Infective endocarditis in patients with hepatic diseases

Few data have been published regarding the epidemiology and outcome of infective endocarditis (IE) in patients with chronic hepatic disease (CHD). A retrospective analysis of the Studio Endocarditi Italiano (SEI) database was performed to evaluate the epidemiology and outcome of CHD+ patients compared with CHD- patients. The diagnosis of IE was defined in accordance with the modified Duke criteria. Echocardiography, diagnosis, and treatment procedures were in accordance with current clinical practice. Among the 1722 observed episodes of IE, 300 (17.4 %) occurred in CHD+ patients. The cause of CHD mainly consisted of chronic viral infection. Staphylococcus aureus was the most common bacterial species in CHD+ patients; the frequency of other bacterial species (S. epidermidis, streptococci, and enterococci) were comparable among the two groups. The percentage of patients undergoing surgery for IE was 38.9 in CHD+ patients versus 43.7 in CHD- patients (p = 0.06). Complications were more common among CHD+ patients (77 % versus 65.3 %, p < 0.001); embolization (43.3 % versus 26.1 %, p < 0.001) and congestive heart failure (42 % versus 34.1 %, p = 0.01) were more frequent among CHD+ patients. Mortality was comparable (12.5 % in CHD- and 15 % in CHD+ patients). At multivariable analysis, factors associated with hospital-associated mortality were having an infection sustained by S. aureus, a prosthetic valve, diabetes and a neoplasia, and CHD. Being an intravenous drug user (IVDU) was a protective factor and was associated with a reduced death risk. CHD is a factor worsening the prognosis in patients with IE, in particular in patients for whom cardiac surgery was required.

Methane intestinal production and poor metabolic control in type I diabetes complicated by autonomic neuropathy

AIM

At the state of art it's unknown the correlation between diabetes and lower gastrointestinal disorders. Some studies show a significantly higher prevalence of small intestinal bacterial overgrowth in patients with type I diabetes in particular complicated by autonomic neuropathy. No data exists about gastrointestinal methane production in patients with diabetes and autonomic diabetic neuropathy. The aim of this paper was to evaluate the correlation of small intestinal bacterial overgrowth and gastrointestinal methane production with metabolic control and daily insulin requirements in patients with type 1 diabetes and. autonomic diabetic neuropathy.

METHODS

Thirty subjects with type 1 diabetes and autonomic diabetic neuropathy were underwent hydrogen and methane lactulose breath test (LBT) to evaluate the presence of small intestinal bacterial overgrowth (double peak of hydrogen) and methane production. The metabolic control was evaluated through the glycated hemoglobin and the daily insulin requirement (calculated as ratio between total insulin units in a day and body weight). Methane producers were treated with metronidazole (500 mg bid for 10 days) and perform a LBT 8 weeks after the end of therapy

RESULTS

Eight over thirty patients (26.6%) met the diagnostic criteria for small intestinal bacterial overgrowth. 11/30 patients (36%) were methane-producers (mean baseline value 16.37 ± 13.01 ppm; mean peak 26.62 ± 11.41 ppm); interestingly this subset of patients showed a worse glycemic control (mean HbA1c 8.16 ± 0.9% vs. 7.49 ± 0.8%, P<0.05). After metronidazole therapy 7/11 (63.3%) reduced CH4 production and they showed a mean HbA1c significantly lower than corresponding value before antibiotic therapy (7.63 ± 0.7% vs. 8.25 ± 0.8%).

CONCLUSION

Our study showed for the first time a possible role of CH4 production in metabolic control. In particular, the most interesting data is that an increased values of HbA1c seems to be related to a gut CH4 production as confirmed by its significant improvement after eradication therapy. We are not yet able to determine whether poor glycemic control is the cause or the consequence of the selection of methanogenic flora.

Nickel free-diet enhances the Helicobacter pylori eradication rate: a pilot study

BACKGROUND

The Helicobacter pylori eradication rate with standard triple therapy is very low. H. pylori is known to require the nickel-containing metalloenzymes urease and NiFe-hydrogenase to survive at the low pH environment in the stomach.

AIM

To compare the H. pylori eradication rate of a nickel free-diet associated with standard triple therapy and standard triple therapy alone as the first-line regimen.

METHODS

Fifty-two sex- and age-matched patients at the first diagnosis of H. pylori infection were randomized 1:1 into two different therapeutic schemes: (1) standard LCA (26 patients): lansoprazole 15 mg bid, clarithromycin 500 mg bid and amoxicillin 1,000 mg bid for 7 days with a common diet; (2) standard LCA plus a nickel free-diet (NFD-LCA) (26 patients). Patients followed 30 days of a nickel-free diet plus a week of lansoprazole 15 mg bid, clarithromycin 500 mg bid and amoxicillin 1,000 mg bid starting from day 15 of the diet.

RESULTS

All patients completed the study. A significantly higher eradication rate was observed in the NFD-LCA group (22/26) versus LCA group (12/26) (p < 0.01). Only a few patients (9 of 52) reported the occurrence of mild therapy-related side effects, without any significant differences between the two groups.

CONCLUSIONS

The addition of a nickel-free diet to standard triple therapy significantly increases the H. pylori eradication rate. The reduction of H. pylori urease activity due to the nickel-free diet could expose the bacterium to gastric acid and increase H. pylori's susceptibility to amoxicillin. Further studies are necessary to confirm this preliminary result.

From small nodule to overt HCC: a multistep process of carcinogenesis as seen during surveillance

Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related death in the world. Despite many diagnostic and therapeutic tools are now available to improve survival and reduce its recurrence, prognosis is closely conditioned by the time of diagnosis. Surveillance and early diagnosis are crucial for a successful therapy. We report a clinical case from the HCC archive of the Hepatocatt meetings held in Ge-melli Hospital (Catholic University of Rome). The case describes a tumor progression in a multistep process from a small liver nodule to overt HCC and its management by a multidisciplinary team.

Nutritional aspects of Helicobacter pylori infection

H. pylori is a gram-negative pathogen, etiologically associated with atrophic and non-atrophic gastritis, peptic ulcer, primary gastric B-cell lymphoma and gastric carcinoma. Several observations demonstrated a correlation between H. pylori and malabsorption of essential nutrients; epidemiological studies have shown an association between H. pylori infection and iron deficiency anemia, while the absorption of some vitamins such as vitamin B12, vitamin A, vitamin C, folic acid and Vitamin E may be affected by the infection. The main mechanism related to malabsorption of this components is the modified intragastric pH (hypo- achlorhydria) due to H. pylori infection. Moreover H. pylori is also able to determine a modification of gastrointestinal hormones by reducing plasma levels of ghrelin and increasing those of leptin and gastrin, thus affecting appetite and promoting the occurrence of dyspeptic symptoms. On the other hand, H. pylori eradication has been shown to improve serum level of iron and vitamin B12, has some effects on Vitamin A and Vitamin E absorption and has a late effects on ghrelin levels. As a consequence of those effects, H. pylori is also associated with childhood malnutrition in developing countries either for the occurrence of malabsorption or for an increased susceptibility to enteric infections caused by hypochlorhydria.

Fecal calprotectin concentration in children affected by SIBO

BACKGROUND AND OBJECTIVES

Calprotectin is a protein especially expressed in neutrophil cytosol. In the last few years, Fecal calprotectin (FC) turned out to be a direct marker of gastrointestinal inflammation. Because of the simplicity of the method, it has been studied in several gastroenterologic diseases but no data are available about its concentration in children with small intestinal bacterial overgrowth (SIBO), a complex and not well known condition defined by an excessive germs proliferation, especially anaerobic, in the small bowel, and characterized by dyspeptic and malabsorption symptoms. The aim of this study was to evaluate FC values in children with SIBO, comparing to healthy subjects, in order to clarify if an inflammatory process coexists with SIBO.

MATERIALS AND METHODS

We enrolled fifty-eight children affected by SIBO, as diagnosed by Lactulose Breath Test (LBT). They were assessed for FC values on stool samples. We compared them with a control population of 60 healthy children.

RESULTS

In SIBO patients, a median value of 36.0 mg/kg and a mean value +/- SD of 43.0 +/- 31.6 mg/kg were calculated, while in healthy controls the median value was 29.5 mg/kg and the mean value +/- SD was 35.7 +/- 20.7 mg/kg, showing no statistically significant differences between the two groups (p = 0.07).

CONCLUSIONS

FC values are negative in children affected by SIBO, not differing from those obtained in healthy children, suggesting that no subclinical intestinal inflammation involving neutrophils occurs in patients with higher proliferation of bacteria in the small bowel. The presence of high FC levels in children affected by SIBO might not be caused by bacterial overgrowth itself and, in this case, another cause should be investigated.

Isolation and characterization of CD133+ cell population within human primary and metastatic colon cancer

BACKGROUND

"Cancer stem cells" (CSC) have been identified as a minority of cancer cells responsible for tumor initiation, maintenance and spreading. Although a universal marker for CSC has not yet been identified, CD133 has been proposed as the hallmark of CSC in colon cancer. The aim of our study was to assess the presence of a CD133+ cell fraction in samples of colon cancer and liver metastasis from colon cancer and evaluate their potential as tumor-initiating cells.

METHODS

Tissue samples from 17 colon cancers and 8 liver metastasis were fragmented and digested using collagenase. Cell suspensions were characterized by flow cytometry using anti-CD133, CD45 and CD31 antibodies. CD133+ cells were also isolated by magnetic cell sorting and their tumor-initiating potential was assessed versus the remaining CD133- fraction by soft-agar assay.

RESULTS

Our results confirmed the existence of a subset of CD133+ tumor cells within human colon cancers. Interestingly, CD133+ cells were detectable in liver metastasis at a higher percentage when compared to primary tumors. Soft-agar assay showed that CD133+ cell fraction was able to induce larger and more numerous colonies than CD133-cells.

CONCLUSION

Our findings data that the CD133+ colon cancer cells might play an important role in both primary tumors as well as in metastatic lesions thus warranting further studies on the role(s) of this subset of cells in the metastatic process.

Percutaneous endoscopic gastrostomy (PEG) in critically ill patients performed at bed in Intensive Care Unit: report of our experience

BACKGROUND AND AIM

Patients with severe brain injures and severe neurological diseases frequently require prolonged nutritional support during their hospitalization as well as during their rehabilitation period. Since 1980, the percutaneous endoscopic gastrostomy (PEG) has become the method of choice for long term feeding. The aim of the present study was to present our experience concerning the placement of PEG in critically ill patients, recovered in Intensive Care Unit (ICU).

MATERIALS AND METHODS

From 3-05-2001 to 28-09-2005, 36 patients (13 female, 23 male) with a median age of 63 years [range: 18-86 years], recovered in ICU of the Sandro Pertini Hospital, underwent PEG. These patients were retrospectively evaluated in terms of complications, indications to the procedures, durability of gastrostomy and mortality. Intravenous antibiotic prophylaxis was administered 1 h before the procedure (ceftriaxone 2gr). The entire PEG was placed in ICU at patient's bed, with the assistance of the anaesthetist. Propofol was used e.v. for sedation and fentanest for analgesia while lidocaine was used for local anesthesia. A 16-Fr or 20-Fr tube was inserted by the "pull method", after a complete upper gastroduodenoscopy.

RESULTS

PEG was performed mainly for neurological disorders including cerebrovascular accidents (13), SLA (8), post-traumatic coma (7), post-cardiac arrest coma (7) and dementia (1). Procedure related mortality was 0%. The tube was changed in 4 patients due to clogging. The durability of the tube was a median of 2 months (range: 1-12 months). In 23 patients the placement of the PEG was definitive.

CONCLUSIONS

Our experience underlines that PEG, in selected critically ill patients, is a safe technique easy to perform even in ICU.

Co-infection with Mycoplasma pneumoniae and human herpesvirus 6 (HHV-6) in an immunocompetent child with meningoencephalitis: a random association?

Encephalitis can represent a complication of both Mycoplasma and Human Herpesvirus type 6 infections and, although uncommon, is associated with significant morbidity and mortality. We describe a 13-year-old girl with fever, headache and mental changes with a pattern of concomitant Mycoplasma and Human Herpesvirus-6 infection. The hypothetical relationship between this dual infection and the central nervous system disease is discussed.

[Endoscopic sphincterotomy in acute biliary pancreatitis. A multicenter study]

BACKGROUND

Severe acute pancreatitis are still dangerous, as can be seen from the high mortality rate (around 30%). It's commonly known that in the last years diagnostic ability, precise stadiation and control over the disease development were increased. Surgical therapy is directed mainly to achieve the control over septic evolution, and in biliary pancreatitis to resolve hypertension and infection inside the biliary tree (now widely accepted as the real cause of this disease). Recently, some authors demonstrated that the prognosis of a pancreatitis can be greatly improved by stopping the evolution toward a severe phase with necrosis and multiple organ failure without any surgical operation. They believe that's possible to achieve this result performing an early endoscopic sphincterotomy in all biliary pancreatitis (recognised by means of echography and CT scan), before the development of necrosis.

METHODS

In our department, following this address, very good results have been obtained: that's why a multicentric trial has been carried out to appraise the results obtained by endoscopic sphincterotomy within 48 hours from the disease onset. Answers from 114 hospitals were received, with a total survey of more than 10,000 pancreatitis. Endoscopic sphincterotomy was performed in 55% of billiary pancreatitis, which were estimated at the onset, on second or third degree of Balthazar classification.

RESULTS

In 86% of patients, endoscopic sphincterotomy was performed within 48 hours from symptoms onset. Complications related to this treatment are reported in less than 4% of patients.

CONCLUSIONS

The procedure, avoiding the evolution toward necrosis and sepsis, allowed the reduction of surgical operations to 6.7%, and of the mortality amongst all cases gathered to 2.5%.

[Endoscopic sphincterotomy in acute biliary pancreatitis: the complications]

The authors report on a multicentric trial performed on early endoscopic sphincterotomy in severe pancreatitis. A large figure (7.764) of biliary pancreatitis was collected and 4.285 sphincterotomies were carried out. The results have been highly satisfactory: removal of hypertension and infection in biliary tree, stopped the trend toward necrosis and infection in almost all cases precociously treated. However, answering to the many doubts raised by some colleagues about the danger of this method, the authors examined all the complications that were reported. Hemorrhages and perforations of the biliary tree were the most common one. There were 120 (2.8%) hemorrhages, most frequently treated by medical means; in 20 cases a surgical hemostasis (1 death) had to be performed. Perforations, 24 (0.56%) were treated by medical therapy in 18 cases; 6 patients underwent surgical approach, with no deaths. Other complications (cholangitis, stent ruptures), less frequent, were treated successfully without surgical operations. The authors believe the main cause of this complications to be lack of experience and delay of endoscopic procedure (papillary oedema, fragility). What they suggest, is that endoscopic sphincterotomy has to be performed by an expert endoscopist, and within 48-72 hours from disease onset. Observing also that contrast introduced in the biliary tree could be harmful, they suggest to practice cholangiography at low pressure, and always leaving a nose-biliary drain. Endoscopic sphincterotomy, therefore, if correctly performed, reduces the necessity of surgery in severe pancreatitis. In this way, operations have to be carried out only in those patients with septic complications, with encouraging results and a sharp reduction of mortality.

The learning disabled college student: some considerations in setting objectives

Many references have been made in the literature to the deficits in social-interpersonal skills that often follow the learning disabled into adulthood, yet few college LD programs address these deficits. Adelphi University's program is unique in that it has a dual focus; academic and social growth. Dr. Barbaro's article was included in this, the first of several issues focusing on the learning disabled adult, because it describes a model for direct intensive intervention designed to enhance psychosocial growth within the college environment. Second, because social adequacy is a critical factor for successful functioning, not only in social settings, but also in academic settings and the work world, more attention to deficits in this area should be given.