Dual X-ray absorptiometry-derived bone status indexes and videocapsule intestinal aspects in celiac disease

BACKGROUND AND AIM

Celiac disease is a risk factor for osteopenia and osteoporosis. Our aim was to evaluate the possible correlation between villous atrophy extension and dual-energy X-ray absorptiometry (DXA)-derived parameters of bone status.

METHODS

We have retrospectively analyzed data of 47 celiac patients (36 women, 52 ± 14 years of age) who underwent video capsule endoscopy and DXA scans within 1 year of interval from 2006 to 2019. Quantitative, qualitative and geometric DXA parameters were collected only from the most recent DXA measurements.

RESULTS

. Patients were divided into three categories; the first included those with no lesions at video capsule endoscopy (23 patients), the second those with typical lesions (mucosal atrophy, mosaicism and scalloping) in less than one-third of the small bowel (SB) (16 patients) and the third those with typical lesions in more than one-third of the SB (7 patients). In the third group, bone mineral density seemed to be lower in both the lumbar spine and the hip ( P  = 0.026 and P  = 0.011, respectively). The deterioration of bone structure in patients with severe and extended SB atrophy was statistically significant ( P  = 0.032). Furthermore, bone density, structure and geometry did not correlate with the duration of the gluten-free diet. Notably, autoimmune comorbidities did not affect DXA results.

CONCLUSION

Neither endoscopic nor histological atrophy itself can explain the deterioration of bone mineralization and structure, whereas atrophy extension appeared to be responsible for bone impairment.

Applying existing clinical staging models in a sample of Italian bipolar patients over a 10-years follow-up

Introduction

Bipolar Disorder (BD) is a life-course illness with evidence of a progressive nature. Although different staging models have been proposed from a theoretical perspective,longitudinal studies are scarce.

Objectives

The aim of the present study was to apply four staging models in a sample of BD patients and to observe their progression in 10 years of retrospective evaluation.

Methods

In a naturalistic sample of 100 BD patients, a retrospective assessment of clinical stages across 10 years of observation at six time points (T0: 2010; T1: 2013; T2: 2015; T3: 2018; T4: 2019; T5:2020) was performed according to the BD staging models (Berk et al., 2007; Kapczinski et al., 2009; Kupka et al., 2012 and Duffy et al., 2014). Socio-demographic and clinical variables were collected and the staging progression across time was analyzed.

Results

A significant progressive staging worsening emerged over 10 years of BD observation for each examined model (p<0.001). Moreover, for all considered staging approaches, stage values were lower over the time points for BD II, lower number of lifetime episodes and hospitalizations (p<0.05). Finally, the stage increase was associated with a lower age at first elevated episode (p<0.05).

Conclusions

Present preliminary results confirm the relevance of illness onset and early intervention in BD, given their role in patients classified into worse clinical staging. There is an emerging need of a standardized universal staging model in order to better characterize BD patients, their treatment and their clinical course.

Disclosure

No significant relationships.

Well being in patients on CAPD and hemodialysis

In the present multicenter study, 120 pts who had been treated by both hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) for at least 6 months each, were invited to answer questions on 34 matters, to compare symptoms and their well-being while on the two treatments. Patients were invited to choose HD or CAPD and indicate the reasons for their choice. For 28 patients the first treatment was HD and for 92 CAPD. The mean time between the change of therapy and the study was 46±35 months. Their final choices were found to be strictly related to the present treatment (p<0.001). The reasons for choice of CAPD were: more free time (21%), more freedom (67%), better well being (44%), less worry (5%); for HD they were: more free time (53%), better well-being (39%), less worry (13%), no need for a peritoneal catheter and fewer clinical complications (19%). The catheter was considered more cumbersome than the A.V. fistula, the time involved was considered to be shorter on HD by 52 patients and on CAPD by 39, thirst and cramps were considered to be more frequent and severe on CAPD by half of the patients. The prevalence and severity of problems and symptoms and choice of treatment were not related to sex, job, education or age.

Calibration of Local Systems with Lyophilized Calibrant Plasmas Improves the Interlaboratory Variability of the INR in the Italian External Quality Assessment Scheme

Calibration with lyophilized calibrant plasmas certified in terms of PT with International Reference Preparations for thromboplastin has been proposed to minimize the effect of coagulometers on the INR. Aim of this study was to test the ability of local calibration with lyophilized calibrant plasmas, combined with a modified statistical approach, to improve the interlaboratory variability of the INR measured on two test plasmas (one coumarin and one artificially-depleted) by participants in the External Quality Assessment Scheme (EQAS). Sets of lyophilized calibrant and test plasmas were sent to the participants in the EQAS, who were asked to determine PT with their own reagent/ instrument combination (local system). Results were returned as PT together with information on the type of local system, the stated International Sensitivity Index (ISI) and the geometric mean of PTs determined by testing with the local system fresh plasmas from 20 healthy subjects. Ninety-two participants using 9 and 11 brands of reagents and instruments returned results. The CV of the INR determined with the stated ISI for the coumarin (Mean INR = 4.39) and artificially-depleted (Mean INR = 4.23) test plasmas were 11.2% and 10.3% and were reduced on the average by 34% and 54%, respectively, when the INR was calculated with the local ISI.

In conclusions, results from this field study involving laboratories and testing systems representative of the real situation in oral anticoagulant monitoring in our country, indicate that local calibration by artificially-depleted plasmas, combined with the proposed statistical approach, is suitable to improve the interlaboratory agreement on the INR.

Changes of Prothrombin Fragment 1+2 (F 1+2) as a Function of Increasing Intensity of Oral Anticoagulation

Plasma F 1+2 levels, the activation peptide originating from the factor Xa-mediated activation of prothrombin, increase in many clinical conditions associated with hypercoagulability and decrease in patients on oral anticoagulant treatment (OAT). However, the usefulness of F 1+2 measurement to monitor OAT has not yet been investigated in clinical studies. Before those studies are attempted, the plausibility of its implementation in the laboratory control of OAT should be evaluated. In this respect, a thorough investigation of the pattern of changes of F 1+2 as a function of increased intensity of anticoagulation expressed as International Normalized Ratio is essential. One hundred and thirty-two patients on long-term warfarin treatment were recruited to cover 8 ranges of anticoagulation from <1.5 to 9.0 INR. F 1+2 was measured in batch on frozen plasma and INR was determined on fresh plasma. The relationship of F 1+2 vs. INR showed a hyperbolic pattern with F 1+2 levels decreasing progressively and significantly as a function of increasing INR up to 3.0. A further decrease in F 1+2 levels observed at INR up to 4.0 was not statistically significant. At INR greater than 4.0, F 1+2 reached a plateau, with mean levels not significantly different for patients at increasing INR up to 9.0. Since the risk of bleeding increases at INR greater than 4.5, our results suggest that F 1+2 is of little value to assess the hemorrhagic risk in patients on OAT.

Five year time course of celiac disease serology during gluten free diet: results of a community based "CD-Watch" program

BACKGROUND

Little information is available on the effect of a follow-up strategy in celiac disease patients during gluten-free diet.

AIMS

To assess 5 year time course of t-transglutaminase antibodies (t-TG) in celiac disease patients enrolled in a community based follow-up program.

METHODS

Annual t-TG testing and periodical clinic visit in 2245 patients.

RESULTS

Proportion of patients with negative t-TG progressively increased from 83% to 93% during the 5-year follow-up: poor adherence to gluten-free diet (HR 4.764), long duration of gluten-free diet (HR 0.929) and female gender (HR 1.472) were independently associated with serological outcome. In individual patients, 69% tested t-TG "persistently negative", 1% "persistently positive" and 30% "intermittently negative or positive". By applying mathematical modelling to t-TG conversion rates observed in this latter group at beginning and end of the follow-up program, the predicted proportion of t-TG negative population increased from 90% to 95% over 5 years.

CONCLUSIONS

Time-course of t-TG serology in the community fluctuates in 1/3 of celiac disease patients suggesting inconstant adherence to gluten-free diet and need of follow-up strategy. Periodical serological and clinical follow-up is a viable and efficacious strategy to promote adherence to gluten-free diet as inferred from time-course of t-TG serology.

Prolongation of antibiotic prophylaxis after clean and clean-contaminated surgery and surgical site infection

AIM

Several guidelines have recommended that antibiotic prophylaxis (AMP) should be given only at premedication, except in selected cases. Conversely, in clinical practice, AMP is often unnecessarily prolonged after the surgical procedure. In this observational study, we evaluated the risk of surgical site infection (SSI) associated with the prolongation of AMP after clean and clean-contaminated surgery.

METHODS

All consecutive patients who underwent a surgical procedure were eligible. AMP was always administered before the surgical incision. Prolongation of AMP for the first 24 hours was allowed only in presence of at least one risk factor for SSI: an ASA score >2 or surgical procedure longer than the specific cutoff (as indicated by the NNIS--the National Nosocomial Infections Surveillance System). SSIs were evaluated during the hospital stay and after hospital discharge.

RESULTS

Three hundred fifty-eight patients were enrolled; 19 (5.3%) and 17 (6.5%) patients developed respectively intra-hospital and post hospital discharge SSIs. AMP prolongation for 24 hours in patients with at least one risk factor did not reduce the risk for intra-hospital SSI (OR 1.102; 95% CI: 0.336-3.612; P=0.873), while it increased the risk in patients without risk factors (OR: 8.99; 95% CI: 1.46-55.4; P=0.018). AMP longer than 24 hours raised the risk for intra-hospital and post hospital discharge SSI, regardless of the presence of risk factors (OR: 3.39; 95% CI 1.11-10.35; P=0.032 and OR: 5.39; 95% CI: 1.64-17.75; P=0.006, respectively.)

CONCLUSION

Postoperative AMP prolongation should be avoided.

Reduced fractional anisotropy of corpus callosum in first-contact, antipsychotic drug-naive patients with schizophrenia

BACKGROUND

Corpus callosum is the most important commissure of the brain and therefore represents a first-choice candidate to challenge hypotheses of disrupted inter-hemispheric connectivity and white matter pathology in patients with schizophrenia. Recent studies on diffusion tensor imaging (DTI) of corpus callosum yielded promising but equivocal evidence of reduced fractional anisotropy (FA) in schizophrenia patients who were, for the most part, chronic cases on medication for a lengthy period of time. To exclude potentially confounding effects of the course of the disorder and its treatment, we compared callosal FA of first-contact, antipsychotic drug-naive schizophrenia patients (n=21) and healthy controls (n=21).

METHODS

Splenium and genu FA were obtained by two independent observers utilizing large, rectangular, tractography-guided regions of interest outlined on directional color-coded maps. Inter-observer agreement on FA was evaluated by means of the Bland and Altman and the Passing and Bablok procedures together with an estimate of the intra-class correlation coefficient.

RESULTS

Strong inter-observer agreement of FA values emerged from each of the three statistical approaches utilized. ANCOVA showed a significant effect on FA for the interaction between patient-control membership and callosal region (F=5.354; p=0.026); post hoc multiple comparisons demonstrated that, when compared to the controls, the patients had lower mean FA values (p=0.005) in the splenium but not in the genu and that this difference tended to be more evident in males (p=0.090).

CONCLUSIONS

Lowered mean FA values in the splenium of first-contact, antipsychotic drug-naive patients with respect to healthy controls strongly support the hypothesis that processes operant at least since the earliest phases of the disorder and independent from exposition to antipsychotic drugs contribute to reduced anisotropy in schizophrenia.

Silent celiac disease is frequent in the siblings of newly diagnosed celiac patients

BACKGROUND/AIMS

Celiac disease is caused by environmental and genetic factors, and the relatives of celiac patients are at higher risk of developing celiac disease than the general population. This prospective study evaluates the prevalence of celiac disease in the asymptomatic siblings of celiac patients.

METHODS

Forty-eight siblings (22 males; mean age 13 years) of 39 celiac children (20 males; mean age 4 years), and 120 siblings (55 males; mean age 33 years) of 55 adult celiac patients (12 males; mean age 31 years) were serologically screened for celiac disease. Positive cases were considered for endoscopic duodenal biopsies.

RESULTS

Forty of the 168 asymptomatic siblings (23.8%) were affected by celiac disease. There were no differences between the index cases with and without affected siblings in terms of age at diagnosis, symptoms at onset, order of birth, associated disorders or other affected relatives. The male siblings of pediatric patients were affected in 40.9% of cases and female siblings in 26.9%; the corresponding figures for adults were 16.4 and 23.1%.

CONCLUSIONS

Silent celiac disease is 24-48 times more frequent in the siblings of celiac patients than in the general population. No predictive factors for sibling involvement were found. Adult females seem to tolerate gluten less than adult males.

Case?control study of multidrug resistance phenotype and response to induction treatment including or not fludarabine in newly diagnosed acute myeloid leukaemia patients

One hundred and six patients aged </=60 years with newly diagnosed acute myeloid leukaemia (AML) treated with fludarabine-based regimens (cases) were matched with 106 AML patients treated with conventional non-fludarabine-based regimens (controls). The cases and controls were matched by expression of the multidrug resistance P-glycoprotein (MDR-Pgp), measured by flow cytometry as mean fluorescence index (MFI), cytogenetics, and age. The complete remission (CR) rate of the cases was 61% among the MDR-Pgp-positive (pos(ve)) patients (MFI >/= 6) vs. 75% among the MDR-Pgp-negative (neg(ve)) ones (MFI < 6) (P = 0.16). Conversely, in the controls, the CR rate was 44% among the MDR-Pgp-pos(ve) patients vs. 67% among the MDR-Pgp-neg(ve) ones (P = 0.02). The 4-year disease-free survival (DFS) and overall survival (OS) of MDR-Pgp-pos(ve) cases were significantly longer than those of MDR-Pgp-pos(ve) controls (DFS, 28.1% vs. 6.5%, P = 0.004; OS, 33.5% vs. 9.6%, P = 0.01). This difference was not found among the MDR-Pgp-neg(ve) patients. By univariate (P = 0.007) and multivariate (P = 0.007) analysis, the MDR-Pgp-pos(ve) phenotype was negatively correlated with CR and it emerged as the most important independent negative prognostic factor, after cytogenetics. Our study confirms the prognostic impact of the MDR phenotype in AML and strongly suggests fludarabine-based induction treatments as a promising strategy for MDR-Pgp-pos(ve) AML patients. In this setting of patients, large prospective randomised studies should be planned.

Efficacy prospective study of different frequencies of Epo administration by i.v. and s.c. routes in renal replacement therapy patients

BACKGROUND

The problem of pure red cell aplasia (PRCA) prompted nephrologists to revert to a wider intravenous (i.v.) utilization of erythropoeitin (Epo). Once weekly i.v. Epo administration has been suggested to be as effective as the twice/thrice weekly i.v. dose. The aim of the present study was to test whether once weekly i.v. Epo administration is equally as cost-effective as once weekly subcutaneous (s.c.) and 2-3 times weekly i.v. administration.

METHODS

We prospectively studied 41 patients (23 males, aged 28-82 years), on renal replacement therapy for 18-286 months, stabilized on twice or thrice weekly s.c. Epo-alpha (basal). The patients were treated for three consecutive 6 month periods with once weekly s.c. (OWSC), once weekly i.v. (OWIV) and twice/thrice weekly i.v. (TWIV) Epo-alpha. The initial dose for each period was equal to the final dose of the previous one; when necessary, the dose was adjusted according to DOQY guidelines. Iron, folic acid and vitamin B(12) supplementations were given throughout all the study periods. At the end of each of the four study periods, the following parameters were evaluated: haemoglobin, haematocrit, hypochromic red blood cells (RBCs), iron, serum ferritin, transferrin, folate, vitamin B(12), C-reactive protein (CRP), Kt/V, parathyroid hormone (PTH) and weekly dose of Epo-alpha.

RESULTS

Thirty-three out of 41 enrolled patients completed the study (there were five deaths, two renal transplants and one transfer). No significant changes were observed as regards iron, serum ferritin, transferrin, folate, vitamin B(12), CRP, Kt/V or PTH level. Haemoglobin levels were not different at the end of the basal (11.7+/-1.21), OWSC (11.8+/-0.86) and TWIV (12.1+/-1.04) periods, while significantly lower levels were observed after the OWIV period (11.0+/-0.97, P<0.01). Weekly Epo consumption (Epo U/week/kg body weight/g haemoglobin) was: basal 11.57+/-5.96; OWSC 10.22+/-4.53; OWIV 15.99+/-7.7*(a); and TWIV 11.89+/-6.3*(a) (*P<0.01 vs basal; (a)P<0.01 vs OWSC).

CONCLUSIONS

From our results, the OWIV schedule seems to have less efficacy in the control of anaemia of chronic renal failure patients on dialysis treatment than either OWSC or TWIV schedules.

Risk of acute myeloid leukemia and myelodysplastic syndrome in trials of adjuvant epirubicin for early breast cancer: correlation with doses of epirubicin and cyclophosphamide

PURPOSE

We reviewed follow-up of patients treated in 19 randomized trials of adjuvant epirubicin in early breast cancer to determine incidence, risk, and risk factors for subsequent acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS).

PATIENTS AND METHODS

The patients (N = 9,796) were observed from the start of adjuvant treatment (53,080 patient-years). Cases of AML or MDS (AML/MDS) were reported, with disease characteristics. Incidence and cumulative risk were compared for possible risk factors, for assigned regimens, and for administered cumulative doses of epirubicin and cyclophosphamide.

RESULTS

In 7,110 patients treated with epirubicin-containing regimens (92% of whom also received cyclophosphamide), 8-year cumulative probability of AML/MDS was 0.55% (95% CI, 0.33% to 0.78%). The risk of developing AML/MDS increased in relation to planned epirubicin dose per cycle, planned epirubicin dose-intensity, and administered cumulative doses of epirubicin and cyclophosphamide. Patients with administered cumulative doses of both epirubicin and cyclophosphamide not exceeding those used in standard regimens (</= 720 mg/m(2) and </= 6,300 mg/m(2), respectively) had an 8-year cumulative probability of developing AML/MDS of 0.37% (95% CI, 0.13% to 0.61%) compared with 4.97% (95% CI, 2.06% to 7.87%) for patients administered higher cumulative doses of both epirubicin and cyclophosphamide.

CONCLUSION

Patients treated with standard cumulative doses of adjuvant epirubicin (</= 720 mg/m(2)) and cyclophosphamide (</= 6,300 mg/m(2)) for early breast cancer have a lower probability of secondary leukemia than patients treated with higher cumulative doses. Increased risk of secondary leukemia must be considered when assessing the potential benefit to risk ratio of higher than standard doses.

Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study

OBJECTIVE

Intraabdominal hypertension is associated with significant morbidity and mortality in surgical and trauma patients. The aim of this study was to assess, in a mixed population of critically ill patients, whether intraabdominal pressure at admission was an independent predictor for mortality and to evaluate the effects of intraabdominal hypertension on organ functions.

DESIGN

Multiple-center, prospective epidemiologic study.

SETTING

Fourteen intensive care units in six countries.

PATIENTS

A total of 265 consecutive patients admitted for >24 hrs during the 4-wk study period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Intraabdominal pressure was measured twice daily via the bladder. Data recorded on admission were the patient demographics with Simplified Acute Physiology Score II, Acute Physiology and Chronic Health Evaluation II score, and type of admission; during intensive care stay, Sepsis-Related Organ Failure Assessment score and intraabdominal pressure were measured daily together with fluid balance. Nonsurvivors had a significantly higher mean intraabdominal pressure on admission than survivors: 11.4 +/- 4.8 vs. 9.5 +/- 4.8 mm Hg. Independent predictors for mortality were age (odds ratio, 1.04; 95% confidence interval, 1.01-1.06; p = .003), Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.1; 95% confidence interval, 1.05-1.15; p < .0001), type of intensive care unit admission (odds ratio, 2.5 medical vs. surgical; 95% confidence interval, 1.24-5.16; p = .01), and the presence of liver dysfunction (odds ratio, 2.5; 95% confidence interval, 1.06-5.8; p = .04). The occurrence of intraabdominal hypertension during the intensive care unit stay was also an independent predictor of mortality (relative risk, 1.85; 95% confidence interval, 1.12-3.06; p = .01). Patients with intraabdominal hypertension at admission had significantly higher Sepsis-Related Organ Failure Assessment scores during the intensive care unit stay than patients without intraabdominal hypertension.

CONCLUSIONS

Intraabdominal hypertension on admission was associated with severe organ dysfunction during the intensive care unit stay. The mean intraabdominal pressure on admission was not an independent risk factor for mortality; however, the occurrence of intraabdominal hypertension during the intensive care unit stay was an independent outcome predictor.

Extracorporeal Lithotripsy for Salivary Calculi: A Long-Term Clinical Experience

OBJECTIVES/HYPOTHESIS

The objective was to assess in a large series of patients with a long-term clinical follow-up the validity of extracorporeal electromagnetic shock wave lithotripsy as a minimally invasive therapy for sialolithiasis.

STUDY DESIGN

Consecutive patient series.

METHODS

Three hundred twenty-two consecutive symptomatic outpatients with single or multiple calculi in the submandibular (234 patients) or parotid (88 patients) gland underwent a complete extracorporeal electromagnetic shock wave lithotripsy treatment. Treatment results were classified into three groups: successful result with complete ultrasonographic elimination of the stone after lithotripsy, successful result with residual ultrasonographic fragments that were less than 2 mm in diameter, and unsuccessful result with residual ultrasonographic fragments that were greater than 2 mm in diameter. Univariate and multivariate statistical analyses were performed.

RESULTS

Complete elimination of the stone was achieved in 45% of patients. On ultrasonography, residual fragments (<2 mm in diameter) were detected in 27.3% of patients, and persisting fragments greater than 2 mm in diameter were assessed in 27.7% of patients. In 3.1% of patients, all with submandibular gland stones, sialoadenectomy was performed. Recurrence of calculi in the treated gland was observed during a median follow-up period of 57 months in four patients with complete ultrasonographic clearance of the stone occurring 10 to 58 months after lithotripsy. Univariate analysis showed that a favorable treatment result was significantly associated with the younger age of the patients (< or = 46 y), parotid and intraductal localization of the stone, diameter of the stone (< or = 7 mm), and number of therapeutic sessions (< or = 6). On multivariate analysis, the age of the patient, parotid site of the stone, stone diameter, number of therapeutic sessions, and number of shock waves were associated with favorable outcome.

CONCLUSION

Extracorporeal electromagnetic shock wave lithotripsy is to be considered an efficient, minimally invasive treatment modality for salivary calculi.

Plasma low-density lipoprotein cholesterol and bone mass densitometry in postmenopausal women

OBJECTIVE

The prevalence and the clinical and social importance of osteopenia and osteoporosis are increasing in western societies. To improve knowledge of the risk factors associated with these conditions, we assessed the relationship between bone mass density and plasma lipid profile in a cohort of postmenopausal women.

METHODS

We studied 1303 postmenopausal women who attended a menopause outpatient clinic. All women underwent bone mineral density determination at the level of the lumbar spine. Plasma lipids and lipoproteins and bone metabolic markers were assessed on a blood sample obtained after a 12-hour fast.

RESULTS

Statistically significant associations were found by univariate analysis between prevalence of osteopenia and age, time since menopause, body mass index, and low-density lipoprotein (LDL) cholesterol. Specifically, women with plasma LDL cholesterol levels of at least 160 mg/dL had a more than doubled probability of being osteopenic compared with women with lower LDL cholesterol (47.9% versus 21.2%, respectively). Time since menopause, body mass index, and LDL cholesterol were the only variables significantly associated with the prevalence of osteopenia, by multivariable analysis.

CONCLUSION

Postmenopausal women with increased plasma LDL cholesterol levels had a greater probability of being classified as osteopenic than women with normal plasma LDL cholesterol levels. Our data, if confirmed, suggest that elevated levels of plasma LDL cholesterol should be regarded as an additional risk factor for reduced bone mineral density.

Rectal hyperreactivity to distention in patients with irritable bowel syndrome: role of distention rate

BACKGROUND AND AIMS

Rectal motor hyperreactivity to distention may be involved in the pathophysiological course of defecatory symptoms in patients with irritable bowel syndrome (IBS), but results of patient studies are conflicting, possibly because of differences in the applied distention rate. Because a fast rate of distention increases the rectal motor response in healthy subjects, it also may show hyperreactivity in patients with IBS. The aim of this study is to compare the effects of 2 distention rates on rectal motor responses and sensations in 16 patients with IBS and 12 healthy subjects.

METHODS

Rectal distensibility and the frequency of rectal contractions and sensations were recorded during volume-controlled rectal distentions at 2 distention rates (10 and 100 mL/min).

RESULTS

Recta of patients with IBS were significantly less distensible than those of healthy subjects during fast distention (P = 0.0006), but this difference was not statistically significant during slow distention (P = 0.07). The frequency of rectal contractions and sensations, the majority of which were sensations of gas and a desire to defecate, were significantly greater in patients with IBS during both slow and fast distentions (both P < 0.025).

CONCLUSIONS

Recta of patients with IBS are hyperreactive to distention, and fast distention magnifies this abnormal motor response. A greater frequency of sensations during a fixed-time distention period may help to characterize the patients.

[The minimal bowel resection in Crohn's disease: analysis of prognostic factors on the surgical recurrence]

OBJECTIVE

To assess the effect of disease pattern and involvement of the margins on early and late results of enteric resections with hand-sewn anastomosis for Crohns disease.

BACKGROUND

Bowel sparing is one of the aims of the surgery for CD. When strictureplasties are not possible, "minimal surgery" (the resection just of the grossly involved tract of bowel) is the current choice.

METHODS

One hundred and forty-six cases of resections in 128 patients were performed in the years 1991-2001. We investigated if there is a relationship between disease pattern (perforating and non-perforating) or hystologic involvement of the margins and recurrence (reoperation for recurrent preanastomotic disease). Hand-sewn anastomosis were performed almost in all the cases; we compared the results with the main series of stapled and hand-sewn sutures.

RESULTS

Nine surgical complications occurred (7%), requiring six relaparotomies and three conservative treatments. Overall rate of recurrence (median follow-up 44 months) is 17%: 9% in patients with non perforating disease and 19% in patients with perforating disease. The rate of recurrence is 6% in the group of patients with involved margins and 23% in the group with non involved margins.

CONCLUSIONS

Limited surgery for CD doesn't increase rate of recurrence; the involvement of margins is not a risk factor for early reoperation. Hand-sewn anastomosis seem to be as safe as stapled ones.

Design of a trial comparing sirolimus plus mycophenolate mofetil versus sirolimus plus cyclosporine

We present the study design of a prospective, multicenter, randomized trial aimed at comparing the effects of two different combinations of sirolimus. Renal transplant recipients will be allocated to receive either sirolimus and mycophenolate mofetil (group A) or sirolimus and cyclosporine (group B). The primary endpoint will be the graft function at 3, 6, 12, 24, 36, 48, and 60 months. A number of secondary endpoints will also be considered. To obtain a significant difference in the primary endpoint 180 patients will be enrolled.

Diagnostic role and prognostic significance of a simplified immunophenotypic classification of mature B cell chronic lymphoid leukemias

We verified the diagnostic and prognostic role of a simplified immunophenotypic classification (IC) in a series of 258 patients (M/F: 1.4; median age: 64 years; median follow-up: 64 months; 75 deaths) with mature B cell lymphoid leukemias (MBC-LL) for whom no histopathological diagnosis was available because of minimal or no lymph node involvement. The IC was based on the reactivity of three pivotal immunophenotypic markers: CD5, CD23 and SIg intensity. On the basis of different expression patterns, we identified four diagnostic clusters (C) characterized by distinct clinico-biological features and different prognoses: C1 (149 patients) identified most classical B cell chronic lymphocytic leukemias (CLL-type cluster; SIg(dim)/CD5+/CD23+); C2, 38 patients whose clinico-hematological characteristics were intermediate between C1 and C3 (CLL-variant cluster; SIg(bright)/CD5+/CD23+/-or SIg(dim)/CD5-/-/CD23 indifferent); C3 (16 patients) most situations consistent with mantle cell lymphoma in leukemic phase (MCL-type cluster; SIg(bright)/CD5+/CD23-); and C4, 55 cases, most of whom were consistent with leukemic phase lymphoplasmacytic/splenic marginal zone lymphomas (LP/S-type cluster; SIg(bright)/CD5-/+/CD23 indifferent). At univariate survival analysis, prognosis worsened from C1 to C4, C2 and C3 (P = 0.0001), and this was maintained at multivariate analysis (P = 0.006), together with CD11c expression (P = 0.0043), age at diagnosis (cut-off 70 years; P = 0.0008) and platelet count (cut-off 140 x 10(9)/l; P = 0.0034). Besides recognising the two well-known situations of classic B-CLL and MCL, our IC identified situations with distinct prognostic and/or clinical behaviors.

Risk factors for late kidney allograft failure

BACKGROUND

While graft survival rates in the short term have improved dramatically, only a modest improvement has been shown in long-term graft survival rates. We evaluated the causes of late failure in renal allograft recipients treated with cyclosporine A (CsA).

METHODS

A total of 864 adults with a functioning graft at one year were evaluated. The end points were dialysis or death with a functioning graft.

RESULTS

The 13-year patient and graft survival probabilities were 0.82 and 0.64, respectively. The graft half-life was 20.1 years and the pure graft half-life was 31.1 years. At multivariate analysis, plasma creatinine at one year (P = 0.0006; RR 1.72), low-density lipoproteins (LDL) at one year (P = 0.0014; RR 1.65), older age (P = 0.0128; RR 1.50) and delayed graft function (P = 0.0350; RR 1.45) were associated with the end point. Chronic allograft nephropathy was the cause of failure in 97 patients, death in 70, recurrence of glomerulonephritis in 24, other events in 6. Cardiovascular complications were the most frequent cause of death. Post-transplant cardiovascular events were associated with: pre-transplant cardiovascular events (P = 0.0012; RR 2.65), older age (P = 0.0001; RR 2.46), pre-transplant arterial hypertension (P = 0.0249; RR 1.57), smoking (P = 0.0235; RR 1.29), duration of dialysis (P = 0.0229; RR 1.28). Mean serum cholesterol, LDL and triglycerides were each significantly associated post-transplant cardiovascular events.

CONCLUSIONS

The graft half-life was 20 years. Chronic allograft nephropathy was the leading cause of late failure, followed by death. If the data were censored by death, the projected pure graft half-life would be 31.1 years. Pre-transplant selection and preparation of the candidate as well as appropriate life style are recommended to improve life expectancy and extend graft survival.

Iron reduction and sustained response to interferon-alpha therapy in patients with chronic hepatitis C: results of an Italian multicenter randomized study

OBJECTIVES

It has been suggested that iron depletion improves the response to interferon in patients with chronic hepatitis C. We aimed to evaluate whether iron reduction by phlebotomy before interferon improves the rate of virological sustained response in previously untreated noncirrhotic patients.

METHODS

One hundred fourteen hepatitis C virus (HCV) RNA positive patients with hepatic iron concentrations of > or =700 microg/g dry wt (men) and > or =500 microg/g dry wt (women), stratified according to HCV genotype and gamma-glutamyltransferase values, were randomly allocated to interferon alone (6 MU three times a week) (group A) or to phlebotomy until iron depletion followed by interferon (6 MU three times a week) (group B). After 4 months dosage was reduced to 3 MU three times a week for another 8 months.

RESULTS

Virological sustained response was observed in 25 patients (22%), nine (15.8%, 95% CI = 7.5-27.9) of group A and 16 (28.1%, 95% CI = 17.0-41.6) of group B. At univariate analysis the variables associated with the response were HCV genotypes 2-3, normal gamma-glutamyltransferase, higher levels of baseline ALT, normal ALT values, and negativity for HCV-RNA at the 3rd month of therapy. At multivariate analysis, genotype and ALT levels at enrollment maintained their association with the response. A trend toward a better response to interferon was observed in patients who received phlebotomy (odds ratio = 2.32, 95% CI = 0.96-6.24, p = 0.082). Patients with hepatic iron concentration of < or = 1100 microg/g dry wt had a trend toward a higher rate of virological sustained response (p = 0.059) when submitted to treatment B.

CONCLUSION

Iron removal by phlebotomy is able to improve the rate of response to interferon, especially in patients with lower hepatic iron deposits; it could be useful as adjuvant therapy to new therapeutic modalities.

[Living-donor kidney transplantation in the cyclosporine era]

BACKGROUND

Renal transplantation is the best possibile form of treatment for chronic renal failure. It offers the patient a longer life expectancy when compared to dialysis. Aim of the study was to evaluate our results with live donor transplantation and the variables that influenced the long-term patient and graft survival.

METHODS

190 patients received a live donor kidney transplantation in our Hospital between 1984 and 2000. Thirty-eight of them received a graft from an HLA identical donor, 130 from an HLA haploidentical donor, 22 from a living unrelated donor (spouse). Fourteen patients underwent a pre-emptive transplantation. Aim of the study was to evaluate which variables could influence the long-term patient and graft survival.

RESULTS

The median follow-up of recipients was 69.5 months. The 10-year patient and graft survival were 94.7% and 73.4% respectively. Graft half-life was 29.6 years. Six patients died. Twelve patients lost their graft because of vascular thrombosis and five patients because of rejection within the first six months. After the first year, 11 patients lost their graft because of chronic rejection and 4 after recurrence of the original disease. One hundred and forty-four patients are still under observation, and at the last examination their mean plasma creatinine was 2.0+/-1.1 mg/dl. At univariate statistical analysis the absence of locus DR incompatibility was associated with a trend toward a better long-term survival of both patient and graft (P=0.05), while less than one year of dialysis showed a significantly better survival rate (P < 0.01).

CONCLUSIONS

Living-donor transplantation offers an excellent long-term patient and graft survival.

Bone marrow-disseminated tumor cells in patients with carcinoma of the esophagus or cardia

BACKGROUND

The long-term prognosis after surgical therapy for esophageal carcinoma depends on tumor stage and completeness of resection. Similarly to other epithelial tumors, the presence of micro deposits of neoplastic cells in the bone marrow may indicate residual disease and the potential for recurrence. This study assesses the prevalence of bone marrow-disseminated tumor cells in patients undergoing surgical resection for esophageal carcinoma. In addition, we investigated the agreement between immunohistochemical and molecular techniques for the detection of micrometastases in a subgroup of patients.

METHODS

Between January 1998 and November 1999, forty-eight patients with adenocarcinoma of the esophagogastric junction (n = 29) or squamous cell carcinoma of the thoracic esophagus (n = 19) and no evidence of overt metastatic disease entered the study. An immunohistochemical assay (capable of detecting 1 carcinoma cell in 7 x 10(5) bone marrow cells) was used to test bone marrow obtained by flushing a resected rib or by needle aspiration either of the iliac crest or of a rib. A polymerase chain reaction (PCR) molecular technique was also used to identify bone marrow and peripheral blood epithelial cells.

RESULTS

Cytokeratin-positive cells were found in 79.1% of the bone marrow samples obtained from the rib, and in only 8% of the needle aspirates either from the iliac crest or from a contiguous rib: This difference is probably explained by the improved removal of metastatic cells with the flushing of the rib. Comparable results were obtained at a qualitative level by the PCR technique on bone marrow. In addition, PCR-positive results were found in 3 of 18 peripheral blood samples. There was no association with tumor type, neoadjuvant therapy, or lymph node status. Patients with a pT3 or pT4 tumor showed, at a borderline statistical level, a higher proportion of cytokeratin-positive cells in the flushed rib.

CONCLUSIONS

Bone marrow-disseminated tumor cells are present in the resected rib of a high proportion of patients undergoing esophagectomy for carcinoma, and immunohistochemistry seems to be the method of choice for their quantitative assessment. However, the prognostic and therapeutic implications of this finding need further investigation.

Length of hospitalization of patients with transient ischemic attacks

OBJECTIVE

To investigate factors that influence length of stay (LOS) in patients hospitalized for transient ischemic attacks (TIAs). This may help to reduce unnecessary days of hospitalization.

DESIGN

Retrospective study.

SETTING

A large, non-academic general hospital.

PATIENTS

All patients hospitalized for TIAs during the years 1996-1998 were retrospectively studied. We analyzed the relationship between demographic, clinical and management features and LOS.

RESULTS

We studied 157 patients. Median LOS was 8 days (range, 1 to 21 days). Statistical analysis showed that female sex, being hospitalized in 1996, hospitalization from Wednesday through Saturday, and second-level cardiological, neuroradiological and miscellaneous investigations significantly increased LOS.

CONCLUSIONS

The LOS of patients with TIAs may be reduced through measures that accelerate the diagnostic work-up and by scheduling the admission to the first days of the week, when this is possibile.

Hepatitis C is more severe in drug users with human immunodeficiency virus infection

Drug users with chronic hepatitis C virus (HCV) infection are frequently co-infected with human immunodeficiency virus-1 (HIV-1), but it is still not clear whether HIV-1 worsens the natural history of hepatitis C. To investigate this, we conducted a multicentre observational study in 163 drug addicts with histologically documented hepatitis C, 92 of whom were also infected with HIV-1: 25 (27%) were CDC stage II, 53 (58%) were CDC stage III and 14 (15%) were CDC stage IV. Eighty-eight (54%) patients had chronic hepatitis (CH) with minimal activity, 28 (17%) had CH with moderate activity, 40 (25%) had CH with severe activity and seven (4%) had active cirrhosis. Twenty-one HIV-negative patients and 15 HIV-positive patients admitted to alcohol abuse (29% vs 16%, P=0.0665). Liver disease was more severe in HIV-positive patients than in HIV-negative ones (P=0.0198): 34 HIV-positive patients and 13 HIV negatives had severe CH and cirrhosis. These two severe liver diseases were seen more often in HIV-positive patients with a history of alcohol abuse than in HIV-negative patients (10 out of 16 vs seven out of 21). Age, alcohol abuse and distribution of the histological categories of liver disease were statistically different in HIV-infected and HIV-uninfected patients. Multivariate analysis showed that age, alcohol abuse and serum antibodies to HIV were independently associated with severe CH or cirrhosis. Thus, HIV may enhance the risk of severe liver disease in drug users with hepatitis C, independently of the degree of immune dysfunction. Alcohol abuse may contribute independently, aggravating the cause of HCV-dependent liver disease.

Long-term results with cyclosporine monotherapy in renal transplant patients: a multivariate analysis of risk factors

There is little information on the long-term outcome of patients initially assigned to cyclosporine (CsA) monotherapy and requiring the addition of steroid therapy during follow-up. The aim of this report is to describe our experience with 143 first renal transplant recipients (120 cadaver transplants, 23 living donor transplants) randomized to receive CsA monotherapy as a treatment arm of three consecutive controlled clinical trials. Median follow-up was 86 months. Thirty-four percent of the patients remained on the original CsA monotherapy, whereas the remaining 66% required the addition of steroid therapy. Cumulative patient and graft survivals at 11 years were 0.89 (95% confidence interval [CI], 0.83 to 0.95) and 0.62 (95% CI, 0.52 to 0.72), respectively. The 11-year graft survival for converted patients was 0.53 (95% CI, 0.39 to 0.67). Cumulative graft half-life was 19.9 +/- 3.47 (SE) years. According to the Cox model, variables at transplantation that correlated with a lower 11-year graft survival were yearly increases in age (relative risk [RR], 1. 04; P = 0.039), monthly increases in hemodialysis duration (RR, 1.01; P = 0.029), no blood transfusion before transplantation (RR, 1.99; P = 0.043), CsA administration in a double daily dose (RR, 2.35; P = 0.008), and a cadaver donor transplant (RR, 4.76; P = 0.039). Multivariate analysis of time-dependent variables showed that delayed graft function recovery (RR, 2.20; P = 0.019) and the need to add steroid and/or azathioprine therapy (RR, 5.28; P = 0.000) were also correlated with a lower graft survival. Patients who added steroid therapy developed infections (P < 0.001), cataracts (P < 0.001), cardiovascular complications (P = 0.004), and arterial hypertension (P = 0.024) more frequently than patients remaining on CsA monotherapy. Patients administered CsA in a single daily dose received significantly less CsA over the years (P = 0.0042) than patients administered CsA in two divided doses. They also showed a trend toward greater creatinine clearance levels, although not statistically significant. In conclusion, this analysis showed that in patients assigned to CsA therapy alone, good long-term patient and graft survival probabilities can be obtained. In approximately one third of the patients, the use of steroids could be avoided for up to 11 years, and these patients had a better long-term outcome than those who required the addition of steroid therapy. Finally, in patients administered CsA in a single daily dose, the possibility of reducing CsA dosage probably led to better intrarenal hemodynamics with improving creatinine clearances.

Prevalence and risk factors for the presence of serum cryoglobulins in patients with chronic hepatitis C

To assess the prevalence and risk factors for cryoglobulinaemia associated with hepatitis C virus (HCV) infection, we studied 360 consecutive patients with chronic hepatitis C (191 men, median age 57 years; 86 [24%] with cirrhosis). One-hundred and sixty-eight (47%) had circulating cryoglobulins (mean levels 208 +/- 256 mg l-1), predominantly of type III (80%; and 20% type II). Cryoglobulins were more common in women than in men (56% vs 39%, P=0.001) and in patients with cirrhosis than in those with chronic hepatitis (57% vs 43%, P=0.024). Cryoglobulinaemic patients more frequently had high levels of serum immunoglobulin M (IgM) (57% vs 30%, P=0.001), immunoglobulin G (IgG) (84% vs 70%, P=0.002) and rheumatoid factor (45% vs 16%, P=0.001); low levels of serum C3 (15% vs 4%, P=0.001) and C4 (51% vs 26%, P=0.001); and low numbers of platelets (21% vs 12%, P=0.018), than patients without cryoglobulins. The presence of cryoglobulins was not correlated with hepatitis duration (cryopositives, 12 +/- 7 years; cryonegatives, 11 +/- 8 years) or HCV genotype (HCV 1b, 48% vs 53%; HCV 2a, 35% vs 29%, cryopositive vs cryonegative patients respectively). By multivariate analysis, female gender (odds ratio [OR] 1.675; confidence interval [CI] 1. 055-2.661), elevated serum IgM (OR 2.296; CI 1.438-3.665), IgG (OR 1. 952; CI 1.114-3.422), rheumatoid factor (OR 3.213; CI 1.889-5.465) and low C4 (OR 1.859; CI 1.138-3.038) could reliably predict the presence of cryoglobulins. When the pathogenic variables IgG, rheumatoid factor and C4 were excluded from analyses, only levels of serum cholinesterase activity < 4500 U independently predicted (OR 3. 663, CI 1.258-10.184) the presence of cryoglobulins. Fifty per cent of the patients with chronic hepatitis C circulated cryoglobulins, with preference for those with a greater impairment of liver function, as revealed by serum cholinesterase activity.

Sensations induced by medium and long chain triglycerides: role of gastric tone and hormones

BACKGROUND

The relative roles of gastric relaxation and the neuroendocrine signals released by the small intestine in the perception of nutrient induced sensations are controversial. The different effects of long chain (LCT) and medium chain (MCT) triglyceride ingestion on perception, gastric relaxation, and hormonal release may help to elucidate the mechanisms underlying nutrient induced sensations.

AIMS

To compare the effects of intraduodenal LCT and MCT infusions on perception, gastric tone, and plasma gut hormone levels in healthy subjects.

SUBJECTS

Nine fasting healthy volunteers.

METHODS

The subjects received duodenal infusions of saline followed by LCTs and MCTs in a randomised order on two different days. The sensations were rated on a visual analogue scale. Gastric tone was measured using a barostat, and plasma gut hormone levels by radioimmunoassay.

RESULTS

LCT infusion increased satiation scores, reduced gastric tone, and increased the levels of plasma cholecystokinin, gastric inhibitory polypeptide, neurotensin, and pancreatic polypeptide. MCT infusion reduced gastric tone but did not significantly affect perception or plasma gut hormone levels. LCTs produced greater gastric relaxation than MCTs.

CONCLUSIONS

The satiation induced by intraduodenal LCT infusion seems to involve changes in gastric tone and plasma gut hormone levels. The gastric relaxation induced by MCT infusion, together with the absence of any significant change in satiation scores and plasma hormone levels, suggests that, at least up to a certain level, gastric relaxation is not sufficient to induce satiation and that nutrient induced gastric relaxation may occur through cholecystokinin independent mechanisms.

Local regulation of postprandial motor responses in ileal pouches

BACKGROUND

Local mechanisms are involved in the postprandial regulation of ileal tone in healthy subjects, but whether these mechanisms affect the postprandial tonic response of ileal pouches has not yet been investigated.

AIMS

To study the effect of a meal on pouch tone and phasic motor activity in patients with gut continuity or ileostomy and, in the latter group, the effect of a pouch perfusion with chyme or saline.

PATIENTS

Twenty patients with ileal pouches: 10 with gut continuity and 10 with ileostomy.

METHODS

Pouch tone and the frequency of phasic volume events were recorded with a barostat under fasting and postprandial conditions and after perfusion of the isolated pouch with chyme or saline.

RESULTS

The meal increased pouch tone and the frequency of phasic volume events in the patients with gut continuity, but not in those with ileostomy. Pouch perfusion with chyme induced a greater increase in pouch tone than saline.

CONCLUSIONS

The meal stimulated pouch tone and phasic motor activity. These effects were at least partially related to local pouch stimulation by intraluminal contents.

Can prolonged treatment improve the prognosis in adults with focal segmental glomerulosclerosis?

Eighty nephrotic adults with focal segmental glomerulosclerosis (FSGS) and plasma creatinine lower than 3 mg/dL were given corticosteroids (53 patients) or immunosuppressive agents (27 patients) for a median of 16 and 75 weeks, respectively. Forty-two patients responded with complete remission (29 patients, 36%) or partial remission (13 patients, 16%). Twenty-six patients who did not respond were treated again. Two patients obtained complete remission and 13 partial remission. The probability of remission was associated with treatment with corticosteroids (P = 0.0001; RR, 3. 93; 95% CI, 2.00 to 7.72), absence of arterial hypertension (P = 0. 0023; RR, 2.59; 95% CI, 1.41 to 4.79), and a percentage of hyaline glomeruli lower than 5% (P = 0.0152; RR, 2.04; 95% CI, 1.15 to 3.64). The probability of being alive at 110 months without doubling of plasma creatinine was 69%. The risk of renal insufficiency was correlated with mesangial proliferation (P = 0.0025; RR, 5.50; 95% CI, 1.82 to 16.60) and with interstitial fibrosis (P = 0.0231; RR, 4. 44; 95% CI, 1.23 to 16.08) at initial biopsy. Considering partial or complete remission as a time-dependent variable, only the lack of remission (P = 0.0027; RR, 7.23; 95% CI, 1.98 to 26.33) and mesangial proliferation (P = 0.0069; RR, 4.59; 95% CI, 1.52 to 13. 88) were correlated with renal failure. Major side effects were observed in 11 patients (5 infections, 1 peptic ulcer, 2 diabetes, 3 neoplasias). This study shows that 70% of nephrotic adults with FSGS may obtain complete or partial remission and maintain stable renal function for about 10 years when given a prolonged therapy with corticosteroids or immunosuppressive drugs.

Lymph node micrometastases in patients with adenocarcinoma of the esophagogastric junction

Recurrences of adenocarcinoma of the esophagogastric junction are frequent even in patients who are classified as pN0 after radical resection, suggesting that occult nodal metastases may have been missed on routine histologic examination. Immunohistochemical analysis using antibodies to cytokeratin was retrospectively performed in 1301 lymph nodes from 46 patients who underwent surgical resection for adenocarcinoma of the esophagogastric junction through a laparotomy and a right thoracotomy. Compared to routinely stained sections, the total number of metastatic lymph nodes was significantly (P = 0.0001) increased when both serial sectioning and anticytokeratin immunohistochemical analysis were performed. Overall 6 (33.3%) of the 18 patients previously considered N0 were recategorized as N1 for the presence of micrometastases to lesser curvature nodes. Three of these patients had recurrent disease within the first year of follow-up. Both the probability of survival or no recurrence and the disease-free survival were significantly greater in patients in whom the ratio of invaded to removed lymph nodes was less than 0.2. Anticytokeratin analysis identified occult nodal metastases in one third of our patients with adenocarcinoma of the esophagogastric junction. This modified tumor staging and had an impact on overall and disease-free survival.

An analysis of the costs of ischemic stroke in an Italian stroke unit

OBJECTIVE

To determine the direct costs of hospital care of acute ischemic stroke in a large Italian hospital, and to identify the main components of such costs.

BACKGROUND

Cost containment in stroke care requires an up-to-date assessment of expenditures in the different areas of stroke management. However, costs may vary among countries because of different health system organizations.

METHODS

All patients with ischemic stroke admitted during 1996 were considered. Total cost was the sum of a daily component, reflecting personnel wages and general care, and an ancillary component, reflecting mostly investigations and treatments. The real costs were used, not fixed charges.

RESULTS

We included 245 patients, with a mean length of stay (LOS) of 13.1+/-7.0 days, and an in-hospital case fatality rate of 8.2%. The mean total cost per patient was 5,087,000+/-2,536,000 Italian Lira (LIT; $3,289+/-$1,640), with a mean cost per day of 388,000 LIT ($251). Approximately 80% of total costs were due to the daily component and 20% to the ancillary component. A multiple linear regression model of length of stay, which determines the daily cost, showed that the Rankin score at entry, the clinical syndrome type, and the destination at discharge independently contributed to LOS. A second linear regression model showed that younger age and longer LOS significantly increased ancillary costs.

CONCLUSIONS

The containment of hospital costs of ischemic stroke may be achieved mostly through measures that reduce LOS, such as effective treatments and a quicker deployment.

Omeprazole in patients with mild or moderate reflux esophagitis induces lower relapse rates than ranitidine during maintenance treatment

BACKGROUND/AIMS

Patients with reflux esophagitis have rapid relapses after treatment withdrawal. This study was designed to investigate the relapse rate of symptomatic esophagitis during maintenance treatment with omeprazole versus ranitidine after the induction of acute healing with omeprazole.

METHODOLOGY

Patients with endoscopically verified acute erosive or ulcerative esophagitis (grade 2 or 3) were initially treated with 20 mg of omeprazole daily for 4, 8, or 12 weeks. After healing, the patients were randomized to maintenance treatment with omeprazole (20 mg every morning) or ranitidine (150 mg twice daily). A control endoscopy was performed at the end of the healing phase and after 6 months of maintenance treatment or symptomatic relapse.

RESULTS

Of 231 initially treated patients, 223 were healed (no erosive esophagitis) and entered the maintenance study. The estimated proportions of patients in remission after 6 months of maintenance treatment with 20 mg of omeprazole once per day (n = 102) and 150 mg of ranitidine twice per day (n = 103) were 89.2% and 75.7%, respectively. The single daily dose of omeprazole worked significantly better than the doses of ranitidine (p < 0.001). The omeprazole group, in comparison to the ranitidine group, had a significantly higher number of patients without symptoms (37.8% vs 54.7%) and a lesser percentage of moderate symptoms (9.45% vs 19.8%).

CONCLUSIONS

Maintenance treatment with omeprazole (20 mg once daily) is superior to ranitidine (150 mg twice daily) in keeping patients with mild to moderate erosive reflux esophagitis in remission over a 6-month period.

A randomized study comparing methylprednisolone plus chlorambucil versus methylprednisolone plus cyclophosphamide in idiopathic membranous nephropathy

To assess whether chlorambucil or cyclophosphamide may have a better therapeutic index in patients with idiopathic membranous nephropathy, we compared two regimens based on a 6-mo treatment, alternating every other month methylprednisolone with chlorambucil or methylprednisolone with cyclophosphamide. Patients with biopsy-proven membranous nephropathy and with a nephrotic syndrome were randomized to be given methylprednisolone (1 g intravenously for 3 consecutive days followed by oral methylprednisolone, 0.4 mg/kg per d for 27 d) alternated every other month either with chlorambucil (0.2 mg/kg per d for 30 d) or cyclophosphamide (2.5 mg/kg per d for 30 d). The whole treatment lasted 6 mo; 3 mo with corticosteroids and 3 mo with one cytotoxic drug. Among 87 patients followed for at least 1 yr, 36 of 44 (82%; 95% confidence interval [CI], 67.3 to 91.8%) assigned to methylprednisolone and chlorambucil entered complete or partial remission of the nephrotic syndrome, versus 40 of 43 (93%; 95% CI, 80.9 to 98.5%) assigned to methylprednisolone and cyclophosphamide (P = 0.116). Of patients who attained remission of the nephrotic syndrome, 11 of 36 in the chlorambucil group (30.5%) and 10 of 40 in the cyclophosphamide group (25%) had a relapse of the nephrotic syndrome between 6 and 30 mo. The reciprocal of plasma creatinine improved in the cohort groups followed for 1 yr for both treatment groups (P < 0.01) and remained unchanged when compared with basal values in the cohort groups followed for 2 and 3 yr. Six patients in the chlorambucil group and two in the cyclophosphamide group did not complete the treatment because of side effects. Four patients in the chlorambucil group but none in the cyclophosphamide group suffered from herpes zoster. One patient per group developed cancer. It is concluded that in nephrotic patients with idiopathic membranous nephropathy both treatments may be effective in favoring remission and in preserving renal function for at least 3 yr.

Dual therapy with high or low doses of omeprazole does not achieve an acceptable rate of Helicobacter pylori eradication in duodenal ulcer patients. A multicentre randomized long-term detailed study

BACKGROUND

It has been reported that dual therapy with high doses of omeprazole and amoxycillin proves efficient for Helicobacter pylori eradication.

AIM

To compare the efficacy, safety and tolerability of eradicating regimens with omeprazole/amoxycillin.

METHODS

In this randomized multicentre study, 267 duodenal ulcer patients were treated for 2 weeks with omeprazole 40 bid (Group A) or 20 mg bid (Group B), respectively, and with amoxycillin 0.5 g. qid followed by 4 weeks of 20 mg omeprazole om. Helicobacter pylori status was assessed by both histology and urease test in the antrum and the corpus. The patients were then followed-up for 9 months.

RESULTS

Helicobacter pylori infection was cured in 62.9% of group A (95% CI: 53.8-71.4) and in 44.8% of group B (95% CI: 35.6-54.3; p = 0.007). Healing was achieved in 91.9% of patients in group A (95% CI:85.7-96.1), and in 87.9% of patients in group B (95% CI:80.6-93.2). The estimated probability of being in ulcer remission for cured patients was 0.95 (95% CI: 0.90-0.99) and for the not cured was 0.41 (95% CI: 0.24-0.59; p = 0.0001). However, between the two treatment groups no significant differences in symptom relief or ulcer recurrence were observed. Both regimens were well tolerated with minor side-effects occurring likewise within the two groups. At two months in cured patients antral histology revealed a total (group A + B) prevalence of 13.7% of active chronic gastritis.

CONCLUSIONS

This long-term, large-size study clearly indicates that dual therapy does not represent a truly effective eradication therapy and this regime cannot be recommended.

A multicenter study on insulin-like growth factor-I serum levels in children with chronic inflammatory diseases

OBJECTIVE

To study insulin-like factor-I (IGF-I) levels in children and adolescents with connective tissue diseases (CTDs), compare them with values obtained in normal controls, and correlate them with age, sex, steroid treatment, and inflammatory parameters.

METHODS

A multicenter, cross-sectional study was performed in 3 Italian pediatric rheumatology centers. The subjects studied comprised 117 patients with juvenile arthritis (53 systemic, 25 pauciarticular and 17 polyarticular) and other CTDs (22), and 78 children without inflammatory conditions. IGF-I levels were measured by radioimmunoassay after acid-ethanol extraction.

RESULTS

Mean IGF-I serum levels were 167.6 ng/ml (+/- 132.5) in patients and 214.4 (+/- 142.8) in controls. A significant correlation was found between IGF-I levels and age in the controls (P = 0.001), but not in the patients. Covariance analysis with age as the covariate showed significantly lower IGF-I levels in the patient group (P = 0.001). No significant correlation was found between IGF-I levels and the total quantity of steroid taken. Multiple regression analysis showed that IGF-I levels were inversely correlated with the ESR (P = 0.0001) and positively correlated with age (P = 0.0002) and sex (P = 0.021) in the patient group.

CONCLUSION

IGF-I serum levels are decreased in patients with CTDs; inflammation could play a major role.

Preoperative laparoscopy in management of patients with carcinoma of the esophagus and of the esophagogastric junction

BACKGROUND AND OBJECTIVES

Adequate preoperative staging of patients with esophageal and cardia carcinoma offers the potential for a rational choice of the therapy. The aim of this study was to assess the diagnostic value of laparoscopy compared to ultrasonography (US) and computed tomography (CT) in detecting intra-abdominal metastatic spread.

METHODS

Between November 1995 and December 1996, 36 patients with adenocarcinoma of the cardia and 14 patients with squamous cell carcinoma of the lower third of the esophagus were studied with CT scan and US, followed by laparoscopy performed at the same session of planned surgical resection. Mean operative time of laparoscopy was 20 minutes (range 15-55 min). There was no mortality nor morbidity related to the laparoscopic procedure.

RESULTS

Laparoscopy lead to a change of the therapeutic approach in five patients (10%): three patients with peritoneal carcinosis undetected at the imaging examinations, and one patient with advanced liver cirrhosis with signs of portal hypertension did not undergo resection; conversely, one patient with a liver hemangioma simulating a metastatic mass at CT/US underwent esophagogastric resection. Laparoscopy showed a higher sensitivity than US and CT in detecting peritoneal metastases (71% vs. 14% vs. 14%, respectively), macroscopic nodal metastases (78% vs. 11% vs. 55%), and liver metastases (86% vs. 71%).

CONCLUSIONS

Laparoscopy represents a safe and effective diagnostic procedure in the preoperative staging of esophageal and cardia carcinoma; it provides the potential to avoid unnecessary exploratory laparotomies and to select the most appropriate treatment.

Helicobacter pylori eradication in the healing and recurrence of benign gastric ulcer: a two-year, double-blind, placebo controlled study

BACKGROUND

Helicobacter pylori infection is associated with idiopathic gastric ulcer in about 90% of the cases, but only a few controlled studies aimed at evaluating gastric ulcer healing and the natural history after Helicobacter pylori-eradication have been carried out.

OBJECTIVE

The aim of the present study was to evaluate the efficacy of omeprazole coupled with amoxicillin in the eradication of Helicobacter pylori and healing and prevention of gastric ulcer recurrence.

PATIENTS

Fifty-nine patients with active gastric ulcer were randomized under double-blind conditions to receive either omeprazole 20 mg twice daily for four weeks plus amoxicillin 3 g daily during the first and second week (29 patients, Group A) or omeprazole .20 mg twice daily for 4 weeks plus placebo for two weeks (30 patients, Group B).

METHODS

Endoscopic studies were carried out at the end of the 4 weeks treatment (or after 8 weeks in non-healed patients) as well as 2, 6 and 12 months later. A total of 3 biopsies in the antrum, 3 in the gastric body and at least seven at the edge of the crater were taken at each endoscopic control for exclusion, of malignancy, histological detection of Helicobacter pylori and for evaluation of gastric histology according to the Sydney system.

RESULTS

With intention to treat analysis, the percentage of healing after 4 and 8 weeks was 86% and 100% in Group A patients and 86% and 93% in Group B, respectively. Two patients dropped out in Group B for non medical reasons. The percentage of eradication was 63% in Group A and 7% in Group B. During a 12-month follow-up gastric ulcer relapsed in 20/32 (63%) of the persistently Helicobacter pylori positive patients. Only two out 20 (10%) Helicobacter pylori cured patients showed a gastric ulcer relapse and Helicobacter pylori reinfection. Twenty out of 30 patients, still healed after 12 months, underwent endoscopic control after two years. A gastric ulcer relapse was observed in three out of nine (33%) patients with persisting infection after treatment. No gastric lesions, but one case of erosive oesophagitis were observed in the 11 Helicobacter pylori-eradicated patients.

CONCLUSIONS

In our experience, Helicobacter pylori eradication does not favour gastric ulcer healing but does positively influence the subsequent natural history.

Liver iron influences the response to interferon alpha therapy in chronic hepatitis C

OBJECTIVE

To define whether there is any relation between the iron status of patients with hepatitis C virus (HCV) chronic liver disease and their response to interferon therapy.

DESIGN

To evaluate the long-term response to 1 year of interferon therapy with addition of phlebotomies after 3 months of treatment if at that time alanine aminotransferase (ALT) had not normalized in a group of patients with HCV-positive chronic liver disease whose iron status had been characterized.

SETTING

A northern Italian hospital.

PARTICIPANTS

Fifty-eight anti-HCV-positive patients (four HCV-RNA negative) with biopsy proven chronic hepatitis and no evidence of iron overload as indicated by normal transferrin saturation at the time of enrollment in the study.

INTERVENTION

Three times a week intramuscular injection of alpha interferon 3 MU for 1 year with addition of phlebotomies (350 ml/week) till iron depletion if after 3 months of interferon therapy ALT had not normalized.

RESULTS

A long-term response was observed in 19 of the 52 patients who completed the treatment, four HCV-RNA negative and 15 positive. The four RNA-negative and seven of the 15 RNA-positive long-term responders had been treated with interferon alone, and the other eight also with phlebotomies. At univariate analysis only HCV genotype, gamma-glutamyltranspeptidase and liver iron concentration were significantly associated with response whereas sinusoidal iron deposition was of borderline significance. No association was found with sex, age, duration of disease, histology, Knodell score, transferrin saturation %, serum ferritin, hepatocytic iron score, and portal iron score. HCV-RNA serum levels, measured in 29 patients, did not correlate with response. At multivariate analysis liver iron concentration was still significant and one unit reduction of liver iron concentration (natural logarithm transformed) was associated with 2.95 odds ratio of response.

CONCLUSION

These results indicate that iron in the liver is more closely related to response to interferon than the other variables considered, including HCV characteristics.

Effects of three immunosuppressive regimens on vertebral bone density in renal transplant recipients: a prospective study

The influence of three different immunosuppressive regimens with cyclosporine (CsA) on the development of osteopenia in renal transplant patients was assessed. Fifty-three adults with first kidney transplants participated in a randomized trial to analyze the efficacy of three different immunosuppressive regimens: CsA alone (group 1), CsA plus steroids (group 2), and CsA plus steroids plus azathioprine (group 3). Lumbar spine bone mineral density was assessed by dual energy x-ray absorptiometry every 6 months for 18 months. The values for trabecular mass were expressed as bone mineral density and as a fraction of the standard deviation of the mean of the normal value for patient's sex and decade of age (Z-score). Statistical analysis was performed on Z-score and "Z-score change" (value after 6 months minus the basal value at transplantation). At the 18th month, the Z-score increased significantly in treatment group 1 without steroids (P=0.006) and decreased significantly in steroid-treated groups 2 (P<0.001) and 3 (P<0.001). Comparing the two genders, Z-score decreased less in premenopausal women than in men (P=0.018). "Z-score change" did not correlate with steroid dosage, was high in patients with high basal bone mineral density, and was directly associated with the duration of dialysis (P=0.008). In conclusion, premenopausal transplant recipients showed a lower decrease of lumbar bone mineral density than men. In transplant recipients given CsA with steroids, lumbar bone mineral density decreased significantly, while it increased significantly in patients given CsA alone.

Prognostic factors of long-term allograft survival in 632 CyA-treated recipients of a primary renal transplant

A total of 632 cyclosporin (CyA)-treated primary renal allograft recipients with a functioning graft at 6 months were retrospectively evaluated for risk factors correlated with long-term allograft function. Mean follow-up after the 6th month was 68.4 +/- 40.6 months. One hundred twenty-one of these patients (19%) were lost: 29 died (23/29 with a functioning graft), 77 of the remaining 92 (83%) lost their graft because of chronic allograft dysfunction, 9 due to recurrence of glomerulonephritis, 5 due to renal artery thrombosis, and 1 due to chronic CyA toxicity. At univariate analysis, factors correlated with a better renal (R) and pure renal (PR) allograft survival were: dialysis duration of less than 5 years, fewer than 2 rejections within the 6th post-Tx month, immediate graft function recovery, plasma creatinine below 1.5 mg/dl at the 6th month, age at Tx above 15 years, and receiving a living donor graft. Cox's regression analysis was also performed to obtain relative risks for the same parameters. Long-term dialysis patients had more frequent late recoveries (P = 0.002) and reductions in therapy (P = 0.01) in order to reduce the side effects of steroids. In young patients receiving an initial oral CyA dose of 17 mg/kg per day, steroids were stopped at the 6th month in order to achieve catch-up growth: only one such patient lost his graft. In contrast, 72% of the young patients who lost their grafts received an initial oral CyA dosage of 13 mg/ kg per day. Thus, young patients did worse not because of steroid withdrawal, but because of inadequate initial CyA dosage. These results suggest that although we cannot exclude alloantigen-independent mechanisms as factors that stimulate progression of chronic allograft dysfunction, it would appear that the initial lesions are induced by events mostly mediated by immunological mechanisms.

Cancer incidence in 854 kidney transplant recipients from a single institution: comparison with normal population and with patients under dialytic treatment

In this retrospective historical study, we compared the incidences of malignancies observed among 854 renal transplant recipients (RT) with at least 1 yr of follow-up, with the incidences of neoplasias among patients under regular dialytic treatment (RDT) and a control population from Northern Italy. Cox's proportional hazard model was used in RT recipients in order to evaluate the prognostic factors related to the development of neoplasia. Seventy six out of 854 RT patients (8.9%) developed some malignant neoplasia: 46% of these 76 were cutaneous neoplasias including melanomas, and the remaining 54% non cutaneous cancers: 33% miscellaneous tumors (MT), mostly adenocarcinomas, 17% Kaposi's sarcomas (KS), 4% non-Hodgkin's lymphomas (NHL). Malignancies had a higher incidence (p < 0.01) among RT recipients than among control and RDT patients. However, MT were equally frequent among the three groups. RDT patients on the contrary, had similar incidence of neoplasias when compared to the control population, but showed a lower incidence of squamous cell carcinomas (SCC). The risk ratios (RR) for the most frequent neoplasias among RT recipients vs. control population were: 224.7 for KS, 7.4 for NHL, 6.2 for SCC, 5.7 for basal cell carcinomas (BCC), 4.0 for MT. The risk of developing a de novo neoplasia was of about 13% at 10 yr and of 34% at 20 yr. In RT recipients, Cox's proportional analysis showed that age > 40 at transplantation and male sex were the only risk factors associated with an increased incidence of neoplasias, while no difference was observed between conventional (azathioprine+methylprednisolone: Aza+MP) and CsA therapy or in CsA monotherapy vs. double or triple therapy. However, KS occurrence correlated both with CsA dose (RR 15.2 for monotherapy; 12.5 for double therapy; 2.98 for triple therapy) and with 10 or more i.v. methylprednisolone pulses for treatment of rejection (RR 5.2). We conclude that in our series CsA does not increase the risk for development of neoplasias, when compared to conventional immunosuppression.

Abdominal ultrasound in the assessment of extent and activity of Crohn's disease: clinical significance and implication of bowel wall thickening

AIMS

The aim of this study was to evaluate the relevance of ultrasound (US) in assessing disease extent and activity in a series of patients with quiescent or active Crohn's disease (CD). In particular, the study was aimed at evaluating whether US may be useful in distinguishing between active disease and bowel wall thickening (BWT) due to fibrosis.

PATIENTS AND METHODS

A series of consecutive patients with ileal, ileo-colonic, or colonic CD previously studied with x-ray and/or endoscopy, underwent abdominal US. The following parameters were also determined in these patients: CD activity index (CDAI), erythrocyte sedimentation rate, C reactive protein, length of disease, previous surgical resection, and number of recurrences. The relationship between BWT and the aforesaid parameters was assessed by means of univariate and multiple regression analysis.

RESULTS

Overall sensitivity and specificity of US for the assessment of anatomical distribution of CD were 89% and 94%, respectively, and there was also a significant correlation between the extent of ileal disease measured by US and that determined by small bowel x-ray. By univariate analysis, statistically significant correlations were found between BWT, CDAI, and biological indices of inflammation (erythrocyte sedimentation rate and C reactive protein), although all the correlation coefficients were low with values not exceeding 0.40, and among these, backward multiple regression analysis identified only CDAI, along with ileo-colonic localization, as the subset of predictive variables of bowel wall thickness. However, both predictions were rather weak and accounted for only 20% of the variability of the BWT. In addition, a significant relationship was found between disease US extent and clinical or biochemical disease activity. However, in a subgroup of patients characterized by quiescent disease and high BWT, CD was complicated by higher prevalence of strictures, as detected by radiological and endoscopic examinations, and more frequent surgical outcome than others.

CONCLUSIONS

Abdominal US is an accurate method for determining the abdominal distribution of CD and appears to be accurate in detecting and evaluating the disease length of ileal lesions. In contrast, despite a weak but significant correlation between BWT and clinical and biochemical parameters, the usefulness of US as an index of disease activity seems to be fairly limited. However, a high BWT in quiescent patients suggests the presence of fibrosis, which is poorly responsive to steroid treatment.