Liver and heart failure: an ultrasound relationship

Liver and heart are anatomically and patho-physiologically related. In heart failure (HF) the increased right atrial pressure and volume overload cause histological changes in hepatocytes, leading to a condition known as "congestive hepatopathy" (CH), with consequent variations in liver functioning and ultrasound (US) findings. CH has specifical US findings especially regarding venous vessels aspect, easily detecting by gray-scale study, but many others can be distinguished by Doppler analysis. Usually, hepatic veins look enlarged and hypocollassing, together with signs of portal hypertension (hepatomegaly, ascites, splenomegaly, porto-systemic collaterals). Typically, in CH Doppler findings regard alterations in venous vessel flow and arterial resistance (venous system hyperpulsatility, reduced velocity flow, high resistance index in hepatic arterial Doppler spectrum). Sometimes CH and other primary hepatopathy can coexist, and therefore some of the expected variations may not manifest: it allows suspecting an unknown underlying liver disease. At last, US technologies of more recent applications, even if not routinely used, allow investigating additional aspects such as elastography that detects changes in liver elasticity or contrastographic US, able to show differences in hepatic venous opacification. However, most of these US signs are not pathognomonic, and therefore a multidisciplinary clinical reasoning must not be lacking. The aim of the present review is to easily provide US signs of liver alterations in HF, in particular right heart failure with volume overload, suggesting including liver US in instrumental diagnosis and therapeutic monitoring of HF.

Treatment of Hydatid Liver Cyst With Double Percutaneous Aspiration and Ethanol Injection Under Ultrasound Guidance: 6.5-Year Median Follow-up Analysis

PURPOSE

Although hydatid liver cyst (HLC) is a benign disease, treatment is recommended to avoid life-threatening complications. There are several treatment options for HLC: "wait-and-watch," medical or surgical or percutaneous treatment. The purpose of this study was to assess the long-term effectiveness of an alternative of the traditional percutaneous PAIR procedure, called double percutaneous aspiration and ethanol injection (D-PAI).

MATERIALS AND METHODS

This prospective, non-randomized study was conducted from 1988 to 2019 using DPAI procedure characterized by no reaspiration of the ethanol injected to replace the aspirated fluid and repetition of the procedure after 3-7 days.

RESULTS

Two hundred and three patients with 290 HLCs underwent D-PAI. Two hundred and two HLC (160 patients) were univesicular cysts and 88 (43 patient) were multivesicular. Seventeen patients underwent one D-PAI session, 15 patients two sessions, and 18 up to four sessions. The follow-up ranged 0.9-21 years (median 6.5 years). On ultrasound, 188 cysts (64.8%) disappeared; 57 cysts (19.7%) became solid (inactive) and 45 (15.5%) showed a small inactive residual component. Parasitologic cure was very high. The overall response to D-PAI was higher than 90% considering also the procedures carried out after the first D-PAI at the time of recurrence. One patient died for anaphylactic shock. The hospital stay ranged 1-3 days. Smaller cysts (< 5 cm) healed sooner than larger cysts (p < 0.001).

CONCLUSIONS

Long-term analysis showed that D-PAI is a safe and effective option in percutaneous treatment of viable HLC, except for CE2/CE3b in which the recurrences can be observed. This inexpensive and simple procedure can be applied everywhere and especially in developing countries.

Adipopenia Is the Rapid Screening Tool that Best Predicts Mortality in Patients with Decompensated Cirrhosis: Results of a Prospective Study

BACKGROUND AND AIMS

Patients with liver cirrhosis (LC) often have malnutrition (MN), which can be associated with decompensation, infection, and death. The aims were to determine: the prevalence of MN in patients with LC and ascites, its impact on mortality, and the relationship between MN and spontaneous bacterial peritonitis (SBP).

METHODS

Nutritional status (NS) was analysed in cirrhotic patients, experiencing their first episode of ascites, who were consecutively admitted at two clinical liver centres between November 2014 and October 2016. The participants underwent diagnostic paracentesis and were followed up to assess their outcomes.

RESULTS

110 participants underwent NS assessment in addition to routine clinical procedures. The prevalence of MN was 30.9% according to corrected body mass index, 67.3% according to upper mid-arm muscle area (UMA) and 40% according to upper mid-arm fat area (UFA). The percentages of the participants remaining alive were 68.1% at 3 months, 59.3% at 6 months, 45.1% at 12 months and 24.2% at the end of the study. Univariate analysis showed that SBP, model for end-stage liver disease (MELD), UFA, UMA and age were significantly associated with mortality. Multivariate analysis showed that only SBP, MELD and UFA (hazard ratio 2.2) were independently associated with mortality. There was a correlation between adipopenia, but not sarcopenia, and SBP.

CONCLUSIONS

Adipopenia, as assessed by UFA, was present in 40% of the cirrhotic patients, and it was independently associated with mortality.

Safety and efficacy of ombitasvir/paritaprevir/ritonavir/dasabuvir plus ribavirin in patients over 65 years with HCV genotype 1 cirrhosis

PURPOSE

To analyse safety and efficacy of treatment based on ombitasvir/paritaprevir/ritonavir/dasabuvir plus ribavirin in the sub-group of GT1 patients older than 65 years.

METHODS

We collected data extracted from the ABACUS compassionate-use nationwide Italian programme, in patients with cirrhosis due to hepatitis C virus (HCV) Genotype-1 (GT1) or 4 and at high risk of decompensation. GT1-HCV-infected patients received once-daily ombitasvir/paritaprevir, with the pharmacokinetic enhancer ritonavir (25/150/100 mg) and twice-daily dasabuvir (250 mg) plus Ribavirin (RBV) (OBV/PTV/r + DSV + RBV) for 12 (GT1b) or 24 (GT1a) weeks. Endpoints were to evaluate safety and efficacy, the latter defined as HCV RNA negative 12 weeks after the end of treatment (SVR12).

RESULTS

Patients who suffered any adverse event (AE) were 74/240 (30.8%); 13/240 (5.4%) discontinued the treatment. A multivariate analysis found albumin < 3.5 g/dL (OR 2.04: 95% CI 1.0-4.2, p < 0.05) and hypertension (OR 4.6: 95% CI 2.3-9.2, p < 0.001) as variables independently associated with AE occurrence. The SVR12 was 95% (228/240). Multivariate analysis identified baseline bilirubin < 2 mg/dL (OR 4.9: 95% CI 1.17-20.71, p = 0.029) as the only variable independently associated with SVR12.

CONCLUSION

Our findings suggest that OBV/PTV/r + DSV + RBV is safe and effective in real-life use in patients with compensated cirrhosis, HCV-GT1 infection, and age over 65.

Reproducibility of shear wave elastography (SWE) in patients with chronic liver disease

The presence of significant fibrosis is an indicator for liver disease staging and prognosis. The aim of the study was to determine reproducibility of real-time shear wave elastography using a hepatic biopsy as the reference standard to identify patients with chronic liver disease. Forty patients with chronic liver disease and 12 normal subjects received shear wave elastography performed by skilled operators. Interoperator reproducibility was studied in 29 patients. Fibrosis was evaluated using the Metavir score. The median and range shear wave elastography values in chronic liver disease subjects were 6.15 kPa and 3.14-16.7 kPa and were 4.49 kPa and 2.92-7.32 kPa in normal subjects, respectively. With respect to fibrosis detected by liver biopsy, shear wave elastography did not change significantly between F0 and F1 (p = 0.334), F1 and F2 (p = 0.611), or F3 and F4 (0.327); a significant difference was observed between the F0-F2 and F3-F4 groups (p = 0.002). SWE also correlated with inflammatory activity (Rs = 0.443, p = 0.0023) and ALT levels (Rs = 0.287, p = 0.0804). Age, sex and body mass index did not affect shear wave elastography measurements. Using receiver operator characteristic curves, two threshold values for shear wave elastography were identified: 5.62 kPa for patients with fibrosis (≥F2; sensitivity 80%, specificity 69.4%, and accuracy 77%) and 7.04 kPa for patients with severe fibrosis (≥F3; sensitivity 88.9%, specificity 81%, and accuracy 89%). Overall interobserver agreement was excellent and was analysed using an interclass correlation coefficient (0.94; CI 0.87-0.97).This study shows that shear wave elastography executed by skilled operators can be performed on almost all chronic liver disease patients with high reproducibility. It is not influenced by age, sex or body mass index, identifies severely fibrotic patients and is also related to inflammatory activity.

Mortality from cirrhosis and hepatocellular carcinoma in Western Europe over the last 40 years

BACKGROUND & AIMS

Cirrhosis (LC) and hepatocellular carcinoma (HCC) are highly prevalent in Europe, with accompanying high mortality rates and social costs. As epidemiological data on these diseases are scarce, age-standardized death rate (ASDR) can serve as an indirect assessment of their burden.

METHODS

We analysed the ASDRs for LC and HCC from data reported in the WHO official death registries from 1970 to 2010, and compared ASDRs over the decades. The European Detailed Mortality Database was also used as source of data.

RESULTS

In 1970, Portugal had the highest reported mortality for LC, followed by France and Italy. However, in 2010, Finland, Austria and Germany were respectively the three highest, while the UK showed the highest increase over those four decades (+284.8%). The annual ASDRs for LC have dropped in Europe from 20.4/10⁵ inhabitants in 1970 to 9.6 in 2010; a 53% decrease. For HCC, Spain, Italy and Denmark were ranked first through third, while in 2010 Italy, France and Luxembourg replaced them. Portugal had the highest increase (+654.7%). In 1980-2010, the ASDR for HCC in Europe increased from 3.4/10⁵ inhabitants to 6.3, up 85.4%. In the majority of nations-except for the UK, Finland and Ireland-there was a decrease in LC mortality and an increase for HCC mortality.

CONCLUSIONS

The LC mortality rate is decreasing in Europe, yet there is a significant increase in HCC mortality. This phenomenon requires greater attention so we can understand the risk factors and implement preventive measures.

Hepatitis delta infection in Italian patients: towards the end of the story?

BACKGROUND

The endemicity of hepatitis delta virus infection in Italy has decreased in the last decades.

AIM

To evaluate the current epidemiology of chronic delta infection in Italy and to compare the present findings with the corresponding figures from the previous studies.

METHODS

A cross-sectional study involving 16 referral centres scattered all over the country in 2014.

RESULTS

Out of the 513 hepatitis B surface antigen-positive subjects enrolled, 61 (11.9%) were anti-delta positive, with a sex ratio (M/F) of 2.05. The majority (80.3%) of them was 50 years or older, while the proportion of subjects younger than 30 years of age was as low as 3.3%. No difference was detected by geographical area of residence. The presence of liver cirrhosis was diagnosed in 52.4% of cases. In comparison to previous studies, a further shift towards the oldest age groups and an increasing proportion of subjects having liver cirrhosis among all anti-delta-positive subjects are observed.

CONCLUSIONS

Currently, hepatitis delta infection mostly affects old people who have an advanced but indolent liver disease, reflecting a survival effect. The defective hepatitis delta virus is near to disappear in the country, where it has been discovered in the second half of 70s.

Boceprevir or telaprevir in hepatitis C virus chronic infection: The Italian real life experience

AIM: To check the safety and efficacy of boceprevir/telaprevir with peginterferon/ribavirin for hepatitis C virus (HCV) genotype 1 in the real-world settings.

METHODS: This study was a non-randomized, observational, prospective, multicenter. This study involved 47 centers in Italy. A database was prepared for the homogenous collection of the data, was used by all of the centers for data collection, and was updated continuously. All of the patients enrolled in this study were older than 18 years of age and were diagnosed with chronic infection due to HCV genotype 1. The HCV RNA testing was performed using COBAS-TaqMan2.0 (Roche, LLQ 25 IU/mL).

RESULTS: All consecutively treated patients were included. Forty-seven centers enrolled 834 patients as follows: Male 64%; median age 57 (range 18-78), of whom 18.3% were over 65; mean body mass index 25.6 (range 16-39); genotype 1b (79.4%); diagnosis of cirrhosis (38.2%); and fibrosis F3/4 (71.2%). The following drugs were used: Telaprevir (66.2%) and PEG-IFN-alpha2a (67.6%). Patients were naïve (24.4%), relapsers (30.5%), partial responders (14.8%) and null responders (30.3%). Overall, adverse events (AEs) occurred in 617 patients (73.9%) during the treatment. Anemia was the most frequent AE (52.9% of cases), especially in cirrhotic. The therapy was stopped for 14.6% of the patients because of adverse events or virological failure (15%). Sustained virological response was achieved in 62.7% of the cases, but was 43.8% in cirrhotic patients over 65 years of age.

CONCLUSION: In everyday practice, triple therapy is safe but has moderate efficacy, especially for patients over 65 years of age, with advanced fibrosis, non-responders to peginterferon + ribavirin.

Radiofrequency ablation versus laser ablation for the treatment of small hepatocellular carcinoma in cirrhosis: a randomized trial

BACKGROUND AND AIM

In patients with cirrhosis and small hepatocellular carcinoma (HCC), thermal ablation is currently recognized as an effective local treatment. Among thermal procedures, radiofrequency ablation (RFA) is the most diffusely used and is the standard against which any new treatment should be compared. In retrospective studies, laser ablation (LA) resulted as safe and effective as RFA. Therefore, we performed a non-inferiority randomized trial comparing RFA with LA in patients with cirrhosis and HCC within Milan criteria.

METHODS

Overall, 140 patients with 157 HCC nodules were randomly assigned to receive RFA or LA. The primary end-point was the proportion of complete tumor ablation (CTA). Secondary end-points were time to local progression (TTLP) and overall survival (OS).

RESULTS

Per patient CTA rates after RFA and LA were 97.4% (95% CI, 91.0-99.3) and 95.7% (88.1-98.5), respectively (difference = 1.4%, 95% CI from -6.0% to + 9.0%). Per nodule CTA rates for RFA and LA were 97.4% (91.0-99.3) and 96.3% (89.6-98.7), respectively (difference = 1.1%, from -5.7% to + 8.1%). The mean TTLP was comparable between RFA group (42.0 months; 95% CI, 36.83-47.3) and LA group (46.7 months; 95% CI, 41.5-51.9) (P = .591). The mean OS was 42 months in both groups and survival probability at 1 and 3 years was 94% and 89% in RFA group, and 94% and 80% in LA group.

CONCLUSION

LA resulted not inferior to RFA in inducing the CTA of HCC nodules and therefore it should be considered as an evaluable alternative for thermal ablation of small HCC in cirrhotic patients.

Prophylactic activity of increasing doses of intravenous histamine in refractory migraine: Retrospective observations of a series of patients with migraine without aura

BACKGROUND

Histamine is thought to play a pivotal role in the modulation of peripheral and central pain. The administration of increasing doses of histamine may lead to desensitization of receptors of histamine types 1 and 2, causing meningeal vasodilation, and to depletion of neuropeptides in the trigeminal ganglion, thus inhibiting the initiation of migraine.

OBJECTIVE

In this study, the efficacy and tolerability of increasing doses of IV histamine in migraine prophylaxis were investigated.

METHODS

This single-center, open-label, retrospective, controlled study was conducted at the Headache Center (Department of Internal Medicine, University of Florence, Villa Monna Tessa, Italy). Patients included in the study had 3 to 6 migraines without aura per month that were refractory to common symptomatic and prophylactic agents in the 6 months preceding the study. Patients were treated with IV histamine hydrochloride for 21 days starting with a dosage of 0.5 mg/d and increasing to 4.0 mg/d. To assess the efficacy of the treatment, these patients were matched for age; sex; and frequency, duration, and severity of attacks with untreated migraineurs. Clinical benefit was defined as ⩽ 1 migraine of mild intensity per month. Tolerability was assessed during the hospitalization period, and patients were instructed to contact the Headache Center to report any adverse effects after hospital discharge.

RESULTS

The histamine group comprised 47 patients (40 women, 7 men; mean [SD] age, 42.0 [8.6] years) and the control group comprised 23 patients (20 women, 3 men; mean [SD] age, 38.8 [8.4] years). The histamine-treated patients showed a clinical benefit lasting for a mean of 10.4 (4.2) months, while the patients in the control group showed a clinical benefit of 3.8 (1.9) months. The difference in the duration of the clinical benefit between the 2 groups was 6.6 months (95% CI, 5.15-7.99). Adverse effects consisted of flushing, heat sensation during infusion, headache, and palpitations.

CONCLUSIONS

In this study, histamine showed lasting prophylactic efficacy in migraineurs. If further research confirms this preliminary finding, histamine could be considered when established prophylactic drugs, such as betablockers, calcium antagonists, antidepressants, and antiepileptics, have not been effective.

[Management strategies and choice of antithrombotic treatment in patients admitted with acute coronary syndrome--executive summary for clinical practice. Consensus Document of the Regional Chapters of the Italian National Association of Hospital Cardiologists (ANMCO) and of the Italian Society of Emergency Medicine (SIMEU)]

This document has been developed by the Lazio regional chapters of two scientific associations, the Italian National Association of Hospital Cardiologists (ANMCO) and the Italian Society of Emergency Medicine (SIMEU), whose members are actively involved in the everyday management of Acute Coronary Syndromes (ACS). The document is aimed at providing a specific, practical, evidence-based guideline for the effective management of antithrombotic treatment (antiplatelet and anticoagulant) in the complex and ever changing scenario of ACS. The document employs a synthetic approach which considers two main issues: the actual operative context of treatment delivery and the general management strategy.

Mortality risk according to different clinical characteristics of first episode of liver decompensation in cirrhotic patients: a nationwide, prospective, 3-year follow-up study in Italy

OBJECTIVES

The occurrence of decompensation marks a crucial turning point in the course of cirrhosis. The purpose of this study was to assess the risk of mortality according to the clinical characteristics of first decompensation, considering also the impact of acute-on-chronic liver failure (AoCLF).

METHODS

We conducted a prospective nationwide inception cohort study in Italy. Decompensation was defined by the presence of ascites, either overt or detected by ultrasonography (UD), gastroesophageal variceal bleeding (GEVB), and hepatic encephalopathy (HE). AoCLF was defined according to the Asian Pacific Association for the Study of the Liver criteria. Multivariable Cox proportional hazards regression was used to analyze the risk of failure (death or orthotopic liver transplantation (OLT)).

RESULTS

A total of 490 consecutive cirrhotic patients (314 males, mean age 60.9±12.6 years) fulfilled the study criteria. AoCLF was identified in 59 patients (12.0%). Among the remaining 431 patients, ascites were found in 330 patients (76.6%): in 257 (77.8%) as overt ascites and in 73 (22.2%) as UD ascites. GEVB was observed in 77 patients (17.9%) and HE in 30 patients (7.0%). After a median follow-up of 33 months, 24 patients underwent OLT and 125 died. The cumulative incidence of failure (death or OLT) after 1, 2, and 3 years was, respectively, 28, 53, and 62% in patients with AoCLF; 10, 18, and 25% in patients with UD ascites; 17, 31, and 41% in patients with overt ascites; and 8, 12, and 24% in patients with GEVB (P<0.0001).

CONCLUSIONS

AoCLF is responsible for a relevant proportion of first decompensation in cirrhotic patients and is associated with the poorest outcome. Patients with UD ascites do not have a negligible mortality rate and require clinical monitoring similar to that of patients with overt ascites.

The influence of three different instrumentation techniques on the incidence of postoperative pain after endodontic treatment

AIMS

Apical extrusion of infected debris to the periradicular tissues is one of the principal causes of postoperative pain and discomfort. Recent researches have shown that reciprocating instrumentation techniques seem to significantly increase the amount of debris extruded beyond the apex and, consequently, the risk of postoperative pain. The goal of the present study was to evaluate and compare postoperative pain using three different nickel-titanium instrumentation techniques: a rotary crown-down technique using TF instruments (SybronEndo, Orange, Ca), a reciprocating single-file technique using WaveOne instruments (Maillefer DEntsply, Baillagues, CH), and a novel instrumentation technique (TF Adaptive, SybronEndo, Orange, Ca), using a unique, proprietary movement, combining reciprocation and continuous rotation.

METHODS

Ninety patients requiring endodontic treatment on permanent premolar and molar teeth with non vital pulps preoperatively were included in the study. The patients were assigned into three groups of 30 patients each, trying to make the groups very similar, concerning the number of root canals, presence of initial pain and periapical lesions. The teeth in group 1 (n = 30) were instrumented with a crown-down technique using TF instruments, whilst those in group 2 (n = 30) were instrumented with a single-file technique using Waveone 08 25. The third group (n = 30) used the 3-file Tf Adaprtive sequence. All techniques were performed following manufacturers' instructions and all canals were shaped, cleaned and obturated in a single-visit by the same operator. The assessment of postoperative pain was carried out at 3 days by using a visual analogue scale. VAS pain scores were compared using one-way ANOVA post hoc Tukey test. A value of p < 0.05 was required for statistical significance.

RESULTS

Results for VAS pain scores showed a statistically significant difference was found between the WaveOne (p=0,021) technique and the other two techniques. No statistical significant differences were found between TF and TF Adaptive (p= 0,087). When evaluating patient experiencing sever pain the incidence of symptoms was significantly higher with the WaveOne technique.

CONCLUSIONS

Since the incidence of preoperative pain, the type of tooth and the pulp and periodontal pathology were quite similar between the three tested groups, and all the other variables (operator, irrigation, obturation) were identical, we may conclude that the difference in postoperative pain can be mainly related to the different instrumentation techniques.

Influence of file motion on cyclic fatigue of new nickel titanium instruments

AIM

The aim of the present study was to compare the resistance to cyclic fatigue of Hyflex® (Coltene-Whaledent, Allstatten, Switzerland) size 40 taper.04 nickel titanium instruments used in continuous rotation versus the use with a reciprocating motion. The null hypothesis was that different file motions had no influence on the lifetime of instruments subjected to a cyclic fatigue test.

METHODOLOGY

24 Hyflex® size 40 taper.04 nickel titanium instruments were randomly divided in two groups (n=12 each), and submitted to a cyclic fatigue test. The first group (CR group) were used with a continuous rotation, while the second one (RCP group) with a reciprocating motion. The cyclic fatigue tests were performed by using a stainless steel block containing an artificial canal shaped with a 135° angle. All instruments were rotated or reciprocated until fracture occurred. The time to fracture was recorded visually with a 1/100 second chronometer. Data were recorded and statistically analysed.

RESULTS

Results indicated that instruments used with a reciprocating motion showed a significant increase in the meantime to failure when compared to those used in continuous rotation.

CONCLUSIONS

The null hypothesis was rejected. Results of the present study showed that reciprocating motion extended resistance to cyclic fatigue of the tested nickel titanium instruments, when compared to continuous rotation.

Impact of age on toxicity and efficacy of sorafenib-targeted therapy in cirrhotic patients with hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) is increasing worldwide and the proportion of older patients with HCC is expected to steadily rise in the next years. Sorafenib is the standard of care for patients with advanced HCC but there is a lack of detailed data on how older patients with cirrhosis tolerate this drug. Therefore, we aimed to evaluate the impact of age on the effects of sorafenib-targeted therapy in patients with HCC and cirrhosis. We analyzed a consecutive cohort of HCC patients not eligible for surgery or locoregional treatment, with Child-Pugh score ≤ 7, and an Eastern Cooperative Oncology Group performance status of 0-1, treated with sorafenib. Clinical outcomes and treatment-related adverse events (AEs) were compared between younger (< 70 years) and older (≥ 70 years) patients. Overall, 150 patients, 90 in the younger (median age 60 years) and 60 in the older (median age 72 years) group, were evaluated. Treatment duration was 4 months in both groups. The median time to progression and overall survival were longer in older than in younger group (12 vs. 8 months and 16 vs. 12 months, respectively), although the differences did not reach a statistical significance. Grade 3-4 AEs were more frequently observed in younger than in older group (15.7 vs. 9.2 %, respectively; p = .0146). In field practice, sorafenib treatment in elderly patients with cirrhosis and HCC resulted at least as effective and safe as in younger patients. However, severe AEs occurred more frequently in younger patients.

Safety and effectiveness of sorafenib in patients with hepatocellular carcinoma in clinical practice

BACKGROUND

Sorafenib is currently the only approved systemic treatment for hepatocellular carcinoma.

AIM

to evaluate safety and effectiveness of sorafenib in the field of practice.

METHODS

We report a single-centre experience on 116 advanced hepatocellular carcinoma patients treated with sorafenib between February 2008 and March 2011. Every 4 weeks, adverse events were graded using Common Toxicity Criteria version 3.0, and every 3 months tumour response was assessed according to modified Response Evaluation Criteria in Solid Tumours for hepatocellular carcinoma.

RESULTS

Cirrhosis was present in 95.7% of patients (83.6% Child-Pugh A class), hepatitis C was the main etiological factor. Median therapy duration was 3 months and median daily dose was 642 mg. Median time-to-radiological progression in the per-protocol population was 12 months and median overall survival in the intention-to-treat population was 13 months. 91.4% of patients experienced mild adverse events (grade 1 or 2), the most frequent were gastrointestinal and dermatological. Jaundice and bleeding were the main causes of definitive drug discontinuation. 3-month overall disease control rate was 70.6%: stable disease in 37.2%, partial response in 30.8%, and complete response in 2.6% patients. The 3-month radiological response correlated with overall survival.

CONCLUSIONS

In daily clinical practice, sorafenib confirmed its safety and efficacy in hepatocellular carcinoma patients.

A fully automatic method to register the prostate gland on T2-weighted and EPI-DWI images

Prostate adenocarcinoma (PCa) is the most frequent noncutaneous cancer among men in developed countries. Magnetic Resonance (MR) has been used to detect PCa and several clinical trials report on the accuracy of the test. Multiparametric MR imaging (mpMRI) is defined as the integration of information from different morphological and functional datasets. mpMRI could be used to increase the performances of prostate MR, therefore allowing a more accurate assessment of the tumor gland extent, while reducing reporting time and interobserver variability. The first step to perform such a multiparametric analysis is to correct for voluntary and involuntary movements during the acquisitions, as well as for image distortion in the Diffusion Weighted (DWI) images. The aim of this work is to present a fully automatic registration algorithm between T2w and DWI images, able to realign the images and to correct the distortions in the DWI. Results showed a good overlap after registration and a strong decrease of mean surface distance in both the central gland and peripheral zone. These promising results suggest that the algorithm could be integrated in a CAD system which will combine the pharmacokinetic parameters derived from DCE-MRI, T2w MRI and DWI MR to generate one comprehensive value assessing the risk of malignancy. However to perform such a multiparametric analysis, it is necessary to correct for voluntary and involuntary (breathing, heart beating) movements during the DCE-MRI acquisition, and to realign also the DCE-MRI sequence to the T2w sequence.

Performance of a fully automatic lesion detection system for breast DCE-MRI

PURPOSE

To describe and test a new fully automatic lesion detection system for breast DCE-MRI.

MATERIALS AND METHODS

Studies were collected from two institutions adopting different DCE-MRI sequences, one with and the other one without fat-saturation. The detection pipeline consists of (i) breast segmentation, to identify breast size and location; (ii) registration, to correct for patient movements; (iii) lesion detection, to extract contrast-enhanced regions using a new normalization technique based on the contrast-uptake of mammary vessels; (iv) false positive (FP) reduction, to exclude contrast-enhanced regions other than lesions. Detection rate (number of system-detected malignant and benign lesions over the total number of lesions) and sensitivity (system-detected malignant lesions over the total number of malignant lesions) were assessed. The number of FPs was also assessed.

RESULTS

Forty-eight studies with 12 benign and 53 malignant lesions were evaluated. Median lesion diameter was 6 mm (range, 5-15 mm) for benign and 26 mm (range, 5-75 mm) for malignant lesions. Detection rate was 58/65 (89%; 95% confidence interval [CI] 79%-95%) and sensitivity was 52/53 (98%; 95% CI 90%-99%). Mammary median FPs per breast was 4 (1st-3rd quartiles 3-7.25).

CONCLUSION

The system showed promising results on MR datasets obtained from different scanners producing fat-sat or non-fat-sat images with variable temporal and spatial resolution and could potentially be used for early diagnosis and staging of breast cancer to reduce reading time and to improve lesion detection. Further evaluation is needed before it may be used in clinical practice.

In vitro evaluation of the cytotoxicity of FotoSan™ light-activated disinfection on human fibroblasts

Background

Root canal disinfection needs to be improved because actual techniques are not able to eliminate all microorganisms present in the root canal system. The aim of the present study was to investigate the in vitro cytotoxicity of FotoSan (CMS Dental APS, Copenhagen Denmark), 17% EDTA and 2% chlorhexidine.

Material/Methods

Fibroblasts of periodontal ligament from healthy patients were cultured. FotoSan (with and without light activation for 30 sec.), 17% EDTA and 2% chlorexidine were used for the cell viability tests. Untreated cells were used as control. The cellular vitality was evaluated by MTT test. The production of reactive oxygen species (ROS) was measured using an oxidation-sensitive fluorescent probe. Results were statistically analyzed by ANOVA, followed by a multiple comparison of means by Student-Newman-Keuls, and the statistical significance was set at p<0.05.

Results

MTT tests showed that cytotoxic effects of FotoSan (both photocured and uncured) were statistically lower (p<0.05) than that observed using 2% Chlorhexidine, while no significant differences were found in comparison with 17% EDTA. No alterations in ROS production were detectable in any of the tested materials.

Conclusions

Since the toxicity of the FotoSan photosensitizer, both light-activated and not light-activated, is similar to common endodontic irrigants, it can be clinically used with precautions of use similar to those usually recommended for the above-mentioned irrigating solutions.

The magnitude of the association between hepatitis C virus infection and oral lichen planus: meta-analysis and case control study

Although hepatitis C virus (HCV) infection is associated with oral lichen planus (OLP), a case-control study and a meta-analysis were designed to investigate the magnitude of such an association. A total of 413 presumptive OLP patients (18-75 years) who referred to a dental clinic in Rasht (Iran) were consecutively selected. OLP was diagnosed clinically (typical forms) and histologically (atypical forms) by a calibrated examiner. A total of 487 adults (20-77 years) attending the same dental clinic were the controls. The two groups were homogeneous in terms of age, gender and occupation. Subjects were tested for anti-HCV antibodies. The odds ratio (OR) for OLP attributable to HCV infection was non-significant [OR 1.2, 95% confidence interval (95CI) 0.3-4.8], suggesting that the association between HCV and OLP was weak in the Iranian context. Meta-analysis of observational studies characteristics of primary studies were that cases were diagnosed clinically (only typical forms) and histologically and exposure was assessed through anti-HCV antibodies. Exposed/unexposed cases/controls were extracted and zero values were appropriately transformed. As much as 44 studies, including the present, were located. Publication bias could not be totally excluded. The pooled OR, estimated using the random-effect model, was 2.8 (95CI 2.4-3.2). Sensitivity analysis confirmed the robustness of results. Subgroup analysis showed non-significant differences between American/European and Asian/African studies. The fraction of global OLP cases associated with HCV (population attributable fraction) was 2.1% (95CI 1.9-2.2%). Although HCV and OLP were significantly associated, the majority of OLP patients were not affected by HCV.

In vitro Evaluation of the Cytotoxicity of Different Root Canal Filling Materials

OBJECTIVE

Aim of the present study was to evaluate the cytotoxicity of Real Seal 1 compared to other commercially available endodontic filling materials: Real Seal (SybronEndo, Orange, CA, USA) and Thermafil (Tulsa Dental, Tulsa, OK, USA).

MATERIAL AND METHODS

Periodontal ligament cells from healthy patients were cultured. The eluate of Real Seal 1(TM) (RS1), Real Seal (RS) and Thermafil (TF) samples was used for the cells viability tests, both diluted (50%) or undiluted (100%). Incubation of the specimens was performed in culture medium for 24 h, 48 h and 72 h at 37 °C under sterile conditions. The cellular mortality was evaluated by MTT test. Results were statistically analysed and the statistical significance was set at p< 0.05.

RESULTS

None of the studied materials showed toxic effects during the period of observation (0 -72 h) when compared to the control group. Only RS induced a very modest increase in cell mortality (about 3% at both concentrations used, during the first 24 hours), when increasing the incubation time, however, only the lower concentration continued to show modest toxicity.

CONCLUSIONS

Results of the present study showed that all tested materials did not exhibit cytotoxic effects when compared to the control group.

The effect of brushing motion on the cyclic fatigue of rotary nickel titanium instruments

The goal of the study is to evaluate if the use of rotary nickel-titanium (RNT) instruments, as Hedstroem files, is safe. Twelve twisted files (TF) RNT instruments size 06-25 were selected and randomly divided in 2 groups of 6 instruments each. Group A (new instruments) were used as control. Group B (test) instruments were clinically used only as Hedstroem files in a canal that had been previously instrumented to the working length with other 06-25 RNT instruments. Group B instruments were used only in the straight portion of the canal (1 minute at 1000 rpm). A cyclic fatigue test was performed for each instrument of groups. Data were statistically analyzed (Student's t-test). Results showed no significant difference (P > 0.05) between groups A and B. Data confirmed that the use of TF instruments as Hedstroem files is a safe procedure. Cross section images and volumes of the same instrument, before and after cyclic fatigue testing, have been obtained by means of microtomographic analysis to evaluate possible microstructure alterations.

Effects of KTP laser on oral soft tissues. An in vitro study

A biopsy is a surgical procedure performed to establish a clear diagnosis of a lesion in order to clarify a clinical diagnostic suspicion. During a biopsy procedure it is fundamental to maintain safe and readable cut margins in order to permit histological visualization of possible marginal infiltrations or malignant transformation of a lesion. The aim of this study was to evaluate the histological peripheral damage caused by application of a KTP (potassium titanium phosphate) laser during oral soft tissue biopsy procedures. A KTP laser (lambda 532 nm) at different power settings and fluences was used to obtain 45 samples from pig cadaver tongues. The samples were then subdivided into five groups of nine samples each. A final specimen was taken by scalpel as a control. All samples were put into test tubes containing 10% buffered formalin solution, and were examined separately under an optical microscope by two pathologists to evaluate the peripheral thermal damage induced by the laser. In all specimens the cut edges of the incision were free from histological artefacts, especially when lower settings were applied. Statistical analysis showed no differences among the groups. The KTP laser demonstrated surgical effectiveness and caused little peripheral damage to the cut edges, and therefore would always allow a safe histological diagnosis to be obtained.

Angular deflection of rotary nickel titanium files: a comparative study

A new manufacturing method of twisting nickel titanium wire to produce rotary nickel titanium (RNT) files has recently been developed. The aim of the present study was to evaluate whether the new manufacturing process increased the angular deflection of RNT files, by comparing instruments produced using the new manufacturing method (Twisted Files) versus instruments produced with the traditional grinding process. Testing was performed on a total of 40 instruments of the following commercially available RNT files: Twisted Files (TF), Profile, K3 and M2 (NRT). All instruments tested had the same dimensions (taper 0.06 and tip size 25). Test procedures strictly followed ISO 3630-1. Data were collected and statistically analyzed by means ANOVA test. The results showed that TF demonstrated significantly higher average angular deflection levels (P<0.05), than RNT manufactured by a grinding process. Since angular deflection represent the amount of rotation (and consequently deformation) that a RNT file can withstand before torsional failure, such a significant improvement is a favorable property for the clinical use of the tested RNT files.

Peginterferon alfa-2a plus ribavirin is more effective than peginterferon alfa-2b plus ribavirin for treating chronic hepatitis C virus infection

BACKGROUND & AIMS

Patients with chronic hepatitis C virus (HCV) infection are frequently treated with a combination of pegylated interferon (peginterferon) and ribavirin. This study compared the efficacy and safety of peginterferon alfa-2a and peginterferon alfa-2b, each in combination with ribavirin.

METHODS

A total of 320 consecutive, treatment-naive, HCV RNA-positive patients with chronic hepatitis were randomly assigned to once-weekly peginterferon alfa-2a (180 microg, group A) or peginterferon alfa-2b (1.5 microg/kg, group B) plus ribavirin 1000 mg/day (body weight <75 kg) or 1200 mg/day (body weight >or=75 kg) for 48 weeks (genotype 1 or 4) or 24 weeks (genotype 2 or 3). The primary end point was sustained virological response (SVR) by intention-to-treat.

RESULTS

More patients in group A than group B achieved an SVR (110/160 [68.8%] vs 87/160 [54.4%]; P = .008). Higher SVR rates were obtained in group A than group B among patients with genotype 1/4 (51/93 [54.8%] vs 37/93 [39.8%]; P = .04), with genotype 2/3 (59/67 [88.1%] vs 50/67 [74.6%]; P = .046), without cirrhosis (96/127 [75.6%] vs 75/134 [55.9%]; P = .005), and with baseline levels HCV RNA >500,000 IU/mL (58/84 [69%] vs 43/93 [46.2%]; P = .002). SVR rates in groups A and B were not statistically different among patients with baseline HCV RNA <or=500,000 IU/mL (52/76 [68.4%] vs 44/67 [65.7%]; P = .727) or in patients with cirrhosis (14/33 [42.4%] vs 12/26 [46.1%]; P = .774).

CONCLUSIONS

In patients with chronic HCV infection, peginterferon alfa-2a plus ribavirin produced a significantly higher SVR rate than peginterferon alfa-2b plus ribavirin.

In Vitro evaluation of Enterococcus faecalis adhesion on various endodontic medicaments

E. faecalis in endodontic infection represents a biofilm type of disease, which explains the bacteria's resistance to various antimicrobial compounds and the subsequent failure after endodontic treatment. The purpose of this study was to compare antimicrobial activities and bacteria kinetic adhesion in vitro for three endodontic medicaments with a clinical isolate of E. faecalis. We devised a shake culture which contained the following intracanalar preparations: CPD, Endoidrox (EIX), PulpCanalSealer (PCS); these were immersed in a liquid culture medium inoculated with the microorganism. The shake system velocity was able to prevent non-specific bacteria adhesion and simulated the salivary flow. Specimens were collected daily (from both the medium and medicaments) for 10 days; the viable cells were counted by plate count, while the adhesion index AI ° [E. faecalis fg DNA] /mm² was evaluated in the pastes after DNA extraction, by quantitative real time PCR for the 16S rRNA gene. A partial growth inhibition, during the first 24 hours, was observed in the liquid medium and on the medicaments for EIX and subsequently for CPD (six logs). EIX showed the lowest adhesion coefficient (5*10² [fg DNA]/mm²) for nine days and was similar to the control. PCS showed no antimicrobial/antibiofilm properties. This showed that "calcium oxide" base compounds could be active against biofilm progression and at least in the short term (2-4 days) on E. faecalis cells growing in planktonic cultures.

Cytotoxicity of epiphany SE endodontic sealer: a comparative in vitro study

BACKGROUND

The Epiphany endodontic obturation system, which was developed for use with all current root canal-filling techniques by substituting for gutta-percha and sealer, has been recently modified by eliminating the priming step and introducing a new self-etch, dual-cure, resin-based sealer; Epiphany SE. As with all new endodontic compounds, this novel material should undergo preliminary testing for biocompatibility. The aim of the present study was to investigate the in vitro cytotoxicity of Epiphany SE and to compare it with the original Epiphany sealer and with a commonly used endodontic sealer (Pulp Canal Sealer).

MATERIAL/METHODS

Mouse 3T3 fibroblasts were seeded and cultured, and extracts of each of the cemented sealers were added. After a 24-hour incubation, cell viability was evaluated by neutral red uptake assay, which is an indicator of membrane permeability. The greater the cell mortality (measured as a percentage), the greater the toxicity of the sealer.

RESULTS

Results showed that all 3 of the tested sealers exhibited cytotoxic effects compared to the control group (P<0.05), but no statistically significant differences (P>0.05) were noted among the sealers.

CONCLUSIONS

Our results showed satisfactory biocompatibility of the new Epiphany SE sealer, which showed similar biocompatibility to the original Epiphany sealer and to the traditional zinc oxide eugenol-based sealer.

Dementia, delusions and seizures: storage disease or genetic AD?

We describe a case of a young patient suffering from a rapidly progressive cognitive decline, associated with delusions, myoclonus and seizures and with no family history for dementia. Clinical features, along with skin biopsy findings were overlapping storage disease; the genetic analysis, however, demonstrated a de novo presenilin 1 mutation. The present report suggests the usefulness of genetic determinations in early-onset cases of dementia, even without an autosomal dominant trait of inheritance; for these cases and their relatives an extensive genetic counselling should be recommended.

Sustained virological response to antiviral therapy reduces mortality in HCV reinfection after liver transplantation

BACKGROUND/AIMS

HCV infection recurs almost in all HCV-positive patients receiving liver transplantation and carries a poor prognosis. Aim of this study was to analyze efficacy and effect on survival of antiviral therapy in this clinical setting.

METHODS

Pegylated-interferon alpha-2b and ribavirin were administered at a dose of 1 microg/kg of bwt weekly and 600-800 mg/day. Planned duration of treatment was 24 or 48 weeks according to HCV genotype. Patients who failed to respond at week 24 were considered as non-responders.

RESULTS

61 patients were enrolled. According to intention-to-treat analysis, 44 (72%) patients were considered as treatment failure (31 non-responders, 4 relapsers, 9 dropout). Sustained virological response was achieved in 17 cases (28%). Genotype 2, higher doses of antivirals and absence of histological cirrhosis were predictors of sustained virological response. In the follow up, patients with sustained virological response had a significantly lower mortality compared to patients with treatment failure (chi2=6.9; P<0.01).

CONCLUSIONS

Response rate to antiviral therapy in HCV reinfection after liver transplantation is higher if a full dose of antiviral drugs is administered and if treatment starts before histological cirrhosis has developed. Sustained virological response improves patient survival.

Prognostic value of quantitative liver function tests in viral cirrhosis: a prospective study

BACKGROUND AND AIMS

Widespread application of quantitative liver function tests as a prognostic tool is controversial. In this study we assessed the predictivity of serial evaluations of galactose elimination capacity (GEC) and the monoethylglycinexylidide (MEGX) test on survival in viral cirrhosis, and secondarily we compared these tests with Child-Turcotte-Pugh (CTP) and Model for End Stage Liver Disease (MELD) scores.

METHODS

In a cohort of 35 patients with viral cirrhosis, GEC and MEGX were evaluated every 6 months for 24 months and compared with CTP and MELD scores at the same time intervals. The end points were patient death or liver transplantation.

RESULTS

Statistically significant differences between dead/transplanted patients and survivors were found for basal values of GEC, MEGX, CTP and MELD. Receiver-operating characteristics curves of CTP and MELD scores showed a higher prognostic accuracy than GEC and MEGX. On multivariate analysis, neither GEC nor MEGX were independent predictors of survival. Repeated-measures analysis of GEC and MEGX did not increase the prognostic accuracy of these tests and did not add useful prognostic information on patient outcome during the following 6 months.

CONCLUSIONS

Our data suggest that neither single nor repeated determinations of GEC and MEGX are superior to CTP and MELD scores in predicting prognosis of patients with viral cirrhosis.

Efficacy and safety assessment of a new liquid tooth whitening gel containing 5.9% hydrogen peroxide

PURPOSE

To evaluate the efficacy and safety of a new 5.9% hydrogen peroxide liquid, invisible gel, (Colgate Simply-White Whitening Gel).

METHODS

A total of 30 subjects were enrolled into the study and divided into two treatment groups (Colgate vs. placebo gel). Efficacy was assessed using VITA shade scores and safety evaluations were performed including the examination of plaque index (PI), bleeding index (BOP), gingival recession and dentin hypersensitivity. Statistical analysis was performed to determine the mean change from baseline.

RESULTS

The new whitening gel containing 5.9% hydrogen peroxide was significantly effective in lightening tooth shade. After only 2 weeks, patients enrolled in the study exhibited an overall mean 4.48-shade improvement from baseline, which was significantly greater than placebo group and far exceeded the ADA minimum requirements to claim "clinical efficacy". In the new Colgate Simply White Clear Whitening Gel group, periodontal health (PI and BOP) improved with time overall. Moreover, dentin hypersensitivity did not significantly increase, and all treatments were generally well tolerated.

CLINICAL SIGNIFICANCE

The new Colgate Simply White whitening gel containing 5.9% hydrogen peroxide allowed consistent bleaching using minimal contact time, without adversely impacting overall tolerability.

Efficacy of anti-retraction devices in preventing bacterial contamination of dental unit water lines

OBJECTIVE

In this study we examine the efficacy of anti-retraction devices in preventing microbial contamination of dental unit water lines (DUWLs).

METHODS

The study was performed on 54 randomly selected DUs in use at private and public institutions for over six months. The selected DUs were all currently commercially available. To evaluate the efficiency of anti-retraction devices, two different methods were employed, mechanical and microbiological. The ADA/ANSI specification #47 (corresponding to a water retraction of less than 40.3 microl) was used for the evaluation of the retraction determined using the mechanical method; the presence/absence of test microorganisms in DUWLs upstream the turbine after the test was used for evaluating the microbiological assay.

RESULTS

Both evaluation methods indicated correct amounts of retraction and prevention of DUWL contamination occurred in only two cases (3.7%). Correct retraction was noted in six other dental units (DUs), but their DUWLs became contaminated during testing. Six other produced the opposite results-improper retraction, yet no contamination. The remaining 40 DUs (74.0%) failed both evaluations.

CONCLUSION

The results showed that the overwhelming majority of the anti-retraction devices did not prevent retraction when the turbine stopped running, leading to a contamination of the water lines, and to a consequent possible cross-contamination of the patients.

Incidence of side effects during therapy with different types of alpha interferon: a randomised controlled trial comparing recombinant alpha 2b versus leukocyte interferon in the therapy of naive patients with chronic hepatitis C

BACKGROUND

Alpha interferon (IFN) alone or in combination with Ribavirin (RBV) is the treatment of choice for HCV related chronic liver disease. There are many types of alpha IFN and to date only few reports are available comparing different types of alpha interferon. We run a randomised controlled trial with the aim to compare tolerability and efficacy of two different types of IFN: recombinant alpha 2b interferon (IFN-R) and leukocyte alpha n-3 interferon (IFN-L) at the same dosage of 3 MU subcutaneously thrice weekly for one year.

METHODS

one hundred sixty eight consecutive anti-HCV positive naive patients, 34 mild chronic active hepatitis (MCH), 81 moderate-severe hepatitis (MSCR) and 53 active cirrhosis (CIRR) that met the inclusion criteria were enrolled into the study. The diagnosis of HCV chronic liver disease was established by liver biopsy performed on patients with abnormal serum alanine aminotransferase (ALT) value for at least one year. HCV serology: all patients were tested for confirmatory test RIBA II, HCV-RNA, and identification of viral genotype. Patients were randomised to receive either IFN-R or IFN-L. Follow-up continued for at least two years after stopping treatment.

RESULTS

no significant differences were observed between the two groups of treatment as far as the incidence of side effects is concerned. Tolerability was good: only 11 in IFN-R and 8 patients IFN-L group respectively had to stop therapy due to side effects. The two types of IFN showed a comparable efficacy: an end of therapy response was observed in 34% of IFN-R and 30% of IFN-L patients; a sustained response was seen in 16% of IFN-R and in 19% of IFN-L patients.

CONCLUSIONS

in the treatment of patients with chronic hepatitis C there was no statistically significant difference in tolerability and efficacy between the two IFNs tested.

MEN 10700, a new penem antibiotic: in vitro antibacterial activity on clinical isolates

MEN 10700 is a new broad-spectrum penem, currently in preclinical development. In the present study, the activity of MEN 10700 was compared to that of imipenem, meropenem, cefotaxime, ampicillin/sulbactam, amikacin and ciprofloxacin against 619 gram-positive and gram-negative bacterial strains, and to that of imipenem, meropenem, cefotaxime, ceftriaxone, ceftazidime, cefepime and ampicillin/sulbactam against 38 strains of ciprofloxacin-resistant Escherichia coli, and against 19 extended-spectrum-beta-lactamase (ESBL)-producing strains of the KES group. MEN 10700 was highly active against most gram-positive and gram-negative strains, and overall demonstrated comparable activity to imipenem and meropenem. Methicillin-susceptible Staphylococcus aureus and methicillin-susceptible Staphylococcus epidermidis were highly susceptible to MEN 10700, which was the most potent among the antibiotics tested. MEN 10700 was less potent than the carbapenem antibiotics on Morganella morganii, Serratia marcescens and Acinetobacter spp. Ciprofloxacin-resistant E. coli were uniformly susceptible to MEN 10700, imipenem and meropenem, with MIC90 values in the range of < or = 0.12-0.25 mg/l, while showing much lower susceptibility to the other antibiotics tested, including the fourth-generation cephalosporin cefepime. This feature was even more evident in ESBL-producing strains of the KES group, with an MIC90 of 1- 2 mg/l for MEN 10700, imipenem and meropenem, and a MIC90 of 16-64 mg/l for the other antibiotics tested, including cefepime.