OSAS in developing age: Screening of a Southern Italy population

AIM

The aim of this study was to determine the prevalence of OSAS' risk in children of the province of Catanzaro, Italy.

MATERIALS AND METHODS

A sample of 2445 scoolchildren aged 6 to 12 years of the province of Catanzaro (Italy) were administered the Pediatric Sleep Questionnaires (PSQs) in its validated Italian version. A total of 1772 questionnaires were collected; however, 130 of them were excluded, and 1642 questionnaires were accepted and scored.

RESULTS

According to final scores of questionnaires, 172 children (10.47%) were considered at risk for OSAS. No statistically significant association between sex and risk of OSAS was found (p = 0.189). The risk of OSAS was equally distributed in all ages (p = 0.984). It was found that the most common habits in children with risk of OSAS were: snoring, heavy or noisy breathing, oral breathing, xerostomia, difficulty waking up in the morning, behavioural disturbances during the day and excess weight.

CONCLUSION

The study showed a high risk of OSAS, suggesting the importance of first-level screening and the need to pay special attention to the diagnosis of this syndrome.

Nutritional status of patients undergoing ileal pouch-anal anastomosis

The nutritional consequences of total colectomy and ileal pouch-anal anastomosis (IPAA) were assessed by evaluating 36 patients at the end of the defunctionalised stage (DS group) and 18 patients with recanalised IPAA (IPAA group). The changes in protein-calorie and zinc status occurring after the closure of the diverting ileostomy were evaluated also in 11 patients assessed both during the DS and the IPAA stage. The results were compared with those observed in 14 patients who underwent a Brooke-type permanent ileostomy (PI group). In the DS group there were protein-calorie malnutrition in 50% of cases characterised by body weight, TSF and AMC values lower than normal associated with normal serum protein levels; severe salt and water depletion with secondary aldosteronism in 90%; normal calcium-phosphorus balance in all but few cases, low values of parameters related to vitamin D and K, Fe, Zn and Cu status in 6-25% of cases and normal folate status. In the IPAA group all the anthropmetric parameters improved significantly after the closure of the protective ileostomy, but muscle mass (AMC) remained lower than normal in 40% of cases; mild salt depletion (urinary Na K ratio between 1 and 2) was observed in 1 3 of cases and of severe degree (urinary Na K < 1 ) in 20%; lower serum Zn occurred in 60% of patients probably due to greater requirements of the metal, secondary to increased muscle protein synthesis; parameters of calcium-phosphorus balance, vitamin D and K, folate, Fe and Cu status, were normal in almost all the cases. In the PI group, protein-calorie and salt and mineral nutritional status were similar to those of the IPAA group, whereas Zn status was normal in all the patients and erythrocytes folate levels and prothrombin time were significantly lower than in the IPAA group. These last two results might be explained by the different characteristics of the small bowel flora occurring in the two types of ileostomy.

Factors associated with gallstone disease in the MICOL experience. Multicenter Italian Study on Epidemiology of Cholelithiasis

The epidemiological associations of gallstone disease were evaluated in a general population sample of 29,584 individuals (15,910 men and 13,674 women; age range, 30-39 years) belonging to 14 cohorts examined between December 1984 and April 1987. Subjects were screened for the presence of gallstones by gallbladder ultrasonography, completed a questionnaire, and underwent a physical examination and blood chemistry tests. Participants were considered to have gallstone disease if they had already had cholecystectomy or gallstones. Statistical associations were established by univariate analysis of the age-standardized data and by stepwise multiple logistic regression. Increasing age and body mass index and a maternal family history of gallstone disease were the most consistent associations (both at univariate and multivariate analysis and in both sexes) found in this study. Personal history of dieting was associated with gallstone disease in men, and at univariate analysis, in women. Decreasing serum total cholesterol levels and increasing serum triglycerides were associated with gallstone disease in both sexes in the multivariate analysis. In women, associations were also found with a number of pregnancies and paternal family history of gallstone disease. A slight but negative association with contraceptive pill use was identified only at multivariate analysis. Associations (investigated at univariate analysis) were also found with diabetes, cirrhosis, angina or myocardial infarction, and peptic ulcer. There was no association with smoking habits and use of aspirin or antirheumatic drugs.

Serum lipid and lipoprotein patterns in patients with liver cirrhosis and chronic active hepatitis

BACKGROUND

An impaired lipid metabolism is often found in patients with chronic liver diseases. Unfortunately, few studies are available concerning serum lipid and lipoprotein levels in patients with liver cirrhosis and chronic active hepatitis (CAH).

OBJECTIVES

To evaluate low-density lipoprotein (LDL), high-density lipoprotein (HDL), very low-density lipoprotein (VLDL), and total cholesterol serum levels in patients with cirrhosis and CAH and control patients and to relate the findings to the severity of the cirrhosis (Child classification).

METHODS

We measured the serum lipid pattern in 34 consecutive patients with liver cirrhosis (15 men and 19 women; mean [+/-SD] age, 55 +/- 14 years; Child classes: 14 in A, 9 in B, 11 in C; patients with biliary cirrhosis were excluded), 34 patients with CAH, and 34 control patients. The 3 groups were matched for sex and age. Total serum, HDL cholesterol, and triglyceride levels were measured by enzymatic methods; serum LDL and VLDL levels were calculated.

RESULTS

In patients with cirrhosis, there was a significant decrease in LDL, HDL, and total cholesterol serum levels compared with both the patients with CAH and the control patients, while the VLDL cholesterol level in patients with cirrhosis was significantly lower compared with the control patients alone. A significant decrease in total cholesterol levels was also observed in the CAH group when compared with the control patients. In patients with cirrhosis, levels of LDL, HDL, and total serum cholesterol were progressively lower when comparing patients in Child class A with patients in class C.

CONCLUSIONS

In this study, the striking decrease in the level of serum LDL cholesterol in patients with liver disease was related to the increasing severity of the disease. Accordingly, the assessment of the serum LDL cholesterol level is important for an effective treatment and prognostic evaluation of patients with chronic liver disease.

Flutamide-induced toxic hepatitis. Potential utility of ursodeoxycholic acid administration in toxic hepatitis

Flutamide is a nonsteroidal antiandrogen commonly used in the treatment of prostate cancer. Hepatic toxicity associated with flutamide has been reported with an incidence from less than 1% to about 5%. Ursodeoxycholic acid (UDCA), a hydrophilic bile acid, has been widely used in the treatment of cholesterol gallstones and of several liver diseases, but few data are now available concerning its use in the management of drug-induced hepatitis. The case of a patient who presented severe hepatitis with jaundice following use of flutamide is reported. UDCA treatment was started on admission and, contemporaneously, flutamide was withdrawn. Clinical and biochemical improvement was progressively observed, and the patient was discharged six weeks after the admission. Since fatal flutamide-related hepatitis has been reported, monitoring of serum liver tests is advocated during flutamide administration, and the effectiveness of UDCA in the treatment of drug-induced hepatotoxicity requires further study.

Bone turnover in patients on home parenteral nutrition: alongitudinal observation by biochemical markers

In order to characterize biochemical markers of bone turnover in home parenteral nutrition(HPN) patients, 8 adult patients on HPN for benign intestinal failure were studied at 0, 6 and 12 months by evaluating serum osteocalcin (bone formation marker), urinary hydroxylysyl pyridinoline, lysyl pyridinoline and beta-galactosyl hydroxylysine (bone resorption markers), serum PTH, Calcitonin, 25 vitD, 1-25vitD, serum and urinary minerals, body weight, rehabilitation degree and HPN characteristics. Three patients entered the study 2-3 months after the beginning of HPN. Their features of bone turnover were homogeneous, characterized by increased resorption associated with normal or increased formation, at baseline, and normalization of resorption associated with an increase or a parallel decrease of formation, at 6 months. At 12 months, the patterns were similar to those observed at 6 months. The patients were not of the same sex and age and had different underlying diseases and types of intestinal failure, HPN composition and serum vitamin D levels. They had weight gain that was already present at baseline and the positive outcomes of the rehabilitation and clinical status in common. Five patients entered the study more than 1 year after the beginning of HPN. They showed heterogeneous features of bone turnover that were stable throughout the study, characterized by increased resorption associated with low or normal formation in two cases, low normal resorption associated with low or normal formation in three. In one patient, who had increased resorption and low formation, the bone turnover appeared to be explained by the nutritional and clinical outcomes, which were negative. These results appeared consistent with those obtained in previous studies by bone histomorphometry, indicating that bone turnover of short-term HPN patients differed from that of long-term patients, and suggesting that the early months of HPN were associated with increased bone resorption.

Serological response to Helicobacter pylori in gastric and non-gastric cancer

1. We aimed to evaluate the seroprevalence of Helicobacter pylori (H. pylori) in gastric cancer, non-gastric cancer and outpatients by ELISA and iso-electric focusing, and to compare histology and serology for H. pylori in gastric cancer and outpatients. 2. In 124 patients with gastric cancer, 78 patients with non-gastric cancer and 110 outpatients, H. pylori seroprevalence was assessed by ELISA and isoelectric focusing. Gastric cancer and outpatients underwent endoscopy with biopsies. 3. Seroprevalence by ELISA was significantly higher in gastric cancer compared with non-gastric cancer (84% versus 56%, P < 0.001) but not with outpatients (84% versus 74%). Iso-electric focusing detection of H. pylori was comparable to ELISA: 85, 51 and 75% in gastric cancer, non-gastric cancer and outpatients respectively. Oligoclonal iso-electric focusing was significantly more frequent in gastric cancer compared with non-gastric cancer and outpatients: 69% versus 45 and 46% respectively, P < 0.01. The reliability of H. pylori detection by antral biopsy was significantly lower in gastric cancer compared with outpatients: 36% versus 74% (P < 0.001). In gastric cancer, ELISA and iso-electric focusing were significantly more reliable than histology in H. pylori detection (84 and 85% versus 36% respectively) (P < 0.001). 4. Serological immune response to H. pylori in gastric cancer, non-gastric cancer and outpatients seems different both quantitatively and qualitatively; serology was more reliable than histology in detection of H. pylori in gastric cancer.

Endoscopic ultrasonography in gastric lymphoma

Endoscopic ultrasonography (EUS) was performed in 82 patients with primary gastric lymphoma. EUS correctly diagnosed lymphoma in 76/82 patients, with a sensitivity of 93%. Positive predictability was 91%, specificity 98%, and negative predictability 98%. Diagnostic accuracy was 97%. In the evaluation of lymphoma, depth invasion EUS was correct in 87% of cases. EUS disclosed metastatic perigastric lymph nodes in 15/27 patients, with a sensitivity of 56%. Positive predictability was 100%, specificity 100%, and negative predictability 82%. Diagnostic accuracy was 85%. Differential diagnosis with EUS among lymphoma, linitis plastic and Ménétrier's disease was difficult. Large particle biopsy must be considered when EUS diagnosis of these diseases remains uncertain.

Bacteria in biopsies of human hypochlorhydric stomach: a scanning electron microscopy study

A long-lasting condition of hypochloridria leads to a bacterial growth both in the gastric lumen and biopsies of human stomach. Some of these bacteria are probably involved in gastric carcinogenesis, due to their capacity of nitrosation. This study was carried out on biopsies taken during endoscopy from both gastric antrum and the body of patients with or without hypochloridria. Scanning electron microscopy observation shows that bacteria, other than Helicobacter pylori, found in hypochloridria, can be located not only over but also into and under the mucus layer covering the gastric epithelium. In such areas, mechanical and biochemical damage may occur.

Enzymatic cytochemistry, DNA ploidy and AgNOR quantitation in hepatocellular nodules of uncertain malignant potential in liver cirrhosis

Conventional histological examination of echo-guided biopsy specimens can be inconclusive in small nodular lesions in cirrhotic livers. We investigated the diagnostic potential of cytochemical analysis of dipeptidyl-peptidase IV (DPP IV), of image analysis of nuclear DNA content, and of interphase silver-stained nucleolar organizer regions (AgNORs) in 12 cases of small (13- to 29-mm in diameter) hepatic nodules visualized in cirrhotic patients by ultrasonography. All cases underwent an echo-guided liver biopsy at the time of detection and in none of them were histological signs of malignancy found. Characterization with the above-mentioned techniques was always done at the time of histological examination. These patients underwent a mean (+/- SD) follow-up of 27.0 (+/- 11.2) months after biopsy, with repeated ultrasound (US) examinations. In the seven patients with subsequent neoplastic growth, DPP IV score was altered in five of six; the fraction of mononucleated polyploid cells was altered in six of seven; and the AgNOR quantity exceeded the cutoff value of 4 microns2 in five of five cases. Among the five lesions whose US appearance remained unchanged during the follow-up, only one abnormality (AgNORs) was found in one case. The combined cytochemical analysis of DPP IV, nuclear DNA content, and quantitative evaluation of interphase AgNORs in biopsy samples may contribute to the differential diagnosis of hepatocellular nodules of uncertain type in the cirrhotic liver.

Gastric emptying of solids in morbid obesity

OBJECTIVE

To evaluate the effect of weight loss induced by dietetic treatment, with or without an intragastric balloon, on gastric emptying of obese subjects.

SUBJECTS

20 morbidly obese subjects (21-54 years, 45.3-58.0 kg/m2) and 20 healthy controls (21-56 years, 20.3-24.8 kg/m2).

DESIGN

Parallel study of a 4 month, low calorie dietetic treatment with or without a 500 ml intragastric balloon.

RESULTS

In basal conditions, obese subjects had accelerated gastric emptying as compared to healthy controls. At the end of the dietetic treatment period, a significant decrease of body weight was obtained. Patients also showed a slowing of gastric emptying. Both the weight loss and the slowing of gastric emptying occurred irrespective of the presence or absence of the intragastric balloon.

CONCLUSION

The present findings are compatible with the hypothesis that gastric emptying, food intake and body weight are integrated parameters in subjects with morbid obesity.

In hepatocellular carcinoma AgNOR protein expression correlates with tumour mass doubling time

AIMS/METHODS

The relationship between AgNOR protein expression and doubling time was evaluated in 20 untreated nodules of hepatocellular carcinoma arising in cirrhotic liver. AgNOR protein quantity within the lesion was defined by image cytometry on histological sections from frozen biopsies obtained under ultrasound-guidance, selectively stained for AgNOR proteins. Tumour doubling time was calculated 6 months after diagnosis by measuring the volume variations of the nodules over a fixed period by "real time" ultrasonography.

RESULTS

The doubling time of nodules characterized by high AgNOR protein area values (> 5.50 microns2, corresponding to the median AgNOR protein value) was shorter than that of nodules with low AgNOR protein area values (< 5.50 microns2). A highly significant difference in the mean doubling time values between the two groups (6.31 +/- 2.68 (E.S.) versus 15.92 +/- 3.03 (E.S.) months, respectively; p = 0.009) was found. Moreover, when the relationship between AgNOR protein and doubling time values was tested by linear regression analysis, a significant inverse correlation was observed (r = -0.68; p < 0.005).

CONCLUSIONS

Our results indicate that AgNOR protein quantity represents a reliable parameter for predicting the tumour growth rate of untreated hepatocellular carcinoma nodules. Among the procedures commonly employed for the assessment of cell proliferation, the evaluation of the AgNOR parameter seems to be particularly suitable for kinetic analysis of ultrasound-guided fine-needle liver biopsies.

Spectrotypic analysis of antibodies to Helicobacter pylori in patients with antral gastritis and duodenal ulcer

AIMS

To investigate the anti Helicobacter pylori (H pylori) spectrotype associated with (a) antral gastritis and duodenal ulcer; (b) the H pylori eradicating treatment.

METHODS

Spectrotypic analysis was performed by isoelectric focusing and reverse blotting (IEFRB) in a cross sectional study on sera from 70 patients with antral gastritis and duodenal ulcer. In addition, a longitudinal study was performed on 40 of these patients (20 with antral gastritis and 20 with duodenal ulcer) who underwent eradicating treatment.

RESULTS

The cross sectional study showed that the oligoclonal spectrotype was present in 74% of antral gastritis patients and in 85% of duodenal ulcer patients. In only a minority of subjects (23% with antral gastritis and 3% with duodenal ulcer) was a polyclonal spectrotype observed. The longitudinal study showed a reduction in the intensity of the spectrotypic bands in 5/10 antral gastritis patients with eradicated H pylori as opposed to only 2/10 patients without eradication. A reduction was also observed in 6/11 eradicated v 0/9 non-eradicated patients with duodenal ulcer. Collectively, a reduction in the spectrotype was observed in 11/21 patients (52%) who--independently of the disease--underwent H pylori eradication, as opposed to 2/19 of the non-responder patients (10.5%). The polyclonal spectrotype was found exclusively in four patients with antral gastritis, all belonging to the group without eradication of H pylori after eradicating treatment.

CONCLUSIONS

The anti H pylori oligoclonal spectrotype is the most common pattern observed in patients with antral gastritis and duodenal ulcer. After H pylori eradicating treatment the spectrotype does not change qualitatively, but the polyclonal pattern seems to be predictive of a poor response to eradication.

Helicobacter pylori status, endoscopic findings, and serology in HIV-1-positive patients

We have carried out a large prospective study of the frequency of H. pylori infection and HIV-1 status in a community of ex-drug abusers including subjects with (N = 210) and without (N = 259) upper gastrointestinal symptoms, endoscopy and serology. Control groups were patients with upper gastrointestinal symptoms not at high risk of HIV-1 infection (N = 219) and asymptomatic blood donors (n = 322). H. pylori was present in 52% of symptomatic community residents having endoscopy and 55% of the control patients with symptoms but not at high risk of HIV-1 infection. H. pylori was less common in HIV-1-positive patients (40%) than those who were negative (66%; P < 0.001). In patients with AIDS (33%), the frequency of H. pylori infection was reduced compared to HIV-1-positive patients without AIDS (53%; P = 0.05). All the residents with AIDS had upper gastrointestinal symptoms. In community residents, peptic ulcer was always associated with H. pylori infection. By H. pylori serology, there was no difference in the frequency of infection in asymptomatic residents (56%) whether HIV-1 positive (55%) or HIV-1 negative (58%) compared with those residents with symptoms. Overall, H. pylori was less common in HIV-1-positive residents (49%) than those who were HIV-1 negative (61%; p < 0.05). This difference was due mainly to the low frequency of infection in residents with AIDS (33%). H. pylori infection is common in HIV-1 positive patients, and only slightly reduced when compared with at-risk HIV-1-negative subjects. Peptic ulcer is associated with H. pylori in HIV-1 infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Portal hypertension: review of data and influence on management

It is evident that endoscopic ultrasonography could have a great clinical role in the selection of the best treatment for the individual patient because it allows the simultaneous visualization of a large part of the portal venous system and its collaterals. It has not been shown that the same kind of treatment is suitable for every patient with portal hypertension, and failure of a particular treatment may be attributable to an incorrect selection of patients. Further perspective studies with EUS in patients with portal hypertension are thus necessary in order to clearly state the cost-benefit of this technique in the management of these subjects.

Peptic ulcer and its course in cirrhosis: an endoscopic and clinical prospective study

The epidemiological and clinical characteristics of peptic ulcer were studied in 324 of 368 consecutive patients with cirrhosis of the liver during a mean period of 1.2 (+/- 0.61) years. Peptic ulcer prevalence rates in patients with cirrhosis were as follows: point prevalence 11.7%, period prevalence 15.1%, and life-time prevalence 24.2%. The annual incidence rate observed in 140 patients with cirrhosis undergoing endoscopic follow up was 4.3%. Ulcers were asymptomatic in more than 70% of patients. The peptic ulcer complication rate at entry was 20% in the whole group and 40% in those who had not a previous diagnosis of peptic ulcer when admitted to the study. Peptic ulcer was more frequent among HBsAg+ cirrhotics (p = 0.05). Patients with more severely decompensated cirrhosis also had a higher frequency of asymptomatic ulcers (p = 0.04), gastric ulcers (p = 0.01) and asymptomatic gastric ulcers (p = 0.005). After diagnosis, during endoscopic follow up, gastric ulcer in patients with cirrhosis tended to heal slowly and recurred with higher frequency than in controls without cirrhosis (p = 0.04). Seventy-nine per cent of peptic ulcer recurrences were asymptomatic in patients with cirrhosis. There were no complications during the follow-up period: this could be due to the regular timing of endoscopy, which permitted early detection and treatment of the recurrences, thus preventing further complications.

Patterns of gastric emptying in dysmotility-like dyspepsia

BACKGROUND

As the gastric emptying time delay of patients with functional dyspepsia is not correlated with the severity of dyspepsia complaints, we investigated the pattern of intragastric distribution of a meal with an ultrasonographic method in different groups of dyspeptic patients.

METHODS

The final gastric emptying time and the postprandial variations of the cross-sectional area of the gastric antrum were measured ultrasonographically, and dyspeptic symptoms were scored in 41 patients with dysmotility-like dyspepsia, of whom 31 did not have digestive or systemic diseases known to affect gut motility (group A) and 10 had scleroderma involving the upper gut (group B). Twelve normal subjects were examined as a control group.

RESULTS

The final emptying times of groups A and B did not differ significantly but were both significantly longer than that of controls, whereas the antral area at 60 min showed a significantly greater increase in patients of group A than in group B. The symptom score showed significantly more severe dyspepsia in group A than in group B.

CONCLUSIONS

The fact that the postprandial antral distention was more marked in the dyspeptic patients with more severe symptoms suggests that this motor pattern could play a more important role in the genesis of dyspeptic symptoms than the delay in gastric emptying time, which was similar in the two groups.

Colorectal cancer in patients with ulcerative colitis. A prospective cohort study in Italy

BACKGROUND

The aim of this study was to assess the development of dysplasia or cancer in patients with ulcerative colitis and to determine the effectiveness of colonoscopy and biopsy follow-up in colon cancer surveillance.

METHODS

From 1980 to 1986, 65 patients who had ulcerative colitis for 7 years or more participated in a surveillance program of colonoscopy and biopsy. This cohort was followed until December 1992. Forty-nine patients (75.4%) had extensive colitis and 16 (24.6%) left-sided colitis. The mean disease duration was 17.2 years. Three hundred four colonoscopies were performed. During each endoscopy, random biopsies were performed.

RESULTS

Seven patients had definite dysplasia of the colorectal mucosa. Four of them had high grade lesions and underwent surgery. In all of these patients, colon cancer (3 Dukes' Stage A, 1 Dukes' Stage B) was found. No cancer was found in the other patients. Pedunculated adenomas were excised from 6 other patients during colonoscopy. When dysplasia was diagnosed, these patients were older than those who were dysplasia free, whereas the age at onset of colitis was significantly higher in the former (P < 0.01). Fifteen patients discontinued follow-up. Two of them developed colon cancer diagnosed at an advanced stage.

CONCLUSIONS

Dysplasia, especially of high grade, is a marker of colon cancer risk in patients with longstanding ulcerative colitis. Intensive colonoscopy and biopsy surveillance can lead to the diagnosis of colon cancer at a potentially curable stage. In this series, older age appeared to be an additional risk factor. A careful selection of patients with ulcerative colitis seems mandatory to minimize the cost and optimize the benefit of colon cancer surveillance programs.

The susceptibility of Helicobacter pylori to the rifamycin, rifaximin

Forty strains of Helicobacter pylori had an MIC(50) of 4 mg/L of the non-absorbably antibiotic, rifaximin. Neither synergy nor antagonism was demonstrated when the drug was combined with ampicillin, metronidazole and omeprazole and the rate of spontaneous mutation was less than 1 in 10(8). With these in-vitro characteristics, rifaximin should now be assessed for clinical efficacy.

Cytochemical detection of a class 3 aldehyde dehydrogenase in human hepatocellular carcinoma

The development of hepatocellular carcinoma in rodents treated with different chemical compounds is associated with the appearance in the cytosol of neoplastic liver cells of an unusual aldehyde dehydrogenase isozyme of class 3 (ALDH-3) which is very active with aromatic aldehydes. This tumor-associated isozyme is readily detected by enzyme cytochemistry using the substrate benzaldehyde with NADP as coenzyme. To determine whether human hepatocellular carcinomas express ALDH-3, the activity of this isozyme was examined in frozen sections from 68 echo-guided human liver biopsies. In 54 cases the guided biopsy was performed on one or more nodules suggestive for hepatocellular carcinoma found at ultrasonography within the liver parenchyma. The remaining 14 patients were affected by chronic active hepatitis or cirrhosis. An intense enzymatic activity was ascertained in 5 out of 36 hepatocellular carcinomas. In non-neoplastic liver, in macroregenerative nodules and in metastatic adenocarcinomas enzymatic activity was not detectable. ALDH-3-positive tumors were typical hepatocellular carcinomas (histological grade II and III). These results suggest that ALDH-3 is a phenotype associated with malignancy in human liver tumors.

Analysis of clinical and virological factors associated with response to alpha interferon therapy in chronic hepatitis C

Interferon alpha (IFN-alpha) therapy is currently the treatment of choice for chronic hepatitis C (HCV) infection, but it fails to achieve a sustained response in approximately 75% of those treated. The factors which determine whether or not an individual will respond to IFN-alpha are uncertain, although a number of potentially predictive factors have been proposed. In this study a wide range of clinical, demographic, and virological parameters were evaluated in relation to therapeutic outcome in a group of 30 Italian patients with chronic hepatitis C. All patients received 3 MU leukocyte-derived IFN-alpha three times a week for 6 months and were then followed prospectively for at least 12 months. 53% of patients responded initially, but a sustained response was observed in only 17%. Responders were found to be significantly younger than nonresponders (45.6 +/- 3.1 vs. 55.4 +/- 2.7), and less frequently cirrhotic (2/16 vs. 7/14). Sustained responders had a mean pretreatment HCV-RNA titer approximately tenfold lower than that of those who did not have a sustained response, but the difference was not statistically significant. HCV genotype was found to be significantly associated with both initial and sustained response. Patients infected with HCV-2a were more likely to respond (89%) than those who were infected with HCV-1b (37%), and they were also more likely to sustain that response (33% vs. 6%).(ABSTRACT TRUNCATED AT 250 WORDS)

Chromosomal instability in multiple endocrine neoplasia type 1. Cytogenetic evaluation with DEB test

Multiple endocrine neoplasia type 1 (MEN 1) is an autosomal dominant condition with high penetrance and variable expressivity, in which tumors or hyperplasia occur in two or more endocrine organs. Some authors have investigated chromosomal instability in MEN 1 and MEN 2; the results are controversial. Chromosome analyses were performed on lymphocytes from seven patients with MEN 1, four healthy first-degree relatives (three of whom were children), six phenotypically normal volunteers, and three patients with Fanconi's anemia. To evaluate chromosomal instability we analyzed phytohemagglutinin-stimulated lymphocyte cultures with and without diepoxibutane. We observed an increase in the frequency of spontaneous chromosomal alterations in four patients. After the DEB test we found an increase in chromatid breakages, gaps, and exchange figures. These findings support the inclusion of the MEN 1 syndrome among the disorders with "chromosomal instability."

Familial adenomatous polyposis and inflammatory bowel disease associated in two kindreds

We describe two families in which some members are affected by familial polyposis syndrome: in one family a case of ulcerative colitis and in the other a case of Crohn's disease were found. This is the first report about this family association, but in our opinion the fact that two cases have been found in one series suggests that this association could be more frequent than reported so far. The research for a genetic pattern of inflammatory bowel disease could be addressed towards chromosome 5.

Abnormal esophagocardiac inhibitory reflex in patients with diffuse esophageal spasm

The aim of this study was to establish if patients with an esophageal dysmotility similar to that found in the majority of patients with 'swallow syncope' may also have a pathologic esophagocardiac reflex similar to that observed in these patients. The effects on heart rate induced by dry and solid swallows and by intraesophageal balloon distension were studied in 8 normal subjects and in 10 patients with diffuse esophageal spasm by simultaneous recording of ECG and intraesophageal pressures. Dry swallows induced a brief increase in heart rate, while deglutition of a solid bolus initially induced an increase followed by a decrease in heart rate, significantly more marked in patients with diffuse spasm. The intraesophageal balloon inflation induced a decrease in heart rate which was significantly more intense in patients with diffuse spasm. In conclusion, the esophageal wall distension either due to solid bolus ingestion or to balloon inflation elicits an inhibitory esophagocardiac reflex which is more intense in patients with diffuse spasm and might induce cardiac arrhythmias in predisposed subjects.

Combination antiviral therapy with ribavirin and interferon alfa in interferon alfa relapsers and non-responders: Italian experience

BACKGROUND/AIMS

A sustained biochemical and virologic response to standard interferon therapy for chronic hepatitis C is seen in no more than 25% of patients, and the efficacy of re-treatment or of higher doses in non-responders and relapsers has not been established. A more effective therapy for interferon alfa-resistant hepatitis C is needed.

METHODS

A study of ribavirin plus interferon alfa combination therapy was conducted in 30 patients with chronic hepatitis C resistant to a previous standard course of interferon alfa (14 interferon non-responders, 16 interferon relapsers). Patients were randomly assigned to receive either ribavirin, 800 mg daily, and interferon alfa, 3 MU thrice weekly (n = 15), or interferon alfa alone, 3 MU thrice weekly (n = 15), for 6 months.

RESULTS

At the end of treatment, normal alanine aminotransferase levels were observed in eight patients in the combination therapy group: one (14%) interferon non-responder and seven (87%) interferon relapsers (p = 0.01). Six months post-therapy, sustained normalization of alanine aminotransferase was achieved in seven (87%) interferon alfa relapsers, but not in any of the interferon alfa non-responders (p = 0.001). In the group of patients treated with interferon alfa alone, sustained normalization of alanine aminotransferase was observed in one interferon relapser only. Serum HCV RNA became negative in eight patients receiving combination therapy--two (28%) interferon non-responders and six (75%) interferon relapsers. Six months later, circulating HCV RNA remained negative in seven patients: one (14%) interferon non-responder and six (75%) interferon relapsers (p = 0.04). Sustained clearance of HCV RNA was not observed in patients re-treated with interferon alone. The sustained response to combination therapy was accompanied by reduced hepatic necroinflammatory activity on liver biopsy. Hepatitis C virus genotype was not significantly associated with response to combination therapy. Side effects were mild and well tolerated.

CONCLUSIONS

Our experience indicates that combination therapy of ribavirin plus interferon alfa induces sustained biochemical, virologic, and histologic responses in most patients who are interferon relapsers.

Comparison between the effects of neostigmine and ranitidine on interdigestive gastroduodenal motility of patients with gastroparesis

The antroduodenal motor effects of ranitidine, and H2-receptor antagonist with cholinergic activity, and neostigmine, a cholinomimetic drug, were compared in 16 patients with idiopathic gastroparesis characterized by dysmotility-like dyspepsia, delayed gastric emptying at scintigraphy and absence of gastroduodenal phase 3 of the migrating motor complex during a manometric recording of at least 300 min. After overnight fasting in 8 of these patients, neostigmine was administered intravenously at a dose of 0.5 mg, and in the remaining 8 patients ranitidine was given intravenously at a dose of 100 mg. Ranitidine induced a gastroduodenal phase 3 activity in a significantly (p < 0.02) higher percentage of patients (87.5%) in comparison with neostigmine (25%). In the majority of patients, neostigmine induced only an irregular increase in gastroduodenal motor activity sometimes characterized by propagated and nonpropagated clustered contractions. This property of ranitidine of inducing a phase 3 activity in these patients cannot be ascribed to its weak cholinergic activity, as neostigmine, which has a more intense cholinergic activity than ranitidine, is unable to produce the effect demonstrated by ranitidine. Another unknown mechanism able to trigger the neurohormonal program of migrating motor complex phase 3 or to abolish inhibitory influences should be taken into account to explain this effect of ranitidine.

Distribution of three major hepatitis C virus genotypes in Italy. A multicentre study of 495 patients with chronic hepatitis C

Different genotypes of hepatitis C virus (HCV) have been shown to have distinct geographical distribution and to associate with variable clinical features. To evaluate their role in chronic hepatitis in Italian patients, we studied 495 consecutive cases with chronic hepatitis C seen in nine sentinel centres homogeneously distributed over Italy. HCV genotyping was carried out using a dot-blot hybridization assay with genotype-specific probes. Four hundred and eleven patients were viraemic and could be evaluated: 57% were found to be infected with HCV-1, 31% with HCV-2, 8% with HCV-3, 1% showed mixed infection and 3% were ascribed to HCV-2b or HCV-4 by direct sequencing. Geographical distribution showed discrete territorial variations. A history of drug addiction was commoner in patients infected with HCV-3. There were no significant differences in activity of liver disease among different HCV genotypes but the response to interferon therapy was reduced in patients infected with HCV-1 compared to HCV-2 or HCV-3.

Morphologic and cytoproliferative patterns of duodenal mucosa in two patients after long-term total parenteral nutrition: changes with oral refeeding and relation to intestinal resection

The morphologic and cytoproliferative patterns of the duodenal mucosa of two adult patients, one of whom had a short bowel, were evaluated after more than 2 months of postoperative total parenteral nutrition and 2 and 12 months after the resumption of oral alimentation. Morphometric analysis was performed on routinely processed duodenal biopsies. Cell proliferation was evaluated by means of in vitro bromodeoxyuridine uptake. The results were compared with those obtained in five healthy controls. After parenteral nutrition, patients showed significantly lower villus height and crypt depth than those of controls and a normal bromodeoxyuridine labeling index. After 2 months of refeeding, villus and crypt returned to normal, and the labeling index was increased. After 12 months of oral refeeding, labeling index, villus height, and crypt depth were similar to those of controls. The patient with the short bowel showed a number of cells per unit length of villus and crypt significantly greater than those of the controls and of the patient who underwent shorter intestinal resection. In human duodenal mucosa, (1) hypoplasia develops after long-term total parenteral nutrition; (2) mucosal recovery occurs through an increased cell proliferation after oral refeeding; and (3) extensive small bowel resection determines the development of relative hyperplasia.

Endoscopy versus endoscopic ultrasonography in staging reflux esophagitis

Precise staging of reflux esophagitis is very important for therapeutic decisions; in fact, chronic gastroesophageal reflux may cause transmural inflammation that leads to fibrosis with loss of esophageal wall compliance. In reflux esophagitis, endoscopic stating is limited to mucosal injury, while endoscopic ultrasonography (EUS) is able to visualize changes in the layer structure and localized or diffuse thickenings of the esophageal wall. In order to evaluate the usefulness of EUS in reflux esophagitis, a prospective study of 31 patients and ten normal subjects was performed. Endoscopic reflux esophagitis was staged as: E1 (erythema, n = 7), E2 (erosions, n = 13), E3 (ulcers, n = 11). EUS findings were recorded and evaluated at five different levels, starting from the gastroesophageal junction, using a quantitative method, the center line method. With this method, the sectorial and mean thickness, and area were calculated for each level. There was a significant difference between patients with reflux esophagitis and normal subjects in our study. E3 patients showed a significant upward involvement of the wall far from the visible lesions. Mild esophagitis may also cause esophageal wall thickening, involving even the entire wall. There was no correlation between the onset time of symptoms and the degree of thickening. In conclusion, EUS seems to be an important supplement to endoscopy in staging reflux esophagitis, as the progression of the inflammation is not related to the endoscopic findings.

Diagnostic and prognostic value of DNA ploidy and cell nuclearity in ultrasound-guided liver biopsies

BACKGROUND

Focal nodule lesions in patients with cirrhotic livers may be visualized by using imaging techniques; however, the diagnostic and prognostic judgment of biopsies from borderline lesions may be difficult using conventional histologic criteria.

METHODS

The diagnostic and prognostic value of DNA ploidy analysis determined by image cytometry of Feulgen-stained isolated hepatocytes was investigated in ultrasound-guided biopsies from 50 nodular lesions found in patients with cirrhotic livers (39 hepatocellular carcinomas [HCCs] and 11 macroregenerative nodules) and from 10 patients with livers affected by viral chronic hepatitis. Of the 11 macroregenerative nodules, 7 presented a subsequent neoplastic behavior. Specimens from the morphologically normal livers of five patients who underwent liver surgery served as control tissues. Image cytometry was performed on Feulgen-stained cytologic preparations, obtained by enzymatic digestion of formalin fixed biopsies. The DNA ploidy of the main stem line and the distribution of mononucleated and binucleated hepatocytes (nuclearity) were compared using histologic diagnosis, Edmondson's grade, tumor size, and patient follow-up.

RESULTS

The main stem line was peridiploid in all benign specimens and in 31 clinically confirmed HCCs, peritetraploid in 11 HCCs, perioctaploid in 1 HCC, and aneuploid in 3 HCCs. The fraction of mononucleated polyploid hepatocytes was found to be the best diagnostic parameter in euploid HCCs and was significantly correlated with the Edmondson grade and the nodular size. Survival information was available for 43 patients, with a median observation period of 350 days. A DNA ploidy value of the main stem line greater than 3c was an important determinant of survival as a single parameter and in association with histologic grade and greatest dimension of tumor.

CONCLUSIONS

This study suggests that the ploidy distribution analysis of mononucleated and binucleated hepatocytes can provide valuable information for making correct diagnoses and for predicting survival outcome for patients with HCCs.

Isosorbide dinitrate or nifedipine: which is preferable in the medical therapy of achalasia?

Oesophageal motor activity was recorded manometrically with a low compliance system in 16 patients with achalasia and a slightly dilated oesophagus. After a basal recording period, nifedipine 20 mg was given sublingually to 9 patients and isosorbide dinitrate 5 mg to another 7 patients. Lower oesophageal sphincter pressure (LESp) and oesophageal body pressure wave amplitude were measured for 60 min after drug administration. Both drugs decreased LESp and pressure wave amplitude, but the effect of isosorbide dinitrate was faster and more intense than that of nifedipine. There was a lower inhibitory effect of nifedipine on the amplitude of pressure waves than on LESp, while isosorbide dinitrate inhibited with a similar intensity both LESp and pressure waves.

Bioavailability of single and multiple doses of a new oral formulation of 5-ASA in patients with inflammatory bowel disease and healthy volunteers

AIMS

An oral multiparticulate coated formulation of 5-aminosalicylic acid (5-ASA: mesalazine) has been developed to provide a controlled release of the drug, in a pH-dependent fashion, in the distal ileum and colon. The purpose of the present study was to assess the systemic availability of the drug and its metabolite, acetyl-5-ASA, following single (800 mg) and multiple (2400 mg for 56 days) oral dose administration.

METHODS

Three groups were investigated: six healthy volunteers, six patients with ulcerative colitis, and nine patients with Crohn's disease in remission. In the single oral dose study (800 mg) all three groups participated, whereas in the multiple oral dose study (2400 mg/day for 56 days) only the patients with inflammatory bowel disease took part. Plasma and urine 5-ASA and Ac-5-ASA were measured for 48 h.

RESULTS

In the single oral dose regimen, systemic absorption of 5-ASA and Ac-5-ASA were low and did not differ between the three groups. Only about 20% of the 5-ASA given was absorbed, with more than 80% of the drug being available in the terminal ileum and colon for therapeutic activity. The multiple oral dose regimen in patients with inflammatory bowel disease produced a significantly higher plasma concentration and urine excretion of both 5-ASA and Ac-5-ASA by the end of the treatment, in comparison to the first dose. There was a statistically higher systemic absorption of 5-ASA in patients with ulcerative colitis than in patients with Crohn's disease. After 56 days of dosing, no adverse event was reported and laboratory screening tests remained within normal ranges.

CONCLUSIONS

The new oral 5-ASA formulation is gradually released throughout the small and large intestine, reflected by a low plasma concentration of the drug and its metabolite, with about 80% of the drug being available for ileum-colon therapeutic activity.

Long term treatment with omeprazole 20 mg three days a week or 10 mg daily in the prevention of duodenal ulcer relapse

BACKGROUND

The aim of this study was to compare omeprazole 10 mg o.m. (daily) with omeprazole 20 mg o.m. on Friday to Sunday inclusive (weekend) in the prevention of duodenal ulcer relapse over a 6-month period.

METHODS

After an open healing phase (4 to 8 weeks) with omeprazole 20 mg o.m., 81 patients entered the follow-up phase. Forty-two were randomized in a double-blind double-dummy technique, to omeprazole 10 mg o.m., and 39 to omeprazole 20 mg at weekends. At 3 and 6 months or on symptomatic relapse the patients underwent endoscopy with gastric biopsies (quantitative assessment of argyrophilic and gastrin cells), symptom evaluation, and laboratory screening with fasting serum gastrin.

RESULTS

Five patients in the 10 mg group and four in the weekend group were lost to follow-up. The estimated relapse rates over six months in the two groups receiving 10 mg daily or 20 mg at weekends were 19% and 31%, respectively (95% CI of percentage difference: -33% to 8%: intention-to-treat analysis, P = N.S.). During the follow-up phase, symptoms tended to be milder in the omeprazole 10 mg daily group compared to the weekend group. Gastrin levels increased significantly during the healing phase but then stayed almost constant in the omeprazole 10 mg group, and significantly decreased with weekend treatment. The median number of argyrophilic cells showed a slight but statistically significant increase in the omeprazole 10 mg daily group, but did not change in the weekend group. Both the healing and long-term therapies were well tolerated.

CONCLUSIONS

Our data do not show a clear difference between the two treatment regimens, but there was a tendency towards a lower recurrence rate with omeprazole 10 mg daily compared with 20 mg weekend therapy.

Diagnostic and prognostic value of DNA ploidy and cell nuclearity in ultrasound-guided liver biopsies

BACKGROUND

Focal nodule lesions in patients with cirrhotic livers may be visualized by using imaging techniques; however, the diagnostic and prognostic judgment of biopsies from borderline lesions may be difficult using conventional histologic criteria.

METHODS

The diagnostic and prognostic value of DNA ploidy analysis determined by image cytometry of Feulgen-stained isolated hepatocytes was investigated in ultrasound-guided biopsies from 50 nodular lesions found in patients with cirrhotic livers (39 hepatocellular carcinomas [HCCs] and 11 macroregenerative nodules) and from 10 patients with livers affected by viral chronic hepatitis. Of the 11 macroregenerative nodules, 7 presented a subsequent neoplastic behavior. Specimens from the morphologically normal livers of five patients who underwent liver surgery served as control tissues. Image cytometry was performed on Feulgen-stained cytologic preparations, obtained by enzymatic digestion of formalin fixed biopsies. The DNA ploidy of the main stem line and the distribution of mononucleated and binucleated hepatocytes (nuclearity) were compared using histologic diagnosis, Edmondson's grade, tumor size, and patient follow-up.

RESULTS

The main stem line was peridiploid in all benign specimens and in 31 clinically confirmed HCCs, peritetraploid in 11 HCCs, perioctaploid in 1 HCC, and aneuploid in 3 HCCs. The fraction of mononucleated polyploid hepatocytes was found to be the best diagnostic parameter in euploid HCCs and was significantly correlated with the Edmondson grade and the nodular size. Survival information was available for 43 patients, with a median observation period of 350 days. A DNA ploidy value of the main stem line greater than 3c was an important determinant of survival as a single parameter and in association with histologic grade and greatest dimension of tumor.

CONCLUSIONS

This study suggests that the ploidy distribution analysis of mononucleated and binucleated hepatocytes can provide valuable information for making correct diagnoses and for predicting survival outcome for patients with HCCs.

Body weight, fat distribution and the menopausal status in women. The VMH Collaborative Group

Since sex hormones are involved in the regulation of body composition and adipose tissue metabolism, in this study we investigated whether menopause may alter body weight and fat distribution in women. Data were obtained from the Virgilio-Menopause-Health Study, which is a longitudinal epidemiological project aimed at investigating the relationship between menopause and related plasma hormonal concentrations, body weight, fat distribution and health. Only data from the first cross-sectional examination are presented. Out of the 952 women living in the town of Virgilio, Mantua (Italy) and born between January 1st, 1932 and December 31st, 1946, 596 (62.6%) participated in the study. Since incomplete data were present in 19 women, 577 was the final sample size available for statistical analysis. The protocol included a collection of blood for hormones and biochemistry, a full clinical history with socioeconomic and personal information, drug use, smoking, dietary and physical activity habits, and several anthropometric measurements. According to the clinical and hormonal status, 160 women were classified as pre-menopausal, 124 as peri-menopausal and 293 as post-menopausal. After adjusting for age, we found that body mass index (BMI) was significantly higher in peri-menopausal than in pre-menopausal women and remained slightly, but again significantly, higher in post-menopausal women. Although waist-to-hip and waist-to-thigh ratios increased significantly and progressively from pre- to post-menopause, any difference was not significant after adjusting for age. Diet, physical activity and smoking habits did not explain the difference in BMI values. No difference was found in the use of estro-progestagen compounds between the groups.(ABSTRACT TRUNCATED AT 250 WORDS)

A pilot study of combination therapy with ribavirin plus interferon alfa for interferon alfa-resistant chronic hepatitis C

BACKGROUND/AIMS

In chronic hepatitis C, interferon alfa (IFN-alpha) therapy fails to achieve a sustained response in approximately 75% of patients. Similarly, ribavirin induces only a transient response. The aim of this study was to evaluate whether ribavirin and IFN-alpha in combination could be effective in IFN-alpha-resistant chronic hepatitis C.

METHODS

Twenty patients with chronic hepatitis C resistant to a previous course of IFN-alpha were randomly assigned to receive either ribavirin combined with IFN-alpha or IFN-alpha alone for 6 months.

RESULTS

Serum alanine aminotransferase levels decreased significantly during therapy in both treatment groups, but after therapy, the levels remained significantly decreased only in the combination therapy group. Nine months after treatment, sustained normalization of aminotransferase levels, associated with sustained loss of serum hepatitis C virus RNA, was observed in 40% of the patients in the combination therapy group but in none of the patients treated with IFN-alpha alone (P < 0.05). The sustained response was accompanied by reduced hepatic necroinflammatory activity on biopsy.

CONCLUSIONS

These findings suggest that ribavirin plus IFN-alpha combination therapy is able to induce a sustained biochemical and virological response in a significant proportion of patients with IFN-alpha-resistant chronic hepatitis C.

Steroid treatment in active Crohn's disease: a comparison between two regimens of different duration

BACKGROUND

Steroids are highly effective in active Crohn's disease; clinical relapse following steroid withdrawal, however, is frequent. We used two steroid regimens of different duration in order to compare their efficacy in inducing and maintaining clinical remission.

METHODS

Seventy patients with active Crohn's disease were treated with methylprednisolone 40 mg/day i.m. for 3 weeks and then with two different regimens of tapering dosage: one for a further 4 weeks and another for a further 12 weeks.

RESULTS

Steroid therapy induced remission within 3 weeks in 91% of the whole group of patients; at the end of each protocol remission rates were 85% of patients in the group treated for the shorter period and 87% of those treated for the longer period (difference 2%, CI = -14 to 18, P = NS); remission rates within 6 months after stopping steroids were 53% and 37% respectively (difference 16%, CI = -9 to 41, P = NS).

CONCLUSIONS

No significant differences were found between the two regimens. Multiple courses of steroid treatment in the previous 3 years and a short time interval following previous steroid treatment seem to be risk factors for relapse.

Mucosal concentrations of interleukin-1 beta, interleukin-6, interleukin-8, and tumor necrosis factor-alpha in pelvic ileal pouches

Concentrations of interleukin-1 beta (IL-1 beta), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-alpha (TNF-alpha) were determined by solid-phase ELISA in tissue homogenates of mucosal biopsy specimens obtained from pelvic ileal pouches in 13 patients with pouchitis (reservoir ileitis) and 17 with pouches without pouchitis. Normal ileal mucosa was used as a control. IL-1 beta was detected in all tissue homogenates from patients with pouchitis compared with only 29% from pouches without pouchitis and none from controls. IL-6 and IL-8 were present in all pouchitis specimens, in 70% of the specimens from nonpouchitis and only 30% of specimens from controls. TNF-alpha was undetectable in all specimens examined. The concentrations of IL-1 beta, IL-6, and IL-8 were significantly greater (P < 0.001) in biopsy specimens from pouchitis compared to those from pouches without pouchitis or normal ileal mucosa and in patients with pouchitis tissue levels of IL-1 beta significantly correlated with IL-6 (P < 0.05) and IL-8 (P < 0.01). Furthermore IL-1 and IL-8 levels were significantly higher in tissue specimens from nonpouchitis pouches than in those from normal ileal mucosa (P < 0.02). These results suggest that an enhanced cellular immunity operates in vivo at the mucosal level in pouchitis as in the case of ulcerative colitis.

Morphologic and cytoproliferative patterns of duodenal mucosa in two patients after long-term total parenteral nutrition: changes with oral refeeding and relation to intestinal resection

The morphologic and cytoproliferative patterns of the duodenal mucosa of two adult patients, one of whom had a short bowel, were evaluated after more than 2 months of postoperative total parenteral nutrition and 2 and 12 months after the resumption of oral alimentation. Morphometric analysis was performed on routinely processed duodenal biopsies. Cell proliferation was evaluated by means of in vitro bromodeoxyuridine uptake. The results were compared with those obtained in five healthy controls. After parenteral nutrition, patients showed significantly lower villus height and crypt depth than those of controls and a normal bromodeoxyuridine labeling index. After 2 months of refeeding, villus and crypt returned to normal, and the labeling index was increased. After 12 months of oral refeeding, labeling index, villus height, and crypt depth were similar to those of controls. The patient with the short bowel showed a number of cells per unit length of villus and crypt significantly greater than those of the controls and of the patient who underwent shorter intestinal resection. In human duodenal mucosa, (1) hypoplasia develops after long-term total parenteral nutrition; (2) mucosal recovery occurs through an increased cell proliferation after oral refeeding; and (3) extensive small bowel resection determines the development of relative hyperplasia.

Timing of the first variceal hemorrhage in cirrhotic patients: prospective evaluation of Doppler flowmetry, endoscopy and clinical parameters

We followed 87 cirrhotic patients with esophageal varices and without previous hemorrhage for a mean period of 24 mo to prospectively evaluate the occurrence of variceal bleeding within (early) or after (late) 6 mo from entry and the contribution of portal Doppler ultrasound parameters to the prediction of early and late hemorrhage. Clinical, biochemical, endoscopic and portal Doppler ultrasound parameters were recorded at entry. Variceal bleeding occurred in 22 patients (25.3%). Nine (40.9%) bled within the first 6 mo. Cox regression analysis identified variceal size, cherry-red spots, serum bilirubin and congestion index of the portal vein (the ratio of portal vein [cross-sectional area] and portal blood flow velocity) as the only independent predictors of first variceal hemorrhage. Discriminant analysis was used to find the prognostic index cut off points to identify patients who bled within 6 mo (prognostic group 1) or after 6 mo (prognostic group 2) or remained free of bleeding (prognostic group 3). The cumulative proportion of patients correctly classified was 73% in prognostic group 1, 47% in prognostic group 2 and more than 80% in prognostic group 3. The addition of Doppler ultrasound flowmetry to clinical, biochemical and endoscopic parameter only improved the classification of patients with early bleeding.

[Acute inflammation of ileal reservoir after restorative ileoanal anastomosis]

Ileo-anal anastomosis (IAA) is a suitable surgical treatment for selected patients with ulcerative colitis or familial adenomatous polyposis. Acute inflammation of the ileal reservoir (pouchitis) is the most frequent late complication and is characterized by endoscopic and histological changes of acute inflammation similar to ulcerative colitis with abdominal and sometimes systemic symptoms. Between May 1984 and April 1993, 160 patients (103 male and 57 female) aged between 7 and 64 years (mean age 32.6) underwent IAA; twenty of these for familial adenomatous polyposis, 138 for ulcerative colitis and 2 for indeterminate colitis. After a mean follow-up of 41.8 months (range 1-108), 138 patients (86.3%) were symptoms free and twenty-two (16 male and 6 female-13.7%) who underwent IAA for ulcerative colitis, had pouchitis. Clinical, biochemical, endoscopic and histologic findings suggest pouchitis as a chronic recurrent disease similar to inflammatory bowel disease. In conclusion, the etiopathology of this new entity is unknown. Bacterial overgrowth is one of the most popular hypothesis, but the onset of the acute inflammation observed by us only in patients with previous ulcerative colitis and in some cases during the period of protective ileostomy suggests a multifactorial pathogenesis.

Respiratory burst of circulating polymorphonuclear leukocytes and plasma elastase levels in patients with inflammatory bowel disease in remission

The activation of circulating polymorphonuclear leukocytes was determined in terms of superoxide radical generation and granulocyte elastase release in untreated patients with ulcerative colitis (N = 10) and Crohn's disease (N = 9) in remission and in control subjects (N = 10). Superoxide radical generation was determined by monitoring spectrophotometrically the reduction of ferricytochrome, after stimulation of cells with phorbol myristate acetate. Plasma elastase concentration was measured by a solid-phase enzyme immunoassay technique as the complex with alpha-1-proteinase inhibitor. Superoxide formation by polymorphonuclear leukocytes from patients with ulcerative colitis and Crohn's disease was significantly lower compared with controls [median (range) nmol/min/mg protein: Crohn's disease 7.8 (7.1-9.6); ulcerative colitis 8.25 (7.4-10.3); controls 14.7 (13.6-15.8)] (P < 0.001), while no difference was found between the two groups of patients. In contrast plasma elastase levels in patients with ulcerative colitis and Crohn's disease were similar to that of controls. This defective respiratory burst of polymorphonuclear leukocytes in patients with inflammatory bowel disease in remission, in absence of an altered degranulation, could represent an important factor for the pathogenesis of these diseases.

Prevalence of peptic ulcer in Helicobacter pylori positive blood donors

This study aimed to determine the importance of raised antibodies to Helicobacter pylori in an asymptomatic population. A total of 128 asymptomatic blood donors who were seropositive for H pylori and consented to endoscopy were investigated. These subjects were from a population of 1010 blood donors screened for antibodies to H pylori. A questionnaire was completed to determine if any subjects had complained of symptoms, and they subsequently had endoscopy. Altogether 121 of 128 were positive for H pylori by histology and urease test and/or culture and all 121 had chronic active gastritis on histology. Twenty five of these subjects had peptic ulcer (20 duodenal, five gastric), a further 21 had erosive duodenitis, and two were found to have gastric cancer. H pylori associated peptic ulcer disease and duodenitis occur more frequently than previously recognised and this suggests that H pylori infection, even if asymptomatic, is of far greater clinical relevance than originally thought.