyclin production in patients with different manifestations of ischemic heart disease

Prostacyclin, a substance produced by vessel wall, has a sustained vasodilating and platelet antiaggregating activity and therefore the variations in its production in patients with ischemic heart disease are of interest. Prostacyclin production was assessed in 59 patients with ischemic heart disease and 59 control subjects matched for age, sex, body weight, smoking habits, blood pressure and serum cholesterol levels. Of the 59 patients examined, 23 had had a myocardial infarction 3 to 12 months earlier; 21 had had spontaneous angina and 15 effort angina for at least 3 months. Patients with myocardial infarction and spontaneous angina were also classified in subgroups with and without acute coronary insufficiency, according to the occurrence of ischemic attacks in the week preceding the study. Both circulating prostacyclin levels and prostacyclin produced after 3 minutes of ischemia were measured by bioassay. Circulating prostacyclin was significantly less in patients with ischemic heart disease than in matched control subjects independent of the clinical type of ischemic heart disease. Circulating prostacyclin was particularly reduced in patients with acute coronary insufficiency in comparison to patients without, both in the group with myocardial infarction (1.11 +/- 0.22 ng/ml and 2.09 +/- 1.32, respectively) and in the group with spontaneous angina (1.24 +/- 0.42 and 2.17 +/- 1.16, respectively). No differences could be found for prostacyclin produced after 3 minutes of ischemia in relation to the presence of acute coronary insufficiency. The lower level of prostacyclin production in patients with ischemic heart disease and especially in those with acute coronary insufficiency may be an important factor in the occurrence of coronary occlusion or spasm.

Comparison between neomycin and lactulose in 173 patients with hepatic encephalopathy: a randomized clinical study

A randomized study was performed in order to compare the course of hepatic encephalopathy in patients treated with neomycin plus magnesium sulfate or with lactulose. Admission criteria were: morphological diagnosis of cirrhosis and absence of comorbidity, of contraindications to drugs, or of previous treatments which could influence the outcome. The treatment groups were similar in terms of clinical characteristics, fatalities, recovery rate from grade 1 encephalopathy, and disappearance rate of neuropsychiatric signs. Transitions from severe to grade 1 or 0 encephalopathy showed a 0.17 (NS) difference in favor of neomycin. Early therapy and evidence of precipitating factors showed a favorable prognostic significance. Ascites, hyperbilirubinemia, poor nutritional state, and hypoprothrombinemia showed bad prognostic significance. This is the first large-scale investigation on hepatic encephalopathy. It demonstrated a similar effectiveness of the two drugs in grade 1 encephalopathy and provides a basis for drug selection in the current management of the syndrome.

Enhanced prostacyclin production by dipyridamole in man

The effects of some phosphodiesterase (PDE) inhibitors (dipyridamole, theophylline, papaverine and SH-869) on prostacyclin (PGI2) production have been studied in vitro and in vivo. PGI2 was bioassayed by Vane's superfusion technique. In rabbit aortic rings, only dipyridamole in concentrations from 1 to 12 microM was able to stimulate PGI2 biosynthesis in a dose-dependent manner. This effect was also detected with so-called "exhausted" rabbit aortic rings. The other PDE inhibitors used, both in microM and mM concentration, did not affect PGI2 biosynthesis. Dipyridamole was found to increase PGI2 production in healthy volunteers, when given both by infusion (8 micrograms/kg/min x 2h) and by oral administration (375 mg/day for seven days). Circulating PGI2 and PGI2 production induced by a 3-min period of ischaemia were increased by an average of 137% (p less than 0.001) and 30.8% (p less than 0.001) respectively. Saline and theophylline (as aminophylline) infusions used as controls did not affect PGI2 production.

Coagulation Disorders in Fulminant Hepatitis Treated by Dialysis

A young man, 28 years old, was admitted to Infectious Division with transaminases over 2500 U/ml, reduced cortical activity and decerebrate posturing. A prolonged APTT, Prothrombin below 15%, very low levels of Factor II, V, VII (5-20%). At III by S-2238 (17%), Antiplasmin (20%) and Plasminogen(5%) by S-2251, Preltallikrein by S-2302 (5%). Fibrinogen (70mg%) but very high VIII AHF(4.5U/ml}, VIII AGN (4.0U/ml) and VIII VWF (3.8U/ml) were recorded. After 3 daily dialysis sessions with polyacrilonitrile membrane (RP 6) a marked improvement was observed. The patient awoke while prothrombin and platelet recovery took place, fibrinogen,VIII AHF and Factor V rose over normal value to 600mg%, 7.5U/ml and 3U/ml rispectively. Antiplasmin, Plasminogen, PKK showed a slow but costant improvement. Unfortunatly a venous thrombosis and sepsis set in during the 2nd day after dialysis, with a rapid decrease of platelets. Heparin infusion 1 mg/kg b.w. was infused every 6 hrs. After 15days platelet returned to normal value and VIII AHF to initial level but it was still higher (4U/ml) than normal value after 2 mounths from recovery.