Pathological evidence in support of total mesorectal excision in the management of rectal cancer

BACKGROUND

Pelvic recurrence following conventional rectal resection for cancer is common. Preoperative iradiation has been shown in prospective randomized studies to halve this risk.

AIM

This multiinstitutional study aimed to assess the necesity of total mesorectal excision in rectal cancer.

PATIENTS AND METHOD

Pathological resections from 50 consecutive patients with adenocarcinoma of the rectum within 12 cm of the anal verge who underwent currative resection incorporating total mesorectal excision were examined. The resection specimen was examined by one of two pathologists. Some 50 total mesorectal excision specimens were examined following rectal excision for cancer. Some 38 had total mesorectal excision as a component of a low anterior resection and 12 with abdomino-perineal resection. "Cure" was defined as absence of metastatic disease and the excision of entire macroscopic tumor tissue with negative proximal and distal borders. TME was performed as described by Heald et al. The mesorectum was evaluated for lymph nodes and tumor deposists in three areas: deep to the tumor, in the proximal mesorectum and in the distal mesorectum.

RESULTS

Six patients had Dukes A lesions. Of 21 patients with Dukes B tumors, five had discrete foci of adenocarcinoma in the mesorectum, with no evidence of lymph node metastasis. Dukes C lesions were more heterogeneous, but 12 out of 23 patients had distinct mesorectal deposists in addition to mesorectal node involvement. Circumferential margin involvement was rare, but mesorectal tumor deposits were present in 17 of 44 patients with pT3 tumors, and 23 of 44 had mesorectal nodal involvement. No patient with a pT2 tumor had mesorectal involvement. Failure to excise the mesorectum completely has the potential to leave gross or microscopic residual disease that may in theory predispose to local failure.

CONCLUSION

Total mesorectal excision is necessary to avoid incomplete pathological evaluation of the mesorectum and understaging of rectal cancer.

Hepatitis C virus-mixed cryoglobulinemia-lymphoma relationship

HCV (hepatitis C virus) chronic hepatitis has become one the most expensive diseases for public health systems all over the world in the past 10-20 years, a real epidemic, the second most frequent, after hepatitis B virus infection. Due to the complex manifestations, one may consider HCV infection as a "systemic" disease. Mixed cryoglobulinemia (MC) is the most common extrahepatic manifestation of HCV infection, but cryoglobulinemic vasculitis (CV) is considered to be relatively sparse although prevalence studies are needed. Presence of serum cryoglobulins is essential for MC diagnosis, but serum levels do not correlate with the disease activity or prognosis. MC can be defined as a B lymphocyte proliferation disease being characterized by polyclonal activation and antibody synthesis. Evolution to lymphoma should be considered continuous but also other infectious, environmental or genetic factors could be involved. The t (14.18) translocation and Bcl-2 activation in B lymphocytes, B cell-activating factor (BAFF), E2-CD81 interaction, immunoregulatory T CD4+CD25(high) + lymphocytes and type III IFNs might play an important role in MC and lymphoma evolution in HCV patients.

Neuromyelitis optica--complication or comorbidity in primary Sjögren's syndrome?

We report two cases of neuromyelitis optica (NMO) associated with primary Sjögren's syndrome (pSS), comparing the clinical and laboratory features of these predominant neurological patients and reporting their different outcome. NMO - a severe demyelinating disorder of the central nervous system - primarily affects the spinal cord and optic nerves, resulting in longitudinally extensive transverse myelitis and/or optic neuritis. Our patients had a late pSS diagnosis, due to the absence of sicca syndrome and specific Sjögren serology in the early stages of their diseases, when the neurological symptoms prevailed. Many NMO patients have an accompanying autoimmune disease, most commonly Sjögren syndrome and systemic lupus erythematosus or a related profile of non-organ-specific autoantibodies. Neurologic involvement occurs in approximately 20% of patients with pSS, usually preceding the diagnosis (in 75-80% of the cases) [1,2]. The frequency of both neurologic manifestations (revealing pSS) and negative autoimmune serology, especially in the event of CNS involvement, could explain why underlying pSS is misdiagnosed [3,4]. Screening for pSS should be systematically performed in cases of acute or chronic myelopathy and/or cranial nerve involvement, mainly because these patients have a severe outcome. The presence of the anti-aquaporin4 antibodies, besides anti-Ro and anti-La, in both reported cases, is intriguing and raises the question of whether we are facing two distinct diseases or the NMO is just complicating an unusually less expressive Sjögren's syndrome subtype.

Anti C1q antibodies in cutaneous lupus erythematosus

Autoantibodies against C1q are strongly linked to immune-complex disorders like systemic lupus erythematosus (SLE). Although anti-C1q antibodies have received much interest in the recent years, their biological functions remain unclear. Anti-C1q antibodies are strongly associated with lupus nephritis. Recent studies describe apoptosis as a key player in LE pathogenesis and C1q is an important opsonin, playing a central role in the uptake of apoptotic blebs. The aim of this study was to evaluate serum anti C1q antibodies, C1q with circulating immune complexes and correlation between serology and cutaneous apoptosis in patients with cutaneous lupus erythematosus.

MATERIAL AND METHODS

79 subjects were recruited and divided into 4 groups-13 healthy controls, 26 with discoid chronic lupus (DLE), 23 with systemic lupus erythematosus (SLE) and 17 with subacute lupus erythematosus (SCLE). Blood samples and skin punched-biopsy specimens were performed. Serum anti-C1q antibodies and C1q associated to the immune complexes concentrations were determined by ELISA. Cutaneous caspase-3 expression was evaluated by immunohistochemistry.

RESULTS

SLE and SCLE patients had significantly higher levels of anti-C1q antibodies and serum C1q-CIC levels when compared to healthy controls (p < 0.05). Serum anti-C1q antibodies correlated with proteinuria in SLE patients (p < 0.05). Anti C1q antibodies levels also correlated with cutaneous caspase 3 expression in SLE and SCLE patients (both p < 0.05).

CONCLUSIONS

Anti C1q antibodies might play a pathogenic role in SCLE pathogenesis and being positively associated with cutaneous apoptosis markers might be associated with a negative prognosis and secondary SLE development.

Treatment of extrahepatic manifestations of chronic hepatitis C viral infection--a challenge

Often, chronic hepatitis C infection is clinically manifested as extra hepatic disease. Therapy of the extra hepatic manifestations (EHM) is always difficult and based on the optimal and individual association of antiviral treatment, immunosuppressant and plasma cleaning techniques. We observed for 4 years 246 patients admitted to "Colentina" Internal Medicine Clinic, of whom 168 were diagnosed as chronic C hepatitis. 130 of those patients have had at least one EHM. In our experience, the presence of an EHM is significantly correlated with lack of early viral response and sustained viral response, as well. Cryoglobulinemic vasculitis needs to be treated with oral or pulse corticotherapy associated to plasmapheresis. When present, peripheral neuropathy and cryocrit greater than 10% are indicators of need of more than 3 plasmapheresis sessions.

T helper 17 cell population in lupus erythematosus

Lupus erythematosus (LE) is an autoimmune inflammatory disease that involves many organs and systems. Immunological factors seem to play a key-role in LE pathogenesis. LE patients have T lymphocytes dysfunctions.Th17 is implicated in the pathogenesis of various autoimmune diseases like psoriasis, multiple sclerosis or rheumatoid arthritis. The purpose of this study was to evaluate the circulating Th17 cell population in LE patients.

MATERIAL AND METHODS

A total of 15 LE patients were recruited and divided into three groups: systemic lupus erythematosus (SLE), discoid lupus (DLE) and subacute lupus (SCLE). Serum IL-17A, IL-17F and IL-23 were detected. Th17 circulating cells were evaluated by flow cytometry.

RESULTS

Serum IL-17A and IL-17F levels were higher in SLE, DLE and SCLE patients compared to healthy controls. The number of Th17 cells were higher in SLE and DLE patients (p<0.05). the number of CD3+IL-17+ cells were higher in SLE, DLE and SCLE patients (p<0.05).

CONCLUSION

Th17 lymphocytes are implicated in LE pathogenesis. Our findings suggest that IL-17 is implicated not only in SLE but also in DLE and SCLE immunopathogenesis.

Immunohistochemical aspects of apoptosis in subcutaneous lupus erythematosus

Lupus erythematosus (LE) has a broad clinical spectrum from exclusively skin damage (chronic discoid lupus-DLE or subacute lupus erythematosus-SCLE) to systemic, multiorgan disease (involving skin, joints, kidney, central nervous system). LE is characterized by an autoimmune component. SCLE is characterized by erythemato-squamous lesions mainly in photoexposed areas. Apoptosis (programmed cellular death) is essential for normal embryogenesis and for normal tissue homeostasis and control. Inefficient apoptotic cell clearance has been correlated with inflammatory diseases and autoimmunity outburst. This study evaluates histological and immunohistochemical expression ofpro-apoptotic markers in patients with SCLE.

MATERIALS AND METHODS

20 patients with SCLE and 10 healthy controls were selected. Biopsies from skin lesions were performed. Biopsies were evaluated for immunohistochemical expression of caspase 3, CD25, CD35, CD21, CD36, CD68, CD31, IgM detection, T and B cell markers.

RESULTS

In the inflammatory cells population we distinguished T lymphocytes, rare B lymphocytes, dendritic cells and macrophages. Within the lymphocyte population IL-2 receptor (CD25) expression was low but caspase 3 expression was intense in lymphocytes, epithelial cells and pericytes. Basal epithelial vacuolations were common. Phagocytic-cell and lymphocytic expression of CD35 (complement receptor 1-CR1) and CD21 (complement receptor 2-CR2) were lower when compared to healthy controls.

CONCLUSIONS

In SCLE patients we observed lymphocytic, epithelial and pericytal cell apoptosis and CR1 and CR2 expression are lower in professional phagocytes, suggesting a delay in the uptake of apoptotic bodies.

Platelet histogram indices and cardiovascular disease in patients with rheumatoid arthritis

BACKGROUND; Previous studies reported the increased prevalence of cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA) compared to the general population. However, the predictors for the development of CVD in patients with RA were not clearly established, and the role of thrombosis mechanisms was inconsistently characterized in these patients. The aim of this study was to evaluate the platelet histogram indices, as markers of platelet activation, in patients with RA with or without CVD.

MATERIAL AND METHODS

In 64 pts with RA (mean age: 58.0 +/- 12.7 yrs) we performed the standard clinical evaluation and biochemical workup with platelet histogram, including mean platelet volume (MPV) and platelet distribution width (PDW) as markers of platelet activation. We divided the study population into two groups: A - 41 patients with RA without CVD and B - 23 patients with RA and CVD (ischemic heart disease, peripheral artery disease or cerebrovascular disease). The values of MPV and PDW were also analyzed in an age- and sex-mached control group of 20 subjects without RA and CVD and in a group of 62 patients with CVD without RA (stable angina).

RESULTS

The platelets number was similar in both groups, but the platelet histogram showed higher values for MPV (9.6 vs. 8.6 fL, p < 0.01) and PDW (16.1 vs. 14.0, p < 0.01) in patients with RA and CVD, reflecting greater platelet activation in these patients. MPV values were lower in patients with RA, but the values of PDW were higher in these patients comparing to control. Patients with RA with CVD have higher values of PDW than patients with CVD, but without RA, showing an increased platelet activation in RA. The PDW values correlate with fibrinogen (0.63; p = 0.003) but not with CRP or ESR, while the MPV was not correlated with the inflammatory markers in patients with RA.

CONCLUSIONS

The pathogensis of CVD in patients with RA may be linked to an increased prothrombotic activity which might be evaluated by platelet histogram indices.

Endothelial dysfunction in inflammatory rheumatic diseases

The importance of cardiovascular disease in inflammatory rheumatic diseases was recognized as one of the determinants of increased mortality in these patients. An increased cardiovascular disease was reported in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), but also in other rheumatic diseases. Several hypotheses were elaborated, but the chronic inflammatory status seems to be a primordial factor. Therefore, the diagnostic and treatment of cardiovascular disease, even in subclinical status, should be one of most important goals in the global management of these patients. The endothelial dysfunction is now regarded as an important and early step in the processes that promote atherosclerosis. In patients with inflammatory rheumatic diseases, the presence of the endothelial dysfunction was reported and linked with several clinical or biological features of each disease. Moreover, the potential benefits on the endothelial dysfunction of several therapies were assessed especially in patients with RA or SLE. The aim of this article is to review the impact of the endothelial dysfunction and the methods to improve it in patients with these conditions.

Traditional and nontraditional risk factors for atherosclerosis in patients with systemic lupus erythematosus

Premature atherosclerosis (ATS) in SLE patients is an important clinical problem. It is explained not only by excess of traditional risk factors, but also by specific factors linked to disease activity and therapy. Such specific factors include the following: antioxLDL and anti CRP antibodies, immune complexes, mannose-binding lectin, disturbances of metabolism of annexin A5, antiphospholipid syndrome, immunologically determined dyslipidemia, influence of medication. As a conclusion,atherosclerosis in SLE patients results from an interplay between traditional and nontraditional risk factors. Therapeutic influences suggest antiatherogenic effects for hydroxychloroquine and immunosuppressants and a doubtful proatherogenic influence of cortisone.

[Fever of unknown origin in Romania. II. Diagnostic Procedures. Prospective multicenter study of 164 patients]

BACKGROUND

The Diagnostic workup of patients with fever of unknown origin is a challenge, due to the great number of possible etiologies. After we studied the etiologic spectrum of fever of unknown origin in Romania, we tried to evaluate the diagnostic procedures used and their efficiency.

METHODS

A multicenter cohort study of two years, with another two years of follow-up was carried out on 164 consecutive patients who met the classic, modified criteria of fever of unknown origin. We used a standardised diagnostic protocol.

MAIN OUTCOME MEASURED

The role of every diagnostic procedure in establishing the final diagnosis.

RESULTS

The diagnosis was made by microbiology and serology in 41 cases (25%), by histopathology in 22 cases (18%), with the help of imaging techniques in 30 cases (1.3%), based on the clinical evolution and response to treatment in 54 cases (33%) and by other methods in 12 cases (7.3%). The abdomino-pelvic ultrasonography had a sensitivity of 60%, a specificity of 70%, a positive likelihood ratio of 2.02 and a negative likelihood ratio of 0.57, while the scanner had a sensitivity of 81%, a specificity of 64%, a positive likelihood ratio of 2.23 and a negative likelihood ratio of 0.29.

CONCLUSIONS

Of all the diagnostic procedures used, none had a good sensitivity/specificity. The clinical evolution and the treatment response had an important role in the diagnostic workup.

[Fever of unknown origin: 1. Etiology. A prospective multicenter study of 164 patients]

BACKGROUND

The spectrum of fever of unknown origin seems to be determined by geographic and economic factors, and it appears to change in time. Excepting a small retrospective study, no other study on fever of unknown origin has been performed in Central or Eastern Europe.

METHODS

A multicenter cohort study was carried out on 164 consecutive patients who met the classic, modified criteria of fever of unknown origin. The study lasted 2 years (1997-1998) and included a follow-up period of another 2 years.

MAIN OUTCOME MEASURED

The final diagnosis at the end of follow-up.

RESULTS

74 (45%) patients had infections (tuberculosis: 27 patients, 16%), 41 patients (25%) had neoplasms, 30 (18%) had non-infectious inflammatory diseases, three (2%) drug fever, and four (2%) other causes. The etiology remained obscure for 12 patients (7%).

CONCLUSIONS

Infections represent the most important etiology, among them predominating tuberculosis.

Chronic hepatitis C virus infection mimicking rheumatoid arthritis

We present the case of a young female patient diagnosed two years ago with rheumatoid arthritis (AR) for which she is taking methotrexate (MTX), who develops cutaneous lesions highly suggestive of porphyria cutanea tarda, diagnosis confirmed by biochemical means. It is noteworthy that she was regularly taking oral contraceptives until the moment of appearance of the skin lesions. The association of those two illnesses, particularly in the case of MTX treatment can raise some problems regarding the potential direct causality relationship. This is why we tried a new diagnostic hypothesis: is chronic hepatitis C virus infection, hypothesis that we verified by means of the presence of anti-VHC and of RNA-VHC. It is well known now the association between chronic viral C infection, rheumatoid syndrome and porphyria cutanea tarda (PCT). The latter are extrahepatic manifestations of that viral infection, thus representing a major indication for antiviral treatment. Our patient received that treatment and she had a very good outcome of the skin lesions. We suggest that the differential diagnosis of any arthritis should always comprise chronic hepatitis C viral infection.

Kikuchi's disease associated with systemic lupus erythematosus and autoimmune-like hepatitis

The authors present a case of Kikuchi's disease associated with systemic lupus erythematosus (SLE) and autoimmune-like hepatitis. Kikuchi's disease, or histiocytic necrotizing lymphadenitis is occasionally associated with SLE and mildly elevated aminotransferases. A 17-year old woman presented with fever, arthritis and bilateral cervical adenopathy. Histopathological and immunohistochemical examinations of an excised lymph node showed evidence of Kikuchi disease. An elevation of hepatocytic enzymes (aminotransferases and gamma-glutamyl transpeptidase) associated with smooth muscle antibodies in a titer of 1/320 was present. Clinical symptoms and laboratory tests improved after "pulse" corticotherapy. The association described has not been described in the literature, but is considered possible due to the immune pathogenicity of the 3 simultaneous diseases. Kikuchi-Fujimoto's disease, or histiocytic necrotizing lymphadenitis (HNL), is a rare condition first described in 1972 independently by Kikuchi and Fujimoto. HNL is rarely associated with systemic lupus erythematosus (SLE). It is a benign illness characterized by fever and cervical adenopathy and has a self-limiting course.

Chronic viral hepatitis, the treatment with spiruline for one month has no effect on the aminotransferases

CONTEXT

Spirulina platensis is extracted from an alga and theoretically has many good effects on the majority of the organs. There is not any published clinical trial on humans.

OBJECTIVE

The evaluation of the efficacy of spiruline in chronic viral liver disease.

DESIGN

Double blind, randomised clinical trial.

SETTING

Secondary care university hospital.

PATIENTS

24 patients with chronic viral liver disease, treated with spiruline or placebo for one month.

OUTCOME MEASUREMENT

Aminotransferases diminution and the modification of a general state score self-evaluated by the patient on an analogic visual scale.

RESULTS

A modification of the aminotransferases level in the detriment of the spiruline treated group has been found (p = 0.036 for ALAT, p = 0.017 for ASAT), and not at the level of the general state score (p = 0.30).

CONCLUSION

Despite the little number of patients, significant results not favouring spiruline have been found.

Has this patient a cancer? The assessment of weight loss, anemia and erythrocyte sedimentation rate as diagnostic tests in cancer. A retrospective study based in a secondary care university hospital in Romania

INTRODUCTION

"Has this patient a cancer?" is a question we frequently ask ourselves in front of some symptoms, signs or laboratory results like weight loss, anemia and high erythrocyte sedimentation rate (ESR). The aim of this study is to assess their value in the diagnosis of cancer.

METHODS

A retrospective study of the records of 5500 patients admitted in the Department of Internal Medicine during the 1998 January-September period has been performed, selecting those patients with weight loss, anemia (Hb < 10.5g/dl) and ESR > = 50 mm/h.

RESULTS

The three diagnostic tests (anemia, high ESR and weight loss) had a low sensitivity (37, 52 and 46%, respectively), but a good specificity (92, 89 and 94%, respectively). For a 4% prevalence of cancer, as seen in our group, the resulting negative predictive value for the three tests was estimated respectively at 97, 98 and 98%, the post-test probabilities being estimated at 3, 2.2% in the case of negative tests. For a parallel utilisation of the tests, the sensitivity was 87%, the specificity 79%, the positive predictive value 15% and the negative predictive value 99%, the post-test probability in the case of a negative test being 1% [LR(-) = 0.17]; for serial utilisation, the specificity grew at 99.6% (CI: 99-100%), the positive predictive value (as the post-test probability in the case of a positive test) being 51% (CI: 50-53%) [LR(+) = 24.62].

INTERPRETATION

Any patient admitted in our department of Internal medicine has a 4% probability of having a cancer. Among those with weight loss, anemia and high ESR, one patient out of two has a cancer; among those with weight loss and anemia, 44% have a cancer; and among those with weight loss and high ESR, one out of three has a cancer.

The significance of chronic hepatitis B and C virus infections in some connective tissue diseases: the association with chronic liver disease

BACKGROUND/AIM

We investigated the pathogenic role of chronic hepatitis B virus (HBV) and C virus (HCV) in some connective tissue diseases including systemic lupus erythematosus (SLE), overlap syndrome, rheumatoid arthritis (RA), seronegative spondylarthritis (SS) and the association with chronic liver disease.

METHODOLOGY

There were studied 155 patients, aged among 18 to 64 years old: 57 with SLE, 22 with overlap, 26 with RA, 30 with SS. The diagnoses were established using modified ARA criteria. There were performed complex immunology tests, percutaneous liver biopsy, HLA, Elisa tests with Riba confirmation for detecting HCV and HBV.

RESULTS

17% of SLE patients were infected with hepatitis viruses, predominantly B (70%). Half of them had a hepatic involvement due to the hepatitis viruses. 23% of RA patients were equally B\C infected with only one case of hepatic involvement secondary to hepatitis viruses. All the HCV infected patients had rheumatoid factor (RF) IgG-IgM type, with low serum levels of haemolytic complement (CH50), increases serum levels of circulating immune complexes (CIC) and evidence of HLA DR4 In the group of SS 40% of patients were infected mostly with HBV. In HLA B27 (+) anchylosing spondylitis (AS) the incidence of HBV was 100%.

CONCLUSIONS

There is no high prevalence of HCV infection in SLE, overlap syndrome or RA, compared to the control group. In SS the prevalence is increased (40%), especially HLA B27 (+) AS group (33%), in which HBV is noticed at a rate of 100%. The association SLE-HCV favours the visceral involvement especially renal ones, while the presence of HBV is associated with decrease of lupus activity. In RA, HCV induces IgG-IgM RF with complement activation, being considered as a trigger of the disease in HLA DR4 patients. In HLA B27 (+) AS. HBV may trigger the development of disease in genetically susceptible individuals.

Treatment with alpha-interferon in chronic hepatitis

The treatment of chronic viral hepatitis with Interferon has been introduced in clinical practice over the past decade an represents an important step in the management of those diseases. The data existing in literature are conflicting about the dose and period of treatment with Interferon, many treatment schedules being proposed. There are also a lot of markers used or proposed to be used to determine the response to treatment, their predicting efficacy being largely studied. The response to alpha-Interferon in a standard 6 month regimen in chronic hepatitis B, chronic hepatitis C and chronic hepatitis B and C is studied; alanine-aminotransferase (ALAT) and aspartate-aminotransferase (ASAT) are the markers used to determine the response to treatment.

Comparison between reverse transcription-polymerase chain reaction and immune enzyme assays in the diagnosis of hepatitis C virus infection

This is the first study of HCV infection performed in Romania by reverse transcription-polymerase chain reaction (RT-PCR). We set up our own protocol, using "nested" primers located in the 5' UTR of HCV. Thirty two patients, 16 with chronic hepatitis, 7 with hepatic cirrhosis and 9 without chronic hepatic disease were investigated. The assignment of each patient to one of the groups was based on clinical and laboratory criteria, especially transaminase levels and hepatic biopsy findings. In 14 out of 16 (87.5%) chronic hepatitis cases and in 6 cases of hepatic cirrhosis out of 7 (85.7%), there was good agreement between RT-PCR and ELISA results. Transaminase levels were concordant with RT-PCR results in 27 of 29 cases (93.1%) but in only 21 of 29 cases (72.4%) transaminase levels were in agreement with ELISA results. In two patients treated with interferon, transaminase levels and the other clinical and laboratory parameters fell in the normal range in parallel with the disappearance of viremia, whereas anti-HCV antibodies were still detectable. RT-PCR has a higher specificity in detecting the etiology of hepatic diseases if compared to ELISA and an at least equal sensitivity. The method proves to be the best means for the confirmation of HCV infection, and for the monitoring of interferon therapy.

Interdependence between Zn and Cu serum concentrations and serum immunoglobulins (IgA, IgM, IgG) in liver diseases

The object of this study was to find out, by means of statistical-mathematical methods, whether the serum concentrations of Zn and Cu had a role in the interrelation among immunoglobulins IgA, IgM, IgG in four groups of subjects with various forms of liver diseases. It was found that the correlation structure between IgA, IgM, IgG and the serum concentration of Zn or Cu were different in the four types of diseases studied, and also that of these two metal ions, Zn was the most important, influencing the interdependence between the immunoglobulins in the active forms of disease.

Variations of zinc in acute and chronic hepatitis (preliminary data)

The variations of serum zinc concentration were studied in acute and chronic hepatitis of various etiologies. Coefficients of correlation were found with serum immunoglobulins and alanine aminotransferase (ALAT). The data obtained suggest the possible utilization of these coefficients in the estimation of prognosis in acute and chronic liver diseases.

Acute abdomen in systemic vasculitides

A presentation is made of abdominal vasculitis in the course of systemic lupus erythematosus (SLE) and polyarteritis nodosa (PAN). The disease is not yet completely known and therefore it is often incorrectly diagnosed as acute abdomen requiring surgery. An accurate diagnosis of this disease is essential for the choice of the correct therapeutic attitude. Some theoretical aspects of the disease are discussed and the personal experience of the authors resulting from the study of some cases hospitalized in the Institute of Internal Medicine, are discussed.

Liver disease in systemic lupus erythematosus

The incidence of hepatic involvement was followed up in a retrospective study carried out in a group of 177 patients with SLE. The liver damage was estimated by clinical examination, the titer of hepatocytic enzymes and, in some cases by hepatic biopsy. The proportion of liver involvement was found reduced but that did not exclude severe hepatic inflammation in certain cases. A high incidence of hepatomegaly was noted in spite of the fact that the histopathologic examination often showed normal values. The entity "lupoid hepatitis" is discussed as well as its real relationship with SLE.

Is cardiac involvement in collagen diseases important? A clinical study in 917 patients

Cardiac involvement in collagen diseases was studied in 917 patients representing all the cases of collagen diseases diagnosed in the "N. Gh. Lupu" Institute of Internal Medicine between 1985 and 1987. The prevalence of the various cardiac disorders was studied within every disease or group of diseases diagnosed according to clinical, ECG, radiologic and when necessary echocardiographic data. Collagen heart disease was diagnosed in 38.2% of the patients. In the case of systemic lupus erythematosus, of polyarteritis nodosa and of progressive systemic sclerosis this proportion exceeds 50%. The most frequent cardiac disorders were the rhythm and conduction disturbances, detected in 112 patients (12.2%). The cardiomyopathies and myocarditis, not infrequent (7.4%) represented an element of severity influencing the evolution and prognosis of disease. Myocardial ischemia secondary to coronary vasculitis syndromes has proved to be an important pathogenic mechanism of cardiac disorders. By their frequency and severity, the cardiac involvements in collagen diseases have proved important, becoming sometimes a central diagnostic, therapeutic and prognostic problem.

Present-day possibilities of diagnosis and treatment of chronic liver diseases. Contributions of the research work in the "N. Gh. Lupu" Institute of Internal Medicine

A short presentation is made of the investigations on chronic liver diseases carried out in the "N. Gh. Lupu" Institute of Internal Medicine--Bucharest from its foundation to the present day. The main courses of investigation (fundamental, diagnosis, prophylaxis, treatment) are specified, with emphasis on the achievements obtained within the general context of the progress of hepatology all over the world.

Possible correlation between the zinc and copper concentrations involved in the pathogenesis of various forms of anemia

The concentrations of three trace elements (iron, copper and zinc) involved in hematopoiesis were studied in 200 patients with iron-deficit anemia, hemolytic anemia and Biermer's anemia, in comparison with a group of normal subjects. The method used was atomic absorption spectrophotometry. The results obtained showed that in iron-deficit anemia resistant to iron therapy the copper and ceruloplasmin serum concentrations are at the lowest limit of normal. This copper deficit has a negative effect on the disease by preventing hemoglobin synthesis. In iron-deficit anemias responding to iron therapy the relatively low (about 90 gamma %) zinc values have a negative effect by blocking the iron in the iron reserve. In hemolytic anemia the very high zinc serum concentrations (over 200 gamma %) may lead to a shortening of the erythrocytes life span due to its "entatic state". In Biermer's anemia zinc by its high concentration has a positive role owing to carbonic anhydrase which eliminates more rapidly carbon dioxide from the organism.

Use of the Romanian product Silimarina in the treatment of chronic liver diseases

The Romanian product Silimarina (synonym Legalon) was administered in a randomized double-blind trial, to a group of 180 patients with chronic persistent hepatitis (CPH), chronic active hepatitis (CAH) and hepatic cirrhosis (HC). The trial lasted for 40 days. The results showed favourable effects similar with those obtained with other preparations produced by foreign drug industries. The Romanian product proved to have no toxic effect. The authors discuss the present possibilities of estimating the evolution of chronic liver disease.

HBsAg positive secondary autoimmune active chronic hepatitis. Immunogenetic aspects

Observations were made in a group of 120 patients with active chronic hepatitis (ACH), using demonstration of HBsAg presence, structural study of the peripheral blood mononuclear cell population by means of scanning electron microscopy (SEM) and typing of HLA-A, B and C antigens. From the whole group 22 patients were proved to have an autoimmune form of ACH secondary to infection with hepatitis B virus (HBV). The authors consider that the diagnostic value of the ratio between B and T lymphocytes (studied by SEM) is relative but the demonstration of an increased percentage of monocytomacrophage cells and the presence of "killing phenomenon" clearly reflect a more severe hepatic inflammation. A higher incidence of the HLA-Bw35-Cw4 was observed particularly in the HBsAg positive forms of ACH and in the HBsAg positive secondary autoimmune forms. The authors discuss the utility of these observations when the opportunity of corticotherapy has to be established.

Observations on HBsAg positive systemic vasculitis

The clinical and laboratory data regarding the presence of serum markers of hepatitis B virus (HBV) were studied in a group of patients with necrotizing vasculitis. A high incidence of skin and articular alterations, of cryoglobulinemia and rheumatoid factor, was observed in HBsAg carriers. The potential role of HBV in the pathogenesis of systemic vasculitis is discussed.

Aspect of the evolution of viral hepatitis two years after the acute phase

A group of 214 nonselected former patients with viral hepatitis of which 15 HBsAg negative and 62 HBsAg positive, was studied prospectively by following the evolutive variations between the first and second year after the acute phase of disease. In both groups the percentage of cured cases increased moderately but the evolutive process toward the chronic stage was observed to reappear in some of the cases apparently cured thus proving that the process of becoming chronic is not completed within 1 year after the acute phase. The percentage of chronic cases after HBsAg positive hepatitis is clearly higher than after HBsAg negative hepatitis the difference being more evident in active chronic hepatitis. The risk of becoming chronic is greater after HBsAg positive viral hepatitis with prolonged clinical forms and the HB antigen also persists longer in the serum. In conclusion the necessity of clinical and biologic control of all former patients with viral hepatitis for at least 2 years after the acute phase is strongly emphasized.

The Bucharest multifactorial prevention trial. The changes of morbidity and of general and specific mortality

The paper presents the results of the Bucharest multifactorial prevention trial of coronary heart disease, concerning changes in cardiovascular morbidity and mortality during the first 5-year-period of follow-up. The age adjusted 5-year-rates disclose important reductions in the intervention group in comparison with the control one: for hard events (myocardial infarction, stroke, acute coronary insufficiency)--by 41%; for myocardial infarction--by 35%; for coronary mortality--by 38%; for stroke--by 39%; for cardiovascular mortality--by 30%. The decrease of hard events, myocardial infarction and stroke incidences are statistical significant. The evolution curves of cardiovascular morbidity and mortality show that both groups (the intervention as well as the control one) began with near the same values, but on the way and especially after 5 years they are differently located, those of the control group being higher than those of the intervention group.

The Bucharest multifactorial prevention trial of coronary heart disease. General methodology and risk factor correction after five year follow-up (1971-1977)

Both the intervention and the control group included each 5000 men aged 40-60 years, randomly selected by their home address in five districts of the city of Bucharest. The intervention group underwent an "at entry" examination for risk factor detection (high serum cholesterol, high blood pressure, overweight, diabetes, minor ECG abnormalities, family history) and subsequently a five-year multifactorial intervention aimed to reduce the risk factors. Both groups were followed up in this lapse of time for major end-points: myocardial infarction, stroke, sudden death. The qualitative analysis of the results used ten evolution indices based on a quantal counting and lead to a classification of risk factors which allowed the setting up of a strategy for their correction. The quantitative analysis showed the following decreases between the first and the last examination in the intervention group: for serum cholesterol greater than or equal to 250 mg/dl -17%; for cigarettes/day greater than or equal to 15-53%; for overweight greater than or equal to 30% - 13.57%; for high blood pressure -8%; for the overall risk computed by multiple regression -33.8%.

Criteria for immunosuppressive treatment (corticotherapy) in the early stage of chronic viral hepatitis

Thirty-five patients showing quatitative deviations from normal of the M and G immunoglobulin (Ig) fractions were selected for study from a larger group of patients with viral hepatitis. In 15 of the 35 cases, most of which showed high IgM and/or IgG serum levels, moderate doses of prednisone were administered for 60 days. Determinations of Ig levels were performed before and after corticotherapy, two and four months respectively after the onset of the acute viral hepatitis. The rest of 20 patients were used as controls. In the cases in which the clinical and biological parameters indicated an improvement after treatment, the initial high IgM titers showed a tendency to decrease while in those with severe evolution, IgM levels increased. A similar behaviour of IgM titers, though less marked, was also noticed in the control group, of untreated patients. These variations are assumed to predict the further favourable of severe course of the disease; Ig variations and particularly the IgM ones, might be useful criteria for the selection of cases with high risk of developing chronic hepatitis, so that corticotherapy could be applied in the early stages, to prevent the progress to more severe forms of the disease.