Single-Center Experience with Swiss LithoClast® Trilogy for Kidney Stones

INTRODUCTION

PCNL remains the gold standard for larger kidney stones. Reducing the operating time of PCNL and its complication rate seems to be the next logical step in optimizing this classical technique. To achieve these objectives, some new methods of lithotripsy emerge. We present the data of a single, high-volume, academic center with combined ultrasonic and ballistic lithotripsy in PCNL using the Swiss LithoClast^® Trilogy device.

MATERIALS AND METHODS

We designed a prospective, randomized study including patients who underwent PCNL or miniPerc with lithotripsy using the new EMS Lithoclast Trilogy or EMS Lithoclast Master. The procedure was carried out with all patients in prone position, by the same surgeon. The working channel size was 24 Fr-15.9 Fr. We evaluated the stones' features, operative time, fragmentation time, complications, stone clearance rate and stone-free rate.

RESULTS

Our study included 59 patients, 38 females and 31 males, of an average age of 54.5 years old. The Trilogy group included 28 patients and the comparator included 31 patients. Urine culture was positive in seven cases which required seven days of antibiotics. The mean stone diameter was 35.6 mm with a mean Hounsfield unit (HU) of 710.1. The average number of stones was 2.08 (6 complete staghorn stones and 12 partial staghorn stones). A total of 13 patients presented a JJ stent (46.4%). We found a very significant difference in all the parameters favoring the Trilogy device. The most important result in our opinion is the probe active time, which was almost six times shorter in the Trilogy group. The stone clearance rate was about double in the Trilogy group, leading to shorter overall and intra-renal operating times. The overall complication rate was 17.9% in the Trilogy group and 23% in the Lithoclast Master group. The mean hemoglobin drop was 2.1 g/dL with a mean creatinine rise of 0.26 mg/dL.

CONCLUSIONS

Swiss LithoClast^® Trilogy, a device combining ultrasonic and ballistic energy, is a safe and efficient method of lithotripsy for PCNL, proving statistically significant benefits over its predecesor. It can achieve the goal of reducing complication rates and operative times for PCNL.

Pancreatoduodenectomy for Malignant Solid Pseudopapillary Neoplasm in a Patient with Chronic Calcifying Pancreatitis, Rheumatoid Polyarthritis and Kidney Stones

We present the case of a patient with rheumatoid polyarthritis treated in our department, with a long history of chronic calcifying pancreatitis which was incidentaly diagnosed during a renal colic with a pancreatic tumor. Pancreatoduodenectomy with lateral superior mesenteric vein resection was performed, the final pathological examination revealed a malignant solid pseudopapillary neoplasm with a positive lymph node. Clinical, surgical, pathological and a review of the literature are presented.

Magnetic resonance/ultrasound fusion targeted biopsy of the prostate can be improved by adding systematic biopsy

AIM

Magnetic resonance/ ultrasound fusion targeted biopsy (Tbs) is widely used for diagnosing prostate cancer (PCa). The aim of our study was to compare the cancer detection rate (CDR) and the clinically significant prostate cancer detection rate (csPCa) of the magnetic resonance/ultrasound fusion targeted biopsy with those of the standard systematic biopsy (Sbs) and of the combination of both techniques.

MATERIAL AND METHODS

A total of 182 patients underwent magnetic resonance/ultrasound fusion Tbs on the prostate for PCa suspicion based on multiparametric magnetic resonance imaging (mMRI) detection of lesions with PI-RADSv2 score ≥3. A total of 78 patients had prior negative biopsies. Tb was performed by taking 2-4 cores from each suspected lesion, followed by Sb with 12 cores. We evaluated the overall detection rate of PCa and clinically significant prostate cancer, defined as any PCa with Gleason score ≥3+4.

RESULTS

Median prostate specific antigen (PSA) level pre-biopsy was 7.4 ng/ml and median free-PSA/PSA ratio was 10.2%. Patient median age was 62 years old. PIRADSv2 score was 3 in 54 cases, 4 in 96 cases and 5 in 32 cases. PI-RADS-dependent detection rate of Tbs for scores 3, 4 and 5 was 25.9%, 65.6% and 84.4%, respectively, with csPCa detection rates of 24.1%, 54.2%, and 71.9%. Overall detection rate was 57.1% for Tbs, which increased to 60.4% by adding Sbs results. Detection rate for clinically significant prostate cancer (csPCa) was 48.4% and increased to 51.1% by adding Sbs. Overall detection rate for repeated biopsy was 50% and 68.3% for biopsy in naïve patients. Sbs detection rate was 55.5%, 8 patients having a negative biopsy on Tbs.

CONCLUSIONS

When Tbs is considered due to a PI-RADS ≥3 lesion on mMRI, combined Tbs + Sbs increases the overall CDR and csPCa detection rates.

The Role of Tranexamic Acid in Controlling Bloodloss During PCNL for Staghorn Calculi

The aim of this paper is to assess the efficiency and safety of the tranexamic acid in reducing blood loss and the need for transfusion in patients diagnosed with staghorn calculi treated by percutaneous nephrolithotomy. Percutaneous nephrolithotomy (PCNL) is a minimally invasive technique used for large kidney stones. Hemorrhagic complications and urinary sepsis are serious complications associated with this type of surgery. Tranexamic acid is an antifibrinolytic drug that has the property of reducing intra or postoperative bleeding. The experience with tranexamic acid in preventing blood loss during percutaneous nephrolithotomy for is limited. The use tranexamic acid in percutaneous nephrolithotomy for staghorn type stones is safe and is associated with reduced blood loss and a lower transfusion rate.

Predictive Biological Markers in Post-therapeutic Evolution in Obese Patients

Childhood obesity is a leading public health concern because it represents a risk factor for many comorbid conditions in youth, such as cardiovascular disease, metabolic syndrome and sleep apnea. The purposes of the study were to evaluate the effect of the program at 6 months after the first visit and determine the predictive factors. We realised a retrospective study that included 69 obese children and adolescent, boys and girls, followed-up at Saint Mary Children�s Hospital and Regional Center of Diagnosis, Counselling and Monitoring of Overweight and Obese Children from �Grigore T. Popa� University of Medicine and Pharmacy Iasi, Romania, aged 12 to 18 years. The patients were included in two groups: group 1 included 38 patients receveived a hypocaloric diet only and group 2 included 31 patients received a hypocaloric diet associated with kinetotherapy and psychoterapy. We evaluated the body mass index, total cholesterol and tryglicerides before and after treatment. Our results confirm that diet and physical activity affects significantly the serum lipid profile. In this context, decreasing obesity in children through diet and exercise should be an important strategy for preventing cardio-metabolical disease in adult.

The Control of Bloodloss During Percutanerous Nephrolithotomy Using Tranexamic Acid

The aim of this study is to assess the efficiency and safety of the tranexamic acid in reducing hemmorrhagic complications and transfusion requirements in patients with renal lithiasis treated by percutaneous approach. Percutaneous nephrolithotomy (PCNL) is a minimally invasive technique used for large kidney stones (]20mm). Urinary sepsis and intra or postoperative bleeding are the very serious complications associated with this type of procedure. Tranexamic acid is used in the treatment of many haemorrhagic conditions. The experience with tranexamic acid in preventing bloodloss during percutaneous nephrolithotomy is very limited. The use tranexamic acid in percutaneous nephrolithotomy is safe and is associated with reduced blood loss and a lower transfusion rate.

The Role of Combining Biochemical Markers in Assessing the Endoscopic Activity in Ulcerative Colitis

Ulcerative colitis (UC) isa chronic, idiopathic and recurrent inflammatory bowel disease (IBD), characterized by periods of activity and remissionwhose monitoring requires invasive explorations associated with discomfort for the patient and important costs. Mucosal healing became one of the most important therapeutic targets in UC. The aim of our study was to identify a score, made up of noninvasive, available, used in current clinical practice biochemical markers, which should correlate with endoscopic activity in UC. We conducted a prospective study on 114 patients with UC. All patients were assessed both for biological inflammatory markers: erythrocyte sedimentation rate (ESR),C- reactive protein (CRP), fibrinogen, platelets, albumin, fecal calprotectin (FC) and by colonoscopy to estimate the endoscopic activity using Mayo score. By linear regression, we tried to identify a biochemical score correlated with endoscopic activity. Out of the serological markers,ESR (p=0.014), CRP(p= 0.021) and fibrinogen (p=0.035) correlated with the endoscopic activity of the disease. The best sensitivity to determine the endoscopic activity was given by FC (96.05%) with a predictable negative value of 91.1% (p=0.001). The score determined by linear regression: 1 (ESR]15mm/1h) x 0.305 + 1(fibrinogen]340.5mg/dL) x 0.309+1 (CRP] 5 mg/L) + 1 (calprotectin]200 μg/g) had an increased positive predictive value compared to each and one biomarker, nevertheless, with a sensitivity and specificity inferior to that of FC. Up to now, it is the first attempt to achieve a score made up exclusively of biological markers. The obtained score, although with an increased accuracy, has proven to have a lower predictability in comparison with FC used individually and cannot entirely replace colonoscopy.

Associations of smoking with cardiometabolic profile and renal function in a Romanian population-based sample from the PREDATORR cross-sectional study

BACKGROUND

The impact of smoking on morbidity is well known, but in Romania, limited data are available regarding the smoking prevalence and relationship with cardiometabolic profile and kidney function.

OBJECTIVES

To assess the association of smoking with cardiometabolic traits and kidney function, in a Romanian population-based sample from the PREDATORR study.

METHODS

PREDATORR was an epidemiological cross-sectional study. Between 2012 and 2014, participants were randomly selected from the lists of general practitioners and enrolled if they were aged 20 to 79 years, born and living in the past 10 years in Romania. Sociodemographic and lifestyle characteristics were collected through interviewer-administered questionnaires.

RESULTS

Overall, 2704 participants were included in the analysis, 18% of them being current smokers and 30.8% former smokers. Current smokers compared to non-smokers had higher total cholesterol (220.6 ± 50.4 versus 213.9 ± 86.8 mg/dl, P = 0.017), LDL-cholesterol (137.8 ± 45.2 versus 130.7 ± 83.7 mg/dl, P = 0.004) and glomerular filtration rate (96.9 ± 16.8 versus 90.7 ± 19.1 ml/min/1.73 m2, P <0.001) in women and higher triglycerides (170.7 ± 129.8 versus 144.3 ± 94.2 mg/dl, P = 0.007), glomerular filtration rate (97.6 ± 17 versus 90.3 ± 18 ml/min/1.73 m2, P < 0.001) and lower HDL-cholesterol (48 ± 15.5 versus 50.4 ± 14.1 mg/dl, P = 0.002) in men. Active smoking was associated with hypercholesterolaemia [OR: 1.40 (95% CI: 1.01-1.96), P = 0.04] and low HDL-cholesterolaemia [OR: 1.39 (95% CI: 1.01-1.91), P = 0.04] and negatively associated with overweight/obesity [OR: 0.67 (95% CI: 0.48-0.94), P = 0.02]. Male former smokers had higher prevalence of abdominal obesity (82.4% versus 76.4%, P = 0.02), hypertriglyceridaemia (43.6% versus 35.6%, P = 0.01), hypertension (64% versus 56.4%, P = 0.01) and ischaemic vascular disease (40.5% versus 30.9%, P = 0.003) than male non-smokers.

CONCLUSION

The PREDATORR study showed a high prevalence of smoking in the adult Romanian population providing data on the association of smoking with cardiometabolic traits.

Recent forest cover changes (2002-2015) in the Southern Carpathians: A case study of the Iezer Mountains, Romania

The paper explores the dynamics of the forest cover change in the Iezer Mountains, part of Southern Carpathians, in the context of the forest ownership recovery and deforestation processes, combined with the effects of biotic and abiotic disturbances. The aim of the study is to map and evaluate the typology and the spatial extension of changes in the montane forest cover between 700 and 2462m a.s.l., sampling all the representative Carpathian ecosystems, from the European beech zone up to the spruce-fir zone and the subalpine-alpine pastures. The methodology uses a change detection analysis of satellite imagery with Landsat ETM+/OLI and Sentinel-2 MSI data. The workflow started with a complete calibration of multispectral data from 2002, before the massive forest restitution to private owners, after the Law 247/2005 empowerment, and 2015, the intensification of deforestation process. For the data classification, a Maximum Likelihood supervised classification algorithm was utilized. The forest change map was developed after combining the classifications in a unitary formula using image difference. The principal outcome of the research identifies the type of forest cover change using a quantitative formula. This information can be integrated in the future decision-making strategies for forest stand management and sustainable development.

Correlation of Glycemic Control Parameters in Non-Diabetic Persons with Cardiovascular Risk Scores - Results from a Cross- Sectional Study

To assess the correlation between main parameters of glycemic control and cardiovascular risk scores in non-diabetic persons. Risk scores were calculated by using the University of Edinburgh Risk Calculator. Risk scores are used to estimate the probability of cardiovascular disease in individuals who have not already developed major atherosclerotic disease. We correlated the results of these scores with the parameters that describes the glycaemic profile: preprandial glicaemia, HbA1c and 1 hour and 2 h post-prandial glycaemia, determined during Oral Glucose Tolerance Test (OGTT).Both fasting glycaemia and HbA1c significantly correlated with cardiovascular risk scores calculated for a period of 10 years. The recorded post-prandial glycaemic values at 1h and 2h after glucose loading didn�t significantly correlate with calculated scores, in the study group. The observed correlations underline the importance of glycaemia in the pathogenesis of cardiovascular diseases.

Prevalence of overweight/obesity, abdominal obesity and metabolic syndrome and atypical cardiometabolic phenotypes in the adult Romanian population: PREDATORR study

PURPOSE

The objectives were to assess the prevalence of overweight/obesity, abdominal obesity and metabolic syndrome (MetS), and to evaluate the characteristics of the metabolically unhealthy lean (MUHL) and metabolically healthy overweight/obese (MHO) phenotypes in a Romanian population-based sample from the PREDATORR study.

METHODS

PREDATORR was an epidemiological study with a stratified, cross-sectional, cluster random sampling design. Participants were classified into four cardiometabolic phenotypes based on the BMI, the cut-off value being 25 kg/m(2), and the presence of MetS (defined according to the Harmonization definition 2009): MUHL, MHO, metabolically healthy lean (MHL) and metabolically unhealthy overweight/obese (MUHO).

RESULTS

Overall, 2681 subjects aged 20-79 years were included in the analysis. The overall age and sex-adjusted prevalence of obesity was 31.90 %, overweight was 34.7 %, abdominal obesity was 73.90 % and MetS was 38.50 %. The age- and sex-adjusted prevalence of MHO phenotype was 31.60 %, while MUHL phenotype prevalence was 3.90 %. MUHL and MHO participants had a cardiometabolic profile, kidney function and CVD risk intermediary between MHL and MUHO. MUHL had higher odds of being associated with CVD risk (OR 5.8; p < 0.001), abdominal obesity, prediabetes, diabetes, hypertriglyceridemia and hypo-HDL cholesterolemia than MHL, while MHO phenotype was associated with hypo-HDL cholesterolemia (OR 3.1; p = 0.002), prediabetes (OR 2.9; p < 0.001) and abdominal obesity.

CONCLUSIONS

PREDATORR study showed a high prevalence of obesity/overweight, abdominal obesity and MetS in the adult Romanian population, and their association with kidney function and several cardiometabolic factors.

Prevalence of chronic kidney disease and its association with cardio-metabolic risk factors in the adult Romanian population: the PREDATORR study

PURPOSE

PREDATORR is the first national study analyzing the prevalence of chronic kidney disease and its prognosis and association with socio-demographic, cardio-metabolic and lifestyle risk factors in the adult Romanian population.

METHODS

Chronic kidney disease was defined according to the KDIGO 2012 criteria as an estimated glomerular filtration rate <60 mL/min/1.73 m(2) and/or urinary albumin-to-creatinine ratio ≥30 mg/g. The socio-demographic, lifestyle and anamnestic data were collected through interviewer-administered questionnaires. Physical examination and biochemical assays were also performed.

RESULTS

This cross-sectional study conducted between December 2012 and February 2014 in Romania included 2717 adults. The overall age- and sex-adjusted prevalence of chronic kidney disease was 6.74 % (95 %CI 5.60-7.88 %), of which 3.31 % (2.50-4.13 %) had only reduced kidney function (estimated glomerular filtration rate <60 mL/min/1.73 m(2)), 2.98 % (2.21-3.76 %) had only albuminuria, and 0.45 % (0.14-0.74 %) had both. The prevalence of chronic kidney disease increased with age and was similar in women and in men. Age, hyperuricemia, impaired glucose regulation (diabetes/prediabetes), hypertriglyceridemia and a family history of renal disease were independent risk factors for the presence of chronic kidney disease.

CONCLUSIONS

The PREDATORR study showed a high prevalence of chronic kidney disease in the adult Romanian population providing data on its prognosis and association with several cardio-metabolic risk factors.

Post-socialist urban growth of Bucharest, Romania – a change detection analysis on Landsat imagery (1984–2010)

In this study, Bucharest, the capital city of Romania was selected as a case study. Based on time series of Landsat TM imagery and statistical data, an analysis on urban growth from 1984 to 2010 was performed, using an integrated approach of remote sensing and GIS techniques. The land cover data were validated by CORINE Land Cover maps. The results revealed that rapid urban growth of the Bucharest region led to accelerated land use conversion from cropland to built-up land. The processes of deindustrialization in the core city and industrialization to the ring road represent other driving factors for spatiotemporal pattern of built-up land. The paper will discuss these processes and their impact on economic growth and residential suburbanization of the studied region.

Nutrition in inflammatory bowel diseases

The relationship between nutrition and inflammatory bowel disease (IBD) is a complex one, the evaluation and correction of nutritional deficits being integral part of therapy in these patients. The diet that consists in excessive consumption of meat, sugar, fats (with a higher 0 6 /o) 3 polyunsaturated fatty acids ratio) are factors involved in the epidemiology and pathogenesis of IBD. Malnutrition is present among most IBD patients, being the result of multiple mechanisms from digestive symptoms to inflammatory process, intestinal resection and administration of medications. Oral diet is high-calorie, high protein at correcting the vitamin and mineral deficiencies. Enteral diet has both an adjuvant role and that of inducing and maintaining remission as single treatment, particularly in children. Parenteral nutrition is reserved for patients with obstruction, fistula, toxic megacolon, short bowel syndrome, severe malabsorption, and other conditions that make enteral nutrition impossible or inefficient.

Rare types of diabetes mellitus

Diabetes mellitus is a heterogenous disorder characterized by chronic hyperglycemia and induced by a large number of etiopathogenic conditions. Beside type 1 and type 2 diabetes, which account for almost 90% of all cases, practitioners may encounter patients with more infrequent forms of diabetes, as those induced by mutations of a single gene, atypical immune disorders or neonatal diabetes. Monogenic diabetes is represented by genetic disorders in the structure of the beta-cell (the MODY syndromes and the mutations of mitochondrial DNA) or in the insulin's action (type A insulin resistance syndrome, Rabson-Mendenhall syndrome, leprechaunism, lipodystrophies). The rare forms of immune diabetes are determined by antibodies against insulin or insulin receptor or appear as a component of the "stiff man syndrome". Neonatal diabetes is induced by mutations in genes that control beta-cell development and function and may have a transient or permanent nature. Knowledge of the uncommon forms of diabetes mellitus enables physicians to apply the optimal treatment, to estimate the evolution of the patient and to apply a complete family screening in order to diagnose all other blood relatives as soon as possible.

Impact of obesity on retrograde ureteroscopic approach

INTRODUCTION

High-grade obesity raises some specific problems regarding the endourological approach. The aim of our study was to determine if this pathology might influence the outcome of retrograde ureteroscopy.

MATERIALS AND METHODS

We evaluated the outcome of 88 ureteroscopies performed in highly obese patients during the last 5 years. The data were compared with the results of 88 consecutive ureteroscopies performed in normal weight patients.

RESULTS

The success rate in the study group was of 91% by comparison with 95% in the normal weight group. The use of flexible ureteroscopes was imposed in 17% of the obese group vs. 11% in the control group. The complications rate (all mild) was of 6.8% in the obese group vs. 4.5% in the normal weight patients. The differences between the two groups, although present, were not statistically significant. However, in two cases with obesity, the weight of the patients was too high for the operating table, imposing supplementary sustaining measures.

CONCLUSIONS

Ureteroscopic treatment of stones in obese patients is an acceptable treatment modality, with success rates similar to non-obese patients. Sometimes it may require some logistic measures in the operating theatre.

Extrahepatic complications of chronic cholestasis: current diagnosis and treatment

Pruritus, fatigue and osteoporosis are the main symptoms of the extra hepatic manifestations of chronic cholestasis that affect patients' quality of life. Pruritus affects more often female patients, varies as intensity during a day and for longer period of time, typically can be localized on the palms of hands and soles of feet or can be generalized. Pruritus can be treated with anions resines exchange--cholestiramine, the pregnanne X receptor agonist Rifampicine, Naltrexone. Liver transplantation can be considered if severe pruritus remains refractory to all medical treatments. Fatigue is the most disabling complain in chronic colestasis. No specific therapies are available for fatigue and liver transplantation doesn't improve it. Osteoporosis and the risk of fractures are more severe with the duration and severity of hepatic disease. For treatment are recommended regular physical exercise, vitamin D and Ca supplimentation and bisphosphonates (Alendronate 70 mg/week) in severe cases. Only patients with atherosclerotic risk and hyperlipemia can be treated with statines. Fat soluble vitamin supplementation can be administrated only in symptomatic and proved vitamin deficiency.

Prognostic factors in laser treatment of upper urinary tract urothelial tumours

INTRODUCTION

The standard treatment for upper urinary tract urothelial cell carcinoma (UUT-UCCs) is radical nephroureterectomy with bladder cuff excision. The endoscopic treatment was introduced with promising results in selected cases. The purpose of this study was the retrospective analysis of the factors that can influence the prognosis of the patients with UUT-UCCs who underwent endoscopic treatment.

PATIENTS AND METHOD

We identified 187 patients who where diagnosed and treated for UUT-UCCs, between 1998 - 2011, in the Urology Department of "Sf. Ioan" Clinical Emergency Hospital, Bucharest. The endoscopic treatment was used in 65 cases. The indications for endoscopic treatment were imperative (41 cases) or elective (24 cases). The retrograde approach (rigid or flexible) was used in 47 cases, while the anterograde approach was preferred in 18 cases. Tumor ablation was performed using electroresection or Nd:YAG laser. The mean follow-up period was 60 months (range between 6 and 120 months). The follow-up protocol included computed tomography or intravenous urography, urinary cytology (selected cases), cystoscopy and ureteroscopy. The recurrence rates were reviewed by retrospective analysis.

RESULTS

During follow-up 31 patients (47.6%) presented upper urinary tract recurrence. In 20 cases (30.7%) bladder recurrence was present. The median time from diagnosis to first recurrence was of 12.6 months. 18 patients (27.69%) underwent subsequent nephroureterectomy. The survival rates without recurrence at 1, 3 and 5 years were 61% (40 patients), 55.3% (36 patients) and 52.3% (34 patients). The most significant prognostic factors were: history of bladder tumour, tumour location and size, tumour stage and grade. The recurrence rate for pyelocaliceal tumours was 53.84% (21 out of 39 cases) and only 45.45% (10 out of 26 cases) for ureteral tumours. The recurrence rate for low-grade tumours was 36,36% (16 out of 44 cases) and 71.42% (15 out of 21 cases) for high-grade tumours. The tumours over 1.5 cm were associated with a higher recurrence rate compared with tumours below 1.5 cm (64.2 versus 43.13%).

CONCLUSIONS

Endoscopic management of UUT-UCCs offers the advantage of preserving of renal function. Laser treatment of malignant urothelial lesions in the upper urinary tract should be reserved for a selected patient. The most important prognostic factors for UUT-UCCs evolution are tumours location, size and mostly tumour grade. The patients' compliance is very important for detecting recurrences.

[Liver cirrhosis--procoagulant stasis]

Abnormal hemostasis tests and bleeding are often associated in liver cirrhosis. In these patients the balance between hypo- and hypercoagulation status is more fragile than in healthy people. In the hemostatic abnormalities associated with chronic liver disease are two main chategory factors: favoring hemorrage and favoring thrombosis. The main factors that favoring hemorrage are: low platelet count, impaired platelet function, decreased levels coagulation factors (II, V, VII, IX, X, XI), quantitative and qualitative abnormalities of fibrinogen, vitamin K defiency, low levels of trombin activable fibrinolisis inhibitor, activat plasminogenic tisular. The factors favoring thrombosis are elevated levels of factors VIII and von Willebrand, decreased levels of protein C, protein S, antithrombin, decreased levels of plasminogen. Traditionally it was thought that arterial and venous thrombosis is rare events in cirrhotic patients but recent studies have indicated that thrombotic complications can paradoxically occur even if clinically an increased risk of hemorrhage is considered. Treatment of venous thrombosis in patients with cirrhosis using routine anticoagulation with heparin and vitamin K antagonists has been described but with a high level of bleeding complications. So, based on the limited data available, AASLD guidelines stated no recommendations for or against the use of anticoagulation in cirrhotic patients with portal thrombosis. Although abnormal hemostasis tests and bleeding are often associated in patients with chronic liver disease it is a relatively poor correlation between hemorrhagic risk and routine diagnostic tests of hemostasis. Management of bleeding complications in liver cirrhosis varies and no general guidelines are available. The main therapeutic strategies are: red cell concentrate, plasma, platelet concentrate, recombinant factor VIIa, factor concentrates, desmopressin, antifibrynolitic agents, thrombopoietin receptor agonists, antibiotics. Clinical studies examining safety and efficacy of the various products for the different bleedeing or trombotic complications of liver cirrhosis need to be initiaded.

[Chronic hepatitis C, steatosis and insulin resistance--clinical implications]

Chronic infection with hepatitis C virus is nowadays responsible for many cases of liver disease. According to recent research, it seems to be characterized by a great deal of metabolic abnormalities, most of them due to insulin resistance, which is present in the virus C-induced disease more often than in chronic hepatitis B or in the general population. As insulin resistance significantly impairs the natural course of the viral disease by reducing the efficacy of antiviral treatment and aggravating the development of fibrosis, it becomes more and more plausible that therapeutic intervention aiming to reduce it might contribute to a better course in many patients. Hepatic steatosis is also a frequent feature of chronic hepatitis C, being either induced by the infection with genotype 3 or by a predisposing metabolic background. The relation between steatosis and viral disease prognosis is controversial, probably due to the various factors inducing lipid accumulation. A better understanding of the metabolic substrate of chronic hepatitis C would help developing new approaches in its diagnosis and therapy, hopefully providing a better future to many patients.

Multiple focal liver lesions - diagnosis challenges. Case report

Multiple focal liver lesions can generate diagnosis difficulties in daily practice. This paper present the case of a 53 years old patient with multiple hyperechoic liver lesions suggestive for hepatic hemangiomas, detected during the ultrasonographic exam. Contrast enhanced ultrasonography indicated focal hepatic steatosis, while computed tomography proposed possible liver metastasis. The histological diagnosis was focal nodular hyperplasia associated with hepatic steatosis. The peculiarity of the case was the association of multiple focal nodular hyperplasia lesions with hepatic steatosis and atypical imaging findings that required histological confirmation.

[Pharmacologic therapy in peripheral diabetic polyneuropathy]

Neuropathy is one of the many complications of diabetes mellitus, along with micro- and macroangiopathy. Chronic sensorimotor distal symmetric polyneuropathy is the most common form between neuropathies; more than 30% of the diabetic patients are affected by this complication. Treatment is based on three cornerstones: (1) multifactorial intervention aimed at normoglycemia; (2) drugs that target pathogenic mechanisms and (3) symptomatic treatment. Among pathogenic treatments, alpha-lipoic acid and benfotiamine are available in several countries. Neuropathic pain, which affects 8-26% of diabetic patients, exerts a substantial impact on the quality of life. Among the centrally acting analgesic drugs, tricyclic antidepressants, carbamazepine, gabapentin and opioids have been mainly used to treat neuropathic pain. More recently, significant pain relief has been reported using agents such as duloxetine, a dual selective serotonin noradrenaline reuptake inhibitor, and pregabalin, an anticonvulsant, a specific modulator of the alpha2delta subunit of the voltage-dependent calcium channels. Until now, at least 50 new molecular entities have reached clinical stage of development. Strategies that may show promise over existing treatments include topical therapies, analgesic combinations and, in future, gene-related therapies.

[Cardiomyopathy in liver cirrhosis--an undiagnosed entity?]

Cirrhotic cardiomyopathy is a condition recently known in liver cirrhosis consisting of systolic dysfunction to stress factors, diastolic dysfunction and electrophysiological abnormalities in the absence of cardiac disease. The prevalence of cirrhotic cardiomyopathy remains unknown until now. It can be diagnosed by using a combination of electrocardiograph, 2-dimensional echocardiography, and various serum markers (brain natriuretic factor--BNP, proBNP, TnI). Pathogenic mechanisms underlying cirrhotic cardiomyopathy development include abnormal signaling betaadrenergic, cardiomyocites membrane fluidity changes, interstitial fibrosis, myocardial hypertrophy, altered transmembrane ion channels as intervention with negative inotropic effect of different substances whose concentration is increased in cirrhosis. Major stresses on the cardiovasculary system such as liver transplantations, infections, insertion of transjugular portosystemic stent-shunt (TIPSS) have been demonstrated to put in evidence the presence of cirrhotic cardiomyopathy. Heart failure is a significant cause of mortality after liver transplantation but the improvement of liver function determines cardiac abnormalities reversal. Current management recommendations include empirical, nonspecific and mainly supportive measures, no specific treatment can be recommended, and cardiac failure should be treated as in non-cirrhotic patients with sodium restriction, diuretics, and oxygen therapy when necessary. The exact prognosis remains unclear. The extent of cirrhotic cardiomyopathy generally correlates to the degree of liver insufficiency. Reversibility is possible (either pharmacological or after liver transplantation), but further studies are needed.

[Adipocytokines and nonalcoholic steatohepatitis]

Nonalcoholic steatohepatitis is one of the most common liver diseases. It is part of the nonalcoholic fatty liver disease, which ranges from simple hepatic steatosis to necroinflammation and fibrosis of various degrees, so that many patients can evolve towards advanced liver disfunction and even cirrhosis. Insulin resistance is the main factor involved in the development of fatty liver. As the adipose tissue is the source of many metabolically active peptides (the adipocitokines), their involvement in the pathogenesis of the hepatic steatosis and steatohepatitis began to be intensively studied during the last years. The most substantial information collected until now concerns the tumor necrosis factor alpha (a proinflammatory cytokine that induces insulin resistance, fat accumulation in the liver and even fibrosis and necrosis), adiponectin (an anti-inflammatory adipokine that acts as an insulin sensitizer and a hepatic protector) and leptin (a signal from the adipose tissue mass with effects on the appetite and food intake, but also acting upon insulin secretion and action and perhaps upon the liver fat accumulation).

[Adipocitokines and nonalcoholic steatohepatitis]

Nonalcoholic steatohepatitis is one of the most common liver diseases. It is part of the nonalcoholic fatty liver disease, which ranges from simple hepatic steatosis to necroinflammation and fibrosis of various degrees, so that many patients can evolve towards advanced liver disfunction and even cirrhosis. Insulin resistance is the main factor involved in the development of fatty liver. As the adipose tissue is the source of many metabolically active peptides (the adipocitokines), their involvement in the pathogenesis of the hepatic steatosis and steatohepatitis has begun to be intensively studied during the last years. The most substantial information collected until now concerns the tumor necrosis factor alpha (a proinflammatory cytokine that induces insulin resistance, fat accumulation in the liver and even fibrosis and necrosis), adiponectin (an anti-inflammatory adipokine that acts as an insulin sensitizer and a hepatic protector) and leptin (a signal of the adipose tissue mass with effects on the appetite and food intake, but also acting upon insulin secretion and action and perhaps upon the liver fat accumulation).

[Alcoholic ketoacidosis]

Alcoholic ketoacidosis is an acute metabolic acidosis that typically occurs in people who chronically abuse alcohol and have a recent history of binge drinking, little or no food intake and persistent vomiting. Alcoholic ketoacidosis is a result of starvation with glycogen depletion and counter-regulatory hormone production, a raised nicotinamide adenine dinucleotide (NADH) to nicotinamide adenine dinucleotide (NAD+) ratio related to the metabolism of ethanol, and volume depletion resulting in ketogenesis. Alcoholic ketoacidosis is characterized by elevated serum ketone levels and a high anion gap. Once the diagnosis of alcoholic ketoacidosis is made, the mainstay of treatment is hydration with 5% dextrose in normal saline. With timely and aggressive intervention, the prognosis for a patient with alcoholic ketoacidosis is good.

[Specific elements of diagnosis in diabetic nephropathy]

Diabetic nephropathy became nowadays the main cause of end-stage renal disease in the Western world. Common diagnosis tools can detect only late stages of the renal disease, without means of reversibility. The scientific research identified some specific methods of evaluation, detecting early modifications in the renal structure and function. These methods are the subject of the present paper.

Experts' beliefs on physiotherapy for patients with ankylosing spondylitis and assessment of their knowledge on published evidence in the field. Results of a questionnaire among international ASAS members

AIM

The aim of this study was to assess both the opinion of an international group of experts about the place and importance of physiotherapy in the management of ankylosing spondylitis (AS) as well as the awareness of the responders about scientific evidence on efficacy and cost-effectiveness of physiotherapy in AS.

METHODS

An e-mail questionnaire ''Experts' Beliefs on Physiotherapy for Patients with Ankylosing Spondylitis'' has been sent to all 71 international ASsessment of Ankylosing Spondylitis (ASAS) members. Completion of the twenty-eight-item questionnaire was done through the ASAS website (www.ASAS-group.org).

RESULTS

The number of responders was 53 (response rate 73%). Altogether 94% of the responders regard themselves as experts in the field of clinical care for AS patients. There is almost unanimous (86-92%) consensus on the efficacy of physiotherapy (widely defined, i.e. as physical therapy-including exercises, application of physical modalities and spa-therapy) for patients with axial and peripheral joint manifestations of AS. Physiotherapy is considered to be indicated for both early AS (less than 2 years after diagnosis) (88%) and AS of longer duration (2 to 10 years) (94%), implying that this non-pharmaceutical intervention should be made available for or should be prescribed to AS patients. Also daily exercises at home are considered indicated for both early (less than 2 years after diagnosis) AS (90%) and AS of longer duration of disease (90%). High-level evidence (Cochrane reviews or publications of one or more randomized controlled clinical trials) favoring efficacy of physiotherapy was considered available by 33% of the participants, whereas 43% replied ''no'' and 24% did not know. Finally, excluding the costs of the intervention, 39% of the participants reported that Spa-therapy might reduce health care costs as usage of NSAIDs, physician visits and ability to work or sick leave, whereas 26% said ''no'' and 35% did not know.

CONCLUSIONS

The international ASAS experts hold a favorable opinion on the efficacy of physiotherapy in AS, including group exercises and spa therapy, almost irrespective of disease duration and type of articular involvement (axial/peripheral). Awareness of published evidence on physiotherapy in AS is unsatisfactory.

[The pathological mechanisms of glycoregulation disturbances in chronic hepatitis B and C]

Despite the abundance of reports concerning the increased frequency of diabetes and impaired glucose tolerance in chronic liver diseases, the mechanisms underlying this phenomenon have not been resolved. 30 patients with hepatitis C virus (HCV) infection and 17 with hepatitis B virus (HBV) infection who showed an altered responds to a standard oral glucose tolerance test were investigated in order to evaluate their pancreatic-endocrine features. We have also evaluated 40 patients (20 with HCV infection and 20 with HCB infection) who developed diabetes after diagnosis of liver disease. Patients with HBV infection showed signs of enhanced insulin resistance but overt diabetes develops in those who, in addition to insulin insensitivity, have a relative defect of insulin secretion. In patients with HCV infection the significantly lower plasma insulin and C-peptide levels suggest that impairment of insulin secretion is the main mechanism leading to both glucose intolerance and overt diabetes.