Hypobaric Unilateral Spinal Anesthesia Versus General Anesthesia for Hip Fracture Surgery in the Elderly: A Randomized Controlled Trial

BACKGROUND

Hypotension during surgery is frequent in the elderly population and is associated with acute kidney and myocardial injury, which are, themselves, associated with increased 30-day mortality. The present study compared the hemodynamic effects of hypobaric unilateral spinal anesthesia (HUSA) to general anesthesia (GA) in patients ≥70 years of age undergoing hip fracture surgery.

METHODS

We conducted a single-center, prospective, randomized study. In the HUSA group, patients were positioned with the operated hip above, and the hypobaric anesthetic solution was composed of 9 mg ropivacaine, 5 µg sufentanil, and 1 mL of sterile water. Anesthesia was adjusted for the GA group. Mean arterial pressure (MAP) was measured with a noninvasive blood pressure upper arm cuff every 3 minutes. Hypotension was treated with a bolus of ephedrine and then a continuous intravenous of norepinephrine to obtain a MAP ≥65 mm Hg. Primary outcome was the occurrence of severe hypotension, defined as a MAP <65 mm Hg for >12 consecutive minutes.

RESULTS

A total of 154 patients were included. Severe hypotension was more frequent in the GA group compared to the HUSA group (odds ratio, 5.6; 95% confidence interval, 2.7-11.7; P < .001). There was no significant difference regarding the short-term outcomes between the HUSA and GA groups: acute kidney injury (respectively, 5.1% vs 11.3%; P = .22), myocardial injury (18.0% vs 14.0%; P = .63), and 30-day mortality (2.4% vs 4.7%; P = .65).

CONCLUSIONS

HUSA leads to fewer episodes of severe intraoperative hypotension compared to GA in an elderly population undergoing hip fracture surgery.

OUTCOMES OF A LONG-TERMS MICROVASCULAR TRAINING FOR RESIDENTS IN ORTHOPEDIC

The acquisition of specific technical skills in the field of microsurgery like the use of operating microscope and microsurgical instruments, arterial and venous anastomosis, vascular grafts, nerve sutures and tenorrhaphies, is very important during the training in Orthopedics and in Hand Surgery in order to deal with management of complex and amputative traumas of the upper limb. The learning curve in microsurgical techniques is significantly shortened for surgeons who benefit from pre-clinical courses on an animal model. The aim of this study was to standardize a long-term microsurgical activity during the training in Orthopedics and Hand Surgery and to document the benefits that the residents of the School of Specialization got by chance of practicing weekly this discipline on in-vivo model. In 2016, a protocol for teaching in vivo microsurgery on Wistar rats for orthopedics and hand surgery residents was approved. In the first 3 years of graduation course, the students performed the training aimed at acquiring manual dexterity and confidence with the microsurgical instrumentations on nonliving models. Subsequent exercises were performed ex vivo on chicken leg models under the microscope or loupes. Finally, the in-vivo rat exercises were intended for residents in the last 2 years who required access to the supplementary diploma in hand surgery. Outcome evaluations consisted of the Global Rating Scale score and time to completion. Two-tailed Student t test was performed to compare initial and final outcome evaluations (p<0.05). Only 8 residents completed the microvascular training of almost thirty microsurgical teaching sessions administered on a weekly basis. The total mean GRS score (and standard deviation) improved from 15±2 points for the initial score to 21±6 points for the final score (p<0.005). Time to completion of the anastomosis also significantly improved (p<0.005), from a mean score of 31:18±9:21 minutes for the initial time to 21:15±6:10 minutes for the final time. A microvascular training curriculum utilizing a live rat model, preceded by a training on non-living models, provides a superior surgical simulation experience and is effective at improving resident microvascular surgical skills.

Hypobaric spinal anesthesia with ropivacaine plus sufentanil for traumatic femoral neck surgery in the elderly: a dose-response study

BACKGROUND

In this randomized, prospective trial, we sought to determine the effective dose of hypobaric ropivacaine with sufentanil providing 95% success (ED95) in spinal anesthesia for traumatic femoral neck surgery in the elderly.

METHODS

Sixty-eight elderly patients with unilateral hip fracture randomly received 6, 8, 10, or 12 mg spinal hypobaric ropivacaine combined with 5 µg sufentanil. Patients remained in a lateral position for 15 minutes after spinal injection. The dose was considered successful if a unilateral sensory block >T12 was achieved, and there was no need for additional analgesia or conversion to general anesthesia. The ED95 was determined using logit analysis. The incidence of severe and very severe hypotension (systolic blood pressure decrease by >30% and >40% baseline, respectively) and the use of remifentanil were compared among groups using χ(2) test for trend.

RESULTS

Three patients were excluded because of failure to reach the subarachnoid space. No differences in baseline demographic data were observed among groups. The ED95 for hypobaric ropivacaine was determined to be 9 mg (95% confidence interval, 8-14). Increasing doses of ropivacaine (6, 8, 10, and 12 mg) demonstrated a positive trend with respect to incidence of hypotension (53%, 47%, 87%, and 81%, P = 0.0004) and a negative trend with respect to the use of remifentanil (41%, 12%, 0%, and 0%, P = 0.0004). A significant difference in the level of sensory block (P < 0.0001) was observed among operative and nonoperative sides but not among ropivacaine dosing groups (P = 0.16). No difference in motor blockade, incidence of very severe hypotension, total dose of ephedrine, duration of surgery, patient satisfaction, operating conditions, or surgeon satisfaction scores was observed among groups. No cases of bradycardia were observed. No patient had a preoperative sensory level <T12 after 15 minutes in the lateral decubitus position, and no cases were converted to general anesthesia. There was no difference in undesirable outcomes or postoperative troponin values among groups.

CONCLUSIONS

The effective dose of hypobaric ropivacaine combined with sufentanil 5 µg providing 95% success in spinal anesthesia for traumatic femoral neck surgery in the elderly is ED95 = 9 mg (95% confidence interval, 8-14). Using doses exceeding the ED95 may increase the incidence of hypotension. If doses less than the ED95 are chosen, the use of additional analgesia may be necessary.

Treatment of carpal tunnel syndrome with alpha-lipoic acid

Carpal Tunnel Syndrome (CTS) is the most common peripheral mononeuropathy; its symptoms and functional limitations significantly penalize the daily activities and quality of life of many people. While surgery is reserved to most severe cases, the earlier stages of disease may be controlled by a pharmacological treatment aimed to "neuroprotection", i.e. to limiting and correcting the nerve damage. Our study was aimed to compare the efficacy of a fixed association of alpha-lipoic acid (ALA) 600 mg/die and gamma-linolenic acid (GLA) 360 mg/die, and a multivitamin B preparation (Vit B6 150 mg, Vit B1 100 mg, Vit B12 500 microg daily) for 90 days in 112 subjects with moderately severe CTS. Demographic, case-history and treatment efficacy data were collected; the Boston questionnaire was administered and the patients were evaluated by Hi-Ob scale and electro-myography. A significant reduction in both symptoms scores and functional impairment (Boston questionnaire) was observed in ALA/GLA group, while the multivitamin group experienced a slight improvement of symptoms and a deterioration of functional scores. Electromyography showed a statistically significant improvement with ALA/GLA, but not with the multivitamin product. The Hi-Ob scale showed significant efficacy of ALA/GLA in improving symptoms and functional impairment, while in the multivitamin group the improvement was significant, but less marked than in the ALA/GLA group. In conclusion, the fixed association of ALA and GLA proved to be a useful tool and may be proposed for controlling symptoms and improving the evolution of CTS, especially in the earlier stages of disease.

A study about mechanisms of des-gamma-carboxy prothrombin's production in hepatocellular carcinoma

AIM

Des-gamma-carboxy prothrombin (DCP) is an abnormal prothrombin, increased in serum of patients with hepatocellular carcinoma (HCC) as result of an acquired defect of post-translational carboxylation of prothrombin's precursor. It is unclear if the reduced activity of gamma-carboxylase is secondary to vitamin K deficiency or to an altered gene encoding this enzyme. The aim of this study was to evaluate the effect of vitamin K administration on DCP and alpha-fetoprotein (AFP) levels, to identify a relationship between vitamin K and DCP serum levels and to investigate mechanisms of serum elevation of DCP levels.

METHODS

The authors determined DCP and AFP serum levels and vitamin K concentration in 64 cirrhotics with HCC and in 60 cirrhotic subjects without HCC. In HCC subjects DCP and AFP levels were measured before and after vitamin K administration. A t-test for unpaired data was applied (P values <0.05 statistically significant).

RESULTS

Only HCC patients had detectable levels of DCP and significant AFP levels. Administration of vitamin K reduced DCP but not AFP levels in HCC patients. No correlation was observed between vitamin K concentration and DCP levels: vitamin K concentration was similar both in HCC patients and in control group without HCC; HCC patients had the same vitamin K concentration regardless of elevated o reduced DCP levels after vitamin K administration.

CONCLUSION

DCP detectable serum levels are the result not only of vitamin K deficiency or selective defects of carboxylase, because probably alterations of membrane receptors or cytoplasmatic transfers, that are necessary for the function of vitamin K, are involved.

[Heterozygosis H63D in patients with steatohepatitis and chronic hepatitis C]

OBJECTIVE

Classic hereditary hemochromatosis is an autosomal recessive iron-overload disorder associated with mutation of the HFE gene. The homozygous genetic defect predisposes to a chain of events that may culminate in severe damage in multiple organs. Pathologic implications of heterozygous defect are still questionable; in fact since these individuals may have slight increases in intra-cellular iron, it has been questioned whether this would enhance damage from other diseases. We investigated whether steatohepatitis and chronic hepatitis C can be worsened by heterozygosis for C282Y and H63D.

PATIENTS AND METHODS

We investigated 216 subjects with Steatohepatitis and/or chronic hepatitis C diagnosed by ultrasonography and liver biopsy with histological assessment compared with 110 healthy subjects. In all subjects we performed Saturated Transferrine, Plasma Ferritin and the research of HFE mutation by a Real Time Method. A statistical analysis was performed.

RESULTS

A H63D mutation was present in 32/108 patients with Steatohepatitis, in 30/108 patients with chronic hepatitis C and in 22/110 healthy subjects. A C282Y mutation was present in 2/108 patients with chronic hepatitis C, in 4/108 with steatohepatitis and in 2/108 healthy subjects. No significant difference was present about incidence of this mutation between pathological and healthy subjects. No significant differences have observed between pathological groups and normal group about the degree of histological damage.

CONCLUSIONS

Our study revealed that steatohepatitis and chronic hepatitis C cannot be worsened by heterozygosis for C282Y and H63D.

Is endoscopic ultrasound clinically useful for follow-up of gastric lymphoma?

BACKGROUND

Endoscopic ultrasound (EUS) is considered the best technique for locoregional staging at diagnosis but its role in the follow-up of patients with gastric lymphoma after organ-conserving strategies has not been established.

DESIGN AND METHODS

We retrospectively evaluated 23 patients with primary gastric lymphoma treated with a stomach-conservative approach. Sixteen of them were affected by MALT lymphoma and seven by diffuse large-B-cell lymphoma (DLBCL). Five patients were treated with Helicobacter pylori (HP) eradication therapy alone (omeprazole + amoxicillin + clarithromycin); eight patients received a treatment including HP eradication and chemotherapy and the remaining 10 patients were treated with chemotherapy alone.

RESULTS

At the end of treatment, a complete remission was documented in 21 (91%) patients by endoscopy with biopsy (E-Bx) but in only seven (30%) patients by EUS. A total of 99 evaluations with both EUS and E-Bx were evaluated and we found concordance between the two methods in 33 occasions (33%) only. No significant difference on the percentage of concordance was recorded between MALT and DLBCL. After a median follow-up of 36.5 months we have not observed any relapse in 12 patients (six DLBCL and six MALT) with a persistent positive EUS but negative E-Bx.

CONCLUSIONS

Although the length of follow-up cannot exclude late relapse, we think that in restaging and follow-up of gastric lymphoma, EUS seems not to be a reliable tool if it is abnormal and E-Bx still remains the gold standard. Therefore, after conventional conservative treatment, persistence of EUS abnormality with a negative histology should not be considered as a clinically relevant persistence of disease and should not be a reason for further treatment.

Somatosensory- and motor-evoked potential monitoring during spine and spinal cord surgery

STUDY DESIGN

Prospective, observational study.

SETTING

Regional Trauma Center, Torino, Italy.

OBJECTIVES

Complex spinal surgery carries a significant risk of neurological damage. The aim of this study is to determine the reliability and applicability of multimodality motor-evoked potentials (MEPs) and somatosensory-evoked potentials (SEPs) monitoring during spine and spinal cord surgery in our institute.

METHODS

Recordings of MEPs to multipulse transcranial electrical stimulation (TES) and cortical SEPs were made on 52 patients during spine and spinal cord surgery under propofol/fentanyl anaesthesia, without neuromuscular blockade.

RESULTS

Combined MEPs and SEPs monitoring was successful in 38/52 patients (73.1%), whereas only MEPs from at least one of the target muscles were obtained in 12 patients (23.1%); both MEPs and SEPs were absent in two (3.8%). Significant intraoperative-evoked potential changes occurred in one or both modalities in five (10%) patients. Transitory changes were noted in two patients, whereas three had persistent changes, associated with new deficits or a worsening of the pre-existing neurological disabilities. When no postoperative changes in MEP or MEP/SEP modalities occurred, it was predictive of the absence of new motor deficits in all cases.

CONCLUSION

Intraoperative combined SEP and MEP monitoring is a safe, reliable and sensitive method to detect and reduce intraoperative injury to the spinal cord. Therefore, the authors suggest that a combination of SEP/MEP techniques could be used routinely during complex spine and/or spinal cord surgery.

Clinical and endoscopic presentation of primary gastric lymphoma: a multicentre study

BACKGROUND

Although the stomach is the most frequent site of intestinal lymphomas, few data are available on both clinical endoscopic presentation of gastric lymphoma and possible differences between low-grade and high-grade lymphomas.

METHODS

Clinical, histological and endoscopic records of consecutive patients with primary low-grade or high-grade lymphoma diagnosed were retrieved. Symptoms were categorized as 'alarm' or 'not alarm'. The endoscopic findings were classified as 'normal' or 'abnormal'.

RESULTS

Overall, 144 patients with primary gastric lymphoma were detected, including 74 low-grade and 70 high-grade lymphoma. Alarm symptoms, particularly persistent vomiting and weight loss, were more frequently present in patients with high-grade lymphoma than in those with low-grade lymphoma (54% vs. 28%; P = 0.002). Low-grade lymphomas presented as 'normal' appearing mucosa (20% vs. 0%; P = 0.0004) or petechial haemorrhage in the fundus (9% vs. 0%; P = 0.02) more frequently than high-grade lymphomas, being also more often confined to the antrum (47% vs. 27%, P = 0.03) and associated with Helicobacter pylori infection (88% vs. 52%, P < 0.0001). On the contrary, high-grade lymphomas presented more commonly as ulcerative type (70% vs. 52%; P = 0.03), being also more frequently diagnosed in stage >I when compared with low-grade lymphomas (70% vs. 21%, P < 0.0001).

CONCLUSIONS

The overall prevalence of alarm symptoms is quite low and may be absent in more than 70% of patients with low-grade lymphoma.

[Surgery of thyroid pathologies in one-day surgery]

The surgery of the thyroid pathologies in Day and/or One-Day-Surgery requires a thorough choice former of the surgery of the patients and the availability of the team specialist that could guarantee an adequate nursing after surgery. The authors describe the advantages and the limits of the short confined to stay in hospital for the surgery of the thyroid pathologies. The selection criteria for patients undergoing thyroidectomy in One-Day-Surgery have been: euthyroid patients with benign pathologies concentrate only thyroid lobe and lack of associated pathologies as cardiopathy, broncopathy, nephropathy, hepatopaty, diabetes, etc. Were executed in general anaesthesia forty lobectomies for uninodular thyroid disease and three enucleoresections for a nodule of pyramidal lobe, and only two cases the histological definitive diagnosis of carcinoma has caused a second hospital stay. In all forty-three cases was used a drainage, removed after 24 hours.

Epidural analgesia with 0.15% ropivacaine plus sufentanil 0.5 microgram ml-1 versus 0.10% bupivacaine plus sufentanil 0.5 microgram ml-1: a double-blind comparison during labour

BACKGROUND

Ropivacaine has been claimed to produce less motor block than bupivacaine during epidural analgesia. However, this advantage has not been clearly confirmed in obstetric studies using low analgesic concentrations in a ratio close to that suggested to be equianalgesic.

METHODS

This double-blind, randomized, prospective study was performed in 140 parturients who requested epidural analgesia. After a lumbar epidural catheter had been placed, patients received either 0.10% bupivacaine plus sufentanil 0.5 microgram ml-1 or 0.15% ropivacaine plus sufentanil 0.5 microgram ml-1 followed by a continuous infusion. Additional boluses were used for inadequate levels of analgesia. Visual analogue pain scores, motor block, level of sensory block, supplementary boluses and main characteristics of labour were recorded.

RESULTS

No differences were observed between the two groups for pain scores, total volume of anaesthetic solution used [59 (23) and 57 (24) ml in the bupivacaine and ropivacaine groups respectively], duration of labour, mode of delivery, side-effects or satisfaction score. The incidence of motor block was not statistically different between the groups (54 and 69% in the bupivacaine and ropivacaine groups respectively, P = 0.07). However, when motor block occurred, survival analysis showed that it occurred sooner in the course of labour with ropivacaine compared with bupivacaine (log rank test, P = 0.012).

CONCLUSION

Combined with sufentanil 0.5 microgram ml-1, 0.10% bupivacaine and 0.15% ropivacaine produce effective and equivalent analgesia during labour, with similar incidences of motor block.

Bone response to polymers based on poly-lactic acid and having different degradation times

Authors studied two degradable and resorbable polymers derived from lactic acid: poly-L-Lactic acid (PLLA), with a relatively long time of degradation (longer than 6 months, PL10 Purac NL); poly-DL-Lactic acid (PDLLA), with a relatively short time of degradation (shorter than 6 months, PDL Purac NL). The animal species was the young adult New Zealand White rabbit. The in-vivo study was performed by implantation of small cylinders of 10 x 3 mm in size (length x diameter) in the distal metaepiphysis of the femur; 34 cylinders have been implanted. Retrievals of PLLA specimens took place at 3, 6, 9, 12 and 24 months; for PDLLA specimens at 1, 2, 4 months. Polarized light microscopy of undecalcified tissue sections was performed. The analysis for PLLA and PDLLA has shown a favorable response of bone tissue: alterations in the bone repair, growth and remodeling have not been observed. PLLA is persistent at the times studied; there is never a tight apposition between bone and PLLA implant and an intervening fibrous layer has often been observed. PDLLA is not persistent at the times studied and it degrades quite fast; bone repair of the empty implantation's hole occurs by bony growth from the endosteal trabeculae. The newly formed bone covers the hole's walls with an elongation parallel to them. For both polymers, whether the degradation is fast or slow, the material's substitution by newly formed bone never starts from the walls of the implantation hole. Only after the complete disappearance of the polymeric material newly formed bone begins to fill the hole.

Plasma endothelin-1 levels in liver cirrhosis

The role of circulating endothelin- , a potent vasoconstricting peptide, in liver cirrhosis is still controversial. It has been postulated that endothelin-1 may play a role in the circulatory derangement occurring in cirrhotic subjects, and increased plasma endothelin-1 levels have been reported in these patients. In this study we looked for a relationship between the severity of the liver disease according to Child's classification and plasma endothelin-1 concentrations in a group of cirrhotic patients compared with a healthy control group. Twenty-two cirrhotic patients and 10 healthy controls, matched for sex and age, were selected for study after informed consent. The etiology of cirrhosis was posthepatitis B in 8 of 22 cases, posthepatitis C in 13 of 22 cases, and alcoholism in 1 patient. According to Child's classification, 6 patients were in class A, 6 in class B, and 10 in class C. Plasma endothelin-1 was measured by a commercial RIA kit (Amersham UK). Mean +/- SD plasma endothelin-1 levels were 8.8 +/- 0.9 pg/ml in controls and 9.2 +/- 1.1 pg/ml in all cirrhotic patients (P > 0.05). In each sub-group of cirrhotics, plasma endothelin- was 8.6 +/- 1.2 pg/ml in Child A, 8.9 +/- 1.9 pg/ml in Child B, and 10.6 +/- 1.5 pg/ml in Child C groups, respectively. There were no statistical differences between control subjects and Child A and B cirrhotic patients (P > 0.05). A significant increase in endothelinl was observed only in the Child C group versus either group A or B (P = 0.004). Our results show that alterations of circulating endothelin-1 do not occur in all cirrhotic patients; higher plasma levels than controls are only detectable in patients with more-severe hepatic failure. We do not know whether increased endothelin-1 levels are a consequence of hemodynamic disorders occurring in the advanced phase of liver cirrhosis or play a pathogenic role.

Early recognition of acute cardiovascular beriberi by interpretation of hemodynamics

Acute fulminant cardiovascular beriberi is an acute thiamine deficiency, which, if not recognized and treated, can lead to high cardiac output failure and death. The symptoms of acute thiamine deficiency include severe lactacidemia, and the presence of a high cardiac output and extremely low oxygen consumption in a patient who is hemodynamically stable. In this case conference, we describe a patient who was diagnosed with acute cardiovascular beriberi.

The effectiveness of the circular external fixator in the treatment of post-traumatic of the tibia nonunion

Authors report the results they obtained when the Ilizarov circular external fixator was used for the treatment of post-traumatic nonunion of the tibia. A total of 20 patients were treated. Of these 12 had been submitted to treatment elsewhere and using other methods; 9 presented with septic nonunion; 10 revealed radiographic findings of atrophic nonunion, and 10 were hypertrophic. There was axial deviation in 18 patients. The results of treatment were always: healing of the nonunion; functional recovery of the limb; correction of leg length discrepancy; recovery of the mechanical axis. The mean stabilization time (days between the application and the removal of the fixator) was 138 days. The Ilizarov method thus proved that it was effective in the treatment of post-traumatic nonunion of the tibia where other types of treatment had failed.

Postoperative acute renal failure secondary to rhabdomyolysis from exaggerated lithotomy position

Perioperative renal dysfunction is a common problem following urogenital surgery. The most common causes of renal failure include ischemic or nephrotoxic acute tubular necrosis, renal vascular injury, and urinary tract obstruction. This case conference describes a patient who developed acute renal failure, secondary to rhabdomyolysis after a 7-hour urologic surgical procedure in an exaggerated lithotomy position. Early diagnosis and aggressive treatment are essential to prevent or limit the severity of acute renal failure. A review of the literature and pathophysiology of acute renal failure secondary to rhabdomyolysis is included.

CREB-binding protein and p300/CBP-associated factor are transcriptional coactivators of the p53 tumor suppressor protein

The structurally related transcriptional coactivators p300 and CBP possess histone acetyltransferase activity and associate with P/CAF, which is also a histone acetyltransferase. CBP and p300 have properties of tumor suppressor proteins; their interaction with P/CAF is disrupted by the adenoviral E1A oncoprotein, and the genes encoding CBP and p300 are mutated in human cancer. We observed a physical interaction between the transactivation domain of the p53 tumor suppressor protein and CBP. Furthermore, CBP and P/CAF enhanced the ability of p53 to activate expression of the endogenous p21(cip1/waf1) gene, whereas E1A and dominant negative CBP mutants suppressed p53-dependent p21(cip1/waf1) expression. These studies link two tumor suppressor families and provide a framework for understanding the molecular mechanism by which p53 activates transcription.

[Surgical treatment of spontaneous pneumothorax: comparison of thoracotomy and thoracoscopy]

The video-thoracoscopic treatment of spontaneous pneumothorax currently has the same role of laparoscopic cholecystectomy in abdominal surgery. The Authors consider thoracoscopic approach and traditional thoracotomy examining advantages versus disadvantages, comparing 50 patients with spontaneous pneumothorax treated by thoracoscopy, from February 1992 up to February 1995, and 50 patients, previously treated by open surgery. Video-thoracoscopy has the same percentage of recurrences of thoracotomic approach but assures a quicker functional recovery and, above all, a remarkable reduction of pain.

Treatment of chronic hepatitis D with interferon alfa-2a

BACKGROUND AND METHODS

Chronic hepatitis D is a severe and rapidly progressive liver disease for which no therapy has been proved effective. To evaluate the efficacy of treatment with interferon, we studied 42 patients with chronic hepatitis D who were randomly assigned to receive either 9 million or 3 million units of recombinant interferon alfa-2a (three times a week for 48 weeks) or no treatment.

RESULTS

By the end of the treatment period, serum alanine aminotransferase values had become normal in 10 of 14 patients receiving 9 million units (71 percent), as compared with 4 of 14 treated with 3 million units (29 percent, P = 0.029) and 1 of 13 untreated controls (8 percent, P = 0.001). Seven patients treated with the higher dose of interferon (50 percent) had a complete response (normal levels of alanine aminotransferase and no detectable serum hepatitis delta virus [HDV] RNA), as compared with three of those who received the lower dose (21 percent, P = 0.118), and none of the controls (P = 0.004). Treatment with 9 million units of interferon was associated with a marked improvement in the histologic findings (reduced periportal necrosis and portal and lobular inflammation), whereas in the untreated controls there was considerable histologic deterioration. In 5 of the 10 patients treated with 9 million units of interferon whose alanine aminotransferase values became normal, the biochemical responses persisted for up to 4 years (mean, 39 months), but the effects of treatment on viral replication were not sustained. In contrast, none of those who received 3 million units and none of the untreated controls had a sustained biochemical or virologic response.

CONCLUSIONS

In about half the patients with chronic hepatitis D treated with high doses of interferon alfa-2a (9 million units three times a week for 48 weeks), the serum alanine aminotransferase level becomes normal, HDV RNA becomes undetectable in serum, and there is histologic improvement. However, a relapse is common after treatment has been stopped.

Comparing the effectiveness of behavioral treatment for chemotherapy-induced nausea and vomiting when administered by oncologists, oncology nurses, and clinical psychologists

Adequate control of side effects during medical treatment of cancer increases patient compliance and quality of life. Antiemetic drugs are not an effective treatment for the one in three cancer patients on chemotherapy who experience anticipatory nausea and vomiting (ANV); the behavioral treatment of systematic desensitization has been found effective for ANV when delivered by clinical psychologists. This study examined the effectiveness of systematic desensitization when delivered by medical personnel versus clinical psychologists. Seventy-two consecutive cancer patients with ANV were randomly assigned to no-treatment control or to systematic desensitization from 5 behaviorally trained clinical psychologists, 6 clinical oncologists, or 10 oncology nurses. The treatment was found effective in reducing anticipatory nausea, anticipatory vomiting, posttreatment nausea, and posttreatment vomiting compared to control patients, with no significant differences in effectiveness found between clinical psychologists and oncology staff. Although medical personnel should not engage patients in psychotherapy or other interventions that cannot be completed successfully, they can treat patients effectively with systematic desensitization and should be encouraged to learn and use this and other behavioral intervention techniques to benefit total patient care.

Randomised controlled trial of interferon alfa 2A (rbe) (Roferon-A) for the treatment of chronic hepatitis B virus (HBV) infection: factors that influence response

In a randomised controlled trial recombinant interferon alpha 2A (Roferon-A, rIFN alfa A) given at a dosage of 10 million units (MU)/m2 thrice weekly for six months was significantly better (p less than 0.02) than no treatment in producing a sustained loss of hepatitis Be antigen (HBeAg) in hepatitis B virus (HBV) chronic carriers. Although lower doses (5 MU/m2 and 2.5 MU/m2) also produced some responses, the seroconversion rate was not significantly greater than that observed in the control group. Sixteen of the 45 patients receiving interferon were human immunodeficiency virus (HIV) antibody positive: none of these responded. Forty one per cent of the anti-HIV negative patients receiving interferon (12/29, p less than 0.005) lost HBeAg and 17% (5/29) lost hepatitis B surface antigen (HBsAg). The response rate among these anti-HIV negative patients receiving at least three months therapy was 46% and 19% respectively. Low pretreatment HBV-DNA and absence of anti-HIV were the only significant independent variables predicting response to therapy (p less than 0.03 and p less than 0.05 respectively). In six patients, neutralising antibodies to alpha interferon were detected during therapy, the majority being non-responders.

Delta infection in eastern Sicily

Sera from 619 HBsAg+ subjects living in eastern Sicily, consecutively collected from 1975-1985, were tested for markers of delta virus (HDV) infection: delta antigen (HDAg), antibodies to delta (anti-HDIg), and also for antibodies to HBcore of IgM type (anti-HBcIgM) and for the system HBe-anti-HBe. The subjects included 210 asymptomatic carriers, 238 patients with acute hepatitis and 171 patients with chronic liver disease. HDAg was not found in any of the samples. Anti-HD was found in 28/171 (16.3%) patients with chronic liver disease, in 13/210 (6%) asymptomatic HBsAg carriers and in 13/238 (5.4%) patients with acute hepatitis. None of our patients were drug addicts. One had a history of blood transfusion, and nine came from the same family unit. The prevalence of HDV infection in eastern Sicily is lower than in other areas of Sicily possibly because of the lower percentage of HBsAg carriers in the local population. Parenteral transmission of HDV does not seem to play a major role in our area, while the familial clustering suggests close body contact as an important way of spread.

Diminished responsiveness of male homosexual chronic hepatitis B virus carriers with HTLV-III antibodies to recombinant alpha-interferon

In a randomized controlled trial, 41 chronic hepatitis B virus carriers were allocated, by opening numbered computerized randomization envelopes, to receive recombinant interferon-alpha 2A at three different doses: 2.5; 5.0, and 10.0 mU per m2. Thirty-two patients received treatment (6 for 3 months, 26 for 6 months), and 9 patients were controls (received no treatment). Ninety-three per cent of our patients were homosexual, and 41% had anti-HTLV-III in their serum. None of the control patients lost HBeAg. In contrast, six of the anti-HTLV-III-negative patients (33%) responded to treatment (p less than 0.02): five of these responders were homosexual (p less than 0.05). The response rate was greatest (44%) in the anti-HTLV-III-negative patients who received 10 mU per m2 of recombinant interferon-alpha 2A. None of the anti-HTLV-III-positive patients responded to treatment. The percentage reduction of hepatitis B virus DNA was significantly less in the anti-HTLV-III-positive group in comparison to the anti-HTLV-III-negative group at 1 and 4 months of treatment and at 3 months after the end of treatment (p less than 0.05). These patients were younger (33 vs. 42 years, p less than 0.02), had lower mean baseline AST values (42 vs. 80 IU per liter, p less than 0.02) and tended to have milder histological disease. Homosexual men with HBeAg-positive chronic liver disease who are anti-HTLV-III-positive appear to be less responsive to the direct antiviral and immunomodulatory effects of recombinant interferon-alpha 2A. This may be due to the subclinical immunosuppressive effects of co-infection with HTLV-III.

[Incidence, type and significance of anti-myocardial autoantibodies in patients undergoing cardiac surgery]

The incidence of anti-myocardial autoantibodies was investigated in 62 patients suffering from congenital or acquired cardiopathy prior to and 1, 10 and 20 days after cardiac surgery. Anti-myocardial autoantibodies were present in about 23.7 per cent of patients even before surgery, practically doubled one day after intervention, reached their peak (60-70 per cent) at 10 days from surgery and began to diminish at 20 days. At all times and incidence was higher in patients with acquired cardiopathy than in those with congenital heart diseases. In the large majority of cases, the autoantibodies were of the IgG class, of the striational type and in low titers. The relevance of anti-myocardial autoantibodies in the pathogenesis of cardiac lesions and the possible causes of the reversibility of the autoimmune phenomenon are discussed.

Comparing the effectiveness of behavioral treatment for chemotherapy-induced nausea and vomiting when administered by oncologists, oncology nurses, and clinical psychologists

Adequate control of side effects during medical treatment of cancer increases patient compliance and quality of life. Antiemetic drugs are not an effective treatment for the one in three cancer patients on chemotherapy who experience anticipatory nausea and vomiting (ANV); the behavioral treatment of systematic desensitization has been found effective for ANV when delivered by clinical psychologists. This study examined the effectiveness of systematic desensitization when delivered by medical personnel versus clinical psychologists. Seventy-two consecutive cancer patients with ANV were randomly assigned to no-treatment control or to systematic desensitization from 5 behaviorally trained clinical psychologists, 6 clinical oncologists, or 10 oncology nurses. The treatment was found effective in reducing anticipatory nausea, anticipatory vomiting, posttreatment nausea, and posttreatment vomiting compared to control patients, with no significant differences in effectiveness found between clinical psychologists and oncology staff. Although medical personnel should not engage patients in psychotherapy or other interventions that cannot be completed successfully, they can treat patients effectively with systematic desensitization and should be encouraged to learn and use this and other behavioral intervention techniques to benefit total patient care.